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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10. Mental Health Services # 3

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Chad remains politically active. We don’t get mentioned much on the BBC anymore, as the news cycle has moved on to other world events, but word is that the government has declared a “state of emergency” for two weeks. On the ground in Farchana, it looks relatively calm, but people are worried. Here are some links if you want to rummage through the politics:





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Much of this post is in direct response to questions and comments I’ve received. Thanks for them… they point out omissions as well as blind-spots, good things to know.  Seems that I skipped over some of the basic structure and history of the project.  To be rectified…

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The MSF-Holland team has been here about 4 years, and has had a mental health officer (MHO) almost all of that time.

Mental Health Services (MHS) was already well set-up by the time that I arrived here. Previous MHOs, with Issakha and Habib, have hired and trained the Sudanese counsellors. Each MHO takes a 6-12 month contract with MSF, so we are a “transient figurehead” of sorts.  The project continues when one MHO leaves, and is self-sustaining, yet the staff indicate that they are most pleased when an MHO is on-site.

Prior to MSF’s presence, if someone was mentally ill, they sought help from a marabou. What this word designates is complicated, as there are “Imam” marabous, who lead prayers, and are trained and venerated teachers; “faux” marabous who hang up a shingle and do who-knows-what to cure the ill  in recompense for money or animals; and “healing marabous” whose knowledge (herbs, roots, rituals, amulets) is handed down through generations. I’ve been told so far that most people prefer MSF to the marabous, but I’ve a biased sample, of course.  Every time that I’ve asked why one person goes to one source of help over the other, cost comes up. MSF is free, and the marabous charge.

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

1) What are the most effective short-term benefits can we provide while we’re here?

2) What are the best strategies for ensuring long-term benefits and high quality care?

3) What do we need to know to adapt our “Western” conceptions of mental health categories and treatments (which are no less fundamental than “ways of viewing the normal and the pathological,” or even “ways of being in the world”) to local or indigenous conceptions?

4) Apart from learning what came before, and mindfully “adding” rather than “replacing” or “extinguishing”, how else can we minimize Western imperialism and the “colonization of minds”?

(ugh, heavy sentences. Je m’excuse.  I have to remind myself that this is a blog and not an essay… the presence of so many “scare-quotes” tells me that I’m at risk of losing the battle.  Thanks for bearing with me.)

Today, I met with the MHS team to discuss their notions of psychosis and its treatment. To my surprise, the two supervisors (who had been lecturing on group dynamics, depression, Maslow, trauma, etc.) had no idea what schizophrenia (or psychosis) was. Nor did the counselors. It was a quiet room, and I kept waiting for one of my awkward French-language paraphrasings to catch. But for the whipping sound of sand on the plastic sheeting, it was dreadfully silent. So I figured I’d start with a few standard symptoms of psychosis (hearing voices, paranoia, getting messages from the radio, etc.) and I’d jog a discussion. Nothing. I asked them what may have done if a patient with these symptoms presented themselves, and they hesitantly suggested that they would ask an Imam, or find a doctor in N’Djamena. Although the incidence of schizophrenia is about 1%, I suspect that for a number of reasons there are fewer in this community. We will discuss as a group how the counselors can identify and treat this disorder.

I’ve “signaled” to the community health workers (CHWs) to let the Marabous know that I’d like to meet them. The head CHW guesses that there are between 50 and 100 Marabous, and if I spread the word that there will be some finger-food and sugar-tea, I suspect that the turn-out will be much improved. Can’t wait to see what that holds!

Having a mental health component to a medical team is, in my view invaluable. We look after patients, not bodies, and mental health workers are trained to attend to the manifold forms of suffering of the human condition. When I see something I don’t understand, I am relieved to be able to refer them to the local GP or specialist. The same relief comes to those who refer patients to MHS; we get by with a little help from our friends. Specialized referral networks are crucial to this system.

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Next week I’m going into the field with the mobile clinic, and will be looking into MHS and community health in three IDP camps (Alasha, Arkoum, and Goundiang). So much time in trucks and how many bandits wandering around? It’s a safe area, I’m told. But it’s still Chad.

