Awakening in CAR

Despite my honest sense I am slowly but surely burning out here in Maitikoulou, I thought I would share with you why I have one of the best jobs in the world. I think the fact I can compose this just before a well-deserved break in the capital, is a good sign this is genuine.

Why perhaps I have one of the best jobs in the world:

1. I spend most of my days treating countless ill but beautiful children who as they get better smile back at you. Nothing beats the joy of working with children and their families, with medicines that cure.

2. I spend my days with the mothers and fathers of beautiful children who smile and laugh at my silly jokes during ward rounds. It is fun to laugh and even more fun to make others laugh.

3. I believe I enjoy the trust of my patients and their families – this is a sacred privilege anywhere in the world.

4. I have a team of MSF volunteers around me, who I would lie down in traffic for, and I believe, they would for me. OK, fine there is no traffic in Maitikoulou but you know what I mean.

5. I live in one of the most beautiful places in the world, rural CAR.

6. I make my own work schedule, generally. I am my own boss most days. As long as the work gets done and done well, I’m free to plan my days.

7. I am mostly surrounded by dedicated national staff who want to learn, get better and work with MSF.

8. I have the privilege to work with a fragile population where each our medical interventions can truly save a life and alleviate suffering. I can do with MSF what I believe most of us MSF’ers signed up to do.

9. I work for MSF who I believe will give me the tools I need to do my job. Hats off to logistics – they make it possible.

10. I work for an organization whose principles and actions inspire (and sometimes challenge) me.

11. I have never felt a day working for MSF has been wasted. Each day I wake up with a sense of purpose, even if it drains all the energy in my heart, soul, mind and body.

Et voila.

Warm wishes from the Central African Republic,
Raghu Venugopal

[Please note: all potential patient identifiers have been changed to protect confidentiality.]

David lives chained to a tree.

His tree is located in a small village close to our MSF sub-base in Maitikoulou. He has been attached to a generously large and graceful African tree for 2 straight years. His accumulated time attached to the tree is 5 years. He never is let go from his tree. He eats there, defecates and urinates there, huddles in the rain there and sleeps there. The chain attached to the tree root goes around his right foot. His body is covered by a small rag at his waist. He is covered in dust and mud. He just sits under his tree all day and all night.

David was once a normal man with a normal village life. He is now 28 years old. He was married, with 2 children and worked in his fields. For unclear reasons, at age 23 he became wild and violent. He beat his mother with a stick and her nose and forehead bear scars from him.

David speaks some French, in fact, more than the usual villager. I was asked to see him by his village chief when MSF was there screening villagers for sleeping sickness. Our sleeping sickness machine – efficiently diagnosing and treating patients sometimes comes across these cases. I ask the machine to stop and make exceptions for cases like this one. When there is a David out there, chained to a tree, the humanity of all of us is tested.

I have examined David twice. This second visit allowed me to take a more detailed family and psychosocial history to understand the nature of this man’s troubled life, and to try and conduct a basic mental status examination.

David lives in a highly disorganized state. His words are a mish-mash of nonsensical French. He makes quick, purposeless movements. When I offer him my hand to shake it, he does not take it. He pushes me away as I try to conduct a basic physical examination. He is not violent with me. Rather he seems scared.

In his village, I learned about David from his family and pastor. He has five siblings, his mother lives near his tree, and his father died long ago. His wife and 2 children live in the village as well. Despite his good marriage and life he became so disruptive and violent that the village did not know what to do for him, so they chained him up.

This is the reality of mental illness around the world and since ancient times. We chain them up.

The family of David has given me permission to try to help him. I plan to try and locate antipsychotic medications for him and start them slowly, under supervision. Then I will see what non-pharmacological therapy is available, if at all, for this man in this country. As well, I’ll have to rule out other medical pathologies which can cause a change in behavior – like sleeping sickness, HIV and neurosyphillis, just to name a few.

It is easy to pretend David does not exist. His family and village care for him rather than abandoning him, doing the best they can under the circumstances of grinding poverty in a forgotten part of rural central Africa. They tell me that they protect David, and they do not let children or others taunt or hurt him. They try to give him clothes but he shreds them off. Given this chronic and seemingly intractable situation in contrast with the emergency mandate of Médecins Sans Frontières, it is easy for me to walk away. I can convince myself and others that there is no real hope and nothing which we can offer this man.

But we can try.

