Ethiopia: Public Health Consequences of Violence and Inter-Generational Trauma

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Trauma is pervasive in many societies and it has intergenerational health implications. Trauma is not a phenomenon that is solely experienced by people in war zones, torture chambers and natural disasters, or isolated to the experience of physical and sexual attack victims.

A landmark study called Adverse Childhood Experience (ACE) done in the United States by the Centers for Disease Control (CDC) and the Kaiser Permanente Foundation during the 1990s found that childhood trauma is common in America and includes experiences such as neglect and divorce and is associated with adulthood behavioral problems, including substance use disorders, depression, chronic illnesses, learning disabilities and shorter lifespans, in a dose response manner.

More recently, other life events, including poverty, exposure to community violence and discrimination have been considered as important ACEs that compound negative life and health outcomes. Traumatic events can be big or small, but they all induce some measure of a sense of powerlessness, fear, recurrent feelings of shame, guilt, rage and disconnection and result in being in a constant state of alertness that can impair health, behavior and cognition as well as poor interaction with others.

There is an increasing amount of neuroscience research being done to understand how trauma affects the brain and the rest of the body and ultimately influence human health and behavior. Trauma primarily affects parts of the brain that controls the basic functions of the body including arousal, sleep/wake cycle, breathing, feeding as well as the limbic system that is the seat for our emotions and memory.

Inescapable trauma causes the constant release of stress hormones such as cortisol that distort memory, interfere with attention and accurate perception of reality, and disrupt basic bodily functions including sleep and mood. Even after the traumatic event has been removed stress hormones tend to spike more quickly and in higher proportions in response to mild stressors in people who have experienced trauma and these people tend to be hypervigilant3. This is one of the classic features of Post-Traumatic Stress Disorder (PTSD).

[Note: The American Psychiatric Association emphasizes that PTSD does not just happen to combat veterans and that PTSD does not even require direct exposure to traumatic events. "PTSD could occur in an individual learning about the violent death of a close family. It can also occur as a result of repeated exposure to horrible details of trauma".

The four symptom categories of PTSD are intrusive thoughts (e.g. involuntary memories, flashbacks), avoiding reminders, negative thoughts and feelings (e.g. persistent fear, shame, anger or detachment from others) arousal and reactive symptoms (outburst, recklessness, trouble concentrating being easily startled). These symptoms have to be present for more than a month for someone to be diagnosed with PTSD.]

Trauma increases the incidence of diabetes, heart disease, obesity, stroke, arthritis, Irritable Bowel Syndrome and many other chronic illnesses in addition to mental health disorders. The mechanism by which chronic illnesses are associated with the history of trauma has not been fully elucidated. One explanation is that the continuous secretion of stress hormones like cortisol and adrenaline are harmful to the body in the long run increasing the risk for chronic diseases. Additionally, people who are under extreme stressful conditions from which they feel powerless to escape may turn to unhealthy behaviors including overeating, high risk sexual habits, the use of substances etc that increase their risks for chronic illnesses.

Traumatic memories are stored in the brain in a distorted manner and may not have an orderly narrative of a beginning, middle and an end. Rather, people experience traumatic memories as flashbacks that contain fragments of isolated bodily sensations, images, and sounds that may lack context. Trauma also has "body memory". The color of a wallpaper seen, a distinct smell, a particular sound heard etc during the time of trauma may trigger spikes in stress hormones when encountered later on during normal events.

One of the most powerful lasting effects of trauma is its power to alter perceptions. For instance, an innocent look by a stranger may be perceived as being threatening, instead of eliciting curiosity to a person who suffers from PTSD. Trauma survivors can easily become hyper-aroused and vigilant by innocuous experiences years after their trauma. Trauma interferes with judgement, and thus can destroy relationships and result in chronic mental health problems including violent behaviors, depression, substance use disorder and suicide.

The opposite effect to the hyperarousal result of trauma is the "freeze-response" of trauma. Victims often "turn off" their emotions towards their trauma as a defense mechanism and may dissociate from feelings of parts of their body. It is not unusual to see some physical and emotional immobility and lack of curiosity in traumatized people3.

The sum total of a traumatized brain, whether mostly hyper-aroused or "frozen" and "dissociated" is its significantly reduced reserve for executive function, judgment and learning. It is thus not hard to imagine the enormous toll trauma takes on individual lives, including their productivity, creativity, and on their relationship with other human beings.

Additionally, the emerging science of epigenetics shows early evidence that traumatic experiences can in fact alter certain genetic expressions that can then get passed on to future generations- the so-called "inter-generational effects of trauma". This field of research theorizes that environmental factors influence the expression of certain genes by altering chemical tags (such as the compound methyl moiety) that are present on the surface of DNA. Subsequently, future offspring of a traumatized parent may exhibit some of the negative reactions exhibited by their parents even when they have not experienced the trauma themselves.

The concept of intergenerational trauma was first introduced in the psychiatry literature in the 1970s. Researchers described behavioral and clinical problems in offspring of Holocaust survivors who did not experience the traumatic events themselves. Since then the concept has expanded to the exploration of the intergenerational effects of other traumatic events of global importance including the Khmer Rouge killings in Cambodia, the Rwandan genocide, the displacement of American Indians and the enslavement of African-Americans. As the Nobel Prize winning author William Faulkner said: "The past is never dead. It's not even past."

Likewise, the lead researcher/author of the ACE study Felitti also said: "The findings from the ACE Study provide a remarkable insight into how we become what we are as individuals and as a nation".

So, what is the lesson for Ethiopia?

