One of the groups of people that suffer heavily from trauma are immigrants. In this issue, Dr. Tekin starts his article on trauma with the example of a couple from Iraq, tortured and abused by terrorists who killed their kids. Now, safe and away from the dangers of their home country, the couple cannot overcome their fears and pains, despite now living under a roof and having plentiful food and work. “Mass Trauma, PTSD, and Treatment Options” raises awareness of this epidemic, which is lived at both personal and public levels. Its effects will not only shape our populations, but will also leave indelible marks in our souls. 

Can one way of dealing with trauma and disasters be relevant to “the way we view the world and our place in relation to it”? Robert Howe suggests it is. “Fundamentally, the problem of environmental decline is a malady of tension – between the self, society, and nature,” writes Howe, for whom “the environment’s decline is a sign that modernity is suffering from a crisis of spirituality.” In his “Regenerating Life with Soulcentric Education”, Howe pinpoints the problem as education systems which value academic intelligences because they serve the economic values the system upholds. For him, the contemporary education is “the story of separation” in which humans are divorced from nature and the world by “othering” and “commodifying” them. One solution, for Howe, could be “regenerative education,” which educates healthy, soul-centered adults who understand why they are on Earth, why they were born, and who live with a sense of belonging to the natural and human communities. It is certainly an interesting piece to read and offers a renewed perspective on our lives.

“Turning the Unknown and the Different into the Familiar and the Friendly” by Ellen Michelson offers a second way of dealing with the troubles plaguing our world: interfaith dialogue. Ellen is the editor of The Menorah newsletter of the Congregation B’nai Israel, in New Jersey. She has been an active member of the interfaith community, and, together with the other members of her congregation, she reaches out to other faith groups to promote dialogue and understanding. Her piece offers a humble reading of what can be done today to overcome prejudice and to build a society that respects differences.

It is usually easy to associate with people from one’s own culture. Why step out of your comfort zone to extend a friendly hand to someone from a different culture? Perhaps, if my experience is typical, to enjoy one of the most rewarding experiences of your life. This opportunity is readily available to Americans who wish to make the effort. To interact successfully with Turkish students and professionals in America, for example, the American host must navigate differing perceptions of family, society, and ultimate duty. By practicing role reversal, a person of goodwill can overcome the barriers of language, religion, and nationality. Allow the person getting help to become a helper, and the student to become a teacher. Take into consideration the enthusiasm many cultures have for personal relationships. You might find your own life changed for the better.

Turning the tables to build intercultural friendships

Americans in university cities can build lifelong friendships with sojourners from around the world. Year after year, bright and ambitious young people leave other countries to acquire an American degree, make American friends, and soak up a culture and language very different from their own. They have traveled halfway around the world to meet us. Traveling a few miles across the city is a small step by comparison, but the rewards are great.

My adventure in trans-cultural friendship combined a personal interest in the Turkish language and culture with a graduate-school class. I analyzed interactions with Turkish sojourners in several different settings, wrote a scholarly paper, and completed the class. My family also made lifelong friendships with fascinating people. Much that we learned can be applied in other contexts.

Edward T. Hall describes Turkey as a “high context” culture, and America as ““low context.” In Turkey, much more time is devoted to developing the relationships behind transactions than to the transactions themselves (Friedman, 1979, pp. 45–54). Relationships, connections, and group harmony are the important values. The validity of the group is more important than individual rectitude.

Given these insights, it would appear that an American wishing to establish rapport with Turkish sojourners should understand the basic elements of Turkish culture. Beyond this, the technique of “turning the tables” has value. Create a situation in which the guest can function as a host, the student as a teacher, the outsider as the portal to an alternate inside.

First adventure

In August 2004, I went to a local university to meet a “language partner.” Picture a casually dressed, fifty-something man walking through the parking lot with an elegant young woman. The director of the language partners program introduces them, gives them a list of suggested activities, and leaves it to them to make further arrangements.

“Dawn” is an engineer who wants help with her colloquial English. The fifty-something man wants to learn Turkish. Each wants to see the world through the eyes of the other culture.

The two arranged a first meeting in a wide-open public place-the university’s student union. They brought notebooks. He brought a Turkish elementary-school primer. They sat on adjacent chairs and practiced reading aloud.