I can begin to help David by telling you his story. His quiet existence under the tree will not be unknown. His existence may remain there, but it will not remain in silence.

Médecins Sans Frontières is an emergency humanitarian organization, and there are limits to what we can do. We cannot save everyone. Nonetheless, we can try to do something for someone clearly suffering indignity. Mental illness pushes our limits, and tests our ability to articulate what we can and cannot do. What we will and will not do. There are few quick fixes, treatment is chronic, and a reliable supply of drugs may be required. But all these arguments were made against treating tuberculosis and HIV and it was shown it could be done.

Warm wishes from the Central African Republic, Raghu Venugopal

It has been awhile since I have written. One factor has been an influx of patients – we had 40 admissions to hospital on August 31. Twenty-eight patients had sleeping sickness and 12 had malaria, malnutrition or other important pathologies.

As well, we had many valued visitors and advisors recently to our project. And this sub-base has been more than a bit stressful lately for a number of reasons. The biggest factor leading to stress is that it is a start-up
project. We are constantly evolving and improving. And to be frank, this is a rough, rural, imperfect project – isolated in every way possible, not yet fully staffed, and with a work overload. You can easily work yourself right into the ground here. I don’t want to end up like that.

Our recent guests included a German journalist and a communications officer from the MSF-Germany. For everyone who has been in the field with MSF they know that visitors are a useful opportunity to reflect on how the mission is going – its strengths, weaknesses and opportunities. Another benefit of visitors is that they bring some well-deserved treats. Our visitors from Europe, in particular Yasmin – brought many items that we cannot easily get in the field and savor:

-excellent coffee

-iced tea crystals

-Haribo candies

-batteries and a recharger for the nurses night headlamps

-good chocolate

-some good soap

On a personal side, I’ve had to adjust my work pace in order to make sure I stay healthy too. This has included:

-more regular walks into the countryside (which our American nurse-practitioner loves go on)

-1/2 beer with dinner

-more movie nights

-more non-medical reading (especially James Orbinski’s book – An Imperfect Offering – which I hope will give me some inspiration and insight)

-stopping work at some point in the evening and not working all night

-sleeping outside more

-moving out of the hospital-office compound to our new expat tukuls across the road

-doing more stretching while our American nurse-practitioner does her yoga

-delegating more simple, routine medical work to our nurses

-more exercise – I’m trying to rig up a stationary bicycle

I’m hopeful these strategies will keep me a good doctor, a good volunteer, a good person and a good MSF’er.

Warm wishes from the Central African Republic,
Raghu Venugopal

One of the important responsibilities of an MSF’er in my opinion is the control of the medical and logistical stock. In a poor country, if you don’t keep a careful watch over the resources of MSF they will walk off. Even if you do keep a good watch it is still hard. People are abjectly poor, jobs are hard to find and the resources of MSF can be readily sold in the local market. My job is to make sure the latter does not happen. As impartial actors, our job is to make sure the humanitarian aid gets to the most affected.

As an emergency physician, I inherently trust patients and families. I can’t practice medicine if I don’t begin at that point. But an old adage in my profession is also “trust no one, believe nothing”. In this spirit, the last
few weeks in my mission have been about planning how to better institute procedures to protect the resources of MSF. I think the prior teams here have been just too run off their feet in my opinion to be able to do that well before. Now was the time.

So today, our logistician, expat nurse and I emptied the entire in-patient pharmacy. We then restocked it based on our best estimation of what was really needed. We then put in place a daily ordering system of medications so that only one day’s medications and medical materials were available to the general staff. Then we locked the medical cabinets and plan to hold one of our national staff responsible for controlling what goes in and what goes out of the medical stock and pharmacy. Trust is not enough. You have to put in procedures to be better than trust.

As we undertook this important procedure in this sleeping sickness sub-base, I helped the pharmacist (he’s not really a pharmacist, but can read and write). I read off the medications the other physician and I had ordered during morning rounds and he prepared them for the following day. One of the medications was 88 tablets of acetaminophen. Another was 2 ampoules of ceftriaxone. Another was 16 doses of Plumpy Nut ready-to-use therapeutic food. It felt good to me that each pill that comes from the money of our donors was ordered, tabulated on a tally sheet, put in a bag, labeled and judiciously made available.

