The Many Faces of Global Trauma

July 10, 2021   •   By Khameer Kidia

I WAS SWAMPED during a busy ICU night shift in April 2020. We were in the early stages of the pandemic in Boston and the unit was filled with the bleeping of ventilators and whirring of dialysis machines: the din of lives and deaths prolonged. I nearly missed the vibrating WhatsApp message. I hear you work on mental health in Zimbabwe, it said. Can you help us?


A team of organizers had added over 250 Zimbabwean doctors from around the world to a WhatsApp group. They wanted to create a platform so that we could support one another as we navigated the pandemic’s uncertainties.


Though the group started out debating hydroxychloroquine, early intubation, and ventilator modes, it soon turned to the emotional toll of the pandemic. In unpunctuated messages, members shared their fears (“what if i get sick”) and concerns (“how do i treat patients without oxygen”). The group called itself “Dr. Batanai” — batanai, in Shona, means “coming together.”


The organizers wanted my help with physician well-being. For the last decade, I have been bisected by two worlds: at home in Zimbabwe, I am a mental health researcher and activist; in the United States, I work as a physician. I travel back and forth, my loyalty divided. There is a community in Zimbabwe that raised me, and there are my patients in the US who feel no less in need. The organizers were pressing on my soft spot for the former.


At first, I was reticent. Night shifts in the ICU were wearing me down and I could barely cope with the emotional weight of the pandemic in Boston, let alone think about home. But when the organizers persisted, I agreed to meet with a group of doctors in Zimbabwe to see if I could be helpful. What, after all, could marry my two worlds better than physician mental health in Zimbabwe?


¤


I held the Zoom for Zimbabwean physicians on my day off from the ICU. More than 30 people attended. After an ice breaker, I asked participants to share their concerns.


Silence.


Silence, in America, is virtually intolerable. But for Zimbabweans it’s not awkward; we can stand long periods of quiet to let the moment gestate, to wait and see what is born.


A junior doctor working in a rural hospital eventually piped up. “I’m scared.”


An eruption of emotion followed, like I had lifted a soda can that had been sitting on a shelf for years, shaken it vigorously, and then cracked it open. Soon, many other doctors joined the conversation, sharing their stories from the previous month in the hospital.


I did what I had been taught at medical school in America: I listened. Sometimes, I validated (“I can’t imagine how hard that must be”). Other times, I named feelings (“It sounds scary”). Unwittingly, I felt myself drawing from the psychiatric vernacular prevalent in American pop culture — what writer Katy Waldman recently termed “Therapy-Speak.” I thanked participants for their vulnerability. Asked them to be non-judgmental. Called for moments of silence. “Held space.” But mostly, I listened.


Finally, I asked the question I had set out to ask in the first place: “What do you need?”


The response was unanimous: Zimbabwean doctors liked Therapy-Speak. They wanted more opportunities like these, where they could share their experiences, process them, feel heard. We scheduled another session for the same time the following week. Without intending to, we had started a peer support group.


¤


By May 2020, health-care worker wellness became a top concern in the United States. At my hospital in Boston, psychiatry faculty offered free therapy sessions. We had wellness meetings led by peers, therapists, and some of the country’s experts in physician burnout. Japanese pastries and gourmet grilled cheese sandwiches filled our workrooms, delivering fleeting delights during difficult shifts. Administrators working from home made attempts at solidarity by sending us free sweatshirts and office supplies emblazoned with the hospital logo. Over Zoom, Sarah Jessica Parker told us how brave we were, and Yo-Yo Ma played his cello.


Meanwhile, in Zimbabwe, there was no analogous physician wellness craze. As far as I could tell, our weekly Zoom support group was the wellness craze. Some of the experiences and emotions expressed in the Zimbabwe Zooms were like those from our Boston wellness meetings: exhaustion, fear of the unknown, isolation. But many of the hardships that Zimbabwean doctors faced were very different. Those living in high-density areas struggled to physically distance. They also complained about low salaries. Most young government doctors, after years of training, earned less than $300 a month — and so, much like the country’s general population, they could barely put food on the table. For comparison, at my hospital, medical residents make more than $5,000 a month.


Operating in a medical education system created under British colonialism, the Zimbabwean junior doctors faced a rigid hierarchy. They were given no recognition for their work, which, without adequate PPE or even sometimes running water, was far more dangerous than in my hospital in Boston. Zimbabwean junior doctors were told to suck it up and do their jobs.


