Is What’s Past Really Prologue?

War has so many faces and wears so many different clothes that you might be forgiven for misunderstanding its refugees. Confusing cause and effect in their behaviour, their appearance, and perhaps, most obviously, in their adaptations to the stress of upheaval and migration. There is no universal pattern that obtains, and few things to offer as a template for relief except, perhaps, a welcoming succour. And when numbers become overwhelming, even compassion is strained in the melange of personalities and temperaments that inevitably occur in those fleeing danger. Not all victims may be to our liking, and when resources become limited and privileges are necessarily constrained, the reactions can be unpredictable on both sides. Empathy can mutate into grudging tolerance. Forbearance. Endurance.

But think of the effects on the refugees, first forced to flee intolerable conditions, often leaving behind members of their families, then subject to the hardships and exploitation of the journey,  finally being forced to trust themselves to the charity of strangers. It cannot be easy for adults to have their identity subsumed by that of victim, and everything they were, everything they had, everything for which they had worked no longer possible. No longer recognized, let alone appreciated, in a strange land with often stranger customs and language.

And what must it be like for their children who haven’t yet learned the curse of humiliation, or understood what the theft of identity may mean to their parents. They’re caught in the middle ground between witness and casualty, understanding neither. Lacking the tools to navigate the waters, some, I suppose, internalize it; others lash out. But none escape entirely.

I came across an unusual manifestation of trauma that seems unique to Sweden (so far), for some reason –the newly coined Resignation Syndrome: http://www.bbc.com/news/magazine-41748485  ‘[…] it affects only the children of asylum-seekers, who withdraw completely, ceasing to walk or talk, or open their eyes.’

‘The health professionals who treat these children agree that trauma is what has caused them to withdraw from the world. The children who are most vulnerable are those who have witnessed extreme violence – often against their parents – or whose families have fled a deeply insecure environment.’

‘As more Swedes began to worry about the consequences of immigration, these “apathetic children”, as they were known, became a huge political issue. There were reports the children were faking it, and that parents were poisoning their offspring to secure residence. None of those stories were proven.’ A not so hidden ‘blame the victim’ scenario that tends to surface under conditions of societal stress.

‘Numerous conditions resembling Resignation Syndrome have been reported before – among Nazi concentration camp inmates, for example. In the UK, a similar condition – Pervasive Refusal Syndrome – was identified in children in the early 1990s, but there have been only a tiny handful of cases, and none of them among asylum seekers. The most plausible explanation is that there are some sort of socio-cultural factors that are necessary in order for this condition to develop. A certain way of reacting or responding to traumatic events seems to be legitimised in a certain context’ writes Dr Karl Sallin, a paediatrician at the Astrid Lindgren Children’s Hospital, part of Karolinska University Hospital in Stockholm.

Theories abound, of course. There is a view ‘commonly held among doctors treating children with Resignation Syndrome, that recovery depends on them feeling secure and that it is a permanent residence permit that kick-starts that process.’ Unfortunately, with increasing numbers of refugees arriving, both the patience and the available resources are wearing thin, so stricter adherence to admission criteria do not always allow a family to stay. ‘Last year, a new temporary law came into force that limits all asylum seekers’ chances of being granted permanent residence. Applicants are granted either a three-year or 13-month visa.’

One treatment seems to be having some success, even with those not granted permanent visas, however. The thesis is that  sickness has to do with former trauma, not asylum. ‘When children witness violence or threats against a parent, their most significant connection in the world is ripped apart’ –the very connection on which the child has been dependent. ‘That family connection must be re-built, but first the child must begin to recover, so Solsidan’s [the treatment center’s] first step is to separate the children from their parents. “We keep the family informed about their progress, but we don’t let them talk because the child must depend on our staff. Once we have separated the child, it takes only a few days, until we see the first signs that, yes, she’s still there…” says Annica Carlshamre, a senior social worker for Gryning Health, a company that runs Solsidan, a home for all kinds of troubled children.

Even if effective, I would imagine that not every family would be willing to part with their child to strangers, nor would the number of treatment centers be equal to the task. Still, it may be a method worth exploring further.

Post-Traumatic Stress Disorder, Resignation Syndrome, Situational Adjustment Reactions, Panic Attacks… I am not alone in wondering what these may produce in the hundreds of thousands, if not millions, affected –either in childhood when coping mechanisms may not yet have been learned, or worse perhaps, in adulthood when the mechanisms may have been discarded. What can we expect from a generation torn from its customs, and rightful expectations of a peaceful family life? A generation often deprived of education, to say nothing of safety? What is normal to those who have never experienced it? And what are the obligations of the rest of us to them?

War, it is said, will be with us always, but we must not be fooled by its seeming inevitability. I suppose it is unbecomingly naïve in this time of terrorism and bellicose patriotism, but I still remember the words of Martin Luther King, Jr: “Darkness cannot drive out darkness; only light can do that. Hate cannot drive out hate; only love can do that.”

