What have we learned in the aftermaths of so many wars again across the Middle East, from Afghanistan to Syria (the Iran-Iraq war, Kosovo, Iraq’s internal sectarian struggles, Lebanon, Palestine-Israel); from the refugee and detention camps that encircle and penetrate Europe and such enclaves as the banlieux of Paris; or from the hearts and minds of successful middle-class migrants from Afghanistan, Iran, Iraq, Syria, and North Africa now living in Paris, Stockholm, Berlin, Toronto, Houston, San Francisco, or Los Angeles, and, indeed, in the ranks of humanitarian aid workers?[note 1]See the op-ed piece by Rosalie Hughes (2015) on the failure of many aid organizations to provide mental health services to their workers despite acknowledging the burnout and need of people suffering insomnia, anxiety, and depression after listening to and dealing with so many dire cases. She singles out Doctors without Borders as a rare exception, but notes that not much has changed since ‘a 2009 survey of 20 aid organizations found that many staff care programs fail to adhere to basic standards’, and that there is a large gap between policies set at headquarters and actual care.
As a prolegomena for a new generation of research frameworks on mental health burdens across the Middle East, the collection of case studies in this MAT Special Section on mental health and trauma in the Middle East marks an important intervention. The collection is admirable in the first instance because of its breadth, sweeping across the Middle East to include Persian- and Arabic-speaking worlds. Exceptionalist claims for particular cases are through comparative juxtaposition held to account; better explanations and responses can be found when exceptionalism (but not context) is abandoned. Further, this collection of case studies helps question individualistic psychosocial models and returns us to social anthropological inquiry that is comparative and attentive to management and governance, both of postconflict reconstruction and of transnational migration and asylum seeking, while at the same time insisting on meaning-centered accounts in local terms for both individuals and groups (see also Malkki 2005; Khosrovi 2010; Fischer 1995; Daniel and Knudsen 1995). It moreover questions the relationship between, on the one hand, population-level, often arbitrary-seeming, ‘bureaucraft’ (as anthropologist Erica James [2010, 2012] has named it in the case of Haiti) of global and regional administered societies (including international donor-supported NGOs) that triage, provide recognition (or nonrecognition or misrecognition), and, on the other hand, elicit the strategizing and self-fashioning of individuals and organizations for resources, rights, and biological citizenship. It also stitches together an intergenerational conversation with researchers experienced in prewar as well as postwar conditions: Margaret Mills (1991) for story telling in Afghanistan and Pakistan; M. Nazif Shahrani (2002 for narratives on pre- and postwar Afghanistan; Vincent Crapanzano (1980, 2011) for transference and exile narratives in North Africa and France; and Michael M. J. Fischer and Mehdi Abedi (1990), Mazyar Lotfalian (1996), and Byron Good, Mary Jo DelVecchio Good, and Robert Moradi (1985) for work on emotion, depression, and exile among Iranians (also Good, Good, and Fischer 1988; Fischer 1988, 2004).[note 2]I note these names because they are advisors or committee members of the dissertations cited below.
Four important questions are raised:
First, what are the moral implications of different forms of intervention? Are there new everyday or ordinary life ‘scenes of instruction’ for how adversity is to be dealt with [Das 2015; Fischer 2015, 2016]? These may include individual modeling behavior or configurations of what Hannah Arendt (1951, 2004) described as the life of political citizenship in a world of displacement and plurality.[note 3]As Hughes (2015) notes, ‘For the first time since World War II more than 50 million people are displaced worldwide’.
Are there new models replacing, for instance, older Persian or Arabic models of selfless protectors, for instance, the gardon koloft (Persian, literally ‘thick-necked’) or the qabadayat (Arabic, ‘tough guy’), who polices the neighborhood and protects it from outside meddling? To behave in a darvishi (meaning selfless, like a darvish or like a sufi mystic) fashion is often modeled on the retired gardon koloft, an older man who is detached from the fighting of this world and who projects a moral selflessness. Transformations of these old models today may be found among the baseej in Iran and the Hezbollah recruits in Lebanon (especially the ‘Masools’ of Beirut or Sidon who replace the qabadayat).
