Saturday was a day of mourning. With dozens gathered in a shady, green park in the centre of Bangui, a minute’s silence was held at 3 pm. This was the hour a week previously when three of our MSF national staff colleagues, along with thirteen community leaders, were murdered in the supposedly sacrosanct confines of the small MSF hospital in Boguila. They had all come, along with many other community leaders and MSF workers, to attend a meeting to discuss, ironically, the security of the project in this small town in the northwest of the country. Instead, as an armed faction raided the safe in a nearby room, they were shot dead. So, as my two-month contract draws to a close and I prepare to make the enormous adjustment to life back in the UK, my heart is heavy. When will the killing end? When will this country be allowed to start to build itself up again? I am grateful that I’ve had the opportunity to play a small part in administering to the enormous medical needs of these benighted people, in one of the dozens of MSF projects spread across CAR. But now, for the next week, all these activities will be suspended, in CAR and the neighbouring countries, apart from essential and life-saving ones. MSF hopes by this drastic action to give a clear message to the leaders of the armed groups and everyone else concerned that we need to have a safe space in which to work. That the humanitarian ideal has to be respected.
“Another abnormal day,” says Paula, one of our expat doctors, in an exhausted voice. “Well, maybe we should say a normal abnormal day,” I replied. “Every day seems to be like this out in Don Bosco.”
Normal abnormal. We’ve become used to expecting the unexpected. But this day had been tough even by our normal abnormal standards. It started badly, with the news when we arrived that little Mbetimale, the baby born prematurely to an HIV-positive mother who had since died, had passed away during the night. We were just absorbing the news when a pregnant woman was carried in on a stretcher by her relatives, all desperately worried. They had taken her during the night to another clinic nearby, as she was bleeding; and she’d been referred to a hospital in Bangui. But for some reason they had brought her to us. Which was a pity, because what she needed was an urgent C-section; and, with no operating facilities here, the only thing we could do would be to refer her as well. By this stage she was in shock, no palpable pulse and very agitated with wide, staring eyes. We tried to stabilise her, but it was too late: within ten minutes, she had died.
I ask myself if she had been taken directly to the hospital in Bangui, could they have performed the caesarian in time to have saved her life? We will never know. What it highlighted for me was the toughness of life here for women, especially during pregnancy. In the developed world, we no longer expect to die during childbirth; in CAR the maternal mortality rate is a horrifyingly high figure.
Since the start of the conflict, access to health care has become increasingly difficult, if not impossible. The abortion rate has risen drastically, many unwanted pregnancies being a result of the war crime of gang rape. And in this stressful environment, premature deliveries are common; the mortality rate of newborns has also risen. At least here at Don Bosco we’re making a good contribution. “Eight safe deliveries today and six during the night,” Vittoria, our expat midwife, hot and dishevelled, told me at the end of one busy day recently. And every morning, the benches for the ante-natal clinic are full of women who have learned the importance of these visits in helping to ensure the delivery of a healthy baby to a healthy mother.
The death of the pregnant woman had been a bad start to the day. And so it continued. The next real emergency – after several cases of children with severe malaria for whom we had been able either to start treatment successfully or refer for a blood transfusion if dangerously anaemic – was the arrival of twin premature babies, just born at home and then rushed in to us. Both tiny, one was suffering from extreme respiratory distress, already tinged with blue from cyanosis, shortage of oxygen. We attached them both to the oxygen concentrator, but it soon became obvious that one would not make it. And soon its tiny body was limp and lifeless.
With the beginning of the rains, we’re approaching the annual peak of malaria. Every day the examination beds in the small emergency department are filled with small bodies, covered in damp cloths to try and bring down their high temperatures, with intravenous catheters inserted to administer the malaria treatment. But soon we hope to be starting a new approach to the annual malaria epidemic that takes millions of lives worldwide: that of prevention. While a vaccine is still being developed, a new drug strategy with a combination of drugs that proved successful in Niger last year and can offer a one-month protection from the malaria parasite will be implemented.
