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 الانتحار في السـودان (Re: زوربا)
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سلام
هذا المقال كتبته
Dr Lillian Craig Harris
عن الانتحار ونظرة المجتمع السـودانى للأمر.
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Sudan Studies 25 (March 2001)
Choosing Death: A Consideration of Suicide in Sudan
By Lillian Craig Harris, Ph.D.
Sudan Studies Society of the U.K. Annual General Meeting.
London, 25 September 1999
Although suicide occurs in every country and is part of the human condition, it is one of the most frequently denied human activities. Faced with self destruction by a relative or friend, people very often feel bewildered, fearful, angry, personally betrayed or humiliated. The response may be to describe the death as “unexpected”, “an accident”, or “the result of a sudden illness”. Because suicide carries such grave possibilities for scandal and legal complication, even medical professionals may resort to euphemism or denial of what is one of the world’s leading causes of death. This is true of all societies.The desire to hide the reality of suicide becomes even stronger in societies in which most people consider the act a sin for which the eternal punishment is damnation and for which the temporal punishment for attempting can include public flogging - as happened to the female relative of a woman I know in Khartoum. Although this is admittedly an extreme response, family shame is a powerful emotion. And today millions of Sudanese, the majority even, live close to the extreme in many ways.
It should come as no surprise that little research has been done into suicide in Sudan - and most of what has been published is mainly of historical interest. For example, S.F. Nadel’s book The Nuba: An Anthropological Study of the Hill Tribes of Kordofan, published in 1947, documents cases of suicide among Nuba tribes.[1] Among the motives for suicide which Nadel cites are incurable disease, desire to escape from an unbearable life and “momentary impulse: resulting from sudden shock”. Other more recent research, published in 1968 and 1978, is likewise dated and - I would argue - unpersuasive, as the suicide rate claimed by both these later authors is less than one per 100,000[2] which if true, would give Sudan one of the lowest suicide rates in the world.
Is it possible that recent indications of a high degree of suicidal ideation and behaviour among both northern and southern Sudanese in Khartoum and environs - which we shall discuss in a moment - result solely from the terrible social disruption of the past 20 years? Or can it be that suicide rates in Sudan, particularly among women, have all along been much higher than generally recognised? I discovered this to be true in neighbouring Egypt where the annual low rate of suicide reported to the World Health Organisation bears little relationship to the degree of suicidal ideation and suicidal behaviour discovered by Befrienders Cairo after that listening service for the despairing and suicidal began in 1992. In Sudan the foundation of Befrienders Khartoum in early 1997 made possible the collection of similar, albeit informal, statistics.
In an article published in late 1998 in Crisis: The Journal of Crisis Intervention and Suicide Prevention. Australian psychiatrist Robert Goldney et al. reported that:
“While it has not been possible to gain a sound epidemiological estimate of suicide, as there are formidable challenges in collecting such data, recently an opportunity arose to estimate suicidal ideation in two selected samples of Sudanese women. This was considered to be an important opportunity, not only because it would be for the first such research in Sudanese women, but its results would also have potential policy implications in terms of clinical services for Sudan. Furthermore, the recent establishment of the voluntary suicide prevention organization, Befrienders International in Khartoum, allowed the research findings to be viewed in the perspective of anecdotal information gained about suicidal behaviour.”[3]
In this study 29 psychology students at Ahfad University for Women in Omdurman and 30 women from Jebel Aulia displaced settlement south of Khartoum were assessed for suicidal feelings on the basis of responses to four questions embedded in a 28-item General Health Questionnaire.[4] The result of this simple survey was that “no fewer than 55% of the Jebel Aulia women compared to 27 percent of those at the Ahfad University for Women reported some degree of suicidal ideation.” The researchers were not surprised that such a high degree of war-displaced women, most of whom had lost family members, all their material possessions, their homelands, their cultural roots, should be despairing. But we were all shocked to discover that such a high percentage of apparently “normal” young northern Muslim women (as most of them were) from relatively well placed families were entertaining thoughts of self destruction.