But there are also new models embodied in, and modeled by, professionals who have put their skills, expertise, and networks into the service of communities, and who are also able to broker between local and wider moral discourses, media, bureaucracies, and funders without taking away local control or reducing local capacity. One thinks particularly of the late psychiatrist Eyyad El-Sarraj of the Gaza Community Mental Health Program, and of the Palestinian psychologist Laila Atshan.[note 4]She was among the speakers at the TEDx Talks in Ramallah that focused on resilience and community building, and were featured on the blog Adonis Diarieshttps://adonis49.wordpress.com/tag/laila-atshan/.
One also thinks of the physicians in Iran, from psychiatrists to infectious disease doctors, who managed to introduce a national HIV/AIDS program in the face of a regime that at first denied the disease could even exist in Iran. People with HIV/AIDS, often war veterans and imprisoned needle-sharing prisoners and their wives, had been condemned to a life of withdrawal, stigma, and depression. Such conditions not only affected those individuals but helped create an unacknowledged epidemic. But now Iran is recognized by the World Health Organization as having a regional ‘best practices’ national HIV/AIDS program, one that protects the privacy of individuals with HIV/AIDS by setting up clinics that also handle other diseases (Behrouzan 2010b). These are models of social and moral intervention.
Second, are there structural transformations over the past three decades or so that can be discerned in discursive, symbolic, or vernacular genres of expression that respond to experiences of war? At least five might be suggested by these case studies: (a) the rise of migrant ‘self-fashioning personae’ tailored to biopolitical and ‘bioethical’ regimes of bureaucratic administration, including demonstration of mental health burdens (the case of Iraqi migrants in Beirut looking to move on to Europe, Canada, or the US); (b) the rise of a vigorous if embattled feminist movement (the case of Afghanistan); (c) the rise of a psychiatric self, replacing earlier poetic-philosophical genres of speaking about mental health only through indirection (the case of Iran); (d) the rise of family therapy (in Gaza); and (e) the rise of psychiatric prophylactic techniques in the training and treatment of Hezbollah sharpshooters through creative writing exercises, computer-simulation gaming, and physical exercises with life-sized cardboard Israeli tanks (Saramifar 2015).
Third, connected to (a) above, what are the transnational implications of local and regional wars for mental health and social resilience in both neighboring countries and in distant countries of exile? These range from life in camps (refugee, detention), diasporas, and new social and political formations that transfer emotions and discursive forms across national borders. Omar Dewachi (this volume), Zuzanna Olszewska (this volume), and Orkideh Behrouzan (this volume) provide examples. This is a big topic in its own right, and I will only comment on it peripherally here, but the ‘Salman Rushdie affair’ and the ‘Mohammad cartoon affairs’ can serve as tokens of these volatile and highly manipulable emotional transfers and channeling (Fischer 2009), with jihadist videos and other forms less well-studied ethnographically or analytically.
Fourth, have we learned anything about the mix of methods required to evaluate laments, witnessing, and physical evidence regarding mental health burdens and social resilience? Psychosocial surveys, life histories, health-seeking behavior, dreamwork, new ritual forms, reburials, histrionic acting out, clinical care, therapeutic mental health centers, and historical analysis of shifting valences of such terms as ‘trauma’ are among the techniques invoked or alluded to in these case studies and their references. I flag this issue as a key problem in being able to make use of the fragmented literature to date. The call is not for more standardized and formal (statistically significant) research (though if that could be done, it could be useful), but for more deeply ethnographically detailed analytic tracings of the connections in a world of ramifying effects that are not as simple as quick punditry, targeted propaganda, or journalistic bar-room reporting would have it.
The workshop convened by Orkideh Behrouzan in London, from which the papers in this MAT issue are revised and expanded (and which included other papers not included here), brought together deeply engaged practitioners and analysts from the region (and elsewhere) who could probe beneath or beyond the aggregate statistics and policy-speak of global health to the existential and moral dilemmas at play ‘on the ground’. At issue is a commitment to the agency and dignity of the people caught up in these dilemmas.
