P1: JLSpp1137-medi-481901 MEDI.cls February 16, 2004
15:3ELIZABETH MARIE COKERTRAVELING PAINS: EMBODIED METAPHORS OF
SUFFERINGAMONG SOUTHERN SUDANESE REFUGEES IN CAIROABSTRACT. This
paper presents the results of a larger study conducted among
SouthernSudaneserefugees inCairo, Egypt.Illness
talkandbodymetaphors arethefocusofthe present work, which is based
mainly on an analysis of the illness narratives of peopleattending
a church-run medical clinic. The ndings suggest that refugees use
certain nar-rative styles in discussing their illnesses that
highlight the interconnection of bodily illsand refugee-related
trauma. The refugees narrated the histories of their illnesses in
termsconsistent and coterminous with their refugee histories, and
articulated illness causes interms of threatening assaults on their
sense of self as human beings and as part of a dis-tinct community
and culture. The use of embodied metaphors to understand and cope
withtheir current and past traumatic experiences was echoed in
narratives that were nonillnessrelated. Metaphors such as the
heart, blood, and body constriction were consistentlyused to
discuss social and cultural losses. Understanding the role that the
body plays inexperience and communication within a given cultural
context is crucial for physicians andothers assisting
refugees.KEYWORDS: embodiment, illness metaphors, social change,
Sudanese refugeesThe term social suffering offers a short-hand way
of referring to this relationship of a medi-cal biography whose
existence and direction are overdetermined by political and
historicalforces over which the individual has no control. Such
illness narratives provide an oppor-tunity for critical
auto/biography. The life history engages with and sheds fresh light
on theanomalies in the core structures of the society.Vieda
Skultans (2000: 11)INTRODUCTIONThe longest-running civil war in
Africa to date is one that receives relatively littlemedia
attention in the West. With no immediate resolution at hand, the
war betweenthe NorthandSouthof Sudanhas
claimedanestimatedtwomillionlives, withmanymillions more homeless
and displaced. The roots of this war lie in long-standingethnic and
religious hostilities between the lighter-skinned Arab-Muslim
rulersof the North and the mostly Christian ethnic groups in the
South, fueled by thediscovery of oil in the southern provinces in
the 1970s, and increasing dramaticallyin recent years (Johnson
2003; Lesch 1998). While a complete analysis of themyriad causes
and complications of this 18-year conict are beyond the scope ofthe
present paper, the immediate result is that in recent years an
estimated 500,000southern Sudanese refugees have ed to nearby
countries. A lucky few have beenresettled in Australia or North
America, the rest are forced to survive in crowdedCulture, Medicine
and Psychiatry 28: 1539, 2004.C2004 Kluwer Academic Publishers.P1:
JLSpp1137-medi-481901 MEDI.cls February 16, 2004 15:316 ELIZABETH
MARIE COKERcamps (e.g., in Uganda), or make their own way in
already overburdened urbancenters such as
Cairo.Cairoisnowthehometoanestimated20,00030,000southernSudaneserefugees,
the majority not yet ofcially recognized as refugees by the
UnitedNations. As the war in their country drags on, making the
chances of a return totheir homeland unlikely at best, their only
hope is to eventually join the ranks ofthose who have been
resettled to the West, most notably the United States, Canada,or
Australia. Like any developing country, Egypt struggles to provide
sufcientsocial services for its own people, and the recent inux of
refugees has proven tobe more than the economy can comfortably
handle. Southern Sudanese refugeesin Cairo are truly outsiders in
this environment; their different religion, skin color,customs, and
language all serve to cement their outsider status. They are
unableto work legally, nd affordable housing, or obtain a decent
education for their chil-dren, regardless of their ofcial refugee
status. When Egypt ratied the 1951 UNconvention, it included many
reservations to the rights of the refugees it hosted, in-cluding
placing limits on the right to work and the right to access public
education.1As a result, Egypt has, de facto, become a country of
transit with most refugeesliving in hope of eventually being
relocated to a third country. Such opportunitiesare limited, very
slow to materialize, and depend on being granted mandate statusby
the United Nations High Commisioner for Refugees (UNHCR).
Nevertheless,Cairo has developed a reputation, deserved or not, as
a gateway to relocationto the West, possibly due to the difculty of
obtaining legal, long-term residence,and the active presence of the
UNHCR. Consequently, thousands of individualsand families struggle
to survive on little or no formal assistance, employed in
theinformal sector, with literally thousands more arriving every
month. In short, theseindividuals and families exist in limbo
socially, economically, and culturally.The social, physical, and
mental challenges of adapting to forced migration havebeen
well-documented elsewhere, and include the collapse of systems of
socialsupport, socioeconomic marginalization, poor physical health,
malnutrition and/orstarvation,
andpsychologicalsymptomsanddisorders(Jablenskyetal. 1992).Cultural
coping systems, mediated through a shared language, history, dress,
andritual practices, must either be adapted to handle the
exigencies of a completely newand unknown situation, or be stripped
away entirely (Muecke 1995). Refugees are,as Victor Turner put it,
transitional beings, caught in between the classicatorysystems that
dene societies and create the link between self, place, history,
andfuture (Turner 1967). The body, as the existential ground of
culture (Csordas1994), is the terrain on which liminality is worked
through and new classicationsare created, as cultural practices,
and even language itself, become insufcient todene self and
community.The present paper focuses on the ways in which refugee
trauma and dislocationare experienced and expressed through
descriptions, narratives, and metaphors ofP1: JLSpp1137-medi-481901
MEDI.cls February 16, 2004 15:3TRAVELING PAINS 17illness. The focus
is on illness talk as represented in the ways in which
refugeesdescribetheirillnesses,
andalsoonbodytalk,orthemetaphoricalrolethatbody and illness play in
the stories Sudanese refugees tell in order to articulatetheir
sense of loss and disruption in the social and economic as well as
physicaland psychological domains. Specically, following Bourdieu
(1977, 1984), ratherthan viewing the body as a mere source of
symbols and metaphor, body awareness,in the narratives presented
here, can be viewed as the locus of social practice,pertaining to
the individuals experience of the social world.The southern
Sudanese refugees who participated in the study told stories
ofphysical and social suffering that simultaneously expressed
mourning for a lostcultural and physical normalcy, moral rage at
their present circumstances, andleft at least a window for some
unknown, reconstituted future (Becker 1997). Theunique contribution
of refugee stories to the literature on embodied narratives
ofillness is just this: Having no ready-made cultural script for
their experiences,they must remake their stories as they go,
telling of illnesses and social breakdownsfor
whichordinarymetaphors are profoundlyunsuited. Inillness, the
bodybecomesa cultural terrain that must be relearned (Becker 1997).
In the refugee experience,the future, present, and even the past
become the unknown terrain that must berelearned. Cultural
narratives and scripts must be recreated from chaos, a chaosthat is
rst and foremost experienced on the bodies of individual actors.
