World Mental Health Day: in times of crisis

The importance of raising awareness of mental health, or mental ill health, is ever relevant. Today, Anna Freud National Centre for Children and Families, where I am Press Officer, joined the Heads Together campaign of which we are a partner charity, in marking World Mental Health Day. One of the key aims of the day was to recognise that all of us will experience a traumatic event or transitional period at some point in our lives, and be that involvement in a car accident; exposure to persistent bullying; or a specific mental health crisis, emotional fall-out is often to be expected. With such an expectation comes an opportunity to share how we can be supported through difficult times. Through such distress, psychological support from each other, as well as from professionals, can be invaluable sources of care-giving and therapy.

We supported an event held at the riverside County Hall and the London Eye, attended by Their Royal Highnesses the Duke and Duchess of Cambridge and Prince Harry who met guests with stories of crisis and their supporting cast of friends, family, and education and clinical professionals who have played a role in helping them through these difficult times. Since starting in this role, such involvement with the Heads Together campaign has created a demanding but brilliant opportunity to rapidly implement and develop press skills and promote awareness for psychological wellbeing in a way that carries integrity to the real experiences of those showcased or helped through the work of the Centre.

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Of course, working in London, for a national charity, it can be easy to forget that this day is celebrated globally and, further, that such commitment to supporting one another and normalising the conversation on mental health must be a continuous endeavour, rather than the perceived efforts of a single day. With this in mind, and having recently submitted my Masters dissertation looking at the psychosocial impacts on persons affected by leprosy (PAL), it seems as good a time as any to highlight, again, the work of Lepra, the organisation who hosted me so brilliantly in Bangladesh during my primary data collection research in the Sirajganj district. In an article published on their website today, they cited preliminary findings from this research  which set out to: 1) Assess the psychosocial impact of leprosy-related disability by employing mixed methods 2) Determine what is understood by ‘psychological’ and ‘mental health’ among this population and  3) Explore perceptions of leprosy at both personal and policy-levels, and its relation to mental health.

Key messages from this exploration into mental health initially highlight that:

  • Lack of education around leprosy is the primary reason for delayed presentation to appropriate medical services.
  • Within this context, leprosy-related disability is figured solely in physical terms classified under medical frames of reference.
  • ‘Alienation’ conceptualises the life experience of the PAL in this study, influenced by trauma, mental and physical disability, and lack of explanatory theoretical frameworks.
  • Following education, economic seed projects were identified as a sustainable, acceptable intervention to tackle the psychosocial impact of leprosy-related disability on past and future PAL in this region by promoting social integration and financial self-sufficiency.

What these findings show is that education of mental health is critical, acknowledging that it needs regular ‘checks’ and appropriate response to challenges i.e. that parity between physical and psychological health must be prioritised and remain a focus for us all.

 

Image Credits (all): A.Bow-Bertrand

Header image: Felix E. Guerrero, Flicke

Literature and Mental Health: Heartbreak

Somehow, working fulltime seems to be less conducive to finding inspiration or time for writing on Matters du Monde than an intellectually exhaustive Masters degree. The transition to professional living has brought with it a slow and not altogether comfortable realisation that no longer are the majority of my days filled with the people, activities and academic focuses that I have actively chosen.

Inevitable transitions and adjustments aside, I’ve also found that the routine and demands of my press role sap all creative energy in a way not too dissimilar from that discussed as a part of the Literature and Mental Health virtual learning course which I mentioned I was pursuing in my past blog.

Over the past weeks, the course has explored a series of conditions bracketed by mental health, or mental ill health, through a mix of videos, readings and discussions with actors, clinicians, lecturers and writers. Professor Jonathan Bate is one of the co-conveners, and a particular draw given that he authored many of the texts on Shakespeare I studied as part of my undergraduate degree and of the primary biography of John Clare, whose work I explored in my final year dissertation titled ‘The lost in John Clare’s writings of space and memory’.

The themes explored so far are: ‘Stress’, ‘Bereavement’, ‘Trauma’, ‘Depression and Biopolar’ and ‘Heartbreak’. Across the latter, the course conveners question whether heartbreak is a medical condition. As with all of the themes, the most interesting parts of the course are those where medical professions are invited to contribute their professional and personal insights, in a way that seems to most legitimately bridge discussions of creativity within a biomedical discourse, for instance the psychosomatic experience of heartbreak within and beyond poetry.

The course introduces its themes, which are also broad clinical diagnoses, with a light touch, either unwilling to restrict understanding or to immediately associate with specific literary and biomedical frames of reference. This extends to the set texts, many of which are familiar for being wheeled out at school assemblies or commemorative days, but through the ensuing discussions and participant forums, the texts are afforded reflective considerations that frequently, and brilliantly, manage to extend and challenge the most infamous critiques and interpretations of them.

It doesn’t do the course justice to pull out aphorisms, but there are many to choose from, particularly in the week focusing on heartbreak. Through discussions on poetry writing Ben Okri, we are offered the view that ‘what really good poetry does is coalesce that which you did not know you were feeling into a body of feeling and words’. Perhaps unconsciously, the lexicon of ‘body’ invites interpretations that are both textual and physical, an imperative that echoes across the course and one which is of most interest during discussions around ‘heartbreak’.

