Dr. Richard Currie writes of his experience on an MSF Mission to the Central African Republic (CAR) from November 2009 to May 2010. The Central African Republic (CAR) is a landlocked country in central Africa bordered by Chad, Sudan, Cameroon, and the Democratic Republic of Congo and the Republic of Congo. It is known as one of the poorest countries in the world and among the ten poorest in Africa.
Dr. Currie has shared his blog of his experience working in an MSF hospital in Boguila, CAR. He currently practices as a family physician in Salmon Arm and completed the UBC Family Practice Enhanced Skills R3 program in Global Health in 2006.
CHAPITRE 1: POURQOI?
Why are we here??
I know why I am here. I come because the work is meaningful; because the people are so generous; because when it comes to “life” and “living” there is so much here to learn. I come because I love a good yam, because napping after lunch is the only civilized way to work, and because goats are more pleasant to listen to than a lawnmower.
But why is MSF here? Of all the run-down, snake infested gin joints in all of central Africa, why Boguila? Why does MSF run a hospital here, and not 200km in any other direction?
It is a surprisingly difficult question to answer, but perhaps one can start with the obvious: why not? The needs of this region are tremendous. I read somewhere that CAR is “the third poorest country in the world”, although I question the implication that absolute poverty of this scale can be ranked, or that human despair can be quantified. Are the conditions here more miserable than Darfur? Somalia? Afghanistan? Not for me to say, although certainly CAR can make a case for itself. The life expectancy here is in the low 40’s, infant mortality greater than 100 out of every 1000, and there is no prevailing sentiment that things are getting better. There are no rallies, no imbedded journalists on assignment, no t-shirts for “Save CAR”. The people here assume that nobody cares, and frankly it’s a hard opinion to contradict.
Boguila is a town in the middle of the bush. And here I mean “bush” in the central African sense of the word: massive sprawling trees growing rogue all throughout town, but not quite disorderly enough to give the appearance of jungle; open spaces of thick tall grass that can’t quite organize itself into a savannah; wild dense undergrowth that can’t be tamed by any human effort and yet chooses – apparently of its own free will — to restrain itself just on the verge of self-suffocation. Boguila is a town that is constantly being cut, burned, carved, and heroically reclaimed from the surrounding bush. The integrity of every footpath is under constant attack, and brazen vegetation challenges every frontier. Yet, at the same time, if you stood in the middle of the village you would have the distinct sense that Boguila has been here forever. You feel, at almost every turn, that someone else has walked these paths for thousands of years.
Surrounding this town of 10 000 people is a dizzying network of trails — including a few lonely dirt roads – connecting Boguila to a hundred other smaller villages in every direction. Each of these other settlements lies hidden in the bush. Human activity here occurs just below the surface of awareness: here a mud and grass tukul peeks from behind a thicket of trees, there a deserted government health outpost lies dilapidated at the end of an unassuming footpath, over here the sounds of children laughing… but from where or why? We cannot know. The people here live hidden lives. They do so not by design or by choice, but by necessity. In a world of war, of violence, of conflict, it is safest not to be noticed.
Boguila proper is controlled by government forces. You will see them at the official checkpoint downtown, at the market, and at the roadblocks along the way. Smile and wave. Most of the region outside of Boguila is controlled by an organized rebel group. You will see them at their own official checkpoints, at their own markets, and at their own roadblocks. Smile and wave. There is currently a peace agreement between the most important of the warring groups, and relative harmony pervades. But, if one is to listen to the locals, those who have been through this again and again and again: in CAR, peace doesn’t last. Don’t let your guard down. Never let your guard down. Now add to this precarious mix the phenomenon of “coupeurs de route”: bandits from anywhere but here – perhaps Chad, perhaps not – who exploit the lack of a cohesive regional authority to exact misery on the lives of the locals through banditry, pillaging, petty robbery, violent crime. There is nothing to be done to insulate oneself from the violence except to fade into the bush, to disappear. Don’t build a school, don’t dig a well, don’t plant a field… it attracts attention and attention is never good. Live on the fringes and, despite overwhelming forces to the contrary, continue to exist.
It is in this context that MSF runs a hospital in Boguila. Unlike my experience in Ethiopia this is a hospital in a distinctly western, overtly identifiable sense of the word. The compound was built many years ago by missionaries and, as typical of missionaries, it would appear that they had every intention to stay. There is a palpable sense of permanence to the compound not typical of MSF: a large hospital with wards and multiple rooms, houses for the staff built of brick, a fresh outdoor shower stall nestled under a mango tree. The missionaries themselves eventually left due to the violence and insecurity, but their impact is still apparent (and appreciated) today. Amongst the locals one finds several individuals with no formal educational credentials but with impressive on-the-job medical training: consider Elysee our local MSF “surgeon-nurse”, who is neither a surgeon nor a nurse but does both quite well so stop asking so many questions thank you very much. Or the unfortunate Darius, our long-suffering expat cook, who is blessed (and cursed) with having acquired the specialized expertise necessary to bake American-style cinnamon buns smack in the middle of central African bush.
We will go on a tour of the hospital later – it is worth an email all on its own – but suffice it to say that there are plenty of reasons for MSF to be here. The story of Boguila is written in each and every room of the hospital, where young men with cerebral malaria languish beside babies with tetanus, who struggle fitfully beside men and women who were shot and robbed or hacked with a machete while unassumingly traveling from one village to another. Here the unyielding nature of the African environment confronts a seemingly unlimited capacity for human aggression. Only those fortunate enough to live unnoticed along the fringes of existence – far enough from human civilization to avoid calamity and yet sheltered enough from the African bush – have a chance to make it through to the next day.
Maybe the best answer to the question “Why is MSF in Boguila?” is, simply put, because right now no one else is here.
CHAPITRE DEUX: IS MY FRENCH GETTING GOODA?
Je veux vous presenter l’incomparable Dr. Yoogooda : professor, theologian, dignitary, and French teacher extraordinaire. Every Monday and Friday afternoon I have one-on-one French class with the good professor, and it is always an event to behold. Dr. Yoogooda was born in Boguila many moons ago, and was raised in Sango, the local language. In childhood his family fled CAR for Cameroon where the little Yoogooda studied French, and later, as the sole survivor of a family of 10, made his way to the USA where he picked up English while attending university in, why not, Indiana. Still with me? In Indiana he became Professor Yoogooda after completing a PhD in theology, then returned to CAR, raised 8 kids of his own and, five years ago, “retired” by moving back to, why not, Boguila. Upon return he immediately took up his rightful place among Boguila’s intellectual elite, as befits his status as Boguila’s sole retired professor from Indiana. Now he teaches me French.
