"When I arrived here, I felt like I was falling into a void," said Dr. Louis-Marie Sabio while standing in the courtyard of the Bakouma secondary hospital. At the beginning of 2023, Dr. Sabio—a former MSF doctor in the city of Bangassou—took over the management of the hospital, which is meant to handle surgical complications in a volatile area near Nzacko, in the northwestern part of the Mbomou prefecture.
"For 12 years, not a single doctor was present here," he explained. "The hospital was run by a health assistant. Well, when I say 'hospital,' that's a big word. There is no electricity, no ambulance, and beds without mattresses. When I arrived, there wasn't even a thermometer, blood pressure monitor, pulse oximeter, or glucometer. The pharmacy was empty, too."
Although secondary hospitals like Bakouma are supposed to provide more advanced care than other facilities, including health posts, health centers, and district hospitals, Dr. Sabio struggles to provide even basic care. Despite the hospital’s size, there are fewer than 10 patients, and the hospital is eerie and silent. Chickens roam the corridors and wards, weaving between broken scales and rusty tables. Except for the vaccinations and referrals provided by MSF, the facility receives no other support. Patients know that despite Dr. Sabio’s goodwill, the lack of human and material resources means that they are unlikely to find the medical help they need.
"There are 18 of us running the hospital, but I'm the only one with medical training," said Dr. Sabio. "Due to our limited technical resources, we can't meet the basic requirements of a hospital. We have no electricity, preventing us from performing ultrasounds or X-rays. The operating theater is virtually bare, equipped with only a small solar panel to power two lightbulbs. When patients need medicine, we have to send them to the local market and hope they find something."
A critical health situation continues
This picture of no supplies, no staff, and no support is replicated in health facilities across CAR. According to a recent report from the World Health Organization and the Ministry of Health, less than half of the country's health care facilities are fully operational, and the ratio of doctors to people is alarmingly low, with only 0.6 doctors for every 10,000 people—one of the lowest ratios in the world.
Decades of political unrest and violence among armed groups have fueled the massive crisis, leaving more than half of the country's 5.5 million citizens in need of humanitarian aid. The country's life expectancy is a mere 54 years. Pregnant women face a substantial risk of death or severe illness due to the scarcity of gynecologists. And child mortality rates rank among the highest globally.
Patients wait in the triage area (left) at the Baliguini health post (right) near Bakouma, Mbomou prefecture. CAR 2023 © MSF
"We often feel alone"
MSF has nearly 2,800 staff members in CAR—it’s one of our largest programs across the 75 countries where we work. Most staff are hired locally, and work tirelessly to support health authorities and communities in improving access to health care in some of the most neglected areas. In the Mbomou prefecture, MSF supports 15 health facilities, from small remote health posts to the Bangassou regional university hospital (HRUB), which is the only specialized reference facility serving a region the size of Greece.
Initially launched as an emergency response to massive violence that shook the country between 2013-2014, MSF's programs in the area now serve a significant portion of the prefecture. MSF sends mobile teams to local health facilities to provide essential equipment, vaccines, and vital medicines that can help treat common childhood diseases in the region, such as malaria, diarrhea, and respiratory infections. MSF also provides training to health workers, and arranges referrals to Bangassou's hospital for patients in critical condition.
"[Our] objective is to bolster health care provision at all levels to reduce mortality in the area," explained Pelé Kotho-Gawe, MSF's nurse supervisor for mobile activities in Bangassou.
However, the needs remain grossly neglected as MSF cannot address them alone. Humanitarian organizations are scarce in this region, even though violence has calmed somewhat in recent years. The massive health crisis is exacerbated by the lack of access to water and electricity in health facilities as well as economic difficulties.
Bangassou hospital, a mirror of the ongoing crisis
As MSF’s team travels between health posts and health centers, this feeling deepens. Without MSF’s assistance, pharmacy stocks would be depleted, parents would struggle to afford treatment for their children, and women would be forced to give birth without the supervision of trained professionals.
However, the situation at Bangassou hospital is a stark reminder that this support is not enough. In other words, patients come to this facility day and night, sometimes traveling hundreds of miles on a motorcycle over rough terrain, because treatment or medications are not available elsewhere. The hospital is the last hope for many patients with complications.
An MSF health promoter provides information on family planning services to women awaiting at Bangassou Regional University Hospital. CAR 2023 © MSF
For example, four-year-old Guy arrived in a coma. His parents brought him to Bangassou from Bao, more than 60 miles away, because the hospitals near his home did not have the insulin he needs to treat his type 1 diabetes. Newborn René* was admitted for the third time to intensive care due to severe malnutrition, as malnutrition prevention programs in Bangassou formerly run by an international nongovernmental organization have been discontinued. Twenty-year-old Fanny was transferred from Bakouma, 80 miles away, because Dr. Sabio and his team lacked the medicines and equipment needed to treat a wound on her back.
"In a normal situation, patients like Fanny should be treated at my hospital," said Dr. Sabio during a visit to an MSF training session. "But you've seen the state of the facility I run. I still send patients to Bangassou who shouldn't need to be referred. Sometimes, I even have to refer patients without being able to stabilize them beforehand, unsure if they will survive. The other day, I had to make an emergency transfer of a baby to Bangassou by motorcycle, as we don't have an ambulance. We couldn't stabilize him, and he died a few miles from here, on the motorcycle."
DR. LOUIS-MARIE SABIO
“We are confronted with realities that make this work seem endless,” said Kotho-Gawe. “We can treat children suffering from diarrhea, but without anyone drilling boreholes [to provide clean water], the problem persists as people continue to drink untreated water. The same goes for malaria: We visited health centers where 90 percent of patients tested positive for malaria, and while we provide free care for the children no one in the area is engaged in preventive measures or distributing mosquito nets. Sometimes other organizations come through, but they are not frequently seen, and we often feel alone in tackling these challenges. MSF clearly cannot handle everything on its own."
"The first time he had an attack, he fell into a coma, and I came here," says Nadia Sasango of her son, who was treated by MSF teams at Bangassou regional hospital. CAR 2023 © MSF
A shocking lack of international attention
"The health situation in the CAR is shocking, but I'm almost as shocked by the lack of international attention paid to it," said René Colgo, MSF's head of mission in CAR.
"Despite the scale of the crisis and the staggering statistics, the plight of people here remains largely unknown to the outside world, and humanitarian funding falls far short of the scale of the needs. For reasons linked to insecurity or logistical constraints, NGOs are not always present in the areas where the needs are greatest. Much more must be done to support people. Where is everyone?"
To bring about change, it's time to see the situation in the CAR for what it is: a severe and lasting humanitarian crisis that requires international mobilization.