27. The withered buffer

When in Chad, I took notes and walked around with a Camera.  My mission was, in my mind, to help with the immediate concerns/suffering, to document, and to learn about a larger world with my feet in it.  Advocacy became more prominent than I would have expected.  In some way, the writing and documentation probably also served an anxiety-mitigating function… intellectualization takes you out of the moment, a bit.  But that was a fair trade-off.

Having returned, though, I have this aversion to taking pictures.  I can be in them, I can want to preserve moments in time, but I don’t carry a camera (one was in my pocket for six months) and have a slight pang of guilt for this.  I wonder what my new Chadian friends will think if they saw photos of me in Canada.  This is foolish on many levels, but the object of this thread is not to be rational and prudent, but to be descriptive.  A photo seems to me a wish to preserve, and I have nothing to add.  My giddy and smiling nephew and niece are rather well photo-documented already… I just play with them and field questions about mud, carrots, monsters and stuff… I like that.

Break…

Casual cruelty.  There is a concept in psychiatry called “over-kill” or “casual cruelty.”  When a guy gets in a “fair fight” in the bar or wherever, and he hits his opponent who then falls over, he stands back.  The fight is done.  If the guy continues to kick and punch and inflict damage, pain and suffering, then this is deemed aggravated assault, and it can happen for a few reasons. I’m not really going to get into it, but the desire to see others in pain is bloody well endemic in our society.  TV shows such as The Sopranos, Criminal Minds and Dexter, all runaway hits, reflect this desire in us to be exposed to this cruelty.  I say experience not in the sense that anyone wants to carry it out.  Not at all.  But to my knowledge (and I’ll admit that I’ve not done any research into this, but I’m guessing that there are more than a few PhD theses written on this very topic), Tony Soprano is the “good guy”, albeit a complex character.  I don’t know when I have ever been cajoled by television into wanting to character identify with a psychopath (again, made more complex in that he is a pro-social one; Tony stands up for Italian culture, family values, community safety, etc).  Dexter is a more striking example.  He only goes after baddies, but the gore, the sadistic drive, and the absence of empathy are there in great part.  Criminal Minds trip over themselves to depict evil in a more provocative and disturbing form each week.

It is too much.  I used to watch them, and now I choose not to.  In one sense, the duty to withstand negativity, psychologically challenging emotions, and disgust, are necessary for a psychiatrist.  Our duty, as is the duty of many other professionals or philosophers alike, is to see the world for what it is, and pay attention to appearances when the mind wants to look away or self-protect.  In some fields this is called “negative capability,” but I think that I am using this term in the Bionian sense (As in Wilfred Bion).  I used to think that I had a high negative capability, but it turns out that the exposure to so much suffering in Chad has worn this out.  My buffer is still thin.

I watch the television, an escape for me that lives on, and while I used to revel in the psychological twistedness of the characters, and their undoing, now I find it banal at best, and usually aversive.  Sure, there are bad people, and they don’t care about others, and some of them are truly callous and perverse.  But the majority of suffering in this world is due to neglect and indifference.  Chad’s government doesn’t give a fuck about their people.  They just don’t.  They would kick every NGO out of the country if it weren’t for the risk of losing aid money and IMF and other assistance.  This is a country that wanted to tax MSF for the medicine brought into the country that was being dispensed FOR FREE.   Right now, to me, the face of evil is the face of the man behind the desk that made that decision.

Break…

Six Feet Under, now that is a good show.

I’ve been back for over a month now, and the fatigue has mostly lifted, I’m getting back to being skinny rather than mildly alarmingly rakish, and the humour is starting to come back without me pretending.   I seek out fun, rather than trying to be a part of it for mainly the sake of distraction.  I think a lot about healing.  The pragmatics of healing psychological distress.  I think about closeness and caring, and the vulnerabilities that this engenders.  I am thinking about connection-making and breaking.  The ties that bind and the ties that keep us from moving on.

26. “Reverse Culture Shock”

 

It’s been about two weeks since I’ve been back, and I have not put my fingers on the keyboard.  There are a number of reasons why this is so, but the primary reason is that I want… to be more present, and the past half year is hauntingly ever-resent.  The very morning I awoke for the first time in my bed in Montreal I received a message from the clinical coordinator in Amsterdam asking me if I was willing to go to the Sudan.  It turned out that the government is kicking out the NGOs for a host or reasons, and there is a need to train local doctors how to continue treating persons with schizophrenia and bipolar disorder.  Good work, and very necessary.  I wanted to go, and I ached to say yes.  But my body was depleted, and I sheepishly wrote back that given my commitments to various hospitals (locum contracts that I had set up), I could not go.    It was true, but I also knew that I was not ready to return the next day.  I didn’t know what I needed, but there was a need that I had that could not be met in Darfur, and I would not have been able to do a proper job.  I sadly declined.

Needs.  Forgetting a very healthy thing, and sometimes is an efficient means of processing.  I once came across a fellow who had served in the army in a war-stricken land, and I asked him the usual questions to see if he had post-traumatic trauma: re-experience with physiological and psychological distress, hyper-vigilance, and numbing, to name a few.  He had what I would consider a healthy, normal pattern of behaviour, and a healthy, normal constellation of sadness, fear, and loathing of the negativity of the experience.  He told me about his buddies who had been diagnosed with PTSD, and his eyes welled with tears.  I asked him what his thoughts were about how he had avoided that, and his answer surprised me:  “I came back, I went on a two-week bender, and when I came out, I just put my head down and worked hard.”  Let’s be clear, I am not advocating this.  That moment has never left me, though.  Forgetting, as Théodule Ribot wrote in his Maladies Des Mémoires, is one of the boundaries of the self.   If you can’t remember, you’re hooped.  And in a surprising way, if you can’t forget, you can be hooped, too.

Omar Khayyam once said something like “I drink not for mere love of wine, nor to scoff at faith, but only to forget myself for a moment, for that alone do I drink.”