Apparently it is not all that uncommon that a maudite anglais arrives in the project fresh from a 4 week crash course in France, and immediately sets to work bedazzling the local health care team with broken phrases of franglais and misguided clinical lessons on “mango-mouth”. Accordingly, MSF keeps Dr. Yoogooda on the payroll for just these kinds of linguistic emergencies, and he is always ready to snap into action. He also, for good measure, keeps his skills sharp by teaching English to interested MSF local staff, and Sango to French speaking expats. The man is a professional.
My first meeting with Dr. Yoogooda immediately set the tone. If I were to use one word to describe him, I would repeat: professional. A small wiry individual with a look of ageless wisdom, he immediately sat me down under a mango tree and set to work with a flip pad and pencil.
“Ton nom?”
“Richard”
“Bon” (making a careful not on the pad).
From here things progressed quickly, his French picking up speed with each question. Where did I learn French? Can I read a French newspaper? Am I better at speaking French or reading French? Can I understand an African French accent? Do I need to improve my vocabulary or my pronunciation? The questions came so fast and furious that I started to slip up: “my pronunciation!” I stammered, “no! wait, my vocabulary” (a crisp crossing of lines on the notepad) “no, pronunciation!” (furious scribbling), finally “tous les deux!”.
At this point he gripped the pencil tightly and looked at me long and hard over the top of his glasses. “Vocabulaire?” I offered weakly, and he set the notepad on his lap. He studied his list in silence, suddenly seemed quite pleased with the day’s events, and said, with finality, “Bon, nous pouvons continuer vendredi”. He stood up abruptly, gave me a warm but formal handshake, and instantly disappeared behind the mango tree. It was all so efficient and professional that I hardly had time to wonder: hey, don’t we pay him for an hour?
The following Friday he arrived sharply on time (an oddity in Boguila), opened up a different notepad and commenced right away with a variety of drills. The notebook, as far as I can tell, is a French language textbook that he has copied entirely by hand. This he supplements with an assortment of decidedly random grammar leaflets, some of which may have been photocopied on Guttenberg’s original printing press. He writes notes like a madman, provides stern but frequent praise, and refuses all offers of food or drink. The man, as I’ve said, is a professional.
There are however a few oddities in learning French from a Centrafricaine Sango-speaking theology professor from Indiana. While he is thoroughly fluent in all three languages, occasionally he forgets which is which. One day – while reciting an intriguing photocopied story of a young girl from Yemen with cholera who vomits her way across the ocean and then is cured by a witchdoctor – I asked Dr. Yoogooda if he could explain to me the word “malgre”. “Ahhhh,” he said thoughtfully, pushing his glasses back up his nose and leaning back reflexively, “In English, it is the same as ‘bien que’”.
“Bien… que??”
“Yes. The English would say: ‘bien que’”.
Hmmm. I happen to know a little English myself, and I’m pretty sure that we wouldn’t say “bien que”. But his tolerance for insubordination is fickle, and his ability to disappear behind a mango tree when threatened is most astounding, and I thought better of continuing my line of questioning.
That night at dinner I asked my fellow expats casually: “bien que I’ve already had more than my fair share of fruit salad, would anyone mind if I took another helping?”. Nobody seemed to mind. Apparently I am not the only graduate of the Dr. Yoogooda school of language.
When he is not otherwise preoccupied with my French recitation of stories of vomiting children, he keeps himself busy in downtown Boguila working as an official functionary and presiding over ceremonial events. Tuesday December 1st was Independence Day in CAR, the biggest national holiday of the year. It is an event worthy of the finest parade, and by Friday of that week by God if Boguila wasn’t almost organized enough to pull one off. It was, you might imagine, a bit of a surprise to be formally invited to an Independence Day parade three days after Independence Day, but the mayor sent word on Thursday night that MSF was invited to attend and our reluctant delegate – a Canadian mental health officer – found herself sitting in a place of honour in the front row beside none other than Dr. Yoogooda himself, patron saint of unnecessarily formal occasions. I received this story second hand, but I gather that the mayor – bedecked in a formal mayoral sash – first numbed the crowd into submission with a lengthy oratory under Dr. Yoogooda’s approving eye, and then the eagerly anticipated main event was triggered. The parade, I understand, was started with as much fanfare and formality that a ragtag group of school children could muster, but then was veered tragically off course by a renegade group of motorcycle tricksters who wowed the crowd with an impressive display of unconventional stunts. Somebody started drumming, the crowd spilled out over the street in an untamed frenzy of color and dance, and the mayor somberly straightened his sash and concluded the event unnoticed with what remained of his fragile dignity. Michelle, our MSF representative, described the finale enthusiastically as a “beautiful display of African rhythm and energy”… but I suspected that Dr. Yoogooda might not feel the same.
The start of my Friday afternoon lesson couldn’t come soon enough. “How was the parade this morning?” I asked in greeting, trying my best to seem nonchalant. Dr. Yoogooda pushed his glasses back thoughtfully, looked at me sternly, and replied: “un désastre”. Then he opened his notebook and launched immediately into a lesson.
The man, as I said, is a true professional.
CHAPITRE TROIS: THINGS THAT GO ‘PING’ (OR FLAP) IN THE NIGHT
I finally got my chance to take advantage of “The Bloc”, our operating theatre here in Boguila.
I’m new to the idea of surgery in Africa – we didn’t have such a program in Abdurafi – and generally speaking I’m thoroughly bedazzled by operating rooms in general. So it was with some trepidation that I “took charge” of the Boguila surgical team upon my arrival in November. Basically I handled my duties by tip-toeing around the operating theatre by day, and peeking curiously through open windows at night. We have one very capable surgeon-nurse here, and a national staff doctor that is willing to try just about anything, and in general things work so well that I limited my participation to popping my head in during the occasional emergency surgery and nodding my head vigorously. Sometimes I’d slip on a pair of the sterile plastic flip-flops and venture in a little closer, standing arms akimbo from a safe distance and nodding approvingly as our surgeon proudly showed me a bullet, or a baby, or whatever else he happened to be removing at the time. Usually this would be accompanied by an animated conversation in French – of which I understand zero when it echoes from behind a surgical mask – and then I would stare with a flourish at the silent VHF radio on my hip and suddenly scamper away as if I had just been called somewhere urgently. Every week I would look at my to-do list and think, “I really should spend some time this week with the surgery team”, but then of course we’d have a biblical plague of cockroaches, or a latrine would collapse, and once again I’d be tip-toeing around the operating room on my way to other adventures.
Then last week I was happily going about my business on night-call and the inevitable happened: a surgical emergency during my shift. Not a raise-your-hands-in-the-air-and-run-around-in-circles kind of emergency, but a 2 year old with an incarcerated hernia who would need surgery before the night was through. Perfect, a 2 year old.