Although he is careful to underscore the limitations of this form of research, Goldney points out that in the 1940s, Nadel “was frequently met with absolute denial that suicide actually occurred in some communities until he gained their confidence”, and similarly concludes of the more recent research that, “It is possible that these relatively high levels of suicidal ideation are now able to be acknowledged because of a relative increase in freedom of expression of feelings, particularly in the context of responding anonymously to a questionnaire, rather than expressing such emotions to another person.” The experience of befriending in Khartoum, as elsewhere, confirms that suicidal people may often mask their self destructive feelings and impulses - including from themselves - during a first or even subsequent conversation even with a sympathetic and supportive listener.
Furthermore, the simple statistics compiled at the Befrienders Khartoum centre itself during its first year of service also suggested far greater incidence of suicidal ideation among people in the Khartoum area than was previously known. It should, of course, be stressed that although all indications of suicidal thoughts need to be taken seriously, by no means do all people who express suicidal inclinations go on to take self harming action. There are many factors such as strong religious faith, family loyalties and responsibilities, and fear of death which help hold individuals back from self destruction. However, fully one third of the 246 caller contacts made with Befrienders Khartoum in the ten months between May 1997 and March 1997 indicated at least a limited degree of suicidal ideation. Problems presented by these callers ranged from loneliness, abuse, inadequacy, bereavement and other loss to difficulties in relationships, finances and housing. Poverty, joblessness and displacement were significant presenting problems masking emotions of anger, fear, inadequacy, humiliation, hopelessness and despair.
What are we to make of this? At the least that we have here an indication of widespread and possibly rising despair which threatens the lives of many Sudanese. Consider this, moreover. The majority of the initial callers to the Befrienders Khartoum office were northern Sudanese, not displaced southerners or westerners among whom as groups despair might presumably be higher. Secondly, due to inexperience among the befriending volunteers, 39 of the contacts were not asked about suicidal feelings - which raises the probability that the true total of suicidal contacts was under reported. Finally, the fact that only 47 of these initial 246 contacts were with women callers also suggests that the actual degree of suicidal feelings in Sudanese society as a whole may be much higher than indicated by these simple statistics.
Conversations with Sudanese women and anecdotal evidence suggest that suicide ratios in Sudan may follow more closely an “eastern” pattern of more female suicides (as in India) than the “European” pattern of more male deaths. In the West one reason more men than women die by suicide is that men choose the more immediate and lethal methods [hanging, shooting] which allow less margin for survival. In Egypt, and even more so in Sudan where drugs are not available to many people, the suicide methods chosen by women who determine to die are likewise less amenable to rescue: jumping into the Nile, burning with kerosene and ingesting of henna hair dye. Is it also possible that Sudanese women are attempting suicide more often than Sudanese men?
A Sudanese forensic pathologist, Professor Ali Kobani claimed in 1997 that at least 20 cases of suspected suicide per month (gender not specified) are brought to the attention of the mortuary staff of the Khartoum Teaching Hospital. According to Professor Kobani, suicide is increasing among Sudanese women with the chief causes in addition to mental illness being marital suspicions, unwanted pregnancy and parental mistreatment. He cited hair dye, selected some 60 percent of the time, as the preferred method of killing both self and a husband who has decided to marry another woman.[5]
Sudanese women in psychological distress often mention a shortage of female therapists as a deterrent to seeking professional assistance. This is particularly relevant because, as Kobani and others point out, many of the difficulties which lead to suicidal thoughts among Sudanese women are sexually related and there are strong social and cultural barriers against discussing sexual matters with a man, even a medical professional. Moreover, in Khartoum there is a great shortage of qualified psychotherapists while elsewhere in the country such expertise is virtually unknown. Treatment of depression and other psychological disorders, when it occurs at all, is almost entirely through medical intervention, i.e. drugs which are beyond the means of all but the most affluent.
Nor, as is true everywhere in the world, is suicidal behaviour always treated with compassion, even by professionals. In 1998 a young woman who had a history of self harm was able to walk out of a private clinic in Omdurman, buy henna dye and return to the clinic where she drank it mixed with Tang. Though she was eventually found by staff and revived, her last conscious memory for several days was of being berated by a doctor who, while performing a tracheotomy, cursed her as a sinful wretch for bringing shame upon her family.