Back home, I see people standing on a street corner in the cold canvassing for MSF. I know the employees of MSF don’t earn the top dollars in the charitable and humanitarian sector. I know our medical and logistical
volunteers take cuts in pay to be in the field. But most importantly, I know it is regular, every-day people who work hard to give to MSF. In respect of all of this, and that fact that our medicines and efforts must go to those who most need them, I am glad I helped us give out 88 tablets of acetaminophen today. Not 87 and not 89. 88.

Warm wishes from the Central African Republic,
Raghu Venugopal

In my last posting I mentioned I would say how the village of Daga 2 fared in its completion of screening for sleeping sickness here at our HAT camp. Hopefully, this will be illustrative of the procedure to diagnose and treat sleeping sickness, along with the other main pathologies in this region.

Of the 60 villagers screened in Daga, 18/60 had a positive blood screening test for sleeping sickness. The 18 walked together yesterday and all came en-mass to Maitikoulou and spent the day outside our lab under a tree. They joked around, I talked with them about how the day would unfold, and they shared food. They looked with curiosity as other patients of all ages and degrees of severity arrived and Dr. Placide and I took care of them.

The 18 from Daga who arrived here in Maitikoulou all received a lumbar puncture, lymph node aspiration and blood smear. 9/18 had the more serious neurological stage of sleeping sickness (stage 2) and 9/18 had the less serious blood-lymphatic form of the disease (stage 1).

Of the 9 in stage 2, 8/9 had a malaria coinfection as well which was no surprise given malaria is the top killer in CAR. This will need treatment before we can treat their sleeping sickness sick our treatment for sleeping sickness will depress their immune system.

Ultimately, we admitted all 18 villagers from Daga. Along with other admissions, yesterday was the heaviest admitting day since I arrived here. We had 25 admissions in total.

Like all our patients, the Daga folks will get a daily food ration here, a roof over their head and medical treatment entirely for free. If they are the severe stage 2, they will sleep on a fairly shoddy locally made bed with a mattress, good blanket and bednet. If they are the less severe stage 1 they will sleep on a mat in an open-air wooden hanger. There are just not enough beds for everyone, even though we are making more all the time.

So there is a snap-shot of our HAT camp in-patient ward bed situation if all the numbers are getting fuzzy:

Tent 1: all 12 beds filled with phase 2 HAT patients

Tent 2: 7/8 beds filled with malnutrition or severe malaria cases. 1 bed with 1 month old baby who has stage 2 sleeping sickness and severe malaria.

Tent 3: 1 patient only. A 1 year old from Chad in isolation due to measles.

Tent 4: 12 patients in 11 beds. Two newborn twins who arrived yesterday and I put them in the same bed. Their mother died in child-birth and the children have not breast-fed in 3 days. Until the family and I find a long term solution, I’ve got to admit them and give them therapeutic milk.

Tent 5: all 12 beds filled. 11 with HAT patients and 1 with a young man with a possible seizure disorder. This tent is close to the nursing station and allows easier monitoring of the patient.

Tent 6: 8 patients in 8 beds. 5 patients are HAT and 3 are other pathologies.

Hanger 1: 5 phase 1 patients and 1 patient with a rectovaginal prolapse I am trying to transfer out for elective surgery (she walked 60km so it’s easier if she just stays here while I await a response from our MSF surgical referral hospital in Boguila).

New admissions: 18 HAT patients (17 go to the hanger, and 1 will go in the 1 free bed)

Total beneficiaries: 77

Free beds: 1 (soon 0 as the new HAT phase 2 patient who can start eflornithine treatment can go there).

That’s all for now. Next week will be busy – we’re planning our 2nd mobile activity and we will have a reporter, health advisor, communications officer and MSF volunteers from other projects here. I’ll keep you posted on what promises a busy time.

Warm wishes from the Central African Republic,
Raghu Venugopal

It was a great week. We moved out of our sub-base and undertook disease screening activities in a local village. Finally, we went mobile. The target village was Daga and all told, things went smooth.

There are advantages to mobile activities. It allows us to better learn about the medical and humanitarian needs of the population, and sensitize the population to the goals and services offered by MSF. It also allows us to bring medical care to those who cannot travel to our sub-base. It gets us out and into the population’s actual living conditions.

