'"The people of the land practise extortion and commit robbery; they oppress the poor and needy and mistreat the foreigner, denying them justice. I looked for someone among them who would build up the wall and stand before me in the gap on behalf of the land so that I would not have to destroy it, but I found no one."' (1)
In post-Christian Europe, we unfortunately have a tendency of doing the very same thing when we consider our attitude towards refugees on our doorstep. I will present some views on the migration issue and include lessons derived from my personal experience of culture shock and reverse culture shock.
I lived as a missionary in an upside-down world. I worked as a director in two mission hospitals, often being the only MD available. In 1998, a centre for HIV and orphan care in a rural part in the northern region of Malawi (2) was established. I experienced culture shock, and on return to the Netherlands, 18 years later, a reverse culture shock. The second was worst than the first; I can say that it took almost five years to experience the Netherlands as 'being home' again.
One of the well-researched risk factors of schizophrenia is experience prior to migration. So as I felt like a stranger during my reverse culture shock, I have been pondering these questions. Feeling detached and out of place creates considerable psychological stress. At the time, a consultant psychiatrist described my status as: 'Bert has not yet touched down'. My mind was still somewhere in Africa, where I established a lot, had really enjoyed the work, and where I was concerned if all was well - it was hard to leave it behind.
The morbidity and mortality rates that I found on return were quite different from what I was used to, doing public health in Malawi. The average age of deceased people in the mortuary of St John's Hospital (Mzuzu, Malawi) in 1996 was 22 years of age. Of course this was because of HIV/AIDS, before the time that anti-retrovirals were widely available. This infectious disease was affecting mainly young people. The under fives were threatened by the same HIV, as well as malaria and diarrhoea.
When I came back to the Netherlands infectious diseases were hardly a major health problem (apart from avian flu and a new spirit of reluctance against immunisation among young parents). Yet the morbidity and mortality figures on mental health in the West were in my observation increasingly shocking. In 2017, in North America, the first reason for death among young adults was opioid abuse; in Russia, alcohol abuse and in Asia, suicide. In Europe, the highest death rates in this age group are due to suicide and drug abuse. The risk that your adolescent child may die of a terror attack, something we all believe is a dangerous reality nowadays, is in fact much lower than your child may die committing suicide or of drug abuse. It should be a concern to us all.
The migration crisis
António Guterres, former United Nations High Commissioner for Refugees and since 2015, UN Secretary General, has described the global refugee crisis as follows: 'We are witnessing a paradigm change, an unchecked slide into an era in which the scale of global forced displacement as well as the response required is now clearly dwarfing anything seen before.' (UNHCR report 2014 World at War). (3)
The UNHCR counted, at that time 42,500 new refugees being added to the total number each day, more than 60 million worldwide. It meant that every two seconds, there was someone who decided to leave home in order to find a safer place. 2015 was the year of Europe's refugee crisis.
Having a passport is something to cherish. When I started my duties in the psychiatric unit for asylum seekers, I was asked by the members of my new department to introduce myself; they had suggested that I present two items that were important to me. I brought my passport and my Bible and briefly explained why they were precious.
We have passed bills in Europe where we can declare people as being illegal when they don't carry a valid passport. Being illegal means they are deprived of all sorts of privileges, such as healthcare and legal protection. We tend to treat them as less human and have de-humanised strangers by giving them a so called 'illegal status'. The UK Parliament passed the UK Immigration Act in 2014 providing limited access to healthcare for illegal immigrants. (4)
Migration can be a trauma in itself. When people leave their own country against their will, their possessions, home, dear ones... they don't just do that because they want to experience Europe and have a better life. When refugees are displaced they are in misery. Nobody willingly gives up a place of safety, calm, familiarity, attachment and belonging. Nor do they give up a place where dreams have been cherished, and where life has been predictable as part of a community that has the same values, norms, and language. These are all primary resources that migrants have lost. When access to a new place of living is perpetually being denied to someone with an illegal status, his threshold to a safe haven will become a never-ending tunnel of desperation and eventually affect his mental health and identity.
