Central African Republic: How we provide medical care in a conflict zone

November 20, 2020

“You see, the children are playing. It means the security situation is stable”, my colleague tells me.

In front of me there are, in fact, a dozen kids. They are there, but I don't really see them; night is falling. I only hear them: some imitate the howling of dogs, two others are skipping rope, copying my colleague who is training in a corner.

Boys try to wrestle each other to the ground and a girl sitting on a mother’s lap is having her hair braided in a way that will always impress me. These mums know an endless number of braiding combinations, they look both focused and nonchalant, precise and random, gentle and rough. And the little girls whose hair they work on often have a distracted look. It intrigues me. It's like those boys fighting over games: it sounds like crazy violence to me. I have always told myself that they are much stronger and tougher than I was at their age.

Speaking of strength, close by a child of about 10 years old draws water from a well. She, too, looks both distracted and focused. Using quick, full movements, mastered to perfection, she pulls a rope which allows her to lift ten litres of water. And because it is knotted every 50 cm, she can do this without much fear of dropping the rope and losing it at the bottom of the well.

The hinterland

We have done five hours by car and five hours by motorbike between the bush, the savannah and the forest.

What they call the "forest" is what I would have called the “jungle”: dark green, dense, with monkeys, giant ants, twisting trees and even masses of bamboo as tall as buildings, bending under their own weight, like papyri, blocking our way here and there, forcing us to stop to clear the route with a machete.

The savannah is what I would have called "bush": tall yellow or pale green grass as far as the eye can see, with a few trees planted here and there, and carnivorous flies that devour your skin at the slightest stop.

In the end, the "bush" is in fact the whole of the savannah and the jungle together, and stretches for hundreds, thousands of kilometers. This is not the "city". This is where you find the villages, this is the "kodoro" or "the hinterland": the local countryside.

Difficult and strange

We are 200 km from Bangassou, the city in the south-east of the Central African Republic where our team is usually based. The small, remote town we're in now brings together Muslim, Catholic and Fulani communities.

The reputation of the place is quite bad. It’s difficult to access, occupied by various armed groups controlling mineral resources, and has constantly rising food prices. There are few sources of uncontaminated water, the only ones available being the river or the old wells dug more than twenty years ago. On top of all this, the population density is higher than in other towns, with little arable land.

The contrast with Bangassou is clear: instead of a grid of tracks delimited by houses, here we find a myriad of straw huts and small houses piled up randomly, with no streets other than narrow footpaths. My Central African colleague even said to me, while we were criss-crossing the streets on a motorbike: "here it's really difficult and strange, it's all over the place, with no clear streets, we really get lost”.

Colossal needs

As for health care, a single, small medical centre exists for an estimated population of between 15 and 20,000 people. No NGOs are active here right anymore, unless we count the random and rare donations of drugs made by plane or helicopter. Because yes, there is an airstrip, used by a few NGOs but mostly, in fact, by planes carrying gold or diamonds from this very poor town to very rich places.

Traditional medicine exists and is done mainly with plants. This certainly helps to alleviate certain diseases, but people’s needs and requests remain colossal. This is particularly true with regards to mother and child health; vaccination and even more importantly access to emergency care in the event of a complication, serious illness or trauma.

That’s why we’re here. We’re staying for two nights and the programme is tight. Our goal is to start by setting up a referral system for patients who need to go to Bangassou Hospital urgently. The team is made up of two nurses, a logistician and two health promoters, including me. The primary goal of the whole team will be to build a network of bikers who will be paid to take patients to the hospital 200 km away.

Why not a network of ambulances, you will ask me?

The answer is simple: they couldn’t drive on these roads.

Our roles

As our nurses train the health centre staff on how to stabilise patients, they realise that the level of staff training here is very low. In particular, there is no doctor and the most qualified guy is a nursing assistant.

For her part, the logistician must assess the basic needs of the centre: access to water, latrines, proper waste disposal, electricity for the cold chain, etc.

Meanwhile my team and I will meet, in groups or individually, the “community leaders”. These are the heads of villages, youth presidents, associations of women or traders, religious authorities, school administrators, etc. We’re meeting them in order to tell them who we are and how the referrals will be organised, but also to understand what people are doing right now when they need care.

Diversity

I love these community gatherings. I always learn a thousand things.