On a personal note, I enjoy getting out of the project base once in a while. Life in the HAT camp 24 hours/day 7 days a week can get long at times. The change of scenery is welcome. My general existence is from my bedroom to the next room which is the office and then to the in-patient ward which is about
a 5 second walk from the office. Work-life balance is not an easy option. Take last night for example. Pierre woke me at 2 AM because he ran out of therapeutic milk for the malnourished children. Then at 6:30 AM Cyriaque needed perfusion sets and syringes for the morning infusions. There is never any real time away from the work environment.

In Daga village our project coordinator (from southern Ontario) first greeted the village chief. He was concerned he was infected and so we first offered him testing for sleeping sickness. We later screened all the village children between 1-5 years for malnutrition by measuring their “MUAC” or middle upper arm circumference (basically how skinny their arm is). Thankfully we only found 1 child with moderate malnutrition and no children with severe malnutrition. Some children and families really got into the
MUAC screening! Although we only really needed children to roll up their sleeve, some exuberantly got completely undressed. A little clarification soon fixed that situation.

The main activity of the day was doing screening for sleeping sickness. We screened 60 villagers on a first-come first-serve basis. Everyone cued up in a line in the center of the village. There was a palpable positive feeling amongst everyone. We were there to improve village health, and I got the sense people really appreciated it. Tara, my project coordinator, turned to me at one point and said “this is what MSF is all about”. I agreed.

A concerning 30% of those screened were positive for sleeping sickness. I met privately with all 18 of these patients (some were children and their parents who were farming in the fields needed to be found). I then explained to them what the test results meant and immediately invited them to the HAT camp. There we will determine if they have the severe form of sleeping sickness or not, and offer immediate hospital admission and treatment.

I’ll keep you updated on how the village of Daga fares.

Warm wishes from the Central African Republic,
Raghu Venugopal

I wanted to let you know that Jean from Dilingala with the severe cerebral form of sleeping sickness is getting better.

To my delight Jean is now walking. He is not quite back to normal, but with his mother’s help he is out of his tent slowly tottering around the muddy hospital compound sort of like a robot. Also ever present are many chickens and dogs which wander through our porous fence. I’ve given Jean’s family all the encouragement I can to keep up the good work. He still does not talk much to me though despite my best attempts in the local language. Our national staff nurse Pierre tells me that Jean is probably shy because I am a foreigner. I replied back that many of the children here are not afraid at all of me as a stranger. In fact, so many Central African children I treat are willing to shake hands with me on morning and afternoon rounds and even
take a stroll with me. But not Jean. Not yet anyways. I’ll keep working on him.

Lately I have been pretty sick to be honest. Three days of fever, lots of “gastrointestinal issues” and a headache that will not go away after loads of ibuprofen and acetominophen. Thankfully, my blood smear for malaria is negative and I think it is just a cold. The word among all the expats I talk to here is that pretty much everyone gets malaria at some point or another. I’m trying hard to avoid that from happening. Already one expat in our project who has lived most of his life in Africa and has never had malaria has already fallen sick with it. I’m terrified by malaria to be honest. I see it kill people.

I’m not sure if you know, but Simon my logistician/team leader in our project here is also keeping a blog for MSF. You might like to read his blog at www.msf.ie/simonblog. There you can get a sense of our sleeping sickness sub-base here in Maitikulu from a different perspective. Simon is a straight-talking and hard-working MSF’er. He is from Ireland and has tons of field experience with MSF and other non-governmental organizations. We both are pretty similar. We’re both 34 and we both tolerate the heat badly. We both also do our best under the circumstances and limitations of rural central Africa. Not everything works out perfectly (except for our omelettes cooked on our open fire pit), and we share a good chuckle often and appreciate each other’s work. MSF is respected in my opinion for our logistical capabilities as much as for our medical work.

I can do the medicine because people like Simon do the logistics (and so much else). Thanks Simon.

Warm wishes from the Central African Republic, Raghu Venugopal MD

I am happy to report that Jean from Dilingala (in Chad) is getting better. You will recall he presented to our HAT camp on August 12 in a semi-comatose delirium. Today is the fifth day he is under intravenous eflornithine treatment for sleeping sickness. You’ll also probably recall sleeping
sickness is more formally called HAT (Human African Trypanosomiasis). Around here in the project where the working language is French, we just call it “trypano” for short.

Maybe all these words for the same nasty disease is confusing you, so let me summarize from the most formal to the most informal terminology.

Trypanosoma brucei gambiense = Human African Trypanosomiasis = HAT = Sleeping sickness = trypano.

