Fragile Nation

Illustration by Daniella Syakhirina.

 

The following is an excerpt from Bangladeshi-Australian psychiatrist, Dr. Tanveer Ahmed’s new book, Fragile Nation Vulnerability, Resilience and Victimhood (Australia: Connor Court Publishing, 2016), exploring changing notions of human vulnerability.

While several of my colleagues were hard at work putting together dissertations on topics like “Diving Injuries in the Caribbean Island of Aruba” or “Respiratory Ailments Encountered while Trekking in the Himalayas,” I threw myself into a cholera hospital in Bangladesh.

It was horrific, tens of people lined up across each floor, lying on thin foam mattresses linked to drips for dehydration. It looked post-apocalyptic but was mundane for the Dhaka based institution famous for inventing a saline solution to treat diarrheal diseases.

Within a week, my skin was turning yellow and I had succumbed to a digestive illness. The most likely culprit was unfiltered water used to wash a salad I shared with a relative at an otherwise posh restaurant. It wasn’t until I returned to Australia having shed ten kilograms that I was tested at a laboratory to discover I had contracted Hepatitis E.

The infectious diseases professor assessing my case was positively ecstatic and called me several times to arrange appointments. Feeling chuffed that he was so interested in my diarrheal project I soon learned that Bangladesh was one of only three countries in the world, along with Bolivia and Peru, where the virus even existed. Professor Kotsiou was interested in me as a post-infectious specimen and not for my elective project. He liked me for my body and not my brains.

I have since opted to scratch my developing world itch by seeing patients who migrated from there, from refugees to newly arrived migrants. As virtually the only qualified Bangladeshi psychiatrist in the city, a common presentation are Bangladeshis who otherwise would never consider their problems, varying from headaches to excessive washing, as psychological in nature.

A memorable case that illustrates many of the issues in such a group was a woman called Farzana, who arrived to my rooms accompanied by her bearded husband.

 

FARZANA AND SHAKIL

He began telling her story by painting a picture of Farzana, living in a stifling hot tiny flat in the Sydney suburb of Lakemba, putting their two-year-old daughter in her cot, and perpetually fulfilling the rituals of wudu – purification.

“First she washes her hands three times, each time reciting the Arabic phrase subhana-alla. Then she moves on to a gentle rinse of her forearms to her elbows – also three times. Finally her face, mouth, and back of the neck.”

In a cracking voice, dripping with concern, Shakil said Farzana sat cross-legged on the brown, cotton prayer mat she aligned with Mecca. She always checked the compass application on her smartphone to make sure the direction was correct, before praying once more. She heard the call to prayer from the neighboring mosque as a notice for another imminent prayer.

The problem was that 20 minutes later, she began her purification again.

 

A CRY FOR HELP?

Farzana was typical of so many of my patients who present for psychiatric services but have little interest in receiving them. Their suffering does not feel like illness, but just the mundane drudgery of conscious living laced with a particularly intense emotional suffering.

Those from ethnic groups rarely see any kind of suffering through the lens of mental illness. They are more likely to be referred when other specialists have investigated and ruled out the possibility of a physical diagnosis. This is especially true when people present in couples: the person with the greatest needs may not be the person who initiated the session. As well, seeking treatment as a couple may encourage a patient to disguise their real need so the other person takes more responsibility. A person might present as seeking to save the relationship, when really they want permission and a safe way to end it. Or vice versa.

Concerned, Shakil leaned forward while Farzana hung back, furtive and not making eye contact. Her nose was pierced with a thin, golden ring and her head covered with a portion of her blue sari, some platted locks of her dark hair visible. I noticed some light calluses on her hands; but then Shakil interrupted my observations.

“I want to help her, but don’t know how,” he said, leaning forward in his cream colored taxi driver uniform, with its embroidered logo on the breast pocket, his booming voice filing the room. Although speaking in an Indian accent, he pronounced occasional words, such as “mate” or “sure” with an exaggerated Australian twang. I imagined him speaking to his passengers trying to mimic them.

He was loud and seemed overbearing and controlling. Farzana cowered in his presence. I wondered if it was he who was in need of help but had no insight or desire for self-examination.

He lamented how he did not receive much in the way of welcomes when he returned home or that food wasn’t prepared for him when he arrived. At the beginning of their marriage, a union he said was arranged through the extended family, Farzana dutifully arranged bowls of curried meat, dahl and boiled rice in the cramped kitchen before placing them before the seated Shakil on the coffee table. She even had bowls of mango chutney and green chilis cut in halves to be enjoyed as accompaniments. But these days when Shakil returned late at night from his usual shift, their daughter was asleep and his wife was deep in prayer. There would be nothing to eat but leftovers.

