Free Kesha: Rape Culture and the Failure of our Justice System

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(Originally published on Medium)

This past week, Kesha lost her injunction against Sony, a legal bid to be released from her contract with producer Dr. Luke. The injunction was filed after a formal complaint against Dr. Luke in October 2014. The complaint charged Dr. Luke with physical, sexual and emotional abuse against Kesha over a duration of nearly ten years, violations of her integrity, dignity and safety that his record label, Kemosabe, and Sony were aware of. Two testimonials particularly stand out: Kesha was twice forced to ingest substances that incapacitated her, only to wake up and discover that she had been raped. Dr. Luke’s sexual exploitation was coupled with an emotional abuse and a controlling supervisory style. Based off of the depiction in the complaint, their relationship had all the characteristics of intimate partner violence.

Kesha, after hearing the verdict of her injunction

Kesha, after hearing the verdict of her injunction

The condition of fear in a household of domestic violence often renders victims silent. Just as mothers may be fearful of the safety of their children, Kesha was “threatened that if she ever mentioned the rape to anyone, he [Dr. Luke] would shut her career down, take away all her publishing and recording rights, and otherwise destroy not only her life but her entire family’s lives as well” (7). Beyond the personal and familial peril that Kesha likely experienced, media and public response has not been especially kind to women who stayed in abusive relationships. The emotional, physical and sexual coercion that occur within such relationships are “private traps,” snares rendered only more dangerous by the lack of empathy for women who stay.

Kesha’s bravery to come forward, and her willingness to abandon her music career in an effort to liberate herself from Dr. Luke and sound the alarm within the music industry, is incredible. Despite the fact that the judge threw out Dr. Luke’s countersuit against Kesha’s mother and manager earlier in February, however, the judge’s decision to hold Kesha to her contract is emblematic of the larger problem of how the justice system handles sexual violence. Criminal courts have historically been unkind to survivors of gender-based violence, in part because the onus is placed upon the survivor to produce evidence that would “substantiate” their claims. The procurement of evidence is complicated by the very nature of sexual violence and the ongoing contestation over the notion of consent. Women who are inebriated, under the influence of substances, or incapacitated are legally incapable of giving consent, yet their incapacitation may also make it difficult to provide a “reliable” account of the event. Sexual violence can also be a traumatizing experience, one that has psychological consequences like short term memory loss, dissociation, lack of affect, and poor episodic memory, meaning that testimony may seem contradictory and therefore fictitious. The criminal justice system, often reliant upon police intake reports, tends to script the sexual violence encounter, a narrative that rarely affords legitimacy to survivors’ stories that deviate from “the truth.” Police officers may also harbor rape myths that survivors are lying or trying to get attention by making rape accusations. The archetype of “the perfect victim” continues to plague the survivors who decide to report.

Jon Krakauer, author of Missoula on NPR

Jon Krakauer, author of Missoula on NPR

Other evidence can be collected through Forensic Nurse Exams conducted by trained Sexual Assault Nurse Examiners (SANE). Because these exams are usually conducted with the purpose of filing a report against a perpetrator, the survivor’s body is treated as a field of evidence, one that must be prodded and scraped for data. Hospitals may not be properly equipped to sensitively handle the intake of sexual violence survivors. The exam itself can also be re-victimizing, including some painful procedures that medically invade survivor’s bodies. Nurse examiners can also demonstrate the same callous attitudes as police officers, believing that some women were “asking for it.”

That is, if a survivor can even get to a hospital or a police station. Abusive partners will do everything within their power to keep the victim from seeking help. Since fabrics like clothes or bed sheets may contain incriminating evidence, perpetrators will often wash or dispose of any materials that would link them to possible allegations of violence. Abusers often monitor the movements of their partners and prevent any personal time or freedom that would provide an opportunity to report or seek treatment. If a survivor finally decides to break their silence days, weeks, or months after the most recent physical altercation, however, there may be no evidence left to collect. Even lasting physical injuries are difficult to convincingly attribute to alleged perpetrators.

If a survivor manages to make it to court, she will be forced to relive her violation day after day, cross-examined by lawyers and impelled to recount her experience. If she is unable to provide evidence from a forensic nurse exam, then her only evidence is testimony, which, as discussed, may be disoriented by the psychological trauma of sexual violence. Lawyers and judges are likely to ask why they didn’t come forward earlier, why they didn’t scream out, why they didn’t fight back; all questions that fail to understand at the most fundamental level the gendered powered dynamics inherent in sexual violence or the neurological consequences of trauma, the body and mind’s fight to survive under life-threatening circumstances.

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The justice system is not set up to support survivors. The judge who denied Kesha’s injunction for emancipation from her abuser employed the kind of logic endemic of rape culture, stating that the dismissal was the “commercially reasonable thing to do.” When profit and corporate contracts are more important than the human rights of men and women, that is rape culture. When a survivor simply wants separation from the very person who has violated them, and that desire elicits a poll on Billboard about whether or not music executives believe her, that is rape culture. When Newsweek decides that responsible journalism is a story about the “other side of the college sexual assault crisis,” that is rape culture. When an alleged perpetrator’s word is taken as more convincing evidence as a matter of fact than a survivor’s and a woman’s, that is rape culture. We don’t only need to free Kesha. We need to address the chains that keep survivors shackled to their abusers and a system that tacitly condones such abuse.