Back to Jean in more detail. Each day he gets a little better. Today he is able to eat some Plumpy-Nut, though he vomits from time to time – a side effect I attribute to the eflornithine. Unfortunately, the medication we use to treat his vomiting also sedates him, which makes it a harder to follow his overall neurological status. It’s always a balance between the potential good a medication can provide in comparison to the potential harm it can cause.

Jean’s older brother who affectionately holds him a lot says he talks to him, but we could not coax any words out of him on today’s Sunday rounds. Jean also still cannot walk very much though he can now follow simple commands like eye closing and shaking hands. The normal smile and giggle of a 7-year-old boy is what we’re waiting for. Maybe soon.

The plan here in the coming week will be our first mobile activity to foremost advance our sleeping sickness project. We will take two MSF Land Cruisers and a small team to one of the nearby villages. There our goals will be fourfold.

First, we will interview the local population on their medical and humanitarian concerns. Second, we will hope to screen all children between 1 to 5 years for severe acute malnutrition. Third, we will do a simple screening blood test for sleeping sickness from the back of the Land Cruisers for about 60-80 villagers and bring back to our HAT camp anyone obviously sick. Fourth we’ll search for a couple of previously diagnosed typano patients who are on our waiting list for treatment.

OK – time to work on monthly statistics and report writing. Sunday is the best day for this sort of thing as there are less interuptions and I can readily get help from our logistician who is also a Microsoft Excel guru.

Warm wishes from the Central African Republic,
Raghu Venugopal

I found Jean in the laboratory. He is from Dilingala in southern Chad.

Something was obviously wrong.

He was a boy who looked about 6-7 years old, though his older brother said he was only 4 years old. Who really knows. Jean was draped across his brother’s arms, limp and barely with his eyes open.

One of our out-patient department (OPD) staff had sent Jean to the lab. He had requested a serological screening test for sleeping sickness. This test looks for antibodies for sleeping sickness and just requires a quick pin prick.

I asked Jean’s brother with the help of a local national staff “securiste” – or nurse’s aid – what was the matter. Jean’s brother said the patient got increasingly sick in the last one week. He could not walk, he would sleep all day, he would not eat and he was having fevers.

When I tried to make Jean walk, he could barely stand. He looked encephalopathic or in a confused state of altered mental status. He indeed could not talk and he could not swallow a few drops of water we tried to give him. He would not cry or protest if pinched. When he did open his eyes he looked around in a wild and confused manner.

This is sleeping sickness. The worst kind.

Not surprisingly, Jean’s screening test for trypanosomiasis was positive. I did his lumbar puncture immediately and he had a very high number of white blood cells – 452 – which is a clear indication of the severe central nervous system form of this disease. Our superb lab technician Yvonne – who is always keen to show us important lab findings – showed the actual trypanosome parasites swimming in Jean’s cerebral spinal fluid. Concurrently I tested Jean for malaria and meningitis. He had a moderately severe malaria as well and no meningitis.

We wisked Jean off to the in-patient department and I had the nurses immediately start his intravenous treatment for sleeping sickness. We also treated him for malaria.

Later in the evening Jean remained in a semi-comatose state. When I did the night rounds I found a woman sitting on the ground near our salle de guard – or nurse’s station. It was Jean’s mother who had come from their village. I told her Jean was very sick but he was getting everything we had to help him. And with that, we put Jean in the closest tent to the nursing station.

Let’s hope Jean can recover from this severe episode of sleeping sickness. I will hope for his awakening and keep you posted dear readers and friends.

Warm wishes from the Central African Republic,
Raghu Venugopal

Since my last entry we have had eventful times here in Maitikulu. Most recently, our sleeping sickness camp was visited by our Chef de Mission/Head of Mission (HoM) accompanied by our Project Coordinator. The visit of the HoM was an opportunity to reflect on the progress and future of our camp. HoM’s usually have tremendous MSF experience and there are often pearls to pick up during formal and informal discussions. During the visit of the HoM he delivered a thoughtful and motivating speech to the national and expatriate staff during our weekly team meeting. Such moments are useful in defining why MSF is in this isolated region of CAR and why MSF as a social movement exists. As a field volunteer, I appreciated his visit.

On a personal note, the process of adapting to a rural and basic living situation continues to evolve. I’ve started to get comfortable shaving using a computer screen as a mirror. It’s tricky to not allow any water drip onto the keyboard, but totally do-able.

