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.

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.

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.

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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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.

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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 10^th 2008

 

The Women of Farchana Refugee Camp

 

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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

 

 

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.

 

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.

 

“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.

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.

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.

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.