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.

Mental Health work in Chad brings you into contact with all walks of life; everybody can show the signs of strain under difficult circumstances. Some people who have heard about our services have walked up to 20km from neighbouring towns for treatment.In the past weeks, I’ve seen an 80 year-old man with obsessive-compulsive disorder, severe autism in 9 and 10 year-old siblings, three cases of sexual violence, post-partum depression, two persons with schizophrenia, and anxiety and depression manifesting in so many forms.  The incidence of trauma is high, and stories of near-unthinkable trauma are shockingly common.  Each person has a story to tell, and given that family members sit down with our patients at the assessment, we often hear their stories, too.It is meaningful work and while endlessly stimulating it is taxing at times, too.

After a heavy day with the mobile clinic last week, Jochen, Christian and I decided to take a walk towards the foothills.Exercise is hard to do here with our schedule and curfews, but it’s important in maintaining a modicum of sanity, so we jetted off from the Arkoum camp toward the nearby hills.

Nothing tells you more about a place than having its earth between your toes.The language of people is translated in so many ways through this neo-cortical helmet, but the messages of the land whisper to you from your blood.“The land teaches us how to live,” I was once told by an Inuit man in Cambridge Bay, Nunavut. The soil here is dry and chalky, and although you find the occasional patch of red and yellow ochres, it is a crusty light brown that pervades.

Walking over the scrub brush and gulleys has a meditative and primal quality. This is where we’re from, really. All of us. Somewhere in the savannahs and steppes of sub-Saharan Africa humans evolved that which makes us who we are: our brains got bigger, we developed language, started walking upright on two legs, and organized social and institutional structures that can loosely be called “civilization.” We fashioned tools, told stories about hunts and herbs, made fires (probably here, but it could have been later in China), and started to sweat. This last development is the unsung hero of human evolution, as far as I’m concerned. It was the sweat gland that allowed us to hunt and forage during the day while the other large predators were sitting under a tree panting like mad in the heat. Humans ruled the noontime, and probably hung out in trees at night for safety. Below is a picture of a copse of mango trees lining a dried-up riverbed.

Some have theorized that language developed while we were hanging out in trees. You could transmit information about danger to your clan along the row of trees lining the riverbed. Statements like “big danger, left river-bed, twenty unhappy-looking jackals” could have been the rather bland start of it all. We had to wait a long time before we were sophisticated enough to ask “does this jacket come in seersucker?” or “would you like to come up and see my frescoes?” And some people say that there’s no such thing as progress.

As I write this, the wind is whipping outside.  I have no clue what time it is because my Tukul is near lightfast.  But somehow, even though light doesn’t make it through—I write this with my head-lamp on—dust has no problem getting itself everywhere.  I’ve noticed that I stop closing my teeth together because I feel the “crunch” of small grains of dust.  And when I chew bread at mealtimes it’s more of a mashing without clamping down for the same reason.  My hands are cold.  It heats up to 40 degrees in the daytime, and at night it’s around 15.  To me, this is utterly bizarre.  You layer up in the morning and peel ‘em off as the day progresses.  I just returned from watching the sun-rise.  Nature here is so stark it that it has a sci-fi quality.  This glowing red orb peeking it’s head above the distant steppe.  Soon we’ll drive west for an hour or so, checking in with various people along the way to assess security concerns.

Yesterday the mobile clinic showed up Hillé-Déyé, a town in the region of Alasha, and an IDP camp of about 2000 Chadians.  There was a strange shine to everything, as there’s a silver iridescent mineral in the rock in this region.  So a patina of dust covering virtually everything sparkled in the sun.  When our two land-cruisers drove in, all the kids came swarming around, smiling and yelling “ok!” or “ça va?!”  It was a sea of bright faces set against the sheen of glitter on tattered clothing, like an 80s party in a Disneyland dystopia.  It was quite infectious, and you just can’t help smiling along.

Our mobile clinic, which has been functional for about a year, finds its “clinic” in the shade of a tree.  But today it was too windy, so we fixed up the thatched-mat sheeting on the side of one of the two school-room structures and stayed there for three hours.  Within ten minutes, the collapsible tables were up, and everyone was in place.  Registration and triage outside, peri-natal care in the back corner, a nurse in another, the pharmacy in a third corner.