The nature of their union, an arranged marriage via rural Bangladesh, suddenly transported into suburban Sydney, already marked their relationship as complicated. Newly married, isolated women from ethnic cultural backgrounds were a common presentation in my practice, particularly given western Sydney is one of the more diverse melting pots in the world.

 

THE INSTITUTION OF MARRIAGE

I escaped an arranged marriage. Despite my parents not being religious, they had an expectation I would marry a Bangladeshi despite having migrated to Australia decades ago. My father was ready to place an advertisement in a Bangladeshi newspaper in search of a bride even after I had been with my partner, and now wife, for several years.

“Bangladeshi Doctor living in Australia wants beautiful, well-educated woman to marry. Has Permanent Visa and Satellite Television.”

Book cover courtesy of Dr. Tanveer Ahmed

Prior to that he considered a union with the daughter of a corrupt former Bangladeshi politician who had fled to Australia after being exposed for siphoning off foreign aid into his own Swiss bank account. He sold off thousands of tons of sugar and came to be known as Sugar Zafar, but because he hailed from the same region as my father, he was deemed to be a friend. Zafar’s daughter was more suitable than a white girl in my parents’ eyes, at least for a time.

Arranged marriage seems ridiculous to most of us now, but we forget romantic marriage is a relatively new concept and is still an unfinished revolution in most parts of the world. In countries like India and Bangladesh 90 percent of marriages are still arranged and many young adults are satisfied with this practice.

In her book Marriage: A History, historian Stephanie Coontz writes, “(marriage) had as much to do with getting good in-laws and increasing one’s labour force as it did with finding a lifetime companion.” The idea of marrying for love was considered a serious threat to the social order. Order has traditionally been valued more greatly than freedom.

Even in the 1990s, newlywed Russians at the height of glasnost rated love as the fifth priority among the top ten reasons for marriage and a third of all French women claimed that their male partners weren’t romantic enough. This was discouraging. If the French with their poetry and obscure philosophical references weren’t considered romantic, my prospects for points were limited with wilting roses and tickets to emerging indie theater.

Measures of arranged marriage are not easily found in Australia, but in Britain South Asian groups had the lowest intermarriage rates of any ethnic group. It was particularly high among Muslims from Pakistan and Bangladesh. There was a social class component, given South Asians emigrated to the United Kingdom often as unskilled immigrants and had a harder time rising up the social ladder. The lower levels of education also meant they set up ghettoes such as those in the WhiteChapel area of London. They returned to their ancestral villages when it was time for the children to marry.

In a book over a decade ago, British Bangladeshi author Monica Ali wrote a novel, Brick Lane, about the challenges of a newly married Bangladeshi woman, having migrated from a village, who found herself in a stifling union with a much older, misogynistic, unsophisticated husband. The book alludes to something that was called the Begum syndrome, a condition that Bangladeshi mothers were said to suffer amid the relative poverty and disadvantage of their situation. They visited their doctor complaining of “burning in my head” and “life pressure”. Researchers concluded that their talk of beesh, which was the Bengali word for poison, was a kind of somatization and internalization of their cramped dwellings and limited resources. The so-called syndrome was an anxiety disorder transmitted through the culturally appropriate expression of physical symptoms.

Like Brick Lane in London, Sydney also has its suburbs that are effectively holding areas, temporary zones for migrants who have not yet settled, whose lives are defined primarily by their past – theirs or their parents – but who want to grab the future. Lakemba is one such suburb, often the initial point for whatever the latest wave of migrants were in much the same way Brick Lane housed post-war Jewish arrivals before the Bangladeshis.

In the past decade Lakemba was less the home of the Lebanese and increasingly the hunting ground of sub Saharan Africans, Pakistanis and Bangladeshis. I regularly treat women like Farzana, who live in Lakemba. When I turned my attention to her during my initial assessment, there were calluses on her hand, unusual for modern women living amid the abundance of domestic, household appliances.

I remember visiting Bangladesh as a child and marveling at village women toiling for hours applying soap on clothes, rubbing them fiercely with their hands mimicking a washing machine. The relief of completing this task was usually met with the call of the kitchen and another few hours preparing food from scratch over a clay stove and firewood. The calluses on Farzana’s hands were more likely to signal excessive washing or rubbing as a repetitive behavior.

