Introduction-  Mark Van Ommeren-WHO Department of Mental Health and Substance Use

‘The culture and context is really important in mental health.’

3.04 Dévora Kestel -Director, WHO Department of Mental Health and Substance Use

‘How can learning things done in a different way will enrich the way we do our own practice? ‘

Visit of Dr Tedros Adhanom Ghebreyesus to Psychiatric Unit-August 2019.

7.06 Introduction to Documentary-Mike Poltorak

‘I have been inspired by the Tongan sense of responsibility, to do justice to their work but also to locate it in a very challenging landscape of sickness and health provision.’

12.20 Comments and Discussion

13.00 Mapa Puloka

‘To contextualize by using those words to contextualize the practice of psychiatric care via Tongan cultural mode, such as the usage of the kava session for further assessment of psychiatric patient to calm patient. ‘

15.40 Zhang Qi-WHO Department of Traditional, Complementary and Integrative Medicine

 ‘I see from the film that the traditional medicine practitioner that practice is going into the home of the patients and provide individualized care at the home and is very well accepted.’

20.20  Peter Ventevogel -Senior Mental Health Officer UNHCR

‘So the first thing that struck me is that, it’s what I would call the pragmatism of the people on the ground. So it’s not traditional spirituality versus Christianity but people use both. It’s not traditional healing or modern medicine or modern psychiatry which we often see as diametrical opposites but people use concepts and methods in a very pragmatic way. We could see that very clearly in the movie.’

26.30 Jae Kyoun Kim-WHO WPRO

‘I really think every traditional medicine anthropologist should watch this movie. When I saw the use of Tevita and Fine, I was very sad and I couldn’t stop thinking what we could do to prevent the second case of Tevita and Fine.’

27.53  Mike Poltorak

‘So there are kind of precedents for possible collaborations that might be Tonga sensitive because they’re already happening with Maori communities in New Zealand.’

29.37 Mark Van Ommeren

‘ In 2007 there was guidelines developed for mental health and psychosocial support in emergencies. IASC guidelines which WHO is a part, and in it there are two action sheets, each three pages. They describe how modern medicine can collaborate with traditional resources.’

Full Transcript:

Mark Van Ommeren– So thank you for all, for coming to this lunchtime event. It’s the first time for me, at least in a year that I’ve been involved in organizing something like a lunchtime seminar. It seems to be from another age. Is it possible? Is it not? So how does it work? And let’s see this is a way we still can engage with each other at this time, when many of us are at home I will give a few opening words. Then I will ask Devora our Director in the Department of Mental Health and Substance Use to give her comments. This event is definitely about culture. I’m quite pleased that we’re having this event. Before I joined WHO I was in a NGO that’s focused very much on transcultural psychiatry and it’s one of my original interests. The culture and context is really important in mental health. And it’s important to realise. Maybe it’s a few comments because there will be people on the call, we have top expertise in this and there were people were just interested and actually may not work in mental health at all, or in culture but why is culture and mental health important? Well, culture provides the explanations people have for their problems and by it giving an often explanation for whatever problem, why they are sick, why they are healthy why something, good things, or bad things that happen to people that can actually influence how people have their mental health problems. And that also influences how people seek help for their problems how they, the kind of terms they use to describe problems. And it also influences the kind of supports that are available and the resources are available and how they’re being used or not used. So culture, in a way is everywhere. The cultural lenses I always found very, very helpful. It’s not the only lens. There is many other lenses we should look at in in mental health, I believe an evidence-based lens. What do the trials say? What does the epidemiology say? The economic lens, human rights lens, feminist lens social constructive lens, all these lenses. We ideally look at mental health problems at the same time which probably gives us the most wisdom to make suggestions and how to move forward. Those were my own thoughts.

I’d like now to introduce my Director, Dévora Kestel Director of the Department of Mental Health and Substance Use. And my question to Dévora is, ” When Mike Poltorak, the filmmaker reached out to you and to WHO to discuss this movie, you said yes. And my question is could you explain why you were enthusiastic to have this exchange today? Thank you.

