Faraz Ali* is among the hundreds of thousands in the former Federally Administered Tribal Areas (FATA) to have experienced the violence of the War on Terror firsthand. Faraz survived a bomb blast close to his office in 2010, at a time when the terror attacks were at their peak.
Faraz’s life came to a standstill owing to the psychological damage caused by witnessing a bombing at such close quarters, as the region continued to reverberate with explosions. He underwent psychiatric treatment for around two years in Peshawar and gradually returned to a normal life. However, the bomb blast still echoes in his head.
“It was a normal day. I was getting ready to go to the office. And yet, that day, I woke up somehow sadder than usual. I arrived at the office around 9 o’clock and started my normal office work,” recalls Faraz.
At around 11 ’o clock, while many in the office including Faraz were taking their tea break, there was a massive explosion. It left the windows and doors of the building shattered.
“I fell from my chair to the ground. For about 20 minutes, I could not comprehend anything. My brain was not working at all. All I could hear was people screaming. I had no idea what was going on,” Faraz adds.
Sirens of ambulances gradually started ringing around the office, and by the time the survivors came out the area had a strong stench of gunpowder. Corpses and body parts were scattered across the ground, which made Faraz fall down unconscious again.
“When I opened my eyes two hours later, I was in the hospital. When the family brought me home, I was not able to speak. Literally, no words came out of my mouth.
‘When I opened my eyes two hours later, I was in the hospital. When the family brought me home, I was not able to speak. Literally, no words came out of my mouth.’
“At night, I took the doctor’s prescribed sleeping pills. As soon as I fell asleep the scenes from the day haunted me again. I kept waking up again and again. My heart was pounding and I was crying in anguish.
“This went on for several days. I took sleeping pills and the tranquilisers prescribed by local doctors, but over time I became more and more restless. Then I consoled myself and started consulting a psychiatrist.”
After 2007, there was a reign of terror in former FATA, which in 2018 was formally merged with Khyber Pakhtunkhwa. The relentless spree of bombings and targeted killings faced by the residents of FATA, and the mental toll that terrorism took, was unparalleled. Suicide attacks have not only killed thousands, the war has also left deep economic, social and psychological imprints. And yet mental wellbeing continues to remain neglected with the health infrastructure painting a sorry picture.
If long-lasting peace is not restored in these areas, and the locals not provided psychological and financial support, the mental health in the region will only be aggravated
The data unveiled by the former FATA Directorate of Health underlines the dire straits that health facilities generally find themselves in. The condition of hospitals is visibly wretched, with severe shortage of medical staff along with modern health tech.
The merged tribal districts have around 1,000 health care centres, which include 461 Basic Health Units (BHUs), 215 community health centres, and seven district headquarter hospitals.
Owing to the violence in the region, the foundations of 39% of the health centres in Pakistan’s tribal districts have been impacted, while 85% of the buildings have been partially damaged. 15% of health centres have been heavily damaged leaving the buildings on the verge of collapse. The BHUs in the tribal districts are facing, on average, 25% shortage of doctors and other medical workers as compared to the staff requirements.
A further breakdown shows a shortage of 35% lady health workers and 28% technical practitioners. Only 14% of the staff of lab technicians is present in the entire ex-FATA. North and South Waziristan especially lack medical officers in the BHUs, with the latter only having 14% medical technicians.
Across former FATA, Medical officers are 47% less than required, with female medical officers nonexistent. Health centres only have 7% nurses, none of whom is female. Only 29% of district headquarters hospitals have physicians. There is a 50% shortage in dental surgeons with only 29% ophthalmologists and 36% gynecologists available.
The psychiatrist also went through trauma owing to many cases in IDP camps. She narrates one case where a woman who had given birth to twins, was pressurised to kill, or give away, one of the two who was weak
Given these numbers, and the overall neglect for mental health, observers aren’t surprised by the fact that no psychiatrist was appointed in any district hospital in ex-FATA until last year. In the merged tribal districts of Khyber Pakhtunkhwa, the provincial government has recently set up seven temporary centres to help people with mental illness.
Khaula Ismail, a psychiatrist overseeing the provincial government’s program, underlines that treatment centres are gradually being set up across tribal districts.
“The [mental health] centres used to be in Peshawar, where people from the tribal districts were provided free treatment and assistance. The government has now launched the programme in all district hospitals and health centres and various teams visit the tribal districts on a weekly or monthly basis to provide treatment and assistance to the people,” she says.
However, Khaula concedes that mental health in the tribal districts has largely been sidelined by the government, and only recently have small steps been taken. She maintains there are no proper statistics on mental illness in the tribal districts owing to nationwide negligence. “There is no survey in this regard even at the national level, so what data can possibly be available in the tribal districts?” she asks.
