[Please note: all potential patient identifiers have been changed to protect confidentiality.]
David lives chained to a tree.
His tree is located in a small village close to our MSF sub-base in Maitikoulou. He has been attached to a generously large and graceful African tree for 2 straight years. His accumulated time attached to the tree is 5 years. He never is let go from his tree. He eats there, defecates and urinates there, huddles in the rain there and sleeps there. The chain attached to the tree root goes around his right foot. His body is covered by a small rag at his waist. He is covered in dust and mud. He just sits under his tree all day and all night.
David was once a normal man with a normal village life. He is now 28 years old. He was married, with 2 children and worked in his fields. For unclear reasons, at age 23 he became wild and violent. He beat his mother with a stick and her nose and forehead bear scars from him.
David speaks some French, in fact, more than the usual villager. I was asked to see him by his village chief when MSF was there screening villagers for sleeping sickness. Our sleeping sickness machine – efficiently diagnosing and treating patients sometimes comes across these cases. I ask the machine to stop and make exceptions for cases like this one. When there is a David out there, chained to a tree, the humanity of all of us is tested.
I have examined David twice. This second visit allowed me to take a more detailed family and psychosocial history to understand the nature of this man’s troubled life, and to try and conduct a basic mental status examination.
David lives in a highly disorganized state. His words are a mish-mash of nonsensical French. He makes quick, purposeless movements. When I offer him my hand to shake it, he does not take it. He pushes me away as I try to conduct a basic physical examination. He is not violent with me. Rather he seems scared.
In his village, I learned about David from his family and pastor. He has five siblings, his mother lives near his tree, and his father died long ago. His wife and 2 children live in the village as well. Despite his good marriage and life he became so disruptive and violent that the village did not know what to do for him, so they chained him up.
This is the reality of mental illness around the world and since ancient times. We chain them up.
The family of David has given me permission to try to help him. I plan to try and locate antipsychotic medications for him and start them slowly, under supervision. Then I will see what non-pharmacological therapy is available, if at all, for this man in this country. As well, I’ll have to rule out other medical pathologies which can cause a change in behavior - like sleeping sickness, HIV and neurosyphillis, just to name a few.
It is easy to pretend David does not exist. His family and village care for him rather than abandoning him, doing the best they can under the circumstances of grinding poverty in a forgotten part of rural central Africa. They tell me that they protect David, and they do not let children or others taunt or hurt him. They try to give him clothes but he shreds them off. Given this chronic and seemingly intractable situation in contrast with the emergency mandate of Médecins Sans Frontières, it is easy for me to walk away. I can convince myself and others that there is no real hope and nothing which we can offer this man.
But we can try.
I can begin to help David by telling you his story. His quiet existence under the tree will not be unknown. His existence may remain there, but it will not remain in silence.
Médecins Sans Frontières is an emergency humanitarian organization, and there are limits to what we can do. We cannot save everyone. Nonetheless, we can try to do something for someone clearly suffering indignity. Mental illness pushes our limits, and tests our ability to articulate what we can and cannot do. What we will and will not do. There are few quick fixes, treatment is chronic, and a reliable supply of drugs may be required. But all these arguments were made against treating tuberculosis and HIV and it was shown it could be done.
Warm wishes from the Central African Republic, Raghu Venugopal