GP Andrew Schuman highlighted that recent research suggests that heartbreak can be a physical phenomenon variously called ‘broken heart’ or Takotsubo syndrome, momentarily disrupting normal cardiac rhythms via a surge of adrenaline to the left ventricle of the heart. This chamber pumps oxygenated blood around the body, but while temporarily paralysed it balloons up mimicking a heart attack even though normal cardiac beating normally resumes immediately. Self-titled psychiatrist and poet, Richard Berlin’s Takosubo Cardiomyopathy offers an anatomy in words of this state or transition:

Takotsubo Cardiomyopathy

I’m reviewing a left ventriculography
from a man with chest pain, MI ruled out,
his wife dead for a post-crash hour.
The scan shows his cardiac apex
bulging with each beat, shaped
like a takotsubo, an octopus trap
a Japanese cardiologist recalled
from his childhood fishing village,
the scan just another broken heart’s
beaten down story of futility and resilience.
And I will say, “I am sorry for your loss,”
explain the image, reassure him
his heart muscle will recover in a week,
all the time wishing I could hug him
with eight strong arms instead of two.

Richard Berlin

Such insights are, of course, fascinating and typical of the course, but it is problematic that the nature of being ‘in’ love is not explored, instead dissecting heartbreak or ‘love melancholy’. As one might expect, discussions start with Robert Burton’s seventeenth-century work The Anatomy of Melancholy. The title suggests linking of emotional experience with physiology and, in one sense, the work is wholly true to its title and it remains, to appropriate Kevin Jackson’s assessment, ‘the most exhaustively detailed work in the English language on the subject of that terrible affliction’. However, moving beyond the preface, through the pages, one realises that Burton cannot constrain himself to matter pertaining solely to psychological concerns.

In the same way that the course introduces more than it can cover, the digressive and hyperbolic interests of Burton divert the text from its encyclopaedic titular claims. What Burton does achieve is a re-writing of the characteristic aim of proponents of utopias – an ideal for all – instead, creating an anatomy of feeling and experience that is subjective, personal and to ‘satisfy and please myself, make an Utopia of mine own, a New Atlantis, a poetical commonwealth of mine own, in which I will freely domineer, build cities, make laws, statutes, as I list myself. And why many I not?’ (Holbrook Jackson, p.3).

Burton’s articulation resonates with the uncertainty surrounding the psychological and physiological symptoms of heartbreak, and echoes the course discussion which highlights that heartbreak is different for each individual because the contexts, subjects and spaces that shape wholeness of heart and circumstances that lead to it being metaphorically, or otherwise, ‘broken’, are never equivalent to another’s. The first section, or partition, of the book grapples with possible medical terms or explanations for heartbreak, for instance ‘where the melancholy blood possesseth the whole body with the brain, it is best to begin with blood-letting’ (Holbrook, p.144; from the Second Partition).

However, by the close, Burton’s understanding sits more closely to that of the course discussion – along a spectrum between ventricle and verbal, emotion and electrical impulses, with the envoi: ‘I can say no more, or give better advice to such as are anyway distressed in this kind, than what I have given and said. Only take this for a corollary and conclusion, as thou tenderest thine own welfare in this and all other melancholy, thy good health of body and mind, observe this short precept, give not way to solitariness and idleness. Be not solitary, be not idle’ (Holbrook, p.172).

Perhaps the most engaging question I am pursuing from course discussions is can such a feeling of breakdown (mental, physical, and so forth), determined neither by clear reason nor by accident, constitute a tragic sense of life – one that aligns melancholia more directly to depression than to heartbreak. Surely any question founded on ‘why?’ is key for looking at the idea of melancholy, heartbreak, and creativity and it is from these interrogations that, to my mind, the most intriguing discussions have arisen.

References:

Robert Burton, The Anatomy of Melancholy, ed. Holbrook Jackson (New York: Random, 1977)

Robert Burton, The Anatomy of Melancholy. A Selection, ed. Kevin Jackson (Manchester, 2004)

Image Credit: debaird, Flickr

 

 

Literature and Mental Health

I’ve always worked here and there: Saturday pharmacy assistant, casual hours waitressing and six months with a Debenhams concession in the back end of nowhere during my gap year. But not a ‘proper’ job, you know, one that alerts Student Finance England that you now need to pay back a hefty wedge of your monthly earnings that are deposited directly into your bank account, post-tax, pre-tips.

So, on top of a fractured clavicle and trying to finish my Masters dissertation writing up the research I carried out in Bangladesh earlier this year, starting work hasn’t been entirely straightforward. Aside from scrambling for press skills in a new context and familiarising myself with the positioning of the organisation I work for, the loss of a daily reading list (be that for a degree course or a personal long-list) has been quite a shock.

Of course, work hasn’t forbidden personal reading, but seems instead to have subsumed all energy and appetite for it. Slowly, I’ve been easing myself back in with some favourite fiction pieces, but it still feels a bit too soon to get my teeth back into the global health journals and the progressive currency of development-focused material that used to shape the thinking behind this blog.

Looking sideways has also helped. A friend who generously reads these pages recommended The University of Warwick’s ‘Literature and Mental Health’ e-learning programme which started earlier this week. I’ve signed up to virtual courses before, but never fully committed, instead cherry-picking choice reads and passively spying on user forums (not sure how this reflects on me, if at all!). This time, I’m going to do it properly. Engage with the material in its diversity and without a motive to ‘get’ anything from it, other than just to start enjoying hearing the voices of people working and writing in this area again.

I’m going to devote the next few posts to how I’ve found the course: looking at content that has appealed or warrants sharing with a wider audience, and to field your views also. If you want to get involved, sign-up to the free course here. I’d love to hear how you find it.

Travel Photographer of the Year

I’ve been twice before. Once to stand on the line representing the Prime Meridian for a school trip with the Brownie group (all the fun), and again last year to see a late night show at the Royal Maritime Museum. To the Royal Borough of Greenwich, that is. This long Bank Holiday weekend seemed the perfect chance to pose as tourists, sleeping in a local AirBnB spot, vintage shopping in the twilight market and heading to the University which is playing host to the Travel Photographer of the Year exhibition (TPOTY).

