AN ANTHROPOLOGICAL DISSECTION OF POST-TRAUMATIC STRESS DISORDER IN CAMBODIAN REFUGEES

Cambodia is a low-income Southeast Asian country, with a population of 13 million, an estimated 85% of Cambodians live in rural areas and 33% of the population is subsisting on working wages of less than $1 US dollar per day (Guhadasan & Pises, 188). Due to scarcity of material resources and the global community’s belated response to social crises, the access to healthcare has become a privilege enjoyed by few because of its conditional nature determined by an individual’s capacity to pay. Access to healthcare is out of reach for many Cambodians, these facts are evident in the World Health Organization’s (WHO) report that continues to rank Cambodia very low in health indicators in comparison to other Southeast Asian countries. In this paper, I aim to address the medical inequality surrounding mental health diagnosis and treatment. In regards to post-traumatic stress disorder (PTSD) diagnoses, internationally recognized mental health assessment tests do not take cultural and historical contexts into consideration and this relationship has led to few resources allocated to mental health throughout the world. The World Health Organization (WHO) estimates that 75-85% of people in developing countries do not receive institutional mental health treatment and almost 33% of countries have no specific budget for mental health services. Writing from the medical anthropology perspective, I intend to focus on the historical context and social realities that characterize the rural Cambodian’s response to conflict-related PTSD occurrences. The urgency of this matter can no longer be ignored.

HISTORICAL CONTEXT

In 1975, Pol Pot and the Khmer Rouge took control of Cambodia and radically transformed the country. For three-and-a-half years, the Khmer Rouge implemented radical socioeconomic changes in order for Cambodia to make a “super great leap forward into socialism” (Hinton, Hinton, Eng & Choung, 386).  People were forced to relocate into rural areas and institutions were dismantled as the cities were emptied. Targeted as enemies of the state, doctors and lawyers fled the country or died from malnutrition or disease. It is estimated that approximately two million people died during the “reign of terror”, a product of continuous labor on starvation rations and psychological disturbances as speech, religion, travel, and communication were restricted. In 1979, the Vietnamese invaded and ended the Pol Pot period, leaving a decade-long civil war battle between guerrilla factions for control of the country. While “nearly a quarter of Cambodia’s 8 million inhabitants had died of disease, starvation, overwork, and execution” the world turned a blind eye to the atrocities that were occurring on the ground (Hinton, Hinton, Eng & Choung, 386).  The only response by world powers would be minimal international assistance and fierce sanctions by most western nations.

In 1991, the Vietnamese left Cambodia and the United Nations drafted a peace agreement between all factions to prepare for the elections of 1993. Despite these steps toward recovery, the destruction on Cambodia’s infrastructure and human resource capacity was so devastating that even today; the country is still working toward reconstruction. As a result of the exiting of legal and medical professions, access to medical care is out of reach for many Cambodians, with a majority of the population working on wages akin to extreme poverty, the choices come down to sustenance or medical expenses. According to the global health watch, about 20% of all healthcare financing comes from general revenues; the rest of medical expenditures are out-of-pocket (Global Health Watch, 64).

THE DEFINITION OF MENTAL HEALTH

Although mental illness is commonly thought of as the domain of developed countries, it is prevalent in resource-poor settings such as Cambodia, where their impact is compounded by a lack of medical training, diagnosis, and effective treatments. The WHO defines mental health as a “state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (Global Health Watch, 154). Mental health instability can be attributed to numerous factors; including food insecurity, unemployment, occupational health, conflict, lack of adequate housing, and mental healthcare services. It is within these social and economic factors that inequalities fester and continue to grow. It is well documented that widening inequalities “negatively affect the poorer and more marginalized sections of society to a greater degree” (Global Health Watch, 154). Within the rural communities of Cambodia where access to basic medical services is a hardship, the traumas inflicted as a result of conflict are remedied primarily by traditional healers who “have been, and continue to be, the mainstay of mental health care in many low-income countries” (Global Health Watch, 157).