Here, we also tend to get up around 6 am. You can’t help it, it is so bright outside and the roosters are crowing. As well, the patients and families in the hospital are up and about – babies are crying, nurses are working and people are starting their day. Given our early rise and the mid-day is the hottest time of the day, I’ve realized the value of a small afternoon nap. This way you can finish the rest of the day stronger, bear the heat a little better and have a bit of energy to do some work in the evening when there are less interruptions. Although it is monsoon season here, between rains it is hot and humid. Our logistician from Ireland and I find it really too hot sometimes. I’ve taken to rolling up my pant legs and not wearing socks anymore. The problem with that is that my legs are covered in mosquito bites and they’re really itchy. Oh well – c’est la vie. It’s all about adaptation and flexibility. Time also helps you get used to almost anything.

Operationally, we’re currently still inviting villagers to our camp who have been previously diagnosed with sleeping sickness. Slowly, but surely, they are arriving, but not as fast as I had hoped. Soon we will be able gradually incorporate some mobile (village based) activities. These will include village based convocation of patients to our camp for treatment, verifying our current village population data, and screening (in their villages) those who have been perhaps missed by previous sleeping sickness screening efforts. I’m really excited about gradually and methodically taking our show on the road.

On another front, case management of severely ill patients remains one our key goals. Not all the time they are successful. Let me tell you about Ndodet and Doulkanoji – the story of two 2 year old boys.

Ndodet, from Bekourou presented this week in a critical state. He arrived in the out-patient department with convulsions, diarrhea, and fever. Our nursing staff quickly realized he was severely ill and notified our national staff doctor who took the child directly to the lab to be cross-matched along with his mother for an immediate blood transfusion. An intravenous line was inserted and intramuscular anti-malarial medications were immediately given. While his mother was being cross-matched I heard of the case and together we took the child to our salle de guard or emergency nursing station. As we began to give the child some intravenous glucose I noted that the child had stopped breathing. We cleared a table of its books and equipment and I put Ndodet on the table in order to resuscitate the child. On the table we could better see what we are doing since inside the salle de guard (or nursing station) its dark even in the day.

Along with our American emergency nurse-practitioner, 3 national staff nurses and our national staff doctor we “coded” or in other words, tried to resuscitate (or reanimiate) this child for 45 minutes. This involved cardiac massage, artificial respiration, intravenous fluid, intravenous glucose and intravenous epinephrine or adrenaline. Unfortunately, it did not work. We never got a pulse back. The child never resumed breathing. The team did a good job in its attempt and the process was calm, fast-moving and methodical. Everyone did what they needed to do. I wish Ndodet had arrived just 2 hours before. Even 1 hour before. I’m sure we could have saved him with just a few more minutes – as we can organize the transfusion of blood in under 30 minutes. During the code, we allowed the mother to stay at the bedside as we would do in North America. She could see what we were doing and I hope there will never be a question in her mind that her child received all the medical care possible in this rural corner of the Central African Republic. As the walk back home to her village is long, after Ndodet died, the mother gathered the body and prepared to leave immediately. A few minutes later I found her outside the hosptial on the side of the road sitting on the ground, crying. A local nurse and I comforted the mother and told her we did all we could do. She thanked us.

In contrast to the case of Ndodet, let me tell you about Doulkanoji. He is also a 2 year old boy, but he has made a dramatic recovery. This patient is from Ndahili a village 30 kilometres away in Chad. He presented in a severely emaciated state and could not sit up when he arrived here. I was very concerned that he would die. He presented weighing only 7.4 kg but after 14 days of therapeutic re-feeding he has bounced back and weighs 8.8 kg. He can now sit and unlike before, he will actually cry if he is scared or examined. Before he would only moan and lie there.

Thankfully, we have many cases like Doulkanoji and few cases like Ndodet. But this is rural central Africa, where about 1 in 5 children under the age of 5 years will die without medical assistance and functioning social services. When we can cure patients it is a wonderful experience, both personally and professionally. They balance the sense of frustration, anger and sorrow when a child like Ndodet dies. To me, is what MSF is all about – doing our best and providing necessary medical care under difficult circumstances, and ultimately measuring our success and the meaning of our work one patient and one name at a time.

Best wishes from the Central African Republic,
Raghu Venugopal