Shanta Choudhary (name changed) is smoking her fifth joint of the day at 5 o’clock in the evening as she gets ready to go about her business as a dancer at a local bar in Thamel. This 24-year-old girl from Chitwan fled her hometown and came to Kathmandu in 2001 to save her life and sanity from repetitive rape by the Maoist People’s Liberation Army (PLA) guerillas during the conflict, dubbed “People’s War” by them. [break]
Initially, the copious amount of marijuana that she has been smoking since 2001 helped her sleep; now it is just become a part of her daily life. However, despite being doped out every night, she complains of recurrent flashbacks, nightmares, and mood swings but refuses to go to a mental health professional for the fear of being stigmatized as “mad.” [break]When suggested that there are organizations she can visit for help, she dismisses them as a source of false hopes only and meddlesome to her daily life.
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On the unkempt lawns of the Mental Hospital at Lagankhel, drugged Mani Ram is oblivious to everything around him but insists that he has to go to the forest to find some khar grass to roof his house. His brother Fatte, a loader at a local grocery, has come to take his brother to a doctor. Mani silently obliges. He, along with Mani Ram’s wife Savitri, who has a small nanglo shop, takes turns to take care of him.
Mani was a subsistence farmer in Baglung. He saw his house, with his 6-year-old son, set ablaze during a PLA and Nepal Army (NA) engagement in 2001, and ever since has lost touch with reality.
“Villagers were the worst hit. But the magnitude of it never reached Kathmandu, perhaps that’s why people here are indifferent because they haven’t felt the impact of fear from violence,” says Fatte who was in Kathmandu during the decade of the civil war.
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The two stories are grim reminders of not what defines a war in all its glorified rhetoric and romantic martyrdom on paper but what happens to everyday life after it is over. The mental health practices in post-conflict settings in low-income countries like Nepal reflect what experts call a “rubber band” model of mental health, which assumes that once large-scale violence ends, life just snaps back to normalcy. Nepal is simultaneously emerging from a decade of unprecedented economic destitution and armed violence, whereby stress levels have skyrocketed, causing increased frequency of mental disorders and psycho-social problems. A large proportion of the population is thus likely to experience nightmares, anxiety and other stress-related symptoms. For many, the sense of hopelessness and helplessness associated with persistent insecurity and exposure to violence triggers ephemeral reactions; for others, it is as eternal as permanent brain damage.
In its March 31, 2002 edition, a feature in The Hindu (India) said that disharmony between the constituent parts within a society promotes a pattern of illness not only in individuals but extends to such macro-systems as societies and nations. When these symptoms of collective pathology are neglected over time, societies begin to degenerate and collapse into anarchy.
History serves examples of the psychological impacts of war: Survivors of the Cambodian Khmer Rouge Genocide (the Killing Fields, 1975-79) continue to grit their teeth at the fact that Pol Pot, the infamous perpetrator of the said genocide, died a free man in 1998. The ethnic war between the Hutus and the Tutsis in Rwanda, even after a supposed peace treaty, culminated to what may be called the biggest genocide in the 1990s that claimed more than 700,000 lives. The reconciliation of the ethnic communities is still an endeavor at best.
The Psychiatry Department at the Tribhuvan University Teaching Hospital (TUTH) at Maharajgunj examines some 60 patients daily. Out of them, two to four are cases of post-conflict traumas. Dr Saroj Ojha, senior neuro-psychiatrist, says, “Mental wellbeing is a grossly neglected area of health in Nepal.” For him, the main reason behind this is the overarching understanding that only “madness” means a mental health issue, and often people visit mental health professionals only after their pent-up problems consolidate into a pathological quandary. Ojha says this is due to the lack of awareness of mental health issues and absence of trained manpower in this field.
“There was a case,” he adds for emphasis, “where this man’s property was seized by the PLA during the war, and he’s suffering from acute depression. Think about it: Losing everything that one has accumulated in a lifetime within a blink of an eye is tremendously traumatic. It’s ironical that even at this sensitive transitory phase; there’s no consideration of any of these issues at policy-level analysis.”
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Currently, at the Birendra Sainik Hospital in Chhauni, two psychiatrists and two psychologists cater to the families of over 90,000 army personnel.
“Due to the lack of realization, some of them have come to us after two years of severe suffering from post-conflict stress disorder,” military doctor Major Namrata Rawal says. “It’s something that can be treated merely by a few months of medication.”
Disturbingly, even educated people are reluctant to come for counsel and treatment because of their need to ‘save face’ from the stigmas of owning to mental problems. “Even though we provide free treatment, soldiers and their families don’t approach us easily,” Dr. Rawal confirms the trend. While there is a dire need for capacity-building in this area, what is needed most urgently is a national level conflict-impact assessment study.