I didn’t quote this to the veteran.  Alcohol is a very bad medium- or long-term solution.  The line that kept coming to my mind, and what we did discuss, was the phrase about smelling the roses, the implication being that if you stop and smell the roses, you smell everything else as well.  Another phrase comes to mind, again I don’t recall who said it, and I am fighting the urge to be academic and look it up.  It lauds “the hard moral work of remembering.”  Yes.

OK, academic diversions aside.  Now.  How am I now?  The staccato sentences mirror my thought process.  I am tired, and have to sleep in the afternoon still… this is fading, but for a week, it was consuming.  My capacity for social interaction is growing, but too many people in a room is exhausting.  The memories of close friends in Chad, especially Issakha and the counsellors, are vividly fixed in my mind.  In psychiatric parlance, I have trouble code-switching.

I am home, wherever that is.  Eating well, sleeping in a safe land and a comfortable bed, and caring all around.  My friends and colleagues are in Chad, listening to heavy artillery, fearful that the fragile stability could break at any moment.   I miss them, and feel for their situation, and the powerlessness to change much of it.

Now.  What is it like now?  Like a faraday cage, where the sounds and smells all seep in, but I am walking around in a haze.  Sparks of stimulus on the periphery.  Like an overexposed picture, my quasi-detached consciousness in the centre.  The sound of cars is disturbing me more than makes sense.  I cannot switch from thoughts of Chad to thoughts of my life… “where are you?” a few of my friends have asked.  “Just catching up on sleep,” I return, and hope that the playfulness in the tone is enough to keep from more prying or concerned questions.   I don’t want to talk about it and have the topic changed.  Sometimes I walk away.  I’ve never done that before.  One of the few things that a psychiatrist never says (or should never say) is “too much information.”  But I find I need to walk away.  My buffer is thin.  My resources have been taxed.  I’ve been working again.  Jumped back into the hospital life, and it has been very busy.  The nurses tell me I look gaunt, and it’s true.  When I look in the mirror, I wonder how I had 15 pounds to lose, but it went somewhere.  I feel like I’m communicating with some barrier in between, like there is an isthmus between me and the mainland of the world I used to be in.  It is a weirdly detached feeling.  Sometimes it goes away, and I enjoy that.  Other times I wonder how long it was like this before, and I never knew.

25. In a Gentle Way

Scz.flipchart red.road orb.steppes.2

It would be fair to say that before coming to Chad, in the months leading up to this mission, I was expecting something alien.  Conditions and life-ways so extreme and dimensionally different from mine that I would struggle to connect with them.  In anthropological parlance, I exoticised the other.  This is almost never a good thing.  It is also somewhat inevitable, at least when exploring new terrain, however much you try and keep it in check.  In order to minimize the anxiety of the unknown and unexpected, we start entertaining possibilities.  Like mythologies and daydreams, they have no direct correspondence with reality, but these animated exhalations are good to think with.  Like a mental jungle-gym.  The problem is not in doing this.  Quite to the contrary, exploring hidden assumptions and their entailments are the scaffolding of psychotherapy.  Or most any insight-oriented activity, really.  Rather, the problem would be in affording these guesses, assumptions or projections a stability that does not reflect their arbitrariness and self-soothing origins.  In the first post that I wrote, I asked some semi-rhetorical questions:

How can a psychiatrist WWHUUMMP parachute into central Africa and expect to do anything useful?

*Tense sigh* These people have suffered such incomprehensibly intense, sustained, and unpredictable trauma, and the situation remains horrendous!! What do you say to a person who has lost his or her family, community, and livelihood?! What do you say to the woman who has been repeatedly raped when going out at night for firewood, and will continue to do so because her children will die without cooked food?! What do you say to say to a child who has been orphaned, neglected, and abused?! What can a psychiatrist do?!?

Both questions are of the same form: what can a psychiatrist do when he or she has no clue how to connect with unfamiliar circumstances?  The uncertainty was palpable—and sensationalistic. [Read more…]

24. Pretty Pebbles

I want a Porsche.  There’s no way around it.  Ever since I was a kid cars have fascinated me, the power, aesthetics, speed, engineering.  My jaw kind of drops when I see one, and has for many years.  I’ve had my eye on an early 90s 911.  The guy who designed this car, Erwin Komenda, is a genius, inspired by turbulence reduction, drag coefficients and rocket ships.  And, at the risk of being improper, rudimentary polling indicates that the golden number for the price of women’s “must have” shoes hovers at $300.  Listen for the choir: “more for boo-oots!”  Whether or not one actually buys these things is not the point.  What I’m trying to  do is reconcile such desires with where I am.

The pen in my pocket (easy fellow Freudians…) is a Uniball extra-fine.  Black, made in Japan, a triumph of mass production and injection-molded plastic.  In Canada, it costs about three bucks, which, incidentally, is about a days labour for an unskilled tradesperson in Farchana.  It is also the price of a beer here, of which you have your choice of two local brands or a bottle of Guiness.  How’s that for distribution networks?  Kids here ask for money occasionally, but most often ask for a cola or a pen, the latter being called a “bic.”  Pens have currency; this is a place where most people do not have one.  Where the “prized seat” is a plastic garden chair, even when dealing with the highest levels of local official.  In the capital, N’Djamena, there are five-star hotels, a parliament building, and a court-house (that’s in construction).  Otherwise, it is shanty-town.  On the same block, in all directions.  From the pool area, you can hear hammers smashing away at fallen concrete structures; people are salvaging the steel rebar inside to sell to scrap-metal merchants.

http://www.economist.com/world/africa/displaystory.cfm?story_id=11670946

In Farchana, the people with money have meat in their food and a plastic lawn-chair at their disposal.  Those without may forego a few meals.  There is no such thing as a Vegetarian outside the expat compound… the idea of passing on meat for ethical or aesthetic concerns is unimaginable.   Not that it’s a failure of imagination, it is just unheard of. [Read more…]

23. Schizophrenia

Patient names and minor details have been changed for confidentaility. “Youssef” has consented to have his story told in this forum. I told him that it was as if his picture and story were posted on every building in the whole camp, in all the villages in the world. He was lucid, in full capacity to make this personal decision, and pleased.  He asked appropriate questions regarding the pros and cons of his story being told.  Prior to this post being made, a translation was given to him courtesy of  the local Imam, whom he trusted.  As well, Youssef made all decisions, in consultation with his family and the treating team, regarding his medication management.   