While all this action is taking place in the emergency department, the dressings room tells its own story: of people who let a wound develop until it’s almost gangrenous. Paula, on her first mission, is stunned by what she’s seen; for me, after many missions in Africa, it is, sadly, more of the normal abnormal. But some are indeed unbelievable. One man came in last week with an open, oozing, infected ulcer covering almost half of his lower leg. He’d travelled nearly 100 kms to reach the clinic, in despair at how a small wound, caused by a splinter of wood spiking his leg, had developed into what may now necessitate an amputation.
The backdrop to our work in the clinic is one of continuing violence. As I brought the vaccines to our small team the other morning, I found them talking agitatedly to each other, with shocked expressions on their faces. “It was one of our nurses,” one young man told me. “You remember her, we worked together in Castor”. This was the hospital I worked at when I first arrived. I now learned that the nurse, together with her husband and her two children, had been bludgeoned to death in her own house. A man had recently been murdered and his body put down a well, in an attempt to contaminate the water supply; the opposing armed faction had then gone on the rampage in retaliation. Nearly every day we hear the rattle of gunfire, sometimes close enough that we edge nervously away from the perimeter walls; and in our security briefings in the mornings we’re given the known details, who and where and sometimes the why.
And yet – outwardly, as we drive in convoy down the main road towards the clinic in the Salesian compound of Don Bosco, life seems to continue as normal. The heavy armoured cars, filled with African Union or French troops armed with machine guns, may not be normal for Bangui, but we’re all used to them now. The enormous container lorries jammed with people trying to reach Cameroon for trading purposes may be more than normal, and are guarded by troops, but they’re now a weekly occurrence. And otherwise it’s everyday Bangui life: taxis queue in endless lines for fuel; scores of people bid for the t-shirts being sold from the back of a lorry. A man carries on his head a tall load of freshly-baked baguettes, arranged in diminishing concentric circles; another man balances an even more improbable pyramid of eggs.
These are resilient people, I think as we enter the compound of the IDP camp and head for the clinic, where already scores of people are awaiting us for another normal abnormal day.
Sadly, miracles don’t happen that often. Which is why, of course, they are miracles. We really wanted one yesterday, for another tiny baby. Just two months old, her mother brought her in with respiratory distress, her tiny chest expanding with the effort of breathing. And every few minutes she would start this dry, barking cough, which would continue, excruciatingly, for minutes.
“It’s whooping cough,” said our new doctor, Ana. She’d seen it before, which I never had. We gave little Merline all the treatment she needed, and kept the oxygen concentrator going; managed to clear a small ward so that she could be isolated; and then just prayed, as we left for the night.
This morning she was dead. It just brought home to me the importance of the vaccination campaign we’re running at the clinic, on behalf of the Ministry of Health. So far, in just over a week, the small team has vaccinated over 1500 children from birth to two years. Whooping cough is included in the eleven vaccines we’re giving.
As I’m supervising the vaccinations, it was one of my biggest challenges to start with: learning what VAA, PCV and DTC meant, what the vials looked like and how many doses were in each different vial, so that I could get out the required number from the cold chain quickly enough, under the eagle eye of our scary pharmacist, for the temperature to stay within the required limits.
I should explain that since my last blog I’ve moved to another position. Now that the conflict is decreasing here in Bangui – still with sporadic daily gunfire and news of shootings, but with fewer admissions to our emergency centre – we’ve handed the hospital back to the Ministry of Health to run, with the help of another humanitarian aid agency.
And our efforts will go to areas in the interior, and the clinic in one of the refugee camps here in the north of Bangui. It’s a refugee camp – or rather, an IDP (internally displaced people) camp that was started in December in the grounds of a school run by Salesian priests. Some 40-50,000 people from the surrounding area sought safety here, displaced by the ongoing conflict between the Seleka and anti-Balaka militia. Many have now returned home, but about 20,000 remain, fearing for their security in an area that is still a zone of conflict.