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Dis-Ease and Distrust: The Connection Between Anti-Vaccination and Typhoid Mary

The anti-vaccination movement is not a new phenomenon, but its tenacity relies upon the short memories of the public. While some have condemned those who choose not to vaccinate their children as “backsliding into medieval ignorance” (Hiltzik 2014), it is also critical to consider the ideological tensions that drive an individual or a community’s decision not to protect their children from harmful pathogens and to contextualize historical precedents that demonstrate the strain between personal liberties and the protection of public health.

When Edward Jenner first proposed an inoculation for smallpox—based off of newly emergency theories about how diseases are spread and the connection between milkmaids’ immunity to the illness—the public erupted in panic, fearing that the newly introduced vaccination, containing a live culture from cows, would mangle their bodies and deform them into half-bovine creatures (Green 2015). The ultimate success of Jenner’s treatment helped to convince the public of the efficacy of vaccination, but doctors also faced the challenge of communicating complex scientific theories and principles to the public, in a way that had to be neither patronizing nor alienating. Scientific discourses and theories are not necessarily accessible or easily digestible to the general public. For many years the widespread use of vaccinations has relied upon the success of eradicating once pernicious and deadly diseases, like polio, to convince the public, perhaps without comprehensive or convincing public education programs about why and how the vaccinations have been working.

Less than 100 years ago, there was also a much greater fear of disease. The Influenza Epidemic of 1919 reportedly killed more people than World War I, wiping out huge swaths of the American population. Measles killed innumerable children. Fear of disease and the promise of protection offered by inoculation may have combined to vest doctors and scientists with public trust in vaccinations, despite unclear understandings behind the biological mechanisms that inform the intervention. Fortunately, or, perhaps, unfortunately, we live in a time when the threat of disease in the Western world is distant. David A. Grimes writes, “Apathy derives from naiveté; many parents of young children today did not live through the ‘bad old days’ before immunization. Vaccination has become a victim of its own success, and our nation has become complacent as a result. An entire generation of Americans has grown up unaware of the danger of measles” (2015). We have forgotten how recently diseases that could not be tamed or controlled threatened our lives. We live in the aftermath of an extensive and successful multi-sectoral public health intervention that has improved food and water standards, attempted to sanitize urban spaces and ushered in an era of hearty herd immunity. But we also live in a time of suspicion—scientists and doctors are not the well-trusted experts they once were. Many Americans are disaffected by biomedicine or the callous attitudes of the public health system, instead turning to traditional or homeopathic remedies that represent more sensitive, holistic approaches to their health needs. Some Americans may also be blinkered by the normalization of health privileges—it is easy not to fear death or disease when you have easy access healthy food, clean water, a social environment that creates positive conditions for health to, and quality health care facilities that you can afford to use if alternative remedies fail.

Hank Green, The Science of Anti-Vaccination https://www.youtube.com/watch?v=Rzxr9FeZf1g#t=86

Hank Green, The Science of Anti-Vaccination https://www.youtube.com/watch?v=Rzxr9FeZf1g#t=86

This is not the case throughout the rest of the world, especially in communities so impoverished that their immune systems cannot adequately fight off relatively benign sicknesses. In America, we are all considered “experts” of our own health, but are not necessarily equipped with the critical tools to tell apart medicine from quackery. We value anecdotes over statistics, the triumph of the individual over the sanitized data and hypotheses of biomedicine. Vanessa Wamsley consulted, “Dr. Kristin Hendrix, a professor of pediatrics at the Indiana University School of Medicine, researches how parents make decisions about their children’s healthcare, including vaccinations. ‘It’s a combination of pretty complex psychological factors,’ Hendrix says. ‘Some folks are very predisposed to trust information about others’ personal experience’” (2014). Within this complicated context of dis-ease, it should not be surprising that Andrew Wakefield’s 1998 Lancet article connecting MMR vaccinations with autism trigged a wave of hysteria. The article touched a visceral nerve, validating confirmation biases and further entrenching mistrust of government mandated medicine. Seth Mnookin’s book The Panic Virus (2012) provides a comprehensive analysis of the scientific, social and discursive debate that emerged from the paper. Within the age of personalized medicine and without adequate mechanisms to launch a convincing public health education offensive that was comprehensive without being pedantic, we began to lose our herd immunity. And from the wake of the latest measles outbreak in California emerges what may be a familiar debate between the responsibility of the state to protect the public’s health and the sanctity of personal choice.

In the early part of the 20th century, Mary Mallon served as a cook for well to do families in New York City. A single, Irish immigrant woman, Mallon’s choices and opportunities for employment were limited. Perhaps due to her aberrant independence, she was a spit fire by nature, private and self-possessed. She may seem typical in a city full of immigrants clawing after the American Dream, were it not for the other part of her identity that remained hidden until the state of New York intervened—she was a healthy carrier of typhoid. Otherwise known as Typhoid Mary, Mary Mallon was initially accosted by public health officials in 1907 when they traced a recent typhoid outbreak to her. As a cook, her profession lent itself to quick yet discrete transmission of the disease. Mary claimed to be entirely healthy, with no symptoms of the illness, and denied the claims that she was a healthy carrier. When she refused the state’s request to discontinued her profession as a cook, she was arrested as a menace to public health and removed to North Brother Island, where she would no longer “contaminate” the upper crust elite of NYC society.