9. Mental Health Services # 2

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There are three MSF project sites in Farchana: (1) the Primary Health Centre, located at the edge of the camp, is where maternity and basic medical care are provided; (2) the Nutritional Centre in the centre of the camp houses the Community Health Service and a Therapeutic Feeding Centre for malnourished children; and (3) the MSF compound, a fifteen minute walk from camp, that has an emergency night-clinic attached.  Mental Health Services works in both of the two centres at the camp.  They consist of simple wooden supports lined with plastic sheeting.  It may seem like a flimsy structure but it’s like a home away from home; a quiet corner of the busy compound where we sit, talk, work, and, if need be, see patients in the room next door.  Four years ago, when this MSF-H project was set up, flowers were planted outside and they are now blossoming lilac and pink.  It’s a small thing, but it’s nice thing. Little pleasures go a far way out here. The flip-chart in the corner—some large pieces of paper stapled to a cobbled-together easel—shows residues of past lectures on personality traits, stigma, Maslow’s hierarchy of needs (need to unpack this one in a place with no soap…), traumatic stress and it’s presenting symptoms, and so on.

Every morning at about 7:30am, the team meets at one of the two sites.  We say our good-mornings and everybody asks everybody else how they slept.  This is the custom, but there is a twist: you answer honestly.  I’m not sure when it came to pass in Canada that the expected answer to the ritualistic “how’re you doing?” was a near-guaranteed “good, you?”  You’d pretty much have to be bleeding out of your eyes before you ventured a “you know, not so hot today.”  But in the camp, people routinely say what’s bugging them, and the morning “how’re you doing?” custom can take fifteen minutes.  I know who’s got diarrhea, who’s feeling a chill from the cool night past, and who’s child has a mild fever that is worrying them.  It’s unexpectedly personal.  I find myself wondering how this could be brought into the Canadian mental health team environment, but then I realise, it is already there, but usually only in groups of 2 or maybe three people who know each other well.  Here the closeness exists to a team of 10 or so, precisely in part because of morning conversations like this.

After this morning harrah, four of the counsellors go off to the « Thé Rencontre » or “Chat with Tea.” This is where everyone is welcome to sit around with friends, to drink insanely sugary tea, and to banter.  All the while, the counsellors circulate, listen, and give their spiel on what mental health services are on offer. It’s a lovely idea, and even though it’s just a large open space with some plastic sheeting over their heads and a few rude wooden benches against the walls, everything changes when you’re sharing drinks. It becomes friendly rather than clinical.  (below is a pic of the corner of tea room, but not during the « Thé Rencontre ».)

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8. Mental Health Services # 1

[This is written from the MSF compound in Abéché, whereto I’ve been partially evacuated.  If you’re following the news, you know that things are a bit hairy here in Chad.  Rumours abound, but I have no good sense as to what’s  happening.  From the compound we can hear tanks, helicopters, jets, and so on.  But no gun-shots.  This blog isn’t really the place to be seen to be monitoring or reporting on governmental ongoings, as that path leads to jail.]


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The Head of Mission (HoM) has, for the time being, restricted all movement in town or anywhere else, but I got permission to quickly scoot off to the nearby UNHCR compound where they have internet.  It’s basically a lock-down-and-wait scenario. The HoM and the rest of the management team continue to work, but the evacuated expats are in limbo. Of the Farchana-team who would have to be evacuated in the case of a crisis, about half went a couple of days ago, myself among them. This was so that if need be, the rest could be moved more quickly, in a single plane-trip. One incident in Farchana camp yesterday led to a gendarme (armed guard) at the camp being shot and killed when he tried to intercept the attempted theft of a truck. Two trucks were stolen (from another NGO). I don’t know the details. Of the persons that were evacuated from Farchana and other projects, about half were evacuated further to Cameroon. Some are providing emergency medical care there, and other are taking their much-needed vacations or early endings of their missions. I decided to stay in Abéché so that I could return to my project ASAP, and so that if there was any need of psychiatric services here, I would be around.  But to do psychiatry in a war-zone, you need a modicum of stability and some planning, neither of which is in place. I’d need a translator (or two), and then a means to integrate services into the existing network, which is complicated. So it probably won’t happen. But that’s why I’m still here and not in Cameroon… maybe it will come about, and I can get to the local hospital and do some work.  Current efforts are mainly directed at surgical interventions. I wait, chat with the other “partial evacuees,” play scrabble (against the computer, mostly), and listen to BBC Africa on shortwave radio. There’re the details, and below is the blog I’d been waiting to post. Waiting because I wanted to see more patients and get a better feel for things, but I figure I’ll put the first part out now and see where the chips fall later. Hopefully it has pics attached, but if not, they’ll be added later).

Let me introduce you to the Mental Health Services (MHS) team.

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The team is nine persons, of which I am the most recent addition. From left to right: Issakha, Habib, Djamillah, Hamra, Fatna, Habib, Nafisa, Kadidja, Rauchaia and Aicha. (The picture captures well the bright smiles and colours of our team.  There is a bright spirit to the group.)

