10. Mental Health Services # 3

CAMH Steven Cohen | boys.puppy1 CAMH Steven Cohen | boys.puppy.2

Chad remains politically active. We don’t get mentioned much on the BBC anymore, as the news cycle has moved on to other world events, but word 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

CAMH Steven Cohen | child.2 CAMH Steven Cohen | child1 CAMH Steven Cohen | plumpy.mozzy

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.  Seems that I skipped over some of the basic structure and history of the project.  To be rectified…

CAMH Steven Cohen | Google map Farchana sky CAMH Steven Cohen | plane.plumpy CAMH Steven Cohen | wadi.above CAMH Steven Cohen | huts.above3 CAMH Steven Cohen | huts.above2 CAMH Steven Cohen | huts.above1 CAMH Steven Cohen | farchana.ground3 CAMH Steven Cohen | farchana.above CAMH Steven Cohen | farchana.ground1 CAMH Steven Cohen | farchana.ground2 CAMH Steven Cohen | cemetary

The MSF-Holland 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 hired and trained the Sudanese counsellors. Each MHO takes a 6-12 month contract with MSF, so we are a “transient figurehead” of sorts.  The project continues when one MHO leaves, and is self-sustaining, yet the staff indicate that they are most pleased when an MHO is on-site.

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 to cure the ill  in recompense for money or animals; 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 or relief health-care provider. In the loosest sense possible, when an MSF project is well established and the “emergency mode” of the situation has been attended to,  MSF arranges for the project/programme to be handed over to a long-term health-care provider.  I’m not sure how other NGOs handle mental health care, but word is that some are much better than others, both in interest, resource-allocation, understanding, and execution. 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 and high quality care?

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. Je m’excuse.  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 at risk of 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, depression, 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 French-language 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 standard 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, I suspect that the turn-out will be much improved. Can’t wait to 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. Specialized referral networks are crucial to this system.

CAMH Steven Cohen | barrel_cropped_(1) CAMH Steven Cohen | barrel_whirlpool

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.

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