A farewell

I knew this day would come. I knew it all the time. I even knew it would come very quickly. But still I am surprised that the day is already here. The day when I go home.

I spent the most amazing 9.5 months in the most fascinating place, little Tari. I witnessed how hot-tempered people here can be, I saw warriors, I saw people injure each other with bush knives, I saw mothers beating their children, I saw limbs being cut off, I saw extreme emotional suffering, I saw people die. But I also experienced the warmth and love that the local people generously share every day, despite all the violence, paradoxically to it.

I have seen how people help each other, protect each other, laugh and joke together even in times of struggle. “How can such kind, warm-hearted people be so violent to each other?” I have always wondered, and still do. The emotional turmoil in Tari is exceptional, probably more so than anywhere else.

And in the middle of this was I. When working for MSF in the field, you cannot observe things from a distance. You cannot leave yourself emotionally on the outside. You must go in to it with your whole being, take a deep dive into the culture, understand people’s history, and listen to their stories. For me in Tari this has meant crying in my room at night from exhaustion and frustration. It has meant feeling anger and rage over witnessed injustice and it has meant laughing my heart out with joy with my wonderful local friends. This little, complex, ignored place on the other side of the world has forever changed my life, and I will carry the memory of it with me for as long as I live.

Thank you Tari.

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Those who smile again despite the odds

Working in the Family Support Center makes one face upsetting and sometimes very disturbing fates on a daily basis. We hear the most horrible things that have happened to our patients. Sometimes even we the staff wonder how anyone could ever survive, physically or mentally, the crimes committed against them. Curiously enough, many of them do. People have often more resources than they themselves or others expect. Counseling, support from family and friends, and positive coping mechanisms all help a person survive. Even early experiences help; if you once were loved, if you know that you were once valuable, that helps you not to lose all faith in other people.

As well as the horrible stories we hear at the Family Support Center, we also witness the survival stories. It gives us great strength to help make them happen and we are privileged to witness them.

A 15-year-old girl came to the Family Support Center after being raped by strangers. She was walking home at night when four men pulled her into a bush, beat her, stabbed her, threatened to kill her and then took turns in raping her. The rape also contained some very humiliating elements.

Fortunately the girl came to the Family Support Center the next morning. She received a 28-day-long post-exposure prophylaxis to prevent HIV infection. She also received medication to prevent sexually transmitted diseases; she was given a hepatitis-B vaccination and emergency contraception (the morning-after pill). Also, she was given counseling where her feelings were explored and normalized, meaning that the nurse told her that her fears and anxieties are common reactions to such a traumatic event. She was told that those feelings don’t mean that she is losing her mind. They will pass with time and treatment. The nurse also discussed possible ways for the girl to cope with her acute distressing feelings. After the counseling the girl told the nurse she felt very relieved. She said it was important for her to hear that the rape was not her fault.

At her last visit some weeks later, when the treatments were finalized, the girl said that she felt much better emotionally. She had used the coping mechanisms that were discussed with the nurse. She had sought support from friends and family, she had taken long walks, she had done relaxation exercises and she completed all her medical treatments. She said she no longer felt overwhelmingly distressed and felt optimistic about the future.

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Science nerd

I admit it, I am a science nerd! I enjoy reading about new studies, analyzing the results, and sharing them with my equally nerdy friends – those who are not already tired of me always asking “Do you have any scientific evidence for this claim?”

So, when it was time to give the Family Support Center staff a new training session, I asked myself how to give them a science lecture that would be both useful and interesting. Eventually I decided to discuss critical thinking when taking clinical decisions. I showed them a PowerPoint slide with the following information:

  • A young woman comes to the clinic, claims that she has been beaten by her husband.
  • We know from before that the woman has new boyfriends every month even though she is married.
  • She is known to have a bad temper, be talkative and has once been seen out on the town beating a neighbour.
  • Her husband is a pastor, a well-respected man in the community who often gives money to charity and the community.

We discussed what associations this information gave us. Most of us agreed that based on the given background information it is easy to think of the woman as a liar. Then we went on to the next slide that contained some further information:

  • The woman was repeatedly sexually abused as a child by her father
  • She often witnessed her father beat her mother
  • When she feels threatened, she screams and talks ugly in order to scare away the other person
  • The woman she was beating out on the town is a neighbor who likes to gossip about the woman’s relationship to her father
  • Her husband is jealous and beats her in the privacy of their home

This new information gave us a completely different picture of the woman. We discussed how we as health care workers might have approached her had we based our judgment solely on the information on the first slide. And how might the woman feel as our patient then? Probably not very good.