Habib and Issakha are the two supervisors, with university training in psychology, and a host of languages at the ready. Both are Chadian nationals, and have been working with MSF for about 3 years. Issakha is technically also my full-time translator, enabling me to speak to the refugee population who are generally unilingual Masalit speakers. The women are Sudanese refugees who have been hired as daily workers or “journaliers” by MSF (because a contract cannot legally be given to a refugee), and they speak Sudanese Arabic, as well as Masalit. I have to speak to the counsellors via translation by Habib or Issakha. The main criteria for hiring the counsellors, as I understand it, were language ability (written and spoken), motivation, as well as that elusive element of “psychological mindedness.” That is, they’re good listeners and have an interest and aptitude for addressing social problems.

On day one, I was thrilled to finally meet the team and get down to business! I think that they were happy to see me. In part this was based on the fact that when Habib shook my hand, he didn’t let go for about five minutes, and smiled a lot. I didn’t understand half of what he said (my French bites, and the accent here will take some getting used to), but it seemed rather friendly. As we went around the circle, each counsellor introduced herself, and they told me where they were from in Darfur (each from a different city), how long they’d been in the camp (about 3.5 years give or take a year), children (alive and deceased), and their marital situation (how many other wives their husbands have).

It was a friendly and inviting group, despite the language barriers and the fact that the women took an hour before they would sustain eye-contact with me for more than two seconds. I had one main question for the counsellors on day one: what problems do people bring to mental health services? And this is the list of the problems, in the order given, and with a bare minimum of exploratory questions by me; I just wanted to see what was salient to them:

1. Violence against women at the hands of military (of all types) and Chadians when they leave the camp to find fire-wood for the hearths and feed for the animals.

2. Domestic disputes between couples, involving money, fidelity, multiple marriages, substance abuse (lots of bootleg alcohol), and everyday things (parenting styles, communication, unemployment, theft, etc.).

3. No jobs for men, which puts strain on everyone. When I asked what the “presenting compliant” was in these cases, I was told that men cannot earn money to pay for the marriage dowry, and were not happy. They arrive with shame, and often with guilt at having committed crimes to try and rustle up some valuables. This often involved the theft of an animal, which is a big deal around here.

4. School refusal. In September, some kids refused to go to school, so group psychotherapy sessions were started and eventually all were convinced to go, I was informed.

5. Unwanted pregnancy. This was between young lovers who were “not yet married,” as it was described, or by young women who had “older men who buy them things.”

6. “Mental Health Problems.” This group were called “victims of violence,” such as being attacked or seeing someone being killed in front of them. And the most frequent presenting complaint was “insomnia” or “nightmares.” I was informed that about 30% of people seen at the mental health services present with this.

7. “Social problems.” Refugees need identity cards that also function as ration cards for their families. Often they cannot navigate the system, and come to MHS “with stress.” As well, financial problems and shortages of food were discussed here, and the gist of the discussion is that the counsellors provide some talk therapy, but mainly just help them connect with the right place to get through the red tape of administration, or to offer emergency provisions.  This would be a pragmatic social work approach, and MSF has hired for the mental health team someone whose primary task is to attend t these complaints.

Over the course of the week, I saw five patients in person, all of whom were those brought to me by MHS staff who were not sure what to do, or just wanted a second opinion (mental health people do this a lot in Montreal, too).

[Thanks for the comments.  If blog-readers have comments, suggestions, musings, please write them. I will try and respond when I have more than twenty minutes at a (relatively slow) internet terminal.]

7. Pit Latrines and Politics

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I’ve never been in a country while a coup d’etat is happening. This afternoon, while at the staff compound, our team hushes while listening carefully to BBC Africa. Every now and again there’s a brief gap in the Africa-cup soccer tournament, and they talk about Chad’s predicament. These moments have a palpable sense of immediacy, and I find myself more than a bit nervous, albeit despite the facts on the ground, it still feels somewhat abstract. There are no signs of imminent danger for us, as Farchana is a dusty town far from the big cities, but we’re on the main road, and who knows what the next few days will bring.

But the mood in the camp this morning was not set by this event. Which is, in itself, kind of remarkable. Children still play everywhere, water is collected, and the line-up at the Health Centre is long. Looking around the camp, one does not have any sense of political stuff going down. My first meeting this morning was with the team of Community Health Workers (CHWs). My role here is to supervise mental health as well as community health. Which I’m very happy about, as the two go hand-in-hand, but I’ll write more on this later.

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The camp is split up into about 27 “blocks,” and twenty Sudanese refugees, hired and paid by MSF, are responsible for their designated areas, comprising between 600 and 2000 persons. Really, who better to ask to understand life on the ground? the only reason that “grass-roots” is a metaphor is because it’s the dry season.