On the second meeting, in the same place, Dawn introduced her husband “Freedom.” The researcher and Freedom chatted for a few minutes, discussing common interests in history and politics. The researcher apparently passed the test, since the couple extended an invitation to continue the lessons at their apartment.

When you are invited into a Turkish home, the researcher had learned, expect to be served food and drink, and be sure to bring a small gift. With this in mind, he purchased a book at a used bookstore. He knocked on the door, greeted the couple, and stepped in. Freedom reminded him to leave his shoes at the door. The three chatted for a few minutes about history and politics, Dawn served tea and cookies, and they began doing language work.

This established the pattern the visits followed over the next eighteen months. The American would speak to Freedom first, discussing Freedom’s academic progress. He would present them with a small gift, usually an inexpensive but thoughtfully chosen book. Dawn would serve tea and a snack of some kind-baklava, spinach cake, yaprak dolmasi (stuffed grape leaves), and so on. The language partners would work together on their parallel projects while the husband was in the apartment. Week by week, I made progress in my Turkish textbook.

Since I am a professional writer, I also proofread Freedom’s scholarly papers for colloquial correctness. Towards the end of the experience, I also helped Dawn translate three affidavits into clear English.

A few months into the adventure, the researcher invited his young friends over for a Thanksgiving dinner. The Turkish couple brought a bouquet of roses. Dawn brought a pair of fluffy slippers in a grocery bag to wear while visiting, which greatly fascinated the American six-year-old daughter. The families ate together, then sat in the living room and talked while the six- and eight-year-old girls frolicked. The guests enjoyed being around children.

Some time later, Freedom and Dawn invited the researcher’s family to their apartment for an iftar, the formal after-sunset feast held during Ramadan. That year, at the end of Ramadan, the researcher’s family had their friends over for a Bayram (Eid) dinner. Over the course of the project, the researcher had the Turkish couple over for dinner several times, and invited them to attend his daughter’s wedding as valued friends of the family.

Towards the end of Freedom’s master’s degree program, Dawn got a job translating for a Turkish family that had come to the USA seeking specialized medical care for their thirteen-year-old son. Dawn introduced the researcher to this family so that he could continue his informal self-study of Turkish. In May of 2006, Freedom completed his degree program, and the couple returned to Turkey.

I e-mailed them nearly twice as often as they e-mailed me (142 to 74). Fifty-one times, these exchanges involved the kind of practical help that a native speaker of English can offer someone whose native language lies completely outside of the Indo-European family.

These numbers are not asymmetric when weighed against the fact that I was a guest in their apartment approximately sixty times, and received from them the coaching I needed to acquire a rudimentary knowledge of Turkish.

Another goal of the encounters, to foster mutual understanding, was also apparently reached. In an e-mail from Turkey several months after their return Dawn wrote:

“Turkish people are religious people (of course not all of them but the majority). I saw the same thing in the USA. From the cinema and TV shows we watch through TV, American people seem like they don’t care about religion and they are very free about what they do in their lives. I think in real life it is not like that. As I see in your family, you care about your family very much and you try to teach your children about what is important in life for you. I think it is the same in Turkey.” (Gençer, 2006)

Second adventure

A second adventure in acculturation involved a Turkish family sojourning in the USA to seek medical care for a seriously ill son. The project began when Dawn introduced everyone at the clinic lounge. Later social encounters included picnics, and a series of language exercises at the hospital cafeteria.

The “Smith” family consisted of “Henry,” the father. “Margaret,” the mother. “Janet,” a seventeen-year-old daughter, and “Eric,” a son who had his thirteenth birthday while in a sterile ward of the hospital, undergoing bone marrow transplant therapy.

I met the family through Dawn, who had found work as a translator for the Smiths, helping them in their dealings with medical personnel. At one highly stressful point in their sojourn, the daughter’s student visa was revoked. Janet had curtailed her exchange student activities to find the university-connected health center, whose services offered the last hope of saving her brother’s life. As she was the only member of the family comfortable with the English language, Janet was needed at the hospital. Furthermore, Eric had only consented to the painful course of treatment because that ordeal gave him the opportunity to spend time with his beloved sister.

While Janet’s visa situation was being negotiated, she, Henry, and Margaret composed affidavits to plead their case. Dawn translated these into English, to the best of her ability, and asked for my help with a final edit.