Ethiopia as a country and Ethiopians as a people have a legacy of years of national trauma including famine, war, government sponsored terrorism, communal clashes, displacement, and migration. Additionally, millions of Ethiopians currently experience a variety of personal traumas ranging from extremes of poverty to physical and psychological violence in their own homes, villages, schools, workplaces, and social settings.

The acknowledgement of the pervasive nature and the devastating intergenerational effect of trauma among Ethiopians can be a helpful lens through which we can see the current state of affairs. The acknowledgement might also move us to offer empathy and healing to those who need it while making it a priority to hold accountable people and systems that traumatize vulnerable population and destroy the health and wellbeing of generations.

In my generation, we have seen regimes traumatize the people of Ethiopia for decades. They have done so overtly by terrorizing communities, incarcerating, abusing and killing opponents as well as innocent civilians; and covertly by planting seeds of hatred and violence against specific groups in order to protect their personal and group interest. However, to think that such despicable abuse of power and violence was limited to leadership only would be shortsighted.

Violence and trauma among Ethiopians are in fact ubiquitous and cross cutting from the street kids of Addis Abeba to high ranking officials of the country; from the locals to the diaspora who live abroad. The horrendous acts of violence we hear about today that make the hairs on the back of our necks stand did not just come out of the blue. The perpetrators are not strange aliens, they are one of us. The atrocities we hear being committed are not 'counter-culture'- they have been groomed and primed for years on existing cultural realities and now given the opportunity to be displayed out in the open.

Inflicting abuse and violence against women, children, and other subordinate groups in the homes, schools, in the work place as well as in other social settings is pervasive in Ethiopia. These toxic cultural remnants are not irrelevant and innocuous bystanders to the current horrifying reality. They factor into the creation of leaders, politicians and youth who are committing acts of brutality against their own people in cold blood. There should be no level of violence that is acceptable for a civil society, in any setting including home, school, work place, or in the custody of government.

Leading figures in the field of Inter-Personal Neuro-Biology (IPNB) such as Daniel Siegel, MD, have found that human connection is a powerful tool to help heal the effects of trauma in individuals. Strong human connection is in fact postulated to be one of the reasons why certain people who experience trauma are more resilient than others. Sadly, what the political elites in Ethiopia have done is systematically and intentionally go after this very important cultural safety-net that offers a measure of protection against the lasting effects of trauma.

Some of the damage trauma has done to and through thousands of Ethiopians will not be reversible but awareness and intervention can help mitigate the pain and the spread of its effects to future generations. Public health awareness and intervention for trauma should start in the home and with protecting the most vulnerable and defenseless of all, the children of Ethiopia.

Violence, abuse of power and hatred against anyone under any circumstances, whether in homes or in public spaces or in the custody of government, should be punishable by law. Public health intervention can also facilitate community elements to organize around health and wellbeing activities that build human connection and improve trauma resilience.

Within existing community groups public health practitioners and trained lay persons can lead in creating a safe space for trauma victims to get the support they need, to engage in culture specific communal rhythms such as dance and prayer which are all known to be helpful for healing. Some of the community development works that are being done in some parts of Ethiopia including tree planting, area cleaning, tutoring school children, building houses etc should be highly encouraged because civic engagement has been shown to help trauma victims "discharge" pent up traumatic energy into productive activities. Furthermore, beautifying our surroundings should not be seen as a concept of luxury and privilege- well-kept surroundings especially well-preserved access to nature have healing power.

The mental health community acknowledges the limitation of "talk therapy" to cure depression, anxiety and behavioral health problems that are common in traumatized people. Trauma symptoms such as uncontrollable rage, "depersonalization", "dissociation" and the alterations in perception of reality in trauma patients have expanded the treatment that is available for them to include "body-based" treatments. These could take several forms but activities that incorporate mindful body movements such as yoga and dancing, deep breathing, meditation/prayer are all helpful. They allow trauma victims to reconnect with themselves and to develop body awareness and begin to integrate their thoughts with logic and their bodily sensations with perceptions. AS

Editor's Note: Sosena Kebede, MD, MPH, is the founder and Executive Consultant of HealthCare Engagement, LLC that provides quality improvement services to health systems and patient engagement trainings to community members. She is an internal medicine physician who worked for the Johns Hopkins Health System (JHHS) for several years on various capacities including as an Assistant Professor of Medicine at the School of Medicine, as Health Policy Instructor at the Bloomberg School of Public Health, as Patient Safety and Quality Consultant at the Armstrong Institute for Patient Safety and Quality and as a Primary Care Physician at one of JHHS' community physician sites.

She can be reached at soskeb@gmail.com

References

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, et al. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine. 1998; 14:245-258.

Cronholm, P. F., Forke, C. M., Wade, R., et al. (2015) Adverse childhood experiences: Expanding the concept of adversity. American Journal of Prevention Medicine, 49, 354- 361.

Van der Kolk, B. (sept. 2015). The Body Keeps the Score. Brain, Mind and Body and the Healing of Trauma. Viking.

Koenen, K.C. & Galea, S. (2015). Post-traumatic stress disorder and chronic disease: open questions and future directions. Soc. Psychiatry Psychiatr. Epidemiol., 50, 511-513.

Dias BG1, Ressler KJ2. Parental olfactory experience influences behavior and neural structure in subsequent generations. Nat Neurosci. 2014 Jan;17(1):89-96. doi: 10.1038/nn.3594. Epub 2013 Dec 1.

Rakoff V. A long term effect of the concentration camp experience. Viewpoints1966;1:17‐22.

Yehuda, R and Bierer LM. Transgenerational transmission of cortisol and PTSD risk. Prog Brain Res. 2008;167:121-35

Benard, B. (2004). Resiliency: What have we learned? San Francisco: West Ed.

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