But the afflictions, the scars, of the Ugandan conflict are more than just skin deep.
Research has shown severe mental illness increases by 50-100 per cent in post-conflict contexts (IASC 2007; WHO, 2005). In northern Uganda, a number of epidemiological studies stated the prevalence of post-traumatic stress disorder stands between 54 and 74 per cent, and depression rates range between 44 and 67 per cent (Vinck et al, 2007; Roberts et al, 2008; Bolton et al, 2007).
Eight years after escaping from the LRA, Janet still awakes screaming most nights fighting off the hands at her throat. She says she can no longer sleep in a room alone.
“If I am sleeping alone or missed saying my prayers, it disturbs me a lot but if I pray I can sleep peacefully. When I am sleeping with people and it starts strangling me, other people can hear me groaning and touch my body then I will wake up…I don’t know what it is. Other people who were also once in the bush have the same experience and we all believe that this could be spirits of those who were killed in the bush.” (Aber, June 2011).
And Janet is not alone. Many of the women I interviewed experienced similar nightmares and visions. Haunting dreams and waking visions are constant reminders of the terrible things they did while with the LRA.
“In my dreams I could see people being killed because we were also made to kill some man who tried to escape. They tied him on a trunk of a tree with his head down and we were asked to make fire below his head on the ground. We were forced not to go anywhere – to see him burn alive…I still dream about such encounters at night and sometimes I even have visions of it during the day. So whenever I see such in my vision, I go mad. Sometimes my family and neighbours just have to tie me down to prevent me from running away in the bush.” (Adong, June 2011).
The Acholi tribe, which inhabits much of the worst affected regions of northern Uganda, believe in the existence of jogi – spirits or forces that can be either good or evil (Mpyangu, 2010). Usually in conflict and post-conflict zones inhabitants complain of hunger, mortality, disease, poverty, homelessness. However, the Acholi are more concerned about the vengeful spirits of those killed during the conflict. They are believed to have a pernicious influence if not appeased. The cen, or polluting spiritual force, possesses those who have killed, done wrong, witnessed a killing, or touched the body of a corpse, by entering that person’s mind or body resulting in dissociative states, nightmares, flashbacks or psychosis that remain until the wrongdoing is put right (Mpyangu, 2010). The Acholi also believe that cen is contagious and can infect an entire family or community (SWAY, 2008). Consequently anyone thought to be haunted by cen is shunned and avoided by the community.
“When I came back home from the bush I started to have visions of the people we’d killed and stripped naked for their clothing. This often drove me mad and I would start running around the village. It would make me piss or even shit myself without knowing it. Sometimes it would come to my room at night and try and strangle me.”
These are the words of Lily Atek, who was 14 when she was snatched from her home. Lily, and the majority of the other women interviewed, describe symptoms that closely resemble what the western world would call post-traumatic stress disorder or PTSD. Nightmares, waking visions, insomnia, phantom pains, and aggression are all typical symptoms of the disorder. These symptoms are not only harrowing, but can also impact their ability to earn a living:
“I was made to kill, and killing in the bush you don’t always have a gun. You are often made to batter adults and children to death, or burn them in their houses…cen still attacks me even today. But at least I can feel it when cen is about to attack me, so I am not able to go to work. I must remain at home with someone who prays for me.” (Aol, June 2011).
Yet in Uganda these experiences are envisaged as by-products of spiritual possession. Returnees are encouraged to pay an ajwaka (traditional witch doctor) to exorcise the spirit, or to combat the cen through prayer. Cen, or even the suspicion of having cen, impedes any chance a returnee has of mental healing or being accepted back into their community (Baines, 2010).
According to the Ministry of Health approximately 60 per cent of Ugandans, particularly those in the northern districts, seek help from these ajwaki as a traditional alternative to more expensive, modern day medicine (Ministry of Health, 2010). That’s not to say that a witch doctor’s services are free – far from it. Ajwaki too need to be paid for their services and the majority of rituals require clients to bring animals for a sacrifice.
The shade from the mango tree couldn’t dim the twinkle in the eyes of the 86-year old Acholi clan elder’s eyes.
He leaned over, touching my leg, and assured me in his customary growl that spirits of the dead do indeed exist.
I was meeting Naptali Ococ, a respected elder in the community, who was to explain the importance of cleansing rituals in Acholi culture and how they’ve been used in aiding formerly abducted men and women returning from the bush.