The wayinwhichthebodyisexperienced,
thebodytalkthatisevokedinnarrative,naturally reects the culture of
origin; refugees are not, as Lisa Malkki remindsus, acultural
tabularasaonwhichanythingcanbeinscribed(Malkki 1995).However, the
reordering of culture and community after complete disruption
mustbegin with the reordering of the body, a process that begins
with a recognition ofthe disruption-as-illness.Sickness, argue
Scheper-Hughes and Lock, is not just an isolated event
orunfortunate brush with nature (1987: 31). Rather, it is a way of
speaking as anindividual, a culture, and a society all in one.
Social and cultural attitudes andstruggles are played out in the
terrain of the individual body. The individual bodyand its
sicknesses are not so much representations of the larger
environment as avital and inseparable part of it. Likewise, in the
present study, the extreme cultural,social, andgeographical
fragmentationexperiencedbysouthernSudanese refugeesin Cairo were
experienced as part and parcel of bodily ills and physical pains.
Whenthe self is broken apart, it hurts, and pain is the ultimate
embodied metaphor. It iseverywhere, and nowhere at the same time.
It is found in the heart, the stomach, thehead, the legs, but
particularly, in these narratives, in the self, or nafs in Arabic
(aterm which refers loosely to ones self or psyche). The self,
identity, and body aretruly one, and pain was expressed by the
participating informants at all of theselevels literally
simultaneously. What follows is an attempt to give certain
examplesof howthis played out in the discourse of my informants,
but in the space providedP1: JLSpp1137-medi-481901 MEDI.cls
February 16, 2004 15:318 ELIZABETH MARIE COKERI can only begin to
do justice to the incredible depth and multilayered texture ofthe
refugee self as experienced by those involved.BACKGROUND AND
METHODOLOGYAll of the subjects in the present study were refugees
from the southern Sudan,an area consisting of up to 100 culturally
and linguistically diverse ethnic groups,(Deng 1972; Seligman and
Seligman 1965). I intentionally chose not to focus onone particular
ethnic group because the goal was to understand the commonalitiesin
experience for those identifying as southern Sudanese. This said,
it must be em-phasized that there was no natural southern Sudanese
collective identity priorto the NorthSouth civil wars that have
ravaged the region on and off since 1955(Johnson 2003). Although
ethnic loyalities and mutual hostilities between south-ern Sudanese
groups still exist to some extent (Deng 1972), the shared threat
ofnorthern cultural and religious domination has brought a newlevel
of cohesivenessand identication as southern Sudanese in recent
years. This is particularly trueamong refugees in Cairo, all of
whomface common external threats based on theirskin color,
religion, and precarious political status. In fact, despite
differences incultures of origin, much of the discourse focused on
we the southern Sudanese,suggesting that the refugees themselves
had learned to experience their identityas members of a common
regional group facing very similar refugee histories andcurrent
problems.The results presented here are part of a larger study
examining the experiences ofsouthern Sudanese refugees in Cairo,
their interactions with health-care providers,and their illness
presentations. The data were collected over a period of one
yearwith southern Sudanese refugees from various ethnic groups in
the Cairo area.The data consisted of the following: 61 open-ended,
semistructured interviewswith refugees presenting to a church-run
health clinic specically for individualswho had not yet been
granted ofcial refugee status by the UNHCR, and assuch had no
recourse to UN-sponsored health care; 16 in-depth interviews
withSudanese men and women fromthe community at large, who may or
may not havebeen granted refugee status; interviews with midwives
and administrators at thechurch clinic mentioned above; a
question-and-answer session with 45
pregnantSudaneserefugeesattendingahealtheducationclassatthechurchsantenatalclinic;
home visits with Sudanese families; visits and staff interviews at
Caritas(a UNHCR-supported health clinic for ofcially-recognized
refugees in the Cairoarea) and interviews with staff members at a
Cairo-based center for victims oftorture and domestic violence. All
data were recorded through written notes. Inaddition, six focus
groups were conducted with between six and eight participants,two
at the home of a research assistant working on this project and
four at thepreviously mentioned church clinic. These focus groups
were tape-recorded andP1: JLSpp1137-medi-481901 MEDI.cls February
16, 2004 15:3TRAVELING PAINS 19the data were translated and
transcribed. Most of the interviews with the southernSudanese were
carried out in Juba Arabic (an Arabic dialect spoken in
southernSudan), by a trained native research assistant, with the
author in attendance. As thepresent focus is on illness
experiences, most of the data used in this study camefrom the
individual interviews with clinic attendees, as well as the focus
groups,most of whom, it turned out, had had direct experience with
illness and healthcareseeking in Cairo.ILLNESS EXPERIENCE AND
ILLNESS TALKThe idea for the present paper stemmed from a series of
conversations with
theBritishmedicaldirectoroftheAnglicanchurch-runclinicwherethemajorityof
the data presented here were collected. He was concerned with the
prepon-derance of what he termed somatization among the many
recently arrived Su-danese refugees presenting to the health
clinic. In other words, he and his staffperceived that there were
many physical complaints in the absence of readily ob-servable
organic dysfunction. Of course, many refugees did suffer from
seriousillnesses such as tuberculosis, and the clinic was well
equipped to treat these ail-ments and/or refer patients to outside
hospitals and clinics. Malnutrition was alsoa commonly recognized
problem, and food programs were in place to supple-ment the
nutritional needs of pregnant/nursing mothers and children, in
particular.However, there were many more who complained of
inexplicable pains and sick-nesses that created frustration on the
part of the medical staff and refugee clientsalike. This medical
directors dissatisfaction with the limits of medical terms suchas
somatization to explain the phenomenon that he was seeing was
obvious;these labels did little to help him understand the
realities and meaning of
whathewasobserving,nordidtheyprovidesatisfactorycluestohowtherefugeescould
best be helped. The conceptual paucity of the term somatization
illus-trates the dualistic nature of western medical reasoning, as
well as the westerncultural tendency to intellectualize distress
(Becker 1997). Research on the mean-ing of somatization in this
particular context and for these particular
refugeeswasthuspartofaninitiativetoimprovetheabilityoftheclinictomeettheirneeds.Therefore,
the present analysis will begin with illness stories as recounted
bypeople attending the clinic for treatment. Whether or not their
objective symptomsconstituted a disease for a given individual was
not conrmed for reasons ofprivacy. These stories, whether they
reect a measurable disease or not, providea glimpse into the ways
in which illness becomes an avenue for discourse aboutthe refugee
trajectory. As will be shown, the refugees in the present study
remem-bered their illness stories with direct reference to their
ight experience, and viceversa.P1: JLSpp1137-medi-481901 MEDI.cls
February 16, 2004 15:320 ELIZABETH MARIE COKERIn his interviews
with chronic pain patients, Kugelmann (1997) determined thatpain,
far from being an isolated phenomenon in the lives of his
respondents, waswoven into narratives reecting, among other things,
how people make sense oftheir suffering and their worlds. In his
subjects stories, straightforward explana-tions of physical (i.e.,
objective) pain inevitably gave way to narratives of socialroles,
identity, economics, etc., that contradicted the imposed dualism
suggestedby the dominant discourse of the medical clinic. The
stories told by the healthclinic clients in the present study
showed a very similar pattern. The respondentsbegan by stating
their actual symptoms, but the physical aspect of the symptomswas
very quickly immersed in a web of signicance that addressed the
realities oftheir traumatic and ongoing experiences as
refugees.There were no clear-cut illness or symptom patterns for
the clinic respondents.In other words, there seemed to be no
typical refugee syndrome other than di-verse somatic complaints.