By terrific good fortune, just as I stepped outside of the consultation room I immediately bumped into Pierre, our surgeon-nurse, who was slinking around the hospital that evening looking for free coffee. I can’t begin to express how fortunate this was, because of course we don’t have pagers or cell phones or even land lines here, and there aren’t enough VHF radios around to give one to the surgeon each night just in case of the rare emergency. Plus, we don’t pay him to be on call. The man needs a union.
Pierre is one of those elderly wonders of Africa who has lived a life of chaos and tragedy and yet somehow manages to radiate contagious tranquility. He is, I believe, a certified pastor, and he was trained to do surgery by the missionaries who worked here before us. He also has something in the order of 25 children, which makes the tranquility part all that much more incredible. Finally, he is a man of very few words, and he examined the child and confirmed the need for surgery in about 30 seconds, before heading off again on the more important task of searching for coffee.
Next we needed the generator to be turned on – that part was surprisingly easy – and finally we needed “a team”: an anesthetist to put the child asleep, and a surgical assistant. Unfortunately for me our national staff doctor was away in the capital that week for a death in the family, and so the easiest option was already eliminated. Pierre – unflustered as usual – quietly gave me the names of the two nurses that he wanted for the team and, that being settled efficiently, the only trick now was to find them.
Theoretical options for assembling a surgical team in Boguila at night include:
1. standing on the porch of the hospital and blowing a conch, or perhaps cupping my hands to my mouth and bellowing: “Surgical Team, UNITE!”
2. illuminating the night sky with a giant scalpel symbol
3. dispatching a guard or hospital cleaner to go into the village and search.
I chose the latter option, although in order to “dispatch” a guard or cleaner at night one first has to search for a person in a guard outfit sitting in a tipped-back chair by a fence, or find the silhouette of a cleaner leaning over a broom in the hallway. Then, regrettably, one has to wake them up. This is rude, unwelcome business in any culture, and all the more difficult in Africa where not only do you have to wake the person, but then you must also give them time to orient themselves, greet them formally, inquire as to the wellbeing of their family and then, at this point, if you still remember the original purpose of the encounter, kick them in the ass and tell them to get back to work. Eventually the cleaner shuffled into the darkness and drumming and barking of the African night, in search of our two nurses.
They weren’t at home.
At this point I was gripped with purposeful madness: it was time to shed my reputation as the useless Canadian physician. After all, I’ve done 4 weeks of anesthesia as a resident, I work with some of these same medications in emerg at home, and, as pediatricians always say, “a child is just a small adult”. Or is it, “a child is NOT just a small adult”? No time for details: I grabbed Pierre by the shoulder, looked him square in the eye and said, “get ready for surgery Pierre — I can anesthetize this child or be your assistant”. Actually I was a little wrapped up in the moment, because I think I said “AND be your assistant”. Regardless, he responded with a partially cocked eyebrow over the rim of his coffee mug, and I burst into the operating room and started to get busy.
How, in the name of all things holy, had I not previously noticed how EMPTY our operating room is?? I don’t expect to find a heart-lung bypass machine, but I would like to open the cabinets and drawers and find SOMETHING. Something other than emptiness, and the occasional tiny beetle scurrying away from the light. Finally the night nurse walked in with a taped up cardboard box labelled “hernia kit”, and on top of the surgical equipment inside I was delighted to find a bottle of ketamine and an IV set. That was a start. But wait, don’t leave yet! I need so much more!!
I immediately set to work building something that might resemble a Canadian operating room. Orders started flying: “the oxygen machine!… grab that pediatric ambu-bag from maternity… do we have a laryngoscope? Yes? Yes, get that too…”. Slowly but surely dusty equipment was mobilized from around the hospital and cobwebs blown off. I was starting to feel a little more comfortable and stood back to take inventory with some satisfaction. But wait! Where’s the machine that goes ‘ping’?!?! I need at least two machines making ‘pinging’ noises to be truly happy, and here I was without even one. I grabbed the handheld pulse oximeter, checked the batteries, cranked the volume, and… yes… yes… there you have it… a “ping”! Good to go.
At this exact moment Marcus, one of our nurse-anesthetists, walked sleepy-eyed into the operating room. “Somebody downtown said you were looking for me?”. He offered his services as anesthetist, changed into scrubs, and wandered lazily back into the operating room where I was standing in a barely controlled frenzy of excitement and our surgeon, at this point, was fidgeting in his seat thoroughly over-caffeinated. If Marcus processed the cornucopia of unusual equipment and pinging machines now scattered willy-nilly all around the operating room, it wasn’t evident in his facial expression. He walked over to the hernia kit, pushed my medical clutter aside with an absent minded sweep of the arm, and quietly filled a syringe with ketamine. Then he walked out of the OR and over to the little porch where the mother and child were waiting, and, a second later, I heard the quiet yelp of a 2 year old child: “Arghh!”. Marcus walked back into the operating room, whistling.
I was dumbfounded. “What the… but… how could… did you just do what I think you did?”. Yes, he did. He had walked outside and completely anesthetized the child with a single shot in the bum, ON THE PORCH, with nary an oxygen machine, IV, or machine that goes ‘ping’ in sight. He explained to me how it was “less scary” for the child that way and then, with the look of one who might have left the oven on, he suddenly rushed back out to the porch. There he scooped up the child – now rigid as a board with eyes open blankly and mouth agape – and carried him into the operating room and laid him on the table.
What came next, you ask? The oxygen mask? The IV? The machine that goes ‘ping’? No, those all came eventually… but first there was the important business of tying the child to the operating table. No use of intubation here means no use of paralyzing agents, which means, unfortunately, that the patients – still very much asleep – tend to twitch or jerk or maybe give a half-hearted kick or lazy punch if given half the chance. And so the child – rigid as a board with eyes open blankly and mouth agape – was tied firmly to the operating table. Now, as Marcus said, “Nous sommes prêt”.
The surgery itself was a breezy success. Pierre abandoned French for elaborate hand gestures that I could easily understand, I managed not to cut myself, and, after about 20 minutes of surgery, Marcus eventually discovered the pulse oximeter and I was calmed considerably by the reassuring ‘ping’.
We changed out of our scrubs, congratulated each other on our success, took a few deep breaths of the refreshingly cool night air, and then I walked home, turned on the solar-powered light in the living room, and was immediately knocked to the ground by a dive-bombing bat.
Yes, a bloody bat.
To be fair, the bat didn’t actually knock me to the ground. I think it got as close as buzzing my hair, and then I finished the job by instinctively dropping to the ground and curling into a fetal position. Probably this is entirely maladaptive, but in my defense, it’s impossible to predict how one will respond to a bat attack until it actually happens. I, it would seem, respond by turtling. I had successfully pulled at least half of my head through the collar of my shirt but was struggling feebly with my arms, flustered no doubt by the fact that I was wearing a short-sleeve t-shirt. Then I lay quietly on the ground listening to the bat flap frantically all about the room, and came up with my second, equally brilliant and maladaptive survival strategy. I turned off the light.
