TRUMATIC STRESS SYNDROME AMONG WOMEN IN SOUTHERN LEBANON

Recent estimates suggest that possibly two-thirds of the population of Lebanon have been subjected to some transient or permanent form of unrootedness from their homes and communities. The population has shrunk from 4 million to less than 3 million. Altogether more than one third of the country’s indigenous population is either in temporary or permanent exile. As always in times of conflict, it is the women who have to find a way to hold the family unit together. Victims racked for so long by the atrocities of human suffering become insensitive 10 real concerns. This is evident in their attitude towards safety in the home and on the roads. A substantial proportion of death among adults and children are due to traffic and domestic accidents including poisoning.

The Ottowa Charter of 1986 stated that basic prerequisites for health are: peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice and equality. The areas south of Tyre have lacked not one or two but all of these factors for a number of years past. Social issues such as wealth, education, class and sectarian beliefs playa major role in determining quality of medical care. The social inequities that exist have a bearing on morbidity and mortality, though few statistics exist to substantiate this fact. In the face of evidence that disparities are growing rather than diminishing in Lebanon during the recovery period, and following a return of tl1e displaced population, the poorer population group tends to be marginalised and does not have full access to health services. The system is characterised by a predominance in curative rather than preventative and promotive services. The problems are most severe in the underserved district on the perimeter of the Israeli Controlled Area (ICA). More than 80% of the population lives in urban areas, which leads to mounting pressure on urban resources and infrastructure and reduced agricultural production.

Around one third of the population in the villages on the periphery of the ICA, are under 15 years old. Women and children living below the poverty line, work in the fields picking olives and cultivating the tobacco crop under the threat of shelling on a day to day basis.

In our work in the villages of Jmai Jmai, Haris, Aita el Jabel, Barachit, Yater and Scrobine, a recurring theme has emerged. Many of the women are suffering from very obvious signs of Traumatic Stress Syndrome. Little is known of this condition in civilian populations. With the continued fear of further conflict, it is an ongoing traumatic stress rather then the 'recognised usual Post Traumatic Stress Syndrome.

Many women present similar problems such as panic attacks, sleeplessness, tiredness and an inability to cope with the slightest overriding illness such as a mild upper respiratory infection. There is a pervasive mood of lethargy, indifference and weariness in their demeanour. Some of these women are thirty years old, with ten children, but they look fifty years old and suffer from premature osteoarthritis and appear malnourished and deprived. They have little knowledge of the world outside of their extended families and life is a constant struggle to exist. These women have no autonomy and have to live with the fact that one of their children out playing may not return; as happened recently when a 12 year old boy picked up a "shiny ball" near the Red Cross building, situated within the grounds of Tibnin Hospital; it exploded in his face.

In Traumatic Stress Syndrome the onset usually follows a stressful event outside the normal range of human experience but in this case the probability of physical injury, loss of loved ones and multiple deprivation on a psychosocial level enhances the impact.

Patho/Physiology of TSS

Traumatic Stress Syndrome manifests itself in symptoms such as:

• Exaggerated startle response
• Poor concentration and memory - survival guilt
• Sleep difficulties
• Phobias

Responsiveness to the outside world is diminished with loss of interest, feelings of detachment and impaired emotional responses. Associated features include depression, irritability, behavior and associated grief. To cause this illness the traumatic events must be sufficient to cause fear, helplessness, loss of control and threat of annihilation. These women have lived their whole lives in these conditions and have a lamentable lack of knowledge about the health related factors. The treatment for this illness should avoid long-term drug therapy and must be centred on Cognitive Strategies in an attempt to alter thinking, reasoning and coping skills in order to reconstruct peoples' lives. We have unfortunately encountered many young women who have attended a variety of doctors and received tranquillising drugs without any knowledge about their effect and correct usage. The resulting lethargy has a compounding effect on their lack of coping abilities, not to mention the expensive cost of both the consultation and drugs, which are predominantly addictive in nature.

HMD Response's Strategy for Raising Awareness

HMD Response's personnel provide an empatic listening and counseling service during consultation visits by villagers to our clinics. Staff are trained to have a holistic perspective toward care and to have qualified counseling and communication skills. The only other mobile clinic to enter these areas are a local NGO sectarian group who stay for one hour only and have an illness focus; they also charge for treatment. They do not consider the psychological aspect as a priority, perhaps due to cultural conditioning.

Having identified the relevant sufferers of this illness, we have commenced women's groups concentrating on Health Promotion to enable them to discuss relevant issues and to feel less isolated.

We have been joined in this project by three local partners who all have a subjective and empathic approach toward this subject. These professional women will act as interpreters and also help to co-ordinate the syllabus and content of the envisaged programme. We have compiled an information document highlighting the signs, symptoms and treatment of Traumatic Stress Syndrome which has been distributed to obvious sufferers with great success and has generated much interest. The first meeting was held in a local house in Jmai Jmai on 23 November 1996. The women invited were between the ages of 20 to 45 and all had attended the clinics on a number of occasions, presenting a range of complaints indicative of stress related disorders.

Topics discussed in the groups include:

• Coping strategies
• Awareness raising
• Advocacy for women and children
• Child health
• Safe motherhood
• Contraception

Other relevant matters include sharing information about safety in the home, nutrition, dental hygiene, pre and post menopausal issues and the role of women in the work force. Individual counselling will be available to those who request it and it is envisaged that these gatherings will become a fixed Saturday morning event. The women appear to have little interest outside the home and appear to be enthusiastic when approached about attending. This strategy will empower the women to cope with their lives by enhancing their knowledge and improving their chance of survival in a difficult situation. As the cruelties of the protracted violence become ever menacing it is understandable why traumatised and threatened groups seek shelter in their communal solidarities and are reluctant to change. But HMD Response, as caring professionals, can hopefully provide them with an insight into developing an attitude of preventing illness by promoting wellness.