Beyond the Frontiers of Healing: Clinical Psychology and Mortality
ALEXANDRA REALE

On a narrow strip of land in the southeast of Bangladesh, there is a collection of temporary shelters and tents that spans many miles. Within its confines are thousands of members of the Rohingya community, a predominantly Muslim ethnic minority dispersed throughout the Middle East and Southeast Asia. Having fled discrimination and violence in their home countries, they are now precariously reliant on a foreign government for safety and shelter. While there are a variety of origin stories for displaced Rohingyan in Bangladesh, the majority of the inhabitants of the largest refugee camp in the world have come from Myanmar. In August of 2017, Rohingya militants, frustrated with the treatment of their community in Myanmar, staged an attack on the police and military. Troops ordered by the Myanmar government retaliated quickly, swarming villages in the Rakhine state, home to thousands of Rohingya, setting shelters on fire, taking prisoners, raping and killing. It is estimated that at least 730 children under the age of five were killed in the ensuing weeks and months.

Rohingya refugees on Myanmar’s brutal crackdown: ‘They slaughtered our people’ | Source: © The Guardian/YouTube

Fleeing Rohingyan, following this bout of violence, swelled the ranks of existing refugee camps in Bangladesh to about 900,000, and in an area beset by monsoons and mudslides, this was an aggravation of a health crisis. Crowded conditions made it nearly impossible to obtain clean water and adequate shelter on a consistent basis, and checking the spread of disease was an ever-present concern. It was common for footpaths to be completely waterlogged, and for makeshift tents to slide down hills. Well-intentioned NGOs kept pouring in, often tripping over each other, anxious to mend and fix. It was difficult to ascertain which problems ought to have been tackled first; the punishing rain served as a painfully apt metaphor for the deluge of issues that confronted the Rohingya on a daily basis. Refugees found that each day was a battle to stay alive, and these battles had to be fought valiantly and constantly. But what happens when death has been staved off for another day? What does tomorrow mean? Zooming out a bit from the binary of life and death to ask higher order questions can feel secondary in situations of crisis, but perhaps to live fully is to assess, holistically, what quality of life really means.

First, Aid

Médecins Sans Frontières, or MSF, (in English, Doctors without Borders) has been working in the world’s forgotten places, caring for the stateless and brutalized, since 1971. The organization was established by a group of doctors and journalists in Paris who, after seeing the effects of war and famine in Biafra, Nigeria, felt there was a need for apolitical expert aid. They approached healthcare providers with an idea: volunteer to travel to a place undergoing a crisis and apply your medical expertise to save and improve lives. Since 1971 they have grown from 300 to nearly 50,000 strong, and have sent tens of thousands of volunteers to places in the world in critical need. MSF is a non-profit, and works on the premise of neutrality in conflict, giving aid to those who need it most, regardless of background or motivation. They have a simple document on their website that details their M.O., and number one, appropriately, is “medical action first.” MSF sees a population in crisis and sends in doctors to help, providing “curative and preventive” care. They use existing infrastructure or build temporary structures to function as health clinics for sick and injured people to come get help. They have done so in hundreds of countries for thousands of people for nearly fifty years.

Rohingya Refugees in Limbo in Bangladesh | Source: © Doctors Without Borders/MSF-USA/YouTube

Though they are world-renowned for dressing wounds and distributing antibiotics, the second principle listed in their simple document has nothing to do with the biological needs of a population in crisis. It reads: “temoinage (witnessing) — an integral complement.” This is where volunteers listen to the people who are suffering, working to understand their situations, asking why and how. Their goal in bearing witness to the people they are helping is to “improve the situation for populations in danger,” which means learning enough about the suffering population to speak about their situation to the larger world. In some cases this means breaking with their commitment to total impartiality. If humans rights violations are so egregious as to be in breach of international conventions, MSF’s tenet of temoinage leaves open “the possibility to openly criticize or denounce… mass violations of human rights, including forced displacement of populations, refoulement or forced return of refugees, genocide, crimes against humanity and war crimes.”