The thinking, I suppose, goes something like this: the bat was irritated by the light, so the light should be turned off. The bat will go to sleep, and then I will go to sleep. The perfect solution.
Bats, you might already be well aware, have limited visual skills. “Blind as a bat,” I believe is how the expression goes. By turning off the light I had managed to eliminate my one and only God-given natural advantage. Nobody can say Rich Currie doesn’t fight fair.
I won’t go into all the hoary details of the ensuing 10 minutes, but let’s just say that the bat did NOT go to sleep when I turned off the light (surprise), and continued his casual on-again off-again love affair with my hair. Eventually I made it into my bedroom using a deft combination of turtling, and commando rolls, and half-turtled commando rolls. There I settled myself, brushed the dirt off my clothes, and… hallelujah… finally prepared myself for bed. Thirsty from battle I reached for the water bottle on the bedstand and, horror of all horrors, it was empty. Needless to say there is no plumbing inside the house. There is, however, a large container of filtered drinking water available… in the living room.
Commando roll, turtle, half-turtle commando roll, drink, repeat.
This is why I don’t like night call.
CHAPITRE QUATRE: A HOSPITAL TOUR
It’s time to take you on a tour of the hospital. Hospital tours are popular here – St. Boguila General (as I call it) might just be Central Africa’s biggest tourist attraction. In my two months here we’ve had visits from local dignitaries, bosses from MSF head offices in Europe, the French NGO Action Contre La Faim, the UN World Food Program, and even a German Ambassador. At least I think he was the German Ambassador, although in the end he might have been the Ambassador’s Assistant. I didn’t get a chance to speak with him directly as the day of his tour just happened to coincide perfectly with the cockroach plague, the discovery of the lice infestation, and of course the spectacularly collapsing latrine. For all those reasons and more I was excused from touring duties and instead left in charge of running diversion that day, storming past the tour group with a stethoscope around my neck at random times, looking frantic and yelling “snake bite!” while doing jazz hands and whatever else I could think of to distract attention. My colleagues then used these opportunities to discretely brush a cockroach off the Ambassador’s back, or guide him around the remains of a collapsing latrine. With hundreds of thousands of Euros of funding at stake, it is best not to skimp on the razzle dazzle. By the time that the German Ambassador peered in on our therapeutic feeding program he saw not a roomful of scratching, lice-infested children, but instead a gleaming collection of newly shaved heads. In the end, I think the tour was a success.
Rest assured as we begin this tour today that the cockroaches were eventually beaten back, the lice problem is well in hand, and, most happily of all, a new non-collapsing latrine has been built. This new latrine, like every structure in Boguila, was entirely built by hand and represents a verifiable marvel of human engineering. During the week of The Big Dig one could easily have been fooled by the perfect stillness of the construction workers sitting around the edge of the hole all day, and wondered when anything would ever be accomplished. Then one evening I had a look down the unguarded hole with my flashlight — more or less curious to see if any of our patients had tumbled within — and was startled to discover that I couldn’t SEE the bottom. Ladies and gentlemen, I have a very strong flashlight. Apparently the workers in a state of hibernation on the surface are merely awaiting the next shift, when they will be lowered to the very core of the earth to continue the awesome task of hand-shovelling molten magma up to the surface. I was told by our logistician that the hole only needs to be 20 feet deep, but perhaps we should have explained it to the workers using the metric system, or perhaps once you get a good dig on it’s hard not to get carried away, because yesterday I dropped a pebble in the hole and the sound of it landing has yet to travel back to the surface. Watch your step.
Let’s begin the tour with the main compound, the fenced off area that includes the heart and soul of the hospital – the inpatient department – as well as the surgical block, the maternity ward, the generator house, the pharmacy, and the storage depots. All of these departments are separate buildings made of red brick with corrugated tin roofing, loosely connected by concrete walkways and or open spaces of packed dirt, laid out in random fashion and without a hint of a sign anywhere to tell you which might be which. Immediately to the west of this compound is a separate fenced area that includes the TB consultation room, the TB patient wards, the HIV dortoir, mental health, and the labarotory, all again cleverly unsigned. Just in front of the main hospital compound, facing it, is a fenced off area that includes the office, and around the corner from that is an unfenced building used for prenatal visits or vaccination campaigns, depending on the day. If from there you look past the giant mango tree back towards to the main hospital, you will see another building yet again with three consultation rooms and a large waiting area which serves as the outpatient department. Confused yet? I sure was. It certainly doesn’t help that the open spaces between all these compounds and buildings are communal village space, used without design or discretion as footpaths, soccer fields, cattle pastures, and/or motorcycle super-highways, depending on need and circumstance. This is perhaps the only hospital in the world where a doctor needs to pace himself when walking from the outpatient department to the maternity ward, or risk physical exhaustion by sunstroke, or possibly death by trampling at the whim of a marauding bull.
To get into the IPD (inpatient department), first we have to get past the guard at the gate. It is one of the great mysteries of Boguila that during the day, when the patients languish in the heat and no one is out and about and the security risk is at its lowest, the guard is always hyper-vigilant.
Leaping out of his chair to open the gate with a flourish, or directing the flow of women carrying firewood on their head like a London street cop, he is the very picture of alertness and attention. At night, when the cool air allows for freer movement and with bandits and hooligans theoretically behind every tree, the guard flops out in the chair as if he was custom built for relaxation, in a fragile state of near-perfect transcendental meditation. At those times it is best just to open the gate by yourself, quietly, and to close it gently so as not to startle him.
What you see next depends entirely on the time of day. During mid morning or early afternoon, you might see nothing at all – just an eerily quiet building with a few people sitting still where one might otherwise expect the hustle and bustle of a large acute-care hospital. The building is laid out roughly like a giant V, with two “wings” of rooms forming a structure resembling a highway motel, each room opening directly onto a concrete porch/corridor protected by a roof, but open to the great outdoors. Each of the 12 rooms, all unique sizes, has between 4 and 10 simple beds crammed within, every one carefully adorned with a mosquito net. Do not be fooled however into thinking that there are only 4 to 10 people living aside, in accordance with the number of beds, as this is an African hospital and African hospitals are… shall we say, “family friendly”. Indeed, not only are visitors not restricted, as they would be at home, but they are practically required… for who else would feed the patient, and wash the patient, and help them to take their medications? Certainly not the nurse. There are only 1 or 2 nurses on at any time, and they are extremely busy, and this is definitely a BYON (Bring Your Own Nurse) party. So each patient has what is formally called a “garde malade”, a family member / caretaker who, in acknowledgement of their service, also gets a ration of food each day at the hospital. There is even a large sheltered cooking area just for the garde malades to prepare the food (bring your own fire, and bring your own wood), and non-collapsing latrines enough for all. At night the garde malade climbs into bed with the patient if space permits, or sleeps unnoticed on the floor under the bed until such time as their services are further required.