Dévora Kestel– Thanks Mark, and thanks for that and for running the show and for the introduction. The reason why I say yes is you just listed you just gave those reasons, right? I have to say that all this was the result of a visit of DG, our Director General, Dr. Tedros to Tonga, where he met Dr Mapa and participated in a ceremony. And so following that I think it was Mike who contacted him or anyway They got in touch. And when DG came back from Tonga, he asked me to follow up. And then at some point COVID happened to all of us. And everything changed. But then when I got the possibility to get in touch with Mike and to watch the movie I simply thought what you just said. I mean, we are so Western oriented in terms of what is valued, what is based on in science and what is science actually, and how do we develop and construct things following those patterns that are once told to us , most of us. And then the years ago, I had the opportunity to interact quite frequently with indigenous communities in the Americas. And it was, I learnt a lot, it was open minding I thought that this was an opportunity to get to know what practices are in other cultural contexts in other countries, in other realities. And what can we learn from that? And yeah, how can learning things done in a different way will enrich the way we do our own practice. That would not necessarily change a hundred percent but maybe we’ll be permeated influenced by learning that things are not so one way, directed and simply that. So I actually was interested with the generosity of Mike to to let us have this session and watch the movie and discuss it together. So those are my reasons. And I thank everybody, I thank Mike I thank the colleagues from Tonga for this generosity, also from their side, and as Mark said before we have unfortunately to leave in a while, but I will stay here for a while. So thank you very much. Over to you, Mark.

Mark Van Ommeren– Thank you very much. So let me now introduce, Dr. Mike Poltorak, Mike is a Social and Medical Anthropologist and his journey in anthropology started with a long-term ethnographic field work on mental illness and spirit possession in the South Pacific in Tonga from 1998 to 2000. He lives near Zurich but he is a honorary research fellow in the UK at the University of Kent. And his research obviously has covered mental health but also separate from this it has covered a vaccine hesitancy, a rather relevant topic, these days. His work in Tonga shows the tensions, contradictions and resonances between local healing and psychiatric practices. I now ask Mike to introduce the film and set it up and then we will be playing it.

Mike Poltorak– Thank you. Thank you, Mark. Thank you, Dévora. In Tonga, it is said, “Ko e koloa a Tonga, koe fakamalo” or one the treasures or valuables of Tonga is giving thanks. So I’d first like to thank yourself, Dévora and Grazia for organizing this wonderful event and to Zhang Ji and Peter Ventevogel for your speaking to the film later. I’m also particularly thankful to Yutaro Setoya for facilitating the Tonga connection, and most thankful when Dr. Puloka will join us. When thinking of how to introduce the film to the beating heart of the WHO in Geneva I was reminded of Dr. Sione Tapa. He was the first Minister of Health of Tonga but also made a huge contribution to the policies and work of the WHO. In 1991 he was awarded the Health for All Gold Medal. As president of the 30th World Health Assembly in May, 1977, he argued how health could not be disassociated from socioeconomic problems. He was central to establishing one of the best known of the WHO goals, Health for All by the year 2000. In the announcement of the award the then director general Hiroshi Nakajima, wrote. I quote, “Dr. Tapa is a gentle man but there can be no doubt about his passionate commitment to social justice and equity.” As a result, our organization has received constant and unequivocal support and encouragement from him in its health for all and primary health care initiatives. I have no doubt that Dr. Sione Tapa drew on the powerful Tongan motivation of fatongia or responsibility. At the WHO and in his developing modern medicine in Tonga. This is something that he shares with the key protagonists of the documentary, the healer, Emeline Lolohea the psychiatrist, Dr. Mapa Puloka and the doctor Dr. Alani Tangitau. Whose fatongia is central to their practice. They and I are honored that you are showing this film. When I talked to Emeline this morning about Dr. Sione Tapa, she told me how her parents would tell her how calming his speech was and how well he received and welcomed people. As a filmmaker and medical anthropologist. I have also been inspired by the Tongan sense of responsibility, to do justice to their work but also to locate it in a very challenging landscape of sickness and health provision. Dr. Sione Tapa lived as he preached. He was also a philanthropist, but died at the age of 94 in May, 2018. Were he alive now, I would hope he would also see the social justice aspect of the documentary. A film is very different to a book or an article. It can only be the start of talanoa. A Tongan concept that captures frank, open and critical conversation to address some of the concerns revealed within it. At the first community screening in Auckland in 2019 the Tongan psychologist, Pauline Taufa described the film as a koloa or a Tongan valuable. I take that to mean that its value and utility is in how it can be used to contribute to the improvement of health outcomes. Like Sione Tapa, the film also has a modest intention to contribute to global health. I very much look forward to our discussion after the film. Thank you.

