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Difficult decisions, serious consequences

"From a western European perspective, this idea is difficult to understand. Here, however, traditions are deeply rooted in the local communities..."

Sylvia Schaber is an internist. She has been with us in Bossangoa in the Central African Republic for four months. In her blog, she talks about new experiences and inspiring people, but also about the hard reality and difficult challenges of life with Médecins Sans Frontières / Doctors Without Borders (MSF)...

After a stay abroad some years ago, I’m still fluent in French. But in contrast to what I thought, this unfortunately only rarely helps me in conversations with patients. Most people who come to us from surrounding villages speak Sango, the second official language in the Central African Republic.

Only on a few occasions, mostly when patients arrive from the "city" of Bossangoa, my knowledge of French helps me. That’s why I need the help of a translating colleague when I obtain a patient‘s medical history or when we do medical rounds. 

"How do you know it is going to take longer for the baby to arrive?"

Because I'm relying on translators I was astonished at the beginning of my time here that so many things in everyday medical life are different from what I'm used to in Germany. For example, when I ask patients how long they have had a fever. It's a simple question … But here it usually leads to a two-minute conversation between the translating colleague and the patient. The answer I get is very often rather vague. Only rarely is it possible to determine an exact day.

After a while, I found out the reason: most people here have never learned to measure time in days, weeks or months. Not everyone was lucky enough to be able to go to school.

This vagueness around timeframes can be a great challenge, especially for my colleagues in obstetrics.

Imagine a pregnancy: how do you know that a baby needs a little longer if it‘s impossible to calculate the date of birth? And how do you decide whether and when to intervene? That’s why labor is rarely ever induced here in Bossangoa.


Most people that come to Bossangoa speak Sango. I need the help of translating colleagues to communicate with the patients.


A life saved, a life destroyed?

The example of gynaecology can be used to point out some cultural and traditional differences between here and home.

A woman without her uterus seems to lose her status in the local society here. From a western European perspective, this idea is difficult to understand. Here, however, traditions are deeply rooted in the local communities.

My surgical colleagues are often confronted with difficult decisions with correspondingly serious consequences: for example, do you leave the uterus in the abdomen of a woman who has suffered a cervical tear during a complicated birth? While in a German hospital the decision would be crystal clear, here it is not.

For the woman, not removing the injured uterus means a greater risk of complications in the healing process. And above all it means a big risk for another cervical tear with a further pregnancy. This would be life-threatening for mother and child. But, if you remove a woman's uterus, you risk her being rejected by her family.

This dilemma became particularly clear in a patient around 48 years of age with suspected malignant tumours in the uterus.

While I examined this patient she begged me not to remove her uterus during treatment. When I asked her if she still wanted more children, her answer was a clear "no". One look at the ward nurses was enough for me to understand that he was objecting out of those very social fears. As a doctor, this is sometimes difficult for me to accept.

Fortunately, there are many colleagues here from the Central African Republic who never get tired of explaining all the subtleties and traditions of the area to me. So I dive deeper and deeper into life here. And I have the feeling that I understand more and more what is important to people here in life, at least to some extent.