Farchana Nights

It would be fair to say that before coming to Chad, in the months leading up to this mission, I was expecting something alien.  Conditions and life-ways so extreme and dimensionally different from mine that I would struggle to connect with them.  In anthropological parlance, I exoticised the other.  This is almost never a good thing.  It is also somewhat inevitable, at least when exploring new terrain, however much you try and keep it in check.  In order to minimize the anxiety of the unknown and unexpected, we start entertaining possibilities.  Like mythologies and daydreams, they have no direct correspondence with reality, but these animated exhalations are good to think with.  Like a mental jungle-gym.  The problem is not in doing this.  Quite to the contrary, exploring hidden assumptions and their entailments are the scaffolding of psychotherapy.  Or most any insight-oriented activity, really.  Rather, the problem would be in affording these guesses, assumptions or projections a stability that does not reflect their arbitrariness and self-soothing origins.  In the first post that I wrote, I asked some semi-rhetorical questions:

How can a psychiatrist WWHUUMMP parachute into central Africa and expect to do anything useful?

*Tense sigh* These people have suffered such incomprehensibly intense, sustained, and unpredictable trauma, and the situation remains horrendous!! What do you say to a person who has lost his or her family, community, and livelihood?! What do you say to the woman who has been repeatedly raped when going out at night for firewood, and will continue to do so because her children will die without cooked food?! What do you say to say to a child who has been orphaned, neglected, and abused?! What can a psychiatrist do?!?

Both questions are of the same form: what can a psychiatrist do when he or she has no clue how to connect with unfamiliar circumstances?  The uncertainty was palpable—and sensationalistic.     

And, like all rhetorical questions, they are also simple statements:  “Holy shit, this is gonna be weird/hard.”  “So much specialized training, but it could be useless.”  And so on.  But like myths and dreams, rhetorical questions are also projections, and answering them is like playing on the jungle gym; it’s good to try and answer them, beg them, or hazard a guess.   

And here’s what I have come up with:  living in Farchana is not so dimensionally different that you can’t hit the ground running; I focused on the victimization and unrest and did not project how suffering would become knowledge, strength, and a tighter sense of community than I have ever seen.  In what I could only call an honest act of remarkable conceit, I thought that psychiatric training could help me through this.  Only insofar as any formal education informs and buttresses ones actionable humanity will it be useful.  Pragmatism has primacy.  The lessons learned have to some extent cleaned off the post-modern/neurotic shelf… sure, the thoughts still spin, but they end with the usual question: now what would be useful?  

OK, I have to qualify this. (So much for being less neurotic.)  Many things ARE exotic in a way, but so are things back home.  Even professionally, the mysterious is ever-present.  Despite training and clinical experience, eating disorders, for example, remain unfathomable.  They exist in practice, but not in resonant theory.  For that matter, alcoholism, psychosis, and lots more retain this air of dimensional disconnectedness.  Of course you don’t have to be a recovered addict to treat addiction any more than you have to be a gymnast to train one of them.  Generations of fat and balding Eastern Europeans and post-Soviet types have provided much empirical evidence to this fact.  You get my point.  I thought that the foreign and different would be more bizarre than the local and different.

 
Inspector Gregory (Scotland Yard detective): "Is there any other point to which you would wish to draw my attention?"
Sherlock Holmes: "To the curious incident of the dog in the night-time."
Inspector Gregory: "The dog did nothing in the night-time."
Sherlock Holmes: "That was the curious incident."

The dog that didn’t bark in the night.  Some things should have seemed odd for years, but needed to be made contrast with the Farchana sky to become visible.  Ethics, for one.  In a way, ethics in Canadian medicine is dead.  In the past ten years, I have watched nearly every discussion about ethics in medical care quickly and contritely devolve into a discussion on medico-legal ethics: what can and should a doctor do to protect him or herself from being sued (most often wrongfully)?  This does not mean that most doctors are not deeply ethical and conscientious.  But the near complete absence of group discussions on purely ethical matters is a problem. (Most likely the heart of the problem is that when a lecture on medical ethics is organized, they send in a lawyer rather than an ethicist to lead discussions.)

