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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Leave Me Alone

I have lived in a hospital as an on-call obstetrician on more days –and nights- than I can count over the years; hospitals were the grudging homes for me ever since medical school and the subsequent ages of specialty training that fell upon me like unbidden hats. And despite the palimpsest of colours I was forced to wear, hospitals have been the lodestars in my ever-changing world.

They weren’t all pleasant, although each beckoned with what seemed, from a distance at least, to be tempting endowments of knowledge and experience. Gifts are gifts, no matter the source, and I accepted each with gratitude, if not a little experientially-acquired caution. But although one must often stride boldly into the unknown to arrive at a destination, adaptation follows close behind. And then comes a fondness for what seemed, initially, to be strange. Chaotic. Frightening. And yet the utility of the situation breeds an eventual reconciliation. The disturbing, becomes assimilated into the quest for advantage. The hope for reward.

At least, that’s how an employee –a doctor or a nurse, especially- might rationalize the initial anxiety in a hospital: ‘short term pain for long term gain’, as the trite political aphorism would have it. But one can only wonder how the experience might strike a person who, travelling along the avenue of illness or accident, is forced to endure the unexpected and probably unwelcome distress.

There was an interesting article in an old BBC News article that questioned whether going into hospital might actually make you sick: http://www.bbc.com/news/magazine-35131678

A Dr. Harlan Krumholz at the Yale School of Medicine became interested in in the statistic that ‘about a fifth of patients who leave US hospitals are back within a month.’ At first glance, this may seem obvious and uninteresting –the original cause for their admission may not have been completely dealt with, or perhaps there were complications from it that only surfaced after their discharge. Indeed, in many countries ‘re-admission rates are taken as a measure of the quality of care a hospital provides.’ But Krumholz realized that ‘only about a third of patient readmissions were related to the original cause of hospitalization. Patients’ reasons for returning to hospital were diverse and linked to their immune systems, balance, cognitive functioning, strength, metabolism and respiratory systems.’ He felt this was an entity unto itself and called it PHS (Post Hospital Syndrome): http://www.nejm.org/doi/full/10.1056/NEJMp1212324

Basically, it assumes that hospitals unwittingly engender stress in patients by imposing disruptive and often intrusive regimes –some of which could safely be postponed or modified at night, for example. Patients already feel vulnerable and powerless in the face of illness or accident, and few would dare complain for fear of alienating those who are the providers of their badly-needed succour.

*

Vesna was not one of those. From the moment I saw her in the Emergency department with a severe and unresponsive pelvic infection, it was obvious she did not intend to relinquish control. Indeed, it was something of a diplomatic coup that one of the ER docs was able to convince her to allow an intravenous catheter to be inserted into her arm. She had to point out one of the only remaining veins –she knew her arm well- and direct his hands when he tried, unsuccessfully, to enter the tiny vessel that was hidden under a tattoo on the skin above her elbow.

It was around 2 A.M. when my resident called me about her, and just as I entered the little cubicle, someone dropped a large metal pan by the door. Before I could introduce myself she yelled at me. “I’m not gonna use one of those f– things, doc!” and she pointed to the bedpan on the floor.

The nurse looked up apologetically. “No, I’m just taking it out of the room, Vesna. It’s not for you.”

“Do I have to stay down here all night, doctor? It’s too f– noisy!” She said this all too loudly, ostensibly so her voice would be audible above the noise, but despite the outburst, despite the angry expression on her face, for a fleeting moment her eyes seemed to betray her when she glanced at me: they twinkled contritely, as if trying to excuse the behaviour of their owner.

My resident shook his head. There was apparently a bed available for her up on the ward so she’d be moved up shortly.

At hand-over rounds the next morning, the resident looked exhausted. Apparently Vesna had complained that the patient in the bed next to hers was snoring so she couldn’t sleep. And the nurses insisted on talking in the corridor whenever they walked by; the medicine carts they pushed were too noisy; or somebody kept coughing in the next room. So, Vesna demanded a sedative. That, of course, required the okay of a doctor first. And then, later, her IV stopped working –it had been inserted into a vein that would not ordinarily have been used- and the so the resident had been called to order the antibiotics to be given by some other route. The ones she needed were not available by mouth, so the only remaining way was by injection into her muscles. Vesna objected, of course, and so the resident had to go up to the ward again and explain things to her.

The hospital food was certainly not to Vesna’s liking –she said it made her sick- although, in fact, it was probably a side effect of her antibiotics. I’ve never liked institutional food either, but there seemed no end to her complaints while she was in hospital. We learned to tolerate her, of course, but I remember deciding to buy coffee for the resident staff when we discharged her.

I suppose I fell prey to the uncharitable assumption that Vesna was simply a grumpy person –someone whose circumstances had taught her to be suspicious of everything around her; someone who had learned to be tough and difficult to befriend. It was a wall she was forced to live behind -makeup she applied to protect the skin beneath.

She was supposed to come to my office for a follow-up visit a week or so after discharge but I have to admit that I wasn’t surprised when she didn’t show up for her appointment. My secretaries had actually double-booked me for her time, suspecting as much.

A few weeks later, I saw her name on my day sheet again but the woman who sat nervously in the waiting room pretending to be absorbed in a magazine was nothing like the Vesna I’d met in the hospital. This time she was dressed in slim black jeans with a frilly light blue cotton pullover. Her auburn hair was neatly combed and her ears adorned with enormous golden earrings that threatened to snag her curls every time she moved her head. When she saw me approaching, she smiled and stood up to extend her hand.

“I’m sorry I missed my last appointment, doctor,” she said, as soon as we were settled in my office, the embarrassment written in her eyes. “I had to be admitted to another hospital so I couldn’t make it…”

“The infection came back?” I said, concerned that we had discharged her too early.

