Interview with Dr. Fernand Marxen, surgeon in Bili, Democratic Republic of the Congo.
Dr Fernand Marxen has worked at the (free of charge) mission for medical care for central African refugees and for the indigenous population in Bili, in the province of Nord Oubangui, in the Equateur region, from the beginning of May to the end of June 2016. He returns at the beginning of February 2017 for a two-month mission.
How is the work of MSF viewed by the local population?
The MSF project in Bili is very much valued by the local population, due to the reliable level of medical services provision, free treatment, and the quality of interventions and drugs available, not forgetting its considerable economic impact. The hospital has an emergency department, with intensive care at the local level, an associated internal surgical/medical department, a gynaecology/obstetrics department, and a paediatrics and malnutrition department (for children and adults).
The Nord-Congo region is a medical desert, and refugees as well as the local population have a pressing need for medical assistance. All the services, and above all intensive care, are in a state of permanent overload, even to the extent that two adults or, as is often the case, four children have to share the same bed. Care is provided according to the degree of urgency.
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Dr. Marxen performs a dressing change on a young boy after abdominal surgery. © Fernand Marxen
For a surgeon, what is the definition of an “emergency”?
An emergency is defined as a situation requiring rapid medical or surgical intervention, in order to avoid, if possible, a fatal outcome, or at least severe complications, which could become irreversible. In the field of surgery, the intervention envisaged needs to be possible within context of what may be limited local resources (human, material, and infrastructure), its follow-up needs to be possible, and it must be the only solution that represents an element of hope, and finally, it needs to be agreed to by the patient and their immediate family and friends.
Alongside these emergency situations, there are cases that may require some discussion, where the situation may not be immediately life-threatening, but may only potentially become so later, such as, for example, cases of post-malarial splenomegaly (increased volume of the spleen), digestive tumours, and digestive fistulas leading to a progressive state of malnutrition. Deciding whether to carry out a major intervention in such cases is solely the responsibility of the individuals directly involved, both surgeon and anaesthetist, who must, without fail be supported in their decision by the patient and their entourage, who have been duly informed of the risks, but also, of course, of the expected benefits.
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Cutaneous incision starting an intervention for an inguinal hernia (displacement of the intestine). © Fernand Marxen
What are the differences between working in Luxembourg and in situ?
Working in Luxembourg is certainly much easier: ultra-sophisticated diagnostic resources, a state of the art technical platform, highly qualified personnel at all levels. multi-disciplinary management of pathologies, an effective, reliable sterilisation department, extensive postoperative monitoring resources, and a continuously available laboratory. But the expectations and requirements are sometimes disproportionate, as though all of this were an entitlement, not forgetting the day to day degree of comfort that we tend to take for granted: the very best standards of treatment, a choice of so many menus, TV and internet access, air-conditioning, etc….
In Bili, none of that exists: no running water in the hospital, regular power cuts, no radiography/-ology or echocardiography, no endoscopy, an embryonic laboratory service, a poorly trained personnel, sterilisation performed using a pressure cooker heated on a charcoal fire, ambient temperatures typically in the region of 30°C., including in the operating theatre block, with a limited range of standard equipment, no respiratory support equipment, no recovery room or, even more importantly, any post-operative intensive treatment facility, with food being provided by the patient’s family…..
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Sterilization is very long and is done on charcoal, in large steel pots. © Fernand Marxen
The need to be creative sometimes to find solutions
And even so, the patients are happy that they can be taken care of by a competent and devoted team, and also free of charge. There are a range of pathologies: hernias and goitres (increased volume of the thyroid gland) of “historic” dimensions, complications arising from interventions by traditional healers, obstetric surgical emergencies, acute cases of malaria and hepatitis, tuberculosis, extreme cachexia (profound weakening of the organism) due to malnutrition, accounting for the majority of cases. There is a need to be able to deal with all types of situation. No plaster to immobilise a fracture? Bamboo is cut into strips of the required length and width. It is something of a return to basics, to the beginning of my career. But it is a matter of providing hope for these people living in destitution.
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During the rainy season the roads then become impassable and transfers impossible. © Fernand Marxen
This hope is sometimes compromised, when access to treatment becomes impossible due to the floods in the extremes of the rainy season, which lasts 6 months, when roads become impassable, except for 4x4s or motorcycles: transfers become impossible and emergency calls receive no response, and the natural wilderness reasserts its grip on the land.
The commitment and dedication of my colleagues
Working under these conditions is an experience of humility and modesty, which quite simply brings together the extraordinary commitment and devotion of the local doctors, who, despite modest conditions, carry out remarkable work.
It was with some regret that I left Bili at the end of June, but I am happy to return there for a two-month mission in February.