She was eventually released in 1910, under the condition that she find other work apart from cooking, but was equipped with minimal assistance and few other marketable skills to find steady employment. She was eventually discovered under a false name in the kitchen of a family, likely out of desperation for income and the dogged belief that she was not ill, especially considering that she demonstrated no symptoms of typhoid. Previously portrayed to the public as a somewhat sympathetic, if misguided character, the media quickly turned on her, labeling her as a mistress of death knowingly brewing disease in the houses where she worked. Newspapers painted her as a heartless villain who wished to infect those around her. Infuriated by the violation of the terms of her release, New York decided to use Typhoid Mary to set an example. In 1915, they permanently removed her to North Brother Island, where she would live out the rest of her life.

Like the contemporary anti-vaccination community, Mary Mallon did not trust the doctors or public health officials who told her that she carried typhoid. As Judith Walzer Leavitt points out in her book Typhoid Mary: Captive to the Public’s Health (1996), Mallon’s clinical status represented an ideological schism between public health officials and the infected individual: “[Mary Mallon] insisted she was not sick and had never been sick with typhoid fever. She used her personal knowledge about her own body to argue that since she had no disease symptoms she could not menace anyone else’s health. She did not want to be treated like someone who was sick when she felt healthy and vigorous, and was in fact leading a productive life when she was taken” (86). Her personal experience and bodily knowledge clashed with those of the scientific community, positing alternative approaches to health. Her vexed condition as a menace to public health was further inflamed by the mistrust of immigrants at the turn of the 20th century. Leavitt also indicates that Mallon’s gender worked against her: “Health officials viewed women carriers of typhoid fever as more dangerous than men in part because cooking, an activity that provided one of the easiest routes of bacilli transmission, was a traditional female activity” (1996: 97). Mallon’s health can therefore be understood as both a biological and a social condition, galvanizing a series of public outcries and institutional responses that also expose belief systems intertwined with health. During the time of Mary’s arrest and removal, the American populace compelled the government to protect public health, a mandate that necessarily involved dictating social order. “In the early twentieth century the law spoke with a single voice and a simple guideline: public health authorities had the medical ability and the legal authority to define a public health menace, regardless of due process or the curtailment of an individual’s liberty and regardless of consistency. The judges were willing to give health departments the power to discriminate among carriers and decide which healthy people who carried pathogenic bacteria in their bodies were to go free and which were to be detained” (Leavitt 1996, 95). The health of the population (particularly the wealthy population) of New York was therefore elevated above the civil liberties of Mary Mallon.

As a healthy carrier of typhoid, Mallon jeopardized the health of those around her, not unlike how the anti-vaccination movement is undermining herd immunity and endangering the lives of those who are either too young to be immunized or the immunocompromised, such as citizens in developing, impoverished countries, unwittingly exposed to carriers through the tourism industry. The United States is not without its own health problems, which means that individuals and families who don’t have access to quality and affordable health care may also be in danger. Mary Mallon was demonized for her actions, and as the measles (declared eliminated in the US in 2000) escalate in numbers and severity, certain members of the public are beginning to treat anti-vaccination as a threat to public health as well. Conor Friedersdorf has made the point that condemning the actions of a group will only solidify their anger and further entrench their actions, especially considering that, “the vast majority [of anti-vaccination parents and proponents] are not, in fact, especially selfish people, and characterizing them as such just feeds into their mistaken belief system” (2015). Mary Mallon’s public health experience transcended the personal into a popular metaphor, one that highlights the perils of conflicting ideological frameworks surrounding health and the compromises that must be made to avert health crises. Biomedicine, though founded upon empirical evidence, also represents an ideology about the body and healing that may be incommensurate with personalized notions about illness.

We are quickly reaching a crossroads when the US government will be faced with a similar dilemma the state of New York confronted in 1907. As Leavitt so cannily writes, ““Because the road from and to the past is a two-way street, we must be alert to how the realities of the present have an impact on how we construct and reconstruct the past […] If we are aware of our present sensitivities, they can help rather than hinder our understanding of history, just as history can help us comprehend our options in the present” (1996, 5). What do we value as a nation—radical individualism or national prosperity and heath? How are our understandings of health shaped by personal biases that are also related to privilege, race, and gender? Are there instances in which public health triumphs over personal liberty?

Works Cited 

CDC (2015). “Frequently Asked Questions About the Measles in the U.S.” http://www.cdc.gov/measles/about/faqs.html

Friedersdorf, Conor (2015). “Should Anti-Vaxers Be Shamed Or Persuaded?” The Atlantic. http://www.theatlantic.com/politics/archive/2015/02/should-anti-vaxxers-be-shamed-or-persuaded/385109/

Green, Matthew (2015). “The Feverish Roots of Today’s Anti-Vaccination Movement.” The Lowdown. http://blogs.kqed.org/lowdown/2015/02/15/the-feverish-roots-of-todays-anti-vaccine-movement/

Grimes, David A. (2015). “Deniers of Science: The Anti-Vaccination and Anti-Abortion Movements.” The Huffington Post. http://www.huffingtonpost.com/david-a-grimes/deniers-of-science-the-an_b_6471684.html

Hiltzik, Michael (2014). “The anti-vaccination movement drives measles to a 20-year record high.” LA Times. http://www.latimes.com/business/hiltzik/la-fi-mh-measles-20140530-column.html

Leavitt, Judith Walzer (1996). Typhoid Mary: Captive to the Public’s Health. Boston, Massachusetts: Beacon Press.

Mnookin, Seth (2012). The Panic Virus: The True Story Behind the Vaccine-Autism Controversy. New York: Simon & Schuster Paperbacks.

