25. In a Gentle Way

July 14th, 2008 by Steven Cohen

 

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!  

24. Pretty Pebbles

July 7th, 2008 by Steven Cohen

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 and rocket ships. 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.

—————————–

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.      

23. Schizophrenia

June 26th, 2008 by Steven Cohen

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. 

22. The Women of Farchana Refugee Camp

June 19th, 2008 by Steven Cohen

The night of Thursday 5 June 2008, seven Sudanese refugee women and girls were tied-up, beaten with whips and sticks, and publicly humiliated by a group of refugee men.

The event was heard and seen by many of the refugees in Farchana camp, some of whom reported the incident to MSF expats the following morning, using the word “torture” unprompted.  Note well: this word has never before been used by MSF staff describing domestic or other violence in Farchana camp.  The beaten women, aged 13-30 years, were accused of prostitution.  The victims have been “fined”; some money and goods have been seized from them and their families; several have had their or their family’s World Food Programme ration cards forcibly removed.  The victims have been threatened with further violence if they do not pay the remainder of the fine.

Despite having been instructed not go to MSF health services, the victims presented themselves to MSF, some coming on their own to the Farchana camp health centre, and others brought by local police.

The women were all visibly seriously injured, including several suspected fractured arms.  It is alleged that all of the victims had their arms damaged or broken in order to prevent them from working for a time.  All of the women fear further violence, including reprisals for speaking out about their abuse.

21. Where is the outrage?

June 11th, 2008 by Steven Cohen

http://www.economist.com/world/africa/displaystory.cfm?story_id=11461685

The compound is where expats (staff from countries other than Chad) eat, sleep, and generally hang out after work.  It’s a space about the size of a couple of basketball courts in a high-school gym, or maybe a medium-sized grocery store.  Life in “the field” is, among other things, a social experiment of the first order.  You have 3-12 ex-pats from all over the world, on staggered six to nine months contracts.  Everybody arrives with a story about why they came, and what they left back home, with attendant hopes, dreams, and dreads.  In short, it’s a reality TV show waiting to happen, except for the obvious.  Short of the surgical amphitheatre, perhaps, I have not seen an environment more rife with social intrigue and drama.  (The surgical amphitheatre wins for personality pathology though, hands down).  Crazy and disturbing shit often happens during the day out here, and everyone blows off steam in their own ways.  It does not take a psychoanalytically oriented psychiatrist to find this rich.  Ask anyone who has spent time in the field, it’s a humanitarian-bent Las Vegas, but nothing goes home on video-tape.  

The thing about being out here is that while it was mostly alien upon first arriving, one settles in rather quickly and adapts to the environment.  It is that despite being in eastern Chad, we are living in a compound environment infused with Euro-Western values that make it so familiar.  

Adaptation has its down sides.  When one adapts to an environment that is not so healthy, it tends towards survival over grace.  Avoidance and desensitization can develop so quickly that within weeks we can become accustomed to something that was perverse and dumbfounding when first encountered.

What’s been on my mind lately are the aspects of work that are truly bizarre and different,  but which have, despite their otherworldliness, become familiar.  The things that for some reason, for many reasons maybe, I cannot tap into, cannot find some common ground or frequency with which I can resonate in my own way with what’s going on.  Since arriving in Farchana, gender roles, writ large in violence, have been one of the largest sources of curiosity, perplexity, frustration, anger, and rage.

“Acceptable reasons for beating your wife.”  This is a mini-list that was told to me by Sudanese women: (1) Refusing sexual relations with your husband, (2) Not doing what you’re told, (3) Not doing domestic duties (cooking, cleaning, fetching water, etc.), (4) Leaving home for a non-duty task such as going to a ceremony without asking permission.  There was a silence in the air when these were being ennumerated.  The women seemed rather at ease, matter-of-factly even.  There is something chillingly disturbing about a well-orchestrated and methodical system of  brutality.  I want to call it inhumane, but how could such a widespread practice be labelled so?  Maybe this is why it is so chilling.

“Unacceptable reasons for beating your wife.”  (1) If you’re drunk, (2) If you demand sex in an inappropriate place, the example given being a demand when children are in the room, (3) If you hit ‘for no reason’, and (4) If you hit her for leaving the house to carry out her expected duties.

I am resisting the inclination to trip over superlatives in describing the extent of the suffering that is endured by women at the hands of a patriarchy that leaves them as objects, vessels, chattel, and reproductive systems.  The first duty is to describe.

