The End of my Blog-- for now

As I indicated in an earlier post, difficulties with my temporary employment permit put me in a position of choosing between a planful exit a month earlier than I had anticipated or spending several days and about $1000 of the university's money to renew my tourist visa and to continue to assume that I would not be hassled for teaching with it.  I was so close to finishing in the time frame of my first tourist visa that I opted to have one extra class period per class the week of April 9 and to leave Zimbabwe April 14th, the day before my tourist visa was set to expire.

People have asked me about the experience overall and whether I would do something like this again.  My answer is that I learned a great deal, got to work with some very interesting (and interested) students, met some people whom I will count as friends for the rest of my life, and overall had a good experience.  I told the vice chancellor and the dean that I would be happy to return to Africa University again, perhaps even next year, if (1) the temporary employment permit situation can be sorted out  and (2) if the political situation permits. I don't want to spend money and 4 days out of every 30 to maintain a status that is not meant for teaching, even volunteer teaching, and which might lead to difficulties with the government.  I have a crystal ball that is notoriously cloudy, and I don't know what the political situation holds for Zimbabwe.  I can imagine some scenarios in which it would be possible to return next year, and some in which that would not be prudent.  I'll just have to wait to see.

For now, I have nothing more that I want to write for this blog.  If you're reading this post, it's a fair bet that it's the last. . . until the next time.  Thanks for reading!  Maggie

Teaching (and learning) about Trauma in Zimbabwe

I was privileged to be able to co-teach a graduate course in trauma in a program in Child and Family Psychology, which is designed to train mental health professionals at the masters’ level.  My mentor for this w

I was privileged to be able to co-teach a graduate course in trauma in a program in Child and Family Psychology, which is designed to train mental health professionals at the masters’ level.  My mentor for this was an anthropologist who is a full-time faculty member at Africa University, and whose work over the past decade has been focused on two issues: mass trauma and the experiences of children who have HIV/AIDS.  I clearly learned much more than I taught in this class.

The other instructor argued strongly that Post Traumatic Stress Disorder (PTSD) is a conceptualization originating in Western culture and not particularly applicable to sub-Saharan Africa.  He had us read numerous critiques of PTSD, which partly focused on important things like the inherent but unrecognized culture biases in the diagnostic criteria.  (I think that argument could be made for most of the current diagnostic categories, and he acknowledged that sub-Saharan Africa has contributed little to date to the research literature and the discussion and formulation of diagnoses, so has to share responsibility for the lack of representation of that region’s experiences and conceptualizations in the diagnostic manual. 

We talked a lot about mass traumas in Africa.  The best known to Westerners is the genocide in Rwanda in 1994, in which 800,000 Tutsis were massacred by the majority Hutus.  However, Zimbabwe has had its share of traumas.  The Second Chimurenga (from the Shona word meaning “fight” or “struggle”), lasted from 1966-1979, and involved displacement and restriction to certain guarded areas and extremely meager circumstances for many natives.  Independence in 1980 turned out not to be the end of oppression, however:

·        In 1987, there was an action by Robert Mugabe’s government to slaughter about 20,000 civilians, mostly minority Ndebele, in Matabeleland.  This was called the gukurahundi (in Shona “the early rain which washes away the chaff”).  I’d never heard of this, and suspect I’m in good company in that respect.  The remaining Ndebele, who comprise 14% of Zimbabwe’s population (compared to the Shona’s 85%), remain chronically hypervigilant about their status, because they tend to be viewed by the leaders of ZANU-PF, the dominant political party, as opposition.

·        In 2000, Zimbabwe land reform went from a gradual process that depended upon having willing buyers and willing sellers to a “fast track” system, in which white settlers (and their farm workers of local descent) were often forced off their land, which was then given to war veterans and ZANU-PF supporters.  There was a lot of intimidation, threats of deaths, and enough deaths to keep the tension high associated with this.  The process has continued intermittently for the past twelve years, with the effect that no white farmers feel safe, and most debate every time they think about making an improvement or planning a crop what the likelihood is that they’ll still own the land for long enough to recover the expense.

In addition to these major traumas, there are many individual ones.  I heard about maybe a dozen, and will share just two here:

·        A man I met while touring told me that in 2000, his parents were killed by ZANU-PF because they were believed to have been recruiting votes for the opposition part.  ZANU-PF soldiers encircled their home with wire so they couldn’t get out, poured petrol on it, and lit it.  The man I talked to was in his mid-20’s at the time and was also sought, so he fled the country and stayed away for almost two years before returning.  He had five younger siblings who were all still children, and therefore not targets.  They remained in Zimbabwe and were cared for by relatives.  He’s still trying to pick up the pieces of his life and reconnect with his remaining family.