“People killed each other, neighbors and families became enemies. It was bloody and hard hitting. And one fine day, it was supposedly over, and everything was to go back to normal. How is that possible? Human psychology doesn’t work that way,” says Psychologist Chetana Lokshum, academician at Kathmandu University. Further, she observes that “social stigmatization” of mental health issues is one of the barriers that is bound to downplay any effort for psychological rehabilitation in Nepal. The sidelining of post-conflict traumas at a large scale could seriously hamper any rehabilitation and reconstruction attempts as Nepal would fail to produce or retain mentally sound manpower for post-conflict reconstructive endeavors.
The shame associated with admitting to being mentally disturbed is a gendered phenomenon globally; and in Nepal, the expression is further stifled by staunch norms of masculinity. The direct participants in the conflict – the army, the police, and the PLA, all associated with professional occupations – are considered more masculine than others, but no less vulnerable to this traditional belief system. While the war and recent political imbroglio have systematically managed to teeter the morale of the soldiers, police personnel, and the PLA cadre alike, there is a high probability that they may force themselves to dutifully shoulder the most traumatic of experiences for the fear of being branded as “weak” and thus incapable of bearing the responsibility of securing even a tattered state.
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Gauri Pradhan of the Nepal Human Rights Commission (NHRC) says, “The paradox in a post-conflict setting, as far as mentality is concerned, is that both perpetrators and victims suffer alike.”
In his experience, even culprits have tearfully expressed deep remorse for their actions that will probably haunt them till the day they die. The lack of outlets to express remorse for people involved in gross violations of human rights means that they choke up emotionally and suffer from acute psychological disorders.
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This issue is further complicated by Nepal’s ethnic diversity. Jagannath Lamichhane, Founder President of the Nepal Mental Health Foundation (NMHF), says, “There’s a social dimension to the experience of post-conflict traumas in Nepal.” He adds that while the culture of admitting to mental disturbance is virtually absent even among Nepal’s privileged castes and classes, the way in which an exploited Dalit would experience and deal with traumas is very different from the former. He concludes, “Depression and substance abuse are rampant among the lower castes. It’s especially substance abuse which often ruefully passes off as something ‘jataile payeko’ (typical to one’s lower caste) stereotype acceptance.”
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“Children are more vulnerable to impacts because they often either don’t understand or know how to express what they feel,” Tara Dhital, spokesperson for Child Workers in Nepal, a non-government organization working for children exposed to armed violence, says while expressing concerns for strong probabilities of development of a culture of violence in Nepali society.
“Psycho-social problems among children who have witnessed violence have largely manifested themselves in one of the two ways: profound depression, and extreme aggressiveness, depending on individual nature,” he says. “So, since most children and communities themselves are unaware of these problems, among other things, CWIN saw the need to train and position community-based social workers in areas that saw worst violence. They, in collaboration with schoolteachers, work with groups of children who have endured similar experiences.”
For him, the rationale behind this is to generate a ripple effect in understanding and dealing with traumas caused by conflicts.
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While terms like “reconciliation” and “rehabilitation” feature prominently both in popular rhetoric and verbose post-conflict reconstruction strategies in Nepal, mental rehabilitation is pathetically sidelined as a trivial component of peace building. At the government level, expecting a specific project with funds for mental rehabilitation out of an estimated budget of, say, over a billion Rupees credited to the Ministry of Peace and Reconstruction passes off as an ambitious idea. Besides this, mental health is allocated less than 0.80% of the total yearly budget for the Health Ministry. In addition, the mental health policy of Nepal, drafted in 1995, is yet to be formulated into a Mental Health Act. This national contingency, actually, seems to be the assumed responsibility of a few INGOs working in this area. The domestic stigma attached to the term “manasik samasya” (mental problem) deems it not sexy enough for activism, let alone research. Internationally, too, it fails miserably to garner sufficient donor attention due to the lack of local ownership of this agenda.
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“There are three actors in every Third World conflict,” The Independent of the UK reported on June 16, 2004. “The soldier with the gun, the politician who stands behind him has a voice, but the civilian has only a pair of legs, only good for running and often not fast enough.” All three have suffered to varied degrees, and all of them need healing, albeit in different capacities and in respective ways.
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At home in Nepal, though, it has already been three years into the signing of the Comprehensive Peace Agreement (CPA). Yet the sad fact remains that little is known about the injurious impacts of conflict in the minds of those who have survived multiple traumatic experiences. Further, and equally disturbingly, and even at this juncture, the only entry point that experts see, in order to deal with this issue, is awareness generation among the general population regarding mental traumas so that they are at least receptive to any step that can be taken in this regard.
However, numerous national and international brainstorming sessions to design a grand plan for the reconstruction in Nepal to “actually” cope with a legacy of a tumultuous past continues to juxtapose itself as an awkward and unattended question.
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