Men and women have specific codes, duties, rights, and obligations.  And, it seems, punishments for infractions thereof.  One of the first things that you see when entering the camp is women lining up for water-collection, with their long lines of jerry-cans.  Or with large bundles of wood balanced on their heads, or maybe hanging off the sides of a mule that they’re leading in return from early-morning foraging in the brousse (bush).  Women clean, cook, sell fruit, vegetables and home-made crafts at the market, collect wood and animal feed from the brousse, and collect water.

Men, by contrast, are the animal herders, butchers, masons, merchants and construction workers.  But there is simply not much of this work to go around, so most often what one sees is a group of men sitting together and chatting away.  It is not uncommon for women to be the ones making bricks with the adolescents and children while men sit by, smoke, and watch.

Chivalry back in Canada conjures images of gallant men on horseback rushing to the aid of a damsel in distress.  Sure, maybe it’s sexist in it’s own way, but in Farchana, and I dare say in the larger region, men coming on horseback is the stuff of nightmares.

Two of my staff and I walked today to one of the blocks to check up on a depressed patient whom we have recently started on medication.  Her husband sat beside her and put his hand on her shoulder while she answered questions about having suffered a spontaneous abortion at five months gestation, approximately three months ago.  He stays at home to look after her and has taken on her duties. For a man to show such tenderness in public towards a woman is rare. There are many good men here, too. It’s a guess, of course, but it seems like he is.

On the walk back to the Mental Health Services clinic, we went by the brick-making pits in the middle of camp.  Only women worked.  We asked where the men were.  Both stories we received were from single women.  Their husbands had left to find work in Geneina (a large city in Darfur, just across the border), one having divorced his wife before he left, the other just never came back.  Two small children, looking bored, watched their mother labour in the fifty degree heat.  They were her twins, she said.  After chatting a short while, we thanked her for her time and walked away.

20. Logistics, nimbly

May 30th, 2008 by Steven Cohen

Much of the work that we do out here is focused on the final act: the prenatal exam, the psychotherapy session, the assessment, diagnosis and treatment of disease, supplements and monitoring for the malnourished. In a very real sense, the good people in Berlin and Amsterdam support the administrative Country Management Team (here in Abéché), who in turn support the logistics arms of the many projects all along along the eastern border of this godforsaken land. And they, in turn, support the medical people. Us nurses, doctors and midwives are left with the task of patient care, pure and simple. Food is on the table, pantries full, land-cruisers to transport, medical centers running triage, pharmacies stocked, electricity flowing, water delivered.

Organizing anything in Chad is no mean feat. This is a place where no opportunity for misunderstanding goes unexercised. Where negotiations often start with a stalemate or a threat and progress from there. Where everybody is needling and clawing for money and kickbacks. Where the security situation hangs over you like a thundercloud in the distance; you never know when it’s going to break.

I wrote a couple of weeks ago about the murder of Pascal Marlinge, the Head of Mission for Save the Children (StC). That day, all NGOs stopped providing non-essential services and retreated to the safety of their respective compounds. StC, understandably, never resumed. Within a week it was unofficially known that they would, again understandably, suspend all their activities and most likely leave the country. This left Breidjing Camp, with 30,000 refugees and 12,000 local IDP Chadians with no organization providing medical care. A vacuum.

This is the story of how MSF took over services and within two weeks, were up-and-running at full capacity.

People. Jochen, our mobile clinic nurse with many years of field experience, stepped up to the Project Coordinator position (PC). With a solid handle on both the medical and logistics side of things, he hit the ground running and hasn’t stopped since. Jean-Marc, the technical logistician also stopped on a dime and headed that way, as did almost all the national staff on the mobile clinic team. Ivan, our PC here in Farchana (but he basically likes to do everything, and would if given half the chance) got to planning. Since ground transport has been declared unsafe, Breidjing would need an airstrip. Ivan called up Karline (our Head of Mission in Abéché) and asked for authorization to build one. On the phone, at that moment, she said yes, and within two days 159 local workers had been hired and were on the job. Within six days the first flight landed and took off, notably bringing Ivan back to Farchana.

A full complement of staff were hired and given contracts. Stock rooms were inventoried and new medications and supplies ordered. Endless meetings with local authorities, and long conversations into the night about what to to the next day. It was, as Ivan calls it, “E-team mode,” which stands for Emergency-team. If there are locks on doors and you can’t find the keys, you cut the locks. You don’t think of overtime costs for national staff, you just work till the day ends (although notably none of the staff even asked for extra pay). Administrative authorization lagged behind implementation. Often. The lines of communication were open throughout, but decisions were made on the ground.

