MALAKAL (Philippe Carr) - The Malakal Protection of Civilian site (known by most as ‘the PoC’)

was created at the beginning of 2014 to offer much needed temporary protection to the population of the area who were caught up in the violence and cruelty of the war in Upper Nile.
But, four years on, the difficult living conditions, the loss of hope , feeling of enclosure as well as limited livelihood opportunities have had a profound effect on the mental health of those who are trapped inside. For most, leaving the site is not yet an option. They are afraid for their personal safety.
MSF runs mental health services within the PoC and is trying to provide support to the struggling population.
In the corner of the main ward a young woman suddenly falls to the ground shaking uncontrollably. Immediately the hospital´s staff rushes to her side to prevent her from harming herself. A nurse pulls a screen across to offer some privacy.
“She had a psychogenic seizure,” explains Dr Jairam Ramakrishnan, the hospital psychiatrist. “It is a common enough sight in the hospital. For many people the anxieties and stresses of being trapped in the PoC are beyond what they can cope with. This convulsing and collapse is the body’s response to the stress.”
In 2017, there were 31 attempted and seven successful suicides. At the end of the year there was a spike of 10 attempted suicides in one month.
“Much of the population face chronically depressing circumstances,” says Dr Ramakrishnan.
“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.”
The PoC was founded in 2014 after fighting in Malakal forced many people to flee their homes. The priority of the United Nations Forces in South Sudan (UNMISS) that founded the camp was to secure a space where people could settle temporarily until it was safe to return home. Improving the living standards in the camp was not an immediate priority.
But as the years passed, the camp´s authorities realized that the PoC was not going away anytime soon. There is a drive to slowly improve conditions, but options are limited.
There are now 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 17 metres per person. In the past it was even worse when the population was 47,000 and there was a chronic space shortage.
The most difficult time in the camp is the rainy season, between June and October, when the black cotton soil in the camp turns to a thick mud and the packed-earth floors of people’s huts turn to puddles. Life becomes nearly unbearable as it is mpossible to stay dry.
Food rations in the camp 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 suffered from post-traumatic stress disorder [PTSD]. But I see a different picture,” says Dr Ramakrishnan.
“Despite periods of continuous violence, people are resilient and survive without many of the tell-tale signs of PTSD. But overtime, 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. They are people that can´t cope with the reality of the situation and often have no families for emotional support.
It is hard to say exactly the proportion of people with mental health issues in the PoC, but MSF receives between 18-20 new serious mental disorders per month. This does not include those in the wider population that have broader mental health issues that might not be seeking treatment. A results from Mental Health Practioners in South Sudan Working Group from 2017 found that close to half of all mental health cases were related to depression and 15 percent to anxiety. These were compounded by psychosomatic conditions, as well as PTSD and psychoses.
The threat of violence is an ever-present factor in this. In February 2016, 25 people lost their lives when fighting erupted in the PoC. Many more were gravely injured and one-third of the camp was consumed by fire. Memories like this do not fade easily and add to the tension.
Adding further to this, cases of family separation have increased, as many women have decided to leave the camp with their younger children and head north into Sudan. The fathers and children left behind must deal with loss of structure and identity this creates. Without work or their families, many men lose their identity as breadwinner and provider, and their self-esteem suffers a huge blow. Without the structure of work and family, boredom quickly sets in and problems like alcoholism can emerge.
One man from the PoC 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. Alcholism is rife in the camp and contributes to health problems such as hypertension and lower natural resistance to conditions like tuberculosis. Some people sell their food rations to earn a few South Sudanese pounds to buy marisa and can end up malnourished.
“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 counsellors. “There are plenty of cases of violence in the family and family breakdown.”
The camp has many stories. One patient in his thirties 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 counsellor, but now his only desire is to leave.
While the routine of family life may help some women, they also have the constant fear of sexual violence hanging over them when they leave the safety of the camp. One of the few sources of livelihood for women is collecting firewood outside the gates of the camp.
“Often they are attacked and sexually assaulted,” explains Natalia Rodriguez MSF´s psychologist in the PoC. “Few will come to MSF for counselling or for medical examination. They are afraid, as abused women will rarely marry.”
Childhood ends early in the PoC. During the second half of 2016, a number of cases of attempted and actual suicide attempt 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, like aggression or bedwetting, are inadvertently dismissed by parents. Abuse, neglect and hunger can be significant factors in driving behavioural changes in children, but are often unrecognised as such.
Throughout the camp, neglected children and orphans are a common sight. Many live on the streets in groups and are sometimes found eating garbage as they have no access to the food distributed in the camp. Again, many turn to alcohol as is a means of escape and can lead to violent behaviour.
Dhan Tap 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 the material and the emotional.
Creating shared spaces like churches or through cultural activities is one way of maintaining hope. On weekends the open ground in front of the MSF hospital comes to life with traditional song and dance, as local groups dressed in elaborate costumes compete with decorative staffs. “Keeping the traditional ways are important way of connecting with the past and maintaining identity,” says Dr Ramakrishnan.
 “With cognitive behaviour therapy, we can help develop peoples coping skills when they are suffering from conditions such as depression which eventually helps them identify mental triggers to depression and find mitigation strategies,” says Natalia Rodriguez.
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 counsellors 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,” says Dr. Ramakrishnan.”
“In the meantime, the camp authorities will need to continue addressing the social and living conditions and the living environment in the camp. Providing food and water is not enough. They must also confront the lack of sufficient housing, develop strategies for greater engagement among the community, and create more opportunities for employment in the camp. There needs to be an understanding of the of mental health capacity. At the moment the psychiatric and psychological resources in the camp are insufficient for such a large vulnerable population.”