All this is to say that I never have the faintest idea how many people are living in the hospital at any given time, nor which of those might actually be patients. I do clinical rounds completely at the mercy of our national staff nurses, who guide me like a blind man around the room pointing out patients and shoving charts in my hand as we go. Occasionally I’ll bend over and carefully examine the wrong baby, or engage in conversation with a garde malade about the stomach pain that they don’t have, and out of politeness nobody ever tries to stop me until I’m good and finished.
At night however the hospital looks very different. Under the ghostly dim glow of sparse LED lighting, the open spaces around the IPD are a beehive of chaos and activity. As the sun slowly sets patients emerge from their rooms and lay claim to the open spaces, sprawling on mats with their families and friends and children and enjoying a communal meal, or simply taking in the sites and sounds of the social scene at Boguila General. The sickest ones are propped up against walls or trees, the healthier ones prepare the food and chase the children.
When I first arrived in Boguila I was spared doing night call, spending my first week frantically trying to learn my way around the hospital by daylight. I will never forget the first time that I saw the hospital after sundown, and was suddenly struck by the chaotic majesty of the courtyard in front of the IPD at night. It was my first Sunday in Boguila, I had not yet started call, and I was about to sit down to something resembling a dinner when the radio crackled and I was called urgently to the hospital by the voice of our project coordinator. Our project coordinator — the “PC” or big boss – is non-medical, and so as I wondered aloud what he might be doing in the hospital at night my mind was already racing with thoughts of disaster. In this context, I was not at all pleased to approach the hospital to the unusual sight of a large empty cargo truck parked right in front: the kind of cargo truck that is all too frequently used in Africa as public transport, usually with a hundred paying customers crammed in the cargo hold and squished between manioc and goats. A truck like that has no reason to stop in Boguila, and it certainly shouldn’t be in front of the hospital gate. The first thing that I registered was the large bullet hole on the driver’s side of the windshield; the second thing was the boisterous sea of humanity sprawled out in the courtyard. Obviously I did not know at this point that the courtyard is ALWAYS a boisterous sea of sprawling humanity at night, and so my mind leapt immediately to a mass casualty situation. A truck full of people has been attacked, we have a hundred shooting victims, we need to triage. Right – I’ve never done this before but I’ve read about it and I’ve seen it in movies. I charged through the crowd to the “salle d’urgence” making a list in my head as I went: people in respiratory distress will be seen first; bleeders will get simple compression and then more attention later; anyone laying face down is presumed dead or close enough to it; those people over there making tea will be… what?! Why are people making tea in the middle of a mass casualty situation???
By the time I reached the salle d’urgence it became apparent that the situation was far less dramatic than I had imagined, although sadly, no less grim. The cargo truck had indeed been carrying cargo, and although I didn’t realize it at the time it was MSF cargo no less. The team of private contractors we had hired for the job had been attacked and robbed about 6 hours out of town. One man was shot in the leg, not very bad, with reports of another shot in the chest who crawled away through the bush in a different direction. The latter victim eventually made it back to Boguila two days later, on the back of a motorbike, and was taken straight to the operating room. The bullet was removed, the damage assessed and repaired, and we felt good about the outcome. Then he died later that night from infection. Wrong place, wrong time, terrible outcome. Could that be said for everyone in Central Africa? Welcome to Boguila.
There are other stories that haunt this hospital, and even after 8 short weeks I have too many ghosts of my own. The woman with the giant cancer on her face that we couldn’t do anything about; the boy that died of malaria because his entire family of potential (and willing) blood donors had infectious hepatitis; the baby that died of TB on New Year’s Eve. There are also a lot of successes however, and that’s what we prefer to focus on.
Maybe we can finish in the IPD by walking past room 7 to meet three year old Pierre, his parents, and his three sisters in order of age: Beatrice, Angeline and… wait for it… his other sister Angeline (seriously). Pierre and his family come from Maitikoulu, a village several hours north and on the border with Chad, where MSF runs a smaller project focused on African sleeping sickness. He and his three siblings all have TB and were transferred to our project for treatment. They are not infectious and we prefer to keep them in the IPD, where the entire family shares two beds, rather than the TB ward where the parents might get sick as well. They don’t speak French, or the local language of Sango, but with a smile and a hand gesture they manage to get by. When I first arrived Pierre was the sickest of the bunch, and his huge bloated belly caused him a lot of pain.
I would be called in to see him at night when he spiked his high fevers, and he would be lying on his back in the darkness suffering under the pain of his giant belly. He never spoke or cried — still doesn’t actually — but would just hold his arms straight out in front of him hoping to be picked up, even though changing position only seemed to make the pain worse. TB is a slow disease to progress, and a slower disease to get better. Weeks of near constant fever went by seemingly without progress and then, on Christmas Day, he was handed a balloon and – voila — he gave us his first smile. Two days later he was smiling almost as often as his three gregarious, holy-terror sisters, and by the end of the week he was willing to formally shake hands on rounds. Yesterday, for the first time, he was wearing pants. Not just any raggedy set of hole-in-the-bum Central African pants mind you, but a snappy set of black and white striped dress pants with tiny, decidedly stylish looking suspenders. The man is finally ready to go out in the world, and if he could just find a shirt to match, he will be the bee’s knees amongst his peers back in Maitikoulu. We’re going to be sad to see him leave next week.
Alright, it’s been a long tour already and maybe we should save the other compounds for another day. The eery world of infectious TB and the masked men who work there, the chaos and nervous excitement of maternity, the circus parade of weird and wonderful that is the outpatient department – we’ll save that all for another day. If you were a German Ambassador, or otherwise inclined to give a half a million Euros, you might get a little more razzle dazzle but for now, I just want to finish by explaining my favourite trick.
If it’s a mystery how many patients are living in the hospital at any given time, it’s an even bigger wonder to figure out where they all disappear to during the daytime. It’s magical really. Over 100 patients in total, PLUS their garde malades, PLUS their extra family and yet, on a tour in the middle of the day, you could be forgiven for thinking that the hospital is temporarily closed to the public. Only the sickest of the sick remain languishing in their bed, the rest are nowhere to be found. A few, to be sure, can be found lying on mats in the courtyard, and a few others will be cooking with their family in the fire shelter or perhaps washing up behind the latrines. Some hang out on the benches in front of the lab and still others like to sit by the OPD and ogle the great tangled masses of walking wounded waiting to be seen. But where on Earth are the others? There is one sure-fire way to find out: put a stethoscope around your neck, and walk into a patient room. Any room, it doesn’t matter which. Within seconds, a previously empty room will suddenly be filled to near-bursting with attentive patients sitting sharply on the beds and waiting to be seen. It literally takes just seconds – blink and you’ll miss it. When a doctor or nurse enters a room it means only one thing – there is free health care to be had. Perhaps they will hand out pills, or ask a question, or scribble in a chart. Perhaps they will weigh a baby, or inject a medication. Whatever is about to happen, don’t miss the show!