We went on to talk about how we can know what information to consider as true. What is the only way of knowing the truthfulness of claims like “Men are smarter than women” or “Everybody should be given debriefing after a traumatic event”. The right answer is: research (and research has shown that neither of the two example sentences is completely true.) We continued discussing similar claims and planned how we would go about studying them scientifically. A whole lot of fun! When I ended the training by asking if “we all love science now?” the staff shouted “Yes!” I really think they were sincere and not only trying to please their (over)enthusiastic supervisor.

 

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Violence beyond belief

This week we saw a patient at the Family Support Center that left us feeling quite disturbed. It was a 24-year-old woman from a village quite far away from Tari who came to our clinic after having been severely assaulted by her husband.

Some weeks ago the husband married another woman (polygamy is common in the area). When the wife complained about this, the husband chased her out of the house. The wife travelled to her family’s village and spent two weeks living with them. Her husband called her family members repeatedly and begged the wife to return home.

When she eventually did and entered their house, he grabbed her arm, started beating her to the ground and kicked her as she was lying down. She was screaming and trying to protect her face. The husband accused her of having affairs with other men and “sleeping around”. After kicking and beating her, the enraged husband tore off the wife’s clothes, grabbed a burning stick from the fireplace and sexually assaulted her with it. Then he sexually assaulted her with his hand, and tried to tear her uterus. I can imagine how distressed the children in the garden must have been, being forced to hear their mother scream in agony.

The woman presented at our clinic with bruises and multiple burn wounds on her body and genitals. At the Family Support Center she received medical care for all her injuries and necessary medication. Also she was given much psychological support in order to help reduce her fears and anxiety.

An important step in counseling violence survivors is to educate them about trauma symptoms; it feels reassuring for most survivors to hear that strong anxiety and fears are common reactions to trauma, not a sign that they are losing their mind. Another important part of counseling domestic and sexual violence survivors is to let them hear that whatever violence was done to them was wrong and it was nothing that they deserved. After completing the treatments, the Family Support Center staff helped the woman contact relatives who could provide her with a safe place to stay, away from the husband.

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Celebrating motherhood

The second Sunday of May we celebrate Mother’s day in many countries all over the world, including Papua New Guinea and my home country Finland. Usually Mother’s day for me is giving my mother a card and maybe a present, telling her how amazing she is, also cursing a little bit over how commercial the day has become. This year, however, I notice that the day has gained new meaning for me. Maybe it is for the fact that many of my best friends have in the recent years become mothers. Maybe it is because I have considered myself an extra mommy for the five puppies we currently have running around our compound. Or maybe it is because motherhood is such a strong background force in the work we do here in Papua New Guinea.

Every day we see mothers’ efforts in coming to Tari hospital to get medical care for their children. They may walk for two hours, without shoes, carrying their children in their bilums (traditional string bag) to reach the hospital. We see women at the Family Support Center who have suffered domestic violence for many years, but whose primary concern is not themselves, but their children.

We treat raped women who need to rush back home to make sure the dinner is served to their children. We see poor women who’ve tried their best to stabilize their child’s injured foot with a piece of cardboard. We meet women who have been assaulted by their own sons and yet they forgive them. But we also see the other side of motherhood. We see women who are so highly traumatized that they are not capable of expressing love to their own children. We see women who abandon their raped daughters, because someone taught them that raped women don’t deserve respect. We see women that hit their children. We see women who stay in a relationship with a man who abuses their child.

There is never a justification for maltreating a child.

But there are circumstances where parents’ capability of protecting and loving their children is limited.

Circumstances beyond the parent’s control. Poverty. Abuse. War. Diseases. Traumas.

I believe mothers give their children as much as they possibly can. Mothers who were supported and believed in can give their children wings to fly. Mothers who only saw the ugly side of life may not be able to show their children the beauty of the world. Mothers who grew up surrounded by love have great amounts of affection to pass on to their own children. Mothers who were never the most important person for anyone else may not be able to show their children how very precious they are. But the little they can do, they do. They little they can give, they give.

