Jessie Gaffric recently completed an assignment as project coordinator of MSF’s program at Bangui’s Community Hospital in Central African Republic (CAR), where the organization performs emergency surgery for victims of the violence that has convulsed the city and much of the country’s northwest since a March 2013 coup d’état. Gaffric, who has worked with MSF in several conflict settings, says this was her “most difficult” assignment yet:
Who are MSF’s patients at the Bangui Community Hospital?
In Bangui, we treat primarily men between the ages of approximately 20 and 35. Most are combatants. Women and the elderly make up a minority of the patients. They happened to be in the wrong place at the wrong time. Children under the age of 15 were treated at another facility: the Bangui Pediatric Complex.
However, many of the patients who came from outside the city—from villages in the provinces that have been burned and looted and who are transferred by the ICRC [International Committee of the Red Cross] or other MSF teams—were women and children.
Nearly all of our patients are victims of violence. The most common injuries are bullet and grenade wounds, followed by knife and machete wounds. Then there are victims of lynching, confinement, and torture, and, lastly, people who have been wounded while fleeing.
What were the obstacles and constraints that you faced in your work?
Insecurity is the main problem. That makes it hard for us to do our work. Our teams cannot stay in the hospital after the 6PM curfew. It’s too dangerous. So we have to do a full day’s work during the 11 hours that we are there. Sometimes, we had to lock ourselves in the operating room or evacuate on short notice.
We often had to postpone surgeries, and some nights there were only a few or no staff members at the hospital. We had to leave patients alone, without medical monitoring. We didn’t know whether they’d be alive when we returned.
On some days when there was fighting, hospital employees couldn’t leave home to come to work. We had to manage as best we could with the MSF expatriates and Central African staff members who had slept at the hospital.
As project coordinator, how did you manage security for the team?
It took a huge amount of time. Armed men would come into the hospital. There were armed patients, and family members and visitors—also possibly armed—who were always coming and going. Some refused to turn over their weapons at the hospital entrance and it was impossible to search everyone. Everyone was terrorized and very suspicious.
We constantly told people, “The hospital is a place where people come for medical care—conflicts must remain outside.” MSF places all patients together and does not distinguish based on group or religion. We talked a lot with the patients and everyone living on the hospital grounds about that policy and explained it to the families. That took a lot of time, too. But I think it allowed us to avoid serious problems.
The issue of security outside the hospital is equally important. I was in constant contact with MSF’s head of mission. I kept him informed about what was happening (for example, shooting or movements of armed groups) and he did the same for me. He provided tremendous support. He would come to the hospital in the event of a serious incident or a surge of patients to help manage the crowd. We made decisions jointly on issues like freezing team movements or evacuating the team when it was too dangerous in the hospital. It would have been much harder to deal with that alone.
Were you ever afraid?
Yes. Some of the armed men in the hospital frightened me. I had to step between them to prevent the lynching of a patient. The attackers looked at me with hate in their eyes.
I was also afraid when we traveled by car when there was shooting, when we would encounter combatants who looked really intimidating, and when we saw corpses on the roads. I was afraid at MSF living quarters, too, when there was shooting in the neighborhood. That happened almost every night, but some nights were worse than others. We even had stray bullets enter the house.
I was also afraid of making the wrong decision when we were evacuating a team. And of my responsibility for their safety.
How was this different from other MSF missions you’ve been on?
On my other missions, things were clear. This group was fighting that group. In CAR, the clashes have developed into inter-communal conflicts. Everyone is fighting everyone. The rise in violence, the levels it’s reached, the hatred that creates this fury to kill and mutilate, the wounds and the injuries, particularly knife wounds—it was horrible.
The workload was heavier. Even “normal” days were much worse than what I was used to. We had several mass casualty incidents with a lot of serious cases. That’s unusual. In Bangui, the percentage of serious cases was greater than that of minor injuries.
I think Bangui was the most difficult mission I’ve ever been on. Luckily, the team was great. We had a tremendous sense of cohesiveness.
Is there a specific patient who particularly affected you?
There were several. Idriss suffered a cranial trauma. His face was torn to shreds. He had to be strapped to the stretcher because we had to leave and he was very agitated. We showed the people who were there with him how to administer pain medication while we were gone. He died during the night.
Another man arrived, upright, walking, with his throat slit and his trachea open to the air. He also had machete wounds on the back of his neck and one ear had been cut off. He had been tortured for four days. He died the next day.
Then there was Michael, who had been stabbed in the throat and thorax. The entire team mobilized. He was stabilized and the surgical team did an amazing job. He’s doing well and can move his arm—which had been lifeless—again. That was a small victory!
All the patients in the orthopedic tent, too, who were there for weeks at a time, face to face, calm and in a pretty relaxed mood, despite their conflicts and differences. They had moved beyond what made them enemies outside.
MSF now manages seven regular projects and eight emergency projects in CAR. Overall, MSF provides free medical care to nearly 400,000 people in 12 hospitals, 16 health centers, and 40 health posts. The organization’s teams include approximately 200 expatriate staff and more than 1,800 national staff.