Wakefield, Andrew et al. (1998). “Retracted: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children.” The Lancet, Vol. 315, No. 9103. pp. 637-641. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2897%2911096-0/abstract

Wamsley, Vanessa (2014). “The Psychology of Anti-Vaxers: How Story Trumps Science.” The Atlantic. http://www.theatlantic.com/health/archive/2014/10/how-anti-vaccine-fear-takes-hold/381355/

 

New Global Study Calls Violence Against Women ‘Epidemic’

So excited to be a part of the Global Women’s Institute and its part in this project.

TIME

When it comes to stopping violence against women, actions speak louder than words. So even though there’s increased worldwide awareness about violence against women, the problem won’t be solved unless countries make significant policy and financial changes to support victims, according to a five-part series of studies in The Lancet, one of the world’s premier medical journals.

The series, entitled “Violence Against Women and Girls,” calls the violence a “global public health and clinical problem of epidemic proportions,” and the statistics are bleak. 100-140 million women have undergone female genital mutilation worldwide, and 3 million African girls per year are at risk. 7% of women will be sexually assaulted by someone besides their partner in their lifetimes. Almost 70 million girls worldwide have been married before they turned 18. According to WHO estimates, 30% of women worldwide have experienced partner violence. The researchers said that these problems could…

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Homes and Health: The Intimacies of International Development

Within the world of international development and global aid, there is a lot of discussion and debate about how to make the most impactful, sustainable change. Do you focus on capacity building at a grass-roots level, in the hopes that installing one well in an impoverished village will have ripple effects throughout a larger country or community? Or do you pay more attention to governmental and structural factors to empower a populace? When it comes to building institutional capacity and local support, politicians and humanitarians often telescope between macrocosmic and microcosmic perspectives. The two can obviously occur contemporaneously, but when you have limited resources and time, how do you decide where to focus your energy? Do you hope for the trickle-down effect, which supposes that efforts to revamp bureaucratic and institutional systems, like legal and economic policies in a developing country, will have the most impact on the day to day lives of a population? Or do you attend to the personal lives of individuals, upon whose bodies suffering and hardship are writ, in the hopes that a single person or community can bring about the groundswell of effectual, long-lasting change?

I spent the last nine months as a Peace Corps volunteer in Fiji, a developing country with significant economic and health care issues. As a representative of the United States government partnered with the Fijian Ministry of Health, I straddled the macrocosmic and microcosmic dimensions of international development. Unlike other aid organizations, Peace Corps focuses on building people and relationships—the organization and its volunteers are acutely focused on how grassroots activism can make enormous changes for communities in need. I spent a lot of my time talking to small groups of women, school children and Church communities, hoping that our community health outreach programs touched just one individual in the group. If I had helped one person at my local health center realize the connection between water contamination and illness, sanitation practices and health, then it was a successful day. Part of working on a grassroots level of international development and health advocacy means readjusting your standards of success. Behavioral change happens one person at a time, and the hope is that that one person will then become an advocate for the cause themselves, forming a multitude of tiny ripples that would eventually spread out over a farther distance.

Teaching reproductive health in a rural Fijian primary school

Teaching reproductive health in a rural Fijian primary school

But as a community health empowerment volunteer, I couldn’t help but think about my own health and the health of my family back at home. For an aid program to be sustainable, it also has to be sustainable for the volunteers as well. And I, among other PCV’s in the country, did not feel emotionally or professionally sustained. I was sick for the majority of my time in Fiji and continually called to question the true impact of my service. Back at home, my father was caring for his ailing parents, each of whom required specialized attention. Both my younger sister and younger brother were dealing with their own, sometimes debilitating, health problems, conditions that impacted the welfare of my parents as well. I have always felt like the caretaker of my family, and I couldn’t help but feel like I belonged at home, focusing my efforts on the most microcosmic of communities—my own family.

There are no awards or accolades given to caregivers or to the individuals that devote their time to the health and happiness of their own families. Yet every day that I was home, I felt myself getting stronger and healthier, and I watched the impact my presence had on my family. I felt as though I was siphoning off some of my brother’s pain, and thereby alleviating some of my parents’ anxiety and stress. I gave myself permission to allow myself to heal and attend to my own physical and emotional well being. These are the mundane, private efforts of personal development that are not often acknowledged or discussed as valuable or necessary. And yet, as we export more and more resources abroad, imposing Western ideals and reproducing dependence on foreign aid, we neglect to look at our own homes, our own lives. Perhaps the most impact we can make in our lives are the personal relationships we develop in our own extended families. Perhaps we have to think about what is ailing us as a country and a people.

Mental Health and Mental Illness in Fiji

The concept of mental health and mental illness, like biomedicine, is still a relatively new concept in Fiji. As a Western, allopathic psychological model, very few people in Fiji are trained in appropriately and sensitively treat mental illness, and, thusly, the resources available to individuals who suffer from mental illness are fairly limited. In addition, very little research has been conducted within the country to assess the success of the training given to health care professionals, the indigenous attitudes toward mental illness, and the experienceof Fijians who are diagnosed with a mental illness or a mental disorder. Most of the services available to address issues of mental health are still very new, understaffed, in a stage of nascent development and largely inaccessible to those outside of Suva or Lautoka (the major cities in Viti Levu). St. Giles hospital is the only mental health facility in the whole country that cares for and treats patients with a variety of mental illnesses; it provides occupational therapy, day care facilities, forensic assessments, counseling services, community psychiatric nursing, electro-convulsive therapy and pharmaceuticals. The support systems for those who may be suffering from mental illness or distress—such as the Hope Center in Lautoka, the Community Recovery Outreach Program (CROP), Lifeline Fiji, Youth Champs 4 Mental Health, the Psychiatric Survivors Association, the Fiji Alliance for Mental Health, Empower Pacific Counselling Services, and the Hope Health Centre—are all contactable by phone, even though many Fijians still do not possess telephone land lines or mobiles/cell phones, so their ability to aid and counsel the majority of the Fijian population is narrow and imperfect.