At the initial meeting, following Dawn’s directions, I found the fourth-floor children’s lounge. Dawn took me in through the airlock, and explained how to put on the disposable overshoes. We went to Eric’s room. He was seated in his bed wearing pajamas and playing a video game. Janet, the big sister, was also present. Dawn and the parents, Henry and Margaret, escorted me to a visitor’s lounge.

We sat around a table, they offered me some donuts, and we conversed. Henry and Janet had an apartment near the hospital, but Margaret spent every night with her son in the hospital room. Dawn explained that American hospital personnel do not understand the intensity of the family bond in Turkish families. Apparently, it would be unthinkable for a Turkish mother to leave a dangerously ill child in the care of strangers overnight. She slept in an overstuffed chair in the room.

Janet’s visa problems were resolved, and I had banked some good will for my earlier efforts on their behalf. They were glad to hear that our church was praying for their son’s healing. After all, Margaret explained through Dawn, Christians and Muslims worship the same God.

I brought a few small presents, including a book of handy English phrases, listed with their Turkish equivalents, and the English repeated phonetically in the Turkish alphabet.

The Turkish tutorial sessions began in June 2006, and lasted almost six months. For our first tutorial session, Henry greeted me with a smile, and led me to the first-floor cafeteria. He was cleanly dressed, but looked as though he had missed shaving that day. I used an unobtrusive digital voice recorder to record the lessons. A continuous buzz of background conversation can be heard on the recording. Henry brought out several sheets of neatly hand-written Turkish sentences, and a brief essay describing his situation. The bulk of the conversation consisted of discussing the prepared lesson. I heard myself on tape frequently interrupting, and interjecting encouraging words (Yes! Yes!) and attempts at Turkish repartee. Henry spoke carefully, slowly, with frequent backtracking and repetition.

After we had talked for a bit over an hour, Henry asked, “Is that OK for today?”

“I’ve learned a little sentence in Turkish that goes like this: Affedersiniz. Kaybolduk. Bana yardým eder misiniz?” I answered. (Excuse me. I’m lost. Can you help me?) He laughed, I turned off the recorder, and we made arrangements to meet the next week.

Time after time, when we settled down to talk, Henry’s careful preparations guided the remainder of the conversation. He was in charge, genial, and seemed to take pleasure in imparting information, in helping.

We exchanged frequent e-mails to set up or cancel our meetings. Henry spent at least five times as long coaching my Turkish as I did his English. In part, this was because his English is much better than my Turkish.

Twice, Henry accepted an invitation to attend a picnic-one on the Fourth of July, sponsored by my church, the other a few weeks later sponsored by the Divan Cultural Center, a Cary, NC organization dedicated to fostering Turkish–American friendship. Both times, he and Margaret seemed to enjoy themselves, and delight in the opportunity to interact with other adults.

Even under conditions of weariness and extreme personal stress, this Turkish professional, a government-employed engineer, was unfailingly polite, and seemed to genuinely enjoy interacting with a sympathetic American. The format of becoming a tutor, a mentor, apparently provided a space of mastery during a time of uncertainty and anxiety.

Henry maintained control of the conversations, staying on the sure ground of a topic he knew well, the Turkish language. Although I was able to buy him a beverage once, he was careful to not let that happen again. When he attended a Fourth of July picnic sponsored by our church, he brought us a gift bag of imported delicacies. When he came to the Divan Cultural Center picnic, he timed his arrival to be after the food had already been mostly consumed. He was apparently wary of incurring asymmetrical obligations.

Conclusions

My family has “adopted” another young Turkish couple. This ongoing project involves several issues. How can an American establish rapport with people from a different nation, linguistic family, and religion? What can he learn once the rapport is established?

The technique of “turning the tables” helped insights and perspectives to cross the boundaries. By becoming a student of the Turkish language, I allowed people who were immersed in an alien linguistic environment to feel at home, and to talk about a topic they knew very well. By demonstrating a sincere interest in, and respect for, their home culture, I helped them to feel at home in my culture. By fulfilling the Turkish expectations of guests, I helped guests in my country to fulfill the satisfying role of hosts.

The first project demonstrates the progress of a mutually satisfying and symmetrical relationship with a Turkish family over the course of nearly two years.

