Survivor instinct

Understanding people's mental health during war and other disasters

War, famine, hurricanes, floods, earthquakes. These complex emergencies all have one thing in common: survivors. We are used to seeing images of these survivors on our television screens—displaced people who have lost family members, homes, possessions—but what is not apparent is how survivors cope with these emergencies and remain sane, which most do. And what are the psychological consequences for those who survive these devastating events?

Astier M. Almedom, the Henry R. Luce Professor in Science and Humanitarianism at Tufts, is exploring these issues by examining the social and cultural factors that affect mental health in complex emergencies. Almedom's approach reflects the interdisciplinary nature of her work: Her faculty position is through the Department of Biology in the School of Arts and Sciences in partnership with the Feinstein Famine Center at the Friedman School of Nutrition.

Astier Almedom © Kathleen Dooher

Small but resilient
Last year, Almedom and her research team conducted field work in the war-affected communities of southern and western Eritrea—a country of less than five million people in northeast Africa, which, after a 30-year struggle, gained its independence from Ethiopia in 1991. Fighting broke out again along the border between Eritrea and Ethiopia from 1998 to 2000, creating what Almedom describes as "a war that nobody could afford." As a result, people had to leave their villages and relocate far away from the border area. Almedom and her colleagues facilitated group discussions with women and men in seven different sites, including three camps for the internally displaced.

"Eritrea is a country marked by resilience," Almedom says. "It is very organized…not your typical image of chaos in an African country at war." Indeed, despite the upheaval that occurred during the 30-year war with Ethiopia, the liberation movement had paid a great deal of attention to everyday matters, such as education and health care. For example, children did not miss school, but instead attended classes in safe havens and underground shelters, even during bombing. Similarly, a high-tech hospital was set up underground in a liberated zone. This extraordinary level of organization by the local government continued during the 1998 to 2000 border war and, not surprisingly, had an impact on how the community members responded to their displacement.

Maintaining their spirit
"How people cope depends on their own resources, sense of coherence, ability to find meaning in their situation—not what humanitarian agencies do for them," Almedom says. "If you lose your home during a disaster…if you have to go somewhere else, you risk losing your identity." She found that despite the disruption, certain mechanisms of social support alleviated some of the people's emotional pain and difficulties. For example, local village administrators warned people of imminent Ethiopian raids, demonstrating what Almedom calls cognitive support—that is, straightforward information in answer to "why" questions. Additionally, the government provided vehicles so people could travel to safety. This type of emotional support was also seen in the government's practice of keeping communities together, with the local administrators keeping track of their villagers. Finally, material support was provided in a timely manner through aid from humanitarian agencies coordinated through the Eritrean Relief and Refugee Commission.

Other survival mechanisms became evident as Almedom and her team conducted discussion groups that were segregated by sex. The women attributed their ability to cope to several factors, including faith in Qidisti Mariam (Saint Mary), who is believed to protect women; a feeling that they were still part of their larger community; and their ability to follow the news by listening to the radio.

Similarly, the men, who were not in military service for one reason or another, were grateful for the radio broadcasts and the regular meetings initiated by the administrators. They felt that their displacement was meaningful in terms of defending their country. Interestingly, the men were more forthcoming about their feelings than the women. "They wouldn't stop talking," Almedom says. Some spoke about their worries regarding their reputation, believing they might be blamed for the war. Others discussed their failure to accept the losses they incurred and their strong feelings of anger and desire to seek revenge. "All normal reactions," observes Almedom, "and not signs of being traumatized."

It's all about context
Almedom's study comes at a time "when trauma projects have been mushrooming everywhere." There is ongoing debate among scholars as to how to understand people's mental health in these emergency conditions: One camp emphasizes the importance of understanding it from a sociocultural framework before acting, while the other side advocates the need to intervene with standard western trauma checklists and therapy.

True to her interdisciplinary nature, Almedom says it is not an either/or proposition. "When doing a study, you must first look at the context. People often fly into the country [they're studying] and start asking questions they have brought with them in prepackaged questionnaires," Almedom says. "You must first listen and then ask questions. The 'we-know-it-all' model is so pervasive, even among anthropologists."

The study was a participatory investigation, which means that the participants supply information and then check that what they say has been understood correctly when the findings are presented to them during feedback sessions. For example, some of the women told Almedom that they had already been asked "too many questions about violence and trauma by other researchers." Almedom noted this as "research fatigue" and respected their wish to drop the subject. She points out that interviewers who are not properly trained to be sensitive to the participants can, in an ironic twist, inflict trauma.

This sculpture, known as Shidda, was erected in Asmara to commemorate the 10th anniversary of Eritrea's independence from Ethiopia. These sandals are all the liberation army wore—unlike the might Ethiopian army with proper combat boots—and the Eritreans see the sandals as symbols of courage and resilience. Courtesy of Astier Almedom

Another issue in this field is how researchers characterize the participants' mental health. The label or diagnosis of "post-traumatic stress disorder" is still used widely in humanitarian circles. Almedom says that this term does not accurately assess people in complex emergencies across the world and is an artifact of the Vietnam era, when it was first used as a way for people to receive support and benefits. No doubt it was an important term then, but it does not reflect the multi-dimensional nature of mental health in dire situations. "In wars, in disasters, we should focus on the life lived by the survivors, not on what is happening in their heads," Almedom says. "Of course we cannot ignore war-induced shock and trauma, but not everyone suffers from clinical depression. If there aren't enough resources available, individuals will be susceptible to depression, but it shouldn't be a blanket assumption."

Oppression of the soul
Earlier research by Almedom set the stage for her current study and confirms why context is so crucial. She conducted field work for her doctorate during the height of the war between Eritrea and Ethiopia in 1987 and 1988. Almedom studied mothers and their babies under age 2. Every month she interviewed the mothers about their health and their babies' health. During some of these meetings, the mothers would reply that they had yemenfes chinquet (translated from Amharic as "oppression of the soul") because their sons had been forced to enter the military or a family member was missing. Almedom kept a record, and her data analysis revealed that the demoralized feelings of the mothers correlated with their children's diarrhea and poor hygiene levels in the home. "This isn't depression. It is low morale," Almedom thought at the time. "Mothers with low morale had related to me that the root cause of their loss of interest in bathing their babies and keeping their homes clean was in the lives they lived, not in their heads." Two years ago, Almedom began her current study to explore the broader issue of survivors' morale in complex emergency settings.

This summer, Almedom will return to Eritrea to continue her study. Her co-investigator is Dr. Zemui Alemu, the director of the primary health care division of the Eritrean Ministry of Health. It is an alliance that represents her goal of influencing policy: "Involve [local] people from the beginning. People who work in policy will feel like they own it," thereby setting the stage for true collaboration.