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. 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Berkeley: University of California Press.Department of Sociology, Anthropology, Psychology and EgyptologyThe American University in Cairo113 Sharia Kasr el AiniP.O. Box 2511Cairo, Egypte-mail: emcoker@aucegypt.edu