The second project demonstrates how important control can be to a Turkish sojourner whose life has been shaped by traumatic events beyond his control. Although Henry often looked tired, he was always punctual and fully engaged in our conversations. The heart of each encounter consisted of animated conversation in simplified English and Turkish, a great deal of laughter, and a sense of delight in being able to make ourselves clear to one another in the other’s language.

What insights were conveyed over the bridges thus built? To some extent, Turkish sojourners and immigrants do indeed bring with them “differing perceptions of family, society, and ultimate duty.” For example, to avoid offending Turkish sensibilities, the wise westerner avoids extended contact with someone of the opposite sex unless the other party’s spouse is also present.

The longing all respondents expressed was for Americans to think beyond their own culture, and to take an interest in the different lives of people in other parts of the world. Given the Turkish enthusiasm for personal relationships, a small effort by a citizen of the United States can dramatically aid cultural understanding in both directions.

Thomas C. Smedley, MS, is a student at Regent University pursuing a doctorate in Communication Research. He is a technical writer with a special interest in building bridges between disparate communities – programmers and end users, Americans and Turks.

References

• Berry, J., Kim, U., Minde, T. and Mok, D. (1987, Autumn). Comparative Studies of Acculturative Stress. International Migration Review. 21-3, 491-511
• Gençer, N. (2005). Personal conversation.
• Gudykunst, W. & Ting-Toomey, S. (1988). Culture and Interpersonal Communication. Newbury Park, CA: Sage Publications, Inc.
• Teske, R. and Nelson, B. (1974, May). Acculturation and Assimilation: A Clarification. American Ethnologist. 1-2, 351-367.
• Weinstock, S. (1963, June). Role Elements: A Link between Acculturation and Occupational Status. The British Journal of Sociology. 14-2, 144-149.

Genetic counselling is the process whereby an individual or family obtain advice and information about a genetic condition that may affect the individual and family, their children and the wider community. The aim of such counselling is to enable appropriate decisions to be taken regarding marriage, reproduction, abortion, and health management.

Islamic teachings encourage counselling. The Prophet Muhammad, upon him be peace and blessings, said: The religion (i.e. Islam) is sincere counselling and good advice (Bukhari, Muslim). He also said: The counsellor should be trustworthy. Genetic counselling is a new field of medical practice that demands extensive knowledge of genetics, the management of genetic disease and how it impacts on the individual, the family and the community at large. The counsellor must therefore be knowledgeable in the field, otherwise he will be answerable. The Prophet said: If a person practises medicine without appropriate knowledge, then he is liable (Abu Dawud). Experts in Islamic law explain that the person must be proficient in the particular field of medicine he is practising; it is not sufficient to know general medicine, the person must have obtained the appropriate specialist training. The Prophet said: No man is wise except through experience (Bukhari, Muslim).

In addition to knowledge and proficiency, the counsellor needs also to be considerate, compassionate and able to guard the confidentiality of the information he is given. The Prophet said: Whoever guards the secrets of a Muslim, God will guard his secret in this life and on the Day of Resurrection (Muslim). And: God will show mercy to those who are merciful to people (Bukhari, Tirmidhi, Ahmad, and others). Being considerate and kind, and giving good advice to those who seek it, is the basis of Islamic ethics in general and medical ethics in particular. The worst thing of all is doing harm intentionally or even unintentionally, the former being a crime and the latter an offence. This rule is derived from the explicit injunction of the Prophet: Do no harm nor return harm with harm (Abu Dawud).

The genetic counsellor may not impose his views on his clients. Rather, he must let them reach their own decisions. The counsellor’s responsibility is to enable his clients’ responsibility by providing them with the necessary facts and information in plain language that they can understand easily and fully.

The Islamic creed places the highest value on personal freedom and hence upon personal responsibility for one’s actions. The genetic counsellor should therefore provide the best available information, and then give the most sincere advice without trying to impose it: the clients must reach any decision themselves.

Genetic diseases

Monogenic diseases, i.e. diseases inherited through one gene, constitute only 10-15% per cent of congenital diseases and malformations in the population as a whole, but account for a much larger percentage of childhood diseases: in many Western countries, for example, some 50% of all deaths of children up to age 15 are attributed to hereditary factors.