The only question that I need to ask out here in Farchana is “what will help in a meaningful way?”  If I need to hire staff, contract for the construction of work-space, order supplies, or bring in resources, I just need to justify their utility in the service of minimizing suffering, respecting human dignity, and providing options.  Maybe a part of this is the luck of being placed in my particular project, but I feel like I am working with an extended team that lives its principles. That plaque on the institutional wall that says “mission statement” is usually not worth the piece of paper that it’s written on; it’s an endless stream of platitudes.  Not here.  From what I have seen, the principles of MSF-Holland reach the bottom floor.  It’s a pleasure to work in such an environment.

What informs this humanitarian space more than anything else is a pervading sense of inclusiveness and equality.  And it needs to be as firm as ever.  This is not an easy environment to live and work in.  Despite having a cushy life in comparison to our neighbours, it is taxing.  Amenities are minimal.  And lets face it, the human stain hangs low.  I feel that stain, and it is not from the outside.  It comes from within.  The stain has seeped through.  The same morning that I looked at pictures of porsches (that were sent to me from a friend who had just bought one), a child of three years came to the health center with injuries consistent with sexually abuse.  And I saw two kids with neurodegenerative disorders whose parents had to hear the bad news.  Then a woman who was beaten by her husband for refusing his advances.  It doesn’t get easier.  This is to point out contrasts we all know exist.  It is not to fuel guilt.  Really.  

This brings me to something else that is notable in its near complete absence:  loneliness.  I would guess that isolation and loneliness are some of the most common complaints in a psychiatric practice in Canada.  And outside of practice, too, which is more my point.  But here the sense of community is tightly woven so that people do not fall through.   I will never forget the response to Fatna, the young girl who cried in the night with nightmares of men on horseback: the women of the village all went to her and they sat together.  Or the religious community that took Youssef into their fold as he sat with them for hours praying.  Contrast this with the fact that despite many of our expat team coming from the same area of Montreal, we had never met.  This is, of course, not odd, the Plateau area being densely packed. What is striking is the fact that the Chadian staff find this hard to believe.  “You don’t know your neighbour?  How is that possible.”   

Anyone who thinks that they will give more than they will take from doing work with MSF (and any NGO field-work, likely) is off their rocker.  My opinion.  In the words of Ivan, the project coordinator in Farchana, “A life of adventure truly does still exist, and it’s good to know that.”  Life is many things here, but one of them is not dull.  Or senseless.  Quite to the contrary, I have not found a learning curve more steep and work more stimulating.  But for the most selfish of reasons, I would have come here many times over.  In a way, even the utter chaos of this space resonates with inner or personal chaos.  The extent to which some people live with this tension and have it so little reflected by their external environment is one measure of their private madness.  I have met many who breathe deeply when they speak of life in various African countries, and finally return for the next mission.  It is a type of weightlessness.  I do not know how I will transit from this space back home.  I am starting to breathe deeply here.  I will miss some of those staff, patients and their families that I have gotten to know.  I will deeply miss the mental health team.       

This is likely the last post that I will write; my contract is about done and I am going home.  Thank-you, in a gentle way, for reading and taking part in the dialogue, the ranting, the giddiness, the navel-gazing, the aching for clarity, the rage, the amusing bits.  This has become more personal than I expected; it’s been an important part of the mission, this chatter between a traveller and his shadow.  

The light of this computer screen attracts bugs.  The rains have come and the air is swarming with insects of all shapes and sizes.  Too much!  

I want a Porsche.  There’s no way around it.  Ever since I was a kid cars have fascinated me, the power, aesthetics, speed, engineering.  My jaw kind of drops when I see one, and has for many years.  I’ve had my eye on an early 90s 911.  More specifically, the 964 C4S or the turbo.  The guy who designed this car, Erwin Komenda, is a genius, inspired by turbulence reduction, drag coefficients, rocket ships, and, I think, the breast… how else could men so routinely go gaga for such an unnecessary contrivance?  (It may also explain why I’d like two of them.)  And, at the risk of being improper, rudimentary polling indicates that the golden number for the price of women’s “must have” shoes hovers at $300.  Listen for the choir: “more for boo-oots!”  Whether or not one actually buys these things is not the point.  What I’m trying to  do is reconcile such desires with where I am.

