Farchana Nights

“It’s not the mountain that wears you down, it’s the rock in your shoe.”

It has been brought to my attention, most unceremoniously, that I have kept the blog more descriptive than personal, more playful than ranting, more academic than grit. That I’m telling the stories of others more than telling my own, and am committing the error that every shrink hates to make, but invariably does: I ask everybody else what they feel about this or that, and am not asking myself this question (or at least not writing about it). Point well-enough taken. How am I doing? Right now I’m starting to feel better, but last week I felt mostly flat, tired, and shitty.

When I arrived here among the standard questions I received (age, length of stay, number of wives and children, etc.) was “have you ever been to Africa before?” And even though I left when I was three years old, my having been born in South Africa was met with a genuinely warm inclusiveness; I was told that I have, and will always have, “un coeur d’Afrique,” or an African heart. I don’t know why, but somehow it fits in a goodly way… I feel a corporeal kinship with the soil, steppes, and people. The words “South Africa” smell of Jakaranda trees in blossom, of my grandparents’ Johannesburg flat, and large platters of freshly cut fruit. My bowels, though, are assuredly Canadian, and have for the past several months been treating me like an angry, antibiotic-crazed prostitute. And you can imagine that my skin, incubated for the past 20-some years in the halogen havens of classrooms and hospital hallways, feels about the same.

The rest of my body is, at times, not so thrilled either. After being here a month or so I got some odd rash on my palms, which I was told was probably from the harsh soaps or maybe dyshydrotic eczema (from sweating too much). Either way, over the following couple of months the skin hardened and then peeled off, but I was just glad that it wasn’t itchy anymore. Some problems with bed-bugs, a painful tooth (for which I went to the capital to see a French dentist who never arrived, so I just came back to Farchana), and some back pain rounds out my list of gripes. No, add the large spiders (like the size of your fist), the fact that a few weeks ago my computer broke (hence no pics on the last few blogs), that the MSF-provided shared computer has a screen that flickers epileptogenically, and that my blog is being censored in ways I don’t understand, and you get some sense as to the frustration. If I were back home, I’d get the computer(s) repaired, take a long walk, catch a movie, rant in-person to the censor, read a dour blurb in The Economist and promptly forget about it, partake of a soul-soothing smoked-meat Schwartz’s combo, paint, and sit across from a good friend or two and, while a smile and beer endure, sing the blues.

For the first time since arriving, I felt tired in my bones last week. It’s been three months here, and I have since mostly marveled, but I recently found myself wanting to not have a 6pm curfew, not live in a 43ºC-in-the-shade dust-bowl, eat some standard fare, crap normally, and otherwise read for a week. I awoke one morning and felt *hesitant* about going into the camp and seeing patients. The crush of suffering was daunting, and I just wasn’t sure if this would be the day that I’d lose my grit and have to go back to the compound, or, dare the thought enter, just leave altogether. Worse still, that the empathy buffer was too thin and I’d show frustration with my patients or colleagues. Everybody has parts of their job that are uniquely hard, and for me it is working with children. It’s a cliché, I know, but the children save you out here (followed closely by your team and patients). I spend a lot of my day playing with tykes who initially yell out “ok!”, “ca va?” or “donne-moi un cadeau.” But when they’re mute and catatonically frightened after some horrific incident, it stays with me in a way that other patients don’t. Images of Fatna sitting on the mat with a perplexed and curious disposition still arrive in my sleep, when I walk from one health center to the other, or sit down to eat; her story, and so many like it, of the sticks and death, isolation and fear, are present. 

I’ve always felt that it is a good thing to follow dreams, in part because they’re inspiring, but mostly because they never give you what you think they will, and you get a whole lot else in the bargain. Sometimes good things, sometimes less so, but it’s definitely good to figure that out sooner rather than later. This isn’t a nod to jadedness… it’s just what one finds when you pay attention to the appearance of things. And so it has been coming out here, to Chad, to Farchana. Last week, in the icy clarity of a protracted and jittery malaise, I started to recognize the pleasures that have been earned by the boys playing soccer with long-destroyed balls or the frustration in the eyes of an old man who knows his children will not be brought up in a political state that could in any way be confused with a meritocracy. Hope is an emotion that operates in accordance with the law of gases: it will expand to fit any container in which it is put. Last week I felt it to be thin, and I wondered, selfishly and somewhat ashamedly, how I would survive in this rarefied environment. If hope is some ether of self-preservation mixed with motivation, it is icy clarity and rage that focuses it like a lens. This helps… to know in that vital way that things here need to get better. It counters the adaptive instinct that can bring with it a well-intentioned but eventual complacency. Well, that and another course of antibiotics that hopefully will get the bug that ails me:)

Inshallah.