·        A student told me about being taken from her work by ZANU-PF interrogators because of her association with a woman friend of hers during the time when that woman’s husband was dying.  He apparently had been engaged in opposition activities.  My student was held, but was allowed to use the restroom at one point and managed to get a message out so that help arrived for her.  She continued to be fearful at work, however, and eventually quit her job because of her anxiety about being singled out for interrogation.

There is a real struggle to try to depict the Zimbabwean experience.  One of the graduate students in the trauma course talked about a community outreach event she participated in, in which people started out talking about a cycle of violence and ended up renaming it “cycle of disappointment”.  Grief over loss and disappointment over the government seemed to be major themes.  Most of what they discussed would not meet the diagnostic criteria for PTSD, and shouldn’t necessarily be pathologized if people are functioning adequately.  The student reported that in one group where this issue was discussed, participants began talking about “emotional suffering” as a persistent pattern for many Zimbabweans.

The trauma, or suffering, or whatever we choose to call it, is compounded for Zimbabweans, in my opinion, by restrictions in the range of affect they have been allowed to express.  In talking with a community leader about a proposed seminar to help Early Childhood Development (ECD) educators help children deal with their emotions, I mentioned that I think of three basic emotions (sad, mad, and happy) from which all others are derived.  She thought about it and said that Shona are allowed two emotions, happy and mad.  Then she thought some more and said that they’re allowed “mad” only under some restricted circumstances.  I’ve heard the stereotype of the happy Africans for decades, but had never realized that it might have developed out of the restrictions on expression of other emotions.  These restrictions are rooted in culture, which makes them difficult.

For example, Shona people don’t express grief when loved ones die.  Within hours, they’ve put on their happy faces and gone on with life.  I discovered that the basis for this is a traditional belief in the nzuzu, the water spirits.  These spirits not only control rainfall, but I was told that the traditional Shona explanation of death is that the nzuzu abduct people and take them to an alternative world with crops and trees, sky and rain.  The nzuzu also come back and listen at the doors or windows of loved ones of the person they’ve abducted.  If they hear crying, they kill the abducted person.  What a powerful belief to squelch expressions of grief!  If a person expresses grief outwardly, they may be responsible for the death of their loved one.  In Zimbabwe, 25% of people say they are Christian, 24% adhere to traditional indigenous beliefs, and 50% identify themselves as “syncretic”, meaning that their beliefs are a mixture of Christian and traditional elements.

Because of the difficulty with outward expression of grief and, to a lesser extent, anger, Zimbabweans experience many more somatic symptoms (e.g. headaches, stomachaches, fatigue) associated with distress than I’ve ever experienced with other groups of people.  This is true of children as well as adults. 

There are special challenges in helping people who have experienced trauma (or persistent grief, or emotional suffering) in Zimbabwe.  Their situation is not safe, and cannot readily be made safe.  Threats of death and actual deaths of individuals suspected of opposition activity continue.  Much of Mutare was locked down when Robert Mugabe arrived to celebrate his 85^th birthday, as members of the Desert Southwest Conference delegation in the city during that time can attest.  I’m told that schools at all levels, from ECD through university level, will close for several weeks before the next election, and foreign NGO’s will have employees leave the country.  This is because prior to past elections, ZANU-PF enforcers have threatened and beaten teachers and others suspected of being sympathetic to the opposition (and anyone with education or social services jobs is suspect).  It is safer to abandon the schedule, close services, and resume them again after the election.

On a day-to-day basis, the attention paid by everyone in Zimbabwe to surroundings and people present is difficult for an American to imagine.  To get the 10 km from Mutare to Africa University meant having the potential to be stopped at three different check points.  Police have the right to search cars at any time.  They often charge “spot fines” for minor infractions, which may not correspond with law.  Once some police tried to charge a fine to a passenger in the back seat of a car in which I was riding because she didn’t have a seat belt on, but I’m told there’s no seat belt law in Zimbabwe.  Another person was hauled out of his car and sat by the side of the road for about an hour before paying a $100 spot fine because of a car registration that had expired, but was within a 3-day renewal grace period which is officially sanctioned. It is widely known that spot fines, of which no official records are kept, are simply graft on the part of police officers.  Additionally, everyone is constantly aware of their setting and who is within earshot, and factors that into what they say.  I was told that every class has at least one member who is CIO (sorry, I don’t know what that stands for—it’s a ZANU-PF informant).  If I wanted to talk politics with someone, I waited until we were alone in a car, or maybe in their home, though some people are even careful about what they say at home because house help or another family member might be CIO. 