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We sit on mats on the floor, shoes off, and I asked people to sit in a circle rather than in rows facing front. It is odd at first, because the women were sitting on one side and now we’re all side-by-side, but it flies well enough. Some men insist that they will not sit near the women.  After introductions (translated from French to Masalit), I ask what the main concerns are for them, their families, and their block inhabitants. This is what was discussed (in the order raised, in case you’re wondering):

1) Some of the pit latrines are full in a number of the blocks, and in block K, they’re all full; they have to walk to another block.  SECADEV (a Christian aid and development outfit) handles this, and they’re behind in digging new pits. It is a massive health problem, really. Pit latrines may have done more to decrease morbidity and mortality than anything else… more than vaccinations, more than economic reform, more than food distribution improvements. Simple hygiene goes a long, long way.  The lack of pit latrines, such an easy and cost-efficient means of decreasing morbidity (sickness and suffering) is incredibly frustrating to me.

Steven Cohen Psychiatrist | Ivan.1

2) “We need another Mobile Zero.” The pick-up trucks are numbered “mobile 1” to “mobile 50”.  There are not fifty trucks, but the numbers just happened this way for no fathomable reason.  Someone decided to call the donkey-drawn carts (that transport the non-ambulatory patients to and from the Health Center) “mobile zero.” Initially, it’s kind of amusing in an eighteenth-century way, but I quickly realize how crucial these carts are. I’m told that if a patient waits too long for the cart, they may miss the day-time clinic hours and will have to wait for the emergency clinic. This latter clinic, which MSF runs 24 hours, is farther from the camp, and, if need be, the MSF trucks are used for transport. Either way, people want another cart, and they want it to run on Sundays, too.

3) For several reasons, people in the camp are not taking prescribed medications once diagnosed with malaria, and they are dying because of it (though statistics from our health centre don’t show this). They say that people don’t take meds because of side-effects, which they know are clearly better than death, but are not initially viewed as troublesome as a trip to the “marabou,” a traditional healer. Competing explanatory models of illness sometimes conflict, and I heard the story of one marabou announcing that people die even if they take the anti-malarials, so what is the use? I do not know if this view is prevalent, but the conversation this morning indicated that it wasn’t uncommon. My initial impression is that people take the medications, experience side effects, and stop them, deciding to see a marabou instead. I’ve got no truck with the marabous (in fact, I’m looking forward to organizing a meeting with some of them), but there is a big problem with taking drugs sporadically. It goes like this: antibiotics kill off malaria parasites, which are all a bit different. The most susceptible get knocked-off first, and the most resistant take a full course of the meds to be wiped out. But if you stop the course early, you eradicate all but the hardiest strains, and then those multiply and spread. It’s bad for the individual, and bad for the population. The CHWs want another education campaign around malaria, it’s symptoms and treatment.

Steven Cohen Psychiatrist | malaria

4) Violence. Every day, about 50-100 women leave the camp, most often in groups, to search for wood and animal feed. It takes about three hours for the return trip, and it’s relatively common for women to be intercepted by groups of bandits (usually men with guns), and have their things stolen or worse. Emotional, physical, and sexual violence are experienced by many (about 10%, by my general polling of the CHW’s), with rape and other forms of brutality affecting 2-3%. Having men with the women leave the camp together makes it safer, but collecting wood and feed “is women’s work,” and men will generally not do it. I’m not sure if I went red in the face, but I felt an impulse of rage when I heard this. Could it be the case that men would rather their wives and daughters were beaten and raped rather than suffer the indignation of taking a morning walk together to collect necessities?!?” On further inquiry, I was told that men suffer beatings (their teeth are broken, for example) if they stand up to groups of bandits. This morning’s story was of a local Chadian woman who stole a large bundle of straw from a Sudanese woman walking back to the camp, insulting her all the while. Later in the week, the Chadian woman was seen wandering through the refugee market-place (that operates on Mondays and Thursdays). The local police were called and some sort of questioning was undertaken, but with no evidence, her denials were enough. No good solutions to the problems of violence were discussed. As I listened, I recognized that most were quite pleased that the numbers of those affected were “so low.” It is of course outrageous that multiple beatings and rapes a day is considered an improvement. The next person waits to speak…

5) In the last two distributions (by SECADEV) there has been no soap. Basic hygiene, the backbone of medical health, is not being attended to, and people are rightly upset. I have been in Abéché and N’Djamena recently, and there was LOTS of soap in the markets… and nobody spoke of supply chain problems. This will have to be looked into.

