MOGADISHU, Somalia — Abdulrahman Habeb was a man with problems, the most pressing of which involved a barrel of tranquilizer pills.
The barrel — containing 50,000 capsules of fluphenazine hydrochloride, a potent anti-psychotic drug ordered from America — was boosting his patients' appetites. This was not good. Patients at the Habeb Public Mental Hospital were scaling the facility's mud walls to scavenge for food outside, in the war-pocked streets of Mogadishu. One had been shot.
"They don't stop when sentries say 'Halt!' " said Habeb, the director of the only mental health clinic in Somalia's capital. "How could they? They are mentally ill."
Hence, the next problem: Habeb chained some of his 47 patients to their cots. This harsh practice was regrettable, he conceded. But many of his charges weren't just famished: They were aggressive.
"They act out the violence of Somalia!" cried Habeb, an excitable man who called himself "doctor," but who really was a nurse — a nurse at the end of his tether. "I cure people's minds, and the war hurts them all over again. You cannot heal here."
He took off his glasses. He doubled over and began to sob. A colleague in one of the cave-like wards rushed over to pat Habeb's shuddering back.
And herein lay perhaps the biggest problem of all: While Habeb and his patients could walk away from their wartime asylum, there was no avoiding the larger nightmare that is Somalia. Doctors and aid workers see troubling signs that untold numbers of Somalis, brutalized by 16 years of chaos and tormented by the suicide bombings and assassinations of a growing Islamist insurgency, are fending off the jolts of violence the only way they can, by retreating inward, into the fog of mental illness.
"Ninety-five percent of the triggering factors here are related to the war," a distraught Habeb said. "The fear and worry. Year after year. It is like a bomb."
Mention the term post-traumatic stress disorder, and what pops into most people's minds are vacant-eyed GIs grappling with the lingering psychic wounds of combat: anxiety attacks, phantom pains, depression, hyper aggression, sleeplessness and flashbacks.
Yet in an age where international terrorism gnaws at the minds of millions of ordinary people, and where millions more are battered by chronic violence in failed states, many doctors have begun to worry not just about the mental health of individual soldiers, but of entire societies.
Interest in the globalization of war's invisible wounds, and PTSD in particular, has spawned a relatively new branch of medical science — traumatology. Popularized in the wake of atrocities such as the Rwanda genocide and the Sept. 11 terror attacks, its core focus involves treating war-haunted populations with mass counseling.
High levels of paranoia, emotional withdrawal, irrational fear and other symptoms of PTSD tend to stifle reconciliation, conflict experts say. Traumatized populations are less apt to forgive.
Moreover, a study to be published soon in the Journal of Marital and Family Therapy suggests that war-traumatized families in hot spots such as Afghanistan internalize their pain, and plant the seeds of violence in the next generation through child abuse.
In effect, whether it involves armies or civilians, mental illness perpetuates states of war.
"The humanitarian response to conflicts has always focused on caring for the body," said Sandro Galea, a post-traumatic stress researcher at the University of Michigan's School of Public Health in Ann Arbor.
"But what we're learning is that treating stress-related mental problems can actually help break the cycle of war."
Not all medical experts buy into this analysis. In Kosovo — the first modern killing field where mental health was made a priority in the aid effort — psychiatrists treated thousands of dazed refugees and war crimes survivors. The results proved ambiguous.
Patient surveys showed that counselors concentrated so narrowly on post-traumatic stress, they overlooked deeper woes such as despair over poverty, the anxieties of displacement, surging drug addiction and the agonies of spousal abuse.
Some experts also question whether a Western concept such as PTSD can be applied across cultures. Human grief is handled differently across the globe, they say. And some skeptics go so far as to label mental health crusades in war zones a form of medical colonialism — force-feeding psychoanalysis and narrative therapy to minority cultures.
Still, few serious physicians deny that the basic symptoms of PTSD can be found everywhere. And in countries where the killing is ever-present, aimed at civilians, and savagely personal — which is to say, in most current wars — its prevalence skyrockets.
A 2001 U.N. report on the state of the world's mental health estimates that 20 percent of all people exposed to low-intensity civil conflicts are scarred by serious behavioral disorders.
In some wars, the toll can be far higher. In Sri Lanka, home to one of the planet's oldest and most brutal insurgencies, 64 percent of the populace exhibited some type of mental trauma, a government survey shows. And in the reliably bloody Gaza Strip, a study conducted by the Gaza Community Mental Health Program revealed that only 2.5 percent of Palestinian children were free of PTSD symptoms. Eighty-three percent of local kids, the doctors found, had witnessed shootings.
More than 70 years ago, Ernest Hemingway wrote of the insanity of the Italian front during World War I, titling one of his bitterest short stories, "A Way You'll Never Be."
Today's psychiatrists argue that whole cities and unstable regions are verging on a "way you'll never be" — whether it's in Baghdad, the bone fields of Darfur, the mountains of Afghanistan or one of the most anarchic capitals in the world, Mogadishu.
SOURCE: Chicago Tribune, November 25, 2007