An exploration of social determinants of health amongst internally displaced persons in northern Uganda

Internal displacement in northern Uganda

Since 1986, northern Uganda has witnessed a war between the Ugandan government and a series of rebel movements, principally the Lord's Resistance Army (LRA) led by Joseph Kony. The LRA have fought a low-level guerrilla war to try and overthrow President Museveni's government, and to rebuild the perceived Acholi nation and culture in northern Uganda. The LRA built upon previous North-South divisions which have marked Ugandan politics and society since independence and grievances amongst the Acholi people against President Museveni and his government [18, 19]. The civilian population has suffered killings, assaults, sexual violence, and the abduction of children to become fighters, forced labourers, and sex slaves for the LRA [18, 20, 21]. The majority of the affected population are Acholi people from the districts of Gulu, Amuru, Kitgum and Pader, who worked on small land-holdings for subsistence and income before the conflict.

The war has been marked by forced population displacement because of attacks on civilians by the LRA, and the government ordering civilians to leave their homes and move to government established camps. The government justification for this forced displacement was to reportedly protect the civilians from the LRA and aid the army's counter-insurgency campaign against the LRA. The government-led displacement was scaled up in 1996, with civilians often subject to violence by the Ugandan army and given less than 48 hours to leave their villages and move into the camps [22]. IDPs could generally not travel from the camps to their homes or farmlands because of insecurity and travel restrictions imposed by the Ugandan army. The majority of people lived in the camps for between 5 and 10 years and some as long as 15 years [23].

Up to 2 million people were forced to leave their homes and live in IDP camps. In the three most conflict-affected districts of Gulu, Kitgum and Pader there were around 100 camps which ranged in size from around 1,000 to as many as 60,000 inhabitants [24]. The camps were characterised by chronic over-crowding, poor housing, water and sanitation. The camp residents were reliant on food aid from the World Food Programme and suffered high levels of poverty as they generally could not travel back to the villages and farm lands.

Although the camps were supposedly established for the protection of civilians, the camps were frequently attacked by the LRA, and IDPs reported poor security and high levels of violent and traumatic events when living in the camps [25, 26]. Human rights abuses against camp residents by the UPDF have also been documented [20, 25]. It has been observed that 'protection' by the government in northern Uganda 'has in fact been a cover for violation and mass humiliation' [8].

The health system in northern Uganda has been seriously damaged by the conflict, with access to health care impeded by insecurity, travel restrictions, impoverishment, and lack of medicines and supplies. Extremely high rates of mortality and physical and mental illness amongst IDPs have been recorded [24, 26, 27]. The chief humanitarian official of the United Nations, Jan Egeland, described the situation in northern Uganda as "the biggest neglected humanitarian emergency in the world" [28].

In August 2006, the government of Uganda and the LRA signed a Cessation of Hostilities Agreement. This has resulted in significant improvements in the security conditions over the last few years and large numbers of IDPs have now finally returned to their home villages. However, a final peace agreement was expected in April 2008 but has yet to be signed and there remain grievances amongst the Acholi over marginalisation and victimisation by the Ugandan government [29].

Determinants of health

Response strategies

The response strategies used by IDPs to support their health needs are described below.

Political determinants

IDPs are often subject to prolonged exposure to politically-induced collective violence as they often experience much greater insecurity than refugees. Much of the collective violence in northern Uganda has taken place against IDPs living in the camps [5, 26]. The respondents were thus living in situations in which mental and physical distress was caused not only by past experiences but also the fear of continuing and future violence. This study provides new evidence on how IDPs in northern Uganda describe the effect of this violence on their mental health. Over three quarters of respondents discussed the effect of collective violence and traumatic events on "over thinking" which could lead to "madness". In the Acholi socio-cultural context "over thinking" can refer to the way in which stressful circumstances cause constant worrying, multiple or obsessive thoughts, difficulty in identifying a clear solution, and a feeling that the mind isn't working properly and is "stuck". The term relates to Acholi terms such as par and two tam which incorporate stress and depression-like symptoms and have been described in detail elsewhere [37]. Studies with other displaced populations have also noted use of the term "over thinking" as a description of poor mental health. Astier Almedom notes how Eritrean IDPs spoke of too much thinking [14]. Elizabeth Marie Coker noted in her study of Sudanese refugees in Cairo how respondents referred to "thinking too much" on their current conditions and past events which in turn "fuelled" their physical illness [38]. "Over thinking" was also referred to by study respondents as an outcome relating to other determinants, particularly economic determinants, and this is discussed further below.