Notably absent from this story is the call for funding. In most organizations, it would take months of proposals and oversight to fund a project that effectively costs about a million Euros a year to run. It’s an onerous, paper-heavy task, leading to what could best be described as administrative fatigue. MSF, however, is independently funded. This means that beforehand they do not need to knock on government doors, UNHCR doors, or whomever, to ask for the means to provide health care. There is minimal lag. The airstrip, which incidentally had been “in the planning” for three years, and was built by Ivan et al. in five days, cost about 2000 euros. This is the cost of doing business out here. Health care for a population of 42,000 people for a whole year. Fantastically reasonable. In my view, administrative fatigue is rather low in this organization. Every cent is accounted for, of course, but money in MSF, at least from my vantage point, is not a “power-grab,” it’s just grease. My guess is that everyone over the age of six knows how rare this is. It likely would not escape the purview of an astute six-year-old, either.

I include the numbers because they interest me, and I figure others may want to know as well what things cost. Money is important.

This is a proud moment. (I was on vacation, so I feel justified in beaming without seeming the least bit self-congratulatory.) On the day that Pascal was killed, Ivan, Jochen and Edith (our logistics administrator) sat under the mango tree and spoke about what it meant for them to work out here. It hit them hard. But the conversation went from personal reflection to planning. What if StC left Chad? What would need to be done to keep primary health care services in Breidjing. It had to be MSF. Literally, nobody else could do it, given the administrative fatigue of other operations. They sat down with paper and pencil the next day and started mapping it out: a proposal to make it happen ASAP, for about two to three months, until a long-term solution could be found.

Group identification is a funny thing. I hear people all the time saying of their favourite football, hockey or basketball team that succeeds: “we won!” This is absurd. In the words of Chris Rock, a comedian, “no, six black guys, who would hate you if they knew you, won.” This is not absurd. But it does highlight the extent to which people ignore every register of class division and common sense to feel associated with something winsome. All of a sudden my friend who works in a bank, from a sheltered, privileged and rather sanitized petit-bourgeois childhood is character-identifying with Shaquille O’Neil. “We won!” Pointing out the absurdity does not mean it shouldn’t happen. Personally, I don’t care one way or the other, it’s mostly just amusing. But it does tell us something. That we want to be a part of something bigger than us, a community, a team, a movement that means something, that does something of which we can be proud. People buy products because some pretty face or talented athlete endorses them. And even the humanitarian world is on this: I see the faces and read the words of cinema- and rock-stars on the plight of those suffering oppression and its hardships all over the world. And why? I’m not arguing that it’s not pragmatic, but it’s strange, too.

I see many faces of MSF, but for me, this week, it is Jochen, Ivan, Edith, and Jean-Marc (three of whom, incidentally, are Canadian). They did not win a football match, nor have they been shortlisted for an oscar nomination. But they did work non-stop for two weeks to fill the vacuum, to enable the provision of emergency health services in a large refugee camp in Eastern Chad. No newspapers picked up the story, of course. Can you imagine what would happen in Montreal if medical services were stopped for two days? What about two weeks? It would topple governments. It would be a national state of emergency. Well, it’s an emergency here, too, but look who did something about it. My team.

19. Zanzibar, Tanzania, Africa

May 22nd, 2008 by Steven Cohen

The ground moves here.  It may look like a patch of dirt, rubble or cracked concrete, but it you crouch down and just wait a few seconds, it starts moving.  Tiny ants doing reconnaissance, larger ones lumbering through, smaller red insects that look like pin-point spiders everywhere. Long things with many legs, beetles, and others start to circle and weave along some hidden meshwork that is beyond the understanding of humans.  Or maybe it is just random, chaotic radiation, turbulence, Brownian motion.  Scurrying like white noise.  There are no straight lines in Africa.

I write “Africa” in the sense that most people that I have met use it here. Chadians will refer to themselves as Africans, as will Sudanese, Tanzanians, Kenyans, Congolese and so on.  It does not escape the Chadian pastoralist that he has a vastly different language and life-way than his neighbour in the next town, the village up, or over the lake yonder.  The word “Africa” resonates as a whole for the people who use it, and this is remarkable.  A few words of Arabic or Kiswahili, and millenia of trade, land rights, marriage arranging, brotherhood brokering, animal husbandry and herding, water-balancing.  These forces stretch a continent.

