Chad: Ensuring anaesthesia and intensive care for women and children

Your most recent work with MSF was in South Sudan late last year, and this wasn't your first time in Chad either, right? How did it feel returning to Moissala, Chad, three years since 2022?

Yes, it was my return to the same MSF project in Chad after three years. It was a project MSF runs in Moïssala in collaboration with the local Ministry of Health authorities. MSF handles obstetrics-gynaecology and paediatrics. MSF only performs obstetric surgeries; other surgeries for adults or children are handled by the local Ministry of Health staff.

Compared to before, there was a point where I thought, “Wow, this has definitely improved,” and as a long-time MSF staffer, I felt a sense of fulfilment there. What exactly improved, you ask?

First, an obstetrics-gynaecology intensive care unit (ICU) was established. Three years ago, the medical staff were already doing their utmost to treat patients, but there's a big difference between frequently checking on patients in rooms near the general ward station and having a dedicated ICU. Of course, it's not as well-isolated or as well-equipped with monitors and ventilators as ICUs in Korea. Still, the concept of having three beds in a separate space with dedicated nurses who can check on patients more frequently is a major change.

Second, a dedicated dressing room – a treatment room solely for wound disinfection and care – was established. Since poor overall hygiene frequently leads to wound infections, this alone makes infection control much more efficient. In that region, mothers also experience wound infections after caesarean sections more frequently than in Korea.

The same applies to paediatric patients with burns. Even in non-traumatic cases, people in remote areas with poor access to medical facilities often resort to so-called ‘traditional treatments’ –  which also include injections of unknown substances – leading to infections and abscesses in wounds, which are not uncommon reasons for hospital admission.

Were there any distinctive medical or health issues at the site?  

Moïssala, along with the entire country of Chad, can be considered a malaria-endemic region. Although the rainy season is considered the ‘peak season’, the incidence rate isn't low during other periods either, making it effectively endemic year-round.

The MSF Moïssala project initially began as a malaria response focused on specific periods, but when it transitioned to a permanent project in 2018, it shifted to providing ongoing response to local healthcare needs, including malaria. Pregnant women and children are undoubtedly extremely vulnerable groups.

Three years ago, I used to witness quite a few cases of mothers in poor condition. Even healthy adults struggle with malaria, but when pregnant women or children under five contract it, the illness often progresses to a critical state. Mothers are prone to anaemia anyway, and when malaria compounds this, it leads to severe anaemia.

MSF has also launched a new malaria vaccination program using the R21 vaccine in Moïssala, Chad, and surrounding areas. I spent time with the team there this time. Seeing their long-term, consistent disease management in the community, I realised that through such new initiatives, they are providing ‘sustained support, not just a quick fix,’ to the local healthcare system.

When I first went to Nigeria for my first MSF assignment, I often saw mothers with haemoglobin levels around 1.2. But this time in Moïssala, I saw many mothers arriving with severe anaemia or even in a coma. Even without malaria, there were many patients with what we commonly call preeclampsia in Korea.

Were there any patients during this activity that particularly stood out in your memory?

Patients who passed away tend to stay with me more strongly. There were two patients who died while under our care in the ICU, though they didn't undergo surgery. One was a pregnant woman who died from an infectious sepsis before she could deliver her baby. The other mother had given birth sometime prior, but she was only about twenty years old. She was brought in after ignoring an infection in her breast for a long time.

By the time we examined her, the area was nearly necrotic. We wanted to remove the infected tissue, but her condition was too poor for surgery. We started her on antibiotics and IV fluids, planning to operate once her overall condition improved. It was a race against time, but after about two days, her condition didn't improve, and she ultimately passed away.

Finally, just before I came home, there was a patient admitted to the ICU who, according to her family, had given birth about two weeks prior. When she was first brought in, her eyes were open, but she was in a confused state of consciousness, barely able to respond. When I asked her family about the cause, they initially didn't give a clear answer, saying something like, “After giving birth, her consciousness became strange.”

Using a French interpreter and a dictionary, I learned that the family had cut out the mother's uvula for some reason. I remember feeling utterly bewildered for a while, even after understanding the word ‘uvula’. They mentioned it was a kind of tradition, but everyone seemed reluctant to explain it properly. The wound from the uvula is certainly a sufficient cause for infection.

Of course, there could be other causes as well. We used various medications, including antibiotics, and the patient's fever seemed to have subsided a bit just before I arrived. I still wonder how things turned out for her in the end.

Even for someone like you, a seasoned international mobile staffer who has worked with MSF across the globe for over a decade, each project must present new challenges that aren't always easy. How was the working environment this time?

Moïssala, and indeed all of Chad, doesn't seem to be in a particularly unstable security situation right now. It was fairly stable when I visited before, and it still is now. It takes about 20-30 minutes to walk from the accommodation to the hospital, and that distance was manageable to walk alone. Eastern Chad likely still sees many refugees flowing in due to the war in Sudan, but Moïssala, located in southern Chad, felt like a peaceful rural village, largely untouched by the Sudanese conflict. It was the rainy season, so it rained daily, and the temperature hovered around 30 degrees Celsius.

The four local nurses in the ICU are also highly motivated. My predecessor in the anaesthesiology department had trained these nurses on medication use and blood transfusion management about two months before I arrived. Since those four were still on staff, I also did some what's often called ‘bedside teaching’ this time, providing ‘reminder’ training right at the bedside. “Alright, let's talk about using noradrenaline. How do we prepare it initially? Right. Now we need to attach it to this machine and administer it to the patient, but how much should we give? How do we calculate that?” That sort of thing.

Do you plan to continue participating in MSF assignments regularly?

As long as my health and circumstances permit, I intend to participate in at least one assignment per year going forward. I enjoy working directly with the patients where MSF operates.

When you're on an MSF assignment, you also really feel how invaluable each and every doctor is. First, the number of doctors produced in countries where MSF operates is incomparably smaller than in places like Korea. In Chad and neighbouring countries, few medical graduates go on to become specialist doctors. Even if what I did in Chad was basically the same work I usually do in Korea as an anaesthetist, you could say that my work there feels as needed and valued as that of 10 persons' work combined.

In areas where MSF operates, doctor anaesthetists are so hard to find that the position is often vacant. It's true that I sometimes wonder, “If MSF weren't here, would these lives have been saved?”

The English translation of this interview has been condensed for brevity.