"Madness" was attributed by some study respondents to the "spirits" and "ghosts" (cen) of people killed. The strong belief in cen is consistent with beliefs of other Luo-speaking peoples [39], but Harlacher et al note how in the context and aftermath of the war in northern Uganda, the vengeful ghosts of those who had died a violent death has become the most widespread interpretation of mental illness amongst those who committed violent acts or event witnessed such acts [40].

The study also provides new information on how the "over thinking" from political violence in northern Uganda has also affected IDPs physical health in terms of "energy", "strength" and "body pain". The connection between trauma and physical suffering was also observed in a study by Tina Sideris of Mozambican women refugees in which respondents reported how the traumatic effects of war and displacement caused physical deterioration, bodily distress, and loss of vitality [41].

Environmental determinants

Environmental factors were noted by respondents, mostly in terms of "overcrowding" and "packing together" which resulted in disease and physical "sickness". This overcrowding was also equated with a sense of environmental "dirtiness" and a lack of "fresh air" and loss of "freedom" by study respondents. These findings reflects those of Elizabeth Marie Coker who noted that for Sudanese refugees, "breathing is directly related to physical constriction in that freedom of movement, freedom of cultural expression and physical space that one can call ones' own are critical to life, to being able to 'breathe' freely, to being human" [38]. The negative effects of overcrowding noted by respondents could also be related to having to share intimate social spaces, and settling with other clans, which Acholi and broader Luo-speaking peoples have strict beliefs about [42].

Economic determinants

The economic impoverishment brought about by the war and displacement and the effect on health was highlighted by many respondents - again in terms of thinking too much which could lead to "madness". The mental health effects of not being able to provide for children were noted by a number of study respondents. This supports the observation by Ambrose Olaa of stress amongst Ugandan IDPs of trying to meet the costs of educating their children [43]; and also studies by Mogollón Pérez et al and Almedom on the stress of IDPs trying to ensure their children's education [14, 16].

Study respondents noted that having "nowhere to dig" because of a lack of access to their land was a major cause of the poverty. This resulted in inadequate food which affected the "energy" and "strength" of respondents. Respondents noted the mental distress caused by the material losses of not being able to dig their land and get food and money from their crops. Ambrose Olaa believes the loss of livelihoods and dependency on food aid amongst IDPs in northern Uganda also led to a loss of self-esteem and feelings of inadequacy [43]. A study by Boutin and Nkurunziza noted how on Burundian IDPs felt the loss of livelihoods and reliance on food aid undermined their dignity. Sideris' study of women refugees from Mozambique noted how the separation from the land was identified by respondents caused a perceived loss of respect and injury to the "spirit" [41]. Other studies in Uganda have described the cultural importance of the land to the Acholi, with the anthropologist Sverker Finnström noting how "crops are central in the Acholi imagination of a good, healthy life" [44]. The cultural aspects of the land were not raised by respondents in this study, but further studies could explore how a sense of cultural loss from being separated from the land may influence health amongst forcibly displaced populations.

Socio-cultural determinants

This study provides new evidence on the influence on health from the changing social behaviour and the erosion of Acholi social norms and values. Other studies in northern Uganda have also observed changing traditional social norms, changing behaviour of children, increased prostitution, and rising alcohol use amongst men [21, 43, 45]. Finnström notes how "young men and women complained that there is no guidance from more senior people, while older men and women saw few possibilities to guard and guide the youth" [44]. This perceived social change also relates to the overlapping influences of other determinants such as the impact of violence and resulting poor mental health which could influence individual behaviour; overcrowded living conditions which may have disrupted traditional cultural norms and behaviours; and impoverishment - particularly the lack of employment and the loss of farming lands and associated roles and functions.

This concern over changing social norms connects to broader concerns about the damage and destruction to Acholi culture caused by the political violence and displacement [18]. Halacher et al state that "the devastating impact of displacement on the social fabric of the communities can hardly be overestimated. A society once characterized by a high level of social cohesion and mutual support... is drifting towards a harsh and unbridled individualism. Tensions between young and old, male and female, and people in general...have been steadily increasing". They note how the loss of cultural values has led to fractured community coherence and the loss of mutual support, both of which are desperately needed in such times of suffering [40].

The link between social suffering and individual suffering has been documented with other forcibly displaced populations. Coker believes the Sudanese respondents "almost invariably saw social and emotional pain as leading to physical pain" [38]. Sideris notes how "the destruction of social and cultural order is manifested in subjective forms of distress reflecting the interdependence between psychological processes and social environments" [41].