This restricted level of access is only further complicated by the lack of education or awareness many Fijians possess about mental illness or mental health. Just as doctors and nurses in Fiji must attempt to reconcile indigenous models of the body and traditional aetiologies with biomedical frameworks, those that work in the mental health sector must attempt to explain, often in the most simplified scientific terms they can find, what mental illness is, a task difficult in almost any language. As a developing country, the Fijian education system may not provide information on the biological and genetic components that contribute to mental illness, insight which would afford Fijians with the baseline knowledge to understand the manifestation and effects of mental illness. Even if psychology is taught in schools, many adolescents tend drop out of school early and may never have been exposed to terms like “neurology,” “dopamine,” or “neural transmitters.” For communities that have never been introduced to concepts like brain chemistry and psychology, how do you effectively communicate the complicated array of factors that contribute to mental illness that many neurologists still puzzle over? Finding the proper explanatory models, metaphors and analogies is a huge challenge for health care workers, especially when you consider the consequences of language and how important medical discourse is to a patient’s understanding and approach to illness. Final Mental Health in the Pacific Region-01Mental health is also affected by “social, cultural, economic, political and environmental factors such as national policies, social protection, living standards, working conditions, and community social supports. Exposure to adversity at a young age is an established preventable risk factor for mental disorders [and] Depending on the local context, certain individuals and groups in society may be placed at a significantly higher risk of experiencing mental health problems” Mental Health Action Plan 2013-2020,” World Health Organization: 9). This interaction between biology, genetics, environment and culture requires an integrated, multisectoral approach to addressing mental illness, especially in the wake of Fiji’s NCD (non-communicable diseases) crisis.

The World Health Organization recently released a Mental Health Action Plan to address the growing concern of mental illness globally, especially in countries that lack comprehensive and institutionalized health care programs. Within Fiji, mental illness is characterized by ignorance or stigma due to indigenous interpretations of madness or family embarrassment. The nurses that are assigned to treat patients with mental illnesses, at least in Tailevu, seem to lack a basic knowledge of mental illnesses, what causes them, and how to sensitively treat patients, even though the topic is taught in nursing school. Nurses will glibly swap stories about their “mental cases,” and refer to patients who have a history of not taking their medications as “defaulters,” as if a TB patient who doesn’t take their meds and an individual with depression who refuses medication are equivalent. The term “defaulting” is usually used to refer to patients who have communicable diseases, and, thusly, risk infecting others when they aren’t “medically compliant.” The terms “default” and “compliance” are also morally fraught and often connote condemnation or shame upon the patients. This shame is routinely used as a tool to compel compliance, reifying stigma in an already stigmatized community, even when a patient simply can’t take their medication for social, structural or economic reasons. But individuals who suffer from mental illness are not contagious and, for many, the choice to forgo medication does not endanger those around them. Very little is still known about how different medications affect the brain and the body, especially among adolescents. Many treatments for mental illness have several serious negative side-effects that may only worsen the patient’s condition. Some patients may also be on several medications at once, promulgating negative neurological and physical interactions between the chemicals. When nurses refer to their “mental cases,” they often lump together very different forms of mental illness, from epilepsy to schizophrenia. Many, when asked what the patient has been diagnosed with, though they’ve been assigned to their case, don’t know and will cover up their lack of knowledge by saying, “But they’re not violent,” as if all mental illnesses predispose people to violence. Indeed, in a study on “Mental Health Workers’ Attitudes Toward Mental Illness in Fiji” by Foster et al. (Australian Journal of Advanced Nursing, Vol. 25, No. 3), they found that 91.3% of the health workers they interviewed in Fiji agreed with the statement that “Psychiatric drugs are used to control disruptive behavior,” revealing a flawed and negative attitude about the nature of psychaitric medications and the conditions they treat.

The patients themselves may also lack a thorough understanding of their own conditions. If the health care professionals that treat the patients aren’t able to explain their condition in a culturally salient narrative, then indigenous explanatory models are likely to be employed in lieu of medical ones. Many traditional aetiologies are utilized to explain psychotic breaks, stress or mental illness. I had a conversation with a representative from St. Giles who mentioned that witchcraft and spirits are often still blamed for mental illness. One of the patients who came in during a Korovou Mental Health Clinic (held once every three months), was diagnosed with schizophrenia at 19. Since then, she’s been in and out of St. Giles five times, and though she’s been medicated ever since her diagnosis, had never heard the term “schizophrenia” to explain her illness. The woman, now in her late forties, believed that she was suffering from a curse a “bad man” had laid upon her, which was why she was not always regular with her medications. It is also believed that if a family builds a house on land that does not belong to their clan or mataqali, the ancestors or Vu of that land may bring about madness or misfortune in the new residents. If an individual becomes wealthy or economically successful, they may incur the envy of their neighbours, who may then entreat witchcraft to lay a hex on their neighbour to punish them for their accomplishments. The St. Giles representative also noted that some people believe that if you are particularly bright or smart in school, you’re more likely to develop a mental illness. She elaborated that mental stress is still a relatively new and foreign concept to Fijians, and that part of their job at St. Giles is to explain the relationship between stress, social and environmental factors, and mental illnesses like mood disorders. Patients and family members who utilize indigenous explanatory frameworks are therefore likely to seek out religious leaders, traditional healers or spiritualists for treatment before seeking out help within a biomedical establishment. Many of the cases St. Giles see, therefore, have far progressed psychosis and rapidly declining mental health making them out of touch with the real world when they’re admitted.