This one took place in the town's school, in a room with glassless windows, surrounded by hundreds of busy children. The schools that I have seen in Africa fascinate me. It's 7.20 am and as I get off my motorbike in the middle of the vast playground, the usual curious crowd appears. They don't say anything, but there is a lot of noise. They all look at us, but don't ask questions. Behind them, the adults run with sticks or ropes to chase them away. Accustomed, the kids laugh, shout, then disperse to their games while waiting for the start of lessons.

In the room, it is hot. 50 adults are gathered on the school benches and I face them next to a health promotion colleague, the school principal and the head of the town. The diversity of this group is anthropologically awesome to observe. There is the youth president wearing a pink polo shirt, the neighborhood chief in a multicolored shirt, the women's representative with an incredible skirt to match the cloth wrap in her hair. There is also a traditional healer sporting dozens of bone, pearl and nut necklaces, and imams in long white or gray robes, with their round-square hats that I adore. I love this diversity.

An important step

Before all that, we also needed to meet the politico-military authorities, in particular the heads of armed groups. This is an important step in setting up our activities because we must ensure both the safety of the team, and unconditional patient access to our services, in full compliance with MSF principles.

I don't really have any experience in negotiating with armed groups and this is mostly the prerogative of the project coordinator; here we just have to go through the proper formalities by indicating our presence. Nonetheless, this visit feels like Hollywood westerns. We are greeted by men in uniform, with gold rings and teeth, their cigarette smoke blocks the rays of the sun, we speak slowly and super formally, each in turn, after introducing ourselves. Then we are escorted to the other camp to let us know that there is an understanding between the groups, that there is security, that we should not be afraid and leave or scare the NGOs away.

The walk from one camp to the other is done in public, everyone is looking at us and I wonder if it does not compromise our neutrality to be like this walking side by side with them, but my colleague tells me that people understood that we were heading towards the other camp, a sign that we do not hold for one group or the other.

Simple

We are warmly welcomed. The visit with the second group strikes me as even more cinematic. "Man, it's like being in a movie", I say discreetly to my colleague.

"Totally,” he replies, “I’ve definitely been more relaxed.”

The scene takes place behind a large building, under a tree, with a few plastic chairs and people, almost children, holding weapons and leaning further against a wall. The two generals, normally in opposition, shake hands for a long time and my Central African colleague says to me: "We have to watch, that's what they expect. Then he will come and we don't even have to talk much.”

So we watch, he comes over, we speak little and we leave. Simple.

A detour

Two days later, we will leave the town after a visit to the mayor. As usual, she is very welcoming, thanking MSF for being there when "everyone else has abandoned us". However, she looks preoccupied and invites us to leave town taking a detour because "someone is waiting for us down the road and we have to meet him."

We are already on our bikes. We exchange glances, but we comply. Farther on, members of one of the armed groups are waiting for us. They stop the convoy and ask us to get out of our vehicles, then to follow them into the back yard of a house. There is a heavy silence, but we stay focused and attentive.

The same rule for everyone

Another general is waiting for us. He addresses my colleague in Sango – the local language here. My colleague answers him directly. The exchange lasts a few minutes and then I get the translation: "You organised a community meeting and we weren't invited. However, we are also the community, we must be present.”

I don't know what to say. Although I don’t say so aloud, the idea of armed groups at our community meetings bothers me. I think that people won’t express themselves spontaneously. That it will compromise our neutrality.

Fortunately, I do not need to speak. My Central African colleague, experienced, has already replied: "You were informed first of the content of this meeting, but if you also want to be present, then you must remain in civilian clothes, without military uniforms. There can be only one person present from the group, and there must be no weapons, even near the place, no protection. And a representative from the other armed group can also be invited. Same rule for everyone.”

“Obviously. We know NGOs well, we will respect your principles to the letter,” replied the general. Deal. Well said.

Neutrality, impartiality, independence

I imagine that with a little more experience it will impress me less, I would feel less like I was in a movie. By the way, the next meeting, they had no military clothes on, had put their weapons away and were out almost for breakfast, sitting in flip-flops on their chairs.

The speech was less formal and finally, in order not to stress too much, I told myself that they were also humans and that my reason for being here and our principles were clear and transparent. I had nothing to hide and there weren't any wrong words as long as what I was honest and straightforward.

I wonder what it's like to be a project coordinator in a context like Central African Republic where there are conflicts. I used to ask myself the same question in Port-au-Prince, Haiti, when the project coordinator had to chat daily with gang leaders. It can’t be easy to manage all these negotiations, but I understand how our principles are crucial and become tangible in these situations.

Neutrality, impartiality, independence. Simple to explain, not always to enforce, but with immediate impact for our patients.