 
The pen in my pocket (easy fellow Freudians…) is a Uniball extra-fine.  Black, made in Japan, a triumph of mass production and injection-molded plastic.  In Canada, it costs about three bucks, which, incidentally, is about a days labour for an unskilled tradesperson in Farchana.  It is also the price of a beer here, of which you have your choice of two local brands or a bottle of Guiness.  How’s that for distribution networks?  Kids here ask for money occasionally, but most often ask for a cola or a pen, the latter being called a “bic.”  Pens have currency; this is a place where most people do not have one.  Where the “prized seat” is a plastic garden chair, even when dealing with the highest levels of local official.  In the capital, N’Djamena, there are five-star hotels, a parliament building, and a court-house (that’s in construction).  Otherwise, it is shanty-town.  On the same block, in all directions.  From the pool area, you can hear hammers smashing away at fallen concrete structures; people are salvaging the steel rebar inside to sell to scrap-metal merchants.   

http://www.economist.com/world/africa/displaystory.cfm?story_id=11670946 

In Farchana, the people with money have meat in their food and a plastic lawn-chair at their disposal.  Those without may forego a few meals.  There is no such thing as a Vegetarian outside the expat compound… the idea of passing on meat for ethical or aesthetic concerns is unimaginable.   Not that it’s a failure of imagination, it is just unheard of. 

Upon arriving in Farchana, I unloaded a few things that I’d brought for the team.  Chocolate, some cheese, magazines and newspapers.  These things are sorely missed in the field.  One of the papers had an insert inside, called “Executive Life.”  Inside were  such notable articles as “A good butler is hard to find” and a guide to “buying handmade suits.”  Advertisements push watches, spas, fancy cars, cologne and such.  The same movie-stars that decry global suffering are smiling at the camera with a coffee mug in their hands.  And why not?  The only thing that makes anything I’ve said less odious than commonplace is their proximity: usually these worlds are kept apart, but for occasional media blurbs that break through.  Here, though, such incongruence is as stark as rain in May.  It is that colour of high frequency orange that tears-up your eyes.  To call it “night and day” does not capture the beacon of privilege and wealth that is an iPod out here.  Or a pair of well-made and practical shoes, for that matter.  But even as the sand trusts that rain will come, so do the local Chadians trust that more opportunities for conspicuous consumption are around the corner.  And they are.

How do I know this?  Well, there are hints.  Like the fact that most of our national staff have cell-phones, and I see them all over the camp, too.  This would not be odd but for the fact that Farchana has not ever had phone service.  A truck with a cellular carrier label moving through town sets people scurrying with buzz.  Some of the women have three hand-bags, despite having as many changes of clothes.  Sun-glasses are becoming more common, and one refugee whom we’ve dubbed “Snoop Dog” walks around in bling and a purple track-suit.  Recently, a bakery opened up and now runs seven days a week.  It’s early days, but you can get bread in the shape of a bun, croissant or baguette.  Calgary couldn’t boast more in 1999 when I showed up there for medical school.  

When in Amsterdam, briefing for this mission, I went for lunch in the cafeteria.  It’s an open-concept design that is what I imagine a military canteen to be like, without the camouflage and with a decidely more Libertarian bravado. People help themselves from the buffet, sit down wherever and chat with their neighbours.  I liked it.  One of the persons whom I was fortunate enough to sit near was a fellow named Olaf.  A logistician, Olaf was one of the first MSFers to arrive in Farchana, and was part of the crew who planned and built this camp.  He mentioned off-hand that when he arrived and started to hire people, many people had never used money before.  That was less than five years ago.  Since, this village went from having no monetary economy to ten stores stuffed with mostly made-in-China and Nigeria stuffs, not to mention busy market-places twice a week.  When last in Abéché, walking from the staff compound to the office, a youngster asked me for a bic.  When I told him that I had no pen or gifts for him, he asked me for a Thuraya, which is a satellite telephone.  Wha!?

http://tinyurl.com/54ruqx
 

There are good and bad ways to be monied.  Having and spending lots of cash is not an issue.  But just as you’d hope that being a devout follower of faith makes you a better person in the end, shouldn’t having money make you more likely to be benevolant?  At a minumum, it seems fair to say that one has a duty to be aware of and appreciate the options that they have… the options that money brings.  Jadedness, or that sense of malaise that sets in when you realize the truffle-flavoured balsamic vinegar does not bring you joy, is a bad quality.  Back to benevolance… I don’t necessarily mean donations.  The end game of money for many is really the time it takes to earn it.  My thought now is how much do I want to pay off that lingering debt, save a bit, and perhaps go shopping?  If I do, that means that I’ll have to work, and won’t have as much time to do a second mission in the next year.  Doing humanitarian work also has an opportunity cost.  I really dislike saccharin questions, but I’ve been wondering at who’s expense excess tolls.  Is it good to want things?  These echo, whether they should or shouldn’t.

