28. Darfur, Sudan – The Magic Quarter

Fast-forward to 2013.  I’ve been working as a forensic psychiatrist at CAMH in Toronto for about 4 years, and it’s been a fascinating apprenticeship and practice at the intersection of psychiatry and the law.  A multidisciplinary team assesses, treats and risk-manages, aiding those with mental illness in transitioning back to the community.   But this post is not about the job.  It’s more about reflecting back on the missions, some years past.

First, a bit about Sudan.   About three months after returning from Chad, in mid-2008, I was asked to join a mission in Nyala, Sudan.  Kalma Camp was, at the time, the largest refugee camp in Darfur, and some said that it was the largest in the world, with about 150,000 internally displaced persons (IDPs).  It was a troubled time, of course, but another emergency had reared its head.  The sitting president was being investigated for charges of war crimes of the worst kind, up to and including genocide.  He had been tolerating humanitarian aid in the country because to not do so looked pretty bad.  Well, in the wake of the impending indictments, he decided that such bad press was the least of his problems, and he was moving to kick all humanitarian aid projects out of the country, and mental health was going to go first.  The mental health staff speak to people, and in gathering stories, so the presidency was concerned, might collect information that would be injurious to his human rights record.

I was only to interact with MSF staff, and have no direct patient contact.  No journalism of any kind.  No cameras.  No notes were to leave the country.  Any transgression would result in being jailed.  This was made very clear to me, and I signed several Arabic language documents (which my translator struggled to explain).  My translator impressed upon me that even suspicion of wrong-doing is enough to be jailed.  And Sudanese jails are the stuff of nightmares.  These people were not fucking around.  Blogging was, of course, verboten.

So MSF needed a psychiatrist to go in ASAP and work with three local doctors on matters of assessing, diagnosing, treating and managing persons with schizophrenia.  There was a small and closing window, so to save time, MSF sent me to Nairobi, Kenya to try and get a Sudanese visa more quickly.  It took some doing, but a week later I was on my way to Khartoum.

The worldwide prevalence of schizophrenia, fairly consistent across all ethnic and social strata, is about 1% of the population.  So in a camp the size of Kalma, one would estimate, all things being equal, that there would be about 1500 persons with this endogenous psychotic disorder.  But that’s a big assumption, the equality part.  The political situation was, to put it mildly, chaotic.  Surviving a dangerous situation, especially a protracted one, takes great organization, stamina and resolve.   Vulnerable populations such as the elderly, children, and persons with physical or mental deficits, are less likely to stay alive without support structures in place, and these very structures were being torn apart by the violence.  It was impossible to state how many persons with schizophrenia were in the camp, but the project had about 200 persons for whom they were providing regular care.

If you want to do emergency psychiatric work, and get the most immediate, profound and potentially enduring benefit for the population, there are many strategies. One of them that should be included is to find the schizophrenic population and, in consultation with their family or other supports, offer low doses of antipsychotic medication.

Steven Cohen CAMH | haldol

Medication is the single best intervention for schizophrenia, and while it does not cure, it controls many symptoms quite well in a large percentage of the treated.   Haldol, an older and well-established medication, was available in large supply, and was available on the open market (through pharmacies; no prescriptions are necessary in Sudan).  Of course, MSF had its own supply chain, and the medications were of the same standard as those provided to anyone in Canada.  But while emergency and relief humanitarian aid does the best it can, and for a whole host of reasons, a person with schizophrenia or their family may need to access antipsychotic medications in the future and not have access to an established clinic, and thus it is very helpful to have a medication that has a local supply chain.

Haldol (or haloperidol) is still used regularly by Canadian psychiatrists, although often for more acute psychosis accompanied by agitation and aggression.  It is in the Canadian guidelines for medical management of schizophrenia.  The well-worn prescribing mantra of “start low and go slow” fit the situation.  Most of the persons with whom mental health staff have contact in Canada are well known to the system, and have been tried on one or more antipsychotic agent, and usually in high dose and even in combination with another medication.  In Kalma Camp, by contrast, almost every person treated was neuroleptic-naïve, which meant that they had never taken a medication of this drug-class.  Haldol came in 5mg increments, and to allow for some sort of standardization, we cut them into quarters (1.25mg per piece) and started there.  Avoiding side-effects while getting the best effect with the lowest dose was the goal, as it always is.  And it turned out that 1.25mg, twice a day, was the optimal strategy.