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So, this is what was discussed over an hour and a half. Basic needs: safety, hygiene, medical care.

For the past few days I have tried to just take things in, asking as many questions as I can. There’s a lot going on. My plan is to try and get a fix on who does what and what they say about it. It is going to take a while, and it is for this reason that I’ve stalled on writing about mental health, which I will do soon. On first pass, so far, the concerns are very pragmatic.

6. The Farchana Sky

Steven Cohen Psychiatrist | C.Nut.RainbowLadies Steven Cohen Psychiatrist | open sky Steven Cohen Psychiatrist | man.grove.far

Every place has something that makes it unique. The background that provides the relief against which all is made contrast, visible, and dynamic. It does not tell a story, but it is the timbre of the voice in which it is told; the flicker of the flame that holds us rapt for hours; the scent that ushers in a distinct memory that we’d long forgotten that we ever knew, and transports us entirely. It is not sustenance, but the flavour that we recall. Not music, but the silences that circumscribe rhythm and cadence. I have been here for three cycles now, and from morning to night, it is becoming clear that in Farchana, all stories start with the sky. It is a soft, back-lit, baby-blue hue that has been washed a thousand times over and clings onto its brilliance still.

It feels that all that springs forth from this harsh land has been carved from the sky, sitting atop a flat and dusty soil, like miniatures on a piece of softly curving sandpaper: the adobe and straw walls that demarcate the small squares of land allotted to each Sudanese refugee family, the tents constructed by myriad NGOs to house food and supplies; the wood and plastic-sheeting structures that offer sitting areas and consultation rooms for the sick, the malnourished, and those seeking mental health or perinatal care; the concrete slabs that look like a heavy strip mall in the early stages of construction that serves as the school; the water pumps at which women in brightly-coloured swaths of fabric move to and fro with large pots and buckets balanced on the heads, small children in wobbly tow; the thatch-roofed tukuls in which we sleep; the wandering donkeys and occasional chicken; the thorny brush.

Steven Cohen Psychiatrist | C.N Steven Cohen Psychiatrist | Breidjing Steven Cohen Psychiatrist | Ahmat.CNut

This morning, the sky opened up as it has every day since I arrived; it is impossibly large, stark, and embracing. It defies us to enter into it, and we do, out of our camp, through the mango grove, over the dried up wadi (the water, I’m told, still runs a few metres beneath the sand), through the small town of several stalls, and into Farchana Refugee camp.  About 22,000 resident Sudanese refugees from the Darfur region.

Steven Cohen Psychiatrist | Google map Farchana sky Steven Cohen Psychiatrist | mango.perch Steven Cohen Psychiatrist | farchana_camp Steven Cohen Psychiatrist | brick_pits Steven Cohen Psychiatrist | Fox.CDS.board Steven Cohen Psychiatrist | man.grove.far

But this is not the story for today. Today was a sad day. The sky witnessed a group of Somali bandits who yesterday attacked some MSF vehicles:

Three dead, including a Somali driver, a Kenyan surgeon, and a French logistician of 27 years.

My condolences go out to their families, friends, msf team, and their communities. And when I say communities, I mean both those from whence they have grown up and onwards, but also the community in the town of Kismayo, near the hospital where the attack took place. I don’t know whether MSF will decide to stay in Somalia or evacuate the other projects, and the situation is so complex that I would not hazard a guess nor valuation. But I do have a sense as to the stability and hope that these projects bring to people. The following is an excerpt of a speech given by David Michalski, the then Head of Mission in Somalia in early 2007, when it was delivered:

Many children die from easily curable disease every day including malaria and respiratory infections. A vast majority of Somalis have no access to health care.

Of course, my description of the humanitarian condition is slanted towards the medical field. However, the situation with regards to education, water and sanitation, and other fields are equally precarious.

In 2006, we performed more than 300,000 outpatient consultations, and 10,000 inpatients were admitted in our hospitals. In general, the quality of the work is verified by high cure rates, low defaulter and death rates. To our regret, we do not have programs in the main urban centers, namely Mogadishu and Kismayo.

This has not meant that our projects are small. In the tiny town of Huddur (approximately 20,000 population), we have the largest inpatient department in southern Somalia with 250 beds full almost every night. Many come from long distances, some traveling for over a hundred miles away to receive care.

(The rest of the speech can be found at: http://tinyurl.com/ywkos2)

At that time, there were over 40 international staff and 600 national staff. They operated in 12 independent sites. I’m not sure how many there are now, but I imagine a similar number if not more. I’ll look into it.