An ounce of prevention is worth a pound of cure? It’s not an answer, perhaps -just a hope…

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Who Wants a Country of Boys?

We mortals seem to be good at assumptions; they are shortcuts that allow us to function without the requirement of constantly checking the validity of beliefs or items in our environment. Part of it is trust; part of it is process, and yet I don’t want to get into a semantic discussion of the manifold vagaries of the word, nor a tedious list of definitions. I just want to concentrate on that very human characteristic of taking something for granted without the need for proof.

But of course that supposes –okay, assumes– that whatever we are considering has been vetted in a way that we are used to. A way that has the common consent of experts in the field, say, or at least something that accords with our experience. It would be acceptable, for example, to assume that if someone is talking about a bus, that they do not need to define it. They will not likely mean a train or a motorcycle…unless, that is, we include metaphors and their ilk -so let’s not.

I want to keep this simple for now. Some assumptions lead to others and so, like the weak link of a chain, conclusions based solely on a trail of assumptions can be a house of cards. At some stage, it would likely be prudent to search for verifiable sources if the issue is important.

I suspect that the trust with which we clothe assumptions is multi-fashioned. Sometimes it is the source, and sometimes it is the subject. Or the wording. Suppose, as an example, we are reading an article purporting to discuss discrepant sex ratios in a country and there is mention of the ‘sex ratio at birth’. (I have covered sex ratios and their definitions in a previous essay by the way: https://musingsonwomenshealth.wordpress.com/2015/08/25/pregnancy-stress/ ) Would we not be forgiven for the assumption that the definitions used would be the commonly understood ones in this context? And that when the ‘natural sex ratio at birth’ is mentioned in the same breath –or in this case, line- as the World Health Organization, couldn’t we relax. A little?

Well, I have to say I was initially seduced by this notion in an article in the BBC News, and then, intriguingly, disavowed of my naïveté. The article was titled ‘Why does Sweden have more boys than girls?’  http://www.bbc.com/news/magazine-35444173  My first thought, of course, was so what? The normal secondary sex ratio for humans would seem to average out around 5 extra boys, for every 100 girls that are born. Various reasons have been proposed to explain this, and I assumed (there we go again) that the article was reporting a new one –or at least new proof.

And then, when that didn’t prove to be the case in the first paragraph or two, I wondered if there were some hitherto unknown problems with northern sunlight, or perhaps residual effects from Chernobyl…

But I quickly became aware that they were using the term not as sex ratio at birth (the secondary sex ratio), but rather the sex ratio at ages 16 to 17 years of age (which would be closer to the tertiary sex ratio). I hadn’t expected this, and so now I had to again switch assumptions.

First of all, they gave a little background: ‘official statistics show that in 2014, there were 108 boys for every 100 girls among Sweden’s 16 and 17-year-olds.’ Okay, 108 boys per 100 girls is not so far off the 105 boys expected. I almost shrugged and moved on to another article until I read the next sentence: ‘But the country now has 123 boys for every 100 girls in this age group’. Whoa, that woke me up. So, not only do they talk in terms of a specific age group, they also report that in one year it has changed remarkably.

Time to examine my assumptions again, I realized. It turns out that the discrepancy is largely explained by immigration –or more accurately, refugees. But am I also to assume that it would be dominated by males -boys, actually? This requires another assumption: that more young men are able to make their ways through the turmoil and suffering of their native lands than their female counterparts. If the family is in dire need, and has little chance of making it out intact, perhaps it sends out the strongest, in hopes he (or sometimes she) will find refuge and then send for them. But is the male preponderance merely related to societal expectations and socially determined male roles?

The article purports to to explain the preponderance of males over females in that age range:  “If you’re underage, first of all, you get housing, you get more financial resources. You also have a lot of staff around you helping you with different issues,” says Hanif Bali, a member of the opposition Moderate Party in the Swedish parliament – which is on the centre right of the political spectrum. “If you need food, clothing, everything, you can go to the municipality and demand this money.” Presumably a young a young girl could do the same if the family had delegated her as the one to leave -but if you were the matriarch or patriarch of that family, would you send your daughter? Or would fear of the probable fate of a young, unaccompanied girl on a dangerous journey with unscrupulous smugglers likely convince you to send your son?

Of course that survivability benefits the young male asylum seeker all right, but what about the family? Were my assumptions about the strength of family ties naïve? Thankfully not. Fascinatingly not: ‘[…] there is another even bigger benefit, which Bali believes is significant. “You have the right to family reunification. So you can bring all of your family to Sweden, if you are underage.” Under 18, that is… And actually make it to Sweden.

So there are huge incentives for getting to Sweden before you turn 18.’