This has been a bit rambling because the current context in Zimbabwe and the experiences of Zimbabweans since independence have been complex.  There are many interlocking pieces which contribute to people’s experiences of trauma, violence, disappointment and suffering.  Americans have had a few—9/11 and the bombing of the Murrah Building in Oklahoma City in 1995 come to mind.  But with the exception of the first few weeks after 9/11, I don’t believe I’ve lived with the kind of uncertainty and sense of threat that is present for many people in Zimbabwe all the time.  Thank God we don’t have to, and pray to God for relief from this kind of pressure in the lives of Zimbabweans.
as an anthropologist who is a full-time faculty member at Africa University, and whose work over the past decade has been focused on two issues: mass trauma and the experiences of children who have HIV/AIDS.  I clearly learned much more than I taught in this class.

The other instructor argued strongly that Post Traumatic Stress Disorder (PTSD) is a conceptualization originating in Western culture and not particularly applicable to sub-Saharan Africa.  He had us read numerous critiques of PTSD, which partly focused on important things like the inherent but unrecognized culture biases in the diagnostic criteria.  (I think that argument could be made for most of the current diagnostic categories, and he acknowledged that sub-Saharan Africa has contributed little to date to the research literature and the discussion and formulation of diagnoses, so has to share responsibility for the lack of representation of that region’s experiences and conceptualizations in the diagnostic manual. 

 We talked a lot about mass traumas in Africa.  The best known to Westerners is the genocide in Rwanda in 1994, in which 800,000 Tutsis were massacred by the majority Hutus.  However, Zimbabwe has had its share of traumas.  The Second Chimurenga (from the Shona word meaning “fight” or “struggle”), lasted from 1966-1979, and involved displacement and restriction to certain guarded areas and extremely meager circumstances for many natives.  Independence in 1980 turned out not to be the end of oppression, however:

·         In 1987, there was an action by Robert Mugabe’s government to slaughter about 20,000 civilians, mostly minority Ndebele, in Matabeleland.  This was called the gukurahundi (in Shona “the early rain which washes away the chaff”).  I’d never heard of this, and suspect I’m in good company in that respect.  The remaining Ndebele, who comprise 14% of Zimbabwe’s population (compared to the Shona’s 85%), remain chronically hypervigilant about their status, because they tend to be viewed by the leaders of ZANU-PF, the dominant political party, as opposition.

·       In 2000, Zimbabwe land reform went from a gradual process that depended upon having willing buyers and willing sellers to a “fast track” system, in which white settlers (and their farm workers of local descent) were often forced off their land, which was then given to war veterans and ZANU-PF supporters.  There was a lot of intimidation, threats of deaths, and enough deaths to keep the tension high associated with this.  The process has continued intermittently for the past twelve years, with the effect that no white farmers feel safe, and most debate every time they think about making an improvement or planning a crop what the likelihood is that they’ll still own the land for long enough to recover the expense.

 In addition to these major traumas, there are many individual ones.  I heard about maybe a dozen, and will share just two here:

·         A man I met while touring told me that in 2000, his parents were killed by ZANU-PF because they were believed to have been recruiting votes for the opposition part.  ZANU-PF soldiers encircled their home with wire so they couldn’t get out, poured petrol on it, and lit it.  The man I talked to was in his mid-20’s at the time and was also sought, so he fled the country and stayed away for almost two years before returning.  He had five younger siblings who were all still children, and therefore not targets.  They remained in Zimbabwe and were cared for by relatives.  He’s still trying to pick up the pieces of his life and reconnect with his remaining family.

·         A student told me about being taken from her work by ZANU-PF interrogators because of her association with a woman friend of hers during the time when that woman’s husband was dying.  He apparently had been engaged in opposition activities.  My student was held, but was allowed to use the restroom at one point and managed to get a message out so that help arrived for her.  She continued to be fearful at work, however, and eventually quit her job because of her anxiety about being singled out for interrogation.