The most common symptoms were stomach aches ordigestive complaints,
chest pain, cough, general body pain, or muscle aches,
heartcomplaints (heart pain), and complaints of burning sensations
at various pointson the body, as well as unspecied itching (a very
common complaint, involvingvirtually any part of the body). Other
complaints mentioned included lafa rasi (asort of dizziness or
tendency to fall down), painful legs, malaria, insomnia/poorsleep,
stiff body, toothaches, and blisters or ulcers anywhere on the
body. Althougha few respondents appeared to have clear-cut, acute
symptoms suggestive of any-thing from a common cold to
tuberculosis, in most cases the complaints weremultiple and
diverse, interspersed with possible causes and contributing
factors.Traveling painWhat was remarkable about the illness stories
told by clinic attendees and othersin the study was the way in
which the stories were contextualized, symbolizingmovement, ight,
andrestlessness, atonceimmediateandpartoftherefugeehistory. If
illness and disease are inseparable from the structure of society
(Good1977), then so are they inseparable fromthe disruptions of
society. Illnesses reectnetworks of social meaning and interaction
as they have become changed and evenwarped by trauma and ight (Good
1977).One of the most consistent aspects of the respondents
narratives was their ten-dency to voice their complaints in time
frames related to the refugees experience(sometimes spanning more
than a decade). Their pain was historicized, movingthrough the body
and stopping at various locations, only to move on to anotherspot
later on, sometimes years later. Respondents would describe pain as
literallytraveling through them, stopping from place to place and
then continuing onelsewhere. To understand this traveling pain, I
prefer to avoid simplistic analo-gies or oneone symbolic
relationships between, for example, moving pain andmoving people.
Rather, to quote Byron Good (1977: 48), The meaning of anP1:
JLSpp1137-medi-481901 MEDI.cls February 16, 2004 15:3TRAVELING
PAINS 21illness termis rather constituted by its linking together
in a potent image a complexof symbols, feelings, and stresses, thus
being deeply integrated into the structureof a community and
culture.It was very common for the presenting complaints to be
narrated in terms ofalong, complexhistoryofsymptomsandremission,
withcausalexplanationswoven into the narratives. Very few of the
presenting complaints were actuallyacute and noncontextual. No
matter what the illness, the clients talked of historieswith that
or similar disorders, and readily articulated the conditions under
whichthesymptomsusuallyappear. Inotherwords,
thenotionofthetravelingpainmirrors the experience of moving from
place to place, but it also carries with it astatement of the
strength or ability of the individual body to withstand the
onslaughtof external disruptions. These disruptions come from all
sides, from all directions.Ifit isnot onething,
itssomethingelsewastheunspokenmessageintherefugees illness stories,
reminiscent of Arthur Franks (1995) chaos narrative, inwhich
stories or narratives are devoid of the solace of restitution or a
foreseeablehappy ending. The pain doesnt end because there is no
end in sight for theserefugees. As Frank puts it, the body telling
chaos stories denes itself as beingswept along, without control, by
lifes fundamental contingency (Frank 1995:102). The traveling pain
articulated in concert with the onslaught and immediacyof
irresolveable life problems suggests an embodiment of just the sort
of chaosnarrative that Frank described. Consider the following
excerpt by a 45-year-oldDinka woman who had been in Cairo for two
months:Imsufferingfromrapidheartbeat(darabatlgelib).
Ialsohaveacough. Theheartproblem started in Tonj [a town in
southern Sudan]. I think it is caused by the cold weatherhere. When
it was cold in Tonj, my illness worsened and when it was warm I
felt better.When it started in Tonj, I was given some tablets and
capsules. I think the illness startedin Tonj because after the
death of my husband and two children I mourned for three years.I
could not eat or drink well. It started by a mere cold and or u and
then a sore
throat.ItcontinueddownmyheartanduptodateImsufferingofit.
Weseparatedwithmyonly child during the war in Tonj. I ran to
Khartoum and he remained in Tonj. I thinktoo much about my family
and my fate. The rst time I came here I got referred to ***hospital
to take an ultra-sound. Today I brought the results of the medical
ultra-sound. Ido not know what the doctors will do to me but I
believe that I will be given the righttreatment. My refugee
situation affects me because Im lonely and in a foreign land. I
thinktoo much about the loss of my family and about my only son
with whom we got separatedduring the war. When I was in Khartoum I
wrote to the pastor about the situation and hegave me money to come
here for further treatment and for a change. Nobody helps meand
life is hard here. I do not have anyone who helps, no husband, no
children, no jobyet. Life is hard. In fact, since my husband and
two children were killed I have remainedunhealthy until now. I do
not have friends to talk to about my problems. I do not want totalk
about my misfortune because the more I talk about my problems the
more I suffer.I have been badly offended, I have no child now, no
husband, not anyone responsible forme. In God I only entrust my
life, and the best place for me would be a convent, where Iwould
stay quietly with the sisters. In fact, my heart does not allow me
to talk too much.Also, I believe that talking to people about my
problems gives me more psychologicaldiscomfort.P1:
JLSpp1137-medi-481901 MEDI.cls February 16, 2004 15:322 ELIZABETH
MARIE COKERThis woman articulated the ultimate chaos narrative.