What will happen to these communities if MSF is forced to pull out of this situation, as so many other NGOs have done in recent years owing to the precarious security situation?  When the refugees in Farchana see the MSF logo on a T-shirt or truck, they see that we are actively engaged in their health care.  When the symbol disappears for a few days, or regular health care clinic hours are not met, for example, it is worrisome, and deeply so.

Anne Frank once remarked, while observing the extent of human depravity in the second world war, that “humans are really good at heart.” While I suspect that Anne herself was good at heart, and saw the world that way, I think that she was wrong. Some are, many are not, but there is a remarkable plasticity. We know this by opening up a newspaper, by flicking on the TV, and by listening to anyone with stories to tell. Which is pretty much everyone. Humans are capable of terrible things. Experiments by Philip Zimbardo and Stanley Milgram suggest that you can take an otherwise respectful and ethically-minded person and, in the right circumstances, turn them into an obedient animal, quickly capable of cruelty, cunning, degradation and actions approaching torture. We can likewise fashion ourselves into caring, compassionate and generous persons, looking out for our brother, neighbour, countryman and beyond. This malleability of spirit has been co-opted by those who inspire us to use our superpowers for good. Stability borne of living wages, accountability (the rule of law), and hope for tomorrow by having our basic needs met.

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This morning I walked along in our small compound, returning to my tukul after brushing my teeth, and found Bienfait, our Congolese doctor, talking on the satellite phone. He seems to be one of those people who Anne Frank was talking about. A teardrop rolled down his cheek and his eyes welled red as he told us of the news from Somalia. To my mind, his tears were for those that died, and for the suffering in Somalia that may come for many.

5. Abéché

CAMH Steven Cohen | girl.abeche.cropCAMH Steven Cohen | NoKaleshnikov CAMH Steven Cohen CAMH Steven Cohen | HoM CAMH Steven Cohen | wadi.above CAMH Steven Cohen | medical storage CAMH Steven Cohen | laden.mule CAMH Steven Cohen | huts.above3

The journey to Farchana is moving along at the pleasant pace of a water-logged pinball. I was expecting a one-day turn-around time in Abéché, but the logistics just worked out such that the scheduled departure is on Friday, so it’ll be a four-day wait here. Our Abéché-departing Land-cruiser met the one sent from Farchana at a half-way point to transfer passengers in both directions. This operation, done twice a week, is uniformly and rather endearingly called “the kiss.” As much as I’m psyched to finally get to my project, I’m finding these extended layovers a great way to get a feel for how MSF operates. Today’s briefings were on security and the regional politics in eastern Chad, and it was no gloss. Lots of details, but I won’t write reflections or a description on this. (When I did, in a previous post, it was edited out by someone in Germany. And just for the record, while it chafes to be censored in any sense, I am not upset, nor particularly surprised. My writing was noted to be too political and, at times, variably factually uncertain or too accurate. C’est la vie. It is the mark of expertise to speak broadly on a complex subject while still maintaining accuracy; needless to say, I’m not there for the most part, and when something may be an accurate comment on the facts in the ground, that statement itself may not appropriate for blog treatment).  Learning.

So I’ve got time to dither, and when I’m not playing scrabble on my laptop (about eight games today… it’s coming out my ears, and I dream of anagramming words at night) I’ve been musing on the set-up here, and getting to know some of the in-country management team better. I’m having a hard time understanding the French spoken by the Chadians, mostly because of my poor ear for these things, and in part because of the dialect. It’s going to be a slog to function in French with the team in Farchana.

 CAMH Steven Cohen | store.room

Abéché: the most pervasive environmentally trenchant fact about this desert town, which is the largest in eastern Chad, and it’s second largest city, is dust.  No paved roads, no grass, just dry earth. It feels like how I imagine Marrakech would have been in the early-mid1900s, but with cell-phones and white Land Cruisers. We’re in the heart of winter now, and it’s actually pretty chilly at night (about 15˚C), while the days get up to 27 or so. I awake to the sounds of birds chirping, and from the tin door of my small room at the compound, I can see streams of them lined up on the coils of barbed wire. While walking from the sleeping compound to the office, there is a chorus of chirping while they flit from barbed metal to spaces between shards of broken glass embedded on the tops of the walls. It’s a rather cheerful sound, if but a heady image, and if you add their stochastic hum to that of the generator and the occasional yelping of the new puppy (named Tonto), you have the deep soundtrack to morning life here.

CAMH Steven Cohen | tonto CAMH Steven Cohen | tonto2

4. N’Djamena

I’m trying to figure out who the other people are who are on the airplane.  It is a 100-person flight from Paris to Chad’s capital, N’Djamena.  The fellow sitting beside me works for Exxon, and at the airport he and many others are greeted by people holding Exxon placards with various names on them.  As well, people in military fatigues are greeting other passengers.  Military, oil interests, humanitarians, missionaries.