I wondered whether any tension among the couple was exacerbated by their different status. In Bangladesh a high status woman like Farzana would never marry a taxi driver. But Australian citizenship elevated the negotiating power of otherwise ordinary men; sometimes creating marked mismatches. Other women I had treated, like Farzana, often arrived in Australia only to realize the man they had married was not in fact a “transportation executive” or “hospitality entrepreneur” as they may have spruiked in the marriage negotiations, but in fact a taxi driver or even a kitchen hand. The negotiations usually take place through phone calls between relatives and exchange of documents such as work resumes and birth certificates. But marriage fraud has reached epidemic proportions such that many families in South Asia are increasingly suspicious of overseas suitors.

There is also greater pressure on the relationship between spouses in modern marriages, whereas in the past such unions were cushioned by interactions with large, extended families. Even among couples choosing their spouses, psychological studies show we are increasingly reliant on our spouses as ties to the number of close friends and other networks have dwindled. As a result, even with the greater tolerance and expectation of compromise that those entering arranged marriages inevitably have, conflicts are harder to endure.

Another kind of problematic, arranged marriage that arises are when children are too scared to stand up to the authority of their parents and agree to unions they have little interest in. The partners arrive only to find that their new spouse has in fact a boyfriend or girlfriend not acceptable to the conservative, ethnic parents. One patient of mine was even told to sleep in a different room a few nights a week while his spouse made love to her pre- existing, personal trainer boyfriend. The parents were oblivious to the arrangement.

It seems inconceivable that anybody would put up with this situation but the new, imported spouse often has a significant disadvantage in that their migration status depends upon the marriage with the Australian citizen. Consequently, they feel powerless and unable to stand up for themselves, especially when their family back home is depending upon them for the marriage to work.

This happens to both men and women. They present to me because one way they can retain their migration status is if some kind of abuse occurs and they can argue they suffered a diagnosable mental condition, then the government may clear them to live in Australia in spite of their marriage failing. It’s quite an obscure loophole in our rules but one that migration experts are all too aware of.

An arranged marriage is a collision of hopes and ideals. He dreams of a traditional wife who will take care of his cultural needs, bring up his children in traditional manner, and someone easy to control. She dreams of freedom, autonomy, control over her life, a great job, and a better lifestyle than that she could hope for at home.

 

FARZANA’S POINT OF VIEW

I would need to see Farzana alone before asking about any prospect of abuse.

“How is the marriage?” I asked matter-of-factly, applying the doctor’s power to instantly access the most intimate aspects of patients’ lives.

Shakil was not taken aback. He said their marriage had been strained while Farzana’s symptoms were worsening, particularly as Shakil was forced to reduce his hours working as a taxi driver because of her behavior. There were also occasions when she had not properly fed their daughter or prepared lunches for daycare. On one occasion Farzana was so ensconced in prayer that their daughter, Aisha, had not been picked up at childcare and Shakil received a phone call from the manager of the center.

“This was very embarrassing,” he said, emphasizing it further by adding the Bengali word for shame, lajja. The word struck me as particularly strong, and highlighted his sense of humiliation.

I asked Shakil to leave so as to interview Farzana alone.

As well as feeling more comfortable talking about intimate details, people often reveal non-verbal markers that give important information about the relationship when they are assessed alone. A woman may more clearly expose bruises associated with domestic violence as soon as her partner steps out. Realizing this, the abusive partner in a violent relationship is often particularly reluctant to leave their spouse alone in the consultation room. But when I asked Shakil, he simply looked towards Farzana who nodded and so he left us alone.

I asked Farzana about her life in Bangladesh. Newly arrived women, particularly after arranged marriages, are at risk of sudden isolation, especially after losing the support of extended families in their ancestral lands.

“I am a good student but had few friends,” Farzana begun.

As was typical of people from her background she began with her academic status when asked about her childhood, whereas Westerners related it in terms of being happy or sad.

Poro-shona was important in our home. Baba, Ma were teachers,” she said, noting the importance of education. The place of religion was relatively minor in their households, in spite of them being surrounded by great religiosity within the community. Farzana said her mother often spoke about how as a child, women wearing burqas and men growing long beards were barely visible, but it seemed to increase during Farzana’s lifetime. The region of Noakhali, where they lived, situated in the southeastern corner of the country not far from Burma, was particularly known for its conservatism. The local mullah was powerful, commanding as much authority as the Member of Parliament.

“I hoped my husband would be more modern too, but he is not,” she said, in a sharper tone. Her statement pierced the room like an arrow. I recognized its significance. In her softer way, she was expressing profound rage. I didn’t pursue it but made sure to acknowledge it. She continued with tales from her development.