In October 1997 Dr. Lakshmi Vijayakumar, an Indian psychiatrist who founded Sneha, a branch of Befrienders International in Channai (formerly Madras), met with students at Ahfad University for Women in Omdurman. The Ahfad students provided the following reasons why Sudanese women kill themselves:
* They have been deserted* The pressures of war* Illegitimate pregnancy or birth* Feelings, especially among the young, of oppression by society or religion* Forced marriage* Parental control and expectations* Rape* Rigid laws governing conduct between men and women* The need for women to fulfil and sustain a “perfect marriage”* Lack of someone to listen to her emotions* No recognition that women have emotions just like men* Feeling unvalued as a human being* Lack of “relationship” (meaning friendship) between husband and wifeWhen I first moved to Khartoum in early 1995 and announced my intention of trying to establish a branch of Befrienders International, I was sympathetically advised by several prominent Sudanese that “not many people kill themselves here because we all believe in God.” But I had received that same well meaning advice in Egypt before establishment of Befrienders Cairo - whose simple statistics, as mentioned, soon revealed a degree of suicidal ideation that approximated that of London at the time -some 25 percent of caller contacts. In Khartoum, therefore, I began by asking people to tell me what they knew, what they had heard or observed about suicide in their society.
Soon I learned of the desperate southern mother of five who threw her children into the Nile and jumped in after them, of the displaced westerner who hanged himself after long unemployment, of the man who decided to leap off a building because he could not afford medicine for his old mother. (Fortunately, this man was rescued by sympathetic passers-by who pooled their scant resources for the old lady’s benefit). In those early days, too, the daughter of an Arab diplomat whose two maids were clearly being abused at first dismissed my expression of concern for the women -and then confided that one of the maids had tried to kill herself the previous week! On another occasion, a friend who initially responded with considerable scepticism to my appeal for support to open Befrienders Khartoum, called later in the day to say that he had learned on return to his office the servant of a colleague had hanged herself that morning “with no warning”.
My point is that much which is very unpleasant goes on around us and we are often not informed or we fail to pay attention because suicide is intrinsically so ugly, so painful even to think about. Both my sceptical friend and a well known surgeon who likewise considered suicide “only an infrequent occurrence in Sudan” when I approached the Khartoum Rotary Club for support are now members of the Executive Committee of Befrienders Khartoum.[6]
Given the physically and psychologically stressful circumstances in which so many Sudanese live, I once wondered why more Sudanese did not kill themselves. But I have come to believe that perhaps they are killing themselves and we simply do not recognise it. A young Sudanese recently admitted that because he wanted to die but was too frightened to kill himself, he joined the army and went south hoping someone would do the job for him. Fortunately this young man was not killed. Instead a terrible experience of being wounded while killing others helped him regain some hope of continuing to live although he has a long way to go towards finding a normal life.
We have no idea what the actual rate of suicide is in Sudan. What is clear is that to live in Sudan today is to risk death not only by disease, starvation and war but also by your own hand as the result of despair and hopelessness. The risks are all there. A list of “the factors which increase suicide risk” is drilled into the carefully selected befriender volunteers, with the admonition that the more of these factors present for an individual, the greater the risk she faces. Among these factors which often lead - anywhere in the world - to suicidal feelings are isolation, loneliness or uprooting, the prospect of having to live with few close human contacts, painful physical illness or long sleep disturbance, financial worries, feelings of uselessness, a family history of suicide, loss of religious faith or of a philosophy of life, dependence on alcohol or drugs, a definite idea of how it would be possible to kill oneself and access to this method.
All of these circumstances are rampant not only in the displaced settlements of perhaps two million people, mainly southerners and westerners, around Khartoum but also in the Three Towns themselves. Loss is the constant factor in suicide: loss of family, home, fortune, status, opportunity, love, health, all of which can lead to loss of hope. And all Sudanese have lost enormously.
“They have sold their jewellery, their window frames, even the taubs,” a woman told me when describing the silent hunger which creeps through the hoshs of Omdurman. Laughing to mask her sorrow, another friend told me of a professional man who - because he could no longer afford to feed the hungry neighbours - could only shame them into staying away by coming to lunch in his underwear. How many of the factors which can lead to suicidal feelings does this small, sad incident portray?
