"She's been hearing voices," says Adala's nephew Diri. "She hears them every night."
The three of us sit in an examination room of my private geriatrics practice. I've been in a community-based practice in Memphis, Tennessee, for nearly twenty years.
Adala is a tall, slender woman. Dressed in a gray-blue guntiino, a long piece of cloth tied over the shoulder and draped around the waist, she has her head covered with a shawl. Her gaze shifts from her nephew to me; her eyes search my face and then stare silently at the floor. Despite the differences in culture and language, she is like many of my patients brought by a family member. She's not here by choice; she came in deference to Diri's wishes.
Diri, a small man with bright eyes, speaks rapidly as he tells me Adala's history. Nearly sixty-five, she was born in Somalia "during the planting season." Displaced by the ongoing civil war between the Somali government and militant Islamist groups, she has been in the US for six years.
At first, she settled in Ohio with her youngest son.
"She couldn't stay there," Diri says. "Too many in the house. She needed quiet."
She moved to a small rural community north of Memphis, to be close to Diri, her brother's oldest son. There she met other women her age, who like her were forced to move from their war-torn homeland. She joined this group of reluctant travelers, starting over in a foreign country, growing a community. They cook together, pray together, take walks and share their lives.
"Describe the voices," I say.
Diri translates my question from English to Somali, then translates her response back again to me. I listen to the cadence of his language, the hard consonants. He is a good translator--patient, watching his aunt's face, pausing to get the nuance of her words.
"They start at night, after it is dark, when she is ready for sleep," he says. "She puts her head down, closes her eyes, and she hears them."
"Are they talking to her?"
"Can she tell what they are saying?"
"Just voices. They last for hours, until sunrise, then they stop, and she goes to sleep."
Adala never sees anyone at night; she denies having visual hallucinations or hearing the voices during the day. She eats well, stays busy and keeps her house in order.
But every night, the voices return.
"When did the voices start?"
He translates the question, then her answer: "A long time ago."
I probe for specifics. "Days? Weeks? Months?"
He translates again. Adala has been looking at him, listening; she shifts in her seat, and her shoulders sag. She answers him, but looks at me.
"Years," he says. But her answer was too long for just that one word.
I've been a geriatrician for nearly thirty years. I confront the infirmities of aging bodies and minds every day. I can treat visions of dead husbands, children crawling from closets at night, faceless strangers milling about the house. But I need more information. I sense that her story is longer.
"When did they start?"
Adala wrings her hands; the friction of dry palm against dry palm fills the room.
"She was in her house, the war is always with them, and the soldiers from the next village kicked in the door, stormed the house, their faces covered, guns drawn." Now Diri translates in real time as Adala speaks, her hands moving; sometimes her voice softens, and he leans in to catch her words. "Her daughter screamed, and a soldier grabbed her, tried to rape her. Her oldest son punched the soldier; he was shot in the chest. She fell to the floor, cried out, cradled him; her son died in her arms."
The voices started soon after that night. Days blended into night; the sounds of war--gunfire, bombs, screams--never stopped. The voices fill her house, her mind, preventing sleep. Perhaps protecting her from the night.
Her story hits me hard. Such cruelty that people inflict on each other...and mothers seem to bear the brunt of it, losing their children, both young and old. I cannot imagine the depth of her pain.
I try to explain what I think is causing the voices. But I only have Western words: depression, PTSD. I struggle to describe grief and bereavement to a woman from a third-world country where war and death are woven into the fabric of life.
"The young people don't have this problem," Diri says. "She says it is only the old ones."
"I am sorry for what they did to him," I tell Adala. My sadness is real, but my words ring hollow. The sound of the ticking clock fills the room.
I tell her about a medicine to help her sleep and perhaps muffle the voices, maybe just enough to allow time to dampen her pain. But is forgetting equivalent to forgiving? There is no justice in a pill, and the sleep it may allow Adala will be harshly rebuffed by her reality in the morning.
More and more often, physicians and other healthcare providers are being called upon to treat the consequences of atrocities that most of us will never experience: gun violence, drug use and, in Adala's case, civil war. In the face of such horrific trauma, our medicines and therapies are often so limited--an innocuous balm applied to a gaping wound.
I write a prescription for the antidepressant mirtazapine and sign the gray paper. I explain the instructions to Adala as Diri translates, and I hand her the paper. She cradles it like a gift and passes it to him.
Adala takes my hand in both of hers and holds it for a second. Then she looks me in the eye, nods and tries to smile before leaving the room.
About the author:
Robert Burns is a board-certified geriatrician in Memphis, TN. He is a professor of medicine and preventive medicine at the University of Tennessee and has a community-based practice where he teaches geriatric medicine to residents and physician-assistant students. He has a degree in playwriting from the University of Memphis. His plays have been produced in Pittsburgh, New York City and Memphis. His short stories, essays and plays have appeared in JAMA, Annals of Internal Medicine, 3Elements Literary Review, Punchnel's and The Sun. "I started writing this essay the day I met Adala and Diri, because of my feelings of helplessness in trying to help her in her grief."