 There is a real struggle to try to depict the Zimbabwean experience.  One of the graduate students in the trauma course talked about a community outreach event she participated in, in which people started out talking about a cycle of violence and ended up renaming it “cycle of disappointment”.  Grief over loss and disappointment over the government seemed to be major themes.  Most of what they discussed would not meet the diagnostic criteria for PTSD, and shouldn’t necessarily be pathologized if people are functioning adequately.  The student reported that in one group where this issue was discussed, participants began talking about “emotional suffering” as a persistent pattern for many Zimbabweans.

 The trauma, or suffering, or whatever we choose to call it, is compounded for Zimbabweans, in my opinion, by restrictions in the range of affect they have been allowed to express.  In talking with a community leader about a proposed seminar to help Early Childhood Development (ECD) educators help children deal with their emotions, I mentioned that I think of three basic emotions (sad, mad, and happy) from which all others are derived.  She thought about it and said that Shona are allowed two emotions, happy and mad.  Then she thought some more and said that they’re allowed “mad” only under some restricted circumstances.  I’ve heard the stereotype of the happy Africans for decades, but had never realized that it might have developed out of the restrictions on expression of other emotions.  These restrictions are rooted in culture, which makes them difficult.

 For example, Shona don’t express grief when loved ones die.  Within hours, they’ve put on their happy faces and gone on with life.  I discovered that the basis for this is a traditional belief in the nzuzu, the water spirits.  These spirits not only control rainfall, but I was told that the traditional Shona explanation of death is that the nzuzu abduct people and take them to an alternative world with crops and trees, sky and rain.  The nzuzu also come back and listen at the doors or windows of loved ones of the person they’ve abducted.  If they hear crying, they kill the abducted person.  What a powerful belief to squelch expressions of grief!  If a person expresses grief outwardly, they may be responsible for the death of their loved one.  In Zimbabwe, 25% of people say they are Christian, 24% adhere to traditional indigenous beliefs, and 50% identify themselves as “syncretic”, meaning that their beliefs are a mixture of Christian and traditional elements.

 Because of the difficulty with outward expression of grief and, to a lesser extent, anger, Zimbabweans experience many more somatic symptoms (e.g. headaches, stomachaches, fatigue) associated with distress than I’ve ever experienced with other groups of people.  This is true of children as well as adults. 

There are special challenges in helping people who have experienced trauma (or persistent grief, or emotional suffering) in Zimbabwe.  Their situation is not safe, and cannot readily be made safe.  Threats of death and actual deaths of individuals suspected of opposition activity continue.  Much of Mutare was locked down when Robert Mugabe arrived to celebrate his 85^th birthday, as members of the Desert Southwest Conference delegation in the city during that time can attest.  I’m told that schools at all levels, from ECD through university level, will close for several weeks before the next election, and foreign NGO’s will have employees leave the country.  This is because prior to past elections, ZANU-PF enforcers have threatened and beaten teachers and others suspected of being sympathetic to the opposition (and anyone with education or social services jobs is suspect).  It is safer to abandon the schedule, close services, and resume them again after the election.

On a day-to-day basis, the attention paid by everyone in Zimbabwe to surroundings and people present is difficult for an American to imagine.  To get the 10 km from Mutare to Africa University meant having the potential to be stopped at three different check points.  Police have the right to search cars at any time.  They often charge “spot fines” for minor infractions, which may not correspond with law.  Once some police tried to charge a fine to a passenger in the back seat of a car in which I was riding because she didn’t have a seat belt on, but I’m told there’s no seat belt law in Zimbabwe.  Another person was hauled out of his car and sat by the side of the road for about an hour before paying a $100 spot fine because of a car registration that had expired, but was within a 3-day renewal grace period which is officially sanctioned. It is widely known that spot fines, of which no official records are kept, are simply graft on the part of police officers.  Additionally, everyone is constantly aware of their setting and who is within earshot, and factors that into what they say.  I was told that every class has at least one member who is CIO (sorry, I don’t know what that stands for—it’s a ZANU-PF informant).  If I wanted to talk politics with someone, I waited until we were alone in a car, or maybe in their home, though some people are even careful about what they say at home because house help or another family member might be CIO.  There's a reason I didn't post this while I was in Zimbabwe.

This has been a bit rambling because the current context in Zimbabwe and the experiences of Zimbabweans since independence have been complex.  There are many interlocking pieces which contribute to people’s experiences of trauma, violence, disappointment and suffering.  Americans have had a few—9/11 and the bombing of the Murrah Building in Oklahoma City in 1995 come to mind.  But with the exception of the first few weeks after 9/11, I don’t believe I’ve lived with the kind of uncertainty and sense of threat that is present for many people in Zimbabwe all the time.  Thank God we don’t have to, and pray to God for relief from this kind of pressure in the lives of Zimbabweans.