Various comments I have heard, scenes I have participated in, come back to me:
* “We have had to learn to disregard our bodies,” said a priest who supports about 30 people, many of them the children of his dead relatives.* “Our lives are filled with such difficulty, we have seen such sorrow, that we have come to consider the abnormal as normal,” a student told me.* “Where will you get the volunteers?” a community health worker asked me in Juba where I had gone to see about the possibility of setting up a befriending centre. “Where will you get the volunteers?” he repeated, “We are all traumatised”.* “I thank God that my brother has been killed in the war for he is now in Paradise,” a young woman replied when asked what had been the most traumatic event in her life. This loss, that of the right to grieve, may in its isolating effect be the most painful loss to bear.Many of the Sudanese who remain in Sudan - and many outside - are “walking wounded,” their minds and often their bodies damaged by great loss and continuing difficulties. An effort is being made to increase the emotional support available to Sudanese refugees in Cairo who are now reaching that city at the rate of about 200 families a week, usually finding little material, educational, or emotional assistance and often falling into despair. Under such circumstances, suicides have increased. Should that surprise us? According to the International Association for Suicide Prevention, “Suicide is a significant health problem in every country in the world, being among the ten leading causes of death. ”[7]
An apparently growing incidence of suicide may be but one manifestation of the Sudanese crisis. But it is an aspect of the tragedy which has been ignored and now needs to be recognised and addressed. Professor Goldney, a cautious professional, says that recent information such as I have given here suggests “that the previous noted figures for suicidal behaviour in Sudan almost certainly needs revision. They also highlight the need for further professional and volunteer assistance with continuing evaluation and research of programs for this vulnerable population.
We all know that the most obvious Sudanese need is for peace. Nothing permanent can occur without peace and we all need to work towards that end. But in the meanwhile is there not something more we can do to provide increased emotional support to those who suffer loss of hope both in Sudan and as refugees? Befrienders Khartoum is a tiny organisation. It needs more volunteers, more community awareness, telephone lines, branch centres, financial support. Much of this may not be possible without peace. But some of it may be.
I am reminded of an advertisement used several years ago by the Samaritans UK, parent organisation of Befrienders International. In this ad, a man encased in plastic wrap shouted but no sound emerged, gestured but remained entrapped. The caption read: “Is there anyone out there?” Is there?
[1] S.F. Nadel, The Nuba: An Anthropological Study of the Hill Tribes in Kordofan, London: Oxford University Press, 1947
[2] cf. Abdel Hafeiz H.B. and Nadim A.A., “Suicide in Sudan,” British Journal of Psychiatry 1978: 133: 380-381 and Elsarrag, ME. “Suicide in the Northern Sudan,” British Journal of Psychiatry 1968; 114:1057-1058.
[3] Robert D. Goldney, Lillian Craig Harris, Alia Badri, Sara Michael, Laura Fisher, “Suicide Ideation in Sudanese Women,” Crisis: The Journal of Crisis Intervention and Suicide Prevention 1998; 19/4: 154-158.
[4] The General Health Questionnaire’s “hidden questions” on suicidal ideation ascertained whether the respondent: “1) Felt that life isn’t worth living; 2) Found yourself wishing you were dead and away from it all; 3) Thought of the possibility that you might do away with yourself; and 4) Found the idea of taking your own life kept coming into your mind.” Considering the anecdotal evidence that many Sudanese have accepted their abnormal lives as “normal” and use by the questionnaire of the phrase “no more than usual” as one possible answer, Goldney concluded that the results of the questionnaire “would, if anything, underestimate the prevalence of suicidal ideation in these samples.”
[5] Based on a private conversation in October 1997. I have been unable to obtain a copy of Professor Kobani’s study, “Violence from a Forensic Point of View” which discusses statistical data compiled in Khartoum mortuaries from 1993-95. See Wafaa Kamil, “Suicide in Society” in New Horizon (Khartoum), 26 January 1997.
[6] The Rotarians of Cairo and Khartoum were independently instrumental in establishment of Befrienders Cairo and Befrienders Khartoum and continue to provide major support to both branches of Befrienders International.
[7] ‘The Adelaide Declaration on Suicide Prevention,” ratified by the Executive Board of the International Association for Suicide Prevention following the 19th Congress of the International Association for Suicide Prevention held in Adelaide, Australia, 23-27 March 1997.
(عدل بواسطة Zaki on 09-10-2003, 09:36 PM)
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