Every Wednesday for a couple of hours, the entire mental health team sits around a table and discusses difficult cases.  The meaningless, absurd, touchy and confusing also find their exploration here.  Minimal direction, gentle redirection, no blocking; this is a safe space.  I hesistate to guess that it is the most important two hours of our week as a team.  Having been here for five months, I am by far the most recent addition to the team; the counsellors know each other well, and a solid trust has developed.  During these two hours, we delay our response to referrals, and counsellors do not book patient sessions.  About the only thing that routinely disturbs them are distribution days by the World Food Programme; few things trump food.

It took a while to get settled into the run of things, but shortly after that happened, I noticed a pattern in the stories. Well, maybe “pattern” gives the impression of something more structured than it was.  Mostly, the stories did not make sense.  But they did not make sense in a way that reflected the cases in a meaningful way.  Chronology is less consistently used as a way of organizing information in Farchana, but even still, there was a fractured or diconnected quality to the case histories.

IMG_1987

We started inviting some of these patients to our meetings to do group interviews, and it became clear that some of these persons were psychotic, and met criteria for a diagnosis of schizophrenia.  This is the story of one man whom we have gotten to know well over several months.  (Note that some parts of this story were written and posted months ago but were later removed from the blog due to confidentiality concerns.)

Youssef, a long-term patient of Issakha’s, was first presented one Wednesday, having the unique complaint of “a burning sensation” in his chest, a head-ache that came some nights, and his family thought that something was wrong.  He isolated himself for long stretches, and occasionally said things that were incomprehensible.  Youssef’s only consistent interest was Islamic studies, and he was a good student when he showed up for lessons.  A visit seemed appropriate.

Some of the larger blocks in the camp are a labyrinthine maze of brick and straw walls, rogue livestock, delapidated latrines, and kids running everywhere.  Without Issakha as a guide, I would not have known where I was.  Eventually, we stopped in a passageway and Issakha poked his head into one portal and called out something in Masalit.  A man who looked as old as the hills came by to greet us warmly.  Youssef’s father ushered us in and put some mats on the ground so that we could sit.

There was one tent, a small shed-like structure of brick and mud in the corner, some space for a hearth and storage for the livestock feed (big bushels of hay held back by sticks).  Youssef’s father put some water on the boil, and then went into the shed and came out with his son.  Youssef agreed to speak with Issakha and I, and sat down on the mat under the hangar that provided sparse shelter (four wooden poles with thin thatched roofing on top).  He expected the interview to take place right there in the opening, with parents, siblings, and livestock circulating, not to mention the mid-day sun beating down.  I asked if we could sit under some cover, and Youssef took us to his shed.  Issakha and I sat on the earthen floor, and Youssef sat on his small, wooden bed, which took up most of the back wall.  If all three of us had sat on the floor, it would have been a tight fit.

IMG_2130

After brief introductions, we started with a few open ended questions that were met mainly with one word answers.  He spoke clearly, deliberately, and had an air of stoicism about him, as if he was in complete control of the information he meted out with an economy of words.  That is, there was zero rambling, and little emotion showed.  At 27, Youssef had been in the camp for about four years, and had no friends, no social life, and indicated that he spoke mostly with his family, whom he felt looked after him well.  His only complaints were trouble falling asleep, occasional head-aches, and a diffuse and vague sensation of burning over his chest and abdomen.  According to Youssef, there was no cause or specific meaning to these symptoms, other than that they indicated that he was “sick.”  I started to get the feeling that there may be some psychosis.  There were reasons to suspect this: he was the right age (in males, it usually shows up in the late teens and early twenties; women a few years later), the vague and unusual somatic symptoms, his lack of social contact, and that his comportment was kind of “distant.”  He answered all of our questions quickly and accurately, but it was as if there was no emotional connection.  In psychiatry, this may be a soft sign of schizophrenia, and we describe it as if you are speaking to a person through “a thick glass wall.”  More directed questions revealed that he heard voices (that argued with each other and were occasionally angry with him) and had thought insertion and broadcasting (he felt that thoughts were “placed” in his mind, and that others could occasionally read his thoughts).

What’s more, several times over the past four years, he had taken an intramuscular injection medication called “Mondeket” (Modecate or Fluphenazine Decanoate), which he said helped him with “the burning.”  Youssef told us that he wanted injection medications from MSF, as they were the best.  When I asked if he had had side effects from this medication, he denied any.  But then when I stiffened up my legs and asked if that happened, he said “yes.”  And when I twisted my head to the side and asked if this had occurred, Youssef lit up like a Christmas tree and excitedly explained how horrible it was for a couple of day last year when his neck muscles were rigidly contracted as if he was looking at his shoulder.

Antipsychotic medication (also called neuroleptics or “major tranquilizers”) can have some bad side effects, dystonia (contracted muscles that feel “stiff”) being one of the most common.  It can be *very* uncomfortable, and Youssef was pleased to know that these symptoms were controllable medication side effects, and that he could continue to take medication that would help him.

While we were doing a short physical exam (ESRS), some food and tea were shuffled through the door and Issakha informed me that not partaking would be impolite, so we washed our hands in a bowl of water, ate the salted tomatoes, drank the tea, and chatted about the drawings on his walls and a subsequent meeting.  We see him every week, sometimes at his home, and sometimes he drops by our health center.  Meetings have proven difficult to arrange, but one way or another, everyone on medications is followed regularly by MSF’s community health worker assigned to the block in which the patient lives, and Youssef sees Issakha and I minimum once a week.   He’s doing well, as are most of the persons with schizophrenia here.  Some suppose that given the protracted brutality of the uprooting and displacement from Darfur to eastern Chad, some four years ago, persons with a more severe form of this disease simply did not survive.  Youssef benefits greatly from a close family and his community involvement.

