August Issue 2012

When Dr Unaiza Niaz did not get the well deserved academic position of professor of psychiatry at Dow Medical College or the Jinnah Postgraduate Medical Centre, primarily because of the quota system (she had a Karachi domicile), her academic pursuits became the focus of her life. Today she is regarded as one of the top academic women psychiatrists internationally.

Dr Niaz has authored Wars, Insurgencies and Terrorist Attacks: A Psychosocial Perspective from the Muslim World, a look at the psychological history and etiology of terrorism and terrorists across the Muslim world.

Sitting in her bright and airy office on Zamzama, Karachi, Dr Niaz is very voluble as she speaks to Newsline about her book, terrorism and the impact it has had on the Muslim world, in particular women and children.

You say that there is a lot of literature available on the psychological effects of war on British and American soldiers and their families but not on their Iraqi or Afghan counterparts. Why is that so?

The researchers and writers are from the West and they are, understandably, interested in their own soldiers. In Iraq and Afghanistan, the infrastructure was destroyed and some of the doctors died or immigrated. There was also no time for researching and writing as their hands were full with treating patients. It is, however, the responsibilty of psychiatrists in Muslim countries to research, write and publish works on this subject.

The problems in the Muslim world include the low literacy rate as well as poor higher education and research facilities. Additionally, the number of mental health professionals in the Muslim world is also miserably low. In the developing world, favouritism and lack of a merit-based research environment are the main reasons for the paucity of literature on the subject.

Language is also a problem, as the international journals are in English. Turkey, Iran and Egypt are a few of the countries that have done research and academic work in psychiatry.

Writing skills need to be developed right from the start of a psychiatrist’s career. In the developing world, few psychiatrists at the helm of affairs allow juniors to grow and develop professionally.

Why did you decide to include so many countries in your book rather than focus on Pakistan or Pakistan-administered Kashmir for instance?

Initially, the intent was to only write about Pakistan and Pakistan-administered Kashmir, but I changed my mind and broadened my focus after attending a Pan-Arab Congress on psychiatry in Syria.

The presentations on violence and people’s sufferings at the Congress were moving and extremely painful to digest. I felt something must be done by psychiatrists in the Muslim world to create awareness, globally, of these miseries which have gone on unabated, particularly in the last few decades. The Jewish psychiatrists have written extensively about the Holocaust survivors. We could use this model to sensitise and create awareness in the world about the sufferings of innocent civilian populations in the Muslim world.

It seemed crucial to me as an office-bearer of the World Psychiatric Association (I am, more specifically, Chairperson of the Section on Women’s Mental Health), to write about the significant psycho-social trauma suffered in the Muslim world by the vulnerable groups (women, children and the elderly) as a consequence of wars, insurgencies and terrorist attacks in our recent past. Hence the book!

Why are women more vulnerable in “situations of adversity?”

Women are often considered particularly vulnerable in conflict situations. Coping with displacement, physical and sexual violence, missing relatives, widowhood and detention are the common challenges and difficulties they encounter.

A large number of women in wars may end up having to bear the burden of becoming the main caregivers of their families, as their husbands have gone missing, thus leaving them to shoulder the unfamiliar duty of providing for their families.

There is growing recognition by international organisations of the specific risks that women face in refugee camps according to the United Nations High Commissioner for Refugees. Women who search for refuge from the misery and privation of armed conflicts may end up experiencing further harassment in the refugee camps or settlements which, from an outside perspective, are perceived to be a safe environment

You say that “90% of the casualties are civilians.” How are civilians affected by modern warfare?

Modern warfare is no longer restricted to the traditional battlefields. It is affecting civilian populations as well. The United Nations maintains double standards on human rights for the developing and developed countries. The old adage, “all is fair in love and war” has never been more true than it is today. Humanity is dwindling fast; materialism and power are the new global religion.

Muslims are not just the victims of war. Most terrorist attacks are, in fact, perpetrated by Muslims “who are not mentally ill.” What then leads a person to resort to terrorism?

There is an entire chapter in the book devoted to this topic.

Common sense and experience tell us that people who are badly treated, and/or unjustly punished, will seek revenge. Certain life experiences tend to be common among terrorists. Histories of childhood abuse and trauma appear to be widespread. Themes of perceived injustice and humiliation often are prominent in terrorist biographies and personal histories.

It is not just political injustice that hurts these individuals but it is intellectual and emotional deceit as well which damages them. And the wounds caused by this betrayal, if not properly healed, can project a subtle resentment against the world which could prove to be subversive; it is the bitter heart that pulls the trigger of a gun.

There are also the cultural factors. We know that 9/11 changed the world overnight. The effects of the war in Afghanistan have destabilised the entire region. The heavy arms and ammunition left over from the previous war made the situation in Afghanistan explosive beyond control.

Terrorist violence, most often, is deliberate (not impulsive); it is linked to and justified by ideological (e.g., political, religious) objectives, and almost always involves a group or multiple actors/supporters. These issues all add complexity to the construction of terrorism as a form of violence and challenge the emergence of a unifying explanatory theory.

How did you go about researching the history of so many countries and obtaining the statistics of psychological trauma suffered by the populace?

I discussed this topic with internationally known researchers and colleagues and I did my own research as well. I contacted academic libraries in the UK and the US for authentic statistical data and published original research papers.

