War's assault on the mind

[Castro]

In a phenomenon that strikes many strife-torn societies, Somalis increasingly retreat into mental illness

 

By Paul Salopek

 

Tribune foreign correspondent

 

8:54 AM CST, November 15, 2007

 

 

MOGADISHU, Somalia — Abdulrahman Habeb was a man with problems, the most pressing of which involved a barrel of tranquilizer pills.

 

 

The barrel — containing 50,000 capsules of fluphenazine hydrochloride, a potent anti-psychotic drug ordered from America—was boosting his patients' appetites. This was not good. Patients at Habeb Public Mental Hospital were scaling the facility's mud walls to scavenge for food outside, in the war-pocked streets of Mogadishu. One had been shot.

 

"They don't stop when sentries say 'Halt!' " said Habeb, the director of the only mental health clinic in Somalia's capital. "How could they? They are mentally ill."

 

Hence, the next problem: Habeb chained some of his 47 patients to their cots. This harsh practice was regrettable, he conceded. But many of his charges weren't just famished, they were aggressive.

 

 

"They act out the violence of Somalia!" cried Habeb, an excitable man who called himself "doctor," but who really was a nurse—a nurse at the end of his tether. "I cure people's minds, and the war hurts them all over again. You cannot heal here!"

 

He took off his glasses. He doubled over and began to sob. A colleague in one of the cavelike wards rushed over to pat Habeb's shuddering back.

 

And herein lay perhaps the biggest problem of all: While Habeb and most of his patients could walk away from their wartime asylum, there was no avoiding the larger nightmare that is Somalia. Doctors and aid workers see troubling signs that untold numbers of Somalis, brutalized by 16 years of chaos and tormented by the suicide bombings and assassinations of a growing Islamist insurgency, are fending off the jolts of violence the only way they can, by retreating inward, into the fog of mental illness.

 

 

"Ninety-five percent of the triggering factors here are related to the war," a distraught Habeb said. "The fear and worry. Year after year. It is like a bomb."

 

 

Mention the term post-traumatic stress disorder, or PTSD, and what pops into most people's minds are vacant-eyed GIs grappling with the lingering psychic wounds of combat: anxiety attacks, phantom pains, depression, hyperaggression, sleeplessness and flashbacks.

 

Yet in an age when international terrorism gnaws at the minds of millions of ordinary people, and where millions more are battered by chronic violence in failed states, many doctors have begun to worry not just about the mental health of individual soldiers but of entire societies.

 

Interest in the globalization of war's invisible wounds, and PTSD in particular, has spawned a relatively new branch of medical science—traumatology. Popularized in the wake of atrocities such as the Rwanda genocide and the 9/11 terrorist attacks, its core focus involves treating war-haunted populations with mass counseling. Indeed, it even aspires to help end wars through therapy.

 

How?

 

High levels of paranoia, emotional withdrawal, irrational fear and other symptoms of PTSD tend to stifle reconciliation, conflict experts say. Traumatized populations are less apt to forgive. Moreover, a study to be published soon in the Journal of Marital and Family Therapy suggests that war-traumatized families in hot spots such as Afghanistan internalize their pain, and plant the seeds of violence in the next generation through child abuse.

 

In effect, whether it involves armies or civilians, mental illness perpetuates states of war.

 

"The humanitarian response to conflicts has always focused on caring for the body," said Sandro Galea, a post-traumatic stress researcher at the University of Michigan's School of Public Health in Ann Arbor. "But what we're learning is that treating stress-related mental problems can actually help break the cycle of war."

 

Not all medical experts buy into that analysis.

 

In Kosovo—the first modern killing field where mental health was made a priority in the aid effort—psychiatrists treated thousands of dazed refugees and war-crimes survivors. The results proved ambiguous. Patient surveys showed that counselors concentrated so narrowly on post-traumatic stress that they overlooked deeper woes such as despair over poverty, the anxieties of displacement, surging drug addiction and the agonies of spousal abuse.

