On Call in the Crossfire – A Voice From the Field about saving lives in the midst of a rebel uprising in the Central African Republic
May 21, 2013
Dr. Tim Schoenfeld took part in an emergency response project by MSF in the Central African Republic, spending four weeks in Sibut, the front line between government forces and a coalition of rebel groups seeking to overthrow the President. Dr. Schoenfeld and nine other MSF staffers provided emergency care to pregnant women, children under five and patients in critical condition at a local hospital that had emptied in late December 2012, when the uprising began.
When I arrived in late January the eastern third of the Central African Republic had been taken over by rebels, including the town of Sibut, where our mission was. The "red line" between Government forces and the rebels was 50 kilometers south of Sibut. The town had been heavily plundered by armed men working for the government and by rebel troops after them, so little was left of the economy. Roughly 90% of the population had fled from sexual attacks, extortions, and beatings they suffered under both the Chadian and rebel troops by hiding "in the bush." The road between the capital city Bangui and Sibut had been closed for over a month, so when we arrived at the hospital there were few medical supplies available. The only doctor, along with the nurses and mid-wives, had fled to the capital. In an area populated by 40,000 people, the medical demand was high because people had been living in rough conditions for a month. They were in desperate straits with children dying of malaria and dysentery, and women giving birth in primitive conditions. It was an urgent situation- this was life saving on a very large scale.
Open for business
On the first morning we began treating patients there were more than a hundred people waiting to be seen. The patients included children aged from 2 months to 5 years old suffering from malaria and/or severe malnutrition, and a case of spinal tuberculosis that had already paralyzed the patient’s lower extremities. In the middle of it all a truck full of rebels arrived with seven soldiers who had been injured in a speeding truck accident. One died as I was examining him, but the others (originally comatose) were revived with fluid resuscitation and brain injury treatment. One of the rebels threatened to kill us if his buddies died but we brought in their captain, explained to him what we were doing, and he put two of his men in “plain clothes” in the ward to make sure none of the soldiers got out of hand. In general, we found the rebel leaders to be very cooperative and supportive of what we were doing.
In my second week I was called to see a 3-year old female patient. On examination, 20% of her body had third degree burns, in the area of her chest, abdomen, and thighs. The burn occurred in the bush where she and her mother and sister had been hiding from the rebels. Apparently the child caught fire by getting too close to the campfire and ran until the mother could catch her and put the fire out. The mother, about 18 years old, then strapped her breast-feeding infant on her back, took her 3 year old burned child in her arms and, too afraid to use the road because of the rebels, made her way through the bush 50 kilometers to our hospital, feeding and hydrating the injured child as well as breast-feeding the baby. The burned child arrived without a fever (infection is the rule, not the exception for third degree burns which have no dermal protection against microbes) so her mother must have been using some sort of traditional African treatment to protect the wounds. The child is doing well and will survive…thanks to Super-Mom!
Back to Life
Over and over we saw patients with amazing resilience! This obstetrical case involved a young woman who arrived at the hospital in early labor, just six months into her pregnancy. The midwife told me it appeared the infant was already dead but the mother was unable to deliver. A Caesarian section would be necessary. When the infant was lifted from the abdomen, to my amazement, a tiny little cry came out! I went over to the neonatal table and saw a tiny (3.0 pounds) little girl struggling to breath, opening her eyes intermittently. Her under-developed lungs were not expanding and her chest collapsed completely with every breath. It was hard to watch so I decided to try to inflate her lungs with the adult ambu bag and adult mask present. I managed to slowly inflate the right lung but the left was resistant. We gave Hydrocortisone via the umbilical vein at the nurse’s suggestion. Eventually the left lung also inflated after 30 minutes of gentle positive pressure, with no oxygen available- just room air! She turned pink and I sent her to the ward breathing spontaneously. After three days the little girl was breast feeding, with no fever, and both lungs inflating well. Unbelievable!
Hard to say No
My greatest frustration while on this mission was having to say "no" to people in dire need of medical treatment. The Sibut mission specifically targeted children under five, pregnant women, victims of violence, and all emergency cases (i.e. life threatening conditions). Many of the adults who walked upwards of 30 km to get to our mission site did not fall into any of the above categories and I found myself several times a day trying to explain to patients that they were NOT a part of our mission. MSF doctors are a self selected group of physicians who in particular find this to be very difficult...that WHY we belong to MSF, to be able to treat "Les Miserables" of this world, not to explain to them once again that nobody is there for them. It was difficult and unrewarding to say the least, but I understand the reasons behind the decisions to limit treatment groups.
A final thought
On the upside - I had a chance to see in real time what can happen when MSF enters an area and begins temoinage...in this case pointing out to the rebel leaders the suffering inflicted on the population by their troops, the rapes, the beatings, the looting and extortion and the suffering directly resulting from living in hiding in the bush. It DID make a very real difference, the leaders DID respond to the needs of the people by maintaining better discipline in their troops (not an easy things as I've already noted).