Right now I think the fellow from the article who bought 200 bespoke suits in a year (from his yacht, incidentally) is guilty of a fashion crime, no matter how good he looks in his suits.  But what if he also donates 10% of his income to charity?  What if donating six months of his time volunteering would be immeasurably less helpful to said charity than the cash he could earn and donate in that time?  When faced with a difficult decision, take both. 

The Sudanese refugees want stuff.  I have spoken here thus far of soap and dignity, but they want luxuries, too.  (e.g., Several people asked me to buy them a digital camera when I went on vacation to Tanzania.)  But what they really want is to go home, find some respite from the endless threat and actuality of war.  For this to happen, more people need to viscerally know what happened in Darfur, what life is like for refugees and displaced persons in places like Farchana.  To know how the politics of sovereignty protects despots in their monopoly of violence.  Only a fool would discount the value of the dollar, but to get to know this place — these spaces, faces, and stories — and to learn from them, that’s what’s going to do it, if anything.  For me, at least, I think that I had to go.  To think otherwise would have been a failure of imagination.

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Note: For those who have writen comments and they have not been posted, or have had long delays, sorry ’bout that.  More than anything else, I wanted this blog to be a dialog, but given the fact that everything written has to be vetted, real-time blogosphere-style stuff is simply not possible.  I’m told that there is tonnes of spam that gets shuffled through, so immediate posting is just not done.  And if a comment is put in on a weekend or holiday that delays things, too.  Patience.  As for the regular posts, they’re looked over by no fewer than four people on three continents before being made visible.  You know how much a two-second delay on a phone conversation affects the rhythm?  Like that.      

Patient names and minor details have been changed for confidentaility.  “Youssef” has consented to have his story told in this forum.  I told him that it was as if his picture and story were posted on every building in the whole camp, in all the villages in the world.  He was lucid, in full capacity to make this decision, and pleased.    

Every Wednesday for a couple of hours, the entire mental health team sits around a table and discusses difficult cases.  The meaningless, absurd, touchy and confusing also find their exploration here.  Minimal direction, gentle redirection, no blocking; this is a safe space.  I hesistate to guess that it is the most important two hours of our week as a team.  Having been here for five months, I am by far the most recent addition to the team; the counsellors know each other well, and a solid trust has developed.  During these two hours, we delay our response to referrals, and counsellors do not book patient sessions.  About the only thing that routinely disturbs them are distribution days by the World Food Programme; few things trump food.   

It took a while to get settled into the run of things, but shortly after that happened, I noticed a pattern in the stories. Well, maybe “pattern” gives the impression of something more structured than it was.  Mostly, the stories did not make sense.  But they did not make sense in a way that reflected the cases in a meaningful way.  Chronology is less consistently used as a way of organizing information in Farchana, but even still, there was a fractured or diconnected quality to the case histories.  

We started inviting some of these patients to our meetings to do group interviews, and it became clear that some of these persons were psychotic, and met criteria for a diagnosis of schizophrenia.  This is the story of one man whom we have gotten to know well over several months.  (Note that some parts of this story were written and posted months ago but were later removed from the blog due to confidentiality concerns.)

Youssef, a long-term patient of Issakha’s, was first presented one Wednesday, having the unique complaint of “a burning sensation” in his chest, a head-ache that came some nights, and his family thought that something was wrong.  He isolated himself for long stretches, and occasionally said things that were incomprehensible.  Youssef’s only consistent interest was Islamic studies, and he was a good student when he showed up for lessons.  A visit seemed appropriate.