Schizophrenia accounts for 70% of the patients St. Giles see and treat. The next most common complaint is mood disorders. The St. Giles representative indicated that globalization and Western media influence may play a role in the increase of mood disorders in the country. She noted that whereas several years ago they’d only have one case of depression a month, they are not receiving anywhere from four to six new cases with mood disorders a week. Dr. Anne Becker, a medical anthropologist out of Harvard, has been conducting research on the increase of eating disorders and binge-eating in Fiji as it correlates with increased exposure to Western media and Western models of the “ideal” body (“Binge Eating and Binge Eating Disorder in a Small-Scale, Indigenous Society: The View From Fiji,” 2003). Although certain conditions like depression and bipolar are caused by a chemical imbalance in the brain, there has also been preliminary research investigating whether Western psychological models of the mind and mental health are necessarily applicable to people in other cultures. Ethan Watters, for example, wrote Crazy Like Us: The Globalization of the American Psyche to complicate our understanding of Western pyschology and its usefulness or salience in other parts of the world. The book researched the new epidemic of eating disorders in China; the treatment of schizophrenia in Zanzibar; and the treatment of PTSD in Sri Lanka.crazylikeus_wide-8f70226ee2a76f78016fcae60bbd0d3ad2549f2e One chapter explores Western pharmaceutical companies’ attempts to market depression drugs in Japan, a country where there was no cultural concept or equivalent for depression as it is understood in America, even though they have one of the highest rates of suicide in the world. He writes, “Americans experience the self as isolated within the individual mind. The Japanese, on the other hand, conceive of a self that is less individuated and more interconnected and dependent on social and environmental contexts. Feelings that Americans associate with depression have, in Japan, been wrapped up in cultural narratives that altered their meaning and the subjective experience for the individual.” (211). Advertisers had to fabricate a culturally salient new framework with which to comprehend sadness in Japan; the Western media literally had to indoctrinate the Japanese into believing that they suffer from depression in order to sell their drugs and make a profit.

In an interview with NPR’s “Talk of the Nation” on his book, Watters said, “I think we do have to understand how these scientific notions cross over into cultural notions of the mind. And I think the only way we can really do that is by looking cross-culturally and understanding that there are other ways to think about the human self. There are other ways to think about the human psyche. And before we tromp into other cultures and try to change them and try to get them to think like us, we should appreciate those differences because they’re really the only mirror we have,” imploring the audience to consider that by exporting Western models of the mind, we are unintentionally perpetrating a form of psychological imperialism. There is still little known about other conditions called “culture bound syndromes,” like susto, which seem to appear only within certain cultural contexts. In fact, medical anthropologists like Margaret Lock have been problematizing biomedical approaches to illness through the theoretical framework of local biologies. Margaret Lock looked at experiences of menopause among women in Japan to scrutinize variations in the ways in which menopause is subjectively experienced, noticing that the physical symptoms of Japanese women differed from those of their American counterparts. She concludes “Menopause, Local Biologies, and Cultures of Aging” (The American Journal of Human Biology, 2001), by stating, “The danger, of course, is that the “Western” body remains unproblematized […] it is appropriate to think of biology and culture as in a continuous feed- back relationship of ongoing exchange, in which both are subject to variation” (503), indicating that bodies nurtured and grown in different cultural context may experience different somatic representations of sickness. The concept of local biologies could, therefore, be applied to the manifestation of mental health and mental illness as well. Not only may we be exporting Western ideas of the mind, but we may also be simultaneously providing a set of symptoms that typically characterize a particular mental disorder that those diagnosed must then fit into. Some believe that the biomedical model of the brain will help to reduce stigma against those suffering from mental illness, but, in reality, quite the opposite might be true. Foster et al. indicated in their study, “contrary to the assumption of de-stigmatization programs, genetic and biological causal beliefs were related to more negative attitudes toward those with mental illness” (73). Watters echoes this trend in his discussion on “Talk of the Nation”: “I mean, we have this assumption that if we can get the world to think like us in terms of the biomedical conception of mental illness, that it’s like a disease like another, that it will reduce stigma. And unfortunately what the studies have found is as this idea gets adopted around the world – and it has been gotten adopted around the world – that oftentimes the very reverse occurs, that people want more distance from the mentally ill. They assume that they’re more dangerous. They want less to do with them.” So perhaps the task to overcome stigma and discrimination lies not in discussions about brain chemistry and biology, but rather the supportive cultural narratives a society already possesses that promote understanding, empathy and support.

The health care workers in Fiji tasked with addressing issues of mental health employ a holistic approach to their outreach and awareness programs. They recognize how important family and local support are to an individual’s health and success. They speak in villages and settlements around the country to increase awareness, while fostering sympathetic understanding, open communication and support so that those with mental illnesses aren’t discriminated against and have the compassion and care of their communities they need to stay healthy. FSNet, another mental health organization in the country, distribute booklets called “The Carer’s Hope for Recovery,” which stresses the carer’s responsibility to be an ally in mental illness and outlines some advice of how to care for those with mental illnesses. The staff at St. Giles, however, only numbers twelve, so their ability to reach all the communities around Viti and Vanua Levu is fairly limited. They’ve been utilizing the media to increase outreach efforts, but television is effective for only a confined target population, as many of the more remote and impoverished villages don’t have television and only sporadic electricity. The demographics that actually do see the television spots, in urbanized areas like Suva or Labasa, are the ones that are closest in proximity to the mental health facilities and thus more likely to have already been exposed to information about mental illness. mental-health-the-factsLegally, the Mental Health Decree of 2010 is supposed to protect the rights of those with mental illness and prevent discrimination. The rights of caretakers or caregivers are also outlined in the Mental Health decree, but it’s unclear how people are informed of their rights if they don’t have access to the Internet and aren’t made aware of the legislation passed down by the government.

