11. Sights and sounds from the Mobile Clinic

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As I write this, the wind is whipping outside.  I have no clue what time it is because my Tukul is near lightfast.  But somehow, even though light doesn’t make it through—I write this with my head-lamp on—dust has no problem getting itself everywhere.  The is no such thing as a surface in Chad without a fine patina of dull-brown sand.  I’ve noticed that I stop closing my teeth together because I feel the “crunch” of small grains of dust.  And when I chew bread at mealtimes it’s more of a mashing without clamping down for the same reason.  My hands are cold.  It heats up to 40 degrees in the daytime, and at night it’s around 15.  To me, this is utterly bizarre.  You layer up in the morning and peel ‘em off as the day progresses.  I just returned from watching the sun-rise.  Nature here is so stark it that it has a sci-fi quality.  This glowing red orb peeking it’s head above the distant steppe.  Soon we’ll drive west for an hour or so, checking in with various people along the way to assess security concerns.

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Yesterday the mobile clinic showed up Hillé-Déyé, a town in the region of Alasha, and an IDP camp by the same name of about 2000 Chadians.  There was a strange shine to everything, as there’s a silver iridescent mineral in the rock in this region.  So the thin layer sparkled in the sun, almost as if a magic spell had been cast betraying the gravity of the situation.  It is a silver lining around a storm-cloud.

When our two land-cruisers drove in, all the kids came swarming around, smiling and yelling “ok!” or “ça va?!”  It was a sea of bright faces set against the sheen of glitter on tattered clothing, like an 80s party in a Disneyland dystopia.  It was quite infectious, and you just can’t help smiling along.

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Our mobile clinic, which has been functional for about a year, finds its “clinic” in the shade of a tree.  But today it was too windy, so we fixed up the thatched-mat sheeting on the side of one of the two school-room structures and stayed there for three hours.  Within ten minutes, the collapsible tables were up, and everyone was in place.  Registration and triage outside, peri-natal care in the back corner, a nurse in another, the pharmacy in a third corner.

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Jochen, the German nurse, handles vaccinations for a while, and is consulted on difficult cases, and Sam, a Chadian nurse’s assistant by trade, works with maternity and nutrition.  The place is swarming, and despite the initial appearance of chaos, it runs smoothly and quickly.  I came to Chad to see how medicine functions in such places, and how mental health finds its niche in the fray.  How mental health could find its place in the fray, more specifically.  My first impression was  wonderment at how two fully packed land-cruisers and about ten people can do so much work in such a short period of time.  One young girl had a nasty infection on her foot that was not healing.  Jochen decided to explore it surgically and he pulled out what looked like a piece of animal bone.  It seems so minor, but without this minor surgical intervention, a child may very well have died of sepsis (when a trenchant infection goes throughout the body in the bloodstream).

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The mobile clinic works with Chadian Internally Displaced Persons (IDPs).  Most come from the “border” with Sudan, which is nothing of the sort.  It’s a patch of land with no political or other fence-type markings, of course, and people identify themselves by language, ethnicity, and means of subsistence.

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Noura is the mental health counselor with the mobile clinic.  She lives in Arkoum, one of the three mobile clinic sites, where the team goes for several days of the week.  Noura is one of those people who can talk to anyone and get them to tell their story, and has many of those “non-specific factors” that make therapists effective: she cares, listens well, engenders trust, and exudes a sense of calm.  You can’t fake such things as “genuineness” and “presence.”   Noura and I walk through the camp to see her patients, most of which have been referred from the Community Health Workers (CHWs).  I watch how women and men come up to her and say hello, and ask to sit down with us to speak their minds.  Several times, someone tells us of a person who cries at night and may benefit from our stopping by.  And we do.

Here are a few stories that we heard. (Note that for confidentiality, names have been changed, as well as some details of the case that do not alter the significance.)