I believe every mother does the best she can. And no one can require more than that.

I wish a happy Mother’s day to all mothers… and to one in particular. One who is on the other side of the world, but whose love and spirit is constantly present, on every road I travel. Min mamma.

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For better, for worse

“Do you want to come and see a bride price ceremony?” counselor Leonie asked us last week. Of course I, the project coordinator and the medical doctor Martina were immediately up for it.

A bride price ceremony is the equivalent of a Western wedding ceremony; it is the ceremony that links two people together as a married couple. The bride price ceremony, however, does not resemble much a traditional Western creamy white wedding. The ceremony is an occasion when the groom has to pay the woman’s family a bride price. The price depends mainly on the woman’s virginity, education and age. A typical bride price is some cash (500-2000 Kina, which equals about 173-693 Euros) and three times ten pigs; ten piglets, ten middle size pigs and ten big pigs.

In the bride price ceremony, the groom displays the pigs and the money (notes are attached to long sticks which are placed in the ground), and the bride’s family inspects the goods and divides it among the family members, based on for example who took care of the bride when she was growing up and who back in the days helped pay the bride price for the bride’s mother. The bride is standing alongside her mother, carrying a bilum bag with few personal belongings. After the bride price has been paid and received, the groom and the bride walk together to the husband’s village where they will settle down and start a life together.

The bride price ceremony Leonie invited us to witness was held in town. Around fifty people were gathered in the hot sun and the pigs were happily rolling around in the soil. I watched the ceremony fascinated and admired the bride, who was shyly hiding under her umbrella. I found myself hoping that she would have a good married life.

When working in the Family Support Center and knowing what the statistics say, I am very much aware that most married women face both physical and sexual violence at home. The bride price is considered a factor that affects domestic violence rates; when a man pays for his wife he might easily consider her his “property” and therefore treat her as such. The bride price also hinders many women from divorcing since she or her family then must pay back part of the bride price. If the woman leaves the husband without repaying the bride price she might face violence from the husband. MSF recently treated a woman whose arm was amputated by an infuriated husband because she had left him without giving back the bride price. The reason why she had left him originally was his violent behavior towards her.

When the bride price ceremony we witnessed was over, the bride and the groom walked away together. Rarely in weddings do I experience such mixed feelings as now. On the one side I feared that the house of these two would be marked by violence. On the other hand, I thought that there is a small chance that this might not be the case.

There are always positive exceptions and there is always hope for a change. I strive never to give up on the latter.

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Change of career

My daily work in the Family Support Center often resembles more that of a teacher than a clinical psychologist. I give the staff weekly training on different mental health related topics and try to create effective learning tools and materials. I have had some great teachers in my life and I notice that I now try to mimic their teaching methods. When I am feeling really courageous I even try to make up some techniques of my own.

Last month, the focus of the training was children. We noticed that all parents presenting at the Family Support Center with traumatized children did not necessarily provide the children most adequate emotional support. For example, there was a case where a family accused a 12-year-old-girl of sexually abusing their seven-year-old son. From our examinations at the Family Support Center, it appeared that it was a case of common child-to-child play and natural children’s curiosity rather than sexual abuse. The family, however, wanted to solve the case by putting the two small children in front of the village court. We feared of course that this might only traumatize the children further. In the last month’s training I therefore talked about early attachment, children’s healthy emotional development, about how to support it, and factors that might jeopardize it. The Family Support Center staff can then use this information when treating children and also to educate the parents.

Related to this training, I also educated the staff about child sexual abuse and its effects on children’s later development and mental health. Since we receive quite a number of cases of suspected child sexual abuse, I also taught the staff some techniques on how to investigate such cases. Since children are very suggestible, it is important that the child is encouraged to give a free narrative of the event and that the interviewer avoids all kinds of leading and suggestive questions, as well as any type of coercion. We discussed the importance of developing alternative explanations to the allegations in order to avoid people being wrongfully accused of sexually abusing a child and also to avoid creating traumas for the child. I also taught the staff about common age-appropriate sexual behavior, since children sometimes naturally exhibit behavior of sexual nature and it is important for health care workers to know what behaviors may likely indicate sexual abuse and which signs likely may not. The topic is complex and challenging, but luckily the Family Support Center staff are motivated and very knowledgeable, which facilitates the teaching.

