In the corner of the main hospital ward, a young woman suddenly falls to the ground shaking uncontrollably. The medical staff rush to her side to prevent her from harming herself.
“She had a psychogenic seizure,” explains Dr. Jairam Ramakrishnan, the psychiatrist at Malakal camp for people displaced by the civil war in South Sudan. “It is a common enough sight in the hospital. For many people the anxieties and stresses of being trapped in here are beyond what they can cope with. This convulsing and collapse is the body’s response to the stress.”
Four years after the camp was opened to shelter the population from the war in the Upper Nile state, the impact on residents’ mental health is telling. In 2017, there were 31 attempted and seven successful suicides. Toward the end of the year there were 10 attempted suicides in one month.
“Most men won’t leave the camp as they are afraid they will be attacked or forced to join an armed group. When in their minds they have reached the end of the line, suicide seems the only option.”
Like so many camps, the Malakal “PoC,” as residents call it (after U.N. parlance “Protection of Civilian”), was meant to be temporary. Today there are 25,000 people living in a very confined space, the majority of whom are children. In some parts of the camp, the average living space is less than 55ft (17m) per person.
The most difficult time in the camp is the rainy season, between June and October, when the black cotton soil turns to a thick mud, and the packed-earth floors of people’s huts turn to puddles. Life becomes nearly unbearable as it is impossible to stay dry.
Food rations are very low. The overall allocation is just enough to keep a person alive, and some sell a portion of what they have to buy other essential goods.
“Given the violence that people have lived through, many would be expected to suffer from post-traumatic stress disorder [PTSD]. But I see a different picture,” says Ramakrishnan, a doctor with the medical charity Medecins Sans Frontieres (MSF).
“Despite periods of continuous violence, people are resilient and survive without many of the tell-tale signs of PTSD. But over time, faced with being stuck in the current living circumstances without any improvement in their lives, many people develop a sense of hopelessness.”
The psychoses push people into a mental prison, separating them from the real world. Solitary individuals can be seen walking around in a daze.
It is hard to say exactly the proportion of people with mental health issues in the camp, but MSF receives up to 20 new serious mental disorders per month. The threat of violence is an ever-present factor in this. In February 2016, 25 people lost their lives when fighting erupted there. Many more were gravely injured, and one-third of the camp was consumed by fire.
Family separations have also increased as many women have left the camp with their younger children to head north across the border into Sudan. The fathers and older children left behind must deal with the loss of structure and identity this creates. Without the structure of work and family, boredom quickly sets in, and problems such as alcoholism can emerge.
One man from Malakal explains: “The loss of status is very hard on my younger friends, as marriage becomes an impossible dream. They don’t have the money or cows to marry or support a future family. Nobody will look at them seriously.”
Some try to find solace in marisa, a local alcohol distilled from sorghum, but this can contribute to health problems such as hypertension and lower natural resistance to conditions like tuberculosis.
“Alcoholism has also been the cause of many social issues. When people are bored or face problems, they turn to the bottle,” says Dahn Tapp, one of MSF’s mental health counselors.
One patient in his 30s saw his friends shot during the fighting and now suffers from paranoia. He says, “People are trying to kill me in this camp. I need to leave this place.” Once a week he sees a counselor, but now his only desire is to leave.
Childhood ends early in the PoC. During the second half of 2016, a number of cases of attempted and actual suicides among children grabbed the attention of the camp’s authorities and led to renewed action. Unfortunately, the plight of children often goes unnoticed. Within families signs of emotional distress, such as aggression or bed-wetting, are inadvertently dismissed by parents. Abuse, neglect and hunger can be significant factors in driving behavioral changes in children.
Throughout the camp, neglected children and orphans are a common sight. Tapp describes how MSF recently admitted a young boy who was living on the streets and drinking a lot. “He stayed in the hospital for two weeks to dry out, and later we found him a foster family. But, shortly afterward he ran away and was back on the streets with his old friends.”
The community is trying to come to terms with some of the problems associated with captivity. Family bonds can be of great support, and solidarity helps many with material and emotional needs.
Creating shared spaces such as churches and staging cultural activities can help. On weekends, the open ground in front of the MSF hospital comes to life with traditional song and dance. “Keeping the traditional ways is an important way of connecting with the past and maintaining identity,” says Dr. Ramakrishnan.
Getting people to talk about their feelings can also be difficult in a society that is very action-oriented. Concepts of depression or anxiety are not a part of everyday language. But the hospital’s mental health counselors spend a lot of time teaching people how to express themselves.
“Nobody knows when the situation in the Upper Nile will improve and this population might return home,” says Dr. Ramakrishnan. “After four years, a new generation of children is growing up in the PoC, without ever having seen the outside world, and it is important that their mental and physical health is addressed.”
The views expressed in this article belong to the author and do not necessarily reflect the editorial policy of Refugees Deeply.