For those wondering, MSF currently stocks three antipsychotic meds (a high- and low-potency typical, and one atypical), one benzodiazepine, one anticholinergic, one SSRI and one anticonvulsant.  A relatively new addition to MSF projects, these medications allow us to provide a solid level of medical care to certain patients with psychiatric disease.

22. The Women of Farchana Refugee Camp

The night of Thursday 5 June 2008, seven Sudanese refugee women and girls were tied-up, beaten with whips and sticks, and publicly humiliated by a group of refugee men.

The event was heard and seen by many of the refugees in Farchana camp, some of whom reported the incident to MSF expats the following morning, using the word “torture” unprompted.  Note well: this word has never before been used by MSF staff describing domestic or other violence in Farchana camp.  The beaten women, aged 13-30 years, were accused of prostitution.  The victims have been “fined”; some money and goods have been seized from them and their families; several have had their or their family’s World Food Programme ration cards forcibly removed.  The victims have been threatened with further violence if they do not pay the remainder of the fine.

Despite having been instructed not go to MSF health services, the victims presented themselves to MSF, some coming on their own to the Farchana camp health centre, and others brought by local police.

The women were all visibly seriously injured, including several suspected fractured arms.  It is alleged that all of the victims had their arms damaged or broken in order to prevent them from working for a time.  All of the women fear further violence, including reprisals for speaking out about their abuse.

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Fox.CDS.board

MSF takes as one of its primary principles that of temoignage.  It means that we bear witness to events like this and then advocate for change.  Further, though, we strive to give those oppressed their own voice.  The right to be heard.

The women were all tended to medically, body and mind, and are still under our care and close watch.  We also sounded a near-deafening alarm, one that has not stopped ringing in the ears of many of those responsible.

Shortly after this event, a respected Sudanese refugee approached MSF and asked for help “to be heard: to ask those responsible for the freedom of women.”  We then suggested she strike up a group and write what needed be said.  The eight women—whose names are not mentioned because they could be penalized for taking voice—wrote the following.  First in Arabic, and then translated into English and French by MSF.

When I read it, I see their faces, and I hear their voices.  Moreover, I hear the thunder, and feel an unspeakable sadness for the world in which I live.

—————————

 

Dialogue theme: Women’s Liberties in Farchana Refugee Camp

 

We, the women of Farchana Camp, have many worries and difficulties concerning the “deprivation of our liberties and absence of freedom of expression.”

 

Nevertheless, we relate them to you, one by one:

 

1)    Deprivation of freedom of expression: women have no voice.

2)    It is forbidden for women to look for work or to better their living conditions.  If a woman works in an organisation or in simple private employment, she must still see to all her responsibilities, such as caring for the sick, household management, being responsible for the children; the husband’s role is non-existent.

3)    Lack of equality between the different wives if a man has multiple wives (injustice).

4)    Women cannot freely decide how to manage their own property such as money, gold, domestic objects, and cattle.

5)    Restrictions over external communications, for example: visiting neighbours, family, friends and especially long distance travel.  If a woman is allowed to travel long distances, she will not receive any money and will have to make do.

6)    Lack or refusal of access to higher education, such as university, for women.

7)    Girls are discouraged from attending school; responsibilities fall back on the mothers.

8)    When a girl becomes pregnant, her mother is held accountable and must take responsibility; the mother is therefore held accountable, which can bring negative reactions from her husband and lead to divorce.

9)    Hard labour is done by women: carrying firewood, collecting grass for cattle, water transportation, shelter construction; all physically gruelling work is the responsibility of women.

10) Lack of trust in women: a woman cannot leave her home without her husband’s approval or knowledge, otherwise she will immediately be accused of having left in order to prostitute herself.

11) Worthlessness of women: a woman has no value, except for sexual pleasure.  Men want to have many children, but do not think of their future.

12) Forced and/or precocious weddings are encouraged.

13) Even during NGO meetings, women’s voices are not being taken seriously; only the men are being heard.

14) Women have no recourse for their grievances and preoccupations.  The space or organisation that will take into account their concerns does not exist.

 

We thank you and hope that women’s liberties and worth will become an important matter in the world.

 

On this day, Tuesday, June the 10th 2008

 

The Women of Farchana Refugee Camp

 

————————————– 

 

Liberté de la Femme au Camp de Farchana

 

Nous, les femmes du camp de Farchana, avons plusieurs sortes de soucis et difficultés concernant le « manque de liberté et privation de liberté d’expression. »

C’est pourquoi nous vous les relatons, point par point :

 

1)    Privation de liberté d’expression : le manque de voix de la femme.

2)    Privation de recherche d’emploi et de mieux-vivre.  Si la femme travaille dans un organisme ou a un simple emploi privé, toutes les responsabilités lui reviennent de tout gérer, tel que : maladie, gestion du foyer, responsabilité des enfants (entretien); le rôle (la contribution au ménage) du mari est donc inexistant.

3)    Privation concernant l’égalité entre les femmes si le mari a 2 ou 3 femmes : injustice.

4)    Privation de la liberté de la femme sur ses propres biens tels que : argent, ors, machines domestiques, bétails.

5)    Privation de la femme par rapport à la communication extérieure avec sa famille telle que : visite des voisins, de famille, amies, et surtout stricte interdiction de voyages lointains.  Si oui, elle n’a aucune opportunité d’avoir de l’argent de voyage; elle doit donc se débrouiller.

6)    Non-acceptation et manque d’accès aux études supérieures telles que l’université pour assurer son avenir.

7)    Le non-encouragement des filles à l’école, et responsabilité laissée aux mères.

