Posts Tagged 'Chad'

Article supplement: Posttraumatic idioms of distress among Darfur refugees

The September 2011 issue of Transcultural Psychiatry is out, and it includes an article by myself and some colleagues based on some work we did with Darfur refugees a few years ago. Publication lag times as they are (a colleague this morning compared them to the aging of fine wines), by the time an article is finally comes out in print the author’s ideas about what he/she sees as the “take-home” message may have shifted slightly. So here’s my chance to provide the 2011 take-home to a study written in 2009.

The article, Posttraumatic idioms of distress among Darfur refugees: Hozun and Majnun, details the development of a questionnaire (a structured interview, really) for Darfur refugees that we used to help evaluate a psychosocial intervention in camps in Chad. From the article:

We took an emic-etic integrated approach, identifying local constructs and then measuring both Western and local distress constructs within the same population in order to compare associations between two sets of symptoms of theoretically related concepts.

This means we (1) talked to a lot of refugees to hear how they defined their problems (including symptoms of psychological distress) and then followed-up with traditional healers to hear how they categorized these symptoms into larger psychological problems (“idioms of distress” for you budding transcultural psychiatrists out there); and (2) conducted a survey that included these problems and Western concepts (PTSD, depression) to measure how the Darfur problems and Western concepts were differentially associated with trauma experiences, loss, and impairment in daily living. The two Darfur problem sets were labeled hozun — “deep sadness” — and majnun — “madness.”

I’ll let you read the article to get the details, but suffice it to say that these sets of disorders — hozun and majnun on the one hand and PTSD and depression on the other — shared many symptoms in common. Related to this, they were associated with traumatic events and functional impairment at comparable levels — in other words, one could “predict” functional impairment using hozun and PTSD and get similar effect sizes (with slight favor for the locally-defined problems).

One might think that if a measure of PTSD is as good as measure developed for a local distress idiom in predicting a third variable you are interested in, then there is really no reason to develop the local measure. In the article we emphasized that the response to this argument had to do with respecting local populations and avoiding psychiatric colonialism. Now although I agree with those ideals, I would emphasize another point we made (but did not emphasize): Just because many of the symptoms of two different disorders from the Western psychiatric canon (here PTSD and depression) overlap with two different disorders from a different medical tradition (here hozun and majnun), it is how the symptoms are arranged in their respective traditions that define the disorders. From the article:

although they accounted for similar variance in Study 2 as a set of items, these symptoms were categorized by traditional healers into sets that were different that the sets of symptoms in PTSD and depression. This, then, suggests that it would be incorrect to argue that PTSD and depression are culturally valid constructs in settings in which respondents report variance on PTSD and depression simply because of that variance.

In other words, just because non-Western participants in a study answer that they have problems (or do not have problems) that fit into Western DSM-IV ideas of psychiatric disorder does not mean that Western DSM-IV ideas of psychiatric disorders are valid definitions of their problems. Figuring out what are valid definitions for their problems is not, at its most basic, a statistical task, but rather a theoretical one. You have to talk to the people who know the theory, not just the people who have the problems.


Blogoshpere updates from the Darfur crisis

A couple notable developments from the Darfur. The first is a news item (hat tip to Gabrielle Grow of the Institute for War and Peace Reporting office in The Hague, Netherlands), the Sudanese government is relocating thousands of IDPs within Darfur because of security concerns:

The recent turmoil started in late July when demonstrations by opponents of peace talks with the government turned violent. Backers of the Sudan Liberation Army, SLA, clashed with supporters of the talks currently taking place in Doha. Several deaths were reported in the violence.

“The problem is that weapons are flowing all over the place, not just in the camps but outside,” Russia’s UN ambassador Vitaly Churkin, who currently chairs the Security Council, said following a meeting on the situation.

The Sudanese government says the planned move is being undertaken for security reasons as well as because of the camp’s proximity to an airport and railway lines.

The second is a study undertaken last year of displaced Darfur refugees  (in Chad) carried out by the group 24 Hours for Darfur.

The US-based non-profit research organization spent four months in the 12 Darfurian refugee camps in eastern Chad, interviewing 1872 randomly-sampled civilians and 280 civil society and rebel leaders. The data gathered from the civilian sample is representative of the adult refugee population in Chad, and sheds light on important questions about participants’ specific beliefs about the root causes of the conflict, past peace negotiations and agreements for Darfur and southern Sudan, the nature and importance of justice in bringing about a sustainable peace, the possibility of reconciliation, land-related issues, democracy, power-sharing, and the national elections, and which actors, if any, best represent their views.