The state of mental health services in Fiji is still as poorly understood as the condition of mental health itself. Many individuals suffer in the shadows in a state of emotional and psychological confusion without knowing where to turn for help or support, let alone equipped with the language to describe their condition. Further research on the indigenous understandings of mental health need to be undertaken, particularly in regard to belief in the role of spirits and ancestors in one’s life. Some of these traditional beliefs have become submerged or considered ilicit due to the Christian missionary work, which labeled indigenous belief systems as “devil worship.” These indigenous beliefs do not necessarily preclude biomedical explanations being used in conjunction to explain mental illness. As many medical anthropologists have illustrated, people are self-reflexive beings that understand the influence of their own culture and have the capacity to combine multiple explanatory models to create syncretic systems that make the most sense to them. In Fijian culture, the head is considered the part of the body associated with knowledge and wisdom, and it is therefore taboo to touch the head or hair of another person. Even the emotional states we have in English don’t directly translate or correlate to Fijian equivalents, suggesting the concepts like depression may be further complicated by language barriers as well. A more thorough understanding of the training in mental health that nurses and doctors are given should also take place. We need to understood how health professionals are taught about mental health and mental illness and what sort of sensitivity training they receive. Nurses that make house visits to administer medication are also supposed to offer therapy, even if they’ve never been trained in different therapeutic techniques. If Fiji is to effectively address its NCD crisis, an institutional as well as a social movement needs to begin from the ground up, utilizing grassroots activism, culturally available narratives and scripts, and community/village health workers to create a society conducive to mental health and stability.

HIV/AIDS in Fiji

On November 27, the province of Tailevu, in the Central and Eastern Division of Viti Levu, celebrated World AIDS Day early. The festivities were held in Korovou, so the various youth and community groups that had been invited to attend gathered at the Korovou Sub-divisional hospital, all dressed in different iterations of red. Each group also brought with them a banner they’d decorated for the occasion, working off of the theme for the year: Zero. Zero new cases of HIV infection, zero HIV/AIDS related deaths, zero tolerance of stigma. When I attended the 2012 World AIDS Conference in Washington, D.C. the speeches and discussions also circulated around the population of eliminating the virus altogether within the next twenty years. Even though ARV’s have become more accessible and less expensive, and new discoveries of eliminating the HIV virus completely have been encouraging, the structural factors that contribute to illness still need to be addressed. The belief that AIDS can be eliminated in the next twenty years may be idealistic considering the structural violence many infected populations still face, but in Fiji the potential for elimination may be possible. Since 1994, there have been 482 registered cases of HIV infection, and adult HIV prevalence in 2011 was only 0.1 %. Compared to other countries around the world, Fiji, it would seem, has a relatively low prevalence of HIV/AIDS. These statistics, however, need to be vexed a bit. We have to consider the fact that Fiji also has a fairly small population and that, culturally, sex is still an extremely taboo subject. The conservative qualities of the Fijian population make it extremely difficult to discuss sexual matters and spread awareness, let alone get the consent from Fijian to test for the disease. Though the hospital I work at provides free condoms, I have to bundle the condoms in old yellow pages. Otherwise, the nurses tell me, the patients and visitors will be too ashamed carrying around the condoms. Even as I set about the task of wrapping the small packets, the nurses came by to tut their pity that I even had to handle condoms, themselves quite shy of even touching them. The taboos around sexuality are further complicated by the heavily entrenched religious beliefs of the country; the Catholic communities especially forbid the use of any kind of contraceptives. And though pre-marital sex is culturally taboo, it’s actually extremely common, with young people often having multiple partners. With such a high prevalence of unprotected sex, even among couples who may be having affairs, the chances of contracting and spreading an STI or HIV increase, and the treat of infection continues.Image

Indeed, in a recent article by Fiji Times, it was noted that the prevalence of HIV/AIDS increased by 50% from 2009, indicating that the threat of AIDS is actually expanding rather than abating. And these are simply the reported statistics. As any health worker knows, especially when working on illnesses that may seem culturally or morally fraught, statistics like these are usually only partial indicators of a health condition and don’t fully or exhaustively represent the prevalence of HIV/AIDS in the country. Of those infected in Fiji, the article noted that 70% of the cases were found in the Central and Eastern Divisions, specifically in the provinces of Rewa and Tailevu. The HIV/AIDS Red Zone, as it were, falls right within my assigned sub-division. The potential for HIV/AIDS to turn into a catastrophe seems very real, especially if people continue to have unprotected sex, don’t know their status, and potentially spread the virus from province to province. Unless an individual has been educated about the way the virus is spread and impacts the body, they may be infected and not experience symptoms until it’s too late.DSCF0817