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It’s the first year that I’ve made it to the show, and it didn’t disappoint with prize titles for both young and adult entries, amateurs and semi-professionals with submissions under portfolio categories titles including: ‘Faces, People, Encounters’; ‘Nature & Environment’; and ‘Monochromal’. TPOTY describes itself as a competition run by photographers, for photographers, with submissions from every continent (over 114 countries are represented), often seeking to highlight points and peoples under cultural or environmental threat.

Upon entry, there is a map that invites visitors to pin where they’d most like to visit in the world, whetting the appetite for an artistic gallop from tanneries in the suburbs of Dhaka to flyover rainbows in Tokyo:

14159868_10154470927289730_2046964138_n The Young Travel Photographer of the Year was the entrant who the judges felt submitted the best entry on the theme ‘Travels Through my lens’. 18-year old Chas Guttman from the USA claimed this title, already a two-time winner of this category, minor Instagram celebrity and recognised travel photographer. His series of images are taken in the frost-laden foothills of the remote nation of Lesotho, where the Basotho people wear traditional tribal blankets for village ceremonies and familial milestones, where shepherds converge on the jagged basalt cliffs of Maletsunyane Falls as the sun begins to rise, and where Basuto ponies are  pictured as crucial to the survival of local Sotho tribes. 14159684_10154470926979730_1689795357_n

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Meanwhile, Marsel van Oosten won the overall title for best submissions across the three portfolio categories. Van Oosten is a professional nature photographer from the Netherlands. His images are best known for his graphic approach to composition, the direct result of his previous career as an art director in advertising. In his work he tries to simplify, to get rid of the extraneous. For him, simplicity is the ultimate sophistication.

His images are featured in galleries and museums, and he is a regular contributor for National Geographic Magazine and together with his wife Danielle he runs Squiver, a company that organizes specialized wildlife and landscape photography tours and workshops for small groups of all experience levels to spectacular locations worldwide. His winning series features Danielle canoeing through the eerie cypress swamps of the Atchafalaya Basin on a trip they took through North America, with a self-referential quality often featuring her with poised camera.

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The exhibition leads you around the continents, guided by sign-posts that also detail distances to key landmarks around the globe. 14191300_10154470927009730_2097421218_o

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The monochromal portfolio category was my personal favourite, with the winning submission from Xia Xuejun beautifully rising to the challenge of creating good composition through light, tone, and shadow without the natural impact of colour. 14138386_10154470926474730_719941436_n

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Running until 4 September, this is just one more reason to make a trip down to Greenwich, covering inspiring ground that might just prompt enough to submit for this year’s TPOTY competition. Who knows where it might take you.14138450_10154470927784730_2076612661_n

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Image Credit (all): A.Bow-Bertrand

Year in Review

MattersduMonde has been around for a whole year! With at least one post per week, it’s been an adventure into my own global health reading, writing and the wider blogosphere. Although the blog was originally motivated by a solipsistic need to textually spell out, and consider the aspects of global health that I find most troubling or intriguing, over the past year MdM has gathered a loyal but modest following that extends beyond my own project. Nothing is more self-affirming than finding others who also want to engage with the people, places and conditions that comprise ‘global health’. As well as introducing regular roll-over features, namely ‘Photographer’ and ‘Book of the Month’, some of the personal highlights on the blog this year have been contributions to the ‘Writing Health‘ section, which also became the subject of my TEDx talk. So it seemed as good a time as any to dig through the archives and revisit the top five most popular pieces on the blog since it started, as marked by you – in your numbers and words.

  1. ‘Pakistan behind the headlines’

This piece was a variation on the monthly photography feature, and was particularly popular in that the photojournalist in focus, Sa’adia Khan, was running an exhibition of material commissioned by MSF at Asia House in London at the time of publication. In the blog, as in person, Khan talks through a narrative of this commission, which becomes about much more than getting the perfect shot, and touches upon the struggles to fairly expose the unwritten, hidden and untold lives and experiences of the most oppressed persons around the globe.

2. Writing the Self: Creating Health

To omit this feature from a line-up of highlights from the past year would be falsely self-deprecating. It details how the ‘Writing Health’ section of this blog piqued the interest of TEDxUCL organisers who were seeking speakers on the theme of ‘Growth’, including personal growth. The first tentative proposal meeting found me discussing personal experiences I though had been more than fully explored and discussed in other guises and spaces, perhaps as a direct consequence of a blogging process that found me revisiting health experiences close to home. The premise of TED talks is that speakers have ‘ideas worth sharing’. Perhaps, if there is anything that this process highlighted, it is that unexpected opportunities often call on you to move and speak in ways you never knew needed, or warranted, expression.

3. Dear Mr Cameron

This was the first in a series of commissioned features for the ‘Writing Health’ section in which the intuitive and brilliant Charlotte Chorley uses spoken word to consider the black hole and contradictions of existent policy around and relays received experience of female genital mutilation across the UK. With her own interests including health, development and policy, Chorley’s creative writing is worth exploring. Clichéd, perhaps, but she is one to watch – and it looks like you all agree.