I was in Chad at the same time as the folks who put this project together. They had assembled an impressive group of interpreters and interviewers (so impressive, in fact, it was tough to find good interpreters for anyone else!). Connect to the report via Jonathan Loeb’s blog (Jonathan was one of the organizers of the study).

Article addendum: Stressors during wartime

The April 2010 issue of the American Journal of Orthopsychiatry includes an article comparing the effects of war-related trauma on mental health to effects of the “current stressors” one finds in refugee camps. I’m the first author on this article, and so I’m going to take the privileges afforded by that role and be somewhat critical of the work here.

The article is based around the idea that there are lots of things that happen during wartime that cause emotional and cognitive distress in addition to armed conflict. In order to decide what to do about distress in displacement camps, one should consider these non-conflict stressors. In the paper, we measured war-related traumas (or “potentially traumatic events” to be more precise) separate from other “camp stressors” and examined which was more highly associated with the psychological problems of posttraumatic stress disorder, depression, and two local idioms of distress (local ways of discussing emotional problems). We found that war trauma and camp stressors among Darfur refugees were both related to all four psychological problems, and in several cases the number of camp stressors was actually more strongly associated with these than the number of war traumas. We went on to find that camp stressors partially mediated the effects of war trauma on most psychological problems. We concluded that humanitarian aid agencies interested in addressing general distress in camps thus had empirical support for interventions that target everyday camp stressors, in addition to popular war-related and trauma-focused interventions (which are already empirically-supported for displaced persons with posttraumatic distress).

Since the manuscript was accepted (fall of 2009) I have had a number of opportunities to think about the variability within this category of “current stressors.” Critical to this was the opportunity to co-author an editorial on trauma-focused versus psychosocial perspectives in humanitarian aid with my friend and sometimes collaborator Ken Miller, who is really the pioneer in this work (look up his stuff on Afghanistan and Sri Lanka for examples). Something has always bothered me about the category “current stressors” and a common criticism is that we are throwing a lot of different types of stressors — with different effects — into the same conceptual bag. So, I’d like to propose — really by way of proposing a starting point, not answering the problem outright — a typology of stressors that are critical to consider in studying the psychological consequences of armed conflict and displacement.

1. Direct war exposure potentially traumatic events (PTEs): Direct (both personally experienced and witnessed) exposure to the violence and destruction of war. Examples include (but are in no way limited to) direct attacks by military (or paramilitary) personnel, being pursued by these forces, bombing, and exposure to mines.

2. Collateral PTEs: Direct exposure to trauma collateral to war (i.e., coming about because of war) but not comprising an act of war itself. This may include abuse by non-military persons during flight (e.g., criminals or fellow refugees), attacks by locals in the displacement context, abuse by peacekeeping forces, and motor vehicle accidents occurring during flight.

3. Other PTEs: Non-war-related traumatic events that increase during wartime. It has been noted that all forms of violence increase during wartime (e.g., see the work of James Garbarino for particularly articulate illustrations), whether because of stress on the perpetrators of these events or degraded safety of settings which allow these events to occur more frequently. Examples include domestic violence, child abuse, and attacks by dangerous animals (e.g., poisonous snakes are evidently a big problem in some refugee camps in Sri Lanka).

4. Social ecological stressors: War-related degradation of social institutions (both formal and informal). Examples are destruction of schools and subsequent lack of educational opportunity, diminished health care, loss of social support networks, religious institutions, war-induced poverty, and famine. It may be difficult to distinguish some of these from preexisting conditions (e.g., the difference between war-induced and preexisting poverty may be minimal in some cases).

5. Daily hassles: Daily hassles are those seemingly minor problems of daily life that either come to exist or increase in intensity in wartime. These have shown to be strongly related to mental health problems in non-war contexts, even moreso than stressful major life events. These may include checkpoints along a commute, regular questioning by military or police, mild forms of humiliation (e.g., degradation by authorities, bribes), needing multiple forms of documentation in order to complete simple tasks, long wait times in order to get basic resources (e.g., food distribution at refugee camps), and hearing complaints about such daily hassles from loved ones. All involve some persistent inconvenience or stressor that is not physically abusive or threatening. Some daily hassles may at times come close to collateral trauma (e.g., regular questioning that involves strip searches).