Mark Van Ommeren– Thank you very much. Wonderful. Wonderful. So, congratulations, Mike, on an exceptionally well run movie and as planned, we will now have a discussions, a short discussion. So we have been joined by Dr. Mapa Puloka from the movie and he is on our screen with us, right? Thank you Dr Puloka for joining us. You at the time of the movie were the only psychiatrist in Tonga I understand that has changed. There are so many messages in this movie. One could take so many different takes on a movie like this. What would you like people to remember from this movie?

Mapa Puloka– Thank you, Mark. To contextualize by using those words to contextualize the practice of psychiatric care via Tongan cultural mode, such as the usage of the kava session for further assessment of psychiatric patient to calm patient. Because of the narcotic effect of kava a form of harm reduction. To take Kava rather than taking marijuana and ice, methamphetamine, heroin and other dangerous drugs. For social gathering and pleasure one of the main reason. The second part of it is my ability to cooperate with traditional healers and able to identify types of ‘avanga, ‘avanga is a Tongan word for all mental illness. Type of ‘avanga for them, the traditional healers, to treat and the type of the ones to refer to us. That’s why we used to have many workshops in the past although I’m looking forward to repeat it again, A workshop with traditional healers, and the third part of it is my ability to do some kind of directed translation and also using Tongan concepts in coining new words in Tongan in order to interpret and also to translate psychiatric terminology. These are the the most important part I think I want the audience to remember and this is going on in Tonga I think going on for I would say 30 years now.

Mark Van Ommeren– Thank you so much, Dr. Mapa. I appreciate your words. You’ve done a lot. I think that the whole translation between the the Tongan language and and the modern psychiatry language to have those two worlds connect is a challenge. And you’ve made a huge contribution to I like to ask the question. Next question is for, my colleague, Dr. Zhang Qi, at WHO. Dr. Zhang is the head for Traditional Complimentary Medicine at WHO and has for many years is basically our global expert on anything related to traditional medicine. Thank you for joining us, Dr. Zhang. Could you give us your reactions to the movie and what lessons should WHO staff take from this? What is your message to them and the other colleagues on this call? Thank you.

Zhang Qi– Thank you, Mark. And also thank you to Devora for your kind invitation for me to join this discussion. So my immediate reaction to this film is very good. And I explained is documented and is reflected in the practices of a traditional medicine practitioner the film we called Healer. By the way, in WHO, our team we call all that traditional medicine practitioner and the psychiatrist through that, some kind of a routine practices focusing some cases during a period of time. So that’s very good an excellent film and reflect that reality. And I see from the film that the traditional medicine practitioner that practice is going into the home of the patients and provide individualized care at the home and is very well accepted. And a lot of our patients even the surrounding people were very positive responses to that outcome. And I also see there are some, looks like some common ground between that traditional medicine practitioner and the psychiatrist from the film, for example the later case that psychiatrist also being interested to follow the patient to close to his life and to reach out better the outcome for that case. And you’ll see that activities interpreted by both and somehow reached common ground, like some of the more the encouraging the patient to utilise themselves. And with the background of music and some other, the interferences, even, in the clinic you can also call that the patient of the sitting wrong or something like that. So that’s the impression from the film. That’s very good. For some kind of message. I would like it to convey to our colleagues here perhaps our department and the other colleagues. So firstly, I would like encourage everyone to understand traditional medicine. So some colleagues usually reflect a traditional medicine as some only somehow based on his or her background. Understanding, so that’s why I’m asking in one country, you want places and you want community. Looking at global traditional medicine. And I would like to say, that’s diversified. We are very often to use, right? Some are very well educated. It’s used in university at the same level. With conventional medicine like China, two Koreas Vietnam, India are some countries and many countries like this, local community based that a traditional medicine practitioner or you’ll call healer or indigenous medicine practitioners who have no formal education even no formal documentation for their practice. They just passed down from the generation to generation or from the community. That different categories and the many countries, traditional medicine in between some institutional education. But not, perhaps university medical school. So that’s the diversity of traditional medicine across the world. To you Mark.