Reproductive Health in Zimbabwe

I haven't written about the content I taught while in Zimbabwe.  I guess I needed to get past teaching my courses in reproductive health (for masters' level MPH students) and family health (for undergraduates in a program training them to be administrators in small health clinics so that I could give some thought to the material I taught.

It's been a rocky road for Zimbabwe in terms of its health care in general.  Before Zimbabwe became an independent country in 1980, the quality of people's health care depended largely upon race, and also upon whether a person lived in a city.  Whites and urban dwellers got pretty decent health care, and most other people did not.  Then there was a period of about ten years in which Robert Mugabe and his government tried to rectify that situation by putting more money into rural health care and providing universal free maternity and child health care.  The result was a decline in infant mortality (often taken as a good indicator of the overall health of a country) from 70.4/1000 in 1978 to a low of 50.2/1000 in 1988. (For comparison, the US, which has been criticized for its high infant mortality in the context of developed countries, was 6.1/1000 in 2005, and has been relatively steady for decades.)  At that point policies reversed, and women began having to pay fees for prenatal care, delivery with a skilled birth attendant present, and neonatal and infant care.  As a result, earlier progress was eroded.  Throughout its history since independence, maternal mortality has been high in Zimbabwe.  In 2006 it was 555/100,000, compared to the US's 12.7/100,000.  A more graphic way of presenting this information is the lifetime risk of maternal mortality for women.  In 2008 is was 1:42 for Zimbabwean women and 1:2100 for US women.

During the period since Zimbabwe's independence, its birth rate has steadily declined from 47/1000 women of childbearing age to 29/1000 (compared to 14/1000 in the US).  Over 21% of Zimbabwean women are mothers or currently pregnant at least once as teenagers, which is very high.     In the 1980's, the HIV/AIDS epidemic hit Zimbabwe, and by 1995, more than 25% of the adult population was infected.  This put a tremendous strain on health care systems, which has continued to the present day.  Largely as a result of the HIV/AIDS epidemic, there are many orphans in Zimbabwe (980,000 estimated in 2003, out of a population of about 12,000,000), and many children being cared for by grandparents or other relatives even if not orphaned because of parental incapacity due to HIV/AIDS.  Only 52% of the population is in the age range (15-64) that usually is responsible for the financial support of everyone, compared to 67% of the population in that age range in the US.  Malnutrition in childhood is an issue: in 2006, 36% of children under 5 years of age were malnourished (height for age), compared to 3.9% in the US, and more than 7% were wasting, compared to .6% in the US.

It is challenging for a sub-Saharan African country with such devastating health statistics and such a precarious economy to make progress on health issues.  As you've seen in some photos in earlier blog posts, equipment is rudimentary at best in rural health clinics.  People often don't seek medical services.  Although there are a small proportion of Zimbabweans who won't use medical services due to religious convictions, lack of money is a far greater factor in people's decisions to postpone or avoid medical treatment. Zimbabwe is a country with a per capita income estimated at $500, compared to $21,587 in the US.  In 2009, the per capita health expenditure in Zimbabwe was $6, compared to $7410 in the US.

Teaching reproductive health in the Zimbabwean context was a challenge.  The class and I had to focus on inexpensive interventions, and to think about how to make those interventions acceptable in the cultural contexts of the countries of my students.  I learned about sexually transmitted infections I'd never learned about in graduate school because they just aren't found in developed countries.  I had to scale back my expectations about routine health care when I learned that very few women ever get Pap smears, much less mammograms.   I learned about current thinking about how to minimize parent-to-infant transmission of HIV/AIDS, again in the context of Zimbabwe (where most mothers don't even know their HIV status). It was a challenge, but one from which I learned a great deal.  My thinking is much more flexible now than it was before, and I respect the barriers in sub-Saharan Africa to providing the kind of health care that I believe all people deserve.
I have no comprehensive answers to the challenges faced in Zimbabwe and the rest of sub-Saharan Africa when it comes to reproductive health.  I'd worry about me if I thought I had the answers.  What I have is a great deal more information about the nature of the challenges, and a huge amount of respect for the health professionals who work every day to try to overcome them.  I feel blessed to have been a part of the development of a few of these professionals, and wish them well in their efforts to develop programs and health clinics that make good use of the few dollars available to them to do the most good for the most people they can.  That's all anyone can do.