Jochen, the German nurse, handles vaccinations for a while, and is consulted on difficult cases, and Sam, a Chadian nurse’s assistant by trade, works with maternity and nutrition.  The place is swarming, and despite the initial appearance of chaos, it runs smoothly and quickly.  I came to Chad to see how medicine functions in these places, and how mental health finds its niche in the fray.  My first impression was  wonderment at how two fully packed land-cruisers and about ten people can do so much work in such a short period of time.  One young girl had a nasty infection on her foot that was not healing.  Jochen decided to explore it surgically and he pulled out what looked like a piece of animal bone.  It seems so minor, but without this minor surgical intervention, a child may very well have died of sepsis (when an infection goes throughout the body in the bloodstream).

The mobile clinic works with Chadian Internally Displaced Persons (IDPs).  Most come from the “border” with Sudan, which is nothing of the sort.  It’s a patch of land with no political markings, of course, and people identify themselves by language, ethnicity, and means of subsistence.

Noura is the mental health counselor with the mobile clinic.  She lives in Arkoum, one of the three mobile clinic sites, where the team goes for several days of the week.  Noura is one of those people who can talk to anyone and get them to tell their story, and has many of those “nonspecific factors” that make therapists effective: she cares, listens well, engenders trust, and exudes a sense of calm.  You can’t fake such things as “genuineness” and “presence.”   Noura and I walk through the camp to see her patients, most of which have been referred from the Community Health Workers (CHWs).  I watch how women and men come up to her and say hello, and ask to sit down with us to speak their minds.  Several times, someone tells us of a person who cries at night and may benefit from our stopping by.  And we do.

Here are a few stories that we heard. (Note that for confidentiality, names have been changed, as well as some details of the case that do not alter the significance.) 

One man, whom I’ll call Ibrahim, was found sitting with a group of male friends.  He’s in his early thirties and is relativey new to the camp.  He jumped up when he saw Noura, excused himself, and found a straw sitting-mat to put on the floor around the corner, under a thorny tree.  He had intensely dark eyes, and looked at me while he told me his story.  It seemed to matter little that Noura was translating from Arabic, I could see his eyes and hands and hear the tremble in his voice.  Several months ago he was relatively happy, living on “the frontière” lands between Chad and Sudan.  He had two wives, five children, and many family members around.  He told me how “the janjaweed came and took everything.” They came and he hid under his bed while they killed his brothers, one wife, and all of his children.  Ibrahim stayed there all night in terror, no knowing who was alive or dead, but he heard voices and dared not come out.  It has been three months since he has been in the camp, and at night he sees “men on horses” in his dreams, and he awakes screaming. When asked about his thoughts during the day, he pauses, and tells me that they took 100 cows, 10 camels, 3 horses, and a mill to grind grains.  Ibrahim is starting to feel a bit better, although he still feels distant from his wife.  He misses his family and his stability, but despite the continued threat of violence in the village (which is NOT imaginary), he is making ties with the community, has found occasional work making bricks, and is thinking of starting a small herd of sheep. He plans to work his way up to cattle again.  I ask Ibrahim if he finds his sessions with Noura helpful, and why.  It’s a fair question, and Noura understands that this is not a knock at her.  He says that Noura is the only person to whom he talks openly about his losses, and that he feels much better after he talks to her.  He tells me that it was Noura who suggested he start raising animals again, and although he thought she was crazy at the time, it sounds like a good idea now. He does not smile at all, but Noura does occasionally when they speak.

Fatna is an eight your old girl who cries at night, and neighbours come and sit with her.  We are directed to her by a woman who is one of Noura’s patients, and eventually come across the right straw door and someone answers our call, bidding us enter. We sit on the straw mat, the women kindly offering me the prized corner in the shade of midday heat. Fatna is quiet and says nothing, even when asked simple questions like her name and age.  Her mother instinctively answers, and I’m told that she has not spoken for ten days. I write this a week later, and it remains a heartbreaking story. In silence, with her short and tightly braided hair and curious eyes, one shoulder of her dress ripped and falling askew, she evoked an almost overwhelming empathic response.  This is her story.  Two years ago, she was out “on the frontière” with her father when the “janjaweed” came and hit him with their “horse-sticks” until he fell. They continued to beat him, and Fatna’s mother described how her daughter spoke of blood coming out of his head. She ran into the “brousse” (a word that means something like country-side, bush, outback, or the steppes).  She does not remember how long she was alone, but said that it could have been a few days. Eventually Fatna returned to her house and, as it was a market day, nobody was home. Her mother returned home and found her in a corner, crying. It was weeks before she told anyone her story, but by then they had heard news of the body of her father that had been found by other villagers. The family packed up and left quickly, and Fatna was doing pretty well in the IDP camp, her mother tells me.  She had friends, was enjoying school, and laughed and played with the other children. Then, about ten days before I met her, she was again out in the brousse, and men on horses came and harassed her and her friends. The other kids ran, but she froze, and was the only child still there. They said angry things, but she did not run. She was hit on the back and chest with the “horse-sticks,” and was left there by the men, in that catatonic state of fearful rigidity.  Apart from slight bruising, she had no physical injuries. But since then, she has not gone to school nor has she played with friends.  A few hours after sunset, she cries out inconsolably because she sees men coming “with horses and knives.” Nightmares wake her up and the women in her block come and sit with her. They will continue doing this, and we encourage her to go back to school as soon as possible, for half-days at first.  And she listens as we encourage her to have her friends visit, even if it takes her a while to speak to them.  Fatna’s mother listens to our words about “stress reactions,” and asks when the mobile clinic will be back to visit again.