Nothing is helping, nothinghas helped, and nothing will help, and
the only solution is withdrawal. Her sickbody and moving pain are
simply another aspect of the chaotic conditions of herlife,
ultimately inseparable from her other life experiences. As she
says, she hasbeen badly offended, and this offense is far from
over. As her story suggests,current illness episodes were
experienced as part of an ongoing process of healthor ill-health
that waxes and wanes according to existential factors ranging
fromtorture to the death of relatives to poor food to hard living
conditions.The way in which illness was contextualized and
historicized as part and parcelof an ongoing process directly or
indirectly tied in with experiences of forcedmigration was one of
most consistent aspects of the narratives. As the
womanquotedabovetestied,illnessesoftenhadtheirorigininSudan,howevertheywere
reawakened and even modied with the transition to Cairo. In the
sectionsthat follow, the theme of traveling pain will come up again
and again, as causesand symptoms are cast in a discourse of
disruption and relocation. In sum, thepicture painted by the
respondents was that of physical illness as an integral
partofadisruptedandilllifeexperience,
notasanisolatedvariableenteringandtemporarily inhabiting the
body.What makes it worseRather than speak of causal explanations of
symptoms or illnesses, I prefer toborrow from Kleinmans (1980)
notion of explanatory models (EMs), whichemphasize not only
etiological explanations of illness but also the personal andsocial
meanings of the illness experience. In the refugees narratives,
explanatorymodels for illness doubled as explanatory models and/or
metaphorical examples ofextreme social and personal disruption and
pain. In fact, there were rarely single,isolated origins for any
illness event. Illnesses were not, as mentioned, even spokenof as
events but as processes, as an embodied thread in a story of pain
(Kleinman1989). Therefore, explanations were multiple, as life
problems and worries
weremultiple.Thetraumaofphysicalrelocationisanintegralpartofanyrefugeesstory.The
very denition of refugee is of one who has been forcibly uprooted,
andthe ensuing disruption of cultural identity reects the
territorialized nature of theculture of origin (Malkki 1995). In
the present stories, the pain of physical dis-location came out in
detailed accounts of the pathological nature of the
Egyptianenvironment, and the contrasting idealization of the
health-giving qualities ofsouthern Sudan. The cold winters in Cairo
(compared to Sudan), dust, pollution,and the physical connement of
a such a large, crowded city were all frequentlygiven as reasons
for illnesses. In addition, the impure food was a very
commoncomplaint, not only among the clinic attendees but among the
focus group respon-dents as well. Highlighting the dramatic
contrast between there and here, theP1: JLSpp1137-medi-481901
MEDI.cls February 16, 2004 15:3TRAVELING PAINS 23refugees lamented
the loss of the clean and pure foods that they could justpick off
the tree in southern Sudan. This abundance was spoken of in
concertwith the purity of Sudan and the food there, and associated
contamination (bychemicals and whatnot) of food in Egypt. For
example, a man who had gone tothe clinic because of severe skin
itching only to be told that he had no diseasewent on to say, What
I came to discover was that the foods [in Egypt] are full
ofchemicals. In the Sudan we live on natural foods that contain no
chemicals. Allthese chemicals have an effect on our
bodies.Theassociationbetweenbeingarefugeeandtakinginimpurefoodwentbeyond
explanations of physical quality or the simple association of
chemicalswithsickness.Tounderstandtherespondentsemphasisontheillness-causingnature
of food, one must consider the meanings of food as linked to
culture andplace. Complaints of chemically-tainted food and water
were underscored by theloss of place, of home, that respondents
experienced when leaving Sudan, andthe subsequent loss of relatives
and social stability. Said one of the focus groupparticipants, in
response to a discussion about what had been lost in the move
fromSudan to Cairo:I have come here to this [Egypt] froma very far
place. Now, with the absence of my relatives,how can I be happy?
How can ones mood be okay? Now, even if I eat the food, I can
eatuntil I am satised but at the end I will begin to think: where
is this brother/sister of mineliving now? And where are the rest?
In this way, the food that you have eaten will not workin your
body.This excerpt suggests the complex role that time and place
play in narrativesand experiences of illness, as well as a
hypothetical mediating factor between thetraveling pain and the
trauma of dislocation. This excerpt also refutes the notionthat
these refugees were somatizing their distress in the sense of being
unable orunwilling to acknowledge the hidden psychological factors
behind it. In fact,the refugees did verbalize their existential and
social traumas, and their bodilypains were an integral part of this
discourse. When one is a refugee in a strangeland and separated
from relatives, the body will not work properly. Even foodwill not
work in the body if ones social environment and nafs (psychology)
arenot healthy. In fact the vast majority of the respondents,
whether clinic attendeesor not, spent more time discussing their
illnesses in social or existential termsthan in physical terms. Of
the 61 clinic attendees interviewed, only 11 did notspontaneously
mention emotional or social factors in their elaboration of
theirillness symptoms. These explanations were woven seamlessly in
with other causalexplanations, and were usually one of several
possible causes.Thinking too much was a very common exacerbating
factor in illness, evenif it was not seen to have directly caused
the illness. Typically, the refugees statedthat they thought too
much about their very hard conditions in exile, or their
pastsecurity problems in Sudan, which fueled their illnesses in one
way or another.P1: JLSpp1137-medi-481901 MEDI.cls February 16, 2004
15:324 ELIZABETH MARIE COKERMany others spoke about their nancial
situations and lack of job opportunities,again,
causingthemtothinkalot about what washappeningtothem. Thefollowing
excerpt illustrates the way in which thinking allows the past to
affectthe body in the present:I sometimes suffer from headache to
the extent that I cannot raise my eyes like this [raiseseyes to
ceiling]. My eyes seem as if they want to drop down. But the only
thing is that Iknow that it is only nafsiyat [psychological
problems] due to too much thinking. The proofis that if you
sometimes sit like this, something will just cross in your eyes and
then youwill begin to think of the way that you were leading your
life before, in the Sudan.As the preceding excerpts suggest, the
respondents had denite notions of howtheir nafs interacted with
their bodies to produce illness. Some version of thistheme was
elaborated by virtually all the respondents in the focus groups and
theindividual interviews when the subjects came up. Anger, guilt,
too much think-ing, and loneliness or separation from relatives
were seen as integral aspects ofillness, or indeed, as sicknesses
unto themselves. This underlines the differencebetween biomedical
models of illness, which see disease as impersonal, andmany
indigenous models that incorporate moral dimensions of power,
weakness,and resistance (Harkin 1994; Swartz 1997). Thinking too
much was a directresult of current nancial, social, and political
insecurity, and an integral part of alarger process of loss and
movement. This implicated the body-self as a part of alarger whole
that was disrupted or diseased, a factor that invariably caused
illnessand distress through the persons loss of social and cultural
mooring (Comaroff1983).Psychological distress was seen as leading
to physical symptoms, but it wasalso seen as a problem in and of
itself. My major problem is psychological illnessbecause of
worryandanxietyfor myfuture saidone manwhocame incomplainingof
back, neck, and ear pain. I keep wondering for how long I will
remain in sucha situation of poor nutrition, shelter, and care.
There is nothing that comforts onespsychological upset. Another man
named anger as a direct cause of his highblood pressure and
constant headache. When asked howand why it began, he said,I think
it began because of anger. Im often angry. The economic and
political problemsinSudanandparticularlyinmyregion, Darfur,
mademenervous. Worst ofall Iwassurrounded by many social problems
at home with my wife. When I talk too much I havesevere headaches,
so when it starts, I abstain fromtalking. I cannot establish the
usual courseof the illness but at one time I have a severe headache
and sometimes it is not there. I thinkit depends on my
emotions.Here, the body remembers the ongoing trauma and pain
having roots in theight experience. According to Casey (1987), body
memory risks the fragmenta-tion of the lived body. In this mans
narrative, we see not only the fragmentationof the lived body but
articulation of the fragmentation of the social and
politicalbodythroughembodiedexperience.
HeisliterallycutofffromsocialcontactP1: JLSpp1137-medi-481901
MEDI.cls February 16, 2004 15:3TRAVELING PAINS 25through his bodys
inability to articulate; to express is to suffer bodily pain.
Inter-estingly, this mans interpretation of the link between his
emotions and his bodilysymptoms, so frequently expressed by the
respondents, posits a mind/body con-nection opposite to that
expressed by the American respondents in Kugelmanns(1997) study of
chronic pain patients. While these Americans saw physical painas
causing emotional problems, the Sudanese almost invariably saw
social andemotional pain as leading to physical pain, an
interpretation that would be threat-ening to many North American
chronic pain patients, imbued as they are with strictmind/body
dichotomies. The man quoted in the preceding paragraph is
literallyliving his anguish through his body, and what is more, he
recognizes this clearly.Anger is pain, pain is embodied. Social
interaction, when disrupted, is embodiedthrough physical pain.In
addition to overwrought emotions, loneliness and lack of social
support werecommonly mentioned as contributing factors to illness.
