Eastern Chad: bringing war surgeons closer to the wounded
More than two years after an explosion of violence shook eastern Chad, some 160,000 people are still unable to return to their homes. Proliferating firearms in the area and the ongoing risk of clashes between the Chadian army and armed opposition groups have created a pervasive atmosphere of potential and actual violence. The ICRC surgical team based in Abéché treats the most serious cases, most of them civilians. Following a three-month assignment there, Dr Ali Touati describes the situation (interview conducted before the clashes of early May).
After the conflict flared up in eastern Chad in 2006, we set up a base in Abéché to help the civilian population in the area. At the time, surgical and other ICRC staff assigned to N'Djamena were sent to Abéché for fixed periods to care for the wounded.
After further fighting in 2007 and 2008, the ICRC stepped up its presence in the east in order to be at the side of people suffer ing the effects of the conflict and also to be prepared for any worsening of the hostilities. At the moment we have sub-delegations in both Abéché and Goz Beida, plus an office in Adré and five other bases: Adé, Dogdoré, Kawa, Guéréda and Iriba.
Nothing has changed in eastern Chad. The agreements reached by the government and the armed opposition have largely been ignored and tension remains palpable. Intercommunal violence persists and people are at risk from the constant banditry. Some 160,000 people driven from their homes by the fighting are still unable to return.
In addition, the conflicts in neighbouring Darfur, and to some extent in the Central African Republic to the south, continue forcing people to flee across the border into Chad. This has further burdened local health-care facilities. So it was natural for the ICRC to start working in the area, especially to treat people urgently needing surgery.
Who are the people treated by the ICRC?
Thanks to sound coordination with the other humanitarian organizations active in eastern Chad, emergency surgical cases from across the area are referred to Abéché and treated by our team there.
What type of wounds did you see?
In three months I personally operated on almost 80 patients at Abéché hospital. About 60% of them had gunshot or knife wounds. Many of the knife wounds were to the chest or abdomen. The other patients had mostly been in road accidents, and in fact those were the cases where we did the most amputations. So not all of our patients are war-wounded.
How and where does the ICRC surgical team work?
The team consists of a surgeon, an anaesthetist and two nurses (one nurse for the operating room, one for post-operative care). They mostly work at Abéché hospital, which is the referral hospital for the entire eastern part of Chad, that is, for an estimated population of one and a half million people. And one of our aims is that this hospital should fully play its role as referral centre. All war-wounded people and other urgent cases admitted to the hospital are operated on by the ICRC.
Once in a while the team travels elsewhere to treat seriously injured people who can't be brought to Abéché and can't be cared for by other organizations. In February, for example, we went to Iriba, near the border with Sudan. It took only an hour to fly there in a small ICRC plane. It would have taken nine hours overland, and we had 48 war-wounded patients waiting for us. We operated on them one after the other for four days straight.
In such cases we travel with all the equipment we need, which we can set up in a primary health-care post, for example. It turns it into a real operating theatre. So the team is completely autonomous, though we do work together with local practitioners whenever possible.
What about training for Chadian medical staff?
We do this as much as we can, usually in an informal manner. We strive to share our knowledge with the staff of Abéché hospital during rounds and the daily staff meetings.
There are few surgeons in eastern Chad. They are all able to do basic surgery: hernias, caesarian sections, etc. But war surgery is a far different matter – it demands specialized training which our Chadian colleagues generally haven't had.
But in the near future, three Chadian doctors should accompany the ICRC team for six months to learn war-surgery techniques. And in November 2008 the ICRC organized a seminar in N'Djamena to make medical practitioners aware of the special nature of war surgery. About 40 doctors, both military and civilian, took part.
What are the main problems you encounter?
The difficulty of reaching health-care facilities prevents a lot of people from getting the care they need. But so does the weight of tradition. Some people a rrive in appalling condition, often because they have had no previous treatment at all, because of the great distance they've had to travel – a journey for which frequently no transport is available – because they didn't know about Abéché hospital or simply because of negligence. But also sometimes because they don't believe in the benefits of surgery. One day, a man came in for a consultation. He had advanced gangrene and we told him that his only hope was amputation. He refused and died at home a few days later.
Another problem is that the staff are often overwhelmed by the number of patients and the lack of equipment, medicines and other supplies. The shortage of paramedical staff, especially physiotherapists, is another difficulty. Patients needing physiotherapy – for a new artificial limb say – have to go to N'Djamena, where there's an ICRC-supported limb-fitting and rehabilitation centre. So we're currently assessing exactly what the needs are at Abéché hospital for post-operative therapy. Depending on the results, we might see a specific programme being launched in Abéché or training in physiotherapy for local staff. Or both.
What is your most vivid memory from your three-month assignment?
Late one afternoon two brothers came in. They had been injured by an anti-personnel mine. Their parents accompanied them on the eight-hour journey on a dirt track. One brother was nine years old and had serious injuries to his leg and hand. We operated on him until late into the night. We had no choice but to amputate several of his fingers. But he's still able to use the hand. Soon he'll be receiving a skin graft for his leg. His brother, who was eight, had suffered multiple wounds all over his body, but they were not serious and he quickly recovered. I will always remember the smiles both boys were wearing only a few days later. And their parents'profound relief.