About 5 years ago I was living on the plateau in a cavernous unfinished loft on St. Laurent, a couple floors above a bar/billiard hall called “Le Swimming.” The place comfortably slept five; at that time there were seven. The plumbing had been done by my buddy and loft-mate Adam who was a master of approximation and invention when it came to fixing things around the apartment. But with all the engineering capacity at his non-negligible disposal, the plumbing in the bathroom needed a better system than the rusty nozzles and showerhead. So we hopped into a beat-up MG that had recently had it’s entire bowels removed and put back in, and head off to where we could exchange money for said necessary product. The guy at the store showed us some pressure-balanced gizmo that adjusted hot and cold water in one nozzle—I’d imagine almost everyone reading this has one. But myself being a first-year psych resident, and Adam being in the throes of an interminable PhD in biomedical engineering (he recently finished, incidentally, and is off to MIT for a hopefully less-interminable post-doc), we decided to hit the hardware store and make do with a cheaper, non-rusty but still-crappy system. This is when the guy in the store, overhearing our conversation, said “don’t buy anything that’s not pressure-balanced, you won’t be happy with it.”

Fast forward to last Tuesday in the mobile clinic, about 25 miles southwest of nowhere, 7 pm, pitch dark on one side of the starry-night horizon, and opposite the last remnants of a faint under-lit glow just visible behind the mountains in the West. The shower was, as are most things here, built with an economy of resources and time as much as plastic sheeting and irregular-shaped bricks and crumbly mortar. So there’s the shower, a pillar of bricks in one corner of an open-roofed, plastic-sheeting-enclosed space slightly bigger than a phone booth. A black jerry can with a refilling hole cut out of it’s top sits on the head-high pillar, and a 2L plastic water bottle has been grafted onto the side of the can, with a rudimentary plastic spigot to adjust “water flow.” The water still hot from the day’s heat, I found myself wondering if the skin on my arms was dark because of the sun or the layers of dust and sweat and more dust. I think it was the best shower that I ever had.

When did I forget this? That it’s not some fancy nozzle that makes a good shower. It’s being dirty after an honest-days work. If but only to learn that again I would have come back to Africa. Tomorrow is Monday… a new week and I’m happy to be here, but I suspect that I’ll also be well ready for that vacation that’s coming at the end of the month.

One of the more conspicuous aspects of psychiatric work is that we deal with syndromes and diseases whose defining elements are often invisible. You can’t see a “depressive or anxiety disorder” in any definitive way, and would usually have no way of telling whether the person beside you on the bus or at the market has schizophrenia. You could say this for so many ailments, but few medical disciplines so completely lack genetic or physical markers, biochemical tests or imaging technologies that we can deploy to confirm or deny our suspicions. We listen, ask questions, and listen some more, and eventually fashion a clinical story that makes sense. And this brings us to Farchana camp, a veritable village of 20,000 Sudanese refugees who have for generations relied on “marabous” as the healers and vessels of a long history of orally transmitted knowledge. A marabou, of course, has his or her their own way of taking these empirical facts such as “feelings of sadness,” “decreased appetite,” “nightmares,” or “confusion” and making sense of them. About four or five years ago, when hundreds of thousands of Sudanese herders, farmers and nomads fled Darfur, they brought their practitioners and practices with them. Along came MSF, shortly there after, and the two healing systems have worked side-by-side, in a way, but with almost no contact. You gotta wonder, who are these people? What do they do and why? And what do they think of us? So I decided to ask.

