David Rothstein

They come in ones and twos, sometimes more. Some of the patients have fresh bullet holes or machete wounds, while others suffer wounds that have been 

Half a million people have been displaced in Bangui, the capital of the Central African Republic.

neglected for days because of an inability to reach the hospital. Some are innocents caught in the crossfire, some the very ones who open fire. And as is most often the case in civil conflicts, the majority of patients are not the ones directly wounded but those who suffer the consequences of the disruptions of an already-feeble health care system: intestinal perforations from typhoid fever; pregnancies complicated by arrested labor; severe skin and muscle infections that have spilled over into the bloodstream, leading to septic shock.

The Bangui General Hospital is one of three main hospitals operating in the Central African Republic's capital, with its population of some one million people. Built in the 1960s by the Moroccan Government, the large complex sits a few kilometers in one direction from the relative peace of the Oubangui River, and in the other direction from the chaos of Bangui's violence-torn PK5 and PK12 neighborhoods. It is from the latter two areas that nearly all of Bangui's Muslim citizens have fled or been evacuated in the past few months as sectarian violence between Muslims and Christians threatens to tear the country apart. Most have continued on to the northwest of the country, or to neighboring Chad or Cameroon.

I am part of a skeleton team of expatriate physicians, nurses and support staff from Doctors Without Borders that works with Central African doctors and nurses to provide emergency room and surgical care at the hospital, while other teams concentrate on outreach in refugee camps and mobile clinics across the country. From the hospital's rooftop we peer across the city. A flock of birds floats languidly across the sky, the crimson glow of the sun setting behind the unlit spotlight towers of the main soccer stadium. The peaceful scene belies the spasmodic chaos below. At night we hear scattered gunfire and grenade explosions in the distance and wonder how many patients will come, and when.

A 23 year-old woman arrives one early morning, her body riddled with bullet holes. Several slugs have blasted through her limbs, shattering bones. Despite our best efforts, her gaping chest wounds portend a death that cannot be averted by limited surgical capacity. I wonder — no more here than back home — what leads people to violence. The human body is not meant to be torn apart by bullets.

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Spasms of violence grip this country, while in the background normal societal structures unravel. Thirteen percent of the population is internally displaced, schoolrooms are often empty and crops go unplanted. A year ago, the overt violence in the capital was perhaps worse; aid workers who were here described dead bodies lining the streets on the way to the hospital and extrajudicial killings occurring daily across the city, some even outside the pediatric ward down the street. And what now? Despite the presence of some 2,000 French troops and 6,000 members of an African Union-led peacekeeping force, the Central African Republic appears to teeter on the brink. The United Nations recently approved the deployment of 12,000 additional troops and police to help maintain order, but they are not due to arrive until September. Meanwhile, the disorder in this former French colony continues. While the war-wounded may be the most visible victims, the real and lasting tragedy may lay in the consequences of worsening malnutrition, estimated to affect over two million citizens, many of them children. A society broken at the center is fraying ever more at the edges.

An emergency MSF operation in the Hospital Communautaire in Bangui.

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From the northern village of Boguila, close to the Chadian border, news of the slaying of 16 civilians, including three Doctors Without Borders national staff, chills our hearts and rattles nerves. Unprovoked, and occurring during an armed robbery at a health outpost clearly marked as a Doctors Without Borders facility, the killings have sparked an internal debate within the organization, used as it is to operating in difficult situations. Doctors Without Borders decided to reduce its activities throughout Central African Republic in protest for a short time, although the work at the hospital continues unabated.

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Last week, a 35-year-old woman in her tenth pregnancy arrives in the emergency room in shock, barely coherent. The shape of her swollen abdomen suggests a ruptured uterus and she is rushed to the operating room. The eight-month-old fetus has perished and the mother's life hangs by a thread as we perform an emergency hysterectomy. Uterine rupture occurs up to ten times more often in least-developed countries than it does in the most-developed countries. It can be a final blow after the domino effect of having many pregnancies, limited pre-natal care and obstructed labor with impaired access to health care facilities. Up to ninety percent of women with uterine rupture die, as will this patient in a couple of hours. There is too little that we can do, too late. The patient's mother waits outside and receives the news, translated from French to Sango and back, with an unmoving face. A short while later, as daylight breaks and the sounds of roosters and the waking hospital fills the grounds, I watch as she carries away the wrapped body of her unborn grandson. She disappears behind a cement column painted a rusty red, bare feet padding along the floor. It ought not end like this…and yet it does.

David Rothstein, 44, is a pediatric surgeon at the Woman and Children's Hospital of Buffalo. He became interested in low-/middle-income country setting medicine in medical school, spending time in Ecuador learning Spanish and Guatemala working in HIV and primary care clinincs, finally cementing an interest in global surgery during his residency. He began working with Médecins Sans Frontières in 2007 in northern Sri Lanka and has made month-long trips for MSF each year since, working in Chad, Nigeria, Democratic Republic of Congo and the Central African Republic. His focus is on surgical education, outcomes research, minimally invasive surgery, and humanitarian relief work. Rothstein worked briefly as a journalist in a previous incarnation, writing for The Daily Hampshire Gazette and The New York Times.