Moral implications of intervention
As anthropologists and mental health researchers, we, desperately need good in-depth ethnography that honors the dignity of the people who help us produce accounts of their lives, their strategies, their moral compasses. Just as in various truth and reconciliation efforts, when some refuse to witness or testify on the grounds that they are being required to pose as victims rather than fully acknowledging their political agency, so too the agency of people in humanitarian crisis should not be undervalued. We need ethnographies that illustrate what is gained from both a scientific and humanist perspective, following the title of When People Come First (Biehl and Petryna 2013), and focusing not only on donors or audit systems or on the efficiency or honesty of delivering ‘aid’. We need ethnographies focused on the moral economies of ordinary ethics in everyday life among families challenged by constraints and adversities (Das 2015; Fischer 2015, 2016). Among the most powerful of efforts to acknowledge the human face of people on the other side of seemingly intractable conflicts are the small but significant activities of such groups as The Parents Circle-Families Forum (PCFF), also known as the Israeli Palestinian Bereaved Families for Reconciliation and Peace (coordinated by Mazen Faraj and Nir Oren with offices in Beit Jala and Israel). Other ethnographies remind us of efforts that briefly worked in short windows of time, but were limited by the temporality of larger political cycles: I think here especially of the remarkable ethnography by Deborah Heifitz-Yahav (2002, 2004, 2005) of divergent masculinity cues of Palestinians and Israelis who worked together in joint border patrols, and of educational ventures as the Arava Ecology Institute whose student body is one-third Israeli, one-third West Bank Palestinians, and one-third Jordanian (Fischer 2006, 2007) .
The ‘pilot ethnography’ presented by Kienzler and Amro as a Think Piece in this collection is, like many reports over the decades, focused on the humanitarian industry and mobile sovereignties of international donors, plans, and formalistic audits. We need a light shone on this, and it is good to have their preliminary analysis of the situation in the West Bank. For more comparative work on the topic, see Kienzler’s earlier work on Kosovo (2010); Duffield 2001, 2007; Fassin and Pandolfi 2010; Ghani and Lockhart 2008. In addition, we need in-depth ethnographies written in conversation withthe people who are supposed to be aided by these circulations of paper and money. Money often flows through local circuits to local political infrastructure needs, itself a mode of governance and social and political structure. Often this generates conflicts between donor instructions and local needs for vital social pooling and redistribution networks. Livia Wick’s (2006) work with midwives, pregnant women, and physicians on the West Bank under constant conditions of stress and occupation provides a detailed and longitudinal case study (see also Shipton 1990, 2010 for an East African example as well as theoretical analysis).
Kienzler (2010), in her Kosovo work, acknowledges important comparative ethnographic research on conflict and postconflict mental health and mental health services beyond what is presented here for the West Bank. We are beginning to get important comparative accounts from Acheh, Indonesia (Good, Good, Grayman, and Lakoma 2006; Grayman 2013), Peru (Theidon 2013), Colombia (Fattal 2014), Haiti (James 2010), Sierra Leone (Benton 2009), and Liberia (Abramowitz 2009), among other places. Good ethnography depends upon such comparative perspectives. The research on Acheh by Good and colleagues (2006), which was funded by the International Organization on Migration, is particularly rich for its systematic surveys revealing both the pervasiveness of beatings, killings, and terrorizing, and the heroic collective bravery and determination of Acheh women in protecting their families and homes and in marching on police stations to demand the release of prisoners. The richness of the research is also due to working with an Indonesian psychiatrist who treats sufferers of trauma dysfunctions, including not being able to sleep or work or smile. The mental health interventions that the Goods, Grayman, and Lakoma helped the Acheh health care system put into place in primary care facilities – and through the team’s own repeated surveys and visits to rural villages and to severely affected individuals, listening to their and their families’ stories – includes documenting the effectiveness of medication (return to degrees of function). What is also interesting is the fact that presentations of the team’s work at times elicited calls from police and army members to be given the same attention, claiming that they too (echoing Fanon’s comments from the Algerian War of Independence) have been traumatized and suffer debilitating nightmares and dysfunction. In Lebanon, Younes Saramifar (2015), as noted above, provides ethnographic accounts of how Hezbollah recruits are taught creative writing and exercises with cardboard Israeli tanks to deal both with the psychic shock of repeated killing as sharpshooters and the fear of mechanized warfare.