Responses

The importance of emotional and social support from family and friends was highlighted by study respondents, and this reflects findings from other studies with displaced populations [36]. Almedom who notes how social support and maintaining social cohesion amongst IDPs in Eritrea was seen as "very important because people who have shared the same experiences and suffered together tend to form strong support groups and provide safe space for expressions of pain, anger and grief" [14]. However, some respondents in this study preferred to "isolate" to help deal with "over thinking". In a study of returning abductees in northern Uganda, Joanne Corbin notes how avoidance of talking about traumatic events was a key contributor to psychological healing and this has also been noted in other studies of conflict-affected populations [38, 46, 47].

Nearly all respondents sought external support for physical and mental health problems. These included biopsychosocial sources such as hospitals, health centres, health workers and counsellors. They also include the use of traditional remedies and traditional healers, reflecting Acholi beliefs in the role of spirits, ghosts and charms as causes of poor health. While a health centre may be able to provide drugs, visiting the traditional healer was viewed as addressing the "root cause" of problem. Both of these sources of help were supplemented by prayer and religious support. This medical syncretism of health seeking practice and behaviour can be viewed as a response to the multiple causes attributed by respondents to poor health, including "spirits", "charms", and "ghosts" [48], and studies have promoted the importance of recognising this syncretism and cultural beliefs as part of psychosocial health interventions for conflict-affected populations [36, 49, 50].

The study findings on medical syncretism correspond with those by Harlacher et al who note the overlapping Acholi beliefs of "normal" disease which have their causes in the "natural" world, and "spirit-related" diseases which are attributed to the "supernatural". This belief in "spirit-related" diseases includes providing remedies and conducting ceremonies for people experiencing mental health problems arising from exposure to violent events and also from committing violent acts [40]. The importance of following traditional and religious ceremonies to help relieve trauma have been noted in a number of studies with displaced people [51–53]

Respondents in this study noted the value of traditional rituals and practices as a means of individual support, but they did not discuss it as a means community support. This contrasts with other studies from northern Uganda which observe the use of traditional rituals and practices as a means of reaffirming Acholi identity [40, 43]. Corbin notes in her study of returning abductees in northern Uganda how rituals help to "reconnect the larger community's sense of share values, norms and history, and support the social reconstruction of communities" [47]. Finnström notes how spirit-related diseases affect not only individuals but also families and entire clans, and therefore the use of traditional responses helps not only individuals but also broader Acholi society [44]. Finnström notes how they can also represents a means of trying to exert control over a situation of apparent powerlessness brought about by the conflict and displacement [44]. Further studies could explore the link between traditional rituals and practices as a means of reaffirming cultural identity and improving individual health outcomes.

Study limitations

This study has a number of limitations. First, the study was a short-term assessment based on single interviews, and a longer qualitative study using more qualitative methods would reveal more details and nuances. Second, the study had 21 participants and a larger sample may have yielded additional perspectives. However, the key themes described above were commonly re-occurring which suggested that a degree of saturation was reached. Third, it is possible that men may have felt less at ease with a female interviewer than a male one. However, there was no evidence of this given the openness of respondents, and preparatory discussions with local experts indicated this would not be a systematic problem. Fourth, the respondents were from an impoverished population suffering from prolonged conflict and dependence on aid, and there was a risk that they magnified accounts of their suffering in the hope of receiving aid even though it was clarified with the respondents prior to the interview that they would derive no material benefits from the study and that the study team were not from an aid organisation. Fifth, specific health conditions could also have been explored in-depth, rather than overall physical and mental health. However, the study deliberately wanted to address the multi-dimensional nature of health and encourage respondents to use their own conceptions of their health. Sixth, in order to gain respondent's explanations for how forced displacement had influenced their health, the interview questions were deliberately broad and did not mention specific determinants. This approach could have limited gaining a deeper understanding of these specific determinants and future studies could explicitly seek to investigate political, environmental, economic and socio-cultural determinants, the relationships between these determinants, and perceptions of the comparable severity of health problems attributed to these different determinants. Lastly, the focus of the interviews was on how the conflict and forced displacement had influenced health. This may have limited the range of responses to those focusing on the conflict and displacement, rather than attributing health outcomes to other non-conflict issues such as cultural change related to modernisation processes in Acholi society, political repression, or generalised poverty. The focus on conflict and forced displacement may also have encouraged respondents to reflect on their mental health rather than physical health. There had also been no recent communicable disease outbreaks and so physical health issues may possibly have been of less immediate concern to respondents.