 

Some experts also question whether a Western concept such as PTSD can be applied across cultures. Human grief is handled differently across the globe, they say. And some skeptics go so far as to label mental health crusades in war zones a form of medical colonialism—force-feeding psychoanalysis and narrative therapy to minority cultures.

 

Still, few serious physicians deny that the basic symptoms of PTSD can be found everywhere. And in countries where the killing is ever-present, aimed at civilians and savagely personal—which is to say, in most current wars—its prevalence skyrockets.

 

A 2001 UN report on the state of the world's mental health estimates that 20 percent of all people exposed to low-intensity civil conflicts are scarred by serious behavioral disorders.

 

In some wars, the toll can be far higher. In Sri Lanka, home to one of the planet's oldest and most brutal insurgencies, 64 percent of the populace exhibits some type of mental trauma, a government survey shows. And in the reliably bloody Gaza Strip, a study conducted by the Gaza Community Mental Health Program revealed that only 2.5 percent of Palestinian children were free of PTSD symptoms. Eighty-three percent of local kids, the doctors found, had witnessed shootings.

 

More than 70 years ago, Ernest Hemingway wrote of the insanity of the Italian front during World War I, titling one of his bitterest short stories "A Way You'll Never Be."

 

Today's psychiatrists argue that whole cities and unstable regions are verging on a "way you'll never be"—whether it's in Baghdad, the bone fields of Darfur, the mountains of Afghanistan or one of the most anarchic capitals in the world, Mogadishu.

 

Vast, mostly lawless and plagued by clan feuds, Somalia hasn't seen an effective national government since 1991.

 

At present, the Ethiopian army and the treasury of the United States are propping up a weak transitional federal government that holds sway over the decayed capital, Mogadishu. The TFG, as it is called, ousted a radical Islamist movement late last year. But the fighting grinds on. And it's getting bloodier.

 

Wary citizens edge through Mogadishu on foot or in dented old buses, flinching whenever gunfire erupts nearby. They brave car bombs, insurgent ambushes, corrupt police and thundering Ethiopian artillery to reach their dusty food markets. Children flatten against classroom floors if the shooting gets too close.

 

More than 170,000 people have fled intensifying street battles in Mogadishu over the past two weeks, the UN says. Today the city, once home to 1 million to 2 million people, sprawls half-empty—a grim incubator of wartime trauma.

 

 

"Nobody knows the scope of the problems because it's too dangerous to work there," said Karin Fischer Liddle, a Somalia specialist with Doctors Without Borders, one of the few Western aid agencies still functioning in the metropolis.

 

Doctors Without Borders had hoped to carry out the city's first mental health survey this year but shelved the plan because of surging violence. "We just assume the needs are enormous," Fischer Liddle said.

 

As it is, Mogadishu's residents have only one option for mental health care: Habeb Public Mental Hospital.

 

Established in 2005, it sees new stress cases every day. Its 50 or so beds technically serve all of central and southern Somalia—a land of war-displaced nomads and farmers with a total population of perhaps 8 million to 12 million.

 

One recent afternoon, its patients sprawled on dingy mattresses in the dim, stifling wards, apparently heavily sedated. Some stared up, glazed-eyed and smiling. Seven were chained by their wrists and ankles to iron bedsteads. A half-naked man stood outside, giggling in purest ecstasy, shackled to a tree. Another's back was crisscrossed with bruises from village beatings.

 

"Somalis treat mentally ill people very cruelly," said Habeb, the shaggy-haired nurse who founded the clinic. "Look."

 

Habeb fired up his office computer. He clicked through photos of hyenas to illustrate the "hyena cure"—a village therapy that involves dropping a mentally impaired person into a pit with the wild predator. The animals are supposed to scare off djinns, or evil spirits, inhabiting the patient, Habeb explained. With a snicker, he ticked off other rustic coping mechanisms for mental illness—beatings, forced starvation, smoking donkey feces.