MSF is perhaps a good case study for the priorities of the better angels of human civilization – even in a purportedly unaffiliated organization, there are situations where impartiality is cast aside, and the truth is spoken. Perhaps equally compelling is the hierarchy of MSF’s prioritization: body first, then, immediately, mind. When the body is threatened, a huge effort is made to salvage it. It is a race against death. But once the red lights are turned off and the insistent beeping of the heart monitor slows, attention is turned to the mind, and the question becomes – now that life is restored, can life be lived? One volunteer clinical psychologist has spent many years asking, and using her expertise to answer, this question.

Harbinger of Life

Laure Weber (Source: Alexandra Reale)

Laure Weber and a member of her staff | Photo courtesy of Laure Weber

Laure Weber is an ocean swimmer, a person accustomed to having cheerful conversations while bobbing in the Pacific with her longtime swim buddies. She has the crisp articulation of a kindergarten teacher, and a big, magnetic energy that belies her petite frame. Laure has worked as a clinical psychologist for more than twenty-five years, specializing in PTSD, trauma, and substance abuse. Every so often she gets a phone call from MSF, and her steady routine of ocean swimming, spending time with her husband, and working in her Pacific Palisades office is hung up like a coat, and she’s on a plane. Laure has volunteered with the organization since 2013, and her resume has included weeks-long (sometimes months-long) stints in South Sudan, Ukraine, Guinea, the Democratic Republic of Congo (DRC), and Bangladesh, living with and among suffering communities. She has a story for each region, and speaks in a doctor’s matter-of-fact tone in her descriptions of each mission. She recalls the fourteen-year-old girl who, having witnessed her own sister’s decapitation in the Kasai Province at the hands of militia, then had to take all her nieces and nephews — now motherless — and flee. When her sister’s husband returned home and found his children and sister-in-law hiding under a bed, he left with only the children, leaving his wife’s sister behind to be captured, raped, and then dropped off at a military station held by opposing forces. Laure underscores that a lot of these details are murky because of the girl’s trauma, and that this story is not an anomaly; in fact, for many of her female patients, it is the norm. Each trip is different, as each crisis is different, but her goal in each place is the same: give her patients the tools to cope with the psychological aftereffects of sustained displacement or trauma, and simply move on with their lives.

Laure spent six weeks in the Rohingyan refugee camp in 2018. She saw firsthand the effects of the displacement on the community, how forced exile, extremely close quarters, and impossibly weak infrastructure took its toll. When she arrived, she began working closely with volunteer community health workers, who would go talk to their fellow refugees about mental health needs in the community. The volunteers (who were really “volunteers” receiving a stipend; MSF had found a nice loophole in the government’s mandate against working) were skilled at identifying other refugees who could benefit from the help of a trained counselor.

“We would talk about depression, trauma, anxiety, PTSD, domestic violence, rape, and how all these could impact people. We would talk about feeling hopeless.”

– Laure Weber

These conversations gave refugees space to unburden themselves, and it gave volunteers a measure of their dignity and agency back — having the chance to earn some of their own money allowed them to support family members locally and abroad. Despite this progress, Laure often found herself at odds with cultural norms during these weeks. She’d give volunteer women gumboots for navigating the roads safely, only to find that they had given their gumboots to their husbands or brothers. “Your husband doesn’t work for me,” Laure would say. “You do.”

Laure Weber (Source: Alexandra Reale)

Photo courtesy of Laure Weber

This is one of her favorite parts of her job, she says – the chance to empower women and give them opportunities to reclaim purpose in their lives. Women in the vulnerable communities that MSF works with are frequently left to support families alone, and refugee women are often attempting to support families spread out in multiple places. Laure makes a point to hold listening sessions (temoinage in action) with interested women, giving them time and space to express their problems and needs without interruption from men. She has seen how the simple act of listening can elevate a situation. In South Sudan, where she went in 2013, she held an art therapy group for women who had become de facto heads of household while men were at war. They had been raped, ridiculed, had things stolen from them, all while trying to raise children and support families. Laure remembers the way they blossomed in the course of the class, how they would return to tell stories of opening up discussions with their sisters and mothers that they had not broached before. They had begun to heal with each other.