Over the course of the year, I related less and less to the experiences of doctors working back home. I was safe and comfortable in my expensive Boston apartment, and every Monday when we gathered online, I felt guilty about the resources I was using up and the relative triteness of my Zoom fatigue or my annoyance at online grocery ordering. I began to wonder whether I had anything to offer the doctors in Zimbabwe. Instead of uniting my two worlds like I thought it would, the support group felt like it was driving them apart. Same pandemic, different problems.


¤


In a New York Times Magazine article entitled “Covid Has Traumatized America. A Doctor Explains What We Need to Heal,” David Marchese interviewed Diane Meier, a palliative care physician at Mount Sinai (I‘ve been a fan of Meier since I watched her give a lecture when I was a medical student there). Meier related the profound mental health challenges of the pandemic to trauma, which she dubbed a “shadow pandemic.”


Post-traumatic stress disorder (PTSD) first emerged in the United States as a formalized category of suffering in the 1970s, after the Vietnam War. Mental health professionals noticed symptoms of “shell shock” among veterans, and the category was then championed by the antiwar movement to obtain official recognition of the harms of war.


The American Psychological Association now defines trauma as “an emotional response to a terrible event like an accident, rape or natural disaster.” [1] Over the last three decades, though, trauma has become slippery, migrating from its narrow medical definition to a capacious concept in our political consciousness.


“There’s a book called The Body Keeps the Score,” Meier told Marchese. The first time I read Bessel van der Kolk’s seminal text as a medical resident, I felt transformed. Everything about my life — my mental health work in Zimbabwe, the patients I took care of on the wards in the US, my relationships with family members and friends — seemed wrapped up in trauma in one way or another.


My four-year-old copy of the book is now dog-eared from overuse and warped from trips to the beach. Every few months, I pluck it off the shelf and thumb through a couple of pages to remind myself of the terrible world we live in and of the empathy required to heal psychological suffering. Van der Kolk’s thesis — that traumatic events are imprinted not just on our psyche but in our physiology — breaks down the problematic binary between mind and body in Western biomedicine. I wish they had taught us this stuff in medical school, I think to myself every time I read his artful blend of anecdote, neuroscience, and clinical research. During the pandemic, I have flipped through The Body Keeps the Score more frequently, desperate for answers. And I’m not alone. For the last year, van der Kolk’s book has alternated between first and second place on the New York Times nonfiction paperback list.


The book opens with an anecdote about a patient — a Vietnam veteran — who, during the war, witnessed his best friend being shot dead and who then himself raided a village and committed murder and rape. “Trauma, by definition,” writes van der Kolk, “is unbearable and intolerable.” [2]


But what about the stuff that isn’t rape or murder? As of this writing, 3.7 million people have died of COVID-19, with the United States reporting the highest number. That loss is enormous, and loved ones have been left to grieve, often alone without ceremonial mourning. And then there’s the average person’s profound isolation, cut off from networks of social and emotional support. Deprived of physical touch.


How many lives must we lose, how isolated should we be, how unsafe do we need to feel before we can say this is unbearable or intolerable? Before we can call it trauma?


It depends.


Since I first arrived in the US for college, I have been indoctrinated in the American social system on how to think about — and live — life. I soon learned that if you weren’t trying to live as long as possible, there was something wrong with you. You were probably depressed. Maybe even suicidal. It’s no surprise to me that simply watching the COVID-19 death toll rise is traumatic to many Americans, a concept called vicarious traumatization. The way we make meaning of events in our lives, including trauma, is determined by our context.


Derek Summerfield, a South African psychiatrist, believes that trauma doesn’t even exist in some contexts; that it is a decidedly Western category. “In Western societies,” he writes in an essay in the British Medical Journal, “the conflation of distress with ‘trauma’ increasingly has a naturalistic feel; it has become part of everyday descriptions of life’s vicissitudes.” [3] Western psychiatry, Summerfield insists, is trying to “convert human misery and pain into technical problems” that can be fixed.


Summerfield’s warning, and that of several prominent psychiatrists and anthropologists, helps explain a tension I have felt between my mental health work in Zimbabwe and my life in America. What many of my Boston friends call trauma — not seeing family, fear of contamination, rising death tolls — didn’t seem to concern Zimbabweans. “In Zimbabwe,” said a doctor in one of our Zoom meetings, “it’s never-ending cycles of trauma.” Zimbabweans, she contended, have lived through constant life-threatening hardship — colonialism, civil war, political violence, drought, cyclones, poverty, disease, famine. In a country where 40 percent of the population lives in extreme poverty [4] and life expectancy in the mid-2000s was down to 45 years, the pandemic merely adds fuel to an ongoing, slow-burning, trauma dumpster fire.


