The tragedy of war.
Authors: Daya Somasundaram
Journal: World Psychiatry (2006)

The dire consequences of war, particularly for the civilian population, are only too well brought out by the survey of the psychological consequences of current conflicts by Murthy and Lakshminarayana. The nature and type of the man-made disaster called war has been changing in recent times. From direct fighting between countries for territory or conquest of land and world wars where several countries could become involved on each side, conflicts have increasingly become internal, within countries, involving ethnic and other civil groups against each other, typically low-intensity conflicts involving poor third world countries.

It has been estimated that there have been over 150 such wars since 1945, where 90% of all casualties were civilians. According to Bracken et al (1), what predominates is the use of terror to exert social control, if necessary by disrupting the fabric of grassroots social, economic and cultural relations. The target is often population rather than territory and psychological warfare is the central element. Atrocities, including civilian massacres, reprisals, bombing, shelling, mass displacements, disappearances and torture, are the norm. As can be expected, the consequences for mental health, not to mention the social, economic, cultural and other costs, can be substantial. The survey of studies in Afghanistan, Balkans, Cambodia, Chechnya, Iraq, Israel, Lebanon, Palestine, Rwanda, Sri Lanka, Somalia, and Uganda shows the devastating consequences.

Unfortunately, in such circumstances the resources to help those affected are extremely limited. In particular, the infrastructure of the  services can be destroyed and the availability of  staff, equipment and drugs depleted. There may be no mental  services at all (2), or they may be functioning at a very basic level.

Thus it behooves us as clinicians to look at how we can address these sequelae. Here, studies on the effectiveness of the various methods are insufficient.

Obviously, primary prevention of war itself would be best. Easier said than done! We may feel rather weak and helpless as far as decision making or finding a solution is concerned. However,  workers in areas of conflict have started emphasizing that as  professionals we cannot remain silent, we need to consider the ethics and take principled stand for victims and society (3,4). The medical profession has a powerful and persuasive voice. Particularly, if we can quietly raise one consistent voice for peace. Reports, documentation and publications are one way that the medical profession can bring pressure. Studies and surveys of the consequences of war can be very useful for advocacy and persuasion of authorities to use more peaceful methods to solve conflicts. Or, this can be in our day-to-day dealings and contacts, where we can take principled stands on issues and express our concerns, for example on such issues as landmines, child soldiers and torture. Another area of intervention, both for prevention and reconciliation, is at the national level, by influencing policy making, rehabilitation and international aid programmes. The World Health Organization (WHO) has developed the concept of using health as a bridge for peace (HBP). Internationally, many members of the medical profession, individually and as a group, have come out strongly against war. Medical organizations such as the World Medical Association (WMA); the Danish, Chilean and British Medical Associations, US Physicians for Human Rights, the American Public Health Association, and the South African National Medical and Dental Association (NAMDA) have clearly voiced their concern on the effects of organized violence and war.

Secondary prevention would involve the treatment of those in the population having the psychiatric disorders discussed in Murthy and Lakshminarayana's piece (5). There appears to be controversy on terminology and approaches. One fundamental issue stems from the narrow definition of mental health, which tends to delineate the psychiatric or medical end of the spectrum to the more general psychosocial problems encountered after a major calamity (6). Further, it is still not clear which methods are effective in such situations. Current practice ranges from psychological first aid and crisis intervention in the immediate aftermath to longer term psychotherapy, cognitive behaviour therapy, traditional relaxation methods, rites, rituals and traditional healing, pharmacotherapy, family and group work, and socio-economic rehabilitation. The WHO (7) has given basic guidelines for use in emergency situations. Special programmes to address the specific needs of vulnerable populations at most risk such as women, children, elderly and disabled will need to be implemented. In view of the widespread consequences affecting large numbers in the population, most authorities are agreed that community based approaches would be most appropriate (8). Psychoeducation for the general population and training of grassroot workers on simple mental  skills using manuals such as the WHO's Mental Health of Refugees (9) adapted to the local cultural context would be effective in ameliorating most of the basic ill effects.

When looking at tertiary prevention, psychosocial interventions integrated with rehabilitation and reconstruction efforts would be judicious. Here, recourse to the role of traditional practices, including cultural rituals and ceremonies to give meaning to what has happened, becomes important. The natural resilience of communities and coping strategies have to be encouraged and built upon. The widespread problem of collective traumatization is best approached through community level interventions. Further, community based approaches will enable one to reach a larger target population as well as undertake promotional public mental  activities at the same time. In these circumstances it may be more meaningful to look at how the community as a whole has responded, and what we can do at the collective level. For example, it may be more beneficial to consider strengthening and rebuilding the family and village structures, reestablish positive social processes, relationships and institutions. It is essential to avoid the development of dependence and learned helplessness found so often in displaced and refugee camps due to improper aid procedures as well as the passivity, conspiracy of silence and resignation due to the chronic violence. Local participation, resettlement, livelihoods, income generation, and vocational training are important to reintegrate affected populations in social and national life by helping them regain their self-confidence, esteem, dignity and motivation.