Fieldset
David and Zo Kwe Zo

Perhaps you have read before in this blog about David. He is is age 28 and has been chained to a tree for the past 6 years. I had thought his confinement was 5 years, but on my fourth visit to him under his tree, his village chief corrected me and told me it was, in fact 6 years.

Perhaps you have read before in this blog about David. He is is age 28 and has been chained to a tree for the past 6 years. I had thought his confinement was 5 years, but on my fourth visit to him under his tree, his village chief corrected me and told me it was, in fact 6 years. I believe David suffers from chronic schizophrenia. I am not using his real name here. His village has found that only by chaining his right leg to a large tree trunk can they control his behaviors and sometimes violent actions.

One of the most important historical and political figures in the Central African Republic is Barthelemy Boganda. He stood up against the former French colonialists and pushed for basic rights for the common people. It is said he coined the Sango phrase "Zo Kwe Zo". Zo Kwe Zo translates into "every human being is a person". When you are in the capital city Bangui, you can see this inscribed on prominent national landmarks. When I first read this saying I thought of David. Even though he is chained to a tree, he is still a person. When I am tired and frustrated and want to be left alone by the nurses and I need to dig a bit deeper this saying helps me muster more energy to take care of someone or some problem the best I can. Zo Kwe Zo. Zo Kwe Zo.

On my last visit to David, which occurred while we were nearby screening for sleeping sickness, I performed some laboratory tests with the permission of his family. I first needed to sedate him with an injection of ketamine, which worked quite well after a second dose. David entered what we call a 'dissociative state' under ketamine, where he did not feel pain and was not be aware of what I was doing to him. We did some blood tests and I performed a lumbar puncture. The whole village stood around and watched quietly. The village chief tried to shoo them away but there were just too many. In our previous attempt to test David for sleeping sickness 7 men and I could not restrain him enough to perform it properly.  That is why we resorted to ketamine.

While sedated, David drooled, and his copious sputum smeared the side of his face. His mother stayed beside him and used an old sack to clean him. While David was asleep his brother also brought over a pair of scissors. Quietly, he gave David a haircut. David soiled himself. His mother covered him with a rag. I asked his family to take the opportunity to bathe him since apparently, he never lets himself be washed.

The lab investigations proved David did not have sleeping sickness but he did have malaria. This is not surprising since he lives outside without a bednet. When the Anopheles mosquito looks for a blood meal at dawn and dusk he is a quite susceptible. Treating this man's malaria will not be easy. He will not accept oral medications, so we'll have to do it by some injectable route. The bigger question is how to prevent future malaria infections.

Maybe we can sew a few bednets together and fashion them around his tree. Hmm, I'll have to ponder this further with help from logistics.

For David's mental disorder, I have sought the advice of my medical coordinator in the capital city, psychiatric colleagues and those at higher levels in MSF. The case of David is complicated as there will be no easy fix, and if we start any treatment for mental illness, it will likely take some commitment on the part of MSF and other actors to see it through. Six years of severe mental illness will not be cured as easily as malaria or sleeping sickness. But at least we're checking out the options, asking difficult questions amongst ourselves, and trying to find a better way than right now.

Zo Kwe Zo.

Warm wishes from the Central African Republic,

Raghu Venugopal