Some of the larger blocks in the camp are a labyrinthine maze of brick and straw walls, rogue livestock, delapidated latrines, and kids running everywhere.  Without Issakha as a guide, I would not have known where I was.  Eventually, we stopped in a passageway and Issakha poked his head into one portal and called out something in Masalit.  A man who looked as old as the hills came by to greet us warmly.  Youssef’s father ushered us in and put some mats on the ground so that we could sit.  

There was one tent, a small shed-like structure of brick and mud in the corner, some space for a hearth and storage for the livestock feed (big bushels of hay held back by sticks).  Youssef’s father put some water on the boil, and then went into the shed and came out with his son.  Youssef agreed to speak with Issakha and I, and sat down on the mat under the hangar that provided sparse shelter (four wooden poles with thin thatched roofing on top).  He expected the interview to take place right there in the opening, with parents, siblings, and livestock circulating, not to mention the mid-day sun beating down.  I asked if we could sit under some cover, and Youssef took us to his shed.  Issakha and I sat on the earthen floor, and Youssef sat on his small, wooden bed, which took up most of the back wall.  If all three of us had sat on the floor, it would have been a tight fit.  

After brief introductions, we started with a few open ended questions that were met mainly with one word answers.  He spoke clearly, deliberately, and had an air of stoicism about him, as if he was in complete control of the information he meted out with an economy of words.  That is, there was zero rambling, and little emotion showed.  At 27, Youssef had been in the camp for about four years, and had no friends, no social life, and indicated that he spoke mostly with his family, whom he felt looked after him well.  His only complaints were trouble falling asleep, occasional head-aches, and a diffuse and vague sensation of burning over his chest and abdomen.  According to Youssef, there was no cause or specific meaning to these symptoms, other than that they indicated that he was “sick.”  I started to get the feeling that there may be some psychosis.  There were reasons to suspect this: he was the right age (in males, it usually shows up in the late teens and early twenties; women a few years later), the vague and unusual somatic symptoms, his lack of social contact, and that his comportment was kind of “distant.”  He answered all of our questions quickly and accurately, but it was as if there was no emotional connection.  In psychiatry, this may be a soft sign of schizophrenia, and we describe it as if you are speaking to a person through “a thick glass wall.”  More directed questions revealed that he heard voices (that argued with each other and were occasionally angry with him) and had thought insertion and broadcasting (he felt that thoughts were “placed” in his mind, and that others could occasionally read his thoughts).  

What’s more, several times over the past four years, he had taken an intramuscular injection medication called “Mondeket” (Modecate or Fluphenazine Decanoate), which he said helped him with “the burning.”  Youssef told us that he wanted injection medications from MSF, as they were the best.  When I asked if he had had side effects from this medication, he denied any.  But then when I stiffened up my legs and asked if that happened, he said “yes.”  And when I twisted my head to the side and asked if this had occurred, Youssef lit up like a Christmas tree and excitedly explained how horrible it was for a couple of day last year when his neck muscles were rigidly contracted as if he was looking at his shoulder.
 
Antipsychotic medication (also called neuroleptics or “major tranquilizers”) can have some bad side effects, dystonia (contracted muscles that feel “stiff”) being one of the most common.  It can be *very* uncomfortable, and Youssef was pleased to know that these symptoms were controllable medication side effects, and that he could continue to take medication that would help him.  

While we were doing a short physical exam (ESRS), some food and tea were shuffled through the door and Issakha informed me that not partaking would be impolite, so we washed our hands in a bowl of water, ate the salted tomatoes, drank the tea, and chatted about the drawings on his walls and a subsequent meeting.  We see him every week, sometimes at his home, and sometimes he drops by our health center.  Meetings have proven difficult to arrange, but one way or another, everyone on medications is followed regularly by MSF’s community health worker assigned to the block in which the patient lives, and Youssef sees Issakha and I minimum once a week.   He’s doing well, as are most of the persons with schizophrenia here.  Some suppose that given the protracted brutality of the uprooting and displacement from Darfur to eastern Chad, some four years ago, persons with a more severe form of this disease simply did not survive.  Youssef benefits greatly from a close family and his community involvement.

For those wondering, MSF currently stocks three antipsychotic meds (a high- and low-potency typical, and one atypical), one benzodiazepine, one anticholinergic, one SSRI and one anticonvulsant.  A relatively new addition to MSF projects, these medications allow us to provide a solid level of medical care to certain patients with psychiatric disease.