Fieldset
The night I met Thomas: Mental health support in South Sudan

"A small incident can be enough. A trigger. A push over the edge. Something mundane."

Raimund Alber is an Austrian psychologist currently working with Médecins Sans Frontières/Doctors Without Borders (MSF) in South Sudan’s Malakal “Protection of Civilians” site – a camp for those displaced by the ongoing conflict. He shares his powerful story about the night he met a young man who had just attempted to take his own life…

(The names of those involved have been changed)

As I'm talking to Simon, the clinical officer responsible for the adult ward, I can see Thomas carefully stuffing the mosquito net under his mattress and lying down sideways.

He is very tired and falls asleep right away.

The barren, bluish light of the few lamps and the soft noise of the ceiling fans in our 20-bed hospital tent seem not to bother him.

19 years old. And he almost would not have grown older.

It's now 00:35. 2 March 2018. My birthday.

Life in Malakal

I have been working here in Malakal in South Sudan since the beginning of February. It’s the middle of the hot dry season.

Once again, I am assigned as the Mental Health Activity Manager.

My team consists of three psychosocial counsellors and a translator. And we are very busy. Soon, we will be supported by a psychiatrist. The full package for specialised care for mental disorders and distress – conditions that many people suffer from here.

No one has called this place home for a long time.

At the height of the crisis, the camp at Malakal was home to 47,000 people. Photo: Philippe Carr/MSF

At the height of the crisis, the camp at Malakal was home to 47,000 people. Photo: Philippe Carr/MSF

The Republic of South Sudan is the youngest country in the world and it had been shaken by the never-ending civil war. After gaining independence from Sudan in 2011, the then leading rulers could not reach an agreement and since 2013 have been fighting for supremacy.

The victims are – as usual – the people. The civilian population.

Tens of thousands dead. Over 1.9 million internally displaced and 2.4 million people seeking protection in neighbouring countries. Constant fear of violence, no functioning health care, economy or educational systems. A patchwork of humanitarian aid.

The UNMISS (United Nations Mission South Sudan) “Protection of Civilians” site is located just outside of Malakal. Nearly 24,000 people live there. MSF operates both a hospital in the middle of the camp itself and one in the adjacent city… or in what is left of it. Although many residents were displaced from the city, between 15,000 and 20,000 people have settled there again.

But no one has called this place home for a long time.

Thomas’ story

Thomas is one of many young people here in the camp. No income, no future, no hope. And last night everything was too much to bear. But, I did not find out what really happened until later that night.

So, Thomas takes a rope and attempts to hang himself in his hut.

Miraculously, a neighbour comes by and alerts others who rush to save him.

How precious is a life really? In a country where death has become normality.

He is the twelfth young person since the beginning of the year who wanted to take his own life. A rope, a scarf, a scrap of fabric or mosquito net, rat poison or bleach. Not many options are available to people here.

But options to find help? Our hospital is open 24 hours a day.

A simple hospital ward, run by MSF inside the Malakal camp. Photo Philippe Carr/MSF

A simple hospital ward, run by MSF inside the Malakal camp. Photo Philippe Carr/MSF

And so Thomas is brought to us by the UN police. It's the police who bring him because suicide is seen as a criminal offence by the people here (and also by law). A few months ago, people who tried to kill themselves were imprisoned. But the community here knows that these people need help.

“Everything is quiet…”

When our radio operator knocks gently on my container door in the Humanitarian Hub, I am already sleeping. It is 11:30 pm.

The days are exhausting and because of the heat, I have no energy left.

I wake up, ask what's going on and he whispers: "Mike Hotel is calling!” This is radio language: M (ike) = MSF, H (otel) = Hospital.

Ten minutes later, I'm in the Hope Centre, a container in the hospital in which we treat our patients with mental illnesses and stress confidentially and discreetly.

I sit down opposite Thomas. Next to me, my translator takes a seat. Everything is quiet.

What keeps a person alive under these difficult conditions? Thomas and I will try to find out together.

The first moments with a new patient are always exciting for me. The challenge to find the best way to build a strong rapport. Gain access. Create trust. The “therapeutic alliance” is a foundation for every psychological treatment.

I decide to keep silent. Intuition.

And so Thomas and I sit there, both bowing our heads. Seconds feel like hours. I notice how my translator gets nervous. It’s not easy for him to be quiet. But then Thomas looks up. Shy. I smile at him and introduce myself: “Hello, my name is Raimund. I work as a psychologist here in the hospital. Can you tell me your name?"

After a seemingly endless pause, he says "Thomas" in a low voice.

I answer: "Hello Thomas. Nice to meet you."

What keeps a person alive?

Why does someone want to end his life? Something that is meant to be one of the most precious things we have.

But how precious is a life really? In a country where death has become normality. In a place where the painful memories of the past throw dark shadows into the present and where thinking of the future only results in hopelessness.

Living conditions inside the camp at Malakal. Photo: Raul Fernandez Sanchez/MSF

Living conditions inside the camp at Malakal. Photo: Raul Fernandez Sanchez/MSF

A small incident can be enough. A trigger. A push over the edge. Something mundane.

What keeps a person alive under the difficult conditions here? Thomas and I will try to find out together. But it's enough for today. He is so exhausted and his eyes are weary. He just wants to sleep.

By the end of March, I will have met nine more survivors of a suicide attempt.

After a brief examination by Simon, we admit him at the hospital and show him his bed. Close to the nurses' station. The night shift wants to keep an eye on him.

The unknowns

As our Land Cruiser passes the second security check after the short, dusty drive back from the hospital and roughly shakes while it comes to a stop in front of the MSF condominium, I  do my final report via radio: "Bravo (base), Bravo for Raimund. Reporting arrival at your location. Over and out."

While I try to sneak over the creaking floor of wooden boards on my way to my container, I think of Thomas and the other patients of the last weeks.

Hopelessness coupled with loneliness, the feeling of not being needed, being alone. How many may still feel this way? Too many.

By the end of March, I will have met nine more survivors of a suicide attempt.

For one person, however, there will be no help. Nobody will find him in time. Nobody will cut him off the rope and bring him to our clinic. Only when it is already too late.

But all of this, I don’t know yet. On the night I met Thomas.

19 years old. And he almost would not have grown older.

It's now 00:50. 2 March 2018. My birthday.