Shift ahead a few days.

A small place called Bwejuu.  South-East coast of Unguja, the main island of the Zanzibari archipelago, itself just off the coast of mainland Tanzania.  It was a seaside town, that forgot to close down, and moved at about that pace.  I’d arrived in the trough of low season, but met a few similarly wayward travellers nonetheless.  By day three I felt that if I was any more relaxed I’d slip into a coma.  Which was nice.  My mornings were spent snorkeling through the fringed coral reefs, and I awoke to the sound of small yellow birds that make small teardrop-shaped nests in the trees all around my bungalow.  Jeremiah, one of the Masai fellows working at the small guest house at which I stayed, asked me if he could take my motorcycle (250cc of Honda Baja glory) to the beach and ride it.  He had the energy and smile of a gleeful person, which struck me as a strange quality in someone carryone no fewer than three concealed blades under his flowing red garb.  As we went out to the beach, I realized that he had never ridden a bike.  But hell, neither had I until a week ago.  The problem came in trying to explain what a clutch is with twenty shared words!

Zanzibar is called The Spice Island, which is a misnomer. Sure, it may have once been the hub for trade in cardamom, lemongrass, nutmeg, chili and peppercorn, among others, but the food is of the blandest I’ve ever eaten.  Luckily this is well made up for, among many other things, by the spectacular views.  I had not bought a new camera by then, so I’ll just have to describe the scene.  Rough-hewn locally made tables on a white-sand beach.  Low-light candle in a corner.  The sun sets quickly and leaves a blotted underbelly of fiery reds and purples on the clouds.  It looked like hell upside down, and from a safe distance.  Lateen-rigged dhows are off in the distance, small wooden fishing boats that have a triangular shaped sail with a scythe-like curve that is masted close to the front of the sliver of a vessel.  Every image was charmed… that kind of a place.  I looked over to the right of me while I was sitting out there and saw about eight other people on the beach, seven of whom were taking photos.  This is a well photo-documented generation.  It struck me that it may be the case that more photos were taken of sunsets that one day than in all of the 19th century.

My days on the island were coming to an end, though, and I had to run back to the capital, Stone Town.  This is, incidentally, also not really a meaningful moniker.  I suspect that it would have been more accurately called Smelly & Cracked-Concrete Town, but alas, that did not track well with focus groups.  The point, though, is how it is that one finds their way around this island, back to the capital.

These were the directions: “Turn right at the T-junction, then left at the second round-about, past the big “Foma” detergent sign, and when you’re close to town, you’ll see an intersection that looks like a platypus… turn hard left there…” and so on.  I was becoming a bit frustrated… the lack of street signage makes it difficult to know where you are, and where you should be going.  Over the past week, with no real destination in mind, this had bothered me none.  I had my rented dirtbike, miles of road and beach, and, of course, throngs of people everywhere to ask directions along the way.  And this is when it struck me… that image.  The one that comes at 5am, wakes you up, and just sits there.  You know the type, no?

Back a few nights.

Imagine a hard flat surface like a book or open hand slapping forcefully against another surface, that of a placid body of water.  Scale is unimportant.  Look at the streams of water that are jetted out from the sides, shooting outwards but connected by small tendrils, some thick and goopy, others impossibly thin.  A viscous crown of molasses-like mesh, curving in all directions.  Like in networks of veins just under the skin or on a leaf.  Patterns on wind-swept desert sand.  The mesh of a sponge.  The petrified pith of trabecular bone.

This was the road back to stone-town, and the people were the network along which I would wind my way.

It started to rain, and I pulled over under the metal sheeting of a small hut where kids were selling fruit.  My clothes were soaked through, but it was warm enough to ward off the chill.  I bought a large papaya and ate the reddish-orange pulp while chatting with the kids in some broken pidgin of English and my ten Swahili words.  The boys were fascinated with the multitool leatherman that I had used, and took turns over the next two hours passing it among them opening and closing every knife and screwdriver.  Despite the rains, lots of bikes, motorized and not, whizzed by.  I waited for the rain to stop, pointed in one direction and said “Stone Town?”  To which the boys smiled and nodded yes, trying to curve their hands to the left, which was what I had to go on.  There are no straight lines in Africa.  But with a belly-full of papaya and the hot sun drying your clothes, this seems less important.