Khaula believes if a survey is conducted in ex-FATA, millions would be diagnosed with mental illnesses. She adds if long-lasting peace is not restored in these areas, and the locals not provided psychological and financial support, the mental health in the region will only be aggravated.
“Psychiatrists should be deployed in the tribal districts permanently. Our teams only go there on a weekly or monthly basis, which is not enough. The cases of mental illness in the tribal districts are such that work must be done on war-footing,” she says.
‘It was a moment of mental anguish every time I saw the esteemed men and women, who had never had to reach out for anyone’s help, being humiliated in the queues for food rations,’
“In developed countries, a certain number of psychologists are designated for a certain proportion of the population, but there is no such system here. Now there’s one psychiatrist for every two to three districts. In terms of population, these deployment numbers are unsatisfactory.”
According to the Khyber Pakhtunkhwa Health Department, all doctors who have obtained an MBBS degree on the medical quota of former FATA were required to perform professional duties in these districts after completing their education. But due to the poor law and order situation, they are reluctant to perform their duties in these areas.
Hundreds of thousands of locals, mostly women and children, have suffered from psychological problems in the War on Terror. Mental health experts say this is mainly due to life uncertainty linked to prevalent terror incidents, and the resulting grief caused by unemployment, curfew, along with destruction of homes and localities. However, experts maintain, the most prominent cause behind the locals’ mental health exacerbation was being rendered homeless as internally displaced people (IDPs) owing to migration from the tribal areas.
Rabia Khan, a psychologist who has been working on mental health issues in the region in collaboration with international organisations for many years, has spent months working in IDP camps, providing psychiatric treatment in times of war and curfews. She maintains both men and women migrating from the tribal districts have suffered from numerous mental health problems, but most of her time was spent working with women and girls.
Rabia reveals the experience of working in these camps and districts has been painful owing to the widespread plight of the terror survivors. “I have seen hundreds of devastated families and have worked with hundreds of people who had lost everything and were caught in a storm of mental illness,” she says.
Mental health practitioners have diagnosed locals with a number of mental illnesses ranging from anxiety to depression to Posttraumatic Stress Disorder (PTSD) and a mix of these ailments.
Rabia told Naya Daur Media that terrorism, and then life in the IDP camps, took their toll, especially on women and children. “[The women] saw their loved ones first in the midst of war and then on the road. Someone’s husband was dead, someone’s son, someone’s mother and someone’s daughter. This caused innumerable mental illnesses.”
Former FATA consists of seven districts and has a population of over five million according to the 2017 census. Over 1.5 million locals had to migrate from their areas and stayed in camps for many years. Mental experts maintain now that many of them have returned to their homes, they’re still living with mental illnesses, further aggravated by the lack of psychiatric treatment facilities.
Rabia Khan maintains the locals still haven’t been able to recover from the living conditions of the IDP camps. “40 to 50 people used to live in two-room houses. There was no bathroom, no kitchen, no place of leisure,” she reveals.
Rabia says as a psychiatrist she also went through trauma owing to many cases. She narrates one case where a woman who had given birth to twins, was pressurised to kill, or give away, one of the two who was weak. “It was a very painful moment for me and there are thousands of such stories that I have personally witnessed,” she adds.
State Of Despair
These countless tales of collective pain augmented the angst that the locals felt. As the war continued so too did the trauma. Mothers, whose children had been left differently-abled by landmines, or terror attacks, were mentally scarred. They used to cry all the time watching their children in bed going through a period of mental anguish. Others had a constant fear of drone strikes.
‘The prices of Indian medicines available in the markets here are 50 to 60 percent lower than those of Pakistani companies. Hence, people buy medicines from India’
“The women said they can’t sleep because of the fear that the drones will bomb their homes. In the camps, anger grew against the state, especially among women,” reveals Rabia Khan. “They not only felt abandoned by the state, they accused it of increasing their suffering. This anger and frustration also contributes to mental illnesses.”
When it comes to being abandoned by the state, the media practitioners, stuck in the crossfire, faced unique challenges. These, in turn, led to specific mental health troubles for local journalists.
Javid Hussain, based in Kurram District’s Parachinar town, has been a professional journalist for the past 15 years. Like other FATA residents, journalists in the tribal districts have also suffered from psychological problems, he tells Naya Daur Media.
“There were two reasons for this. The first was working in war-torn areas without being compensated by the media houses. The second reason was the law and order situation and the killing of journalist friends. The problems were exacerbated by the lack of psychiatrists in the area,” he says.
Javid maintains reporting on terrorism in Parachinar was a difficult task, especially amid the frequent reports of a journalist being killed in tribal districts. “I was scared to go out. Whenever we went to cover a story, especially at a protest, we feared that there might be an explosion or a suicide attack. Because of this there was constant stress.”