After over a month of planning and a broad invitation, we received this week about 20 “healing” marabous to our mental health services. “Marabou” is the term given to Sudanese traditional healers, and could be translated into “teacher” in English, or maybe more accurately into the way the Japanese use the term “sensei.” It refers to someone who has attained mastery in a field, and uses that mastery to guide others. I wrote previously about three subtypes of marabous: 1) Imams, or scholarly religious leaders; 2) Faux marabous who have no real training, and practice their charlatanism on the credulous; and 3) Healing marabous, who have apprenticed in the therapeutic use of Koranic verse, botanicals, insects, small animals and their by-products for ingestion or ritual practices. When asking around, I found that these healing marabous are usually venerated by the Sudanese, although some scoff at them as well. Either way, well over half of our patients see marabous for the same symptoms for which they come to our mental health services, sometimes in parallel and sometimes after one or the other system has “failed” to meet expectations. Marabous were in this Sahelian region of sub-Saharan Africa well before MSF showed up, and’ll be here long after we’re gone so I figured that it would be clinically useful to sit around a table, munch on nuts, drink sugar-tea and start a dialogue. And, yeah, I thought it could be kinda trippy, too. This is what happened.

Pretty much everyone arrived at once, and I was giddy to have the opportunity to meet them. After some introductions and polities, they were informed of our “rule” in mental health services, that “anyone can say pretty much anything at any time, and nobody needs to put up a hand to request to talk… if people talk at the same time or disagree, it is like family.” For some reason, this seems to set the right tone here.

Who do you feel is best treated by marabous?

The room was silent for about ten seconds, which seemed like a long time. Most of the group, which consisted of men in white Jalabias (long shirts over a fair of pants), and one woman wearing a bright orange stole, were studiously avoiding eye contact; there was no “predetermined leader” here. I was going to paraphrase when one fellow in the corner promptly said that for every person that comes to him for treatment, he sends them to MSF’s Health Center for a first-pass assessment. And only if MSF’s shot at things is found ineffective, the marabou will then offer treatment. I double-checked to make sure that I’d heard correctly, and then polled the room to see if this was standard practice or a one-off thing. No dissent… nodding heads and few more statements indicated that this was the norm. Wow. It’s possible that we had a biased sample of marabous, and the ones who were less enthralled with our services did not stop by for tea, but again the group said that this was not the case; they liked the fact that we were there, and trusted our services. Marabous come to MSF all the time, they said, we’re “good for some things.”

What ailments are the most common for which people seek their services?

“For invisible things” was the answer. The list includes joint pain, back pain, change in eyesight, bone pain, infertility, head-ache, insomnia, stomach troubles, malaise, and fast heart-rate (what I assume meant palpitations). This is basically a list of non-specific and chronic symptoms for which there is often no good diagnosis nor treatment in the allopathic Western medical system (e.g., a Canadian hospital). One fellow added that for “nightmares” he’ll just jump straight in and forego the “referral” to MSF.

So what does a marabou offer?

The first and by far most commonly used treatment is translated as “black water” or “sacred water.” A small object shaped like a star is placed in the Koran at a random page, and when the verse that it touches is read, it hints at both the diagnosis and treatment. On a wooden board, this verse is written alone or with a few others. The ink used to write the words is scraped off and put into some water, and mixed with a specially made concoction of herbal, animal or mineral elements, and is then drunk by the patient. The most common examples given were roots and ground-up insects, but the phrase “it’s complicated” came up a few times. The marabous wait two days and then adjust the concoction depending on the result of the first trial. One marabou suggested that if two trials do not work, or if the symptoms change, then the person is sent back to MSF, but others had a few other possibilities for treatment: A beaded necklace could be used to direct the prayers of many Imams, if need be; or concoctions could also be applied to various body parts, although I could not really understand which ailments routinely called for this approach. There is also another ritual whereby the tip of a ram’s horn is inserted under the skin of the chest of a man who has heart troubles, and some “bad blood” is removed. A specific ointment may be placed on the skin, and the quality of the scar indicates the success of the treatment and an indication of the quality of the remaining malady. These were some of the examples given, but there was not enough time to explore much more into their local significance, unfortunately.

What happens if the service is ineffective?

