Farchana Nights

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.