18. Power

May 8th, 2008 by Steven Cohen

The day that I left Chad a text message arrived an hour before hopping on a plane for my holidays (I write this from idyllic-but-obviously-not-too-distant Stone town, Zanzibar). The text message said that a fellow named Pascal Marlinge, the Head of Mission for an NGO (Save the Children, UK branch) had been shot and killed in a car heist a short drive from Farchana.

http://news.bbc.co.uk/2/hi/africa/7378304.stm

http://www.reliefweb.int/rw/rwb.nsf/db900sid/ASIN-7E8QNG?OpenDocument&rc=1&cc=tcd 

It left me sad and a bit numb; I write this with heavy hands.  I found myself trying to make sense of it. How could this have happened? And, inevitably, why did this happen? Why would someone shoot a clearly unarmed person exiting a clearly marked humanitarian vehicle with his hands in the air? And this is where my mind has gone while sitting in airport terminals, eating street food in the grungy Escape-from-New-York backdrop of Dar es Salaam’s Kariakoo district, and watching the waves foam up on shore.

The word that I keep coming back to is "power." Several years back, one of my mentors in psychiatry casually said "there is only one type of power." I am not sure if he’s right, but he’s the type of person that you listen to, and figure out how they came to that conclusion, even if you’ll disagree with it eventually. Over the years I’ve muddled around with the question of what it would be, this one power, if there was just the one. And what I’ve come up with is this: power is the ability for one entity to set the viability conditions for another. That is, one entity can effect a gross difference in the capacities, choices, and mortality of another entity. For humans, this would include, for example, a parent or state feeding their young so that their bodies can grow and learn; teach skills leading to more vocational choices; or the provision of basic health care so that a premature death doesn’t cut this potential all to shreds.

It is also, notably, the power at the end of a rifle, an apron string (families excommunicating members), an emotional outlash.  Images of tyrants always come to mind whaen I think of "powerful" people. Mussolini, Mugabe, Stalin, Pol Pot, Mao Zedong, Nikolai Ceausescu, Saddam Hussein. Basically what these guys did was whatever the fuck they wanted, and nobody could say otherwise. They were, and are, barbarians. 

Lust, gluttony, avarice, sloth, wrath, envy, pride. These are the seven deadly sins, which may as well be a laundry-list of the manifest entailments of 20th century Western success. "Get rich or die trying." Envy was used in the sense of "malice" in the fourteenth century, as in "creating equality" be taking or destroying that which someone else had… the vulgur side of jealosy: hate someone for havng more or being more.

But this is here it gets complicated. I think that most of my cohort can rally against the despots, but what of the seven sins? It may be schlocky, but I think that TV is a sophisticated barometer of an ethos. While practicing up in the Canadian North, I had too much free time and a satellite connection, so I watched all seven seasons of The Sopranos. Hellava good show, and to my mind, there has not ever been a character as complicated as Tony Soprano. Somewhere along the way (maybe in the second season), I realized that this guy was a simmering psychopath (however pro-social). Enter "Dexter," another TV character, who is a blood-lusting psychopath who "uses his evil powers for good," killing "bad" psychopaths. Brilliant premise, but can you imagine the pilot being pitched twenty years ago? Not a chance. For 50 years, the bible of broadcasting was the Production code of motion pictures, and for 40 years or so up until the late 60s, it stated that:

"No picture shall be produced that will lower the moral standards of those who see it. Hence the sympathies of the audience should never be thrown to the side of crime, wrongdoing, evil or sin."

You couldn’t even watch someone pretending to be evil!  As if just the perishing thought could shift the balance to the dark side.  I remember being timorous in medical school when I asked patients if they had ever hade ideas of suicide or self-harm (a standard part of the psych exam, and for good reason). It was hard for me to ask the question, as I did not know what I’d do with the answe, or worse, that I’d throw their symathies to such an act.  It’s kind of absurd that someone’s going to say "wow, suicide, great idea! Never thought of it, but you’ve been a great help, doc." I needed to gain experience with the idea of suicide in the same way that I have needed, in Chad, to become more familiar with ideas of genocide, mass displacement, and wanton violence the likes of which I had only read about, but never seen.

But what do we do, then, when we character-identify with Tony Soprano in some way but are also revulsed at the mindlessness of actual wanton destruction and death? This is not a rhetorical question. We talk about it, and the dialogue makes it more real. There is no answer, of course, but exploring it carefully may lead to a better ability to balance the essential urges of war and peace that wage their quotidian battles in us. Maybe we’ll even gain a better understanding of what power means to us, and use some of those superpowers for good.  