Success, I was told, is guaranteed or you get your money back. Initial payment can be cash, some food, or, if it’s a complicated ritual, a goat. One question that I’m still very interested in asking at a subsequent meeting is “what counts as a positive outcome?” But we were running out of time.

We finished the tea and nuts and asked at the end if there were any comments or questions that the marabous had for us at MSF. The only one that came was “how can you afford to do this?” MSF runs a big operation in Farchana. We have seven ex-pats, over 50 national staff, and over a hundred Sudanese employees (like the counselors and community health workers with whom I work most closely). Apart from the health center, there is a busy maternity center and nutritional center, and, of course, our mental health services, which has about 500 “patient visits” per month. Over 85% of all the births in the camp happen in our centers, which run 24 hours a day. And if the job is too big for us (we don’t do surgery here, for example), then ambulances are available at all hours to take patients to a nearby town where there is an MSF team with surgical services. And, of course, all of this is free. So how we pay for this is a fair question, but it still came as a surprise. I’m Canadian, and free health care is what we do… the idea of anyone paying for health care seems distasteful. But it’s not taxes that have subsidized the exporting of socialized medicine to the eastern border of Chad, and since I don’t know how to say “good will” in French, I told him the other commonly-used phrase in our mental health clinic: “we’re all in this together.”

This entry has been hard to write. The fact is that while trauma is used as a medical term, it is deeply embedded in our social history, meaning that it has political, legal, economic, and moral components.This is fascinating stuff, and I can think of no better starting point than the concept of trauma to dive into how psychiatry itself, and the therapies it deploys, are themselves products of a rich social history.But after many starts, I’ve realized that this blog entry ain’t the place!  I want to write on what we say and do in Farchana or Arkoum when sitting with a person on a mat under a tree.The theory informs our practice greatly, but this is another discussion.  For people who want to track this down, I highly recommend reading the following two books:

• “Inventing posttraumatic stress disorder: a harmony of illusions” – Allan Young (1995)
• “Understanding Trauma” – edited by Kirmayer, Lemelson and Barad (2007)

What I want to address here is, in a sense, the first and last question that we need to ask ourselves as confidants, counsellors, caring friends and neighbours: what can we do to help someone who we think has been traumatized?  In the Farchana mental health services, we see many people who have lived through horrific events, and we talk a lot about what we can, should, and should not do to help them.About a week ago, we sat down for a few hours and explored this, and here I’ve amalgamated their words and experiences with some of the psychiatric lingo that is commonly used.

In other words, what can a counselor say to Ahmed when told of Amane’s story?  He is waiting for a response that is useful.

Assume Resiliency: First, assume that the vast majority of people are going to get better without professional intervention. The counsellors in Farchana know this intuitively, whereas back home early intervention is more the norm.  I think an evolutionary perspective helps explain this phenomenon of resiliency: for literally millions of years, humans have lead lives that have been characterized as solitary, poor, nasty, brutish, and short.  Deaths were by infection rather than chronic diseases, mortality rates (especially in infancy and childhood) were high, and violence and food shortages were common. Whether you now wear a business suit, an animal skin or a tutu, you’ve got a brain that was baked in the Paleolithic period.  Even in the more recent ten-ish millennia since the invention of agriculture, these conditions have mostly persisted. Adaptation to stress was a necessary part of survival and often a source of individual strength and community bonding.Humans are survivors, and assuming that someone who suffers is a helpless victim is rude, crude, and wrong.

Listen and Follow: Listen to what a person says and feels and simply hear them out, using empathy and curiosity as guides. The counselors tell me that often they’ll spend up to three one-hour sessions just listening before they finally start asking anything specific. Statements like “How’re you doing now?” “Do you want to talk about it?” “Then what Happened?” and “Holy shit that sounds terrifying! What was it like?” strike me as good starters.  Sure, they’re campy, and even run the risk of being cliché, but that’s no big deal.  The most common form of an epiphany is when you get the deeper meaning of an otherwise throwaway statement.  Note that open questions are much more useful than directives; an open question would be like the ones above, whereas a “closed” question has a yes-or-no form, such as “were you sad when that happened?”