4. Character is what you are in the dark

I developed MdM during my lunch breaks of a summer internship with Roll Back Malaria at the World Health Organization headquarters in Geneva. At the time, I’d recently graduated from Cambridge, had no job definitively lined after the internship which found me communicating around Neglected Tropical Diseases (NTD), a long-held area of interest. I’d also been Press Officer for Polygeia, a student-run global health policy think-tank, so when, mid-way through my internship I decided to start writing about developmental topics of interest, and with no finite plans, I looked into a friend’s recommendation that I pursue a Masters in Global Health and Development. I’m fortunate that I was able to apply and consider my place, starting at UCL the same week I flew back from Switzerland. The finite deciding factor in continuing in education at the time was the prospect of conducting primary data collection for my Masters dissertation. Unsurprisingly, perhaps, this found me researching leprosy, and the mental health of persons with this NTD alongside Lepra, an organisation with whom I had previously volunteered on a policy commission. This blog offers a snapshot of my first days in Bangladesh, where I spent a month collecting data earlier this year.

5. MdM Talks: Daniel Flecknoe on Darfur

For someone who has always experienced an unhealthy level of imposter syndrome, it is surprising that curating a blog has positioned me to narrate the stories of others. Conferences and press events have become a rich source of connections and potential interviewees, with the blog network lively in it’s own right, evidenced in invitations to guest blog for Global Health NOW  (article available here) and to speak at the November conference of Medicine Unboxed. In this interview, Dan shares his own experiences of making connections across languages, and marrying seeming impasses in the conflict zone of Darfur. His professional capacity as a lecturer in public health lends a fascinating research steer to his reflections.

Want more of the same? Areas you would like covered? People interviewed? With feedback here’s hoping the next year on MdM doesn’t just become a personal indulgence and can contribute to the wider global health conversation.

 

Image Credit: A. Bow-Bertrand

What’s ethical about that?

This is the final blog in a series of four in which I document my research in Dhaka and the Sirajganj district of Bangladesh. You can read the other posts here. My work was facilitated by Lepra, but all views expressed are my own.

Outside Lepra Office, Sirajganj. Image Credit: A. Bow-Bertrand

Outside Lepra Office, Sirajganj. Image Credit: A. Bow-Bertrand

One of the prerequisites of any primary data collection research project is ethical clearance. In the case of work beyond the bounds of the UK, this means both in-country and university specific proposals and checks. It’s a painful, but necessary process, and as the wise-guys on my University College London (UCL) ethics committee crack, the process isn’t over once you’ve received the letter saying ‘go for it’ (it kind of is, but obviously you can’t suddenly morph into an amoral researcher à la Victor Frankenstein, but UCL don’t really do jokes, so I’ll just leave that there).

Flippancy aside, there have been many points during my time in Bangladesh where I have actually been more than usually aware of self-doubt, which is better figured as ‘researcher reflexivity’ for the purposes of a Masters dissertation report. Questions such as ‘what should I do here?’, to ‘how do I eat with my hand without making everyone watching me feel physically sick?’ or ‘what’s right?’ cropped up on more occasions than I might have anticipated, some of which will resonate with others who have carried out fieldwork in non-native countries, and possibly in languages in which they are not conversant.

View of Lepra Office, Sirajganj. Image Credit: A.Bow-Bertrand

View of Lepra Office, Sirajganj. Image Credit: A.Bow-Bertrand

Both non-fluency and non-nativity were true of my status researching in Bangladesh. Certainly, the investigative scope and my suitability were deemed appropriate by the ethics round table, but the everyday reality raised ethical, or rather moral (the two not necessarily being interchangeable, the latter representing a personally bound set of values rather than perhaps an institutional status quo) considerations. I am fully aware that my work here would have been near impossible without the facilitation of Lepra who supported me from sourcing ‘in-field’ accommodation (incidentally a lovely top floor room in their offices), liaising with their remote clinic staff during the recruitment process and acquiring a Bengali-English translator.

In many ways, their support mitigated many logistical and personnel related ethical dilemmas that may otherwise have arisen, including sustainability of interaction and management of medical and psychological circumstances established or exposed through the course of my in-depth interviews and focus group discussions. Indeed, as the staff here remark, the majority of the participants involved in my research had at one stage been treated or had their conditions managed by the Lepra team or associated government staff. Lepra is an entirely non-profit organisation, reflected in their two-pronged methodology in Bangladesh: early detection of leprosy cases alongside health education and the provision of free disability or reaction management and multi-drug-resistant therapy (MDT) for all identified persons with leprosy.

DFID group; participatory observation. Image Credit: A.Bow-Bertrand

DFID group; participatory observation. Image Credit: A.Bow-Bertrand

This free at the point of care delivery is a divergence from the charges imposed on participants for other diseases with many of their medical histories clouded by financial crisis through travelling, without relief or clarity, between local health service doctors unaware that the person before them was presenting with leprosy. For those who found themselves too financially crippled to pursue treatment or, indeed, prior to their awareness or referral to Lepra, there are common narratives of self-medication in the form of daubing non-itchy anaesthetic patches (a telltale early sign of leprosy) with ghee, and of doubled visits to the mosque to pray for deliverance. For the majority, Lepra’s infiltration into their lives represented a proven treatment, the hope of a restoration of their former life, and a manageable programme that was not financially restrictive.

One side-effect of this is that many such participants feel indebted to Lepra on personal levels of trust and gratitude. It was little surprise that all participants invited to my research programme agreed on first invitation – and willingly so. This was the first ethical minefield to navigate – managing participant expectations, and iterating their option to either decline participation at invitation or at any moment during data collection without any prejudicial treatment towards them from Lepra, and vice versa should they decide to take part. This aside, the lesser acknowledged and perhaps unexpected ‘what should I do?’ rhetoric was associated with information provision.