Many of the most common diseases world-wide, e.g. diabetes mellitus, hypertension, ischaemic heart disease and cancer, have a hereditary component. Many neurological and psychiatric ailments are either monogenic hereditary diseases or heredity is a major causative factor. Similarly, diseases of the blood are either directly caused by a monogenic hereditary factor, or other hereditary factors have a major causative role. Thalassemia and sickle cell anaemias are examples of autosomal diseases that cause malady and high morbidity in many countries, notably in the Mediterranean and Arab world.

Close-cousin marriages and their consequences

Consanguine or close-cousin marriages are commonplace in most Arab countries. The incidence of genetic diseases is correspondingly high; for example, 5-10% of the population as a whole carry the gene for thalassemia. Islamic teachings do not forbid but do discourage first cousin marriages – i.e. insofar as they are permitted at all, such marriages are only allowable exceptionally, not encouraged as the norm. It is narrated that when it was brought to the attention of ‘Umar ibn al Khattab, the second Caliph, that the children of the Bani Assayib were often weak and sickly, he advised this tribe to avoid close-cousin marriages and to seek spouses for their children from remote tribes; he said: ‘Marry from remote tribes, otherwise you will be weak and unhealthy.’

Responses in the Arab world

In the first half of this century, many Arab governments (Egypt, Syria, Lebanon, Tunisia, Morocco and others) made a premarital medical examination mandatory. However, this had little effect on the incidence of consanguineous marriages or hereditary diseases as there were no means for searching out carriers of genetic diseases. In any case-as we are bound to note with deep regret-a medical certificate was often provided without even a routine medical examination.

Several recent symposia (for example, in Amman, Jordan, 10th August 1994) have discussed the implementation of a law making it obligatory to test for the thalassemia gene as a precondition for granting a marriage license. However, there are immense difficulties with this policy. The cost of such a test would be huge. Who would bear the cost? Most governments could not do so, and if they could, it would be by diverting funds from other more urgent medical needs. Individual citizens might decline the test or evade it on the grounds of poverty. If made compulsory, it is possible that medical certificates might be forged or false certificates sold for money. More serious is the question of personal autonomy: even if such tests could be funded and carried out with integrity, who could compel a couple, either or both of whom showed positive, not to marry? Attempting to do so would surely be, if at all practicable, wholly unethical.

In the case of such a couple, a number of alternatives might be put to them:

1. contraception or sterilization to avoid pregnancy;
2. adoption;
3. donation of a sperm or ovum or pre-embryo;
4. pre-implantation diagnosis;
5. diagnosis during pregnancy (e.g. chorion villus sampling, amniocentesis, blood tests from the expectant mother and the foetus, ultra sonography, etc.)

Each of these procedures needs to be scrutinized from an Islamic perspective:

1. Contraception and sterilization

Contraception is allowable under Islamic law as a temporary measure if the couple decide upon it and if there is no harm from the particular method used. Sterilization, however, is not acceptable unless there is danger to the mother’s health from pregnancy. Most couples long to have children and will not choose sterilization unless there is a serious impediment preventing safe procreation in their case. As infertile couples are willing to pay out huge sums of money and go to great lengths to have a child, it is impractical to expect couples carrying a recessive gene such as for thalassemia to opt for sterilization. Everyone of us carries some recessive genes and no-one will choose celibacy or sterilization for that reason alone.

We may note that there is support for sterilization from at least some of our jurists in the situation where a couple have already had some congenitally affected children and some not so affected, in which case they might accept this option.

2. Adoption

Adoption was abrogated by the Qur’an, and in Islamic law adoptive parents are not recognized as parents in the way that natural parents are. The child must be attached in lineage to his or her natural parents, and legitimate pregnancy is, according to the law, only within wedlock. The Qur’an says:

He did not make your adopted ones your sons. That is only a saying from your mouths which has no reality. Call them by [the names of] their [true] fathers. That is just in the sight of God. But if you do not know their fathers, call them your brothers in faith or your mawlas. There is no blame on you if you are mistaken. What counts is the intention of your hearts, and Allah is oft- forgiving and most merciful. (33, 4-5)

Bringing up orphans is a highly commended act of charity, encouraged by Islamic teachings, but even then the lineage of the child must remain to his or her natural father. Therefore, while a couple who are carriers of a lethal gene or a gene that carries a risk of great malady and morbidity for their offspring cannot become natural parents, they can nevertheless adopt one or more orphans in the sense that they can look after and care for them and have all the rewards of bringing them up.