In most sources on this subject, there is both an encouragement to get someone to “tell their trauma story” in full detail and emotional tenor, and to let people know that they are having a “normal response to an abnormal event.”To me, it seems better to say something like “some people benefit from talking about it” rather than prescribing this path.  Likewise, I find the phrase “a normal response” troublesome.  In some senses, “normal” implies “expected,” and we don’t want to give anyone the impression that feeling better quickly, or not having any “traumatic reaction” is unexpected or in any way “abnormal.”  I think it is better to say something like “you’re not going crazy, what you are going through is an understandable response to what you’ve been through, and the vast majority of people feel much better in a few weeks to months.”  This is both true and encourages health rather than focuses on the sick role.  Of note, it is much more therapeutic for a person, if they are to tell their story, to have a high level of emotion as they go through it.You can say the words till the cows come home, but if there’s no emotion, there’s less benefit.

The final question at the end of our session is, of course, “would it be helpful for you to come back and see us again.”  If no, a smile, a well-wishing word, and a statement that our services are always available, are phrases commonly used by the staff.

Red Flags: A red flag is something that makes you think that professional help is likely necessary.  Things like suicidality, violence or escalating aggression, panic attacks, refusing to eat or drink, extended bizarre behaviour and confusion are the most common.  The formal intervention is to keep a person and those around them safe while in this state.  As well, if someone is not getting better and several weeks to a month has gone by, this may be time to ask for help, too.  Of course, some people may want to see a therapist without these red flags being present, and that’s fine, too. I just wouldn’t push for that.  Lots of studies have shown that one-off “debriefing” sessions after a difficult event can make things worse.

Encourage family and community support:  Healing is like learning to trust again… and trust means being comfortable with letting another take care of you. Family, close friends are the obvious choices, but it could be your ultimate Frisbee team-mate, rabbi, hiking buddy or flower vendor.  We’re all in this together.

Encourage meaningful activities: This could mean doing laundry or helping someone build a latrine or tukul. It could mean cleaning up after a meal or taking your half-hour walk everyday.  Something with a start, a finish, and a feeling of satisfaction that comes with the accomplishment.  As soon as someone is capable, going to school, a volunteer position, a job—whatever—is good.  Join the knitting bee, have tea with the regular group, or get back to the chess club… just get back into the world as fast as possible.  One study found that people who looked after children got better faster. Makes sense to me!

(In the following story, names and minor details have been changed for confidentiality).

Ahmed, one of the national staff pulled me aside today.  He hesitantly asked if he could speak with me about a member of his family who was “traumatized,” and specifically how he could help.  This is the story that was told to me.  Several weeks ago, Amane, his 32 year-old first cousin was fleeing violence in N’Djamena, the capital of Chad.  Fighting had escalated quickly and within 24 hours parts of the city were destroyed and looting and random violence were rampant.  Amane, her husband and their two children decided that it would be safer to flee at night, but she became separated from her husband and continued to the bridge to Cameroon with her two children, a 5 year-old daughter and a 9 year-old son.  Many people left N’Djamena for the villages outside the capital or fled to neighbouring Cameroon (UNHCR registered over 30,000 Chadian refugees).

I imagine that the 500 metre-long bridge was a welcomed sight.  There are three bridges across the Chari river, and the closest for Amane was single-laned, large enough for one truck and a few feet on either side.  Enterprising boat-owners were cashing in on the chaos, charging people up to 10,000 CFA (CAN $24) for passage across the short channel, but few could afford this and opted for the walk.  Stories tell of the flood of frantic people pushing to get by the abandoned vehicles to the other side.  The walk that normally takes fifteen minutes took up to three hours.  I’d like to think that it was to avoid the danger of her small children being trampled that Amane steered toward the side of the bridge, but it was probably bad luck and the madness of the crowd that pushed them against the rails.  And it was in this same madness that her children fell over the edge, into the water about 20 feet down.  There were no lights at all and when they fell, there was probably no way to see them in the dark water.  Ahmed tells me that Amane tried to jump in after them but people held her back, and she finished crossing the bridge not knowing whether her children were dead or alive.