Image Credit: A.Bow-Bertrand

Image Credit: A.Bow-Bertrand

I am all too aware of the pitfalls of the so called white-saviour complex, something that my own privilege denies full dissociation from. However, a lesser extent of the saviour debate manifested in education or what such a narrative would most likely term ‘enlightenment’. While any patient diagnosed with leprosy by the Lepra central hub and clinic stations who is then marked for MDT treatment must compulsorily receive health information relating to the causes of leprosy, its infectivity and complication management such as washing techniques to limit the potential development and recurrence of ulcers, there is evidence that there are failures in comprehension and dissemination. A blanket question asked to all interviewees was ‘what do you think is the cause of leprosy?’ Largely, the literate participants identified germs or bacterium as causative agents.

But at least half of all participants expressed uncertainty, or a host of other perceived factors deriving from places as diverse as religious scripture, cinema, folklore and personal imagination. Amongst the most deviant answers were ‘hot summer air’, ‘sin’, ‘a cut on my finger’. One of the gold standards of research, particularly qualitative which more typically garners – moreover, encourages – personal narratives, is lack of expressed surprise or judgement. I have a dead-pan poker face on tap when required (cultivated from a childhood with a twin who tells even worse jokes than I do), but such responses did not inspire judgement so much as a dilemma – to educate or not? My personal first point of inquiry if I were to suffer from any condition – including, ironically, mental health – would be to try to identify the cause or trigger. How else does one begin to contemplate seeking an appropriate course of treatment or getting one’s head around the nature of our own health without this knowledge?

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Children of the focus group discussion participants arrive to wave us off. Image Credit: A. Bow-Bertrand

Of course, I wanted to pause the interview and throw ‘germs’ into the equation, for it has been proven that health condition knowledge not only empowers persons with leprosy to manage and even mitigate prejudiced comments based on such unfounded misinformation, but also feeds into an effective preventative strategy. However, how does someone – me – who is neither a clinician nor a person with leprosy inform said participant of the actual cause without somehow sounding condescending or irreversibly traversing the boundaries between researcher and medical care professional? In actuality, it is very difficult. The first time the situation arose I questioned why I didn’t pause then and there, but something instinctively told me that a passing correction was neither context nor time appropriate.

For many participants, including those who have no idea what has caused their leprosy, this is not due to ignorance, but rather a process of consideration that has not provided any understandings, or an inductive method that has established their own system of meaning, even one that is incorrect according to the biomedical model. On the second instance, I was prepped at the end of the interview with a bog-standard Lepra information leaflet, which I was able to talk the participant through with the support of clinic staff. In many instances the participants were willing to reassess their disease understandings, but for most part the fundamental truths remain the same, and all that really matter – that following the provided course of MDT and self-care programme they can restore their health to at least a functional level while personal treatment adherence limits the chances of both relapse and disability progression.

This research has highlighted that there is a lot to learn – on both sides of the table, or on the same side if you’re a fan of bench seats, which I absolutely am.

Leaning, Jamuna River. Image Credit: A.Bow-Bertrand

Leaning, Jamuna River. Image Credit: A.Bow-Bertrand

Lost in Translation?

This is the third blog in a series of four in which I document my research in Dhaka and the Sirajganj district of Bangladesh. You can read the other posts here. My work was facilitated by Lepra, but all views expressed are my own.

30 words a day. That was the target. While I’m not as well-versed in Bangla as I would have liked in the final days of my stay, I have developed a potentially useless food and drinks vocabulary, as well as being able to throw about basic emotions. No doubt my everyday spatterings are loosely translated as ‘pumpkin, happy, I’ll eat fish tonight, comfortable – are you?, thanks, tasty’. Fortuitously, I have had both a facilitator and translator while working with Lepra. The former – Chanchal, a coordinator of the leprosy programme in Sirajganj was a welcome surprise, but a necessary third party during interviews able to support my official translator – Raha, who also happened to be a first year student of English Literature at Dhaka University and the regional director’s daughter.

Raha and I in the gardens of the former summer residence of poet R. Tagore. Image Credit: A. Bow-Bertrand

Raha and I in the gardens of the former summer residence of poet R. Tagore. Image Credit: A. Bow-Bertrand

Between us we completed thirty-one in-depth interviews. I’d like to add ‘successfully’ because isn’t that the popular lexical precursor to ‘completed’ but such a marker of quality is too subjective to be warranted, and for all our peaceable interactions, the data collection approaches of interviews and focus group discussions were not without their challenges. Above all, these included the two-way struggle to be heard, or rather ‘heard’ in the oscillating rapport between participant and I. Prior to engaging with the team in Bangladesh I had spoken to Cahn Vasudevan, a longtime supporter of the Colchester branch of Lepra and mental health researcher in his own right. It was his guidance that shaped my persistent focus that the people whom were sharing with me their stories and answers were just that – people. Not subjects, certainly, participants perhaps but thinking, feeling beings above all.

This trip to Bangladesh is the first solo travels I have made to a country where I cannot confidently make myself understood in the native tongue. Through no effort of my own Gallic is in my blood thanks to my Montpelier born Dad, while Spanish and some Central American dialects have been what my Curriculum Vitae most probably lists as something horrific i.e. ‘linguistic passions’. Sadly enough this is actually entirely true. I always favoured Spanish studies over say Ancient Greek, purely because of a cost-per-use attitude. I’m an aficionado of all things Hispanic (apologies eye-rollers, I am being a little facetious) and have made my entire family very aware that I wish to relocate to Mexico post-Masters, so if they want to see me again they better start banking those air miles.