A young fellow with a bright smile that shows all his teeth wanders calls out my name and looks relieved to have found me. “Papi” introduces himself and takes me directly to the bar, where I meet the administrative coordinator (AdminCo) who seems a bit fatigued, but offers me a beer almost before saying hello.  This is a good thing.  We chat briefly before heading back to the MSF compound, and I’m shuffled into the back of a 4X4 and we zip off.  Very quickly, however, we’re off paved roads and traveling slowly on bumpy ground in what looks like a sprawling shanty-town.  There is nothing that would betray that this is the capital city of a country.  Nothing.  You know you’re off the beaten path when you’re in the capital city of a country and there’s no Starbucks.  I’m not being anti-corporate, because if there were a Starbucks I would probably be there right now, and it wouldn’t be for the coffee.  As it stands, there is one (count it: ONE!) internet café in the city that the staff here know of, and it ain’t wireless. (The UN people may have wireless…)

Fast-forward a day.

Steven Cohen Psychiatrist Toronto

I’m now on the patio under the thatched-roof gazebo.  High white walls topped with barbed wire surround the compound, and there are guards 24/7, without guns, of course (this is MSF… more commentary to come on that). Most neighbourhoods that I’ve seen so far have this look, with the lucky ones having paved roads in front (ours does not). Muslim garb adorns people in the street, with goats and chickens running free amidst the ubiquitous vendors of gasoline (in old 2L drink bottles) and cigarettes. Also common are “recharging stations” for your cell phone. Toyota land-cruisers are the call-sign of humanitarian aid workers, and are surprisingly common, emblazoned with large identifying logos.

Steven Cohen Psychiatrist Toronto | msfcars

As it turns out, rather than scooting through N’Djamena in a day, I’ll likely not get my in-country “circulation” certificate for a week.  This is due to an unfortunate incident about a month ago wherein a group of French aid workers (working with the group “Zoe’s Ark”) tried to leave the country with 103 Chadian children.  Well intentioned at best.  Woefully stupid, irrespective.

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At the training session for this mission, we were give talks by a number of people, but that by David Trevino stands out, probably because he is diva-like in his dramatics, brief, and has one of the best jobs of anyone I know (logistical consultant). He said that there were only three things we had to take from this week: 1) If you want to leave, just say so, and you’ll be on the next flight out, 2) If you are told to leave (ie. you’re being evacuated), don’t argue the point, just go where you’re told and argue later, and 3) never forget that your actions affect other MSF and NGO staff, even long after you’re gone.

Steven Cohen Psychiatrist Toronto | David

It’s this third point that’s the most interesting. I’ve made comments to friends about the “brand management” that is done by MSF. They’re a $400 million-dollar outfit and collect most of it in donations from grandmothers to bake-sales (I’m told this, but it must be more complicated; at any rate, there is a push to deemphasize funding streams from private/governmental sources) . At any given moment, there are about 3000 expats, and many more inpats, in the field, all with the MSF logo on their sleeves, hats, car doors, etc. In this world of viral information transmission, a story or picture can be seen by thousands of people, and have greatly unintended consequences. To this end, in my briefing today, I was reminded that drug use leads to direct repatriation; sexual liaisons with local staff and Chadian nationals are forbidden; that I have to radio my whereabouts at all times; and even that my blog postings must be read and approved before being posted. Usually my big-brother hackles get raised pretty quickly with these things, but not this time. It just strikes me as uber-prudent and well thought-out so far

Steven Cohen Psychiatrist Toronto

Non-sequitur: this arabic keyboard is bloody hard to navigate…   damned punctuation.

Well, I was told this afternoon that I may be off to Abeche, Chad (the largest city on the eastern border of the country, about 40km from Sudan’s Western border, the Darfur region.  If all goes well, in a couple of days I could be in the field! The next post will be from Farchana, in shala.

3. The day of…

I awoke to the feeling of my thudding heart.  The rate was the same old 55 or so, but it was pounding. This may just be the unholy by-product of malaria prophylaxis and the alcohol from last night’s impromptu dinner party, but it likely has something to do with the fact that I’m off for my mission today.  Packed and stoked, I am! First to Berlin for a briefing, and then Amsterdam for another briefing, and then to Chad on the 17th, I think. Nobody’s given me tickets to anywhere except Berlin, so that’s where I’ll go. I feel like the humanitarian equivalent of a sure thing.

freud feel

“How are you feeling?”