This trick is most spectacular when you walk into the pediatrics ward, because the patients there are by far the keenest for attention and it is a tremendous spectacle to watch The Great Migration of Eager Mothers leaping up from the ground or appearing from behind trees and running – yes, full stop running – across the courtyard with 3 or 4 children dangling precariously from each arm and a wash basin of food balanced on their head. There is a bit of a bump-and-shove bottle-neck at the door but usually everyone still ends up on a bed within 5 seconds or less — waiting breathlessly to be seen — albeit not necessarily in the right bed or holding the right set of children. Within seconds of leaving… the room will be empty again.
Step in: full. Step out: empty. I could do this all day.
CHAPITRE CINQ: SNAPSHOTS OF BOGUILA, PART ONE
SNAPSHOT 1 – The Pediatric Nose Trumpet
On Friday last week a 4 year old girl came to the hospital with a rock stuck up her nose. WAY up her nose. It is a universal truth that children all over the world, of every race and culture, are constantly scheming ways to perplex overworked emergency room physicians by sticking inanimate objects into their orifices. The children of Boguila are no exception.
Taking inventory of the blank walls and empty shelves of our “salle d’urgence”, I wasn’t confident that I would be able to find any of the variously shaped instruments I would usually use to go fishing for nose-pebbles. So I described what I thought I might need to Daniel, our Centrafricaine head nurse, and asked for his help in finding them. He looked at me sceptically. He wasn’t sure we could find what I was looking for but, if I was taking suggestions, he did have an idea of his own. Why don’t we just BLOW the pebble out?
Pause.
“Please continue”, I said, my interest now peaked. The idea was exactly what you might imagine: just give him a large 60 mL feeding syringe filled with air, and he would point it into the other nostril, clamp the mouth shut, and blow the pebble out from the other side. Why not?
Pause.
Because it can’t possibly work, that’s why not!! I was about to tell him so when…at the same time… I reminded myself that African doctors and nurses are constantly amazing me with things that I previously believed impossible. Why not give him a chance? Plus, as a general rule, I never let appropriate clinical care interfere with my own potential amusement. I eagerly ran off to get the syringe.
Readers with a medical background can skip ahead to the next paragraph, but for the rest, I am obliged to explain what happened next. Daniel lowered his thick black-rimmed glasses further down his nose, aimed the syringe with careful precision, pushed a puff of air with dramatic gusto and then, excitedly, looked into the other side and confirmed that… no, the pebble had not moved. The four year old however seemed decidedly satisfied with the attempt.
At this point in the effort I have already abandoned Daniel and am in the corner opening up one of our giant sterile instrument kits from the operating room, rooting past saws and blades and everything else needed for a limb amputation and looking for something appropriate to stick up a nose. Daniel, in the meantime, has hatched another brilliant plan: he will SUCK it out.
I heard the sound first, before I saw the action. He had draped a thin piece of sterile gauze over her nose, closed her mouth gently with one hand, and then formed a firm seal with his own mouth covering her entire nose. Then he sucked. He sucked so hard and so long that his face was bursting, his very body trembling, and in so doing he created a noise the likes of which this world has never known. It was a long, sorrowful, trumpeting sound… and while it may not have succeeded in moving the pebble even one inch I do believe that his sweet bellowing siren call moved every whale around the world to tears.
Camera, click: the pediatric nose trumpet.
SNAPSHOT 2: POVERTY
One of our nurse-consultants called me to the outpatient department to review a potential hospital admission. A thirteen year old boy, with a chronically draining wound on his outer thigh, who could no longer walk on his leg. He had been brought to the hospital by his older brother, age 16, who was shoeless and also dressed, like the boy, in tattered rags.
The brother bent down to carry the boy over to the examining table, and when he lifted him up out of the chair the boy’s shorts fell down. Too big. His brother lifted the shorts back up – as he had clearly done many times before – and placed him gently on the table. The boy’s legs were two thin sticks of bone, with giant knobs for knees, and the small draining wound on his thigh was chronic. A skin infection that had progressed over weeks, maybe months to osteomyelitis? TB of the bone? Whatever it was, it was not new. I learned that he had been too weak to walk for 6 months, and I asked our nurse in French why they hadn’t come to the hospital sooner.
I was upset: the odds are always stacked against us, right from the beginning. Why do people wait so long to come??? I asked the question with a brisk sharpness. Too sharp. I don’t think that the brother understood the French, but he did recognize my tone. He looked at the ground, embarrassed. He was looking after the both of them by himself, as best as he could, but he was clearly failing. He didn’t need me to remind him of that.
The nurse explained that they came from a village far away. “Forty, fifty kilometres,” she said with a casual wave of her hand. There would be a lot of military checkpoints, a lot of obstacles, in between.
The brother scooped up the boy and slung him over his back and then marched, bent over, to the inpatient ward to find his assigned bed. It looked like hard work… but then, what’s another 100 meters after 50 kilometres?
Camera, click: poverty.
SNAPSHOT THREE: JUST SMART ENOUGH TO BE DUMB
The animals, birds and insects of Central Africa are amazing, and would take several chapters to describe. From amongst the weird and wonderful hodge-podge of feathers and legs that is the Boguila Animal Kingdom, let me choose but one: the dastardly corbeau. Corbeau is the French word for raven, and these birds do indeed look like the big black ravens we have at home – yet even bigger, stronger, and with bright white “cravats” around their neck and chest. They are also louder, if you can believe it.
We have two corbeaus that share our living space at the expat house. They are a couple, and do everything together. And the “everything” that they do includes squawking at 4am, dive bombing people in the outdoor shower, stealing soap, and giving us dirty looks that dare us – from the safety of a mango tree – to do something about it. This is not your grandmother’s budgie, let me tell you.
It got so bad just before Christmas that our logistician – bleary-eyed from another 4am wake-up call — did the otherwise unthinkable and hired a young man from the village to come into our yard and “take care of business”. I wasn’t informed in advance, and met the assassin quite by accident after work one day on my way to the shower. I’m terrible with names, but it’s very rude to pass someone here without a friendly greeting, and so I was doing my usual walk to the shower waving at friendly strangers like the pope on parade: hello guard who wears the rubber boots all the time… hello cleaner whose name I’m too embarrassed to ask anymore… hello strange man in rags sitting under the tree.
Wait a second.
Why is there a strange man in rags sitting under the tree? With a giant SLINGSHOT?? Little did I know that I had just walked into an elaborate bird trap, and I was the shower bait.