In the article, “PTSD and Key Somatic Complaints and Cultural Syndromes among Rural Cambodians”, the reader examines the results of a needs assessment survey in rural Cambodia as part of a project labeled Victims of Torture (VoT). The purpose of the project was to document the experiences of the local people under the Khmer Rouge and to identify villagers with significant distress and provide the appropriate medical services. According to the article, little is known about mental health in Cambodia. Previous research was conducted using the Harvard Trauma Questionnaire (HTQ), which was deemed by researchers as not culturally sensitive in the context of rural Cambodia. Using a standard assessment tool labeled “C-SSI”, researchers sought to “assess somatic symptoms and cultural syndromes that are a key part of the response to trauma among Cambodian refugees but are not among the Diagnostic and Statistical Manual of Mental Disorders (DSM) PTSD symptoms” (Hinton, Hinton, Eng, & Choung, 385). While concept of theoretical importance defines the symptoms that we examine in the PTSD definition found in the DSM, it is important to examine the clinical utility of such assessment tests. To assume that a standardized assessment test can be implemented with the same success around the world is wholly inaccurate, local ideologies regarding health and wellness vary according to conditions, culture, and lived experiences.

CULTURAL FEATURES OF PTSD

The C-SSI assessment aims to identify somatic symptoms and cultural syndromes experienced by Cambodian refugees that are part of their response to trauma but not defined in the DSM PTSD symptoms. By examining the “biology of the trauma, ethnophysiology, cultural syndromes, metaphoric resonances, and trauma associations” researchers hope to holistically aid the Cambodian refugees who are suffering from PTSD (Hinton, Hinton, Eng, & Choung, 387). Some features of the test involve the assessment of dizziness, orthostatic dizziness (dizziness from standing), neck soreness, and heart weakness. To Cambodians, these symptoms are of more concern than the clinical markers used to diagnosis PTSD, which examines re-experiencing symptoms, avoidance symptoms, and hyperarousal (Hinton, Hinton, Eng, & Choung, 385).

In the case of dizziness, the historical context is important to consider. During the Pol Pot period, Cambodians were forced into slave labor while simultaneously starving to death, this caused “great dizziness”, Cambodians were often beaten by the Khmer Rouge or forced into watching executions and corpses as punishment; this form of torture brought a renewed sense of fear, nausea, dizziness. The most common form of slave labor was being forced to carry large loads of dirt at the neck on a pole; this caused extreme neck soreness and discomfort (Hinton, Hinton, Eng, & Choung, 391). Researchers have found that the cultural and historical context may be important in terms of diagnosis and treatment;“if a Cambodian now experiences one of these trauma-linked somatic symptoms for any reason… that somatic symptom may bring to mind the trauma event that featured the somatic symptom” (Hinton, Hinton, Eng, & Choung, 393).

KYÂL ATTACKS & HEART WEAKNESS

Cambodians believe in a potentially pathogenic element called Kyâl. In a healthy individual, Kyâl flows throughout the body alongside blood and exists by passing through every pore in the body, exiting by the action of burping and flatulence. When Kyâl is disturbed it surges upward in the body, causing dizziness, blurry vision, headaches, nausea, neck soreness, shortness of breath, cold bodily extremities, and energy depletion (Hinton, Hinton, Eng, & Choung, 394). These “Kyâl attacks” are greatly feared by all Cambodians. Another SSI syndrome is heart weakness. For Cambodians, “breathing is thought to be driven by a piston-like action of the heart" (Hinton, Hinton, Eng, & Choung, 395). Heart weakness, which is thought to precipitate cardiac arrest, is of major concern to Cambodians and a deep stressor for individuals who are faced with issues that contribute to stressful existences such as extreme poverty and malnutrition. Rural Cambodian refugees have drastically different trauma ontology than that of western populations. Local PTSD diagnoses are comprised of heavy importance on certain somatic symptoms such as dizziness, orthostatic dizziness, and neck soreness; and incidences of unique cultural syndromes, such as Kyâl attacks, Kyâl overload, and heart weakness (Hinton, Hinton, Eng, & Choung ,399).

MEDICAL ANTHROPOLOGICAL CONCEPTUALIZATION OF CAMBODIAN PTSD

It has been well-documented in medical research that there has been continuity in trying to address the issue of “culture against the success of the diagnostic construct of PTSD and even against the general psychiatric conception of trauma” (Rechtman, 2). In Margret Lock’s essay “Medical knowledge and Body Politics”, Lock explains the discourse of medicine and culture in relation to historical narratives. “People everywhere have amassed knowledge and practices designed to preserve health, account for the occurrence of illness, and provide therapeutic relief” (Lock: 190). The body is a biological entity and also a manifestation of history. It is a site of resistance and conformity to culture. Lock argues that medicine has currently become a part of society and its form and purpose is shaped by societal values, customs, and language.