One day a fellow with schizophrenia was brought in by his family for follow-up care.   He had been started on Haldol before I arrived in the camp, and I was seeing him at what might have been his “best baseline” or mental status at his best treatment level.  I’ll call him Abdul, although for the life of me I can’t recall his name…  I kept no notes, something that was prudent, but most regrettable nonetheless.  Abdul was in his early-20s.  His family provided most of the history: Abdul started exhibiting psychotic symptoms (the harbingers of what would become fully blown schizophrenia) in his mid-late teens.

While he was once gregarious, athletic, and sociable, he became more reserved, isolated, and unable or unwilling to engage in basic behaviours such as maintaining hygiene, social protocols and schooling.  Unfortunately, he also developed strong paranoia, and believed that his brother was trying to do him harm.  About two years prior to when I met Abdul, he became aggressive, and killed his brother.  His family recognized that he was ill, and was not to be punished, but they had to contain the risk, and chained him to a log.  Abdul could move slowly from one place to another, and was cared for by his family as best they could.  The family found antipsychotic medication in the marketplace (the pharmacy medications, likely of purer provenance, were too expensive), which had some beneficial effect, but not consistently so.  The family heard of the MSF project, and travelled between camps in order to find treatment for Abdul.  He had been treated with MSF-provided antipsychotic medication for about a year prior to my having seen him.  Abdul was pleasant, conversant and fairly engaging, albeit somewhat emotionally detached, and he mainly answered questions that were posed to him rather than speaking spontaneously.

He was well-dressed, living with his family, and was taking part in the family business.  He was betrothed to be married.  Abdul recalled little of the incident leading to the death of his brother, and his family jumped in and explained that this was not the “real Abdul… it was the sickness in him.”   Abdul recalled being chained to a log, and while it was deeply unpleasant for him, he recognized on some level that his family was acting in his best interests, and he did not appear to harbour any resentment for it.  He indicated that he needed the medication to stay well, and that the “magic quarter” had saved his life.  I agreed that his family and the magic quarter (of Haldol) had saved his life.  The status of the MSF project was in jeopardy, and the Abdul and his family were understandably quite worried about what would happen if the free medicine became unavailable.  They were provided with a solid supply of the medication.  To this day, I wonder how Abdul is doing now.

The structure of the day involved waking up early in Nyala, eating a perfunctory breakfast, and hopping on the “landy” (Land Rover) that took 45 minutes to get to Kalma Camp.  The bench seats in the back were simple wood planks, and six or eight people would cram in.  The terrain was rough.  I had tweaked my back (degenerative discs are not kind to the aging), and could feel the bumps.  We’d arrive at camp, and I’d head off to meet with the three local doctors.  We spoke in English, but also had a translator for some of the trickier concepts.  We saw patients with their families all day, and made time for a lecture over the lunch-hour.  One after the next, each doctor would take turns assessing, presenting the case to the team, proposing a treatment strategy, and then discussion and implementation.  This happened as many as 20 times a day.  Rough and ready guidelines flowed from these discussions, and they were translated in Arabic.  MSF encouraged the guidelines to be distributed widely, and many photocopies were left with the Sudanese doctors.

By the end of my two months, the three doctors were not only managing this population well, but were holding their own lectures for other staff, and training what would be their support staff for the continued clinic.  It was a resounding success.  I was elated, proud to be a small part of MSF and the mission.  And it felt like something new, something that I resolved not to forget, as it is so easy to.  I was not a simple cog in the machine out there, but a part of something larger than myself in which I had a crucial role.  I was part of something that would not have taken place had all the elements not been in place.  There was a type of satisfaction in this work that does not often come from other types of work.  It was brief, meaningful, and nourishing for that core of the self for which we have so many names but nothing concrete.

Steven Cohen CAMH | Us.Stock