Mark Van Ommeren– Thank you. That’s very interesting. Quickly move over to Peter Ventevogel who we work with a lot at the WHO. He’s a psychiatrist and an anthropologist at UNHCR Peter, you are very familiar with the tensions in the field between anthropology and psychiatry. Could you give us your reflections on the movie and importantly, What are the practical implementations for WHO in UNHCR’s work in countries?

Peter Ventevogel– I thank you, Mark. Thank you for inviting me. I’d like to start with some reflections and then maybe go to your more difficult question in the end. So first of all, I’d like to thank Mike for his work and yeah, it was really, really a privilege to see the lived reality of traditional healing and what I liked so much. This was not just a documentary of anyone as it was clear that the filmmaker, you, had the personal relation with the people you work with. And it almost look sometimes like the shots are taken by family members. You are a family member and the people were very much at ease. That’s important because they were not trying to show off or to give a very positive image. And this often happens in research that people want to want to show the only the best side of what they do. I didn’t see that so much here. I saw people genuinely being troubled by problems trying to find solutions. Sometimes it works, sometimes it doesn’t but they navigate their way through different systems of thought. And as Dr. Zhang already said it, it showed reality. The reality of the different sources of support. Secondly, I would like to thank Dr. Mapa and it’s really great to have you here. I want to thank you for your kindness and your wisdom. We saw you working with people with mental health problems and I really wish we would have more psychiatrists like you in all hospitals. I think it would be much better for patients if that would be the case. Now, some reflections on the film. I know nothing about Tonga or even any of the islands in the ocean there but I know a little bit about traditional healing in other contexts. And I do see some similarities and I’d like to share a few things with you. So the first thing that struck me is that, it’s what I would call the pragmatism of the people on the ground. So it’s not traditional spirituality versus Christianity but people use both. It’s not traditional healing or modern medicine or modern psychiatry which we often see as diametrical opposites but people use concepts and methods in a very pragmatic way. We could see that very clearly in the movie. And sometimes that may seem inconsistent from an outsider on a conceptual level but you could see actually how people very pragmatically use different ways in ways that they seem that they think it may be beneficial to them. Now, the second part is the concept of change, change within traditional healing. I do think just as any other form of thought and knowledge, healing changes, and I, of course I don’t know how that happened in Tonga but I guess it’s different now than it was a hundred years ago. And you could also see a certain syncretism happening. I was struck by the fact that the healer was also a preacher in the church, for example. And again, that’s very interesting. Now then a little bit more about the healing itself. I think it was quite interesting to see the social aspects of traditional healing being laid out so powerfully. It really helps to bring people together. So that is something of collective meaning-making which I saw of course, in the work of the healer but actually also in the work of Dr. Mapa, which I think is why you’re such a good psychiatrist. So the social aspect of traditional healing is I think very important. Now, if you would probably talk to Emeline she would say, “Yeah, but that’s not all.” There’s also the importance of the spiritual world. And there, of course I’m not a believer in Tongan religion or whatever. I don’t know much about it but so there we may have different views but it’s so clear that for the people on the islands that is, the spirits are everywhere. There is an omnipresence of the spirits. And I think Dr. Mapa mentioned that so interestingly as well, like the brain and the mind and the soul, they swim in a spiritual ocean or something like that, you said. So it means it’s everywhere. Spirituality is everywhere. Questions to, perhaps to Mike because I saw Emeline using mainly, in the film at least, mechanical physical ways of healing putting plants in water or using leaves or massage. But I just wonder to what extent does she also use spiritual ways of healing? Because in my experience often plants are not just plants. It’s not just the physical substance. It’s also the magical power that is inherent in the plant because of spirits that can drive away other spirits.