Image Credit: A. Bow-Bertrand

Image Credit: A. Bow-Bertrand

Anyway, apart from sounding like an intolerable voluntourist, my motivation to speak the language of the place I am visiting is not solely self-serving – it is also inspired by a wish to be able to integrate into a locale, so that I am living there rather than just passing by, and invariably local inhabitants respond remarkably well to even the most over-excitable, and grammatically questionable, speakers of their mother tongue. In Bangladesh I wanted to resist the English speaker abroad stereotype, and was immediately thrown not only by the questionability of the assertion that English is the second language in Bangladesh (officially it is, but the competence and universality of such deviates enormously from country to country) but by my complete inability to either make myself understood or to understand the people around me without resorting to a mortifying mixture of signed actions (no, I don’t follow my logic here either) and facial muscle stretching.

Even in the London-based Bangladesh embassy I am ashamed to say that I had to resort to Google Translate to iterate my wish for them to relocate my passport and update me of the visa status. Safe to say I was put to the back of the queue (who am I kidding?!) and had to befriend (read: was taken pity on) a fellow travel applicant who was returning home to see his family over the Bangla New Year celebrations. With the entire world around me completely unrehearsed and unfamiliar, even non-verbal cues or fields of possible perception that might normally be derived from another persons’ accent, sartorial inclination or mannerisms are done away with when everything is plainly foreign.

As an avid people watcher, and constructer of improbable life narratives for strangers, I found this ignorance to social pointers frustrating on a personal level and potentially restrictive in the capacity of researcher. Asking people about their understandings of mental health, and indeed their experiences of it, cannot be plunged into blindly. While Lepra’s association had pre-established an element of trust and the information sheet and consent process soaked up any immediate practical questions, I found myself smiling inanely, nodding without knowing what I was agreeing with and generally looking so intently that I was probably just eyeballing everyone. The flipside to this potential weakness is that my total ignorance to any externally derived or verbal semiotic system avoided my interactions tipping into researcher prejudice or associative bias.

(L-R) Raha, me, Mr Shakhawat (TB Programme Officer) and Masud (office support officer and cook). Image Credit: A. Bow-Bertrand

(L-R) Raha, me, Mr Shakhawat (TB Programme Officer) and Masud (office support officer and cook). Image Credit: A. Bow-Bertrand

Perhaps this post is inspired by participant 10, or rather the reason for our having 31 rather than 30 interviewees as originally scheduled. Whether a selection error, or just incomplete patient details on the Lepra record sheets, this participant arrived, stooped over a self-fashioned wood crutch, with saliva pooling in his beard from a face half dropped from what I guess was a mild stroke. It was soon apparent that he was near wholly deaf, with his paralysis inhibiting all but the most restricted consonant sounds. The interview did not proceed as the others – the questionnaire was immediately disregarded as was any attempt to pursue the pre-defined topic guide.

The man was evidently desperate to make himself understood, clutching my hands and speaking in broken ejaculations. The majority of his narrative, or medical story perhaps, was relayed via the clinic staff in an assembly of dates, facts and diagnosis labels, all negating any reference to the psychological self that was so palpably in need of being explored and given room for in this interaction. Moving away from questions of suitability of the participant in relation to the selection criterion, it was painful to neither be able to make myself heard nor to be able to receive, verbatim, what he wished to say. I doubt he was fully aware that I neither spoke nor understood Bengali, but the complete lack of verbal offering and response afforded by the trajectory and closure of the normal research interview was an impossibility with participant 10. The session was considered closed once the clinic staff’s notes had dried up, and this was uncomfortably signaled to the participant with the monetary transaction or compensation for his travel costs, which in itself falsely pins ‘value’ to participant stories and their willingness to share.

Did I really understand anything about this individual? No. Could I sense and see his struggle? Absolutely. For felt communication is as essential to both verbal and visible communication and was something I took forward in the subsequent interviews. It is pertinent to close with this translated section from Closed Path by Bangladesh’s infamous poet Rabindranath Tagore whose language transcends national boundaries of geography and language, and continues to touch many: ‘and when old words die out on the tongue, new melodies break forth from the heart’.

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Can I take your photograph?

This is the second blog in a series of four in which I document my research in Dhaka and the Sirajganj district of Bangladesh. You can read the first post here. My work was facilitated by Lepra, but all views expressed are my own.

The first time was an awkward neck-crick inducing in-flight selfie with a little girl who watched A Bug’s Life on repeat (cue uncontrollable sobbing each time the grasshoppers bring their greedy ruination of the bugs) and her mother. Both also in-transit through Dubai, by the time we’d landed we had bonded over our collective Frozen screening (compulsory watching should be introduced during political question times nationally. Walt Disney: infamous cohesive gelling agent) and a selfie was deemed warranted.

From that point forward every tourist snap I took in Bangladesh was matched by at least two less than subtle phone shutter snaps and camera flashes not to mention the many, many photos taken upon request. I’m not averse to ridiculous gurning shots for my social media profiles, but the sudden level of interest in me as subject was both as hilarious as it was unexpected and unnerving. So much so that I actually questioned it.

A shop opposite the TB/Leprosy clinic in Sadar, Sirajganj. Image Credit: A. Bow-Bertrand

A shop opposite the TB/Leprosy clinic in Sadar, Sirajganj. Image Credit: A. Bow-Bertrand

When based in Sirajganj, the requests increased which is perhaps understandable given that many locals had never met nor seen a fair-skinned individual in person. Indeed, my Bangla soon developed an armoury of vocabulary based on what might be termed shouts of surprise namely ‘white’, ‘lady’ and similar that would travel up the street bringing with it an audience before our rickshaw had so much as careered past the first roadside tea stall. There is something of the Instagram fever here – the desire to showcase something perceived as ‘other’ or different for appraisal.