The same could be said of minoritized populations in America. Women and queer people have faced worsening domestic violence during the pandemic, and Black and Latinx communities have suffered the effects of white supremacy and structural inequity. But since these communities perpetually experience such hardship, they can’t point to when trauma begins and ends; they rarely have the luxury of reflecting on their circumstances and voicing their grievances through the lens of trauma. They’re trying to survive, not rereading The Body Keeps the Score. Calling trauma by that name is a privilege afforded to a select few.


This doesn’t mean that some people are immune to trauma. It does mean, though, that people construct meaning out of traumatic events and express trauma in diverse ways. In Zimbabwe, most people haven’t heard of PTSD or trauma. Those who have experienced severe traumatic events like abuse tend to use the Shona expression kufungisisa, or “thinking too much,” to describe their suffering. [5]


By itself, thinking too much is less a discrete psychiatric disorder like depression or PTSD (though it is often linked to both by cross-cultural psychiatrists). Instead, it is a way of expressing mental anguish, what medical anthropologists call an “idiom of distress.” Thinking too much exists across many other non-Western cultures: kut careen among Cambodian refugees who have experienced trauma, and aomom na epol in post-conflict Uganda. When people think too much, their minds become hazy with issues like financial hardship, interpersonal relationships, and spiritual concerns, sometimes to the point where it becomes difficult to function. But anthropological research shows that, for the most part, people living under conditions of poverty or violence are less concerned with the traumatic event itself. Instead, they ruminate about material issues like money and food. What’s clear is that even if trauma exists outside the United States and Europe, the response to trauma doesn’t necessarily take on the shape or form that American psychiatrists expect.


¤


In early 2021, the South African variant swept through Zimbabwe and the COVID-19 death rate soared. Multiple doctors died, including a close mentor. I flew home to see if I could help. I was six months post-residency as a newly qualified internist and one of the only vaccinated Zimbabweans in the world.


“The group is really struggling,” wrote one of the senior organizers in a WhatsApp message. “Is there something we can do?”


When a patient dies in an American hospital, we are taught to conduct a formal debriefing. As doctors, we gather the team, sit in a quiet place, and honor the life lost. We discuss the case. Make space for emotion. Grieve.


“Maybe I can do a workshop on trauma debriefing,” I wrote back.


I set out to make the trauma debriefing workshop rich and constructive. I started with the model used in our hospital in Boston: PAUSE. Prepare. Analyze. Understand. Sentiment. Educate. While searching the literature, I found a name for this technique: Critical Incident Stress Debriefing. It was pioneered in 1983 by Jeffrey Mitchell, a paramedic and firefighter turned trauma specialist. I was impressed by the simplicity of the approach: a short, structured conversation performed within 72 hours of the traumatic event.


Then, I stumbled upon a paper in The Lancet that aggregated data from 29 studies on trauma debriefing. It found that not only did critical incident stress debriefing “not improve natural recovery from psychological trauma,” but it actually fared worse than other trauma interventions.


I paused, in shock. Here was evidence that my hunch about the benefits of this type of debriefing might be wrong.


Nervous about its questionable evidence base, but emboldened by hubris nonetheless, I went ahead and scheduled the workshop. Although I was in Zimbabwe at this point, I used Zoom so that doctors working in all parts of the country, including rural communities, could log on.


One doctor, a woman in her late 20s, shared her story of losing a colleague to suicide during the pandemic. We role-played debriefing the scenario as though we had all experienced the trauma. I had one doctor pretend to lead the debriefing, and I fed him phrases he could use to help us discuss the event. “How was this for everyone?” “What part of this felt difficult or emotionally challenging?” “What went well?” “What is one takeaway from the situation?”


The conversation became stilted; people started dropping off Zoom. Twelve. Eight. Seven. Four. Eventually, there were only two left, including the doctor whose case we were debriefing. I forged ahead, convinced I was helping.


I closed the workshop with a plot twist — we would debrief the debriefing workshop. A meta debriefing. “So,” I said to the two remaining Zoom participants, who, by this point had turned off their cameras, “How was this for everyone?”


Silence.


I stared patiently into the black rectangles, knowing that for Zimbabweans this silence could be a natural pause. But the rectangles felt emptier than usual.


That’s when I realized I was alone and had been for quite a while. I tried one last “hello?” and then clicked End Meeting for All.