It is important to note that for individuals exposed to the different types of stressors delineated above, differences may seem phenomenologically trivial. Stressors related to direct attacks, harassment and abuse during flight, and loss of social networks may be part and parcel of a single, undelineated narrative of war. Moreover, for many these categories may not be readily distinguishable from non-war-related stressors. War-induced poverty may be seen as an extension of preexisting poverty, increases in domestic abuse may be experienced as an extension of pre-war abusive relationships, and bribes paid to police during wartime may have the same effect as bribes during peacetime. In order to study the effect of conflict, researchers should conduct work that estimates the change in prevalence, incidence, and effect on outcomes of these phenomena over time (i.e., pre-conflict to conflict).

Let me reiterate that these are only a first pass at types of stressors, and I welcome all comments. Next: The sticky problem of stress generation among displaced populations.

37 year-old refugee crisis comes to an end

Where do refugees go after the crises that made them refugees leaves the headlines? The options are: go home, get resettled to a wealthier country, stay in the camps.

The UN estimates that at the end of 2008 (the last year there are reliable numbers for at the moment) there were 15.2 million refugees in the world (a refugee here is a person who has fled across a border because of political violence). Eighty percent of these refugees, or about 12.2 million, lived in camps or urban areas in neighboring countries in the developing world (e.g., the 1.8 million Afghans in Pakistan).

Some refugees go home. How many? In 2008, 600,000 refugees went home; 600,000 / 15.2 million = 4%. This was the lowest number since 2004, suggesting that going home is less and less an option.

What about all the refugees resettled in wealthy Western nations? In 2008, 121,000 were proposed for resettlement to wealthier nations (US, Canada, and Western Europe, primarily), or 0.8% of all refugees at the time.  Only 67,000 of these were actually resettled, about 0.4%.

So, most refugees remain in camps and foreign cities for very long periods of time as refugees. Surely there must be some other plan. Well, recently UNHCR has been proposing a policy of “local integration.” Local integration means what it sounds like  — making refugees part of the local economy and society of the region in which they live, with full citizenship rights and privileges, and no more refugee aid. The involves getting local governments to accept that refugees they have played host to for years are there to stay, and getting the refugees themselves to accept that they cannot receive aid forever. This long-term solution is usually pretty long-term. In Chad, the UNHCR started encouraging local integration for refugees from the Central African Republic who had been there for 1o years.

One of the oldest refugee populations are Burundians in Tanzania. Burundi is now infamous for ethnic conflict in 1994 (similar to neighboring Rwanda’s), but many Burundians in Tanzania are there because they fled from massacres in 1972. In other words, these Burundians have been sitting in camps for 37 years. This week, Refugees International reported that last month Tanzania gave citizenship to 162,000 of these Burundians. This is a welcome and generous move by Tanzania, a country that has been host to several large refugee populations — the price of being a peaceful place in a dangerous neighborhood.

(162,000: That’s 1% fewer refugees, for those of you counting.)

Afo de kurnaŋa, Hadjer Hadid: Massalit literacy developing in eastern Chad

My coverage of disappearing languages in New York City made it all the way to Hadjer Hadid — which is, incidentally, my favorite place in Chad, hands down. It seems that currently there is a project on the ground to develop a written form of Massalit in Roman script. Eunice Kua of SIL International is working on the Massalit Language Development Project in the refugee camps of Bredjing and Treguine (Bredjing is the largest Darfur refugee camp, with approximately 30,000 residents, Treguine with about a half to two-thirds that). She reports:

You may be interested to know that there is a written form for Massalit, though the orthography is still a work-in-progress (and will probably be for the next few years, as people sort out how they want to spell things, etc! We’re working on a dictionary, but it takes time).

I am working in mother tongue literacy project with refugees in Bredjing and Treguine in eastern Chad – in fact, I should right now be preparing for this afternoon’s session of a refresher teacher training course for teaching the Massalit primer rather than writing emails.

I don’t think that we would have been able to help you much in terms of the survey, as Massalit right now is written in Roman script (when the written form was being developed years ago, the Massalit people consulted chose Roman over Arabic script, and recently when the literacy project was getting started, those who were consulted then reaffirmed this decision and continue to reaffirm it, tho’ we have expressed doubts from time to time). Your interviewers probably read Arabic script fluently but would have trouble reading Roman script… your friend’s solution is probably the way to go for now…

In response to my query about the languages of the other major ethnic groups from Darfur, Fur and Zaghawa, she writes:

There is indeed written Fur, but Zaghawa is ‘very much at the beginning stages’, also in Roman script, from what I understand.

