First, forget about witchcraft....

Dr Egip Bolsane Dr Bolsane knows he cannot meet demand

The only psychiatrist working in the African country of Chad has his work cut out to convince patients their issues are medical, rather than spiritual.

The sign outside Dr Egip Bolsane's surgery in the sleepy riverside district of Chagoua in the Chadian capital N'Djamena proclaims "the pioneer".

Even by Dr Bolsane's own account psychiatry was an unusual choice: it is not a discipline that many Chadians understand.

"Going to see a psychiatrist in Chad is a difficult thing for many people," said Dr Bolsane, seated behind a sparse wooden desk with just a bunch of white plastic flowers in a gold vase as decoration.

"Public opinion here thinks that it means something is really wrong in your head, it might be because you're possessed.

"We need to demystify the more or less diabolical image of psychiatry."

Case study: Adamu

Adamu sought help from a psychologist in Canada via Skype:

"I was having real problems in my family life. It was about my wife. We were arguing a lot and I was very upset.

"It was by chance that I came to hear about these services. It was through a friend that I used to go to every time I had problems.

"He saw that I was really upset about my relationship. I wondered if talking to someone about psychological problems might work.

"It was really a good thing. We talked about everything and I learnt new techniques of dealing with my relationship and the conflicts we were having.

"Even after five or six weeks the advice helped us to approach things in a different way. With this help I found a new balance in my family life.

"There is no medical help here for mental health problems. It's difficult to ask for help.

"Any Chadian will think in the first instance about talking to a friend, or perhaps their mother.

"But you can never be honest about it.

"Talking to a family member means someone feels like they're being accused and it can lead to misunderstandings.

"I'd never heard about any of these ideas before. If you go to the hospital they would never offer you anything like that. It's a shame. I see people all the time who really have a problem, maybe the man and the woman live under such stress that they're psychologically unstable.

"People don't know how to change. It can end in fights and violence. The other possible solution is religious belief, but I don't think that works."

A listless fan rotates erratically behind him and he wipes the sweat away from his face - Dr Bolsane himself is not in particularly good health and he can't afford air conditioning.

Mental health problems are poorly understood by the majority of Chadians who tend to conceptualise illnesses such as depression and schizophrenia as having a spiritual, rather than a medical cause.

Many people believe in the existence of witchcraft and curses, and phrases such as having a "hot head" or persistent headaches are often euphemisms for much more serious problems.

Lack of education

It is easy to see people whose mental health issues have been left untreated, and whose families can no longer cope, living rough on the streets of the capital.

Dr Bolsane said one of the biggest obstacles to changing attitudes to mental health - and getting people to understand that it is an illness and not possession - is lack of education.

"Mental health issues are not talked about in society," he said.

"I often find when people come to see me that they don't know how to discuss their problems with anyone."

Improving mental health services is not easy in Chad, a country which comes fourth from bottom in the UN's Human Development Index.

Dr Bolsane receives no state support for his services, his clients often have trouble paying his modest fees and often drugs are not available.

Anyone wishing to study psychiatry still has to go to France.

"A country of 12 million people which has lived through many years of war has enormous need for psychiatric help" he said.

"But I'm just one person. There is no way I can satisfy the demand even though I feel every day I'm trying to help people."

Civil wars

From the early 1980s until just a few years ago, Chad endured a seemingly unending succession of civil wars, rebellions and coups which have left many thousands of people traumatised.

Under the 1982-90 brutal dictatorship of Hissene Habre, who was recently indicted in Senegal on war crimes and crimes against humanity charges, some 40,000 people disappeared and many more thousands were tortured and imprisoned without charge.

Start Quote

I have observed that cases of schizophrenia here are much more common that you would find elsewhere, and my theory is that it's linked to what the country has gone through. ”

End Quote Dr Egip Bolsane

Both rebel groups and the national army are known to have persistently used child soldiers.

Dr Bolsane believes this background helps to explain what he's observed about the occurrence of certain illnesses.

"I have observed that cases of schizophrenia here are much more common that you would find elsewhere, and my theory is that it's linked to what the country has gone through."

He has also noticed unusually high numbers of cases of paranoia, possibly brought on by substance abuse, and stress within family relationships.

Very few of these people have ever received professional medical help.

In a country which is currently battling an outbreak of malaria with 14,0000 new cases over just a few weeks, where polio and measles are still very real threats to children, and where the under-five mortality rate is 169/1000 live births, it is easy to see how resources will not be directed at mental health issues.

Dr Bolsane is disappointed that the country's new found oil wealth has not contributed more towards improving all aspects of health provision in Chad - the country has earned some $10bn from oil sales in the last 10 years but many of the country's hospitals are still in a parlous state.

So how does he manage to find the motivation to continue?

"The human being is not a machine which can just be easily repaired.

"Trying to understand the full range of the human experience, how emotion links to health, is one of the most exciting and challenging things anyone can do," he said, with a smile.

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