So, having just got to grips with one job, it’s a new job for me as from last week. The nurse has just left, and we had two days together for me to learn the ropes.
The first day was chaotic. I arrived on the day of the feeding programme for moderately malnourished children – which meant an influx of some 200 children under five. And on top of that, it was the first day of the vaccination campaign: another 250 babies and infants trickling in. Getting a new team of vaccinators into action, organising a logical flow of the mass of patients – and at the same time trying to learn how the feeding programme worked before I could actually supervise it – was quite a challenge.
In between all that, Mila – the nurse I was taking over from – managed to show me round the rest of the clinic. It had grown a lot from the provisional clinic opened last December, and as well as an outpatients department, providing about 200 consultations a day, there are nine or so inpatient beds, an ever-expanding maternity department (mothers seem to come from far and wide to deliver here) and a small section for emergency admissions. Oh – and don’t forget the pharmacy, the unloved province of MSF nurses. They are often fairly disorganised and always very busy, and it’s difficult to keep an accurate track of consumption and therefore ordering. This one looks like no exception, and one of my first tasks will be to get to grips with it.
As well as learning how many doses in VAA and PCV and DTC, and how many we need to order each day.
I was slightly anxious about my move to this clinic, because of the security risk. A week or so ago, there had been an incident in the surrounding area that resulted in nine people being admitted at once with gunshot wounds. And all car movements had been stopped in and out of the area. Would the staff have to spend an uncomfortable night in the clinic? Luckily things calmed down before curfew time, so they were able to return to our base.
All new challenges; let’s see how I rise to them. The expat doctor who has been running the clinic – very experienced, very calm – has just left, so we’re a new medical team. And I’ve taken over as what is called Medical Focal Point – which basically means I have to be a problem solver. I’ll let you know how it all goes!
Meanwhile, we have another baby to worry about. Little Mbetimale was born twenty days ago prematurely to an HIV positive mother. The mother has since died, and the father sleeps in the clinic with the baby. Mbetimale weighs a bit more than a bag of sugar, and it seems another miracle that she has survived this long. It didn’t seem possible – but she’s a fighter. I hope she manages to keep on fighting.
My natural alarm clock woke me this morning, as usual, at 5.15: a bird warbling in a mango tree outside my room. That sounds idyllic, a far cry from the horrors that are still occurring regularly just a kilometre or so from our house/office here. As I sit writing this, on my day off (in spite of the emergency, we try to have a day off each week, to recoup our strength for the week ahead) the birds are still singing, but their sweet sound is interspersed by the rattle of gun-fire.
It’s surprising how quickly you get used to an abnormal situation. As well as the background of gunshots and shelling, I’m getting used to the strong military presence, with heavily armoured cars rolling down the main streets heading to the flash points. I was fairly alarmed, on leaving the hospital one afternoon, to find the perimeter wall surrounded by crouching soldiers, machine-guns at the ready. For a brief second I thought we were being attacked – but quickly realised they were protecting a journalist who was interviewing someone for television.
I’m also getting used to different classifications for the MSF statistics. Normally I’m filling in details of how many cases of malaria, respiratory tract infections, diarrhoeal diseases or malnourished children we’re treating; now I’m classifying the admissions to the emergency department by wounds from gun shot, grenade or “arme blanche” – the latter being any other type of weapon, mostly machetes.
I’ve been here two weeks now, as the nurse/medical focal point for the hospital MSF started running on behalf of the Ministry of Health when the recent conflict started here in December last year. Previously a primarily maternity hospital, we provided a team to deal with the emergency trauma cases as well as keeping the maternity department going. I’m just beginning to get to grips with everyone’s names: as well as about 25 expats, I’m struggling to recognise the huge team of national staff and acknowledge a smiling “Bon jour, Alison,” with the correct name in response!