This is the question that I’ve been asked more than any other (yes, there may be a bias here in that lots of my friends are in the psy discplines…). Mostly, I’ve had a bland response. Other than some non-specific giddiness that could just be gas, my feelings haven’t betrayed (until maybe this morning) an imminent six-month trip to do cultural psychiatry in war-torn central Africa. And I have a guess as to why: I’ve got nothing to compare it to. I’ve never worked abroad, nor have I really travelled in Africa. I was born in South Africa, and immigrated to Toronto when I was 3 years old. And despite heading back every summer for about 7 or 8 years, I feel no more than a vague-yet-oddly-meaningful kinship with the place. A white privileged kid in an apartheid nation cannot validly empathise with the continent any more that a glass-bowl goldfish can with the open ocean. But more than that, I realise that I’m being careful with my assumptions.

“Are you always analyzing people?” / “Are you analyzing me?”

This is probably the most common question I get when I tell people that I’m a shrink. (The second most common is “Are you serious?” to which I like to answer “Hell, who lies about that?… If I was gonna make something up I’d tell you I was a surgeon.” This doesn’t make things less awkward, but somehow it does make it less weird.) The training for this job is 5 years. That’s 3-4 years of medical school, plus an extra five to specialize. It’s a bloody long haul, and a few ingrained habits are (hopefully) beaten out of you, the most entrenched being the idea that you can know something or someone quickly and surely. Yes, first impressions and intuition are invaluable tools, and you’d be a fool to discard them, but they’re just guesses that more often tell you about yourself than the other. As Anais Nin said: “We see the world not as it is, but as we are.” She was clever, amongst other things.  This quotation of hers is one of the very few things I could imagine Wittgenstein ever saying “I wish I’d said that.”

brain music

In my view, you gotta listen to a lot before assuming anything to be the case. How many jokes are there about the psychiatrist who just sits there, like some inert rock, for the first 6 months of therapy, repeating in some nauseating voice: “and how did this make you feel.” The kicker is that despite this being some mix of cliché and farce, it’s a stellar question. It’s the answer to this question that hints at who someone is in the world, and you’d often never know otherwise.

When a patient’s partner or parent dies and you say “I’m so sorry for your loss,” it’s more common than you’d think to get a “I’m glad he’s dead… he was an asshole!” in response. Or you congratulate someone for a promotion or accolade, and they only see it as a way for the higher-ups to substitute better pay for some empty title. They’re fuming inside. It simply pays to ask… and although some might consider the question intrusive at best, the short, open-ended question is often the most valuable and telling.  Any hack can jump to a conclusion and think they’re right without testing their assumptions, or grand to their personal choir, whatever form that takes.  It takes a boat-load of active, conscious effort not to do this.


Back to Chad. I’ve simply got no clue what it will be like… I have nothing to meaningfully compare it with; I’ve got no ability to empathise with my projections. Just some vague notion of something coming that’s gonna be big. My dreams have some danger, adventure and disorientation, though, so that’s a place to start guessing, for what it’s worth.  In some way, though, I do feel ready.

2. Unpacking Chad

If you want to zoom around Chad from the bird’s-eye point-of-view, get Google Earth.  It’s a fantastic programme. (But, if it’s not possible, look at the pictures below.)

If you scroll about, you’ll see Breidjing Refugee camp, made up of approximately 30,000 Sudanese refugees, and Farchana refugee camp, with about 20,000 persons.

Steven Cohen Psychiatrist Google map Farchana sky

Steven Cohen Psychiatrist farchana_camp

The top one is an image from Google Earth, which is the Farchana camp from about 2 km above, and the one below that same camp at ground level. From the UN-map below, you can get a sense as to where the refugee camps are located.

Steven Cohen Psychiatrist

Steven Cohen Psychiatrist

(NB: All of these maps, and frequent updates to the situation in Chad and other humanitarian projects can be found at 1) Reliefweb and 2) the MSF International site.

UN map chad 1

chad map actors on the ground

I don’t know about you, but I can’t think without a map. So, now that you have one, this is what I’m in for starting mid-January of 2008: The plan is that I’ll be stationed in Hadjer Hadid for about six months doing daily trips to nearby refugee camps (mostly Breidjing and Farchana, I think), and IDP (Internally Displaced People; Chadians who have fled violence in their own country) camps scattered around the area. Like most things in life however, and from what brief information I can gather, MSF is an on-the-fly fast-response medical relief organization, so even the best-laid plans can change dramatically and frequently.  The MSF contingent is 8-9 expats, and about 50 national staff.  Not sure about the size of the Mental Health Team contingent, or what the set-up will be.  My mind is racing with possibilities.