 

"We are modern here at the hospital," he said. "Mania, schizophrenia, epilepsy. We diagnose them all. We treat them all—scientifically."

 

Habeb's office was littered with jars and bottles of pharmaceuticals. Most of it was paid for by the $50-a-month fee he charges inpatients' families, who often begged the money from relatives in the Somali diaspora.The barrel of American tranquilizers occupied pride of place, the center of the floor.

 

"We don't get many ordinary depressives," he said. "Why? Withdrawal. Sadness. Lack of interest. Low psychomotor activity. In Somalia, all this is natural. These kinds of people just stay in their houses for two or three years."

 

Habeb described his mental health training: a 90-day course sponsored by the World Health Organization.

 

A few weeks before, aid workers had stopped by to see if they might help with funding. They left in a hurry. In their report, they noted that a toddler suffering from malaria had been misdiagnosed with "organic psychosis."

 

Experience literally reshapes the human brain. Memory rewires neurons. That fact has been known by psychologists for some time.

 

Thus, it comes as no surprise that war leaves its own distinctive, scorching thumbprint on the brain.

 

Research indicates that the left frontal region, a nexus of verbal communication, malfunctions—becomes disconnected—when people are exposed to continual, violent stress. A new brain-wave study of torture victims, carried out by scientists at the University of Konstanz in Germany, has borne that out. There's even a name for this wounded state of mind: speechless terror.

 

"Language-related centers become impaired in these cases," said Michael Odenwald, one of the study's authors. "There is a pattern of social withdrawal. This helps explain why reconciliation in traumatized populations becomes more difficult."

 

The war-injured mind exacts other strange costs.

 

Unexplained back pains, stomach cramps, chronic headaches—all are widely recognized as signs of mental trauma, even in Mogadishu's basic first-aid stations. Meanwhile, the links between serious physical diseases and PTSD have been long recognized by the medical community. A landmark study by The New York Academy of Medicine showed that Vietnam War veterans with PTSD were six times more likely to suffer heart disease than those without it.

 

Habeb knew this.

 

"I am a patient too," he confided, making the rounds in his clinic wards. "I am taking medication for heart problems and diabetes. It is the stress."

 

Habeb said he spent too much time at the clinic. His wife was divorcing him. The things that alarmed his patients were starting to trouble him as well. The knocks on doors that sounded like explosions. The steady buzzing in the sky above Mogadishu—purportedly CIA drones on spying missions—keeping him awake at night.

 

A few miles away, over the city's sandy streets, another Somali health worker commiserated.

 

Laila Mohammed Abdi was a shy intake clerk for a maternal health clinic. Two years ago, clan militiamen shot her husband because they wanted his cell phone. He bled to death in her arms. More recently, Mogadishu's police held a gun against her neck and stripped her naked in a market. They stole everything, including her dress. She couldn't take proper care of her children. She couldn't do her job.

 

"I have got some problem in the brain," she said. "It's getting worse, not better."

 

Abruptly, she began to cry. One of her colleagues, who was translating, turned his head away and started weeping as well. It seemed the most normal reaction in the world, in Mogadishu.

 

psalopek@tribune.com

 

Copyright © 2007, Chicago Tribune

[AfricaOwn]

Too depressing, the times when I face hardships is nothing compare to what some folks are going through.

[xiinfaniin]

Ayyaan darro!

[Kool_Kat]

It is really sad and painful to see...

[Castro]

^^^^^ Imagine then what it is like to experience such misery. I will forever be haunted by these images.

[Jacaylbaro]

It'll stick to the minds of all Somalis forever .... very sad indeed.

[Baashi]

^Now you know what it is like to be living in the hell hole Mogadishu has become, try to moderate your warmongering calls in the name of jingiosm. You, Kaligii-Muslims of the site, and other fake nationalists have shown their lust for war.