Mobile phone usage is as pervasive as social media and without any judgement being passed, wishing to record the novel or atypical is perhaps an innately human desire to have and to hold something that might otherwise be fleeting or difficult to memorialize without physical evidence. After all, so much photography is about capturing snippets of narrative, or perhaps more importantly, in triggering one. Indeed, this must be the reasoning behind my presence in many distant selfie snaps from sneaky youth paparazzi. I can only apologise that these records will feature a generally sweaty me – not my best angle by all accounts.

But this is not a linear activity. During my fieldwork interviews, it was the norm for clinic staff to photograph patients to support written disability assessments, presumably as a visual point of reference. These images fill iPhone camera rolls and personal cameras – stills of entire people rather than dismembered or exposed bodily segments. These photographs are identifiable and identifying, something that would rarely be seen in our own National Health Service. But there is real value in these visuals in this context. The rural population from whom we drew persons with leprosy for interview has a wildly variant education level from illiteracy to higher secondary education (equivalent to A2 levels in England).

Image Credit: A. Bow-Bertrand

Image Credit: A. Bow-Bertrand

Visual used during FGD. Image Credit: A.Bow-Bertrand

Visual used during FGD. Image Credit: A.Bow-Bertrand

What is seen, and re-seen, is the single common denominator of information dissemination in Sirajganj supported by the spoken word (necessarily barring those persons with hearing or visual impairments). As such, the basis of my focus group discussion (FGD) was a series of visual aids or themed drawings inspired by lexical codes established from the semi-structured interview transcripts with these participants. But of course, perception and comprehensions derived from the visual are not fixed. The opening activity of the FGD was a word association exercise, which invited participants to express states or labels associated with the image they were witness to. For instance, a line drawing of a Singer sewing machine garnered reactions of ‘sewing machine’, ‘weaving’, ‘income’, ‘employment’, ‘asset’, ‘own home’, ‘independence’, ‘hard with clawed fingers’, ‘heavy’ and ‘job’.

Image Credit: A.Bow-Bertrand

Image Credit: A.Bow-Bertrand

VIsual aids used for FGD ordering activities. Image Credit: A.Bow-Bertrand

Visual aids used for FGD ordering activities. Image Credit: A.Bow-Bertrand

So too, the clinic staff’s photographs of the participants with leprosy do not tell a singular, nor comprehensive, narrative of the individual depicted. From the nascence of a research question, my focus has been on the experiences of psychological distress amongst this target populace, or rather the awareness of limitations or challenges to the mental health of the individual. For many of the participants we encountered, disability is measured according to the biomedical model of grading as approved by the World Health Organization (Grade I for anaesthesia to extremities, Grade II for shortening of limbs and fixed or mobile clawing) with diagnosis based on physical, external examination. There is a checkbox for ‘visual disability’.

However, mental health here, like mental health anywhere in the world, is rarely ‘visible’. This idea proved to be both difficult to explain to participants versed in this system of disability measurement and for whom understandings are mainly composed from received images rather than from internalized understandings of the self. They are more familiar with the disability gradation of a nose as ‘depressed’ than as a lexical term for a psychological state. The closest to participant self-awareness I discovered was a self-reflexivity in the name of their faith, largely Islam with some 90% of Bangladesh Muslim. The dedication to individual cleansing and improvement in accordance with Islamic doctrine and the affiliation with a deity who is figuratively invisible has useful and potentially productive parallels with investigating awareness of, and experiences of, psychological health.

In profile. Image Credit: A. Bow-Bertrand

In profile. Image Credit: A. Bow-Bertrand

I would be wary of directly inviting participants to parallel their faith-based introspection and worship with an understanding and prioritisation of mental health and self-care, but the two are not so wildly irreparable. What was apparent from my research is that while there is little resistance to mental health per se, this openness is partly owing to its nature as an intangible entity. Stigmatisation of persons with leprosy is almost always related to the visible deformities or physical handicaps associated with late diagnosis and challenged disease management. However, national provision for mental health care and awareness of it as a priority within a multisectoral health system is all but non-existent and resource-poor.

Perhaps the increasing use of interactive healthcare and research techniques such as PhotoVoice in which participants are encouraged to photograph scenarios or things in their everyday life that represent the research focus, could be applicable to mental health work. Just because mental health is difficult to see, does not mean that it cannot be helpfully considered manifest in the physical – an image of a bed perhaps representative of anxiety-induced insomnia, or as a vast white island of security for the depressed patient. I am more than happy for this understanding to be free from labels of the ‘mental’ or ‘psychological’, providing an understanding and prioritisation is established for each person in their own manner.

If this means starting with selfies and inviting a conversation around the resultant medium, then this is something I’ll willingly keep posing in the name of.

Image Credit: A.Bow-Bertrand

Image Credit: A.Bow-Bertrand

Character is what you are in the dark

This is the first blog in a series of four in which I document my research in Dhaka and the Sirajganj district of Bangladesh. My work was facilitated by Lepra, but all views expressed are my own.

My trip to Bangladesh is not my first trip to Asia, nor is it my first long-haul flight. It was, however, the first time that I’d flown into Dubai. Arriving in the early hours the capital glowed bright like a throbbing motherboard that never blows. But I was glad it was only a stopover, for all the actual capital this hub holds to many, including some of my university friends who have relocated there for financial and commercial jobs, the glowing chequers and social workings have never much attracted me.

Admittedly, Bangladesh is not somewhere that previously featured on my wanderlust list, perhaps because tourism is less of an industry than a novelty there and my current travelling capacity is less casual holidayer, more researcher. That, in itself, has taken some getting used to. Since Lepra, whom I first encountered as editor for a joint commission with Polygeia, expressed willingness to facilitate my Masters research at one of their in-country offices, very little about my pre-trip preparation smacked of my usual ‘YES, I’m escaping’ planning.