8)    En cas de grossesse d’une fille, c’est la mère qui est responsable et doit endosser la responsabilité; la femme (mère) est donc accusée; peut parfois même susciter des réactions (négatives du mari) et engendrer le divorce.

9)    Travaux pénibles tels que : fagots, recherche d’eau, construction des abris, herbes des animaux; bref, toutes tâches qui engendrent les souffrances physiques sont la responsabilité de la femme.

10) Le manque de confiance envers les femmes; par exemple, la femme ne peut en aucun cas sortir à l’insu du mari, sinon elle est directement accusée d’être sortie pour se prostituer…

11) Dévalorisation de la femme, sauf lorsqu’elle donne le plaisir sexuel; les hommes veulent (faire) beaucoup d’enfants, mais ne pensent pas à leur éducation.

12) Incitation aux mariages précoces et mariages forcés.

13) Même lors des réunions avec les ONGs, la voix de la femme n’est pas prise au sérieux; seuls les hommes sont entendus.

14) La femme n’a aucun recours pour porter plainte par rapport à ses préoccupations.  L’espace ou organisme qui tiendra comptes les doléances des femmes n’existe pas.

 

Merci, et nous espérons que la valorisation de la liberté des femmes sera un point d’importance dans le monde.

 

Ce jour, mardi le 10 juin 2008

 

Les Femmes

Camp de Réfugiés de Farchana, Tchad

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Arabic original

arabic manifesto

 

 

http://www.youtube.com/watch?v=-DfeOTR_lZE

pharmacy.gound

21. Where is the outrage?

http://www.economist.com/world/africa/displaystory.cfm?story_id=11461685

The compound is where expats (staff from countries other than Chad) eat, sleep, and generally hang out after work.  It’s a space about the size of a couple of basketball courts in a high-school gym, or maybe a medium-sized grocery store.  Life in “the field” is, among other things, a social experiment of the first order.  You have 3-12 ex-pats from all over the world, on staggered six to nine months contracts.  Everybody arrives with a story about why they came, and what they left back home, with attendant hopes, dreams, and dreads.  In short, it’s a reality TV show waiting to happen, except for the obvious.  Short of the surgical amphitheatre, perhaps, I have not seen an environment more rife with social intrigue and drama.  (The surgical amphitheatre wins for personality pathology though, hands down).  Crazy and disturbing shit often happens during the day out here, and everyone blows off steam in their own ways.  It does not take a psychoanalytically oriented psychiatrist to find this rich.  Ask anyone who has spent time in the field, it’s a humanitarian-bent Las Vegas, but nothing goes home on video-tape.

tahir@carla  table_round tukul

The thing about being out here is that while it was mostly alien upon first arriving, one settles in rather quickly and adapts to the environment.  It is that despite being in eastern Chad, we are living in a compound environment infused with Euro-Western values that make it so familiar.

Adaptation has its down sides.  When one adapts to an environment that is not so healthy, it tends towards survival over grace.  Avoidance and desensitization can develop so quickly that within weeks we can become accustomed to something that was perverse and dumbfounding when first encountered.

What’s been on my mind lately are the aspects of work that are truly bizarre and different,  but which have, despite their otherworldliness, become familiar.  The things that for some reason, for many reasons maybe, I cannot tap into, cannot find some common ground or frequency with which I can resonate in my own way with what’s going on.  Since arriving in Farchana, gender roles, writ large in violence, have been one of the largest sources of curiosity, perplexity, frustration, anger, and rage.

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“Acceptable reasons for beating your wife.”  This is a mini-list that was told to me by Sudanese women: (1) Refusing sexual relations with your husband, (2) Not doing what you’re told, (3) Not doing domestic duties (cooking, cleaning, fetching water, etc.), (4) Leaving home for a non-duty task such as going to a ceremony without asking permission.  There was a silence in the air when these were being ennumerated.  The women seemed rather at ease, matter-of-factly even.  There is something chillingly disturbing about a well-orchestrated and methodical system of  brutality.  I want to call it inhumane, but how could such a widespread practice be labelled so?  Maybe this is why it is so chilling.

“Unacceptable reasons for beating your wife.”  (1) If you’re drunk, (2) If you demand sex in an inappropriate place, the example given being a demand when children are in the room, (3) If you hit ‘for no reason’, and (4) If you hit her for leaving the house to carry out her expected duties.

I am resisting the inclination to trip over superlatives in describing the extent of the suffering that is endured by women at the hands of a patriarchy that leaves them as objects, vessels, chattel, and reproductive systems.  The first duty is to describe.

Men and women have specific codes, duties, rights, and obligations.  And, it seems, punishments for infractions thereof.  One of the first things that you see when entering the camp is women lining up for water-collection, with their long lines of jerry-cans.  Or with large bundles of wood balanced on their heads, or maybe hanging off the sides of a mule that they’re leading in return from early-morning foraging in the brousse (bush).  Women clean, cook, sell fruit, vegetables and home-made crafts at the market, collect wood and animal feed from the brousse, and collect water.

Jerry.cans

Men, by contrast, are the animal herders, butchers, masons, merchants and construction workers.  But there is simply not much of this work to go around, so most often what one sees is a group of men sitting together and chatting away.  It is not uncommon for women to be the ones making bricks with the adolescents and children while men sit by, smoke, and watch.

Chivalry back in Canada conjures images of gallant men on horseback rushing to the aid of a damsel in distress.  Sure, maybe it’s sexist in it’s own way, but in Farchana, and I dare say in the larger region, men coming on horseback is the stuff of nightmares.

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Two of the staff and I walked today to one of the blocks to check up on a depressed patient whom we have recently started on medication.  Her husband sat beside her and put his hand on her shoulder while she answered questions about having suffered a spontaneous abortion at five months gestation, approximately three months ago.  He stays at home to look after her and has taken on her duties. For a man to show such tenderness in public towards a woman is rare. There are many good men here, too. It’s a guess, of course, but it seems like he is.