 

Xiinoow, the "ayaan darro" can be stopped. The E-factor is the LCD of the equation. Asmara Group hit and run, provoke Tigre and go awol when goings get tough and tough get going, and the TFG's ********* is what made the situation ayaan darro.

[BiLaaL]

Harrowing images. What else can one expect after 17 years of unrelenting violence and displacement? Laila's story is typical of what ordinary folks have had to go through. Losing loved ones in the most incomprehensible of situations, suffering numerous daily injustices and still having to soldier on regardless. Given what we've had to go through, it is amazing that we haven't become a nation teeming with mental illness patients. This is down to the resilience and strong character of our people. Having said that, however, there is no doubt that many more people may have simply become so apathetic that they don't realise just how damaged their mental state is.

 

Ironically, the true scale of this problem may only be become evident once peace returns. It is only then that people will be able to take stock on the true state of their mental health.

[Kool_Kat]

Originally posted by Castro:

^^^^^ Imagine then what it is like to experience such misery. I will forever be haunted by these images.

I can't imagine cuz I've never been through such thing, or anything remotely close...So anything I imagine, I am sure it will be thousands of times worse...

[Xoogsade]

If not afflicted with mental illness, many whose relatives live in Muqdisho do contend with severe anxiety. I have had days I had to call my parents ten times within the span of 12hrs just to make sure a mortar didn't land on them after I have spoken with them. It was even more difficult and still very difficult to log on here and see some individuals with the luxury and safety for their families write the most disgusting comments about the events back in Muqdisho. It goes to show soomaalida qaarkeed haba yaraatee wax xiriir ah inaysan la lahayn soomaalida kalee Muqdisho ku nool. I don't have the luxury to be indifferent or blame some group when I know my flesh is being burnt and who is responsible for the misery.

[Che -Guevara]

Originally posted by Xoogsade:

It goes to show soomaalida qaarkeed haba yaraatee wax xiriir ah inaysan la lahayn soomaalida kalee Muqdisho ku nool. I don't have the luxury to be indifferent or blame some group when I know my flesh is being burnt and who is responsible for the misery. [/QB]

Waa Runtaa.

 

P.S. I would be lying if I say understand the mental anguish people in Xamar through. I remember 91 dagaalkii, intaas aa iigu filneed,if i was there any longer in Xamar, I would probably gone nuts.

[Xoogsade]

Originally posted by -:

quote:Originally posted by Xoogsade:

It goes to show soomaalida qaarkeed haba yaraatee wax xiriir ah inaysan la lahayn soomaalida kalee Muqdisho ku nool. I don't have the luxury to be indifferent or blame some group when I know my flesh is being burnt and who is responsible for the misery.

Waa Runtaa.

 

P.S. I would be lying if I say understand the mental anguish people in Xamar through. I remember 91 dagaalkii, intaas aa iigu filneed,if i was there any longer in Xamar, I would probably gone nuts. [/QB]

You understand their anguish enough to not defend or find excuses for A/Y and warlords he brought back to Muqdisho. Hopefully, you will have nothing to regrett after these tragedies come into passage and you look back saxib.

[Miskiin-Macruuf-Aqiyaar]

Dad baa buufis buufis ku haaye, oo ciyaar ka dhigan jiray. Muqdisho, before this carnage and genocide, aan soo arkay and what I had seen in my own eyes, I think, a significant numbers mentally meel ka wada waalnaa, even those who thought they were fine as well. No person can stand a seventeen years of non-stop violence.

 

The first who had gone inay isla hadlaan, ku dhuftaan and finally waalnimo were dadkii "reer magaalka" ahaa, the former injineers, dhaqaatiirtii and other professionals who couldn't tolerate the animal-like behaviours and merciless violence meesha socoto any longer. Isolate and inay isla hadlaan bilaabeen and that eventually leads to a full waalnimo.

 

Eebboow u gargaar umaddeena, meel walba laga haayo, walaahi.