3. Donation of a sperm, ovum or pre-embryo

In the West, a new technology of procreation is being made available to infertile couples. This technology, making use of semen banks and in vitro fertilization techniques, may involve donated sperm or ova, a donated pre-embryo (blastula or morulla), or, in the case of surrogate motherhood, a None of this technology is acceptable in the view of Islamic teachings which recognize procreation only within the bounds of wedlock excluding any third party from the process. Therefore, a Muslim couple who are carrying a lethal gene or serious disease gene cannot make use of either donated sperm or ova or pre-embryos or surrogate motherhood. These methods are refuted by all Islamic jurists on the grounds that procreation must be limited to the spouses alone, without the intervention of third parties.

4. Pre-implantation diagnosis

Advances in medical technology over the last decade or so have made it possible, at least in some specialist clinics, to remove one or more cells from donated womb, the blastula (pre-embryo) prior to its implantation in the womb. A husband’s semen is allowed to fertilize in vitro the ovum taken from his wife; when fertilization occurs, the zygote is allowed to grow to the blastula or morulla stage – this happens a few days after fertilization. If genetic disease or chromosomal abnormality (e.g. triosomy 13, 18 or 21) is suspected, one or more cells are taken from the blastula for appropriate testing. If the blastula is shown to have the defective gene or chromosome, it is discarded and another one tested. Only the unblemished blastula is reimplanted.

The main disadvantage of this technology is the low rate of success after reimplantation (pregnancy rate 30% in the best centres; while take-home-baby rate is around 15%). The merit of the method is that it avoids abortion. The technique is also paving the way for gene therapy and manipulation at an early stage: as yet unfeasible, this will surely be possible in the near future. However, along with the technical problems facing gene therapy, there are also a number of ethical problems (see below).

5. Diagnosis during pregnancy

Better and more accurate diagnoses of congenital malformations, genetic diseases and chromosomal abnormalities are becoming available with the tremendous advances in medical technology.

Simple blood tests from the expectant mother can help the diagnosis of, for example, alpha feto proteins in cases of neural tube defects, viz. anencephaly and spina bifida. Ultrasound can detect many dysmorphic abnormalities as well as congenital defects of the heart, brain and kidneys. CVS or chorion villus sampling, which can be done during the 8th week of pregnancy, can detect genetic and chromosomal defects when suspected. So too can amniocentesis but at a much later stage of pregnancy, between the 14th and 16th weeks. The advantage of early diagnosis by CVS is offset by higher percentage of abortions and complications (2-3%), compared to amniocentesis which is safer albeit giving a much later diagnosis. The couple are offered the choice of abortion when a serious congenital or hereditary disease is discovered.

The Islamic Jurisprudence Council of the Islamic World League in its 12th session (Makka, 10- 17 February 1990) agreed a fatwa by majority vote which allows the option of abortion to the parents on the condition that the pregnancy is less than 120 days old (computed from fertilization and not last menstrual cycle); that a committee of specialist experts have decided that the foetus is grossly malformed and that its life would be a calamity for the foetus and for the family; and that the malformation is very serious and neither treatable nor manageable. On the basis of this fatwa, abortions of foetuses with serious congenital diseases are carried out in the hospitals in Saudi Arabia.

Unanswered ethical questions and dilemmas

There are many dilemmas. Is it allowable to abort a foetus showing Downs syndrome although even with this condition it is possible to live a quiet, peaceful life? If the Huntington’s disease gene is detected, is an abortion justified, although the disease will not appear until age forty or even sixty? Is it permissible to abort those who are homozygous for sickle cell disease or thassalemia or phenyl ketonuria or homocystinuria? For the last two diseases mentioned there is a treatment, namely to avoid foods that contain phenyl alanine or methionme. There is some treatment possible also for the haemolytic anaemias, namely blood transfusion and iron chelation therapy (desferrio-xamine injections).

It is greatly to be hoped that in the not too distant future advances in gene therapy will remove the need to consider abortion in such cases. In the meantime, the best policy is to encourage couples considering marriage to have pre-marital medical examinations for the infectious and hereditary diseases common in their community. It is also important to educate people more effectively and actively about the dangers of consanguineous marriages which, as noted earlier, are very common in most Arab countries.