It’s been over a month and they have not been found, and Amane has been taken to live with her husband’s extended family in a quiet village far from the capital.  I’m told that she sits with others at meal-times and looks as if she is “in a daze.”  She doesn’t talk, eat, or make any emotional contact most of the time, and when children are playing nearby, she often breaks into tears and has to get up and leave.  At night Amane is not able to sleep for longer than an hour; she wakes up crying, calling out the names of her children.  In the early morning she often informs her family that she needs to go to the market “to see her kids,” but given that loud sounds and sudden movements cause her great distress, a trip to the market would be quite difficult; she has not been able to leave the house for weeks.  Soon her sisters will visit, and the family hopes that this will help.

Of course, one cannot make a diagnosis without a full in-person assessment.  But it does appear that Amane may suffer from a constellation of symptoms that is labeled in the Western psychiatry manual, the DSM-IV-TR, posttraumatic stress disorder (PTSD).  The label in-itself is not so helpful, and there have been other names of syndromes that collect and organize symptoms of re-experiencing, numbing, and hyper-arousal in other ways.  The diagnosis is a bit of a misnomer, too, as in many situations the threat and actuality of trauma continues, so there is nothing “post” about it.  But what is PTSD? And how does our understanding of its origins lead us to treat psychological trauma?

PTSD is a malady of memory.  To function well, we need the capacity to remember some things and to forget (or dull) others.  It is good to remember that touching a hot stove is dangerous, and in a near-literal way, this memory is seared into our minds by virtue of the pain—and emotional arousal—of the moment.  But we need to dull this memory allowing us to attempt to use the stove again, albeit more cautiously.  In PTSD, this natural dulling of the emotional tone of a bad incident is thrown off, and the smallest sound or sight takes you right back to the pain; in a real sense, every night since, Amane may be back on that bridge, with all the horror, helplessness, and loss.  The adaptive “high-alert” vigilance that helps her keep safe when cooking on hot stoves has turned against her, like a disease of adaptation, and now exhausts her resources.  Any loud sound or unexpected movement can be perceived as a threat, and it is this distorted threat-appraisal that must be unwound.  In a manner of speaking, our sense of who we are (our “self”) is bounded by the ability to remember and to forget, and if one is compromised, we lose who we are.

The question of what can be done to help Amane and so many other people who continue to suffer in this way, must be split up into two questions: 1) How can we prepare ourselves for this type of calling, and 2) What can we do to help?  The rest of this blog will answer the first question, and the second question will be the subject of the next entry.

1) Preparing to listen

In blog #11, I gave an account of the narratives of Fatna and Ibrahim, which were quite emotional for me.  A few days later, a friend from Montreal wrote a comment asking what we do in our mental health team to protect against “vicarious traumatization,” which means in this case a counsellor being themselves traumatized by hearing such difficult stories.  It’s a good question.  One has to balance empathy with self-preservation, while doing honour and justice to the integrity of the patient, his or her narrative, and the attendant empathic emotions that they evoke. A therapist needs to be able to withstand the brutal side of empathy to simply bear witness to it.  In psychiatric terms, the ability of a person to do this is their “negative capacity.”  In my opinion, the role of a good therapist is to facilitate a surface upon which meaningful communication can flow.  And we have to prepare ourselves for a torrent of words and emotions… whatever may come, a counsellor must be capable of simply letting the moment happen.

As you can imagine, discussion among our team of counsellors gets heavy at times.  We go from laughing about small things to presenting difficult cases to the group and getting support and counsel from each other.  We talk of our patients, and of our experience of being with them. Once a week, two hours are set aside for this exact purpose, and other “supervision” times are available, too.  (Of note, 24-hour psychological support is available for MSF staff.)

It quickly becomes clear that fear and pity can be dangerous if they lead to a paralyzed empathy and inaction.  Through these discussions, in a number of ways, we become more familiar with the pain of suffering, so that we can contain the harshness of it, rather than have to dissociate, isolate, or destroy within us that which resonates with it.  This does not minimize the horror of the situations or stories that we witness and feel, but it increases our negative capacity, or ability to withstand it. And by doing so, we can attend more closely to our patients rather than to ourselves.