Stories of Flight: Trauma and mental health among forcibly displaced and conflict-affected refugee populations in Uganda

Hazar H. Khidir, M.D. 

Resident in PHS Emergency Medicine Residency

PGY 2

June 18, 2019

“There are so many princes here” Doddy, a community health worker in Nakivale, relayed to me. We stood under a corrugated tin-roofed gazebo on the premises of Nakivale Health Centre Number III in Uganda. He points to a man standing across the dusty courtyard between the health centers wards. This man, a refugee who had lived in Nakivale for many years, was once the son of a powerful chief in the Congo. He had a privileged life by international standards with material wealth,  a high-quality private school education, trips to the United States as a child. Everything changed when his father died and a rival Congolese community group seized power. He lost all his material possessions and was forced to leave, fearing that conflict with the new community group would result in loss of his life, too. Though he has half siblings in the United States, he could not ask for their help. With no other social supports, his migration took him to Nakivale. After many years alone in the refugee camp, he turned to substance use for comfort.

I had just met Doddy a few minutes before. He came to the health center with a kind-appearing couple that he brought for a medical check-up. They recently made it to Nakivale in the past year from the Democratic Republic of Congo. The couple were happily married and had eight children. They migrated to Nakivale to escape political violence. The husband had been kidnapped by a local rebel militia group and was taken to the group’s secluded base in the bush. He was forced into servitude and underwent disturbing physical and sexual violence. He managed to reunite with his family and they all fled the DRC together. He came to the clinic requesting HIV testing. He abstained from intimacy since reuniting with his wife due to fears that he had contracted HIV during his assault. He recounted each traumatic incident with complete composure and no betrayal of his emotion, speaking to the health worker calmly and politely. Next to him, his wife wept silently for him.

Doddy left for a home visit within the settlement. Soon after, a smiling, tall, dark-skinned Ethiopian walked up to greet me. He informed me that he worked as an Amharic translator at the health center. When I asked how he had come to Nakivale, he explained that he was born in Ethiopia and belonged to the Anuak Tribe. As an ethnic minority within Ethiopia, his tribe had endured persecution time and again through the booms and busts of civilizations in the region, serving as slaves during the Abyssinian Empire to freedom but second class citizenry under a brief period of British rule to de facto servitude after the Ethiopian government regained authority of the region. In the 1970s, when he was relatively young, both his parents were killed during a forcible eviction of his tribe from their land in the Gambella region of Ethiopia. He was able to flee to South Sudan with a few of his siblings. He lived in a refugee camp in South Sudan until four years ago when violence erupted between the South Sudanese government and anti-governmental rebels. During an escalation in the conflict, rebels opened fire at the refugee camp, killing a few refugees. He made a one month and ten day journey crossing the northern Ugandan border and traversing hundreds of miles to the southwestern region of the country to reach Nakivale settlement. He made the journey with one of his brothers. One of his children and few of his siblings stayed in South Sudan. Somewhere along the journey, through an experience that I was too reluctant to inquire about, he was separated from his daughter. He has been unable to contact or gather any information about her since he fled South Sudan.

Trauma and mental health among forcibly displaced and conflict-affected refugee populations in Uganda

Hazar H. Khidir, M.D. 

Resident in PHS Emergency Medicine Residency 

PGY 2

June 18, 2019

What makes one want to leave their home? For refugees, it is the feeling of needing to flee from violence, poverty, and/or persecution. This impetus  is what fundamentally distinguishes refugees from other migrants.  Refugees flee whereas migrants immigrate. Thus, the pre-migration, perimigration, and post-migration experiences of refugees are uniquely marked by higher incidents of trauma. I understood this from by background research on incidents of trauma and prevalence of mental health illnesses (depression, anxiety, post-traumatic stress disorder) among refugee populations globally. My aim in traveling to Nakivale in person was to try to understand the forces of flight, migration experience, and the mental health outcomes of refugees on a more individual, human level. 

Nakivale Refugee Settlement was opened in 1958 and officially established as a settlement in 1960. Officially, based on UNHCR (the UN Refugee Agency) figures, Nakivale hosts > 100,000 refugees from Burundi, the Democratic Republic of Congo, Eritrea, Ethiopia, Rwanda, Somalia, Sudan, and South Sudan. During the Burundi crisis in 2015, the population of the settlement greatly increased and has since remained this high.

The settlement span across 185 km. It is at times both sparsely populated with small clusters of modest homes scattered across a large area of land and densely populated, informal shopping markets. The markets are impressive in scope, with hundreds of stalls. Stalls sell food, offer salon services, and locally manufactured goods such as metal gates, wooden bed frames, and cultural garb.

There are several individual communities within the settlement that are largely separated based on country of origin (i.e. Burundi Camp, Somali camp, Ethiopian camp, “New congo”). There are one or two camps that host an integrated community of refugees. Religion appears to be a factor that has resulted in self-segregation of the Somali refugee community from refugees of other nationalities.

There is also noticeable variation in socioeconomic status. There are those who have established successful shops and are relatively thriving and those who can’t afford enough food and are dependent on World Food Program distributions. All residents of Nakivale Settlement receive care from three clinics. These clinics off very basic medical testing but no imaging (including chest x-rays) or other diagnostics. The nearest referral center for the clinics is Mbarara’s University Hospital, the second largest referral hospital in Uganda.