Usually I give training sessions in the afternoon after all the patients have gone home. By then, some nurses tend to be tired since they often have to get up around 5 am in the morning to prepare food for their families before they head to work. Therefore our sessions are often preceded by a short muscle exercise or intense salsa dancing to get the blood circulating. We close the door to the training room, turn up the volume of the rhythmic music and dance, dance, dance our hearts out for some minutes. This pedagogical technique is one of those I am most proud of.

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Many faces of evil

Monday morning for us at the Family Support Center started in a sad way. We received a female patient who had been raped by eight men. The woman was travelling to visit relatives during the weekend and, when she got off the bus, a group of men attacked her and took turns in raping her. She came to our clinic with her clothes torn and muddy, experiencing severe physical pain.

Another patient that presented at the Family Support Center had been travelling on a bus when it was stopped by a group of thieves (here usually called rascals). The rascals robbed all the passengers in the bus of their money and valuables; they forced out all the female passengers, took them aside and raped them.

Since I started working in this project and began to witness all the horrible fates we see in our clinic each day, I have countless times asked myself why. Why does someone commit these awful crimes? Who does it? Like most people, I guess, I am at times inclined to think about the perpetrators as evil by nature – as abnormal, sick and crazy. Separate people: in us, the good; in them, the evil. This simplistic dualism of good vs. evil, however, is not very constructive if we really want to understand acts of evil.

Social psychologist Professor Philip Zimbardo writes that horrific deeds are possible for any of us in the right (or wrong) circumstances. Social situations and environments have a significant effect on people’s behavior; it is not only about personality variables or genes. Look at the classic example of Nazi concentration camps, which were run by ordinary men and women. Therefore, Professor Zimbardo writes, in order to understand odd behavior, we should always start by analyzing the situation – yet avoiding determinism: people are still responsible for their actions. Neither should people be categorized as evil or good. When upholding the approach of people being either good or evil, the people considered “good” lack all responsibility

Yes, it was the rapist who raped, but what about all the rest of us who contribute to maintaining a system where gender inequality prevails? And would any of the eight men who raped our patient have done so if they had met her alone?

Suggested reading: Zimbardo, P. (2007). The Lucifer Effect. Understanding How Good People Turn Evil. New York: Random House.

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Rest in peace, princess

I was standing in the hallway of our clinic one day this week, chatting with my staff. We were about to go and have a training. Suddenly we heard a chilling scream from outside. “Someone must have died,” one of our nurses said. We went outside to find a huge crowd gathered outside the emergency room. The people were crying out highly and loudly, almost like singing – a characteristic sound for mourning in this area.

From the crowd we quickly heard fragments of what had happened. A young girl was brought in to the emergency room. She had been found lifeless on the floor in her home. Someone said she had been sick for a while. I saw our expatriate nurse come out from the emergency room and approached him. He said there was nothing they could do. She was dead when they brought her in.

We stood there watching the mourning, crying crowd. Then all of a sudden the cries and screams escalated. They were earsplitting. The girl’s family members started jumping up and down, in deep, deep distress. We understood that the girl’s body was being brought out now. I stood near the pavement leading to the emergency room. I saw the girl’s closest family members coming out towards me, crying and pushing a hospital bed where the girl was lying. The girl’s mother ran by the bed, holding her daughters face, screaming from the roots of her heart.

I stood paralyzed. It is rare to witness such deep, pure pain. The family passed me with the bed. I saw the girl’s face. A beautiful, peaceful face. She looked like she was only sleeping.

The family lifted the girl into their vehicle, accompanied by their chanting cries. I saw the girl’s little sister jump and shudder, like the pain was so great it had no space in her body and had tried to force its way out.

Next, the family would start the wake, where family members and friends sit by the girl’s side day and night. Telling stories about the girl. Holding her hands. Crying, even laughing at some moments.

I couldn’t help but think about deaths and funerals in my own country. Deaths are treated as a quite ’clinical’ matter. The body of the deceased is taken quickly to a morgue and later discreetly to the funeral home. The funerals are held with closed caskets. We cry silently into our handkerchiefs.

