Dr. Sylvester Barancira has no time to let a patient lie back on the couch and talk about his problems. As the only psychiatrist in Burundi, a country at war with itself for nearly eight years, he sometimes feels he has 6.5 million patients.
Fighting in the central African nation between Hutu rebels and soldiers of the Tutsi-dominated government has killed more than 250,000 people, most of them civilians. Millions more have been terrorized.
For those scarred mentally, Barancira is their only hope.
Patients crowd the waiting room at his office, most of them suffering from post-traumatic stress disorder. They relive the massacres, ambushes, kidnappings and rapes--memories relived mostly in their dreams, but sometimes even when they are awake, Barancira said.
He estimates that 59% of Burundi's 8 million people report some form of war-related mental problems. The University of Burundi professor has found that 40% of the people he sees suffer anxiety attacks, 21% experience insomnia and nightmares and more than 30% are depressed and discouraged.
"If the war does not come to an end, the rate of drug and alcohol abuse will increase in the youth," said Barancira, 47. "It is not enough to give food or material assistance. What Burundi needs now, and urgently, is people who can help heal the mind."
Two postgraduate students he was counting on for help died of illness and a third was killed in fighting.
"In Burundi, we have not had much luck in this area," he said in his tiny office in Bujumbura's town center. As much as time and resources allow, he uses traditional psychotherapy, family therapy and medications, such as antidepressants.
He said there is not enough time to treat all of his post-traumatic stress patients with psychotherapy, so he is forced to rely mostly on medication. But medicines to treat depression and anxiety are in short supply.
Most Burundians are Hutus, but the minority Tutsis have controlled government, the military and the economy for all but a few months since independence from Belgium in 1962.
Thousands died in politically motivated ethnic fighting in 1965 and 1972. The current conflict broke out in October 1993 when Tutsi paratroopers assassinated President Mechior Ndadaye, a Hutu and the country's first democratically elected president.
Barancira, who is married with three children, returned to Burundi 14 years ago and found it difficult at first to start working. Officials couldn't believe a 33-year-old had certificates in both psychiatry and neurology after just 12 years in France.
He also had to deal with patients who understood little about mental illness and usually turned to traditional healers. If that did not help, the patients were usually abandoned.
After proving himself to the Ministry of Public Health, Barancira was appointed director of the new Kamenge Neurology and Psychiatric Center, but found only a few patients.
He then paid a visit to Prince Regent Charles Hospital, a colonial-era facility with 120 patients that had fallen into chaos.
"When I first saw the place I was astounded. The patients were walking around nude, most did not have a name, nor did they receive any medicine. The entrance of the asylum was guarded by a man with a club. I just could not believe my eyes."
He started spending most of his free time there. When he studied the patients, he found that 20% were beggars or severely handicapped people whose families had abandoned them. Sixty percent had chronic problems, while 20% suffered severe mental illness.
Only three of the seven nurses under his supervision had any psychiatric training.
Slowly, he managed to return most of the patients to their homes and then transferred the severe cases to Kamenge, which was overrun in 1996 with thousands of people displaced by the war.
"I could no longer separate my patients from the displaced and dispersed," Barancira said.
He decided to resign his post and open a private clinic, but continues to treat patients at Kamenge with the help of a nurse who had studied neuropsychiatry, Edourade Habonimana.
Government resources mostly go to the military, and little attention is paid to mental health. Dozens of clinics and hospitals treat war injuries and disease, but Kamenge is Burundi's only psychiatric ward.
"I have been working in this hospital for over 11 years, and I have never seen anybody from the Health Ministry visit here," Habonimana said. "We have to depend on assistance from international organizations like the World Food Program and the International Red Cross. It is as if [the ministry officials] have forgotten we exist."
Barancira, a Tutsi who also teaches at Burundi's medical school, said he has hopes that a Burundian doctor now studying psychiatry in France will return to help.
"I hope that, upon his return, we can exchange views."