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One man, whom I’ll call Ibrahim, was found sitting with a group of male friends.  He’s in his early thirties and is relatively new to the camp.  He jumped up when he saw Noura, excused himself, and found a straw sitting-mat to put on the floor around the corner, under a thorny tree.  He had intensely dark eyes, and looked at me while he told me his story.  It seemed to matter little that Noura was translating from Arabic, I could see his eyes and hands and hear the tremble in his voice.  Several months ago he was relatively happy, living on “the frontière,” lands between Chad and Sudan.  He had two wives, five children, and many family members around.  He told of how “the Janjaweed came and took everything.” The Janjaweed are commonly held to be the Arab, Sudanese-government backed militia. When they came, and he hid under his bed while they killed his brothers, one wife, and all of his children.  Ibrahim hid all night in terror, no knowing who was alive or dead, but he heard voices and dared not come out.  It has been three months since he has been in the camp, and at night he sees “men on horses” in his dreams, and he awakes screaming. When asked about his thoughts during the day, he pauses, and tells me that they took 100 cows, 10 camels, 3 horses, and a mill to grind grains.  Ibrahim is starting to feel a bit better, although he still feels distant from his wife.  He misses his family and his stability, but despite the continued threat of violence in the village (which is NOT imaginary), he is making ties with the community, has found occasional work making bricks, and is thinking of starting a small herd of sheep. He plans to work his way up to cattle again.  I ask Ibrahim if he finds his sessions with Noura helpful, and why.  It’s a fair question, and Noura understands that this is not a knock at her.  He says that Noura is the only person to whom he talks openly about his losses, and that he feels much better after he talks to her.  He tells me that it was Noura who suggested he start raising animals again, and although he thought she was crazy at the time, it sounds like a good idea now. He does not smile at all, but Noura does occasionally when they speak.

Fatna is an eight your old girl who cries at night, and neighbours come and sit with her.  We are directed to her by a woman who is one of Noura’s patients, and eventually come across the right straw door and someone answers our call, bidding us enter. We sit on the straw mat, the women kindly offering me the prized corner in the shade of midday heat. Fatna is quiet and says nothing, even when asked simple questions like her name and age.  Her mother instinctively answers, and I’m told that she has not spoken for ten days. I write this a week later, and it remains a heartbreaking story. In silence, with her short and tightly braided hair and curious eyes, one shoulder of her dress ripped and falling askew, she evoked an almost overwhelming empathic response.  This is her story.  Two years ago, she was out “on the frontière” with her father when the “Janjaweed” came and hit him with their “horse-sticks” until he fell. They continued to beat him, and Fatna’s mother described how her daughter spoke of blood coming out of his head. She ran into the “brousse” (a word that means something like country-side, bush, outback, or the steppes).  She does not remember how long she was alone, but said that it could have been a few days. Eventually Fatna returned to her house and, as it was a market day, nobody was home. Her mother returned home and found her in a corner, crying. It was weeks before she told anyone her story, but by then they had heard news of the body of her father that had been found by other villagers. The family packed up and left quickly, and Fatna was doing pretty well in the IDP camp, her mother tells me.  She had friends, was enjoying school, and laughed and played with the other children. Then, about ten days before I met her, she was again out in the brousse, and men on horses came and harassed her and her friends. The other kids ran, but she froze, and was the only child still there. They said angry things, but she did not run. She was hit on the back and chest with the “horse-sticks,” and was left there by the men, in that catatonic state of fearful rigidity.  Apart from slight bruising, she had no physical injuries. But since then, she has not gone to school nor has she played with friends.  A few hours after sunset, she cries out inconsolably because she sees men coming “with horses and knives.” Nightmares wake her up and the women in her block come and sit with her. They will continue doing this, and we encourage her to go back to school as soon as possible, for half-days at first.  And she listens as we encourage her to have her friends visit, even if it takes her a while to speak to them.  Fatna’s mother listens to our words about “stress reactions,” and asks when the mobile clinic will be back to visit again.

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