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On the walk back to the Mental Health Services clinic, we went by the brick-making pits in the middle of camp.  Only women worked.  We asked where the men were.  Both stories we received were from single women.  Their husbands had left to find work in Geneina (a large city in Darfur, just across the border), one having divorced his wife before he left, the other just never came back.  Two small children, looking bored, watched their mother labour in the fifty degree heat.  They were her twins, she said.  After chatting a short while, we thanked her for her time and walked away.

20. Logistics, nimbly

Steven Cohen Psychiatrist store.room

Much of the work that we do out here is focused on the final act: the prenatal exam, the psychotherapy session, the assessment, diagnosis and treatment of disease, supplements and monitoring for the malnourished. In a very real sense, the good people in Berlin and Amsterdam support the administrative Country Management Team (here in Abéché), who in turn support the logistics arms of the many projects all along along the eastern border of this godforsaken land. And they, in turn, support the medical people. Us nurses, doctors and midwives are left with the task of patient care, pure and simple. Food is on the table, pantries full, land-cruisers to transport, medical centers running triage, pharmacies stocked, electricity flowing, water delivered.

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Organizing anything in Chad is no mean feat. This is a place where no opportunity for misunderstanding goes unexercised. Where negotiations often start with a stalemate or a threat and progress from there. Where everybody is needling and clawing for money and kickbacks. Where the security situation hangs over you like a thundercloud in the distance; you never know when it’s going to break.

I wrote a couple of weeks ago about the murder of Pascal Marlinge, the Head of Mission for Save the Children (StC). That day, all NGOs stopped providing non-essential services and retreated to the safety of their respective compounds. StC, understandably, never resumed. Within a week it was unofficially known that they would, again understandably, suspend all their activities and most likely leave the country. This left Breidjing Camp, with 30,000 refugees and 12,000 local IDP Chadians with no organization providing medical care. A vacuum.

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This is the story of how MSF took over services and within two weeks, were up-and-running at full capacity.

People. Jochen, our mobile clinic nurse with many years of field experience, stepped up to the Project Coordinator position (PC). With a solid handle on both the medical and logistics side of things, he hit the ground running and hasn’t stopped since. Jean-Marc, the technical logistician also stopped on a dime and headed that way, as did almost all the national staff on the mobile clinic team. Ivan, our PC here in Farchana (but he basically likes to do everything, and would if given half the chance) got to planning. Since ground transport has been declared unsafe, Breidjing would need an airstrip. Ivan called up Karline (our Head of Mission in Abéché) and asked for authorization to build one. On the phone, at that moment, she said yes, and within two days 159 local workers had been hired and were on the job. Within six days the first flight landed and took off, notably bringing Ivan back to Farchana.

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A full complement of staff were hired and given contracts. Stock rooms were inventoried and new medications and supplies ordered. Endless meetings with local authorities, and long conversations into the night about what to to the next day. It was, as Ivan calls it, “E-team mode,” which stands for Emergency-team. If there are locks on doors and you can’t find the keys, you cut the locks. You don’t think of overtime costs for national staff, you just work till the day ends (although notably none of the staff even asked for extra pay). Administrative authorization lagged behind implementation. Often. The lines of communication were open throughout, but decisions were made on the ground.

Notably absent from this story is the call for funding. In most organizations, it would take months of proposals and oversight to fund a project that effectively costs about a million Euros a year to run. It’s an onerous, paper-heavy task, leading to what could best be described as administrative fatigue. MSF, however, is independently funded. This means that beforehand they do not need to knock on government doors, UNHCR doors, or whomever, to ask for the means to provide health care. There is minimal lag. The airstrip, which incidentally had been “in the planning” for three years, and was built by Ivan et al. in five days, cost about 2000 euros. This is the cost of doing business out here. Health care for a population of 42,000 people for a whole year. Fantastically reasonable. In my view, administrative fatigue is rather low in this organization. Every cent is accounted for, of course, but money in MSF, at least from my vantage point, is not a “power-grab,” it’s just grease. My guess is that everyone over the age of six knows how rare this is. It likely would not escape the purview of an astute six-year-old, either.

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I include the numbers because they interest me, and I figure others may want to know as well what things cost. Money is important.

This is a proud moment. (I was on vacation, so I feel justified in beaming without seeming the least bit self-congratulatory.) On the day that Pascal was killed, Ivan, Jochen and Edith (our logistics administrator) sat under the mango tree and spoke about what it meant for them to work out here. It hit them hard. But the conversation went from personal reflection to planning. What if StC left Chad? What would need to be done to keep primary health care services in Breidjing. It had to be MSF. Literally, nobody else could do it, given the administrative fatigue of other operations. They sat down with paper and pencil the next day and started mapping it out: a proposal to make it happen ASAP, for about two to three months, until a long-term solution could be found.

Group identification is a funny thing. I hear people all the time saying of their favourite football, hockey or basketball team that succeeds: “we won!” This is absurd. In the words of Chris Rock, a comedian, “no, six black guys, who would hate you if they knew you, won.” This is not absurd. But it does highlight the extent to which people ignore every register of class division and common sense to feel associated with something winsome. All of a sudden my friend who works in a bank, from a sheltered, privileged and rather sanitized petit-bourgeois childhood is character-identifying with Shaquille O’Neil. “We won!” Pointing out the absurdity does not mean it shouldn’t happen. Personally, I don’t care one way or the other, it’s mostly just amusing. But it does tell us something. That we want to be a part of something bigger than us, a community, a team, a movement that means something, that does something of which we can be proud. People buy products because some pretty face or talented athlete endorses them. And even the humanitarian world is on this: I see the faces and read the words of cinema- and rock-stars on the plight of those suffering oppression and its hardships all over the world. And why? I’m not arguing that it’s not pragmatic, but it’s strange, too.