Despite the cultural taboos about sexuality, I was impressed that so many youth groups had congregated to join the fight against HIV/AIDS. One group, to my delight and astonishment, actually started blowing up condoms and tying them to their banners as balloons. This may seem like a trivial act, but in such a conservative and repressive climate, the use of condoms in their presentation was very progressive. Once all of the groups had gathered at the hospital, we marched down the hill, through Korovou Town to the playground off the main road, where two covered structures had been erected for all the guests and speakers. A doctor from the Reproductive and Family Health Association of Fiji spoke, followed by a judging of the banners and an oratory competition between the youths, some of whom were only 14 or 15. After the students’ speeches were given, representatives from each group gathered for a brief quiz on HIV/AIDS.DSCF0813 Though these were all students working towards HIV/AIDS awareness and advocacy, the depth of their ignorance about the disease startled and scared me. They did not know the difference between HIV and AIDS, nor what the acronyms stand for. They could not name the methods of transmission, nor the fluids that transmitted the infection. This ignorance about the most basic information about HIV/AIDS seems to me to be yet another red flag about how precarious Fiji’s situation is. All the youth groups seemed extremely enthusiastic about the day, but festivities don’t matter unless there is something to celebrate. An increase in HIV prevalence and a general lack of knowledge or awareness about HIV/AIDS should only commemorate how much work remains to be done in Fiji, lest it turn into a South Pacific epidemic. Anti-retroviral treatment is completely free to all Fijians, but the will and knowledge to protect themselves still seems woefully lacking. Image

“Going Thin”

In preparation for my impending trip to Fiji with the Peace Corps, where I’ll be serving in the Health Sector working on community health development and empowerment on a variety of health concerns, though primarily non-communicable diseases such as obesity and diabetes, I’ve begun research on the cultural beliefs and practices of the Fijians. One of the most useful authors I’ve encountered is Anne E. Becker, a professor of Global Health and Social Medicine at Harvard Medical School, who’s conducted extensive fieldwork in Fiji and whose research focuses specifically on eating disorders and body image in relation to their social or cultural environment. In 1995 she wrote Body, Self and Society: The View From Fiji, an ethnography that relates her fieldwork and experiences while studying in the country, highlighting the cultural conceptions of the body and health in relation to the larger community or society that an individual is inevitably enmeshed in. She notes how, in juxtaposition to typically Western notions of the body—which is conceived of as independent and separate from society, each individual body its own autonomous entity—Fijian society emphasizes a community, in which each person is responsible to and for the other people in their geographic area and kin group. As Becker notes, “A body is the responsibility of the micro-community that feeds and cares for it; consequently, crafting its form is the province of the community rather than the self. And because the individual body is the locus of vested efforts of this community, the individual’s own efforts are directed back toward the community” (57). Subsequently, attempts at bodily cultivation or efforts to distinguish the body as a unique entity from the group is looked down upon. In reading the blogs of other volunteers currently working in Fiji on community health, I’ve encountered attempts to establish exercise groups or regimen for their local communities, in an effort to impart Western notions of bodily healthy and physical fitness. I wonder how Fijians have responded to these encouragements to exercise and whether it’s considered socially acceptable to spend time cultivating your body. It seems that this may be regarded as selfish, as it takes time away from the community and represents an attempt to separate, rather than engage with neighbors and kin. Image

            Two thirds of the Fijian population is either categorized as obese or overweight, yet Anne Becker notes, “many obese and overweight Fijian women apparently perceived their own weight as appropriate or under a desirable weight, with 54 percent of obese female respondents indicating they felt they should maintain their weight and around 72 percent of overweight women answering they felt they should maintain their present weight. In addition, 17 percent of obese women and 8 percent of overweight women responded that they wished actually to gain weight” (41). I don’t want to diminish the severity or seriousness of the health complications that accompany obesity, one of the most prevalent being diabetes, which is also rampant in the country, but overall health is not solely dependent on physical health. Under the ascendency of Western biomedicine, the body is often atomized, segregated into supposedly discrete and separable parts accessed separately to ascertain a diagnosis, rather than looking at the body holistically or within a larger social context. Concepts of health and illness are socially contingent and constructed, and while these men and women may need to reassess their diet and level of physical activity, I think mental health is just as important of a consideration, especially since Becker’s recent work has focused on the recent phenomenon of eating disorders among the young generations of Fijians. She indicates that the recent introduction of Western media, such as movies, television shows and magazines, has also imported Western body ideals, as well as Western conceptions of the way the body should be regimented, controlled and disciplined, often into unrealistic or fetishized weights. In her book, Becker indicated that “Any evidence of weight loss is assumed to reflect a disruption in connectedness to the social milieu or gross negligence on the part of the caretakers. The common phrase ‘going thin’ (e luju hara ga elala) generally identifies a perceived weight loss as a social loss” (79), which raises questions not only about how a group or organization would approach a program specifically geared to help Fijians lose weight, but also about how the older generation is reacting and will react in the future to the younger Fijians suffering from anorexia or bulimia.

            During my orientation and training upon my arrival in Fiji, I’m eager to learn about how the Peace Corps considers these cultural conceptions of the body in developing and implementing health programs targeted at obesity. I also wonder how much they consider the larger political, economic and historical factors that likely contributed to the obesity epidemic, such as colonization and tourism. In a culture that demonstrates connections and forms social bonds by feeding one another and by providing bountiful feasts to guests and loved ones, how do you intervene in a way that is culturally sensitive and isn’t simply a neo-imperial indoctrination into Western conceptions of the body and health? My hope is to learn as much as I can about Fijian culture before I depart and use my anthropological training and expertise in the field to best serve the Fijian community I’m placed in, remaining constantly aware of my own Western biases and prejudices toward health. I’m sure that the Fijians I will work with have a lot to teach me.