治疗遭受暴力创伤的受害者

NEW YORK — An estimated one billion people around the world have experienced mass violence, torture or terrorism and are suffering from post-traumatic stress disorder, depression and anxiety. Some are unable to work or care for themselves or their families. Now, a small American foundation, begun by the family of a victim of the September 11 attacks, is establishing trauma clinics in poor countries scarred by violence.

New Yorker Liz Alderman and James Okello, a child psychiatrist visiting from Uganda, would never have met if not for tragedy. Her youngest son, Peter, was killed in the September 11th attacks on the World Trade Center.

"He did not work in the building, he was there for a meeting, and he was 25 years old when he died. My husband and I needed to create a memorial for him, to leave a mark that he had existed and that the world would be a better place because Peter had lived," Alderman said.

Watching a TV show one night, she and Peter's father, Stephen Alderman, stumbled on the idea of bringing mental health care to people in poorer countries traumatized by mass violence and terrorism. The first Peter C. Alderman Trauma Treatment Clinic opened in Cambodia in 2005.

"In the first year, we had 4,000 patient visits, and and a 14-month waiting list, so we opened a second clinic 18 miles down the road the next year," she said.

"People often ask us why are you seeing patients in Cambodia? I mean Pol Pot was 30, 35 years ago," she said. "Traumatic depression doesn't go away. You see this in children of Holocaust survivors. Traumatic depression can go from one generation to the next, and unless you treat it, it's still there.

"We are dealing with people who have been so traumatized by what they have experienced that they can no longer function," Alderman said. "If people don't care whether they live or die, they're not going to be able to follow the very difficult HIV/AIDS regimen, they're not going to walk the extra mile for potable water. A lot of our patients can't even get out of their beds.

In Uganda, where there are four clinics, patients include many former child soldiers and others abducted into war over two decades by the Lord's Resistance Army. James Okello directs the clinic in Gulu, in the North, which helps patients through counseling, group therapy and psychopharmacology.

"If there's no form of intervention, with almost every trauma there's going to be a problem. We sometimes talk about delayed post-traumatic stress disorder. That's the concept that, when the guns stop firing, the mind starts firing. So, a lot of things happen when the emergency situation is long gone," he said.

Okello is one of only four child and adolescent psychiatrists in Uganda, he said.
Most of the country's 32 other psychiatrists work in the capital city region.

"Fortunately, the mental health problems we see in children and adolescents tend to be self-limiting, if you can provide them with a child-friendly space, psycho-social program interventions, and re-connect them with their families. A lot of these children are very resilient, and by the nature of the African setting, people are more communal, so there is some semblance of normality coming back, in terms of family structures," he said.

Even so, he said, the incidence of post-traumatic stress disorder is very high in northern Uganda, and about five percent of those affected will not recover without help, which often includes antidepressants or antianxiety medications. Psychological education is also important, he said.

"We try to explain to people that their experience of trauma is the abnormal thing, and the reactions, the symptoms, are a normal physiological reaction," he said. "I think there's where we have a big fight with the Western world about pathologizing normative responses. One of the key factors is when patients realize the symptoms they are experiencing are actually normal. That is a first step to recovery," he said.

The clinics are set up in partnership with each country, and staffed solely by indigenous healthcare givers who understand traumatic mental illness in medical terms and according to local culture.

"We use cultural idioms to express the same Western symptoms," Okello said. "You start from their perspective, their own understanding of what is happening to them. [A patient might] say, 'I am bewitched,' or 'I am experiencing spirit possession,' or 'I didn't do any rituals.' And then, if you see there's a big fit with the Western model, you explain it to them. So, I think anybody who is not culturally literate, who does not understand the culture, you're likely to miss a lot or even over-diagnose, depending on which tool you're using.

The Peter C. Alderman Foundation also has a clinic in the Kibera slum in Nairobi, Kenya, and has worked in Rwanda, Liberia and Haiti. It holds an annual training and research conference in Africa in July, and funds a new medical publication, the African Journal of Traumatic Stress. Alderman says more than 200 indigenous health care professionals have been trained, who have gone on to teach many others, and care has reached more than 75,000 patients.