I have worked in the field of psycho-trauma for the last two decades. I worked with the Pakistan earthquake survivors and published the book, The Day the Mountains Moved: International Perspectives on Handling Psycho-trauma.

You have visited several refugee camps in Afghanistan and Pakistan. Were you there essentially as an observer or a researcher?

I went there mostly to handle the psycho trauma in victims needing professional help. I held supportive group therapy sessions for adults and children. I also conducted short courses to help mental health workers, medical officers and social workers/volunteers handle trauma survivors in the refugee camps.

How do symptoms of psychiatric illnesses vary depending on the circumstances?

There are standard psychiatric problems with specific symptoms which are standard more or less the world over. Symptoms are mostly psychosomatic in the developing world, though the presentations may vary according to culture. Disasters, wars, terrorist attacks and insurgencies have their own range of symptoms.

Individual physical and mental health, psycho-social support and personality are important factors in the presentation of an illness, its progress and then the recovery. The quality of care, a good rapport with the psychiatrist, and family support ensure steady progress and recovery.

You say that “people don’t become used to violence they become more vulnerable.” Can you elaborate on this statement.

The cumulative effect of violent episodes does not necessarily make people more vulnerable. It depends on the age, the type of violence, gender, and physical and mental status at the time of the violent episode. Family support and professional psychiatric care by trauma experts can help in developing resilience.

Relentless, unabated violent episodes, as seen in Palestine, Kashmir and the Afghanistan war, may cause complex trauma and the well known trans-generational psycho-trauma (TGPT), which leads to genetic changes and trauma vulnerability in the coming generations. Simply put, the next generation acquires symptoms that are very similar to those of the survivor generation.

So stress in early childhood can also affect the developmental process and the effects of trauma can be transmitted through generations. Is there any hope for these victims?

Hans-Otto Thomashoff, in his book Roots of Human Violence, states: “That by incorporating the knowledge of neurobiology, psychoanalysis and psychology a concept evolves, which reveals a series of influences on the aggressive potential an individual will develop as a character trait or under the specific environmental circumstances.”

According to him, aggression is not a biologically inborn drive. In fact, it is a reactive behaviour to frustration. Though aggression is genetically predetermined, it is built up by stress experiences (through the release of the stress hormone cortisol) starting much before birth, possibly in the third month of pregnancy (hence, giving rise to more aggressive children in war zones). Any experience, starting at this early point, is transformed into stored information in the brain and will influence all later experiences.

More than six decades of the unresolved Palestinian conflict, the recent Iraq War and presently, the Afghan War will clearly impact the mental health and have serious repercussions on the children of these regions.

The ensuing detrimental, possibly irreversible neurological and anatomical changes, in the brain of fragile minds and the consequent maladaptive behaviours in children in war-zones must be highlighted by the mental health professionals at professional forums.

Can these victims be helped by medication or by therapy?

Standard treatment includes drug therapy, psychotherapy, group therapy and different types of trauma therapy. In some victims long-term follow ups may be necessary, which should not be considered taboo. Trauma sometimes causes biochemical changes in the brain which may abate with medication and therefore long-term follow-ups are needed. If there are signs of biochemical changes in the brain, medication is needed.

Which country has received the most assistance in fighting psychological trauma from agencies like the UN and the World Health Organisation (WHO)?

Palestine, as they have had 62 plus years of ongoing war. Most of the United Nations Relief and Works Agency’s (UNRWA) funding comes from European countries and the United States. UNRWA provides food aid, cash assistance and helps with shelter repairs. UNRWA’s microfinance department (MD) extends micro-credit and complimentary services to small entrepreneurs, households and businesses.

Fundamentally, all lending seeks to empower the MD’s clients, and in this respect particularly targets women and youth, as well as other economically and socially vulnerable groups who face particular challenges in obtaining affordable credit.

The Mental Health Directorate in Gaza has emphasied the need for psychotropic drugs and vehicles for crisis intervention teams.

Have you visited most of the countries you have written about? Where does the the future look most bleak and why?

I have visited most of the countries, except Lebanon and Iraq. My recent trip was to Gaza, Palestine. This is a country or strip which has the most unique Muslims in the world. They are highly educated, resilient, positive, balanced practicing Muslims, with a very positive attitude and an amazing faith that they will succeed in achieving their lost sovereignty. Compared to Pakistan, they are confidently constructing and reconstructing their country, with determination and faith in their cause. I salute the people of Gaza.

When I visualise this scene I feel the possibility of a great future for all us Muslims. Gaza has a 90-97% literacy rate, there is no overt violence, though it is the world’s largest open prison on earth. Bomb strikes and firing from the Israeli border take place frequently and fuel outages are the norm. Pakistan, particularly Karachi, sadly seems like hell compared to the apparently peaceful, brave and heavenly city of Gaza.

You end your preface with a poem by Khadim Hussain.

“Now the land of flames, bombs and armoured cars, I can’t imagine the nightingale singing…”

Khadim is talking about Afghanistan, a war-ravaged country. Afghanistan especially Kabul, was a very modern country which has been pushed to the middle ages. I went for a visit and it was like being on the moon. What an amazing contrast when you step across the border from the greenery of Pakistan into the desolation that is Afghanistan. Not a twig in sight. The ground is like talcum powder. It was a frightening contrast, seeing the horrors of war and the cluster bombs.

This article was originally published in the August issue of Newsline.