One of the primary lossesfor the refugees was the loss of the
extended family as a means of support, a situa-tion that is common
to refugees throughout the world (see Gold 1989; McSpaddenand
Moussa 1993; Williams 1993). The family, for the southern Sudanese,
consistsof an elaborate network of kin who are always ready and
virtually obligated to offertheir help to family members. In the
Cairo context, not only are family membersoften not present, but if
they are, they may be unable to offer help. This placesenormous
stress on individuals on both sides. Respondents frequently
lamentedthe fact that they were unable to support additional family
members continuallyarriving from Sudan. Not only were they
penniless, but their landlords frowned ontoo many people living in
one at, and this was often a cause for eviction. Thiswas an
enormous source of shame to those unable to provide the requisite
supportto their relatives, and a source of pain to those who had
come to Cairo expectingsupport from relatives and were rejected.
For those who were virtually alone, withno extended family members
nearby, this alone was enough to cause or exacer-bate sickness. In
fact, several respondents assured me that this family breakdownwas
a sickness in and of itself, and was bound to show itself in the
body of theindividual.The narratives wove concerns about lack of
social support with multiple othercausative factors. The sense of
loneliness as contributing to illness was common inthe narratives,
suggesting that the sense of family and community breakdown wasvery
strong. As one man put it, My situation as a refugee has affected
my illnessin that I have no needed support from my close relatives,
they are all in Sudan.To sum up notions of etiology for the
respondents in this study, physical, so-cial, and psychological
themes were woven together in the explanatory
aspectsofthesenarratives. Disruptions, deprivations,
andoverload(sensory, physical,food-related) all contribute to
general ill-health. However, causation cannot beunderstood without
reference to the specic ontological world of the SudaneseP1:
JLSpp1137-medi-481901 MEDI.cls February 16, 2004 15:326 ELIZABETH
MARIE COKERrefugees. The self is not contained within the
boundaries of the physical body, butextends to the social world and
its important relationships. Thus, social sicknessesare spoken of
as if they are physical sicknesses, and in fact, are often
experiencedas such. The physical body is sick if the social self is
not intact. Likewise, therefugees had quite elaborate notions of
the relationship between the mind (emo-tions) and the body.
Basically, the two conceptual entities of nafs and the physicalbody
were not spoken of as separate. It was taken for granted that
emotional paincould cause physical pain; it was for this reason
that the doctors pills sometimesdid not work.In this sense, illness
talk revealed the ways in which being a refugee impacted theself
and rendered it sick on various levels. At the same time, illness
talk
revealedimportantareasofresistancetothetotalannihilationoftheself-as-refugeeinEgypt.
The simple fact of being in someone elses land, losing the social
supportand the identity grounding and the food, air, and space of
southern Sudan was, asso many said, a sickness in itself. By
identifying it as such, the refugees wereable to articulate their
embodied pains, and identify what, exactly, was ailing them.This
was more than the medical profession was able to do. The following
excerptby a female focus group respondent poignantly expresses the
futility of medicaltreatment when the social and geographical basis
of identity has been lost:There in the Sudan if you are sick, you
will tell your mother this. Your brothers and sisterswill come. You
will see your relatives beside you and as a result you will be a
bit better.When it comes to a situation where you dont have money,
whether for medicines or foranything [i.e., food] you will nd a
number of people ready to help you. Your brother, yourcousin, or
your niece or any other relative of your father or mother will be
there to helpyou. But when we compare with the situation in this
country, who is there to help you?Nobody. Even if you get a
medicine to swallow in order to make you feel better, you
cannot[feel better] because of nafsiyat (psychological problems).
You will nd that your sicknesscannot be treated because of the
percentage of thoughts. Now, if I was in the Sudan, whenI am sick
like this, Ah, my sister would come to see me. Oh? Who is that? My
mother,she has come to see me. And who is that? A relative of mine.
And so forth. There is agreat difference here.As this suggests, the
relationship (if, indeed, one can talk about a
relation-shipbetweenthingsthat arenot
separatetobeginwith)betweenthepoliti-cal, social,
andphysicalbodyisalsoaboutcontrol, andresistance. Iftheselfis
bounded by social and community ties rather than individual skins,
then theconnectionbetweenpolitical powerlessness, social
disintegration, andphysi-cal illness becomes clear (Douglas 1966,
1973). The powerlessness of modernmedicine to cure illnesses rooted
in social distintegration and politically-basedtrauma suggests
resistance to modern medicines hegemonic claims to the body-self
(Foucault 1975). Medicine as a concept is neither complete nor
effective un-less it addresses the social as well as physical
transformations of bodies (see Green1996).P1: JLSpp1137-medi-481901
MEDI.cls February 16, 2004 15:3TRAVELING PAINS 27EMBODIED
METAPHORSAs demonstrated in the previous sections, illnesses were
historicized and givenmeaning through the constant juxtaposition of
time, place, and movement in nar-rative. At the same time,
experiences of suffering, exile, and marginalization
werearticulated through the consistent use of common themes and
metaphors. Muchrecent anthropological theorizing has centered on
the use of metaphoric languageto express embodied experiences of
everything from embarrassment and anxietyto identity loss and
political resistance (Good 1977; Holland and Kipnis 1994;Jenkins
1991; Kirmayer 1988; Lock 1990; Low 1994; Ots 1990). The
metaphorsused by the subjects in the present study reected
important themes in the con-struction of identity in southern
Sudan, however, they also served to reestablishorder out of chaos
and bridge the gap between the idealized past and the
disruptedpresent (Becker 1997).Low (1994) describes metaphoric
language as strategic, allowing for the ex-pression of otherwise
inexpressible suffering, but also as creative and
generative,supposing the possibility of change. Thought results
from embodied experienceand is creative, using metaphor, metonymy
and mental imagery based on bodilyexperience. Thus, metaphor is
grounded in the body and emerges from it, pro-ducing categories of
thought and experience (Low 1994: 143). For example, themetaphor of
nervios commonly used by Central American refugees has been
putforth as an example of an embodied metaphor of the self and its
relation to socialsystems, in particular the breakdown of these
systems (Jenkins 1991; Low 1994).Nervios, in other words,
represents the loss of the self as it is socially and
culturallydened.Jenkins and Valiente (1994) concluded that, among
El Salvadoran women pre-senting at a psychiatric clinic in the Los
Angeles area, the metaphoric use of elcalor (heat) served as a
narrative vehicle through which terror and political ightwere
expressed. El calor was an embodied form of emotional engagement
withthe reality of the refugee situation; a somatic mode of
attention (Csordas 1993).In other words, the metaphors used by the
southern Sudanese refugees to describetheir situations and their
pain were not stand-ins for things (i.e., gender orrace or loss),
but rather ways to describe the ongoing, dynamic embodimentof
process and experience, self and other (Goslinga-Roy 2000).United
heartsAn analysis of the symptom presentations of the refugees
attending the healthclinic did not reveal any syndrome or common
metaphor as clear-cut as nerviosor el calor. However, a comparison
of some of the more typical loci of illnesswith the body talk
revealed in the focus groups and in-depth interviews suggestsways
of talking through and about the body that have much in common with
theP1: JLSpp1137-medi-481901 MEDI.cls February 16, 2004 15:328
ELIZABETH MARIE COKERtypes of metaphors presented by Jenkins and
others. To begin with, the heart hasan important place in the
embodied experience of illness for the Sudanese. For theclinic
respondents, the heart was often an end place in the traveling of
the illnessthrough the body. In all, ten clinic attendees
specically mentioned pain in theheart in addition to other
ailments. In most of the clinic narratives, the heart wasa point in
which pain rested, often originating in another area of the body; a
locusof illness but not a cause or a focal point. This was reected
in the way the heartwas used to discuss the refugee experience for
the respondents in general.The heart is the locus of social and
emotional pain, wounds, and sicknessesfor the southern Sudanese.