Image Credit: A. Bow-Bertrand

Image Credit: A. Bow-Bertrand

Dubai. Image Credit: A. Bow-Bertrand

Dubai. Image Credit: A. Bow-Bertrand

Some things remained the same – nighttime page turning of guidebooks peppered with leprosy guidelines (OK, not so typical) and learning some basic phrases. What differed was the process. Bangladesh is not set up for foreign pit-stops: my visa application process was a vexed endeavour best summarized as: three days lapsing over a fortnight, five trips, a punctured bike tyre, a misplaced Passport, relocated Passport with visa pass and pained expressions from housemates disinterested in the lengthy drama. In all honesty, if I was not so impassioned by my project working on the prevalence of psychological distress amongst persons with leprosy in the Sirajganj district, I would have put down the bike pump, thrown the espadrilles to the back of the cupboard for another year and considered it a learning experience.

What regret would have been borne from such a decision. I can now say, as a survivor of said bureaucratic nightmare and inefficiency mountain, that Bangladesh is a riot of colour. The concrete heat trap of the roof terrace at the Sirajganj Lepra office which became home proved the best spot to watch sunsets comparable to split peaches laced with loose cream. Our own lengthwise hung washing line and those that crowned many other rooftops flapped clothes and fabrics in cyan, ochre and every shade in between to that crisp dryness only achieved in dry bone air. For a part of the world that sees life through a throbbing vibrancy in food, clothes and landscape, it is telling that ‘character is what you are in the dark’ is the motto painted on a mural outside the government school in the district.

Image Credit: A.Bow-Bertrand

Image Credit: A. Bow-Bertrand

Over rooftops. Image credit: A. Bow-Bertrand

Over rooftops. Image credit: A. Bow-Bertrand

Much of my time in Bangladesh has necessitated a navigation of new cultures and attitudes. In particular, the opportunity to meet participants and engage with them through in-depth interviews, sometimes meeting them on at least one further occasion, I have been afforded an insight into the generosity of this population. While Sirajganj is one of the less socioeconomically privileged districts of Bangladesh, absolute poverty is scarce, but living hand to mouth is a real truth. Notwithstanding, throughout my stay, everyone I met invited me to look beyond their bright adornments, clothes and the spectacle of richly coloured life that is simply their cultural touchstone. People who were all but strangers offered me their all – from prayers, their sole assets such as handicrafts and openly welcomed me into their homes for refreshment.

Beyond the sugar-crusted jewels of sweets and droplet bananas strung from every street stall, I encountered a generosity of spirit that was all too overwhelming by comparison to the insular London life which I have come to lead, constantly seeking to escape a drive for materialism, and richness in outer accoutrements and possessions. Materialism and its damaging conveyor belt of consumerism is an overwrought modern world burden, but even the most frugal or fashionably termed ‘minimalist’ of dwellers in London pales in comparison to the simplicity of want – and the integrity of character – that persists here. Context (environment, purpose and empirical knowledge pathways) aside, life in Sirajganj is, according to the stories related by the Lepra staff and evidenced in my research interviews, about just that – existing – with joy.

'Kalā'. Image Credit: A. Bow-Bertrand

‘Kalā’. Image Credit: A. Bow-Bertrand

The basic human needs of shelter, food, and potable water are matched with an endemic prioritisation of an extended family network. Education and self-instruction through academia and apprenticeships are welcome extras. What might be considered aspirational goods in the United Kingdom, such as branded clothing or socially recognised status items are certainly still present here, but their value is somehow self-limiting. The persistence here of what might be considered ‘clean-living’ to a UK audience in itself prevents such objects from being tainted with the perception of a Midas touch. Idolatry of assets is both alien and actively resisted. Instead, riches are frequently figured in terms of religion, family sanctity, and personal wholeness.

Of course, by the same token, these are shrewd businesspeople. During a focus group discussion facilitated by UK Aid, a gift of a beaded handbag as part of a seed money project (accepted only following an expressed desire on my part to act as purchasing customer) was caveated with the entreaty to showcase their wares upon my return to England. Trade and export – particularly of commodities of the external – the ‘IT’ bags, the designer fashion, the jeweled merchandise has long been a truism of the Bangladeshi-British connection. Yet are they selling the same goods in the same manner to themselves? No. Largely, the discourse is different. Surely, the ethos behind online shopping mecca ASOS, that is ‘as soon on screen’ exists here – emulation is, after all, one of the greatest forms of flattery precisely because it is so pervasive, but it is not overwhelming, nor is it prioritised over the pillars of social ‘want’ here – familial and spiritual happiness.

Dusk from Lepra field office, Sirajganj. Credit: A. Bow-Bertrand

Dusk from Lepra field office, Sirajganj. Credit: A. Bow-Bertrand

The walk to school. Image Credit: A.Bow-Bertrand

The walk to school. Image Credit: A.Bow-Bertrand

What is also true is that this part of the world is noisy – deafeningly so. Tuktuk, bus, delivery truck and advertising vehicle create their own electrophonic mating calls, matched only by the eclecticism of colour and variety of terrain. Over the Bangladeshi New Year, I was locked away in a deserted office and for the first time made room to metaphorically shut my eyes, block my ears, and still feel an extraordinary warmth – possibly something to do with the record-breaking 45 degree heatwave this area is currently experiencing, but you follow my gist . Even when the outward sensory bombardment one experiences coming afresh to this country is muted, there is a wholesomeness amongst this society and their way of life that brings greater contentment and stillness than one might expect when knee deep in visa applications or racing through a dusted researcher commute to who knows what hidden stories.