Mental Health in the Middle of War
It was 2015, in the Central African Republic (CAR). I was on my weekly outreach visit to a camp for internally displaced persons (IDP) in the capital, Bangui, talking to a group of women in the community about mental health care. Two women suddenly came over to me, “Sarah, you have to come with us to meet this woman, she is beating her baby.” I followed the women to a small one-room “house,” partly destroyed and largely unkempt. Inside, I met Justine, a young woman clearly in distress.
CAR has been entangled in a brutal civil war since 2012; over 800,000 people have been forced to flee their homes, half of whom have fled to neighboring countries. Justine was from the north of the country, where rebels were attacking villages, burning them to the ground, killing the men, and sexually assaulting the women.
I took Justine and her baby to the hospital for assessment and discovered she was in a state of psychosis. I talked with her for a while, and listened to her story: Justine fled her home when the rebels attacked her village, but along her journey to safety, had been attacked several times by several men and became pregnant.
Having a baby in a refugee camp, or an IDP camp is a nightmare. Without medical care, often the baby will not survive, often the mother as well. Justine’s baby did survive, but sadly became a reminder of what had happened to her and the trauma she had suppressed. After the birth, Justine became delusional, having hallucinations whenever she was near the baby, and beating it.
Justine and her baby desperately needed help.
There are so many factors to think about when choosing how to treat someone for mental health issues, there is never a “one size fits all” solution that can be implemented around the world; there are too many cultural nuances to consider. I knew I could not make this decision in the same way as I would back home in France; I needed to think differently.
If I put her on medication for her psychosis, she would not be able to breastfeed. Breastfeeding in this part of Africa is so important; the nutrients and disease immunity it can provide is almost necessary for the child’s survival. I have seen women, skinny and frail, unable to find food for weeks, breastfeeding chubby babies that might otherwise be sick with malnutrition. If I gave Justine the medication, her baby might not survive without breast milk — it was not a decision I could take lightly.
I began to wonder, if Justine had received the support she needed immediately after the attack, would it have come this far? But when you are fleeing for your life, you are simply trying to survive, so talking to someone about your experiences is either not an option, or not something you would think to do.
This was my first assignment with Doctors Without Borders/Médecins Sans Frontières (MSF), and, as a psychologist managing the sexual violence program, the bulk of my job was raising awareness within the camp about the stigma and taboo surrounding mental health care and sexual violence — a world-wide issue, even in France.
In CAR, women who become infected with HIV or pregnant as a result of sexual violence are often isolated or rejected by the community. Whether or not she had been isolated from the community, Justine was isolated; she fled her village alone, and we were unable to find her family.
Justine’s psychosis was evidently a serious accumulation of the trauma she had experienced, isolation, and lack of family or community support. I had to consider separating Justine and her baby, so that they could both survive. I visited a few orphanages, but they were in terrible condition, I could not possibly leave the baby there.
I was at a loss as to what to do. This was one of the greatest challenges I have faced, it tested my ethics as a medical professional, and also as a human being. My decision would change this woman’s life, for better or for worse, and the life of her child’s.
Finally, I decided take the baby away from his mother, temporarily, and give Justine the medication she so greatly needed. I introduced the bottle to the baby, and hired another woman to take care of him day and night. Much to my relief, after a few days, Justine’s condition improved; she had calmed down, she was making eye contact with her baby, and her communication skills were much better. However, after switching from breast milk to the bottle, the baby lost a lot of weight. I was very concerned; I had made the decision to save the lives of two people, not just one. I kept a close eye on the baby, and thankfully, bit by bit, the baby got used to the bottle, and, bit by bit, the baby got better.
After two weeks, both Justine and her baby were stable and were able to be together again. I took them back to the camp, happier and healthier than when they left. But I knew Justine needed the support of her community in order to continue on her path to recovery.
Being a psychologist in Europe is different to being a psychologist in CAR. No matter where in the world I am with MSF, this is the principle we work by: we are here in this moment right now, trying to save the life of this baby right now; we are not staying here forever and we are not here to disturb the culture.
In CAR, mental health care is about the community: understanding the way people are resilient; the way they cope with their suffering; the way they deal with mental health. Once I understand that, I use their strength — the strength of the community — to help.
As a part of my outreach in Bangui, I explained to the various communities why it was so important to support people with mental health issues and not reject them: if you can improve the mental health of one person, you improve the mental health of the entire community.
Once Justine and her baby returned to the camp, I organized a meeting with the leaders about the importance of rebuilding community support around them. Together, we found four women who agreed to support Justine in her recovery. The women kept an eye on her and her baby, making sure she took her medicines and making sure she was taking care of the baby — becoming the community she had lost after fleeing her village.
For the six months I was in Bangui, I saw 376 patients. Each of these people had their own story to share. Today, there are 65 million people around the world who have fled their homes, each with their own story to share.
Justine’s is the story I tell at Forced From Home, MSF’s travelling exhibit aimed at humanizing the global refugee crisis.
I have been a tour guide on the exhibit since September. We have visited New York, Washington D.C., Boston, Pittsburgh, and this weekend—from November 5th to 13th — we will visit our final destination for 2016, Philadelphia.
I decided to join the tour as it provides us—the MSF aid workers — a great opportunity to share our stories in a useful way, not just for useful us, but useful for the people we have met in many situations all around the world.
So many of the people on my tours had no idea what displaced people around the world experienced. The exhibit really forced them to put themselves in a refugee’s shoes, to think: If I was in this situation, what would I do? What would I take if I was fleeing? Where would I go? And, most importantly, who would I take with me?
At the end of the tour I ask people to remember that all the people they’ve seen on the documentaries, all the people they’ve seen in the pictures, all the people I’ve shared stories about, used to have a home, used to have a job, they had children going to school, they were organizing birthday parties on Saturday afternoons: they used to have a life exactly like yours and mine. They are not different from us. It could be us; what happened to them could have happened to us.
They never never wanted to leave their homes, they never never wanted to come inside our countries. They’re not refugees by choice, they are refugees because they had to survive.