Chad remains politically active. We don’t get mentioned much on the BBC anymore, but news is that the government has declared a “state of emergency” for two weeks. On the ground in Farchana, it looks relatively calm, but people are worried. Here are some links if you want to rummage through the politics:

http://www.economist.com/world/africa/displaystory.cfm?story_id=10666429

http://www.walrusmagazine.com/articles/2006.11-international-affairs-problem-in-africa/

http://www.reliefweb.int/rw/rwb.nsf/db900sid/RMOI-7BVMEM?OpenDocument&rc=1&cc=tcd

http://allafrica.com/stories/200802140671.html

Much of this post is in direct response to questions and comments I’ve received. Thanks for them… they point out omissions as well as blind-spots, good things to know.

The MSF-H team has been here about 4 years, and has had a mental health officer (MHO) almost all of that time.

Mental Health Services (MHS) was already well set-up by the time that I arrived here. Previous MHOs, with Issakha and Habib, have done a good job with hiring and training the Sudanese counsellors. Each MHO takes a 6-12 month contract with MSF, so we are a “transient figurehead” of sorts.

Prior to MSF’s presence, if someone was mentally ill, they sought help from a marabou. What this word designates is complicated, as there are “Imam” marabous, who lead prayers and are trained and venerated teachers; “faux” marabous who hang up a shingle and do who-knows-what; and “healing marabous” whose knowledge (herbs, roots, rituals, amulets) is handed down through generations. I’ve been told so far that most people prefer MSF to the marabous, but I’ve a biased sample, of course:) Every time that I’ve asked why one person goes to one source of help over the other, cost comes up. MSF is free, and the marabous charge.

MSF is an emergency-situation health-care provider. After several years, we pack up and hand the programme over to a long-term health-care provider, and I’m not sure how other NGOs handle mental health care. So we need to ask ourselves:

1) What are the most effective short-term benefits can we provide while we’re here?

2) What are the best strategies for ensuring long-term benefits?

3) What do we need to know to adapt our “Western” conceptions of mental health categories and treatments (which are no less fundamental than “ways of viewing the normal and the pathological,” or even “ways of being in the world”) to local or indigenous conceptions?

4) Apart from learning what came before, and mindfully “adding” rather than “replacing” or “extinguishing”, how else can we minimize Western imperialism and the “colonization of minds”?

(ugh, heavy sentences. I have to remind myself that this is a blog and not an essay… the presence of so many “scare-quotes” tells me that I’m losing the battle! Thanks for bearing with me.)

Today, I met with the MHS team to discuss their notions of psychosis and its treatment. To my surprise, the two supervisors (who had been lecturing on group dynamics, Maslow, trauma, etc.) had no idea what schizophrenia (or psychosis) was. Nor did the counselors. It was a quiet room, and I kept waiting for one of my awkward paraphrasings to catch. But for the whipping sound of sand on the plastic sheeting, it was dreadfully silent. So I figured I’d start with a few WWHUUMMP symptoms of psychosis (hearing voices, paranoia, getting messages from the radio, etc.) and I’d jog a discussion. Nothing. I asked them what may have done if a patient with these symptoms presented themselves, and they hesitantly suggested that they would ask an Imam, or find a doctor in N’Djamena. Although the incidence of schizophrenia is about 1%, I suspect that for a number of reasons there are fewer in this community. We will discuss as a group how the counselors can identify and treat this disorder.