Ococ says these rituals are vital to ensure that community members cannot single them out for stigmatization.
There’s a number of ceremonies, of which Ococ says he’s performed thousands of over the years.
There’s nyono tongweno (stepping of the egg) that is the traditional welcome ceremony for anyone who’s been away from home for a length of time. The majority of the 40 women I’ve interviewed underwent this particular ceremony.
Then there’s moyo cer growled Ococ.
Moyo cer, or cleansing of the land, is performed at the site of a former battlefield where a number of people were killed. Ococ says the Acholi believe dead spirits hover around the place where they were killed
There’s mato oput (drinking the bitter root) that helps reconcile two different parties, typically a returnee and the family of someone they’re accused of killing. The ceremony is supposed to remove guilt from the family of the perpetrator and ensures that the spirit can now accept that something has been done to appease its family members.
Oput is a tree commonly found in northern Uganda. The elders squeeze the root to get a bitter juice. This is mixed with beer and ram’s blood and drunk by both parties. Afterwards, the family of the deceased is typically paid some money. From that day on the families are seen to have become friends again, and the spirit can now no longer haunt them.
But the journalist in me wanted to dig deeper.
Did Ococ really believe in spirits, or did he believe that cen was merely a manifestation of PTSD?
Also most of the women I interviewed underwent one or several of these ceremonies but said they didn’t understand why they were done, and that they had no impact.
Is Ococ afraid that the old Acholi ways and customs are being left behind as a result of the new generation growing up in IDP camps, and as the north becomes more gentrified, more westernized?
Well, I’ll let him tell you.
But one woman’s testimony reminded me that not all these women were simply victims, made to kill. It’s not as black and white as that. While I’m sure all of these women were forcibly abducted, some adjusted more easily to the brutal ways of life in the LRA.
Alice, like many of the women I interviewed, experiences cen. But her recollections had a more sinister side:
“There was some woman who we killed in a group - I was even the fourth person to cut her with a machete. She still comes to me in a dream telling me that my daughter you are killing me for nothing…others that I killed appear in an open grave and they talk to me. I normally wake up then, I get a terrible heartbeat and start crying. Prayers have at least reduced the problem. There’s another man I personally killed because when we abducted him, he slapped me. I pierced him with my bayonet. He also comes into my dreams but normally appears lying face down the ground but says nothing to me.” (Oyella, June 2011).
Alice’s account of bayonetting the man suggests something more than mere cen. She seemed to enjoy her new role, her elevated status in the bush. Her account of how she was promoted into the Chapu battalion, a particularly feared and brutal branch of the LRA, borders on bragging. She confesses to me that coming back to her old community, losing that status, has been hard for her.
More worryingly, she tells me she still has violent impulses:
“Even now when I see a civilian, I feel very angry and develop the intent to do something bad as we us to do while in the bush. It is the same when I see the army soldiers.”
It seems a life in the bush has habituated Alice to violence, and she is clearly still traumatized and is potentially a danger to other members of her community.
But this cen, or spiritual possession, is just one of five major mental health categories identified by a 2011 UN research team. Cen and the categories of neurological conditions, ‘over-drinking’, ‘over-thinking’ and ‘madness’ were also seen by local communities as parts of entrenched cycles of negative change, where cause and effect are blurred (UNPBF).
What then was done to help these women?
Certainly counseling was offered in the reception centres and is even offered today by varying NGOs. Why then, years after their return, are these women continuing to suffer with cen and other mental health issues?
The answer is startlingly simple – it’s down in large part to a lack of funding and training.
The Ugandan government spends less than one per cent of its health budget on mental health – far below the recommended five per cent (WHO, 2005b; Development, Research and Training, 2007). At the district level, there is no specific budget for mental health and health managers must use money from other limited funding sources (UNPBF). IN addition, trained psychiatric personnel are also strikingly absent from many health centres, particularly those in more rural regions.
A UN report issued in 2011 also criticized the Ugandan government’s PRDP initiative to re-build the north. Mental health isn’t currently catered for in the framework – an element which the report says is crucial to future development efforts in the region:
“Mental health, development and peacebuilding are closely linked; an increase in mental ill health increases poverty and negatively affects social capital and ability to function and recover, thus placing a greater burden on communities.”