He says the situation in Kurram was especially bad from 2007 to 2011. The highway connecting Kurram to the rest of the country was closed due to the ongoing war. This created logistical hurdles for local journalists.
“On our way to Kurram we first used to go to Afghanistan via the Torkham border and then Peshawar. Then we took the same route back. It was a mental anguish that not only local journalists but also ordinary people went through,” Javid maintains.
Local journalists feel especially sidelined by the state when they think of the potential menace engulfing their family members. “When I know that my media outlet will not pay any compensation to my family if I am killed in the line of duty, can you imagine the extent of the fear? This is not just my story, other journalists are also victims of the same fear, especially among those reporting on the war in the tribal districts,” adds Javid.
The Bitter Pill
With certain professions carrying their unique mental challenges, in addition to the trauma faced collectively by the locals, many eyed desperate solutions to ease their pains. Given that there weren’t any psychiatrists in the area many locals, especially the returning IDPs, resorted to purchasing special sleeping pills available at shops on every street. Thousands still take them along with other drugs.
South Waziristan-based Danish* has been traveling to Islamabad for the past three years to seek psychiatric treatment. Danish was a 16-year-old eighth grader when his family had to migrate. They have seen people dying on the streets and then going through severe ordeal in the IDP camps, where not only was there a lack of basic facilities, but also scorching heat.
“It was a moment of mental anguish every time I saw the esteemed men and women of my area, who had never had to reach out for anyone’s help, and always lived a life of dignity, being humiliated in the queues for food rations,” he recalls.
After returning to the area Danish, along with his family and other locals, saw homes and markets obliterated. Locals maintain that the government’s compensation didn’t allow more than a room or two to be reconstructed. Amid destruction of the town, and deaths of relatives, Danish started taking sedatives and sleeping pills for temporary relief.
“But as soon as the effect of these medicines faded I felt like my world was falling apart. I took them for many years and with increasing agony started increasing the dose,” he says.
“As my suffering increased I started taking drugs because I was tired of using medicines. Not only did this affect my mental health, but it also made me very thin. Then I decided that I will not waste my life and live with a new determination.”
Since there wasn’t any psychiatrist at the South Waziristan Headquarters Hospital, a friend took him to a psychiatrist in Islamabad. “Despite having many patients in the clinic, my psychiatrist listened to me for hours. She encouraged me, telling me ‘life is not over yet’ and ‘you have to start life again’. According to my psychiatrist, I have PTSD, and I need treatment for many years to get cured.”
Danish, like many others who are under treatment, hides the fact that he visits a psychiatrist owing to the taboo surrounding mental health. “People have the impression that anyone who goes to a psychiatrist is crazy. I have met dozens of young people who take sedatives, sleeping pills and drugs but do not go to a psychiatrist because of social pressure.”
Tranquilisers from many companies are easily available in local medical stores. Locals buy these medicines as much as they want even without the doctor’s prescription. That is, again, also due to the fact that there weren’t any psychiatrists to write those prescriptions.
Shaukat Ullah runs a pharmacy in Bajaur District. He says there was no psychiatrist in Bajaur till last year when a doctor from Peshawar started a private clinic. Three months ago, a psychiatrist was posted at a government hospital in Bajaur. “But for such a large population, the posting of one psychiatrist is an absolute joke!” exclaims Shaukatullah, whose own elder brother has a severe case of depression and is now seriously ill.
Shaukat unveils that now that mental health practitioners are finally working in the region, the treatment and medicines that they prescribe for depression and other mental health ailments are being repudiated by the locals. “They refuse to take medicines or follow treatment saying ‘we are not crazy!’ In their eyes, only lunatics take these medicines,” adds Shaukat.
He believes the toll that the war has taken, coupled with the resistance towards addressing the mental health predicament in the region, necessitates a multi-front effort, maintaining that medical facilities need to be complemented with social awareness. “Social institutions need to be strengthened locally as well. The government should prioritise spreading awareness [about mental health].”
North Waziristan-based shopkeeper Shamil Khan says the government’s negligence in his district, where the main hospital lacks basic medical practitioners, let alone psychiatrists, has pushed the locals into further ruining their lives.
“I too survived the hardships in IDP camps and became a patient of depression. The destroyed localities have left the locals hopeless and abandoned. That’s the main reason that due to this uncertainty and lack of government healthcare facilities that the locals are resorting to temporary sedatives, which many purchase from my shop,” he says.
Shamil Khan says the ongoing economic crisis, and the resulting inflation, has meant that even the local tranquilisers have gradually become unaffordable for most.
“People used to buy medicines from Pakistani companies but due to the continuous rise in prices, they now look elsewhere,” he adds.
“The prices of Indian medicines available in the markets here are 50 to 60 percent lower than those of Pakistani companies. Hence, people buy medicines from India.”
*The names have been changed to protect the identities