I’ve “signaled” to the community health workers (CHWs) to let the Marabous know that I’d like to meet them. The head CHW guesses that there are between 50 and 100 Marabous, and if I spread the word that there will be some finger-food and sugar-tea, the turn-out will be much improved. Can’t wait t see what that holds!

Having a mental health component to a medical team is, in my view invaluable. We look after patients, not bodies, and mental health workers are trained to attend to the manifold forms of suffering of the human condition. When I see something I don’t understand, I am relieved to be able to refer them to the local GP or specialist. The same relief comes to those who refer patients to MHS; we get by with a little help from our friends.

Next week I’m going into the field with the mobile clinic, and will be looking into MHS and community health in three IDP camps (Alasha, Arkoum, and Goundiang). So much time in trucks and how many bandits wandering around? It’s a safe area, I’m told. But it’s still Chad.

There are three MSF sites in Farchana: (1) the Health Center, located at the edge of the camp, is where maternity and basic medical care are provided; (2) the Nutritional Center in the center of the camp houses the Community Health Service and a Therapeutic Feeding Center for malnourished children; and (3) the MSF compound, a fifteen minute walk from camp, that has an emergency night-clinic attached.  Mental Health Services has “offices” in the two centers at the camp, which are wooden supports lined with plastic sheeting.  It may seem like a flimsy structure but it’s like a home away from home; a quiet corner of the busy compound where we sit, talk, work, and, if need be, see patients in the room next door.  Four years ago, when this MSF-H project was set up, flowers were planted outside and are now blossoming lilac and pink.  It’s a nice thing. The flip-chart in the corner—some large pieces of paper stapled to a cobbled-together easel—shows residues of past lectures on personality traits, stigma, Maslow’s hierarchy of needs (need to unpack this one in a place with no soap…), traumatic stress and it’s presenting symptoms, and so on.

Every morning at about 7:30am, the team meets at one of the two sites.  We say our good-mornings and everybody asks everybody else how they slept.  This is the custom, but there is a twist: you answer honestly.  I’m not sure when it came to pass in Canada that the expected answer to the ritualistic “how’re you doing?” was a near-guaranteed “good, you?”  You’d pretty much have to be bleeding out of your eyes before you ventured a “you know, not so hot today.”  But in the camp, people routinely say what’s bugging them, and the morning “how’re you doing?” custom can take fifteen minutes.  I know who’s got diarrhoea, who’s feeling a chill from the cool night past, and who’s child has a mild fever that is worrying them.  It’s unexpectedly personal.

After this morning harrah, four of the counsellors go off to the « Thé Rencontre » or “Chat with Tea.” This is where everyone is welcome to sit around with friends, to drink insanely sugary tea, and to banter.  All the while, the counsellors circulate, listen, and give their spiel on what mental health services are on offer. It’s a lovely idea, and even though it’s just a large open space with some plastic sheeting over their heads and a few rude wooden benches against the walls, everything changes when you’re sharing drinks. It becomes friendly rather than clinical.  (below is a pic of the tea room, but not during the « Thé Rencontre ».)

If people have comments, suggestions, musings, anything!, please write them. I will try and respond when I have more than twenty minutes at a (relatively slow) internet terminal. I have no clue when that will be, though

I’ve never been in a country while a coup d’etat is happening. This afternoon, while at the staff compound, our team hushes while listening carefully to BBC Africa. Every now and again there’s a brief gap in the Africa-cup soccer tournament, and they talk about Chad’s predicament. These moments have a palpable sense of immediacy, and I find myself a bit nervous. There are no signs of imminent danger for us, as Farchana is a dusty town far from the big cities, but we’re on the main road, and who knows what the next few days will bring.

But the mood in the camp this morning was not set by this event. Which is, in itself, kind of remarkable. Children still play everywhere, water is collected, and the line-up at the Health Centre is long. Looking around the camp, one does not have any sense of political stuff going down. My first meeting this morning was with the team of Community Health Workers (CHWs). My role here is to supervise mental health as well as community health. Which I’m very happy about, as the two go hand-in-hand, but I’ll write more on this later.

The camp is split up into about 27 “blocks,” and twenty Sudanese refugees, hired and paid by MSF, are responsible for their designated areas, comprising between 600 and 2000 persons. Really, who better to ask to understand life on the ground? the only reason that “grass-roots” is a metaphor is because it’s the dry season.