I see many faces of MSF, but for me, this week, it is Jochen, Ivan, Edith, and Jean-Marc (three of whom, incidentally, are Canadian). They did not win a football match, nor have they been shortlisted for an oscar nomination. But they did work non-stop for two weeks to fill the vacuum, to enable the provision of emergency health services in a large refugee camp in Eastern Chad. No newspapers picked up the story, of course. Can you imagine what would happen in Montreal if medical services were stopped for two days? What about two weeks? It would topple governments. It would be a national state of emergency. Well, it’s an emergency here, too, but look who did something about it. My team.

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19. Zanzibar, Tanzania, Africa

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The ground moves here.  It may look like a patch of dirt, rubble or cracked concrete, but it you crouch down and just wait a few seconds, it starts moving.  Tiny ants doing reconnaissance, larger ones lumbering through, smaller red insects that look like pin-point spiders everywhere. Long things with many legs, beetles, and others start to circle and weave along some hidden meshwork that is beyond the understanding of humans.  Or maybe it is just random, chaotic radiation, turbulence, Brownian motion.  Scurrying like white noise.  There are no straight lines in Africa.

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I write “Africa” in the sense that most people that I have met use it here. Chadians will refer to themselves as Africans, as will Sudanese, Tanzanians, Kenyans, Congolese and so on.  It does not escape the Chadian pastoralist that he has a vastly different language and life-way than his neighbour in the next town, the village up, or over the lake yonder.  The word “Africa” resonates as a whole for the people who use it, and this is remarkable.  A few words of Arabic or Kiswahili, and millenia of trade, land rights, marriage arranging, brotherhood brokering, animal husbandry and herding, water-balancing.  These forces stretch a continent.

Shift ahead a few days.

A small place called Bwejuu.  South-East coast of Unguja, the main island of the Zanzibari archipelago, itself just off the coast of mainland Tanzania.  It was a seaside town, that forgot to close down, and moved at about that pace.  I’d arrived in the trough of low season, but met a few similarly wayward travellers nonetheless.  By day three I felt that if I was any more relaxed I’d slip into a coma.  Which was nice.  My mornings were spent snorkeling through the fringed coral reefs, and I awoke to the sound of small yellow birds that make small teardrop-shaped nests in the trees all around my bungalow.  Jeremiah, one of the Masai fellows working at the small guest house at which I stayed, asked me if he could take my motorcycle (250cc of Honda Baja glory) to the beach and ride it.  He had the energy and smile of a gleeful person, which struck me as a strange quality in someone carryone no fewer than three concealed blades under his flowing red garb.  As we went out to the beach, I realized that he had never ridden a bike.  But hell, neither had I until a week ago.  The problem came in trying to explain what a clutch is with twenty shared words!

Zanzibar is called The Spice Island, which is a misnomer. Sure, it may have once been the hub for trade in cardamom, lemongrass, nutmeg, chili and peppercorn, among others, but the food is of the blandest I’ve ever eaten.  Luckily this is well made up for, among many other things, by the spectacular views.  I had not bought a new camera by then, so I’ll just have to describe the scene.  Rough-hewn locally made tables on a white-sand beach.  Low-light candle in a corner.  The sun sets quickly and leaves a blotted underbelly of fiery reds and purples on the clouds.  It looked like hell upside down, and from a safe distance.  Lateen-rigged dhows are off in the distance, small wooden fishing boats that have a triangular shaped sail with a scythe-like curve that is masted close to the front of the sliver of a vessel.  Every image was charmed… that kind of a place.  I looked over to the right of me while I was sitting out there and saw about eight other people on the beach, seven of whom were taking photos.  This is a well photo-documented generation.  It struck me that it may be the case that more photos were taken of sunsets that one day than in all of the 19th century.

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My days on the island were coming to an end, though, and I had to run back to the capital, Stone Town.  This is, incidentally, also not really a meaningful moniker.  I suspect that it would have been more accurately called Smelly & Cracked-Concrete Town, but alas, that did not track well with focus groups.  The point, though, is how it is that one finds their way around this island, back to the capital.

These were the directions: “Turn right at the T-junction, then left at the second round-about, past the big “Foma” detergent sign, and when you’re close to town, you’ll see an intersection that looks like a platypus… turn hard left there…” and so on.  I was becoming a bit frustrated… the lack of street signage makes it difficult to know where you are, and where you should be going.  Over the past week, with no real destination in mind, this had bothered me none.  I had my rented dirtbike, miles of road and beach, and, of course, throngs of people everywhere to ask directions along the way.  And this is when it struck me… that image.  The one that comes at 5am, wakes you up, and just sits there.  You know the type, no?

Back a few nights.

Imagine a hard flat surface like a book or open hand slapping forcefully against another surface, that of a placid body of water.  Scale is unimportant.  Look at the streams of water that are jetted out from the sides, shooting outwards but connected by small tendrils, some thick and goopy, others impossibly thin.  A viscous crown of molasses-like mesh, curving in all directions.  Like in networks of veins just under the skin or on a leaf.  Patterns on wind-swept desert sand.  The mesh of a sponge.  The petrified pith of trabecular bone.

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This was the road back to stone-town, and the people were the network along which I would wind my way.

It started to rain, and I pulled over under the metal sheeting of a small hut where kids were selling fruit.  My clothes were soaked through, but it was warm enough to ward off the chill.  I bought a large papaya and ate the reddish-orange pulp while chatting with the kids in some broken pidgin of English and my ten Swahili words.  The boys were fascinated with the multitool leatherman that I had used, and took turns over the next two hours passing it among them opening and closing every knife and screwdriver.  Despite the rains, lots of bikes, motorized and not, whizzed by.  I waited for the rain to stop, pointed in one direction and said “Stone Town?”  To which the boys smiled and nodded yes, trying to curve their hands to the left, which was what I had to go on.  There are no straight lines in Africa.  But with a belly-full of papaya and the hot sun drying your clothes, this seems less important.