She chuckled merrily at the thought and shook her head, making the earrings dodge in and out of her curls like it was a game of tag. Then the look of embarrassment returned. “Overdose.” She took a long breath and then shrugged. “Occupational hazard, I’m afraid.” She looked out of the window behind my seat for a moment. “Interesting, though…” she said slowly and deliberately, as if something had just occurred to her. “Same source, same amount… Never happened before and my boyfriend was okay so he couldn’t have cut it with bad shii…” She glanced at me and quickly corrected herself mid-word. “…ah, stuff… so I wonder how I could have overdosed.” She sat back in her chair and shrugged it off. “Maybe somebody’s trying to tell me to change my ways while I still can, eh?” She giggled like a school girl -and for a moment, she was.

Was she a victim of PHS or, in her case at least, the recipient of an opportunity? Were the two events even related, or in my rosy-eyed naiveté, am I projecting my own hopes on an otherwise indifferent world? I don’t know, of course, because I never saw Vesna again, but I’d like to think that something changed her. But for the better this time… Could PHS do that too?

I remembered the words of Emily Dickinson:

‘Hope’ is the thing with feathers that perches in the soul                                                                                    And sings the tune without the words and never stops at all.’

 

Pregnancy Stress

Curiosity is a curse sometimes. It strikes in the most unusual circumstances and often with little warning. Some little thing will set it off and bang, you’re hooked. I’m an obstetrician, so procreative issues are constantly surfacing in my life. Environmental stressors and reproductive failure also seem to be de rigeur in the social media nowadays so there’s no escaping it. The worry may have started with animal data -animals are the easiest to study so we often look at what evidence they provide and then extrapolate. I’m thinking of those dark mysterious star-filled nights at summer camp when there is howling in the distance, and everybody huddles together with questions.

And worst of all are those important things that don’t have ready answers, or the answers have different explanations each time you look for them. Different causes. The secondary sex ratio has always been that type of enigma for me: why isn’t the ratio exactly 1:1 in humans? Well, first of all, some definitions. The primary sex ratio is the ratio between the sexes at fertilization, and the secondary sex ratio is their ratio at birth. There’s even a tertiary ratio -the sex difference in mature organisms.

In the past, the gender ratio at conception was unknowable, so the only useful ratio was the one at birth -and that seemed to favour males (1.1 males for every 1.0 female). So did that mean that male sperm somehow outswam the female ones or damaged them on the way to the egg? Did it speak to the quality of the gametes or merely suggest that to balance tertiary sex ratios (the ratio in sexually mature organisms, remember) more males were needed because, unlike females, they were less able to make it through childhood..? Until recently, as I mentioned, there was no way to measure the primary sex ratio, so it remained a mystery. Now it seems there is, and, surprise surprise, there would appear to be an equality of sexes -at conception at least: http://www.pnas.org/content/112/16/E2102.full.pdf  This fascinating study tracks gendered mortality during development in the uterus. There is a theory (the Trivers-Willard hypothesis) which posits that more males are born in a favourable environment and more females in an unfavourable one because just one sex will be better at ultimate reproduction under those differing conditions.

So what conditions might effect the secondary sex ratio? Well, amongst other things, there is some evidence that major stressors may influence it. Large disasters have certainly been implicated -earthquakes, for example: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881738/  And then, of course, there were the changes in secondary sex ratio immediately after the 9/11 World Trade Center attack in 2001… One explanation that has been offered to explain how this could occur is that males typically attain a critical fetal weight earlier than do females (the average weight of newborn males, for example, is ∼100 g greater than females) and this might exert a higher metabolic demand on mothers. So, depending on the gestational age and the extent of the stress, the mothers may be able to abort the male fetuses, but maintain the less physiologically demanding female ones. In other words, evolution would seem to have selected for those females that can regulate the sex of their offspring… Really?

That explanation seems rather contrived to me. Exactly how would the mother accomplish this feticide? And avoiding direct maternal involvement by referring it back to changes in placental function merely pushes the question back another layer. Of course, some have tried other approaches -for example citing the epigenetic environment (factors influencing the functionality of genes): http://humrep.oxfordjournals.org/content/20/9/2662.full But even when I force myself through the commentator’s words, the explanation still seems a little strained.

And yet, statistically, there does seem to be reason to believe that something is happening that relates to stress.

Of course pregnancy itself is a stress -levels of stress hormones increase as pregnancy unfolds: (http://www.jogc.ca/abstracts/full/201505_Editorial_1.pdf) -although, as the editorialist explains, ‘as a pregnant woman approaches term, environmental stress has less effect in triggering the usual response in the hypothalamic-pituitary-adrenal axis, and she becomes less responsive to the effects of stress’. Uhmm… So, pick your answer from a hat?

Well, in the rubble of destroyed answers and ever blossoming questions, what are we left with? Is there something special about violence that triggers it? Or does any stress threaten the ratio? And what constitutes a stress anyway? All imponderables, I suppose, but at least a recent article in the JOGC (Journal of Obstetrics and Gynaecology of Canada) brings it closer to home: http://www.jogc.ca/abstracts/full/201505_WomensHealth_1.pdf  And in an ‘Only in Canada, eh?’ fashion it demonstrates that we, too, can participate in the secondary sex ratio debate -on our own terms, of course. I mean, who would have thought that our two referenda on Quebec secession from Canada could provoke such a response? I’m almost proud that it did –it shows how involved we are in our country. How much it matters. And how we don’t need earthquakes, either.

And maybe the slight increase in female births that the worries about the referenda caused says something about our growing appreciation of women in Canadian society as well… I live in hope. But you gotta love this stuff, eh?