Chad: Sudan refugees Mental Health needs

In the Metché displacement camp in eastern Chad, home to over 43,000 Sudanese people who have fled war, Médecins Sans Frontières (MSF) mental health teams help refugees and host communities cope with the impact of war and with the harsh conditions on their psychological well-being. In three different areas of the camp, MSF has community spaces where mental health counsellors offer individual sessions. Community health workers organise programmes tailored to children, young people, and adults. At the MSF hospital, mental health consultations are also offered in tandem with other types of treatment: maternity, paediatrics, surgical, emergency. Psychologist Jade Lage shares her experience as MSF’s mental health activities manager in Metché, and her concerns for the future of refugees who feel trapped in a cycle with no foreseeable end.

Why are the mental health needs of refugees in the Metché camp of particular concern?

The psychological well-being of refugees is affected by two factors. The first is linked to their poor living conditions and refugee status. Most of the people who have taken refuge in Metché have left behind a life that could be described as normal. They owned a house, a car, ran a business, cultivated land, had leisure activities, studied, and lived as a family.

Here, the reality is quite different. The camp is in the middle of the desert, isolated on all sides, in a region where there is virtually nothing to do. The climate is harsh, with extreme heat and hardly a tree under which to shelter from the sun. Living conditions are extremely difficult: recurrent shortages in food distribution, very limited access to water, no electricity, straw or plastic-walled shelters walls that are not secure. The dwellings are very close to each other, with a proximity that leaves no room for intimacy or privacy.

Hygiene in the camp is catastrophic; it’s not uncommon to come across rats, snakes and stray dogs. Most of the people are women, struggling to support children, who are often left alone, and elderly dependents.

The other aspect is directly linked to the brutality of the war in Sudan and the terrible violence the refugees have fled. The harsh memories of the refugees’ experiences of violence, and the resulting psychological after-effects, are still very present.

What do the refugees tell you about their experiences in the war that forced them to flee?

Most of the serious cases we see are people traumatised by the violence they have experienced or witnessed. Patients often speak of relatives or neighbours who were massacred before their very eyes; of lifeless bodies strewn across the ground as they fled; of recurrent threats received before arriving in Metche; of torture they endured.

A significant number of these people, of all ages, present psychotic symptoms. These include visual and auditory hallucinations, delusions, confused speech, and altered perception, such as the feeling of having insects inside their bodies. In mental health, when a person reaches the psychotic stage, it means that their psychological situation has reached alarming limits, and that their distress level is enormous.

“We came from El Geneina to Adré on foot. It was a Thursday, and it was an extremely difficult day. People were injured and lying in the streets, children were dead or displaced, and no-one was helping them. We arrived completely exhausted. We lost the people dearest to us.” Nour

Which are the groups of people who are the most vulnerable to surviving?

Women and children are in a particularly critical situation. We meet many widows who have lost their husbands in the conflict, and who must find ways to support their families. Dependent on humanitarian aid, and with no financial support, they go off on their own to fetch water and wood for cooking, often far from the camp. They are exposed to sexual and physical violence, which is unfortunately a sad reality in the camp. And while the mothers are away, the children are often left unsupervised and unprotected.

What other mental health needs are there?

Among the main symptoms observed, our teams mention psychological distress, difficulty sleeping, nightmares, and mood disorders such as depression and psychotic symptoms. The younger generation, girls and boys under the age of twenty, is also greatly affected, as they struggle to envisage a better future and are more vulnerable to chronic stress and anxiety. The teenagers we meet tell us very little about the future. In Metché there are no opportunities to look for work, to start studying, or simply to plan and start a family one day. I regularly hear young people say that they no longer have any desires or hopes.

All these young people, who today don’t have the privilege of choice, are skipping an important stage in their lives. They have a good understanding of the situation and their condition, but they don't yet have the tools to manage their emotions and frustrations. And the adults around them are not always able to provide the necessary support, as they themselves are experiencing psychological distress and struggling to cope in these difficult living conditions.

Our community health workers and counsellors regularly hear of problems such as physical aggression, excessive alcohol consumption and conflictual family relationships. We had the extreme case of a teenager who, after losing his father and experiencing episodes of violence, set fire to his own home three times. In our group sessions for young people, we deal mainly with issues of aggression, irritability, and frustration, which more often affect boys.

“My brother and I were deeply exhausted, so we left. When we were in Sudan, I had reached an advanced level in education. I got to high school. I came here and found no way to continue my studies, and now I’m doing nothing.” Muthadir, 20 years old

What is MSF doing to meet the specific needs of young people?

Our mental health teams, for example, run groups sessions for people aged between 12 and 17. We also organise activities such as soccer matches or traditional toy-making workshops. In group counselling sessions, we explain the importance of mental health and how it contributes to the well-being and stability of each individual. We also offer relaxation techniques and a range of tools for dealing with frustration.

At the beginning of April, we began activities in schools. The aim is to explain to pupils how to identify emotions and deal with them. We will also be working with teachers to ensure that they have the relevant information and tools to help them recognise signs of suffering in pupils and, if necessary, provide psychological first aid, as well as identifying pupils whose symptoms might mean they need to be referred to a health professional.

What concerns do you have for the future of Sudanese refugees, and for their evolving mental health needs?

Listening to and involving the people directly affected by this crisis is crucial. It enables us to provide an appropriate response to needs, but also to ensure the continuity of best practices and other coping mechanisms used by the refugees. However, with April marking the second anniversary of the civil war in Sudan, the transitional and difficult situation of people living here will probably continue for some time to come.

Access to healthcare is of course vital, and we will continue to provide medical assistance, including mental health care. However, if displaced people are to be able to live in dignity, additional efforts must be made at all levels. Since the beginning of the crisis, MSF has regularly called on UN agencies and donors to increase the humanitarian response in Metche, and in all refugee camps in eastern Chad.

With the US government halt on foreign aid announced in January, the situation can only deteriorate further. By way of example, the NGO in charge of the schools in which we have begun our mental health education activities could be directly affected due to a lack of funding, which might compromise its activities in the future. The consequences for the mental health of thousands of children and teenagers would be dramatic, as schools play an important role in the protection and intellectual and social development of pupils.