My first day our departure to the hospital was delayed because of an “incident” in a largely Muslim neighbourhood bordering the hospital; when we arrived, there were several people in the emergency room being treated for shrapnel wounds. It seems a young boy had thrown a grenade – an accident? A child soldier? We will never know. And so it has continued most days, although this last week the number of admissions for conflict trauma has diminished dramatically. From dozens every day a few weeks ago, it’s down to a handful.
But even one can be a tragedy: the young man who came in unconscious, from a deep machete wound to his head, never recovered consciousness and died after a few days. With no specialist neurosurgeons here, there was nothing we could do to save him. So I was overjoyed when another young man, let’s call him Jean-Claude, also admitted unconscious following a head injury, recovered consciousness. But he was deeply disturbed and agitated, and made no verbal response. Day after day, he would stare at us but would not talk, drink or eat. “He’s been tortured,” his brother, who stayed close to his side, told us.
So what a joy to be met one morning by one of our psychologists: “He’s talking!” And soon he was ready to be discharged.
There are other joys amongst the tragedies. Belen, one of our expat doctors, came into the pharmacy where I was doing the boring but necessary task of counting stock. “Do you want to see a miracle?” she asked me. Of course I did. I looked down at the tiny bundle, the 800 grams baby, who had arrived prematurely. Tiny but alive. This conflict brings hardship to so many, but delivering a baby safely can be especially difficult. This little mite could now be referred to a specialist paediatric centre run by another section of MSF.
It’s good to have the miracles in the midst of the ongoing tragedy.
I’ve just come back from a bike ride. The sky is blue and cloudless, the green verges are splashed with the bright yellow of the first daffodils. Birds are singing, ponies graze happily in the fields. Spring is arriving, and all is tranquil in the peaceful countryside, where I ‘m lucky enough to live.
And my mind turns to where I will be in just four days. Bangui, capital of the Central African Republic, and scene for the last few months of the most horrendous acts of violence. I’ve seen the news reports, and the reports and videos on the MSF website, of sectarian brutality: Christian “anti-balaka” militia apparently taking revenge on their Muslim neighbours. I’ll be working in one of the hospitals, or maybe in a clinic in a makeshift camp in the airport for IDPs (internally displaced people) where Muslims are seeking shelter before they can flee the country; and I wonder what kind of dreadful wounds, the result of machete attacks or gunshots, I will be faced with. ………………It’s hard to imagine.
Meanwhile it’s on with the packing. My master packing list – yes, I’m totally anal, surely the delight of any MSF logistician – has lots of ticks and a few yellow highlights of things still to be bought. Thank goodness the undies dilemma is solved. Who would have thought what underwear to pack could involve so much deliberation? Everything will be on full view on the washing-line in a multi-cultural society. So no scanty lace Elle MacPherson numbers, nor do I want to own up to the sagging, greying cotton pants on the line. So that meant a special trip to M&S. Now it’s just a question of which of the shirts & trousers scattered across my bedroom floor I most want to wear for the next two months, to fit into my 23 kg weight allowance. Marmite, English Breakfast tea, my down baby pillow, a silk sleeping bag – they’re on the Essential list and are already packed.
When I came back from the Congo just before Christmas, I said I’d done my last mission. It was incredibly tough physically, and I thought that at my age – which is a secret, but I’ll admit to having my bus pass – I didn’t think I wanted to put myself through that again. But I always say going on mission is rather like having a baby: you forget what an ordeal it was and just go for it again! Getting a request to help in such an extreme situation, where the need is so great – it’s a challenge I can’t refuse. Tough it will be, probably tougher than anything I’ve done before; but we’ll be providing health care to a terrified and distraught population where otherwise there would be none. I’ll be working in a team of dedicated professionals, all of us giving 100% to one aim. And the feeling of fulfilment that comes from that is hard to beat.
Which is why I’ll be on the plane to Bangui in a few days. Next update will come from there. Far from this green and pleasant land, where, in the lottery of life, I had the good fortune to be born.