Her parents were both teachers in the local district high school in the southern part of the Bangladesh. There was a significant presence of the Islamic party Jamaat-e-Islam in their district adjacent the Bay of Bengal, and they created a degree of resentment in Farzana’s parents. She told me that a Jamaat office bearer once chided a teenage schoolgirl for flicking her hair too seductively. Farzana remembered her father having a verbal conflict with a man parading a long, henna stained beard. She worried about her father, but the scuffle settled. Farzana noticed days later that the girl in question started wearing a headscarf to school.

Farzana also described the period when her maternal grandfather died. She was barely ten years old and remembered her mother soaking a tea towel with water and rubbing his forehead several times a day. Children were kept at arm’s length from sick relatives, the belief being they were not mature enough to see such suffering. Her grandfather, who she described as having an especially long, henna stained beard in his final years, couldn’t swallow for months. When he died after a tortuous few months, she remembered the household being transformed into a prayer sanctuary. They were flooded with grieving relatives, cupping their hands together to pray, a practice known as dua, usually while holding prayer beads. The beads numbered 99, corresponding to the number of names given to God in the Koran.

Farzana expressed surprise to see her mother suddenly involved in the religious fanfare, which she didn’t understand at the time, given their family appeared virtually atheist. Her mother said that things would be clearer when she grew up, that it was impossible to process death without some kind of religion.

My psychologically sensitive ears pricked up.

“Why do you think you remember this Farzana? What does it mean?” I asked, thinking the sudden religiosity of her mother may be related to Farzana’s own sudden religiosity. Her response was a surprise.

“I think about death more often,” she said, making direct eye contact. “I worry about my daughter dying, maybe from asthma or being kidnapped.”

“Does she have serious asthma?”

“No, but she was in hospital as a child for a breathing problem. I know it’s silly.”

“Who else are you worried about dying?”

“My mother and father in Bangladesh. They are getting old and I am not there to look after them. I feel guilty at times.”

“Do you worry about your husband?”

Aktoo,” which was Bengali for “a little.” “But he is stronger than me and can work for long.”

While death anxiety is in the background for many patients, this didn’t seem to be what drove Farzana’s pathology, which she soon confirmed when she began to talk about an unusual, undiagnosed abdominal pain as a teenager. It was put down to “gastric”, which is a term used to describe acid reflux in the stomach. Irritable bowel is in that category, a pain that had no associated physical pathology attached. The symptoms are common in my ethnic patients, along with headache or dizziness, and are often related to anxiety where the culture didn’t provide other outlets to communicate it. The condition confirmed for me that Farzana had a prior history of anxiety that wasn’t identified as such.

I examined Farzana’s hands and had a closer look at the early signs of calluses from the repeated washing. She also exhibited a tiny bump on her forehead from the praying, which even had a word in Arabic, zebibah, translated as raisin. Her mother did not sound anxious, but Farzana said that her mother suffered a bout of tuberculosis soon after giving birth. I wondered whether her anxiety was triggered by some disturbance in the initial bonding to her mother.

At this stage, I raised a critical aspect of the encounter. Did Farzana think there was a problem?

“My husband is very worried, I know,” she said, becoming more relaxed and engaged. She leaned forward in her chair.

“He thinks I can be a better mother and wife.”

“And you?”

She nodded sheepishly. She did want help and could see possible benefits for her, but there was a degree of reluctance. I asked her to expand about her marriage.

“I thought coming to Australia, I would be part of a more modern society, but it’s like going back to the village living with Shakil sometimes.” she spoke more rapidly and was holding back tears. “I thought I would make him happier if I was more religious, like his family.”

Farzana’s newfound religiosity seemed to be an unconscious way of seeking approval from her traditional husband. She said the call to prayer, audible from the local mosque, calmed her. She described her compulsion to pray, relating her ritual, from the purification to the repeated bending, standing and kneeling. For completeness, Farzana showed me the compass application she used to align her prayer mat on her smartphone.

She revealed the home screen with a photo of her daughter, Aisha, smiling at the camera with red ribbons in her hair. Farzana bowed her head in guilt and shame when I commented how beautiful her daughter was.

I brought Shakil back into the room, who anxiously looked toward Farzana before sitting back on the couch.

“What do you think bhai?” he addressed me more familiarly as “brother”.

Back with the two of them, we sat along with the elephant in the room; a strained, marital relationship and the mismatched expectations of both parties, which could not be sorted during this consultation.

Order your copy of Dr. Ahmed’s book here.

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