Health, wellness, and healing are embedded within individual experience and are affected by cultural and social context. In class we learned that “It is not always just about the individual, it’s about how we experience the world around us and how other people treat us and these are embedded into our beliefs systems and cultures” (Cade Cannon, lecture). In regards to mental health treatment, the idea of legitimacy is significant because the social perception of suffering determines whether it is medicalized or stigmatized.

In rural Cambodia, where researchers know PTSD exists in mass quantities, an explanatory model of the occurrence of PTSD is vital to understanding what part of the population is tormented by this disorder. The local perception of PTSD is different in terms of semantics and behavior toward the illness. Local healthcare providers focus on culturally-defined symptoms such as heart weakness and dizziness; and I should note that lack of medical terminology does not invalidate the suffering of the rural Cambodians who experience PTSD. It is not clear if the emphasis on traditional healers in the case of mental distress is a product of financial restriction to institutional healthcare or simply cultural preference; the impact of socioeconomic status is vast and individualized so perhaps we may never be able to fully understand. The context of perception is important simply because it helps identify local ideologies about health and the hierarchy of resort in the pursuit of wellness.

The restriction of impoverished populations to healthcare is another stark example of biopolitics at work; which is defined as regulation through power of health and life. In the face of conflict, whole families were forced to flee into the forests and to take shelter among the foliage in an effort to preserve their own life and protect their loved ones. The government assassinated all medical professionals and educated individuals, anyone who they saw as a threat to control the whole population’s access to health and human rights to life. People were starved, beaten, overworked and forced from their families in an effort to work toward socialism and political gain. The medical anthropology concepts of biopolitics have played an immense role in my own understanding of the lack of healthcare services in Cambodia. With little access to a salary worthy of comfortably providing for a family, citizens of Cambodia (rural or otherwise) are subjected to structural violence’s of their government and international agencies.

After examining the implementation of mental health and PTSD assessment in Cambodia, I have come to understand that the politics of social change starts at the ground. The incidence of PTSD in Cambodian refugees is well-documented in countries such as France, Australia, and the United States but little has been documented in Cambodia itself. (Rechtman, 2). The incidence of mental health disturbances in Cambodia isn’t even mentioned in the WHO statistics, they cite that “The number and density of psychiatrists are the most widely available and reliable indicators of the human resources available to mental health services”, however as we have learned from this paper, the sheer number of individuals who utilize the medical system does not reflect the actual need for the services (WHO statistics, 122).

CONCLUSION

In order for mental health problems to be remedied, effective responses “need to take place at individual, local, national, and international levels, and involve all members of society as well as health professionals” (Global Health Watch, 159). The extreme poverty in Cambodia restricts the rural refugees from utilizing life-sustaining healthcare treatments. In a country where nearly a third of the population subsists on less than US$1 dollar a day and average annual out of pocket expenditure is US$49 dollars per person, biomedical assistance will always be a privilege enjoyed by the wealthy and the continuation of unfair biopolitics will persist. During the next few decades, as these countries develop and the burden of conflict-related PTSD occurrences begins to subside, the contribution of mental disorders to the family unit will become increasingly apparent in the psyche of future generations. Consequently, there is a major need for healthcare professionals, medical faculties and aid agencies to start to consider and to act on, these problems now.

BIBLIOGRAPHY

1.      World Health Organization (2012). World Health Statistics Report. Geneva: WHO. Available at:http://www.who.int/gho/publications/world_health_statistics/EN_WHS2012_Full.pdf

2.      Global Health Watch (2011). Global Health Watch 3: An Alternative World Health Report. Available at:http://www.ghwatch.org/sites/www.ghwatch.org/files/global%20health%20watch%203.pdf

3.      Hinton, D. E., Hinton, A. L., Eng, K.-T. and Choung, S. (2012), PTSD and Key Somatic Complaints and Cultural Syndromes among Rural Cambodians: The Results of a Needs Assessment Survey. Medical Anthropology Quarterly, 26: 383–407. doi: 10.1111/j.1548-1387.2012.01224.x

4.      Margaret Lock, 2002, “Medical Knowledge and Body Politics.” In Exotic No More: Anthropology on the Front Lines, ed. Jeremy MacClancy (Chicago: University of Chicago Press), 190-208.

5.      Cannon, Cade. "What is Medical Anthropology" University of Washington, Architecture Hall Room No.147, Seattle, WA. 08 2012. Lecture.

6.      Rechtman, R. (2006). The survivor’s paradox: Psychological. Taylor and Francis Group, 13(1), 1-11.

7.      Trankell, I. (2004). French colonial medicine in Cambodia: reflections of governmentality. Anthropology And Medicine, 11(1), 91-105.