Vignette: being illegal
Ahmed, was a 32-year-old man whom I met when he came as a patient to see me. He had left Iran at the age of 21 when he was a promising engineering student who had run into political conflict with the Shiite regime. Upon arrival, he requested asylum in the Netherlands, only to hear within a month that his request was rejected. As a result, all of the European Union countries were closed to him; he had no access to freedom and he did not dare go back. He decided to survive on the streets, living undercover, offering himself as cheap labour in restaurants. He tried Sweden but was forced to return. He tried again, moving up and down between Sweden and Holland. As his fingerprints were taken and shared between border authorities, he was unable to escape. Three times he ended up in detention, of which he said, 'Those were my darkest days. That was truly horrible. I will never again talk about that time of my life.' He experienced nightmares and panic attacks. He could not share this without crying. As a young, intelligent man he must have had an attractive appearance, but he now looked like he was 40-years-old. He was anxious, depressed, tired, easily crying, very alert and agitated. He was a lonely young man, detached from his cultural, social and even personal identity. He felt very much ashamed and he literally cried to me, saying, 'Doctor, please help me. I have forgotten who I am.' He had lost all his primary resources, he had nothing to hold on to, he had been denied a new home and in the process he had lost himself. This is what migration can do to any of us, especially when this happens against our will and we're forced to go to another place where in due course we are not accepted. Only extremely resilient people can cope with this alone. As figure 1 shows: social support is a key factor in resilience. You may have personal strength, but when there is a tremendous amount of stress, social support is needed and should not be denied, as it was in this case.
As Europeans, there is a growing tendency to reduce social support to those in need. We have built and continue to build Fort Europe, even finding pride in this. Like any other culture we are biased and ethnocentric; the present neo-liberal stand is simply this: 'Our culture is better.' These words came from the former Dutch Minister of Health Mrs Edith Schippers in 2016. 5 This is egalitarian neo-liberal ethnocentrism. However, there is a gap between what is so perfect on paper. In Malawi, I was often surprised that Malawian healthcare was being presented as if it was the best system in the world. Yet the realities I faced were quite the opposite. On the outside and on paper, it all seemed pretty well organised, but on the inside there was no power to do what was needed.
When we say that our culture is better than another culture we are actually saying that culture is static. A static view of culture causes us to think in terms of 'we' versus 'they'. We generalise, stereotype, stigmatise, and build up a confirmation bias (figure 2). As a result our healthcare delivery will be biased and poor. Rather, we need to look at culture as dynamic: cultures are continuously changing. Culture is a process through which ordinary activities and conditions take on an emotional tone and a moral meaning for its participants. (6)
As Christian physicians, we need to be culturally competent. We need to understand people coming from another culture are different. They cannot just do a course and train to become a European or British citizen. We need to make the effort to understand people who come to us with their problems, not only being as quick as possible to find a reliable diagnosis, but to understand the illness as the patient understands it. Only then will we get close to the patient, build trust and find a solution together. Doctors need to be good communicators and good collaborators. In trans-cultural practice we have a fine opportunity to build this cultural competency.
The Apostle Paul was very intentional and culturally competent. He knew how to align, how to make contact with Jews, becoming like a Jew to those under the law. (7) The challenge is not to expect strangers in need to adopt our systems. It is whether we are willing to become their neighbours by practising adequate cultural competence.
Understanding migration: liminal phase
We have already noticed that migration can be experienced as trauma. I would like to highlight here the liminal phase of migration. The term liminality comes from two anthropologists who studied social transition processes. Arthur van Gennep researched initiation rituals among young men and women in central Africa and called them rites de passage, in which the liminal phase was the key transition phase. (8) Victor Turner characterised the liminal phase as a space where the individual ends 'being betwixt and between'. (9) He called it an anti-structure, where the previous and familiar structure has completely disappeared. There's nothing to hold on to, nothing is any longer the same. Only after the participants have gone through that phase, can they be introduced into the new phase. (10) A liminal space is not intended to last forever. Turner applies the concept of liminality to a number of transition processes, including migration.