Despite all the immense pain and sorrow I saw around me on the hospital lawn, I felt it was a healthy way of grieving. Crying and shouting out the pain. Letting it out, showing the world how much it hurts. Seeking comfort in loved ones and in physical nearness. Helping each other live through the loss. Celebrating her life.

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TGIF

Ta-daa, it is Friday again. It never ceases to amaze me how many different sounds I can and do wake up to here in Tari. Either it is the guards calling for each other on the VHF radios, or pigs grunting and having a good time rolling in the soil, or the characteristic high-pitched group singing indicating that compensation after a clan fight has been agreed upon, or a cry indicating that a clan fight is starting, or the paradise bird singing, or an airplane landing, or a fellow expat Skypeing or lighting the gas stove. This morning, it was – surprisingly –my alarm clock.

Up I get, make a quick Skype call to a friend in Finland while applying my make-up (a small, rare luxury I refuse to abandon in the field). Take my morning tea to go and join the other expats and the national staff for the weekly staff meeting. We go through security issues, patient numbers and other relevant matters (this morning our acting project coordinator had to clear out a rumor that had been spreading around the staff that MSF would be now leaving Tari because some of our buckets had been stolen from the waste area).

After the meeting all the staff – from nurses to guards to expats to supervisors – put on expired surgical gloves and walk through the hospital compound collecting each piece of rubbish we find. A tradition we repeat every last Friday of the month to keep the hospital clean and to set a good example. After the rubbish picking I run to the office, print and cut out awareness cards, run to the MSF office to pick up our loud hailer and go with two of my counselors to the MSF car where the driver and our surgeon are waiting. We are going to the Tari marketplace to raise awareness about family violence, sexual violence and the services we offer for the survivors in the Family Support Center. This is a usual Friday activity for us since Friday is the main market day and people from all the surrounding villages gather at the marketplace. Today our surgeon is joining us on a rare occasion when she has managed to arrange to leave the hospital compound for an hour or so.

Tari marketplace © Minja Westerlund

Tari marketplace © Minja Westerlund

 

People at the market place are curious about us expats. They quickly gather around us when our national staff start talking and presenting MSF. Many smile and wave and probably wonder what these white people are doing there. When our staff come to the point where they mention family and sexual violence, all eyes are suddenly off us expats and focused on the national staff. Facial expressions immediately get serious and people seem to strive to hear everything our national staff are saying. They recognize the problem with the violence. Many are most likely survivors themselves. On Friday afternoons we usually see patients presenting at the Family Support Center that say they come after hearing our awareness raising.

When we head back to the hospital we are – as usual – accompanied in the car by a living, confused looking chicken that our cook has bought for that night’s dinner. Back in the Family Support Center my nurse consults me about a patient who has been brought here by her mother who claims the daughter was raped. The girl herself denies it. Is it because of fear of stigma or was she really not raped? We discuss how to assure the girl about our confidentiality without pressuring her or disrespecting her story. Later I help another nurse to have a counseling session with a man who severely injured his wife after she beat him during an argument. The wife has left her husband and taken the children along with her and refuses to communicate with the husband. The husband is very distressed and anxious.

After lunch I give our new counselors the last part of their training on counseling skills. Today’s topic is mental disorders: what they are, what causes them, how to recognize them. The training triggers interesting discussions about how mental disorders are generally perceived here. It seems that in this area, as in most other places, there is a lot of unfounded fear of psychiatric patients.

We wrap up the day with a peer supervision session with the staff where we discuss tricky counseling cases. Today everybody is tired and the discussion does not flow as it usually does. We keep the session short. Little do the staff know that together with the medical doctor I have organized a small surprise celebration for the last 15 minutes of the day. One of our nurses recently completed a Provided Initiated Counseling and Testing (PICT) training and we will celebrate it with chocolate and salsa dancing (a new favorite in our clinic).

With serious faces, we ask the staff to gather in the office for a meeting. They come and wonder what is up… until we start the music! We dance and have a great time. We also call in the formerly hypnotized expat (see previous blog post) and he comes and shows us some nice salsa pirouettes (is it just me or did I notice someone blushing?). What a superb way to end a hectic work week! A little sweaty from the dancing we close the clinic and go home. Since the Latin rhythms still work their magic on me, I decide to try to convince the expat team to celebrate Friday with a little dance fest after dinner…

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