Anorexia and trauma: why the world needs to worry about the Middle East

Get used to opening windows wide

To see what the past has done to the present, 

And weep quietly, quietly, 

Lest our enemies hear 

Broken shards clattering within us. 

Sometimes I walk late into the night and roll the words of Palestinian poet Mahmoud Darwish over in my mind. I don’t know where I’m going and I don’t know how long I will be walking but the thud of my feet on London’s pavements remind me that I am alive.

The enemies can hear the torn shreds inside clatter all too easily, because the worst fiends are inside too. They are part of an internecine conflict that means I walk to keep myself sane. I do it to deal with the intensity of sadness, and loneliness, and rage that all too easily I will otherwise deal with in a more harmful way.

I have written about anorexia before. I have written about the sadness, and the loneliness, and the sheer desperation. I have written about how it destroys life.

Eating Disorders Awareness Week – the week just gone – emphasised the difficult relationship between eating disorders and working in the UK. How to tell an employer one is incapable of working because you cannot think for hunger?

The campaign is commendable. It highlights the personal and financial losses of a poor attitude to eating disorders in the UK.

But the choking difficulty remains. Eating disorders – including anorexia, the one I can write of with personal experience – do not discriminate geographically. As a quick précis of the many, complex, causes of eating disorders, they prey on those with emotions so intense they fear to feel them – from traumatic experiences, abuse, or personality, and who bail by corrupting his or her relationship with food. They fester and then bloom in those who have a tendency to perfectionism, and who use food as a means to try to achieve impossible ideals which promise that “everything will be OK” when reached. Of course, everything is not OK, and the sufferer merely finds himself or herself spinning closer to depression and death.

The only person I knew from a non-Western background – Saudi Arabia – who had anorexia was one of the worst affected. She is now dead.

Although there are trends that show certain cultures and socio-economic classes are affected more than others – very broadly – “Western” and wealthier social groups showing higher incidences – this may be more because of reporting and awareness issues than a real reflection of numbers of people affected.

But the only person I knew from a non-Western background – Saudi Arabia – who had anorexia was one of the worst affected. Although she was fortunate enough to be able to access medical treatment, it was not enough. She is now dead.

Anorexia will sequester its way into lives pretty much anywhere in the world. I have learnt to lend myself the respect to believe that there is not a fixed amount of compassion in the world. I do not have to neglect myself because there are people struggling against the illness in more difficult circumstances than myself – without money, family support or medical resources.

beirut view

The view to Beirut – access to healthcare and psychological support may not reach the most in need in Lebanon. 

And yet. There are places in the world where anorexics and bulimics suffer without access to the physical, psychological and social support that saved my life. According to one scientific paper from 2004 comparing prevalence of eating disorders in “Western” and “non-Western” countries, “population-based and patient-based estimates of anorexia nervosa in non–Western countries ranged from 0.002 per cent to 0.9 per cent.” That is a small percentage but still represents a lot of people in real terms. The same paper said that Iran reported the highest rate of bulimia nervosa outside the Western world and that “abnormal eating attitudes” in non-Western countries have been gradually increasing.

I worry a lot about the places where there are fertile feeding and starving grounds for anorexia as a result of mass trauma, combined with poverty, stigma and lack of resources to diagnose or treat eating disorders. The Middle East Eating Disorders Association based in Lebanon says accurate prevalence rates for each country in the region do not exist. Although it provides some background information on the various illnesses under the “eating disorders” umbrella, and some training, with the best will in the world it is not going to be enough to meet the needs of an under-researched and, potentially, at risk population.

mt qasoyun

Damascus in Syria, before the five-year conflict that has traumatised generations of its nationals.

It links to the few research papers that have been written on eating disorders in the Middle East. Even those are unlikely to show the whole picture because the research samples often come from private universities in urban areas, that are often akin to mini Western bubbles where financial and medical resources are better.

“Practices to control weight, particularly extreme and unhealthy weight-control behaviours, are common among adolescents in the Palestinian territories.”

One paper that questioned nearly 1,000 Lebanese students found that “strenuous exercise” and “avoiding particular foods” were behaviours most often engaged in, while a paper from the International Journal of Easting Disorders in 2010 found that “practices to control weight, particularly extreme and unhealthy weight-control behaviours, are common among adolescents in the Palestinian territories.” The paper said the findings showed the need for “appropriate prevention and early intervention programs for for adolescents in Palestine.” Another 2014 paper on perception and treatment of eating disorders in Jordan urged awareness campaigns after finding that 14 per cent of those surveyed self-reported an eating disorder, and “the majority” had deliberately skipped a meal.

lebanon looking towards homs

The view into Syria from the mountains west of the north Bekaa Valley, Lebanon. How many people who fled here from Syria will suffer mental illness as a response to trauma?

The research so far is limited, but shows an increasing prevalence of eating disorders in the Middle East. But outside of the wealthier urban areas in Cairo, Amman and Beirut, and without wishing to sound sensationalist or simplistic, I worry about the future mental health of a generation of Syrian, Iraqi and Palestinian refugees. If we know that trauma is one of the triggers of an eating disorder, how many of them will find solace in starvation from the suffering of years of displacement and violence?

There are a few NGOs and charities providing psychological help and trauma management to young people in the Middle East who may be vulnerable to mental illness because of the conflicts in their homelands. But with limited resources and training, and government apathy or inability to provide more money and social services, they will struggle to cope if the number of people affected rises. I admit that I have no statistics to show eating disorders will flourish as a trauma response in the region – and as far as I am aware none have yet been collected. But as a large scale trauma event – and what we know about eating disorders forming as a response to such duress, I think there is reason for concern.

How many people will find themselves walking into the night, tossing Darwish’s words over in their minds, wishing that they knew of some other way than starvation to numb themselves to the pain of memories of death and assault, hurried border crossings and drownings in the night, as the Aegean sea tosses and swirls?

 

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