¤


In Crazy Like Us, journalist Ethan Watters writes of how, in 2004, Western traumatologists flocked to Sri Lanka after a tsunami hit Southeast Asia. They believed there would be a “second wave” of psychological distress and that the biggest problem faced by Sri Lankans would be the depression, PTSD, and suicide that followed.


An industrial complex of trauma therapy and research ensued in what Watters calls “the largest international psychological intervention of all time.” The therapists imported techniques like play therapy, yoga, meditation, and, of course, Mitchell’s Critical Incident Stress Debriefing.


The Westerners meant well. But when Sri Lankans didn’t experience trauma in the anticipated way — they had more body aches than typical PTSD symptoms and sometimes no symptoms at all — the Westerners assumed the Sri Lankans were “in denial.” “The idea,” writes Watters, “that people from different cultures might have fundamentally different psychological reactions to a traumatic event is hard for Americans to grasp.”


Mortified after the failed workshop, I wondered if I shared the naïveté of the American traumatologists in Sri Lanka. I reached out for feedback. I wanted to understand why our informal support group worked, but this more structured approach did not.


“It feels alien to us,” a young doctor confessed shortly after the workshop. “It just wouldn’t work in Zimbabwe.”


Sure, the workshop could have failed because of the poor scientific evidence or because of the contrived role play scenario. But the doctor pointed to a cultural divergence. Speaking to others, I realized that what made our earlier peer support group (rather than the formal debriefing workshop) successful was our overwhelming need to come together. Batanai. Bessel van der Kolk draws a similar conclusion after observing the healing power of the South African Truth and Reconciliation Commission. He points to ubuntu, the Xhosa word that literally translates to: “I am because we are.” Ubuntu, which captures the collective nature of many African cultures, means that we depend on each other, on a communal existence, to survive. Zimbabwean doctors, I realized, didn’t come to the peer support group for me, they came for each other. My unlimited Zoom link was just a vessel. So, when I asked them to use the rigid Mitchell debriefing framework, I set boundaries for how they could relate to each other. I — regrettably — made the space less collective. In Western therapy, collectivity holds less value. Therapists guide us in self-exploration; they help us confront our singular demons. But such an individual-centered epistemology is far from universal.


Over the last decade, as I have straddled the worlds between Zimbabwe and the United States, I have felt the cultural tug of war over how we perceive concepts like trauma, well-being, and mental health. In America, I have learned how and when to claim trauma. As a doctor in Boston, I’ve acquired “Therapy-Speak” and learned to practice trauma-informed care at work. Although I am Zimbabwean, I’ve spent more than 10 years viewing the world through American eyes, and right now, more than ever, American culture is wearing its trauma spectacles.


But after the failed workshop, something changed for me. As I reflected on the consequences of the pandemic on my well-being, and that of my colleagues in Boston and my compatriots in Zimbabwe, I couldn’t help but question a category like “mass global trauma.”


When I first read the New York Times Magazine article about Diane Meier, I found myself cheering. Yes! We are all being traumatized! But looking back, I wonder who I included in this “we” and “all.” Over and over during this pandemic, I keep hearing that its defining feature is that, for the first time in a century, everyone, everywhere, is undergoing the same experience. But living bisected between worlds an ocean apart has made me interrogate how this universalizing tone flattens the multiplicity of trauma; how it forces an overly simplistic conception of well-being and suffering in places where such a conception may not be welcome or useful.


Looking ahead to when we piece together the debris left in the wake of the pandemic, what remains to be seen is whether we can leave our assumptions at the door and rise to the cultural humility required for a truly communal rebuilding of society. Can we be sensitive to trauma’s kaleidoscopic determinants, experiences, and solutions — even the ones we cannot see or begin to imagine? Or will we repeat the errors of those who have gone before us claiming to be bearers of universal salvation?


¤


Khameer Kidia is a writer and global health physician on faculty at Harvard Medical School.


¤


Banner image: “Milad Hospital during COVID-19 pandemic” by Pouya Bazargard is licensed under CC BY 4.0. Image has been cropped. Attribution: Mehr News Agency.


¤


[1] https://www.apa.org/topics/trauma


[2] The Body Keeps The Score, Bessel Van Der Kolk, p. 1


[3] https://www.bmj.com/content/322/7278/95.short?casa_token=rSyaK8maBmYAAAAA:-NUjJdmVrgBS5zlbtyJHr2iuXwRKRKE-TTuztosvI8yAQIoPswKUuKqqpTErx8QANy4h095eE1A


[4] https://data.worldbank.org/indicator/SI.POV.NAHC?locations=ZW


[5] https://www.tandfonline.com/doi/full/10.1080/20008198.2018.1536286