The article turned out to be thought provoking for me on several levels. One I have to attribute to age-naïveté: how does news of this kind of stuff leak out to people in a war-zone, fleeing for their lives? And secondly, how effectively the refugees have been able to use the Swedish social system to allow something on a scale for which it was likely not intended. But it also speaks volumes about assumptions and where they can lead us. You can almost hear the Hamlet-like defence of those 16-17 years olds when confronted with their manipulation of the system: ‘Why, man, they did make love to this employment, They are not near my conscience.’

 

An Unfamiliar Worry (for some)

I don’t know how the world used to manage with just men at the helm. There are so many things –obvious things- that simply pass by us uncharted. I don’t think its intentional; it’s more likely that those things just do not affect us in the same way. They have different consequences; we assign them different priorities –if we assign them at all…

There are, of course, some issues at which men seem relatively proficient at first glance- such as dealing with the needs of refugees arriving in Europe or wherever, from war torn areas of the world. When they arrive, attempts are made to provide for their health and safety while they are being processed. Because of the large numbers arriving, this often means settling them temporarily in camps where the basic needs of shelter, food, and medical care can be provided.

But those are relatively easy things to plan for -easy things to discuss at any  rate. Add in education for the children, maybe phone service so they can communicate with their families back home, and perhaps even, as icing on their cakes, leisure activities, and… Well, apart from a chance of permanent resettlement or, of course, improving the chaos in their home countries so they could return, what else could refugees possibly need? Or want?

Full disclosure: I am a man, and despite my forty-plus years as a gynaecologist, I’m afraid my brain is still sometimes stuck in Y mode. One would have thought that if anyone could transcend gender –wear other shoes- a gynaecologist might be in the running. But I missed this one: ‘About one in four of Zaatari’s [Jordan’s largest refugee camp] residents need sanitary pads. The UN does distribute them now and again to women aged 14 to 45, but there are never enough to go round.’ Sanitary products, even if they are available, can be expensive; the temptation is probably to use whatever personal money is available for other, more survival-oriented necessities. I learned this from an insightful article in BBC News: http://www.bbc.com/news/magazine-34925238  A British woman named Amy Peake not only discovered the need, but found a simple machine in India that would allow women  to make sanitary pads cheaply and on site. ‘On top of that, Peake discovered, there is a desperate need for incontinence pads for the many wounded, elderly and disabled people – and traumatised children. “The children are really suffering,” says Peake. “The problem is that the mothers have been trying to cope for so long that basically they’ve given up. Night after night of urine and they can’t keep them clean.’

There are so many things in everyday life that most of us take for granted until they are not available –things like a clean and timely change of clothes, the ability to maintain personal cleanliness in a culturally sensitive manner, and in private if desired. Although necessary, it is simply not sufficient to provide only the obvious -food, shelter, and so on- and then assume normalcy will ensue; we are all products of societies laden with traditions and expectations –this is what it is to be human. To strip these away is not only cruel, and disrespectful, it is also degrading. Inhuman. After all, they were living lives much like us until forced by war and unspeakable danger to flee from their homes for the sake of their families. For the sake of their futures… They are not merely bodies in need of sustenance, they are mothers and fathers… children… and so are we. So the question we must continue to ask ourselves is whether we would be comfortable treating our own families in the same way as these refugees. Would we feel that we have been sensitive to their needs?

Admittedly, in times of crisis and overwhelming numbers, some things must be prioritized, while others, perhaps less important to survival, need to be relegated to the background. But not neglected. Not forgotten. The refugees, already traumatized and exhausted by the hardships of their journeys and often bewildered by the contrasts with their previous lives, are ill equipped to complain. They are initially powerless, and confused, but very soon understand that once the basics have been provided, once the threat to life and limb has receded, there is another thing they desperately require: dignity. If they are ever to be assimilated into another country, another culture, another life, they must regain their self-esteem. Their pride.

We must not forget that different societies may view the world in different ways. Things to which we in the West have long since been accustomed are sometimes still problems elsewhere. Attitudes about the management of menstruation is one such problem. In many traditions, it is not only a secretive event that must be concealed from others for fear of ridicule, but also dealt with by whatever is at hand. The stigma around menstrual periods is complicated and culturally sensitive as I have already discussed in several other blogs:

https://musingsonwomenshealth.wordpress.com/2014/11/26/menstrual-taboos/, https://musingsonwomenshealth.wordpress.com/2015/04/01/menstruation-and-sports/, and even: https://musingsonwomenshealth.wordpress.com/2015/03/13/the-tampon-tax/

So I’m not sure why this article came as such a revelation. Maybe it was a reminder that we all see the world from our own perspectives: two people crossing one bridge is really two people crossing two bridges… And yet, to a third who is watching from the edge, it’s still the same bridge.

I should have known!  ‘But every little difference may become a big one if it is insisted on.’ as Lenin said.’ so I suppose I’ll have to accept that Time is a series of tests, and you only get marked at the end… I hope.

I can only offer the words of Iago in Shakespeare’s Othello:

I will wear my heart upon my sleeve
For daws to peck at…