Essay
Conflict and its aftermath: the experience of civilians
VIOLENCE is a phenomenon intrinsic to class-based societies which are inherently unequal and oppressive. Violence here may either take implicit forms in the manner of institutionalised oppression and inequality, or a more explicit form of state oppression through the use of state sanctioned institutions, such as the police, the military and courts. It could even assume a more direct form, whereby civilians manage the task of a weakened state through militia groupings. Large-scale violence may also take the form of mass uprisings against the oppression of dominant classes, or turn into a civil war with different classes battling it out for the reins of power and control of the forces of production. In all this, the role of imperialist forces cannot be underestimated in the quest for land, labour and natural resources and in reinforcing the brute power of the supra-national state.
Civilians are increasingly being targeted in these episodes of contemporary violence. To reduce military casualties, civilians are used as protective shields; to facilitate guerilla warfare, they are abducted or enslaved; torture, rape and executions are carried out to undermine morale and to eradicate the cultural links and self-esteem of the population. Most civilians in zones of conflict witness war-related traumatic events such as shooting, killing, rape and loss of family members. The extent of psychosocial problems that results from this mass exposure to traumatic events can ultimately threaten the prospects for long-term stability in society (de Jong, et al 2000) and yet remains little acknowledged by policy-makers. This is particularly true of the more endemic conflict regions in West Asia – notably in Palestine, Afghanistan and Iraq, as well as regions within the Indian subcontinent, namely Kashmir, Gujarat and the North East.
Despite growing evidence over the past two decades of the terror – both of the physical and mental dimensions of war upon civilians – much of post-conflict activity tends to concentrate on physical reconstruction – roads, bridges and more recently oil wells. In addition, even though psychological and psychic injuries can have equally, if not more damaging, long-term consequences as other injuries from a situation of conflict, they remain undetected and distanced from any plans for rehabilitation. Partly this is because these injuries are difficult to fathom in terms of the enormity of scale and the delayed manifestation of symptoms which can sometimes take years to surface. Equally because historically, it has been difficult to collect evidence from the field due to the practical problems of conducting studies in war zones. Furthermore, mental health issues continue to carry a major stigma and remain little understood; thus to avoid them is an easier option than to have to deal with them.
‘Physical violence maybe easier to identify, name and quantify than psychic or symbolic violence. We can always do a body count, discern patterns in the amputation of limbs and explore a torturer’s agenda by the mark he leaves in his victims’ body. On the other hand, the workings of symbolic violence are often more elusive but may be equally devastating in the long run.’ (Robben and Suarez-Orozco 2000.)
The instruments currently available to gauge trauma among civilians also remain poorly developed, with a focus on the individual and individual symptoms dislocated from their socio-political and economic contexts (American Psychiatric Association, Diagnostic Manual 1994, Summerfield 1995, Mollica et al 1997). Few studies have been undertaken in the developing world to assess Post Trauma Stress Disorders (PTSD). Research on traumatized civilian populations is also rare since the focus of much of this research has until recently been on combatants. As a result not much is known about civilians who are not directly involved in war. According to a recent review (Hamblen and Schnurr 2002) civilian stressors includes life-threat; being bombed, shot at, threatened or displaced; being confined to one’s home; losing a loved one or family members; financial hardship; and having restricted access to resources such as food, water and other supplies. Particularly horrific war stressors include torture, beatings, rape, forced labour and witnessing sexual abuse of or violence towards a family member and mock execution (ibid 2002).
Thus, studies in regions such as the Middle East (other than a plethora of studies on Israeli citizens, see Hamblen and Schnurr, op cit 2002) or Africa have been severely neglected. In India, neither from Kashmir nor from the Northeast, have such studies been reported, although violence, particularly against civilians, has been endemic in both these areas for decades. Even the impact of more recent political and civil violence in Punjab or Bengal and Telengana in earlier decades has not been studied from this perspective. Only in Gujarat have there been some limited attempt to document and treat PSTD over the longer term – although the impulse for this has come from earthquake-related events rather than the recent pogrom. In other parts of Asia too there has been a remarkable dearth of such efforts, perhaps because the methodology for doing such studies is not too well understood. For example, an innovative study of ‘suffering’ undertaken among refugees of Vietnamese origin in the US suggests that traditional instruments utilized to measure levels of trauma require urgent re-examination (Candib 2002).
