As I’ve mentioned before, Zemio, and the province it sits in to the extreme east of CAR, is by and large an oasis of relative peace in this belaboured country. With the exception of occasional reports of roaming LRA elements, my nine months here have been unexpectedly free of many of the usual sights and consequences of country in conflict. War-wounded, malnutrition and diseases of displacement were by far the exception rather than the norm in our little hospital.
Exception I say – not unheard of though.
The road leading north west out of Zemio passes at the 40km point though Bahr, a village that has a small brick and mud walled health post. Our outreach nurse Brigitte visits Bahr on a two weekly basis to coach and train Paulin and Daniel, the two health workers there, and restock their small pharmacy which contains supplies to treat the main killers out here – malaria, diarrhoea, pneumonia and infected wounds.
Last November the wave of insecurity that threatened Zemio originated there – a long running feud between the stationary population and migrating groups (split on intercommunal grounds) that erupted in the form of an armed attack. In Bogou, the village adjacent to Bahr, houses were burned, and the resident population of both villages were forced to flee into the surrounding forest.
In December, Bahr was attacked again. This time some houses and food-stocks were burned, three villagers were killed and others injured. Owing to ongoing insecurity on the road we were unable to reach any remaining wounded. You can’t save them all, we were forced to remind ourselves as we kept the rest of the hospital going through the instability.
The repercussions of this continued well into the New Year. Most of the village was still camped out by the river a couple of kilometres from the village.
Astoundingly Daniel and Paulin at the healthpost continued their work undaunted, and Brigitte came back from one outreach trip some weeks later bursting with pride and reported that Paulin was making trips throughout the village with malaria rapid tests and oral medication to treat his community, many of whom were too afraid to make even the short journey to the health post and others who were still camped out in the bush and beginning to suffer the effects of displacement. Of the four health posts that we support, malaria rates there were the highest, and this in the dry season too which generally sees an natural ebb in the number of cases
Still going with caution, Brigitte’s next movement to Bahr in January was again approved with two expats. Needing a break from the hospital I volunteered, and on this trip was able to see first hand the after-effects of the violence. The village, always erring on the sleepy side, in contrast to the relative bustle of Zemio, was deserted, save a handful of wary youths with hunting rifles sat under a tree. After checking the health post, restocking their small pharmacy and shaking our heads with dismay at the malaria statistics, we took a walking tour of the village.
The quiet was eerie, compounded by the intermittent sight of burned out huts and houses. Here the blackened remnants of a bike – someone’s pride and joy I should imagine – there the sobering sight of a pair of charred flipflops left behind in someone’s haste to flee. And in one sad corner a fresh burial mound, hastily constructed, covering the bodies of those claimed by the attack. My feelings are complex; as much genuine sympathy as I have for the village affected, there are no truly innocent parties in this conflict – the cycle is sustained by both sides and one community’s loss today will be another’s tomorrow. More fighting, more lives, more loss. An eye for an eye will make us all blind, as Gandhi said. I feel slightly nauseous on the ride back, and I don’t think it’s the bumpy roads.
Brigitte and Daniel tour the burnt-out village
The next day in the hospital sees a family from Bahr come in, having just walked the whole 40km from the village, carrying their desperately ill ten-day-old daughter Emeline. Happily both Rob and I are in the hospital when Emeline’s parents carry her in – her mother fatigued from the long walk and wide-eyed with the unfamiliarity of the surroundings; her father stoic and silent in the background. Our secourist (nurse's aide) starts the history taking and then calls us over when the infant’s oxygen saturations won’t pick up on our monitor.
I take a brief look and holler Rob over – the baby is floppy, grey and scarcely breathing – and we start resuscitating right there on the mother’s lap, on the hospital veranda. Intraosseous needle (I’m getting very good at them now), rapid fluid and glucose bolus, oxygen, CPR on her tiny chest… this family reached here in the absolute nick of time, because five minutes later Emeline is miraculously pink and crying and her heart rate and oxygen levels have risen to near normal again.
Emeline day 1: Nasogastric tube feeds, oxygen, kangaroo care © Emma Pedley
The next few days with her are knife edge – newborns, even full term ones are fragile creatures and following other similar losses in recent months I tense myself every morning as I walk into the ward braced to see an empty bed. This baby was delivered on the forest floor with no medical attention – no disinfectants, no vaccines, nothing – and in addition to the infection that she already has, the biggest risk for her is tetanus which could have been contracted through the umbilical cord stump at birth.
I watch her closely for signs of rigor or spasm, having already seen children die from this during my previous mission in South Sudan. Thankfully she remains free of the symptoms, and we take advantage of the family’s hospital stay to get her mum vaccinated to help protect future siblings. This ruled out, we treat with IV antibiotics for neonatal sepsis, and hope for the best.
Emeline is the third child of her parents and they are fiercely and heartbreakingly meticulous about her care. I encourage the mother to drink and help her to hand express breast milk to give by nasogastric (NG) tube while the baby is too weak to suck, and talk with them through a secourist as translator about skin to skin care to guard her temperature. Mum and dad listen attentively and then for the next three days conscientiously alternate having Emeline tucked up on their bare chests while the secourists push small regular quantities of milk down the NG tube. We offer HIV counselling and testing which is eagerly accepted; once tested negative, and well nourished and hydrated again, Emeline’s mother is willing and able to donate surplus breast milk to another sick baby in our care.
After three days Emeline is sucking again and we are able to remove the NG tube. I breathe a little more freely. Day five and she is weaned off oxygen. I step down her vital signs to three hourly. Day six and she has gained weight and I can move her out of intensive care. Day 11 and she is ready to be discharged, except by this time I don’t want to let her go, because this little miracle baby and her parents are pretty much my favourite people in the hospital and the thought of sending them back out to live scared in the bush around Bahr again breaks my heart into a million little pieces. The hospital doesn’t have enough bed space for me to be sentimental though, and I reluctantly bid them farewell. It’s rare to have such a wonderful and obvious success story; a baby quite literally pulled back from the brink.
Any warm fuzzy feeling that I may be holding onto is rudely shattered the next day with more bad news from Bahr.
Another attack. Another fatality. But this time is somehow so much worse than before because the dead man is Paulin – our sweet, earnest, dedicated health post worker.
The whole project reels with shock at this – no one more so than Brigitte and Hayley who knew him best. Even now, writing almost a month after the incident, I don’t know how to express the sheer sorrow on the faces on some of our staff, and the profoundly painful sight of Brigitte’s usually exuberant and smiling face suddenly clouded and tearful.
We speak in his memory at the hospital meeting – messages of condolence and support come flooding in from the capital staff and other projects – we have a collection so as to have something, anything to offer his wife and children, as if anything could begin to compensate for their loss.
Nothing can and nothing will. But Paulin’s shy warmth and determination at his work will never be forgotten, and the least and best we can do in his memory is to continue to work – his work and ours – in the belief that all lives matter and with the hope that one day the fractured and divided communities in CAR will too overcome their conflict and realise it too. And just maybe, there’s a baby girl in Bahr who will be able to see this during her lifetime.
Rest in peace Paulin. We will carry on what you were so dedicated to.
Me, Paulin and Daniel, December 2014. © Emma Pedley
All names and photos used with permission