18. Power

The day that I left Chad a text message arrived an hour before hopping on a plane for my holidays (I write this from idyllic-but-obviously-not-too-distant Stone town, Zanzibar). The text message said that a fellow named Pascal Marlinge, the Head of Mission for an NGO (Save the Children, UK branch) had been shot and killed in a car heist a short drive from Farchana.

http://news.bbc.co.uk/2/hi/africa/7378304.stm

http://www.reliefweb.int/rw/rwb.nsf/db900sid/ASIN-7E8QNG?OpenDocument&rc=1&cc=tcd

It left me sad and a bit numb; I write this with heavy hands.  I found myself trying to make sense of it. How could this have happened? And, inevitably, why did this happen? Why would someone shoot a clearly unarmed person exiting a clearly marked humanitarian vehicle with his hands in the air? And this is where my mind has gone while sitting in airport terminals, eating street food in the grungy Escape-from-New-York backdrop of Dar es Salaam’s Kariakoo district, and watching the waves foam up on shore.

The word that I keep coming back to is “power.” Several years back, one of my mentors in psychiatry casually said “there is only one type of power.” I am not sure if he’s right, but he’s the type of person that you listen to, and figure out how they came to that conclusion, even if you’ll disagree with it eventually. Over the years I’ve muddled around with the question of what it would be, this one power, if there was just the one. And what I’ve come up with is this: power is the ability for one entity to set the viability conditions for another. That is, one entity can effect a gross difference in the capacities, choices, and mortality of another entity. For humans, this would include, for example, a parent or state feeding their young so that their bodies can grow and learn; teach skills leading to more vocational choices; or the provision of basic health care so that a premature death doesn’t cut this potential all to shreds.

It is also, notably, the power at the end of a rifle, an apron string (families excommunicating members), an emotional outlash.  Images of tyrants always come to mind when I think of “powerful” people. Mussolini, Mugabe, Stalin, Pol Pot, Mao Zedong, Nikolai Ceausescu, Saddam Hussein. Basically what these guys did was whatever the fuck they wanted, and nobody could say otherwise. They were, and are, barbarians.

Lust, gluttony, avarice, sloth, wrath, envy, pride. These are the seven deadly sins, which may as well be a laundry-list of the manifest entailments of 20th century Western success. “Get rich or die trying.” Envy was used in the sense of “malice” in the fourteenth century, as in “creating equality” be taking or destroying that which someone else had… the vulgar side of jealousy: hate someone for having more or being more.

But this is here it gets complicated. I think that most of my cohort can rally against the despots, but what of the seven sins? It may be schlocky, but I think that TV is a sophisticated barometer of an ethos. While practicing up in the Canadian North, I had too much free time and a satellite connection, so I watched all seven seasons of The Sopranos. Hellava good show, and to my mind, there has not ever been a character as complicated as Tony Soprano. Somewhere along the way (maybe in the second season), I realized that this guy was a simmering psychopath (however pro-social). Enter “Dexter”, another TV character, who is a blood-lusting psychopath who “uses his evil powers for good,” killing “bad” psychopaths. Brilliant premise, but can you imagine the pilot being pitched twenty years ago? Not a chance. For 50 years, the bible of broadcasting was the Production code of motion pictures, and for 40 years or so up until the late 60s, it stated that:

“No picture shall be produced that will lower the moral standards of those who see it. Hence the sympathies of the audience should never be thrown to the side of crime, wrongdoing, evil or sin.”

You couldn’t even watch someone pretending to be evil!  As if just the perishing thought could shift the balance to the dark side.  I remember being timorous in medical school when I asked patients if they had ever had ideas of suicide or self-harm (a standard part of the psych exam, and for good reason). It was hard for me to ask the question, as I did not know what I’d do with the answer, or worse, that I’d throw their symathies to such an act.  It’s kind of absurd that someone’s going to say “wow, suicide, great idea! Never thought of it, but you’ve been a great help, doc.” I needed to gain experience with the idea of suicide in the same way that I have needed, in Chad, to become more familiar with ideas of genocide, mass displacement, and wanton violence the likes of which I had only read about, but never seen.

But what do we do, then, when we character-identify with Tony Soprano in some way but are also revulsed at the mindlessness of actual wanton destruction and death? This is not a rhetorical question. We talk about it, and the dialogue makes it more real. There is no answer, of course, but exploring it carefully may lead to a better ability to balance the essential urges of war and peace that wage their quotidian battles in us. Maybe we’ll even gain a better understanding of what power means to us, and use some of those superpowers for good.

So what, then, would be the luminescent side of power… how can we counterpose and salvage the beauty in willful and benevolent expressions of it? It would then be the exercise of might in capacity-building, the prolonging of life and heightening of health, all in the service of preserving the right for people to choose what they want to do. If freedom is some waffly continental breakfast, options and choice are the sustenance that sticks to your ribs.

MSF came out with a position paper of sorts called “The Chantilly Document.” It starts with a single line, before getting into two pages of text:

“The overall purpose of MSF is to preserve life and alleviate suffering while protecting human dignity and seeking to restore the ability of people to make their own decisions.”

In my opinion, Pascal was doing this. He was working away from his wife and two children, in an inhospitable place, quite likely for less pay, less stability, and higher job-related anxiety than he could have found elsewhere. Like so many people that I’ve met out here, they hold it together for some reason or another so that, in the long run, others will have more options. This character trait I call integrity, the exercise of which is strength.

It is apalling the abuses of power that I have seen in the past several months. The stories, the lives, the wounds physical and psychological. They track closely with the absence of wide, transparent, and consensus-driven means for accountability. With no accountability, it seems that power prevails over strength.

In the end, Tony Soprano got punted by his Shrink.  Strength prevailed after seven seasons:) I hope that Farchana does, too. We’re in our fifth year, now.

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sorry, no pics.  My camera broke.  The fellow at the repair shop said “There is a lot of dust in here, where have you been?”

    “Chad, four months.”

    “oh.”