However the birds, on this particular occasion, could not be baited. Highly unusual that they forego an opportunity to terrorize me in the shower, but there you have it. Somehow they knew to keep a low profile that afternoon.
On leaving the shower I found the logistician in the yard, talking to the assassin. I was apprised of the evil scheme but alas, could offer no help. The corbeaus were nowhere to be seen. Reluctantly, our assassin went home for the night.
Two minutes later, now inside the house and before I had even finished towelling off, I heard the familiar shriek of delight that signals the presence of a corbeau up to no good. I looked out the window to see the two of them pecking our bar of soap beside the latrine. They were looking at me cock-eyed and attacking it with even extra relish than normal. They knew.
Eventually the corbeaus won their right to continued existence, through a combination of dogged persistence and lovably comical antics. The unsuccessful assassin was relieved of his duties, and the logistician started an early morning exercise program to make good use of the extra waking hours.
With time the corbeaus lost interest in dive-bombing the shower, although they retained their insatiable appetite for soap. Meanwhile, in the front of the house where the MSF trucks are parked, they discovered something much more interesting than caucasions in the shower: their own reflections. At 5pm each day the sun hits the windshield from just the right direction, and the corbeaus – waiting nervously on the hood in eager anticipation — are treated to the spectacular magic of seeing themselves mirrored on the glass. It comes as no surprise now, and they are always primed and ready for battle. The bigger one is the better fighter, and he scratches and pecks and puffs his chest and generally gives the windshield the wing-flapping of a lifetime. Sometimes he even manages to get part of himself snagged in the windshield wiper, and at those times I secretly wonder if the Land Cruiser is going to win. There is about 30 minutes each night of quality reflection time, and he never calls it quits early. By the middle of the fight however he starts to look exhausted. If it is possible to imagine a bird breathing heavily and looking winded, imagine it. At about this time he turns to his mate in desperate exasperation, wondering when, if ever, she is going to pitch in and give him a little help.
His mate, however, is much too distracted to notice. Once again she has caught sight of a particularly stunning looking corbeau on a different windshield, and once again she has fallen in love.
Camera, click: just smart enough to be dumb.
CHAPITRE SIX: THE BEAUTIFUL GAME
Part One: Lean vs. Fat (Plus The White Guy)
I don’t need to tell you that soccer is played all over the world. Wherever trash can be tied into a ball, children will play football. The equipment is the same, the rules are the same, and the enthusiasm is the same. The style however can vary.
In Vietnam I played football on a tiny patch of sand – a fast, undisciplined game of sliding and diving and tiny whirling Vietnamese feet bedazzling me at every turn. In Ethiopia we played on an open pasture, a limitless game where sidelines were restrictive and unwelcome and two players chasing the ball out of bounds might lead, at any moment, to the start of an impromptu marathon. In CAR, the style is different once again. In a country filled with tension, even the leisure activities are intense.
I was first invited to join an afternoon soccer game by Wilfred, my colleague from the Ivory Coast. Wilfred lives and breathes football, to the extreme that in the 15 kg of luggage he was allowed to bring for his 9 month mission in CAR, he somehow found room to pack soccer cleats and shin pads.
In the quiet cool of the mornings when I jog along the airstrip, I see him alone doing “footing”, an entertaining combination of stretches and side-steps and unnecessarily elaborate footwork that I’m sure he learned by studying the warm-up routines of premier league football players on television. With that in mind, when Wilfred asked if I’d like to join the MSF team for a match one afternoon, I was thrilled. I remembered all the good times playing football in Ethiopia – casual, carefree games with MSF colleagues and random kids from the community all mixed together, chasing a ball in the heat and the dust for mutual fun and exercise.
“Carefree”, “casual”, “random”, “mixing” – apparently these are not words in the Centrafricaine sporting dictionary.
The games here are played on a rough, uneven field where the tall grass has been hacked short and two rudimentary sets of wooden goalposts have been erected. It is proudly maintained by the head cleaner at the hospital, a man who apparently identifies more with his role as unofficial Boguila groundskeeper than he does with his salaried position at MSF. The 8 hours a day he spends standing perfectly still in the hospital are merely the resting hours in between his more rigorous routine of hacking back the grass at Boguila Stadium. And, let there be no doubt, he does fine work in his night-job. The sidelines are cut crisply into a regulation sized field: the difference between the trim grass of the pitch and the thick knee-high thistles of the surrounding terrain signify not only the boundary of “in” versus “out”, but also “safe” versus “filled with murderous snakes”.
On this very regulation style field, a very regulation style game takes place. Any delusions I might have had of a carefree rough-and-tumble soccer scramble were instantly cast aside when I arrived at “le stade” with Wilfred to see two clearly segregated teams doing warm-up drills, an assembled crowd of spectators, and, lest there be any doubt, an official referee. I got a little sweaty.
I didn’t feel a whole lot better when I surveyed the field and quickly identified which team was ours. On the one side – lean, strong, muscular 20 year olds from the village hammering the ball at tremendous speeds and wowing the crowd with fancy headers. On the other, team MSF: a rag-tag group of aging pot-bellied health professionals and administrators, grunting heavily in the heat and straining audibly as they bent over to tie their shoes. It wasn’t necessary, but the teams were further segregated into shirts versus skins. This must have been done out of politeness, as both teams could easily have kept our shirts and divided instead into lean versus fat. Or more accurately, lean versus fat plus the white guy.
After considerable debate amongst the team I was told to play outside defence – erroneously presumed to be the position where I could cause the least harm – and with a solemn nod from the referee the game was started. What happened next is just a blaze of hazy images – cheetah-like forwards spinning me in circles, scissor kicks, head butts, cat calls from the crowd – all set to the background noise of Dr. Barthelemy’s bellowing… Dr. Barthelemy being a giant, intimidating MSF Centrafricaine doctor and also our self-appointed MSF team manager. He paced the sidelines like a caged lion, waving his arms madly and hollering fierce instruction in fast French while – to his infinite frustration – I ran around befuddled and panicked shouting back “English! English!!”. Over on the sideline our shoeless substitute players hurled shouts of encouragement and waved us off the field one by one, each swap requiring not only official referee approval, but also the deft transfer of soccer shoes from one to the other. From the opposite sidelines, Dr. Yougooda stood amongst the rest of the village elders, arms akimbo with a look of wary amusement on his face.
If I have led you to believe that Team MSF was set up for a sound thrashing, fear not. Despite our significant physical disadvantages, we still had a few tricks up our sleeve. For one we were older, wiser, cagier; deft with our passes and conservative with our energy expenditure. For two we had a water boy, an advantage not to be taken lightly in the dry heat of a Boguila afternoon. And for three, and by far the most important, the referee was on our payroll. He works in our lab. He knows where his paycheque comes from.