Gauging violence-related trauma may require special disciplinary tools. The Vietnamese study, for instance, found that the enormity of pain and psychological distress involved in the life cycles of survivors of war and torture may not be fully understood through the sole use of traditional diagnostic tools with their highly clinical measurement criteria. Candib, for example, suggests that the suffering of people exposed to war events, especially those of a prolonged nature, may not be expressed explicitly or be accurately understood through simple instruments (Candib 2002). According to Robben and Suarez-Orozco (2000), collective violence, as in the killing fields of Vietnam or Cambodia, state-generated terror in Latin America, and the mass rapes in former Yugoslavia, cannot be reduced to a single level of analysis, simply because these have targeted not only the body, but the psyche as well as the socio-cultural order of the groups affected.
In such a context, the present study is rare because it is one of very few that considers the levels of depression and PTSD in a population group that has experienced chronic conflict for nearly two decades through internecine warfare as well as substantial external aggression through frequent Israeli invasions. It is based on primary data collected among Lebanese and Palestinian populations in Lebanon in the late 1990s, undertaken to gauge the effects of 17 years of civil war and external aggression and to ascertain the differential coping strategies. Few studies have been undertaken among this population, though during our literature search we found two, which suggested that the loss of loved ones and the destruction of social networks (Farhoud, et al 1993) had a far more damaging effect than did the loss of limbs among survivors. The main objective of this study was to impress upon policy-makers the utmost urgency to consider the emotional well-being of the population in their plans for reconstruction in the aftermath of conflict.
Farhoud’s earlier community health survey in Greater Beirut indicated that even though the prevalence of depressive symptoms was higher among mothers than fathers within the family, for adults these symptoms were positively associated with both war-related events and reduction in social networks. In contrast, among adolescents, reduction in social networks was the only significant dimension (Farhoud et al. 1993). Similarly, a 1996 community study conducted by Karam et al. showed that the prevalence of PTSD was inversely influenced by the frequency of symptom occurrence (Journal of Traumatic Stress 1996). These two studies, therefore, reinforce the hypothesis that social institutions and cultural practices have a major influence in structuring experience and in giving meaning to human lives and may be reinforced and supported by social networks that may have been severely fractured and dislocated during conflict. Social structures may provide and allow meaning in human lives.
The present study carries the hypothesis further and demonstrates that, while coping strategies were to a large extent determined by social variables, there was a differential impact of violence upon civilians experiencing mass terror. For the Lebanese groups, the greater the understanding of the reason for the war the easier was the coping strategy. For Palestinians, on the other hand, the belief that their entire history was one of facing the threat of annihilation (‘for us the war has never ended’) rationalised the frequent violent assaults upon their community as inevitable and, despite higher levels of physical injury and death, enabled better coping than among Lebanese civilians. Among both groups, combatants had high rates of depression but lower levels of traumatisation. In the long term social relations were much more fractured among the Palestinians than among the Lebanese since large numbers of the former were expelled from Beirut following the Israeli invasion of 1982, fracturing once vibrant primary networks.
Briefly, the study involved three main phases. The first was a cross-sectional survey of around 2750 households selected randomly from Greater Beirut, including the Palestinian camps. The household survey targeted all individuals in the household and information was solicited from a key informant, usually the mother, with the objective to screen for disability and to assess exposure to war-related events. In the second phase, the 395 identified disabled individuals, between the age of 15 and 65 years, were inter-viewed to assess the nature and causes of disabilities, estimate war-induced disabilities, and examine current (formal and informal) social care arrangements and available support. The third phase of the study, the subject of this paper, was an in-depth study consisting of semi-structured interviews among a sub-sample of 107 subjects with the aim of assessing mental health (PTSD), social integration and the nature of coping. These 107 subjects were compared across three groups: those exposed to war-related events, victims of war-related physical injuries, and, those not exposed to either.
The quantitative part of the study showed that war perceptions, rather than objective exposure to war events or disabling war-related injuries, were crucial factors determining the state of mental health of our study population. In addition, the quality of emotional support was as important for depression as it was for PTSD cases. Finally, the overall health status of individuals (both objective and subjective) revealed itself to be more crucial among PTSD cases than among depressed cases.
The qualitative approach on the other hand gave rise to several thematic patterns. The interviewees had different ways of expressing their unhappiness and rationalizing what they had seen, yet there were underlying commonalties. Most depressed individuals cited financial concerns as their greatest worry – a factor that was not significant based on quantitative findings. However, when probed there were always other factors involved. It was true that in several cases material comfort reduced the long-term impact of the adversities on the person’s emotional well-being, yet these were not sufficient on their own.