Clinical Elective in Trauma Emergency Department at Groote Schuur Hospital, Cape Town, South Africa Part 2

Kelsy Greenwald, MD

Resident, Harvard Affiliated Emergency Medicine Residency

PGY 2

May 30, 2019

Bruising from a sjambok

The busiest times at Groote Schuur Hospital are weekend nights. On one such weekend night, we heard a bell go off, which would be a sign to everyone in the trauma section that a patient was being brought to the resuscitation unit. When we arrive, the EMS providers tell us this patient was involved in a community assault. This is a form of vigilantism. Distrustful of the local police force, a community mob will attack a person who was involved in a robbery or other crime. Instead of calling the police, the mob (often 20 or more people, including children) will take it upon themselves to punish the offender, often beating him with bricks, sticks, and sjambok (whips) until his family members call an ambulance or the police. Here you can see bruising marks from the sjambok.

The Lodox

The patient had multiple lacerations around his scalp, multiple skull fractures around his occiput, bilateral hemopneumothorax, right humerus and femur fractures, but luckily no intra-abdominal injuries. He was placed on a special stretcher that is used to take a full body x-ray with the special x-ray machine that is located right in the resuscitation room, the Lodox.

After receiving bilateral chest tubes, intubated, and given blood, he was stable enough to rush to the CT scanner (3 hallways away). Rather than a mobile ventilator, a doctor bags the patient the whole way, with epinephrine/adrenaline and fentanyl in their pocket. Only after first receiving a brain CT, showing a non-fatal head bleed, did the radiologist consent to further scans of the c-spine, chest and abdomen. The patient eventually went to the operating room with orthopedics. This was one of eight resuscitation patients of the night.

Clinical Elective in Trauma Emergency Department at Groote Schuur Hospital, Cape Town, South Africa.

Kelsy Greenwald, MD

Resident, Harvard Affiliated Emergency Medicine Residency

PGY 2 

Groote Schuur Hospital - a hospital situated in gorgeous Cape Town, overlooking one of the modern seven wonders of the nature. And yet, a violent area, with a homicide rate of 62 per 100,000, and in the poorest sub-district of Khayelitsha the rate is 120 per 100,000 people. For comparison, Detroit’s homicide rate is 40 per 100,000.

Groote Schuur Hospital is a government funded public hospital, where most patients pay little to nothing for their care. It is a tertiary hospital and is well respected for its trauma care.  Many visiting physicians come from around the world to train at GSH. The trauma center alone sees 1300 patients each month, with 50 beds in total and 10 high care beds. The trauma center sees both blunt and penetrating trauma, intentional gunshot and stab wounds and unintentional motor vehicle accidents. The number of gunshot wounds is high, averaging 70-80 per month.  Groote Schuur Hospital is the referral site for many of the surrounding hospitals as it is one of two hospitals in all of Cape Town with 24 hour access to CT scanner (though it is still at least a 5 min walk/run from the resuscitation area). 

Shifts in its trauma unit are run from 8am-6pm, and a night shift from 6pm-8am. Each shift usually has 2-3 registrars, or residents, and 2 interns. Attendings round with the residents at each shift change, but otherwise the registrars run the trauma center. Most registrars work roughly 50-60 hours per week. The trauma center is split into three sections: green (the most stable patients, left in chairs), yellow (those that require a stretcher), and resuscitation (those that require monitoring – codes, unstable vitals, penetrating trauma to the chest or abdomen, or those with Glasgow Coma Scales less than 14).

I spent my time doing 4 15-hour overnight shifts each week, from Thursday to Sunday, the times the most trauma occurred. I was able to learn from these incredible registrars who would see more trauma in one month than the residents in my home hospital would see all year. From crash chest tubes, to open skull fractures, hemorrhaging bleeds from stab wounds to the neck, and multiple chest and abdomen gunshot wounds, the registrars calmly and efficiently manage it all. I was incredibly impressed with the capabilities, knowledge, and courage of the South African residents.

Capacity Building in Rwanda

Jessica Crothers, MD

Fellow, Medical Microbiology, Brigham and Women’s Hospital

PGY7

May 30, 2019

Working in the Lab in Kigali, Rwanda

I went into medicine with all sorts of ideas about what my career would look like, not many of them very usual. Global health, anthropology, art therapy, women’s advocacy, integrative care, and innumerable other things that seemed to pop up by the month. I’ve always been like that, interested in most things that come my way.  But then I started the long road of medical training and I began to meet the neigh-sayers. Your career can’t look like that because of reimbursement. That sounds nice, but you don’t get that much time with patients. Academic careers won’t allow you to take that much time for international work. I began to feel trapped by the confines of real-life medical practice, but I always found ways to keep my secret career dreams alive.  My path rambled, as they all do, and I eventually found my way into a fellowship at BWH where I was introduced to the COE. I began going to dinners, symposiums and even applied for a travel grant. Through the Center I have met physicians with careers that look even more diverse and interesting than the dreams I had been quietly keeping alive. And, more importantly, I began to see how to make my dreams become reality.  The COE serves a powerful role as connector, facilitator and dream builder. I am incredibly grateful for the opportunities it’s afforded me, and the people it’s brought into my world. The career I once dreamed of is finally taking shape.