In figure 3, I try to demonstrate the difference and similarity between the liminal phase as a rites de passage in an existing culture, where the individual goes back into the same culture, but now as a different person with a different identity versus the transition of the migrant. Only by memory does the migrant carry his cultural identity with him, but he has to adopt an entirely new culture. If he gets the opportunity and autonomy to make choices with respect to his future development he may succeed well in this transition and he will eventually integrate and feel at home in his new country, having a new (often) bi-cultural identity. It must be mentioned here that this process will not go without grieving: the lost culture is dear to the very self and the migrant often experiences sadness and a sense of loss. Migrating is indeed a mental health risk.
Not all migrants integrate well. Berry identifies four patterns. (11) There are those who prefer their original culture and being ethnocentric they stay separated, and often live in their own community where they fail to appreciate the new culture and from where it is even more complicated to be accepted by the receiving culture. Behind their front doors, their homes are as if they are still in Somalia or Pakistan. During times when they go out and try to adapt, they often experience shame. There is also a pattern of the migrant who completely forgets and ignores his previous culture: he idealises the new culture and at all costs presents himself as being part of it. He risks becoming arrogant like the proselytes in the New Testament times who had become more Jewish-like than the Jews themselves. Often they have an underlying narcissistic pathology, being easily offended. Lastly, there is a pattern of marginalisation leading to an estranged identity - that's what I described in the vignette of Ahmed, who lost his cultural identity and never got entry into a new culture.
The identified problem with Ahmed as mentioned earlier, was that he was denied access. He was not accommodated in Europe, and therefore his liminal phase became a permanent state. He had no access to a new cultural and social identity - it was denied to him, and as this lasted for so many years he eventually got detached from himself. He had grown up as a young man in a healthy family, but all that was no longer of value. By God's grace I can add however, that - while in prison - he came to know Christ and in the end he even got a permit to stay legally in Europe. He is now on his way to re-finding his identity as a disciple and citizen of heaven.
Liminality in present day Europe
I would propose that the post-Christian culture we are part of is in a liminal space as well. It is quite astonishing to realise how fast we have moved from a predominantly Christian society into a post-Christian, secular society. It appears that almost within one generation we have abandoned these roots completely, even believing these roots historically were more a bother to society than that faith made a significant contribution to science and development.
Paul warns us in Romans 1, 'For although they knew God, they neither glorified him as God nor gave thanks to him, but their thinking became futile and their foolish hearts were darkened... and exchanged the glory of the immortal God for images made to look like mortal man and birds and animals and reptiles.' (12) When we say bye-bye to the creator God, who created us in his very image, we risk losing our identity. If we neglect worshipping him, we will develop an identity crisis. Indeed, we need to find our identity again in the Eternal.
Psalm 84 is an interesting passage to have in mind when you think of refugees and people coming to us from other cultures: 'Blessed are those whose strength is in you.' (13) In other words, resilience comes when you find strength in the Lord. 'Better is one day in your courts than a thousand elsewhere; I would rather be a doorkeeper in the house of my God than dwell in the tents of the wicked.' (14)
Staying close to Jesus and abiding in his presence is what we need; it is what we need to offer to those around us. We need to find and live out our identity in Christ. We are not shaped by our culture, but we, by living out our identity in Christ, shape the culture around us. 'Therefore, come out from them and be separate, says the Lord. Touch no unclean thing and I will receive you. And I will be a Father to you, and you will be my sons and daughters, says the Lord Almighty.' 15 That's a great promise: when we seek him, he will then call us his sons and daughters. Therefore, if we, as Christian medical practitioners seek and practice his presence, especially to those who have nothing to identify themselves with, there will be light at both ends of the Euro-tunnel.
Migration is a very risky exercise. Liminal spaces are universal and colour all cultures. Migration is characterised by the liminal phase - it marks a transition into a new identity. Effort is required to be a neighbour to those in need in a changing culture.
And the righteous will answer that day in surprise, '"Lord... when did we see you a stranger and invite you in?"' (16) We are all called to stand in the gap!
Bert Nanninga is a transcultural consultant psychiatrist based in The Netherlands. This article is based on his Rendle Short Lecture at the 2018 National Conference