When people discussed loneliness, fear, or the poortreatment they
received at the hands the Egyptians, the heart was where this
wasfelt, rst and foremost. We have wounds in our hearts said one
woman, referringto the loss of her country. Said another woman: We
have no freedom, we areinsulted on the streets, we could be
arrested at any time and deported back to ourcountry. All this adds
to the pain that is already in our hearts. As Byron Goodfound in
his study of illness semantics in Iran (Good 1977), the heart is an
importantembodied symbol of emotional distress, and, at the same
time, its use is reectiveof certain types of emotional distress and
not others. Generally, heart pain wasmentioned specically in
relation to loss of identity and culture. When peoplediscussed the
loss of their children, for example, through lack of education
andantisocial habits, they did so through the metaphor of the
wounded heart. Whendiscussing their inability to move freely and
mingle with other members of theirsociety, the fear was placed in
the heart. When wives were too busy to attend totheir husbands
needs, this too, was due to an unclean
heart.Havingabadoranuncleanhearthadrepercussionsbeyondthesimpleexperience
of loss and heartache. The southern Sudanese accused themselves
ofhaving bad hearts due to, for example, interethnic discord which
caused tensionswithin the refugee community. Said one
respondent,Our people have bad hearts towards one another and if
you today go to the UN and yourheart is not clean, God will not
grant you refugee status. If truly you have love in your heart,God
will grant you acceptance from the UN. If you have in your heart
bad things, such asthis person is like this and this person is like
that; this is something that we Sudanesehave as a habit. What is
this?In other words, the heart was clearly the place where unity of
community andidentity were located. Tensions, breakages,
fragmentation in unity between
groupmembersorfamiliesliterallydirtiedtheheart andmadeit
unclean.Ontheother hand, strength, stability, and devotion to the
family and community werelocated in the heart. At this particular
moment, said one woman, we
shouldallbewithoneheart,becauseweareinexile.ThephraseAtthisparticularmoment
underlines the role of the heart in symbolizing community and
unity,and the meaning of the common placement of heart pain at the
end of the painP1: JLSpp1137-medi-481901 MEDI.cls February 16, 2004
15:3TRAVELING PAINS 29trajectory in the narratives. Consider the
following excerpt by a 39-year-old Bariwoman.I dont know what my
illness is. It is an illness that affected me some years ago. I
dontremember what year it started but I think it began around ve
years ago. It started in mylegs. I have a burning pain in my legs
and after the burning pain, they become cold like coldwater. My
legs developed itching and I scratched them. But recently it has
moved to affectmy hands and heart too. I feel as if there is a re
burning in my hands and heart. The painhas now moved to my stomach
as well.This woman had been in Cairo only a short while at the time
of this
interview,havingarrivedfromKhartoumacoupleofmonthsprior.Hernarrativeclearlyillustrates
the theme of traveling pain, and also the association of the
heartwith her recent move to Cairo. It is in Cairo, the latest stop
in their journey, thatcommunity and cultural unity are most under
threat. As urban refugees, theserefugees must assimilate multiple,
shifting, and sometimes conicting identitiesjust to survive, a very
different experience from that of camp refugees (Malkki1995).
Hence, the heart, an important symbol of community, relation, and
unity,was transformed into a potent symbol of distress and a
frequent focus of illnesscomplaints in an environment where unity
and identity were breaking down.Human bloodIf the heart was the
locus of unity and community (and the breakdown thereof), theblood
was the metaphor used to express the idea of humanness. The
refugeesoften described being treated as nonhuman by the people
they were forced to dealwith in Egypt, whether the institutions
designated to help them or the Egyptiansthemselves. Not being human
was how they described their sense of not beingrecognized as
functioning, intelligent people. A sense of humanity was what
theyhad had in abundance in the southern Sudan, and what they had
lost during theirrefugee trajectories. Being human was described in
many ways, but it was oftenexpressed through the metaphor of blood.
Blood relationships were the strongest,and these were breaking
down. Blood (or the recognition of one as having blood)was the
recognition of one as a fellowperson. We the southern Sudanese said
oneman, God gave us good blood and the foods we eat. However, their
blood wasnot recognized by those who would not recognize them as
humans. One womancomplained of the arbitrary way in which she was
treated by the UNHCR ofceresponsible for granting the coveted
refugee status to asylum seekers:If they [UNHCR] want to accept you
they will look at your personality, or your face. If yourblood goes
with them, then they will pass you and resettle you. But if your
blood does notgo with them completely they will reject you or even
close your le.Recognizing blood, in other words, is the act of
recognizing one as human,or, in this case, recognizing one as a
legitimate refugee and therefore worthy ofP1: JLSpp1137-medi-481901
MEDI.cls February 16, 2004 15:330 ELIZABETH MARIE COKERofcial
recognition and its accompanying benets. Not recognizing one as
humanmeans not acknowledging ones human blood, which is akin to
being nonhuman,or an animal. Said one man, Here, you are overworked
like a donkey, as if yourbody has no blood.While generally not used
as a symptom of illness per se, blood neverthelessis a common
symbol for the collective sense of existential loss that the
southernSudaneseexperienceasurbanrefugeesinCairo. Asametaphor,
bloodhaspowerful cultural and symbolic connotations. In many
different cultures, acrosstime and place (including Egypt and many
parts of Sub-Saharan Africa), the notionof blood is a potent symbol
of the self, the soul, and the relationship betweenrelated people
or close associates (Du Boulay 1984; Frazer 1890). Arguably, itis
the very essence of symbolic humanity, as evidenced by the huge
number ofmetaphors relating to blood in many different languages.
In English, a
cold-bloodedpersonisonewithnoconscienceorthoughtforothers;inEgypt,
alight-blooded person (damma khaif ) is one with a carefree spirit,
etc. Like theheart, blood can symbolize personal human
characteristics, but unlike the heartit is also the symbolic locus
of actual kinship or relatedness (there is no a priorireason why
one could be related by blood but not by heart, liver, etc.). In
thesouthern Sudan, as in Egypt, the importance of blood ties is
paramount, andindeed, recognition of one as a person implies
recognition of ones bloodline.Given this, the signicance of the
above excerpt becomes clear. The perceivedtreatment that the
southern Sudanese receive at the hands of their Egyptian hostsis
that of complete nonrecognition of their personhood or humanity.