[Miskiin-Macruuf-Aqiyaar]

Somalia: No Place for a Child

 

WAJID, Somalia (

AP

) — Nov. 14 — Abukar Mursal stopped going outside to play after a bullet grazed his back during a soccer game in Mogadishu, the wretched seaside capital where he was born.

 

Abukar, just 15 years old, simply added sports to his list of banned activities — no joining up with militiamen patrolling the streets. No guns. And finally, no soccer with his friends.

 

"In Mogadishu, fighting is everywhere," Abukar told The Associated Press some three months after he fled the city in a car packed with his parents, three siblings and other relatives. "Every morning we heard bullets. I thank God we left that place."

 

After more than a decade of chaos, some aid groups now are focusing on the psychological problems of Somalia's children of war.

 

In this country of 7 million people, with its ferocious violence and debilitating poverty, a quarter of all children die before age 5. Bullets zoom through the streets every day.

 

"The children from Mogadishu have seen dead people in the streets, wounded people in the streets," said Ibrahim Haji, a counselor for the aid group World Vision Somalia.

 

Often, Haji can tell if children have just arrived from Mogadishu by the way they act. "They can be very unfriendly," he said. "They just go and sit somewhere and think. That's all."

 

World Vision recently opened a "child-friendly space" in Wajid, a U.N. aid base in southern Somalia, where counselors help children affected by the conflict, some of whom have suffered rape, brutality and other traumas.

 

The aid base offers a place to relax — there are soccer balls, Frisbees and small classrooms with mats where children can take naps.

 

Abukar, who said he associates mostly with kids from Mogadishu who have been through similar experiences, now lives in a camp with relatives and comes to the World Vision center to play soccer and to rest.

 

Chris Smoot, program director for World Vision Somalia, acknowledges that basketball and soccer might seem like luxuries in a country where the average life expectancy is just 46 and where malnutrition is common.

 

"But this is just another need — a place where kids can go and play and not feel scared," he said. "This is an opportunity for them to be kids. They're the future leaders of Somalia and we are helping them to learn and grow."

 

World Vision's facility, with its fresh white paint, basketball court and cool concrete floors, is an anomaly in a nation that has not had an effective central government since 1991. In many parts of Somalia, government buildings and other structures were dismantled long ago and looted.

 

A radical group called the Council of Islamic Courts ruled much of southern Somalia for six months last year, but it was driven into hiding during a lightning-quick war in December. The Islamists have vanished from the streets, but are fulfilling their promise to launch an Iraq-style insurgency, using land mines, roadside bombs and suicide attacks.

 

Human Rights Watch has accused all sides in the conflict of war crimes, saying fighters target hospitals and other medical facilities. The battles have devastated the capital, already one of the most violent and gun-infested cities in the world.

 

Over the summer, five children who apparently mistook a land mine for a toy were blown away when it detonated — a stunning reminder of the toll war takes on the young.

 

Thousands of civilians have been killed since December, and a fifth of Mogadishu's 2 million residents have fled. Fighting that started late last month has driven about 36,000 people from their homes, according to the United Nations.

 

Many have come to Wajid, about 175 miles northwest of Mogadishu, where there is relative peace. The town also has makeshift camps where entire families squat in huts made of tarps and thorny branches.

 

In September, international humanitarian agencies agreed on new guidelines to address mental health, focusing on building social networks and other support groups.

 

"Until now, many people involved in emergency response have viewed mental health and psychosocial well-being as the sole responsibility of psychiatrists and psychologists," UNICEF said, adding that long-term mental problems "threaten peace, human rights and development."

 

Siad Abukar, a 13-year-old who came to Wajid two months ago from Mogadishu, said he tries not to think about his former home.

 

"When I think of Mogadishu, I feel like fighting," Abukar said. "I won't go back, never."

 

Safiya Aden, who also arrived two months ago, said she sleeps easier here than in Mogadishu, where she heard rumors that "ladies were being raped."

 

"I came here with my parents," she said. "We heard there was peace."