Healing war wounds: For Somalis, faith rivals Rx drugs

There are no words for "depression" or "post-traumatic stress disorder" in the Somali language.

"You are either crazy or not crazy," said Samira Dini, a Somali mental-health and outreach coordinator at Community University Health Care Center (CUHCC) in Minneapolis. "There is no middle ground."

But 10 years of civil war, violent upheaval and forced resettlement have taken their toll on the human spirit, and mental-health-care workers in Minnesota are struggling to meet the needs of a refugee group that does not even have a language for what it has experienced. At least not a language that is recognized by American psychiatry.

One word did come into currency during the war -- to describe, for example, the man who wanders the refugee camp, sleepless, unable to eat, talking to himself. The word is "buufis," which, translated literally, means inflating a balloon to the point of bursting.

Before the war, a Somali person in a troubled state typically would not visit the local clinic for a mental-health diagnosis and dose of antidepressants. A troubled person, along with his family, would visit the Muslim sheikh. Verses of the Qur'an, the sacred book of Islam, would be read and symbolically "spit" into a bowl of water. The troubled person would drink the holy water, receiving the verses into his body. Qur'anic verses would be rolled in leather and worn as a pendant around the neck.

With the help of his friends, his family, his faith, he would be better.

The therapists, nurses and outreach workers at CUHCC try to recount their Somali clients' experiences and don't know where to begin. Some have been tortured. Some have witnessed killings and torture of loved ones. All have had the traumatic experience of being driven from home.

Public officials and relief agencies estimate there are 20,000 Somali refugees living in Minnesota. The Center for Victims of Torture in Minneapolis estimates that 35 percent of all refugees in general have been tortured.

"You are numb," said Ahmed Yusuf, a Somali mental-health outreach worker at CUHCC who came to the United States in 1984, just as civil war was brewing. "You have seen it all. You have seen countless dead bodies. You have seen your brother skinned before your eyes. You have seen your wife or someone else raped."

The refugee camps in neighboring Kenya and Ethiopia had their own horrors.

"They lived in shanties, with no protection from the elements," said Kay McMahen, a nurse specialist in adult psychiatry at CUHCC, recounting what clients have told her. "Hoodlums would raid the camps. There wasn't enough food. There was inadequate medical care. In one situation, a child died from a minor illness that went untreated."

Add to war trauma the stresses of resettlement: finding housing and employment; navigating the school, welfare and transportation systems; adjusting to a new language, a new culture and a climate that is utterly foreign.

"Some of my clients have war wounds," McMahen said. "But a lot of them also have hand, wrist and ankle injuries from falling on ice after arriving here. They simply did not have the proper footwear."

Dr. Jerome Kroll, a University of Minnesota psychiatrist who practices at the center, invites his clients to talk about their experiences. They do not lament their fate or ask, "Why me?" he said.

They simply say: "It is the will of God."

Getting to 'I'

The people are resilient and determined, Dini explained. "They trust God. They accept their fate."

Besides, Yusuf said, it's a communal society, and before you worry about yourself, you worry about everyone else: "Before I get to the 'I,' I have to cover my entire clan -- my cousin, my mother, my sister, my brother."

The predisposition to accept one's fate, the fear of being labeled "crazy" and a suspicion of medication that alters the brain's chemistry keep many refugees from seeking help.

By the time they do, Kroll said, their symptoms are severe: loss of appetite, sleeplessness, irritability, hallucinations, anxiety attacks, chronic muscular pain, headaches and dental pain.

Depression and post-traumatic stress disorder (PTSD) are the most common diagnoses.

Often Kroll is asked, aren't these normal responses to abnormal situations?

"Yes, it's 'normal,'" he said. "PTSD and depression are understandable responses to life's stresses. But not eating, not sleeping and feeling no meaning in life are symptoms that threaten the life of that person and everyone around him."

Kroll and Evelyn Lennon, a project coordinator at the Center for Victims of Torture, were among experts who conducted a workshop last week for about 20 Somali health-care providers and social workers. They offered myriad cautions:

Focus on the symptoms, not the label. Ask: "Are you sleeping? Are you eating? Do you have a loss of energy? Are you sad? Isolated?"

• Be aware that trauma victims can be easily retraumatized: by aggressive questioning and by simple events, such as waiting their turn in a doctor's office (which can remind some of waiting their turn to be tortured).
• Don't ignore the individuality of each person by assuming that he or she is behaving only according to the culture.

  Taking their medicine

  The battle would be half over, it would seem, once a client was persuaded to accept treatment. But the health-care system is tough to negotiate. Mundane problems become huge obstacles.

  "There are tremendous problems with something as simple as getting a prescription refilled," McMahen said. "If you don't read or speak English, you have difficulty describing what you need to the pharmacist over the phone. Once at the pharmacy, you need to have your Medicaid card, you need to know what it's for and you need to know what the pharmacist is asking for. If you don't have the card, you need to know where to call to get one."

  And there are some problems that defy solution.

  Yusuf remembers persuading one woman to come to the clinic for an appointment. She had no transportation, so Yusuf offered to pick her up at 9 o'clock. But the woman, a nomad, had no concept of time that is determined by a clock. In Somalia, he might have told her, "I'll pick you up when the goats are to be let out of the corral." Or "I'll pick you up when the sun is right about here."

  "By the love of God, I could think of no way of explaining to her what I meant by 9 o'clock," Yusuf said, throwing up his arms at the memory of his frustration.

  With their faith and their Western medical know-how, Dini, Yusuf and two other Somali health-care workers at CUHCC act as a bridge for other Somalis, helping to allay suspicions and to remove the stigma of seeking help.

  "Medicine can't fix everything," Kroll said. "But if someone is not sleeping at all -- to give them a safe, nonaddictive antidepressant is to be 50 percent ahead of the game."

  Said Lennon: "We want people who can benefit from mental-health care to have access. We want them to know that mental illness can happen to anyone and that something can be done about it.

  "At the torture center, we say they are healed when they can put the past in the past and when they can see there is a future."

  Sarah T. Williams can be contacted at swilliams@startribune.com © Copyright 2001 Star Tribune. All rights reserved.