– What do you think is the practical?

– Yeah.

– That would be good stuff.

– Well, I think it’s just, what I think is clear is if you if you’re working in psychiatry you need to be open to other explanatory models. So you need to be curious. And I think that’s the strength of Dr. Alani and Dr. Mapa is that they it’s not that they become traditional healers. They are firmly Western practitioners but they can communicate effectively because they’ve learned the metaphors and the right words. So I think that’s the first thing, check what’s out there. Be curious, link with healers, learn what they do. I’m less, personally, less sure about formal collaboration, I think. And the basic reason is quality control. So I think healers do what they do and doctors do what they do and they can cooperate but we shouldn’t merge it and say it is actually the same because I think there are differences. So that will be my 2 cents. But let’s open it for discussion because I see it’s already late

Jae Kyoun Kim– My name is Jae Kyoun Kim. I’m working in WHO WPRO on traditional medicine. I first like to thank you, Mike very much for the inspiring movie. It was really inspiring. And I really think every traditional medicine anthropologist should watch this movie. When I saw the use of Tevita and Fine, I was very sad and I couldn’t stop thinking what we could do to prevent the second case of Tevita and Fine. And my question is, ideally, we should have psychiatrists like Dr. Mapa in all the islands and areas. But obviously this is not the case in Tonga, and at the medical conference [In the Film] I remember they says only 10% of the mental health is done by government and 90% were from traditional healers. So in the current situation, you have no chance to encourage traditional or primary healthcare I’m so sorry.

– No problem.

– Yes. I want to test to do that, what kinds of measures could you take. So if I rephrase it in what way would Dr. Mapa be comfortable with working with Emeline? So that was my main question, thank you.

– Thank you and congratulations it’s a brilliant movie. What would you like to say?

Mike Poltorak– I’m very touched by the reception and I’ve taken many notes and there’s many questions that come out of the questions. And the question of collaboration I think is really fascinating. And as was said that has happened in other places in Africa it’s also happening in New Zealand in very interesting ways. So there are kind of precedents for possible collaborations that might be Tonga sensitive because they’re already happening with Maori communities in New Zealand. The pragmatism, I’m so glad that that was communicated and that resonated with Peter because that is the case. And I feel in some ways, Dr. Mapa is also extremely pragmatic in terms of thinking through what would work in in Tonga and the pragmatism of his principles and his inspiration is what makes him such a remarkable inspiration and and psychiatrist in Tonga but also as an inspiration, more broadly. The question of the spiritual that Peter asked about, that’s a very good question and something that I  have yet to fully understand after 20 years working in Tonga, but the plants have sensory qualities, they smell in certain ways. They also have meaning properties in the sense that they come from nature. That was from land that was given to God by Tupou ‘Uluaki, Tupou the first. So there’s a very powerful sense that all plants have a spiritual power. And so, in a sense, when plants are used it very much reminds or brings into consciousness, the fact that land is God-given and and healing is spiritual by virtue of just using plants.

 

Mark Van Ommeren-It was really great. Of course as always happens is there’s not enough time for discussion after these kind of events. It’s also extremely late for Dr. Mapa and for Yutaro Setoya. I put in the chat a comment, which is that in 2007 there was guidelines developed for mental health and psychosocial support in emergencies. IASC guidelines which WHO is a part, and in it there are two action sheets, each three pages. Describe how modern medicine can collaborate with traditional resources. And for anybody who is interested in that have a look because these actions sheets, when they were written, I know them quite well, they have not received a lot of criticism. They were generally perceived as a way of modern organization, I call modern now but whatever, what you want to call it your favorite term, modern allopathic whatever you want to use, work together with traditional resources in settings, on mental health. It’s now a one minute after two, and one minute ago another meeting started that I should be in. I want to thank you all. And particularly Dr. Mapa, and Yutaro because of the hour. To Mike for getting us into this space which was a great pleasure. And for Peter and Dr. Zhang to join us, for Grazie for organizing and for all of you who have been with us, it was a pleasure. Thank you so much and have a good rest of the afternoon or rest of the night, depending where you are.

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