GULU, Uganda -- As an 11-year-old, Alfred Odida did awful things. He killed people with machetes, he abused the dead. He says he had no choice. The rebels who abducted him forced the young boy to commit atrocities, as they have thousands of children during northern Uganda's long civil war.
Now 18 and safe, he sat with a psychiatrist recently to discuss his lingering mental trauma, such as the haunting visions he has of victims coming back for revenge. "I think it's the spirits of those people," he said, his brow crinkled in an expression of worry.
Antidepressants and antipsychotics have largely calmed his demons, said Dr. Thomas Oyok. And that makes Odida a rarity in a country with 20 psychiatrists for its 26 million inhabitants. Here, people dealing with emotional turmoil are far more likely to turn to traditional healers, pastors or counselors, if they seek help at all.
Oyok, a Ugandan psychiatrist, is trying to even out that imbalance. He has linked up with a small American foundation established to help societies around the world, including Cambodia and Afghanistan, cope with the anguish caused by mass violence.
Besides training indigenous health workers in Western ways, the Peter C. Alderman Foundation aims to foster closer ties between two camps often suspicious of each other: physicians and traditional healers, many of whom say they can appease angry spirits with herbs and ritual animal slaughters.
"A lot of these countries, Uganda for one, have rich traditions of traditional healing," said Stephen Alderman, who started the foundation in memory of his 25-year-old son, who was killed in the Sept. 11 attacks on the World Trade Center in 2001.
"It would be crazy," he added by telephone from his home in Bedford, N.Y., "if we tried to lay [only] Western medicine on these people who have cultures that predate ours by years and years and years."
In attempting to build bridges with these medical workers, the foundation plans to help organize one-on-one sessions with healers to reinforce their good practices, such as letting patients vent emotions at length. Dangerous methods -- tying up patients or withholding food -- will be strongly discouraged. Some healers have received training to dispense antipsychotic drugs in certain cases and to refer serious cases to a psychiatrist.
The Alderman Foundation has trained 35 medical doctors and psychologists from 12 countries through the Harvard Program in Refugee Trauma. It has also opened two "psychotrauma" clinics in Cambodia and one in eastern Uganda, paying staff salaries in return for government-supplied psychotropic drugs.
Early next year, the second Uganda clinic will open here in Gulu, bolstering Oyok's ability to treat patients at the modest government clinic. He says the timing is good, given what he predicts will be a spike in trauma-related disorders.
Hopes are high that peace talks will end a 20-year war between the rebel Lord's Resistance Army and Uganda's government. While he wants peace as much as anyone, Oyok expects a surge in post-traumatic stress disorder as more people leave de facto refugee camps and return home to villages -- the scenes of so many abductions, rapes and killings.
The United Nations says 700,000 people have left the camps -- dangerous, squalid places that are hardly conducive to good mental health. Still, more than a million people have yet to depart for rural areas.
"I'm sitting on a minefield as far as PTSD is concerned," Oyok said, referring to a condition that can cause people to sleep poorly, startle easily, remain constantly on edge and relive traumatic episodes. "When they go back, they will get a shock. That is when I'm expecting the problems."
The stakes go well beyond individuals' mental health. Happier people, he says, are generally more productive and more peaceful.
Oyok, an affable man of 56, is one of three psychiatrists in all of northern Uganda. The low number is partly due to the paucity of doctors of any kind in this impoverished East African nation. It also stems from widespread doubts that unquiet minds need medical intervention.
Rift between workers
Here even physicians harbor prejudice against psychiatrists, said Dr. Seddie Alibusa, hired by Alderman to run the Tororo clinic in eastern Uganda. Chuckling, he said some Ugandan doctors label him and fellow psychiatrists as "mentally ill." In the general population, he and Oyok agree, most people first try a traditional healer, or maybe a pastor or priest.
Some members of the medical community are uneasy with traditional healers. Oyok tells of a doctor who, during a visit to a village, tried to get the police to round up all the healers and cart them away.
But Oyok said he wants to work "hand in hand" with traditional healers. He even persuaded one to obtain the antipsychotic chlorpromazine to complement the herbs and cactus leaves he prescribed.
Oyok wants to "at least make sure their practices are safe." That concern is not limited to healers. One patient arrived at his clinic with a chain around his leg. A pastor had used the chain to keep the man still while he prayed over him. It turned out the man had epilepsy.
Oyok said he tries to follow a 60-40 ratio between talk therapy and medication. Drugs can help a person "settle down," and "that's when you can go to talking therapy." One benefit of healers, he said, is that they talk for a long time, and patients need that.
As Alibusa put it: "What we can do best is the psychiatric treatment -- look for the best medication, apply it in the right dose, explain the illness. But when it comes to comforting the people, those traditional healers can do a really good job."
And, say both doctors, reaching out to healers will encourage the referral of serious cases for medical evaluation.
Traditional healers come in many stripes. In and around Gulu -- a tidy, welcoming city despite its swollen wartime population of 200,000 -- some advertise their services, while others can be found only by those in the know.
One self-described healer, a burly 48-year-old named Alex Okello, said he inherited from his grandfather the power to consult spirits. They guide him on which herbs to use for ailments and whether to give them as a nasal drip or in drink form, he said.
"The main problem is mental problems," he said, describing cases he sees. Among those he helps, he said, are people who have killed, willingly or not, and are suffering nightmares and other problems.
"We have a belief that when you kill, the spirits of that person will come and disturb you," he said, so he purports to chase away those spirits for his patients.
Some conditions, such as epilepsy, are beyond his reach, he conceded, and those he refers to Oyok's clinic.
But a man in another part of Gulu who advertises himself as Doctor Kanga has never made such a referral: "I don't even understand the word 'psychiatrist,' " he said.
Still others take a religious stance. Severino Okoya, 78, said he regularly uses the "spirit of God" at his New Jerusalem Temple to rid people of psychological trauma.
Alderman suggested bringing a traditional healer on board the clinic in Tororo, said Dr. Ivan Kamya, medical superintendent of St. Anthony's Hospital, which houses the clinic. But because St. Anthony's is Roman Catholic, Kamya said it would require finding someone with no ties to witchcraft.
Few people in northern Uganda have been unscathed by the war, which the International Crisis Group, a nonprofit organization focused on resolving deadly conflict, calls "one of Africa's longest, most brutal conflicts." The Lord's Resistance Army targeted civilians in its anti-government campaign, and Ugandan troops forced thousands of villagers into camps to ensure they did not aid the rebels.
Children have suffered most. Some 30,000 were snatched by the LRA and made to serve as soldiers or laborers. Girls were typically forced into sexual slavery. Thousands escaped or were freed by Ugandan soldiers.
In Gulu, one organization operates a center for war-affected children that uses counseling, prayer and art therapy. Another group lets youths shape their treatment, whether it's a visit to a traditional healer (arranged by relatives), counseling or prayer. It has referred a few cases to Oyok's clinic.
Alfred Odida did not go through either center before enrolling last year at the Laroo Boarding Primary School, whose 673 pupils include former soldiers and those born in captivity. A few dozen students have been treated by Oyok, including 30 who had what he calls a "mass episode of PTSD" last year.
Odida was part of that episode. One night, school staff members found him and the other students pulling down light fixtures and breaking windows. Many were hallucinating and screaming that they were being chased, recalled the principal.
Odida says his symptoms have subsided, and the psychiatrist agrees he is doing better. But now Odida worries about leaving the school and returning to his village. Former child soldiers, despite being forced to fight, are widely despised for the atrocities they visited on civilians.
"There is a lot of stigma and finger-pointing," the young man said, still looking nervous. "They say these are the people who came and killed all of our children."