Her comment on the preference of a Roman script is notable because many Massalit do study Arabic in Koranic schools. I have also heard that there are some written versions using Arabic script developed in Darfur, but these have not been codified.

Eunice also sent little language lesson. Here’s “Good morning” in Massalit:

Afo de kurnaŋa (the ŋ represents the sound of the ’ng’ in singer)

Non-written languages and refugee research

Often one of the biggest challenges in working with displaced populations is speaking to them. This is because most of the people who have the resources to undertake these activities are from Europe and North America and speak English or French, and most displaced populations do not. In addition, as many displaced populations are ethnic minority groups, they often speak languages for which there are a very limited number of interpreters available. The poverty and resulting lower education levels that is often common among groups that have been discriminated against makes good interpreters even harder to find. In other words, with many displaced populations you are often limited to the most rudimentary of communication.

My most problematic encounter with this issue was in Chad, trying to document conflict history and consequences among Darfur refugees. Most of the refugees we were working with were fluent in Massalit, a tribal language with no systematic written form. I needed to design a structured survey so that refugees we hired to carry out the survey could document things that had happened to their community members and the consequences in a systematic way (i.e., everyone had to ask the same questions). So how do you write an unwritten language? Well, I didn’t know, so I had the interview questions first translated into Arabic (then translated back into English to check the equivalency), then did a lot of training (in Arabic) with the people who would be conducting the interview — all of whom spoke Arabic and Massalit. The interviewers then had to interpret from the written Arabic to Massalit when they conducted the interviews. Messy? You bet. But how else could we have done this?

Later, my friend and sometimes co-conspirator Ken Miller had an answer for me. For his doctoral dissertation, he worked in Mexico with Mayan refugees from Guatemala. The Mayan dialect most of them spoke had no written form. What he did was to record someone speaking the questions in that dialect and take the tape and tape recorder into the field (he used cassette tapes at the time — Ken got his PhD a little while ago). He would then play the recording for the participants in the field, and all of them could then answer the same questions, not some slightly different interpretations of each question (as was almost certainly the case in my chad research).

Another answer is presented in today’s New York Times: create your own written form of the language in question. It turns out that for Massalit, this is being done… right here in New York City… at New York University… where I work. New York City, like other large US cities, is apparently something of a linguistic treasure trove for linguists interested in disappearing languages. A couple years ago Daniel Kaufman, an adjunct professor of linguistics at the City University of New York and NYU, established the Urban Field Station for Linguistic Research. He has recruited and recorded speakers of several disappearing languages in New York, including one man from Indonesia who appears to be the sole remaining speaker of his language.

He has also recruited Daowd I. Salih, 45, a refugee from Darfur who lives in New Jersey and is a personal care assistant at a home for the elderly, to teach Massalit, a tribal language, to a linguistic class at New York University. They are meticulously creating a Massalit lexicography to codify grammar, definitions and pronunciations.

“Language is identity,” said Mr. Salih, who has been in the United States for a decade. “So many African tribes in Darfur lost their languages. This is the land of opportunity, so these students can help us write this language instead of losing it.”

The lesson? You don’t have to go too far to get good language help. Start with the diaspora of the groups you think you will encounter.

Read the rest of the article and view the accompanying video here.

New York Times on Darfur now: A New Year’s resolution to cover African conflicts with nuance?

Today’s New York Times features (above the fold in the non-virtual version) an article on the peace in Darfur, and at no point do they use the word genocide, talk about the conflict as a race war, or even discredit the African Union! The article actually presents the situation with nuance, only a few buzzwords, and even has interviews in which people from different perspectives admit that things are a bit different from what they feared. Could it be that the flagship of US journalism has a New Year’s resolution to turn the page on US coverage of African armed conflicts?

The conflict and refugee crisis in Darfur and neighboring Chad has become the new textbook case in the perils of humanitarian aid and refugee advocacy, influenced as it has been by a mini-industry in Western activism (e.g., Save Darfur) as well as biting criticism of these movements by academics (e.g., Mahmood Mamdani at Columbia). Anyone having anything to do with displaced populations should know all sides of these arguments in order to really understand what it is you are getting involved with when you get involved in internal conflicts. Such conflicts are anything but clear cut, anything but simple. Nuanced situations don’t play well in US media, aren’t easy to market, and certainly don’t fit Western stereotypical views of “war in Africa.” However, if the rest of the world is going to intervene in African nations’ politics and care for refugees from African conflicts, it’s high time articles such as today’s become the standard.

December 2018
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