They are trulyliminal (Turner 1967) in the sense that they have no
place as people or as humansamong other humans as long as they are
outsiders by blood. As refugees and non-Muslims, they are denied a
place in the social fabric of Egyptian society, in thenetwork of
blood ties so important in this context. It is truly as if they
have noblood, as long as it goes unrecognized by the society in
which they are living.The silenced bodyYou all know there is a
proverb like this: If a person is living in kutura (danger), you
areactually on re inside the grass, the whole grass is burning.
What you are supposed to do isto get another re and burn the grass
around you so that you are left in a clear place. But forus, we ran
from re there in the Sudan and then we enter another re here in
Egypt. Nowthere is no freedom.Theabovestatement
byamalefocusgrouprespondent illustratesthenalmajor theme that
characterized the narratives in the present study, that of
physicalconstrictionandhelplessness. Freedom,
thismanseemedtobesaying,
meanshavingthepowertoghtrewithre,toeffectchangeintheenvironmentandclear
your ownspace.However, theabilitytoresist waslost withtheP1:
JLSpp1137-medi-481901 MEDI.cls February 16, 2004 15:3TRAVELING
PAINS 31move to Egypt. Themes of physical constriction or
restriction, being unable tomove, abounded in the narratives of all
the refugees, whether clinic attendeesor not. For the clinic
clients, restriction was often expressed as feelings of
beingpassive while the body was controlled by unknown forces. Said
a 24-year-oldPojulu woman, My body stiffens and my head, legs, and
hands are forced toturn backwards. It started suddenly when I was
preparing supper. I had a severepain after the incident and I found
a wound on my hand. Refugees in the presentstudy present themselves
as helpless, inert, literally unable to move. Their
literal,physical, embodied constriction represents their
helplessness and hopelessness.The narratives reect bodily
constriction on many levels: the pains associatedwith working in
the homes of others, the sicknesses caused directly by
physicalconstraint and lack of air to breath, the fantasies woven
around hopes vestedin dances, traditional ceremonies, escape from
Egypt. Physical constriction wasone of the most important
contributing factors to illness, and was directly relatedto the
physical and existential conditions associated with being a refugee
in Egypt.Constriction was the embodied loss of freedom and the
ability to practice onestraditional culture, and this was
emphasized over and over again. Said one woman:I will now
concentrate on how my body pains. Truly, in the Sudan it was okay.
Sudan ismy own country. I had freedom. I could leave our home and
move freely without anyoneinsulting me. I was free in my movement.
But now, what pains me a lot in my body is thathere you cannot work
or move freely.Refugees almost unanimouslycomplainedabout thelackof
freedomandphysical restrictions imposed on them because of their
marginal status as (usually)illegal residents in a foreign country.
As the above excerpt suggests, this was oftennarrated in terms of
restricted bodily movements. The respondents feared walkingin the
streets of Cairo because of the abuse they suffered there. They
stayed in theircrowded apartments, often not visiting relatives or
friends even if they had anybecause everyone was toobusy or
preoccupiedwithhis or her owntroubles. How-ever, the physical
constriction was also experienced as an active repression of
thephysical expression of their beliefs and culture. In the
southern Sudan, each ethnicgroup has its own dances and songs.
Rituals such as births, weddings, and funeralsare
celebratedthroughlarge gatherings, of whichdrummingandtraditional
dancingare an integral part. The refugees were acutely aware of
their inability to sing, danceor drum, andstatedover andover that
this was a crucial locus of their sense of loss ofcommunity and
identity. If they tried to practice traditional rituals or dances
in theirsmall, rented apartments, they risked being kicked out by
landlords who did not ac-cept either noise or large gatherings.
Even the church, which was a gathering placeinwhichthe refugees
felt safe, constrictedor restrictedtheir physical expressions
ofculture.P1: JLSpp1137-medi-481901 MEDI.cls February 16, 2004
15:332 ELIZABETH MARIE COKERInside the church there in Sudan we
could hit the drums, clap our hands and sing in a loudvoice. But
here we cannot do these things. If you sing aloud you will be told,
bera bera(lower your voice), we are inside the church. There in the
Sudan if you were going on theroad [traveling], you will travel
while singing. But here we do not have this. You only walklike a
dog that has reached someones house and bends its tail
downwards.Although physical constriction was linked to
psychological distress, it was alsocommonly associated with what
the refugees referred to as or rotuba (translatedloosely as
rheumatism), a disorder that could affect literally any part of the
body(even the heart) and which, they claimed, was not commonly
found in the southernSudan. Said one respondent,In the Sudan we
dont have rotuba. But here the lack of walking makes us affected
byrotuba. There we move about. If you dont run, you move. You may
walk long distances.But here, supposing you go out, you will nd
that after a short time you will begin to breathe,ah ah ah, and you
will feel as if your breathing needs to stop until you cannot
breatheanymore. Therefore, the rotuba has its effect on us because
of lack of physical exercise in ourbodies.As this excerpt suggests,
breath, or loss thereof, was often spoken of in
con-junctionwithbeingunabletomoveabout freely. Lackofphysical
exercisesuggested a physical explanation for rotuba and other
illnesses. But metaphors ofrestriction and constriction were more
about the body being literally silencedthan about any physiological
explanation of muscle atrophy. That silencing of thebreath or
breathing difculties were commonly related in stories of loss of
freedomdemonstrates the lived nature of cultural and physical
constriction, as in the fol-lowing statement by a male focus group
respondent: We were staying in our ownland, we were pushed to come
North, where we have no way of breathing. In otherwords, breathing
is directly related to physical constriction in that freedom
ofmovement, freedom of cultural expression and physical space that
one can callones own are crucial to life, to being able to breathe
freely, to being human.Consider the following excerpt by a male
focus group respondent:Our life in Egypt is not easy. It is not an
easy life. You can see that my body is silent, aha,aha, it is
because I am not happy. It is because I am in hell. I am in hell. I
was in Paradiseand now I am in hell. I have my own country but I
was forced to leave my country. I thoughtthat I was going to be
happy but I nd myself in hell, not Paradise, and a human
beingcannot continue to live in this situation.DISCUSSIONWhen the
southern Sudanese refugees discussed their illnesses, they told of
phys-ical pains brought on by unfamiliar foods, overwork, worry,
and stress. Throughtheir use of language, they revealed the
cultural schemas, linguistic patterns, andexpressive metaphors
rooted in their cultures of origin. However, in their storiesP1:
JLSpp1137-medi-481901 MEDI.cls February 16, 2004 15:3TRAVELING
PAINS 33they went a step further, beyond the connes of the physical
body or cultural habits,to express the chaos of the refugee; a
chaos that is beyond words or experiencebecause it is
unprecedented. Refugees must endure the most traumatizing form
oftranscultural contact that exists, being thrust, physically and
socially defenseless,into the midst of a hostile and powerful
other. This is a reality that does not justgo away or fade into the
past, nor is it something that can be easily adjusted to. Itis a
reality that cannot be ltered through the comforting lens of
historical scriptsand past experience, but must be lived on an
immediate level, through the sensesand through the body. The
illness stories in the present study told of ight, fear,pain, and
culture-loss writ large in immediate bodily experience. Their
movementwas a pain that moved through them, their loss of freedom
was their inability todrawa deep breath, and even their blood was
invisible to those around them. Thesestories were simultaneously
moral commentaries, attempts at resistance and criesfor help. The
challenge is to interpret these stories as the ongoing creations
thatthey are; the reality is that the exigencies of providing care
to refugees gives pri-ority to biomedical hegemony in reading the
stories that the refugees are tellingwith their bodies and
words.From a medical perspective, many of the refugees in the
present study weresomatizers; people with multiple physical
complaints in the absence of objec-tively veriable disease. This,
in fact, was the self-identied challenge of thosewho wanted to
treat them. Abiomedical practitioner nds meaning in pain throughthe
identication of organic dysfunction, the absence of which indicates
the alter-native label of somatization, a condition notoriously
impervious to treatment,and quite commonly diagnosed among refugees
in general (De Girolamo 1994;Harding et al. 1980; Orley 1994;
Peltzer 1999). Fromtheir own perspective, on theother hand, the
illnesses experienced by these particular refugees articulated
thesocial and emotional breakdown they were suffering, experienced
through the lensof their culturally-constituted notions of self. To
ignore the meanings they attributeto their illnesses is to ignore
the illness itself, and this meaningless treatment will,and does,
generally fail in the long- or short-term, regardless of its
absolute effecton the organism.Attending to discourse about illness
within a particular cultural and social set-ting reveals illness as
part and parcel of the symbolic structure and social lifeof a
community (Foucault 1975, 1977; Good 1977). Notions of causation,
bodymetaphors such as the heart and the blood serve as idioms of
distress todescribe losses in various life domains (Nichter 1981).