So what, then, would be the luminescent side of power… how can we counterpose and salvage the beauty in wilful and benevolent expressions of it? It would then be the exercise of might in capacity-building, the prolonging of life and heightening of health, all in the service of preserving the right for people to choose what they want to do. If freedom is some waffly continental breakfast, options and choice are the sustenance that sticks to your ribs.

MSF came out with a position paper of sorts called "The Chantilly Document." It starts with a single line, before getting into two pages of text: 

"The overall purpose of MSF is to preserve life and alleviate suffering while protecting human dignity and seeking to restore the ability of people to make their own decisions."

In my opinion, Pascal was doing this. He was working away from his wife and two children, in an inhospitable place, quite likely for less pay, less stability, and higher job-related anxiety than he could have found elsewhere. Like so many people that I’ve met out here, they hold it together for some reason or another so that, in the long run, others will have more options. This character trait I call integrity, the exercise of which is strength.

It is apalling the abuses of power that I have seen in the past several months. The stories, the lives, the wounds physical and psychological. They track closely with the absence of wide, transparent, and consensus-driven means for accountability. With no accountability, it seems that power prevails over strength.

In the end, Tony Soprano got punted by his Shrink.  Strength prevailed after seven seasons:) I hope that Farchana does, too. We’re in our fifth year, now.  

————————————–

sorry, no pics.  My camera broke.  The fellow at the repair shop said "There is a lot of dust in here, where have you been?"  

    "Chad, four months."

    "oh." 

 

  

 

17. Tea-time at the non-sequitur café

May 2nd, 2008 by Steven Cohen

hamraNote that none of the following pictures contain patients, and all parties have signed written consent to have their pictures included in this blog.  Of course, parents signed for les petits.

———————————————————————-

Not sure what it was that helped me turn the corner, but after a couple of feverish nights and a loose string of, well, phlegmatic days, some energy returned!  Whether it was the anti-parasite medications, a few long walks under the mango trees, good days at work, or the regime of sun salutations, vitality creeped back in.  You need it here, too.  In the same way that it’s hard to remember the summer heat on your skin in the dead of winter, after a trudge through the dregs I’d lost sight of the joy in many little things out here.  So I thought that this is what I’d write on, or just show.  The things that you do that make this place fun…

My good friend Jerry sent me a few care-packages of junk food and sundry, which included a bag of ring-pops, some original star-trek cards (odd), bubble gum tape, pez, and nerds.  This is a picture of Patrice, eating nerds for the first time.

Jochen brought a slack-line from Swabia, and we’ve been practicing our tight-rope walking on weekends.  Seriously, you you make this up?

Make a Ouaddai-tini:  
1) Go to Eastern Chad, in the Ouaddai region of the Sahel
2) Find hooch (locally called “diable” or “demon”)
3) Mix it with home-made Hibiscus juice
        
Walk pretty much anywhere and get accosted by jovial screaming tots 

Play soccer with them

Kidnap a wee malnourished goat, nurse it back to health for a couple of days, and set it back out with it’s kin.  Be told by one of your staff to never touch local animals because the rules of Chadian ownership of animals is “more complicated than sex between ducks.”  Look confused.

Relearn the extent to which necessity is the mother of invention

Read while listening to Ivan playing guitar under the mango trees

Say hello in the morning to Fatima, a worker at the Nutritional Center, and her twins, Safi, and Safia

Say hello to Habib and Hamra, some of our MHS staff

Hamra

 Wonder after unfortunate abbreviations

Say hello to the theatre group.  This week they presented a little ditty on “family planning.”  Later I learn that Zakariah has three wives and 19 children.  He looked disappointed when he learned that I had none of neither.  You either laugh or cry.

Uh, hello-moto?

Walk through the camp and happenstance upon a volleyball game.  Be given a prized seat and asked if you want to help officiate.  Politely decline.

Hang out with Bienfait in the Health Center.

Eat some lunch with the boys

Greet the new sheriff in town

Keep on providing good health care for free

Wipe dust off your computer screen when you post blog entries

16. Fruit in a Bowel

April 28th, 2008 by Steven Cohen

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

ggt.mp

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.

 

joint.mp

 

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.

 

bb.mp

 

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.

 

hitsuyo spigot

 

 

psk.mp

 

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.