Each trip is different, as each crisis is different, but [Weber’s] goal in each place is the same: give her patients the tools to cope with the psychological aftereffects of sustained displacement or trauma, and simply move on with their lives.

Working as a clinical psychologist in places touched by deep trauma means meeting people where they are, and finding ways to reach them. When two teenage girls in desperate need of medical attention arrived at MSF’s clinic in the Kasai Province of the DRC, Laure recognized a need  for a gentle approach. Both girls, as a consequence of the violence in their home, would be living out the rest of their lives with portions of their bodies missing. One’s leg was gone, amputated, and the other had recently stepped on a grenade, which had left most of her groin area mutilated and infected. They were admitted for expert care from the MSF staff, and while other doctors took care of their bodies, Laure considered their minds. She decided on something simple: she sat with them and played cards. Though Laure is fluent in French, in this case her language skills were of no use to her, as the two girls spoke only Tshiluba. But she watched as the warm, comforting presence that she tried to adopt helped the girls transition from trouble and scared to relaxed, even cheeky — in short, normal young teenagers. With all her patients, she is looking to guide them towards healing, suffering under no delusions that there is a “cure,” knowing that all too often there will be setbacks. (In fact, a few weeks later, the girl who had stepped on the grenade is picked up by her mother on a motorcycle, taken away, and brought almost immediately back when infection flares up.) But Laure’s objective is simple: she wants to help them to feel safe again, to help them see that people do listen and care. She hopes that this feeling of being heard will be a contribution to restoration of life meaning for her patients, even in the midst of deep suffering.

Laure Weber (Source: Alexandra Reale)

Photo courtesy of Laure Weber

Life over Death

In Being Mortal: Medicine and What Matters in the End, prominent physician Atul Gawande takes us on an oft-elided journey in the United States — to the very end of our lives. American physicians, he argues, are trained from the get-go to defend their patients from death, with unshakeable tenacity, only yielding when there is nothing left to give. Casting all reflections on the nobility of this aside, his point is that American culture at large does not consider death a natural part of the fabric of life. Americans enjoy longer lifespans, with a higher standard of living, relative to much of the world. We expect life to be not “nasty, brutish, and short,” but mostly pleasant and quite long. Starting with this premise means that we spend billions of dollars keeping patients alive, even when their quality of life has all but evaporated. Put succinctly by Gawande: “In other words, our decision making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality.” We obsess over quality of life, but at the very end, we forget to let go.

Dr. Atul Gawande on Aging, Dying and “Being Mortal” | FRONTLINE | Source: © FRONTLINE PBS | Official/YouTube

Zooming out a bit from the binary of life and death to ask higher order questions can feel secondary in situations of crisis, but perhaps to live fully is to assess, holistically, what quality of life really means.

A large proportion of Laure’s patients live lives that are stained by death. She has listened to the stories of mothers who have lost five of eleven children in their infancy, worked out difficult compromises with families of Ebola victims in Guinea who just wanted to touch the hand of their brother one last time, and carried the corpse of a malnourished baby to his final resting place alongside his stricken grandmother, who had lost both a daughter and a grandson in one day. Each one of her patients is faced with learning to cope with the violence that has been visited upon them or their loved ones, how to continue to live their lives past something gruesome and tragic. They have to accept mortality, even when it comes early. In describing her role in this, she does not self-aggrandize: “I just have the right temperament. I’m there not to feel all this horrible stuff but to work with them to help them.” This, for her friends, resonates. She is a giver, and she is acutely aware of and grateful for good fortune. One friend who has swum with her for nearly twenty years says that a biweekly Laure exclamation — regardless of weather, water temperature, or strength of current — is, “Oh my God, wasn’t that just such a beautiful swim?” She fights against death, and she cheers on life. Sometimes this is in the quietest of gestures: in the tiny arena of a card game, a small victory won, death pushed away for another day, the laughter of two young girls echoing in the air.

 





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