Final score MSF 2, Village 1: the winning goal being scored when MSF was awarded a penalty goal kick for, as far as I can tell, an opposing defenseman having sneezed without saying bless you. It was a sporting triumph.
Part 2: Togolese Sissies
In this context of football madness, it will surely not surprise you that all of Boguila was completely swept away by the pomp and circumstance of the bi-annual African Cup of Football this past January. I had the pleasure of watching the last African Cup from Ethiopia, and I awaited this year’s tournament with tremendous anticipation. Not as much anticipation as Wilfred — who didn’t sleep for days before each Ivory Coast match — but anticipation none the less. Let me tell you my friends, the African Cup of Football is no namby-pamby over-paid advertising spectacle, it is football, real football, and this is one tough tournament.
How tough? For starters, this year’s tournament was hosted by Angola. Unofficial tournament motto: “come if you dare”. Angola proved to be such a welcoming host that this year only one team was shot. That was poor Togo, who drove all the way down from west Africa only to have their team bus shot to pieces as they tried to cross the border. If you think that is a tough introduction to a soccer tournament consider this: when Togo didn’t show up for their first scheduled match – presumably owing to the time it took to remove bullets from their coaching staff – they were disqualified from the rest of the tournament. Honestly. No moment of silence, no apology, no “here’s a couple of bucks to fix your bus”… disqualification. And just in case anyone else might be tempted to turn tail and run home at the first sign of gunfire, Togo was further punished with an official banishment from the NEXT tournament as well. Try again in 2014 sissies… this ain’t Wimbledon.
In Boguila, there are two ways to follow the action of the African Cup of Football. The first is the radio, free to all comers, and you can be sure that for the month of January no self-respecting Boguilan male was ever further than 2 feet away from his tinny, hand-held two-dollar radio. At game time each night the antennas went up in the air, and all of Boguila walked around dreamily with a radio to their ear, oblivious to everything but the crackling distant French of the radio announcer on the national station. This of course included the hospital guards as well, although they at least had the good sense to leave their posts altogether and listen to the game collectively under a tree, rather than risk being caught inattentive at the gate.
The second option for following the action is television. Specifically THE television, as Boguila only has one. It is located in a large hall downtown, rigged up to a speaker system, generator, and satellite. It is known locally as “le cinema”, although most cinemas that I know have a screen larger than 24 inches. Regardless, admission is only 20 cents, so even if you can’t see the ball on the tiny screen 30 feet away you can at least recline comfortably – on the knobby wooden logs that serve as benches – and immerse yourself in the sounds of a sporting spectacle. And what a spectacle it is. I accompanied Wilfred on a couple of occasions to cheer on my team (Ghana), and although I could barely see the television I never regretted the 20 cent expense. In the front, the family section – fathers and their young sons who were learning about professional football for the first time. In the middle, the soldiers, legs splayed out in front with their Kalishnikovs hanging jauntily off their backs… the universal posture of the off-duty soldier. In the back, the great unwashed masses of rabid football fans. A teeming collection of excitable fanatics who make up for the inconvenience of not being able to see the screen by sitting shoulder to shoulder with radios pressed to their ears… the air above them a giant electric tangle of wire and antennas. This is football, African-style.
Part 3: The Day The Roof Collapsed
Those of you otherwise preoccupied with the world of Olympic luge might not have known that dear Ghana made it all the way to the finals this year, where they eventually succumbed to that dastardly Egypt. Normally I would have gone to the cinema to watch the game in person, but the night of the finals I had the misfortune of being on call. So I was sitting on the porch at home listening to the game on the radio — watching the complicated ballet of Wilfred adjusting the antennae with the determination of a diamond cutter — when I received a request on the VHF radio from Orphé, the night nurse, demanding my prompt arrival at the hospital. The reason, I ask? “Une situation.”
In Ethiopia there are never any “problems”, only “gaps”. Likewise in CAR they do not have disasters, just “situations”. For example, the recent breakdown in the national peace mediation process is a “situation”, as was the coup d’etat a couple of years ago, the earthquake in Haiti, and World War II. As a general rule I don’t want to be called to the hospital for, “une situation”.
When I walked up to the hospital in the fading daylight there was a disorganized mob of 50 people trying to push their way through the front gate. Beyond the gate, in the front courtyard, was a small MASH scene of walking wounded. Beyond that, through the packed corridor of shouting spectators, I knew I would find Orphé, doing heaven knows what in our tiny Salle d’Urgence. I pushed my way through.
I wasn’t successful getting into the salle d’urgence, but I was able to force my way to the door and take in the scene. Our salle d’urgence has two beds – only one with a mattress – plus a table, a cupboard of drugs, and an oxygen machine. On one bed was an old man lying very still, bleeding from his face. On the other, a young man with a head wound. On the floor were several others… some lying prone and others sitting up. In between were about 25 spectators, gawking, and in the very centre of it all was Orphé, looking thoroughly unimpressed. Orphé always looks unimpressed — it’s his default face — but this evening he looked even less impressed than usual. He stared at me grumpily: “Good evening doctor. The roof collapsed”.
“Which roof??” I asked.
“Le cinema.”
Oh dear.
I wanted to get closer to the two patients on the bed, thinking it might be a good idea to check if they were alive or dead, but I couldn’t make any progress from my position wedged in the door. “Anyone who is not injured or does not work for MSF please leave now,” I hollered, at which point two old woman shuffled out reluctantly… shooting me disappointed looks as they passed. Now that the local television was buried under rubble, the salle d’urgence was the only show in town.
It took awhile to clear the rest, but eventually I was able to make some space. The maternity team – ever so helpful – was eventually persuaded, after some convincing, that none of the drunken men were pregnant, and reluctantly returned to the maternity department. Others were put to work doing triage, or crowd control, or opening the pharmacy to get supplies, or suturing the walking wounded in other rooms, or organizing a truck to look for more victims down at the cinema. The two patients on the beds had nasty cuts but not much else, and the ones on the floor were bruised and battered but not seriously hurt. We quickly threw them out to make space for the sickest but fortunately, incredibly, no one was seriously hurt in the accident. In the end we had 14 people who needed admission to hospital for observation, and a host of wounds and potential broken bones to sort through.
In the middle of this chaos – the shouting nurses, the moaning wounded, the hysterical spectators – there was one sound pervading through all the rooms, echoing above all the noise, drowning out all the others: the sound of a hundred synchronous radios, blasting out the finals of the African Cup of Football. Towards the end of the match Egypt scored. Everyone in the hospital collectively stopped: suture threads were held in mid-air, patients paused mid-moan, and knowing glances were exchanged. Absolute silence. Then, after a suitably respectful pause, chaos and hysteria erupted once again.
Soccer – the beautiful game.
Stay tuned for Dr. Currie’s upcoming Peruvian blog……..