Another significant factor was the amount of social support the individual received. In cases where the family had pulled together or the friends remained loyal, the person was likely to adjust regardless of the intensity of the injury or event. Finally, there was another factor that became apparent as we were interviewing the soldiers. These men had understood that they had taken part in a war, and that what they saw/experienced was part of their role. This became more apparent when we interviewed the women (Lebanese sample) that had been injured, and none could give a rationale behind their injury. All said they had been hiding indoors throughout the war. Actually only one of them was injured outside of her home. The idea that the event or injury could be explained was essential to coping with the event in its aftermath came across in all the interviews. The more they felt the war was meaningless, the worse they felt.
For instance, one male subject mourned his daughter more than he did his son, because his son had been a fighter whereas his daughter died a violent death during shelling and following a visit to her parents. Overall, the PTSD cases varied tremendously. Whereas one person was worried about his/her own loss, another was more worried about the loss of a loved one, while yet another was worried about a near loss. The issue of the ‘unknown’ and in particular of what might have happened was a critical factor in the condition of PTSD and continued to play a role long after the actual incident and the end of the war. Yet there was no one overriding pattern for the cases.
However, if one were to link one factor that kept them from recovering from their trauma, it would have to be the opportunity to heal. These people could not explain the tragedies they had experienced, nor could they locate anyone else around them who may have been able to do so for them. The anxiety levels remained high, and there was no calm period for them to reflect within. Any conflict within the region triggered levels of anxiety.
The surprising finding of PTSD cases among Palestinian ‘controls’ (technically unaffected by either witnessing an event or being injured) can be explained by several factors. In reality, there were in fact no controls among the Palestinian sample, since they had all been injured or witnessed some hard war events that was not disclosed at the time of the baseline survey. The second reason, which also explains the latter statement, is that the Palestinians were living, and continue to live, in very confined quarters. During the camp wars (1985-1988), the camps were surrounded and the shelling was very concentrated. Only those who were able to escape the camps did not witness or experience any harm. The final reason became evident as the cases were analysed, but it deals primarily with the period after the injury, and the social support received.
There are important points of divergence between the Palestinian and Lebanese sample. First, most of the Palestinians did not feel the war had ended. To them, the threat or fear of harm was still expected and real. In addition, most had not received any additional social support, nor any assurance of securing their well-being. Once they were injured or became single parents, their ability to provide for their families became minimal. This was a major negative factor contributing to the state of their mental health. For the Palestinians, social and cultural institutions were systematically devastated during the period of war and they were in effect left with little intact in terms of wider social institutions, unlike the Lebanese population, where facilities such as schools, health centres, roads and employment opportunities in particular were to a large degree re-established and revived community networks.
On the physical and psychological level, the work of healing most often includes some effort to restore some semblance of basic trust. At the wider socio-cultural level all healing involves reconstructing trust in the social institutions and cultural practices that give meaning to human lives. As previously indicated, it has been easier for the Lebanese to pick up the pieces and re-integrate where possible into the post-conflict world as their social institutions were reconstructed to some degree. Although, it should be noted, that this did not ameliorate the class conflicts inherent in Lebanese society and that continued to maintain its hegemonic form, through confessional ties and patrimony. However, for the Palestinian sample in Lebanon, their world continues to haunt them with little reconstructed and their current status being much worse than it ever was prior to the war. There has been no reorganisation of institutions to enable the population to live and to ascertain some degree of normality. For them the war never ended.
These findings may be of relevance to other conflict zones in Asia and Africa where, for substantial sections of the population, the ‘war has never ended’ over decades of strife. In both continents, there are parallels to the situation of the Lebanese and Palestinians population groups. This study not only provides some methodological clues about how psychological trauma may be explored in these populations, it also points the way to structures of healing. As we have seen, both quantitative as well as qualitative information is required to plan for intervention and to construct policy. Such information gathering has to be part of the process of establishing trust within victims. The re-establishment of physical infrastructure is necessarily crucial for those devastated by violence. But the restoration of social networks and institutions is as, if not more, important for the healing of physically and mentally damaged groups of people.
Hopefully, some of these lessons will be picked up by policy-makers and victims’ organisations in, amongst others, Gujarat, Kashmir, and the Northeast.
Kasturi Sen
(in collaboration with Abla Sibai)
* The paper is based on a major study, ‘War Injuries and Rehabilitation’ funded by the European Commission in Lebanon and Palestine between 1996 and 2000.
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