We sit on mats on the floor, shoes off, and I asked people to sit in a circle rather than in rows facing front. It is odd at first, because the women were sitting on one side and now we’re all side-by-side, but it flies well enough. After introductions (translated from French to Masalit), I ask what the main concerns are for them, their families, and their block inhabitants. This is what was discussed (in the order raised, in case you’re wondering):

1) Some of the pit latrines are full in a number of the blocks, and in block K, they’re all full; they have to walk to another block.  SECADEV (a Christian aid and development outfit) handles this, and they’re behind in digging new pits. It is a massive health problem, really. Pit latrines may have done more to decrease morbidity and mortality than anything else… more than vaccinations, more than economic reform, more than food distribution improvements. Simple hygiene goes a long, long way.

2) “We need another Mobile Zero.” The pick-up trucks are numbered 1 to fifty-something, and someone decided to call the donkey-drawn carts (that transport the non-ambulatory patients to and from the Health Center) “mobile zero.” Initially, it’s kind of amusing in an eighteenth-century way, but I quickly realize how crucial these carts are. I’m told that if a patient waits too long for the cart, they may miss the day-time clinic hours and will have to wait for the emergency clinic. This latter clinic, which MSF runs 24 hours, is farther from the camp, and, if need be, the MSF trucks are used for transport. Either way, people want another cart, and they want it to run on Sundays, too.

3) For several reasons, people in the camp are not taking prescribed medications once diagnosed with malaria, and they are dying because of it (though statistics from our health centre don’t show this. They say that people don’e take meds because of bad side-effects which are clearly better than death, but are not initially viewed as troublesome as a trip to the “marabou,” a traditional healer. Competing explanatory models of illness sometimes conflict, and I heard the story of one marabou indicating that people die even if they take the anti-malarials, so what is the use? I do not know if this view is prevalent, but the conversation this morning indicated that it wasn’t uncommon. My initial impression is that people take the medications, experience side effects, and stop them, deciding to see a marabou instead. I’ve got no truck with the marabous (in fact, I’m looking forward to organizing a meeting with some of them), but there is a big problem with taking drugs sporadically. It goes like this: antibiotics kill off malaria parasites, which are all a bit different. The most susceptible get knocked-off first, and the most resistant take a full course of the meds to be wiped out. But if you stop the course early, you eradicate all but the hardiest strains, and then those multiply and spread. It’s bad for the individual, and bad for the population. The CHWs want another education campaign around malaria, it’s symptoms and treatment.

4) Violence. Every day, about 50-100 women leave the camp, most often in groups, to search for wood and animal feed. It takes about three hours for the return trip, and it’s relatively common for women to be intercepted by groups of bandits (usually men with guns), and have their things stolen or worse. Emotional, physical, and sexual violence are experienced by many (about 10%, by my loose polling), with rape and other forms of brutality affecting 2-3%. Having men with the women makes it safer, but collecting wood and feed “is women’s work,” and they will generally not do it. I’m not sure if I went red in the face, but I felt an impulse of rage when I heard this. Could it be the case that men would rather their wives and daughters were beaten and raped rather than suffer the indignation of taking a morning walk together to collect necessities?!?.” But on further inquiry, I was told that men suffer beatings (their teeth are broken, for example) if they stand up to groups of bandits. This morning’s story was of a local Chadian woman who stole a large bundle of straw from a Sudanese woman walking back to the camp, insulting her all the while. Later in the week, the Chadian woman was seen wandering through the refugee market-place (that operates on Mondays and Thursdays). The local police were called and some sort of questioning was undertaken, but with no evidence, her denials were enough. No good solutions to the problems of violence were discussed. As I listened, I recognized that most were quite pleased that the numbers of those affected were “so low.” It is of course outrageous that multiple beatings and rapes a day is considered an improvement. The next person waits to speak…

5) In the last two distributions (by SECADEV) there has been no soap. Basic hygiene, the backbone of medical health, is not being attended to, and people are rightly upset. I have been in Abéché and N’Djamena recently, and there was LOTS of soap in the markets… and nobody spoke of supply chain problems. This will have to be looked into.

So, this is what was discussed over an hour and a half. Basic needs: safety, hygiene, medical care.

For the past few days I have tried to just take things in, asking as many questions as I can. There’s a lot going on. My plan is to try and get a fix on who does what and what they say about it. It is going to take a while, and it is for this reason that I’ve stalled on writing about mental health, which I will do soon. On first pass, so far, the concerns are very pragmatic.