Many of the refugees
wereliterallyimmobilizedbypain,butnotjustanypainapainthatreectsmorethan
an illness, but a sense of helplessness in a foreign culture that
has stolenaway the social and cultural framework supporting the
physical body. When theclinic attendees were asked to describe
their symptoms, they did so by situatingthese symptoms within the
social context that produced them. Nor did the refugeesP1:
JLSpp1137-medi-481901 MEDI.cls February 16, 2004 15:334 ELIZABETH
MARIE COKERsomatize to the extent that they allowed their physical
pains to speak for them;they recognized openly that their physical
pains were a result of a cultural and so-cial breakdown that
affected the lived body as a matter of course. Their symptomswere
part of being a refugee, part of the pain of losing their country,
losing their rel-atives, and living constantly in fear of
deportation, public harrassment, or nancialcrisis.While medical
anthropologists have beenquicktocriticize the medical
establish-ments overreliance on reductionistic labels, few, if any,
have explored the conceptof refugee somatization as a phenomenon
worthy of an interpretive study in andof itself. Refugees
fromdifferent backgrounds are certainly not culturally homoge-nous;
however, the experiences of disruption, loss and fear articulated
by those inthe present study would undoubtedly evoke a visceral
recognition in anyone whohad been forcibly uprooted from his/her
home by war, and forced to lived in ahostile environment, faced
with an uncertain future. Sure, they all somatize, butin this body
talk is there a deeper level of analysis, a common ground in
whichthe role of the body becomes, for a time, explicit in a way
that would never beseen in a society that remained more securely
tied to its institutions, history, andgeography?By exploring the
embodied nature of narrative, and the narratives of the ill
body,the present study attempts to answer this question for at
least one refugee popu-lation. What made the results so intriguing
was not that the refugees consideredthemselves to be ill on many
levels, and expressed this distress largely throughmedium of the
body, but the way in which their embodied pain constituted a
narra-tive in its own right. It is no wonder that their physicians
became frustrated in tryingto treat pains that shifted and
travelled through time and somatic spacemedicalreality has no way
to interpret such pain, and so it becomes reied as somatizationor
depression. On the other hand, by reading these pains as stories,
by payingattention to the use of metaphors both in speech and in
embodied experience, onebecomes privy to history-making in progress
(Ferreira 1998). Refugees are livingchaos narratives such as those
described by Becker (1997) and Frank (1995).However, in the case of
refugees it is not the ill physical body that must recreateitself,
but society that is thrust into chaos. Refugee illness narratives
have muchto tell us about the process of coping with the loss of
society that is unique to therefugee experience. As they emplot
their stories with their bodies and their words,refugees are
actively reconstructing their stories and helping to shape an
uncertainpresent and future (Becker 1997).Allan Young and others
have recently argued for a more nuanced analysis ofpain and
suffering (Das 1997; Young 1997). Pain, in this analysis, needs to
belistened to not just for what it communicates about the state of
the physical body,but what it communicates about the social and
moral realms as well. Through theirembodied metaphors and illness
talk, the southern Sudanese refugees in Cairo areP1:
JLSpp1137-medi-481901 MEDI.cls February 16, 2004 15:3TRAVELING
PAINS 35communicating a message about the existential crisis in
which their community isembroiled. They have literally lost their
country, their society, and their traditions.They are physically
constricted on all sides. Their cultural practices are lost tothem,
they fear the total annihilation of their identity as southern
Sudanese, anidentity which is partially constructed through the
very situation in which theynd themselvesthat is, attacked and
marginalized by virtue of their skin color,religion, and place of
originbut which is informed by strong ties to culturalpractices and
the place fromwhich they have been violently separated.
Sickness,according to Frankenberg (1986), is a cultural
performance, lending itself to anunderstanding of illness that is
not limited to the individual or biological realms.This is a
sickness, they are saying. You have no sickness, is what they
arehearingfrommedical practitioners andothers whoreduce their
physical complaintsto organic processes or psychiatric entities
like depression or
posttraumaticstressdisorder(seeWatters2001foracompletereviewofthePTSDdebatewithin
refugee mental health).Please tell our story to those outside, in
America and elsewhere in the West,said many of my informants when I
asked for their cooperation to participate in thisstudy. In
Palestine, one person dies and everybody hears about it, but
thousandsof southern Sudanese die and nobody pays attention. The
goal of this paper wasto tell this story of sickness, loss, and
fear of death (social, cultural, and physical),using the very
metaphors and idioms with which the people involved understandtheir
pain. By listening to these metaphors and discourses, one comes to
understandthat the integrity of the individual, or the individual
body, is highly contextual anddependent upon the integrity of the
culture and community that is under assault.Recovery, or relief, is
vested in refugees faint hopes of returning to their place oforigin
and putting back together what they have lost.ACKNOWLEDGMENTSI
thankthestaff of theJoint Relief Ministryof All SaintsCathedral,
Cairo,Egypt, forprovidingaccessandsupport throughout thisproject.
IalsothankMs. ReginaPoni JacobandMr. JamesWani-KanaLinoLejukole,
whocol-lected and translated most of the data for the present
project, and were
invaluableinhelpingmetounderstandthesituationofSudaneserefugeesinCairo.Thisproject
was funded by The Social Research Center of the American University
inCairo.NOTES1. Egypt is also a signatory to the 1969
OAUconvention, which would give refugee statusto almost all
refugees from the Sudan. However, in Egypt UNHCR takes
responsibilityP1: JLSpp1137-medi-481901 MEDI.cls February 16, 2004
15:336 ELIZABETH MARIE COKERfor asylum determination, and does not
(for unknown reasons) apply the criteria of
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