There was a general sense among my participants that PRDP, and specifically NUSAF, was pre-occupied with the physical, tangible, visible signs of recovery. One NGO worker posed a valid rhetorical question: what good are new roads if the people in those outlying communities are not healthy enough to trade? Perhaps a World Bank report best summed up the situation:
“The easiest part of any Bank operation is reconstructing the bricks and mortar;l the hard – but more essential – part is restoring the institutional societal bases of post-conflict society.” (Kreimer et al, 1998).
But NGOs, as well as the government, are also guilty of largely being unable to cater for the mentally ill.
Field research revealed that counseling sessions conducted by NGO staff are often brief, lackadaisical affairs of two to three meetings where the women were told they were guilty of “over-thinking” their experiences. Rather than confront their past, counselors encouraged them to simply forget about their time in the bush.
I interviewed Dennis Eyalu, a social worker for the Lira-based NGO Centre for Children in Vulnerable Situations, about how he counsels returnees who are experiencing cen :
“You ask them, ‘when you are alone, what do you do?’ As she gives you the answer, you inform them that really they are hearing voices because they are over-thinking. The only way of dealing with that is staying with friends or by coping through prayers…sometimes this cen would even attack the girls in class, during daytime. From our experience this cen comes when they are sorrowful – they then begin recalling the past - the good things their parents used to do for then and the good life they had before their abduction. So it is only after that over-thinking that the cen usually comes, often with a knife.”
It’s clear in our interview that Dennis cares for these women. But to dismiss PTSD as simply over-thinking was staggering. I found that the notion of counseling in Uganda was quite different to our western definition. Talking about painful memories, analyzing them, making peace with them, is often actively discouraged. Rather prayer and company are seen as the remedy. But these seem like mere placebos.
I ask Dennis how long he’s been a social worker.
Two years, he replies. He says he was a cashier for a brewery before.
Follow-up visits with returnees are also an issue. One study concluded that only 13 per cent of returnees had received a follow-up visit from center staff (Baines, 2005). This has typically been blamed on a decrease in funding and a lack of documentation.
Dennis tells me they try to see the women in town at least every two weeks, but that many of the women they help live in remote villages outside of Lira. A round-trip can cost around 20-30,000 shillings, or 10 dollars – money the organization cannot spare.
Those women who live far away must depend on God’s mercy, he says.
I had the opportunity to go with a young counsellor on a follow-up visit with another organization – the Kitgum-based KICWA.
This visit opened my eyes to the fact that the issues weren’t purely monetary.
The staff member upon arrival at the family compound conversed briefly with the woman. The counselor said the woman was doing well since their last meeting.
However, a subsequent interview with the formerly abducted contradicted what turned out to be a typically cursory analysis. Further questioning revealed that the woman was still suffering stigmatization from the community, and was unable to work due to a mechanical fault with her sewing machine.
I also spoke to Grace, another formerly abducted woman, who had passed through the KICWA centre in 2001.
“The only help I got at KICWA was some counselling…after I left the centre they never made any follow-up on me as they promised. That was many years ago now…I feel if I go on talking, it will bring back many bad memories and it will break my heart even more.”
These two experiences, in addition to others, demonstrated that if they happened at all, follow-up visits were often poorly conducted, leaving the women to fend for themselves. The staff member lacked any formal training in counseling, and appeared to be unengaged with the returnee. It could not be determined whether properly trained staff could not be afforded, whether in peacetime these returnees’ problems are not viewed as of immediate importance, or whether there were other issues affecting the effectiveness of the follow-up visits.
I asked Dennis Okwir, project coordinator for NGO Empowering Hands, for his opinion of psycho-social support efforts in northern Uganda.
“I work with these women daily and I know that there is a high degree of recurrence of trauma…For me this emanates from the fact that we gave had so many children returning and too few reception centres and we didn't have enough psychotherapists. So if you were friendly with them, sang with them, then that meant you were a good counselor…being nice was the thing. It didn’t take care of individual aggravation in captivity, or coping mechanisms. I wish that these people had helped these women develop personal development plans, so that we know for each person what the issue is and how we’re going to overcome it.”
Regardless, a suitable approach to helping these women with their psychosocial problems seemed to be lacking. The successful reintegration of these women cannot realistically be achieved until they have come to terms with their abduction. Mental ill health and psychological distress in the post-conflict region of northern Uganda also impacts the rehabilitation of a community itself. Restoring normality, reducing humiliation and resentment, are essential elements to sustainable peace and recovery.