Work on mental health in Gaza and the West Bank is not a tabula rasa. Most importantly we have the experiences of the Gaza Community Mental Health Program (GCMHP) founded in 1990 by the late Dr. Eyed El-Sarraj, and supported by many donors and connections including a joint grant with the Social Medicine Department at Harvard Medical School, and his training efforts with a number of international universities, including (importantly) Tel Aviv University (El-Sarraj 1996; Afana 2003; Afana and Neda 2003; Afana et al. 2002a; Afana et al. 2002b; MECA 2009; Qouta, el-Massri and Termaz 1999; Qouta, Punamaki, and El-Sarraj 1995; Punamaki, Qouta, and El-Sarraj 1997; Robson 2012). Although I have never had the chance to visit Gaza or the GCMHP, I did meet and talk with Dr. El-Sarraj on a number of occasions, and heard him speak at Tel Aviv University as well as at several international conferences of Friends of Palestine-Israel Peace in Jerusalem, in Amsterdam, and elsewhere.
Dr. El-Sarraj was never shy about rebuking Israel for the occupation conditions, nor about rebuking his own government in Gaza, but unlike most commentators on Palestine or on mental health in Palestine, he did not reduce the issues to merely politics, nor did he myopically focus on Palestine as if Israel did not exist except as an enemy. He acknowledged the psychodynamics of children and families in Israel, often using the language of obsession to characterize the deadly (even thanatological) drives fuelling cycles of violence. He would say that Israelis are obsessed by security, while Palestinians are obsessed by the need for dignity. These (and other contrasts/comparisons) are never equivalences, nor commensurable, but they are intertwined and mutually exacerbating in cycles of violence.
Dr. El-Sarraj was particularly concerned with family therapy, and the need to make Palestinian families more democratic as one important function of listening to child patients, that is, concerned not just with a therapist listening, but with a father listening to his children. The goal of course was not just improving life in the family, but building larger socially resilient solidarities.
Dr. El-Sarraj’s perspective about the need for wider psychosocial community facilities is supported by Nadje Al-Ali, who at the London workshop put forth a feminist call for modes of attentiveness in postconflict settings in the Middle East that avoid exceptionalism and stereotyping, especially by using Islam or stereotyped culture (patriarchal, tribal, honor-shame) as a way of flattening differences, erasing histories, and legitimizing outside intervention (for more on her work, see Al-Ali 2007 and Al-Ali and Pratt 2009). Echoing Dr. El-Sarraj, she reminds us: ‘Gender-based violence exists within the workplace, on the street, at home before, during and after armed conflict’ (Al-Ali 2014). And further, as has become only too obvious in the past forty years, she emphasized that sexualized violence is part of torture and abuse in prisons and in capture by militant groups and criminal gangs for men as for women, and has become a psychological weapon of warfare, not a byproduct.
Acknowledging specific differences, Al-Ali points out, is not just a descriptive obligation, but also a moral and pragmatic one. These specificities are critical to people’s abilities to cope and overcome adversity, to live on, and perhaps to construct socialities that are healthier and not so isolated by the nationalisms that have rent the contemporary post-Cold War world. Just as militaries have taught their soldiers to give no more than name, rank, and serial number, so too nowadays civilians across the world have learned from innumerable prison memoirs to rehearse modes of spiritual resilience and coping strength. Easier said than done, perhaps, but the ‘games’ of self-fashioning have intensified from the days of Marcus Aurelius, Saint Augustine, or even Franz Fanon and Michel Foucault. Particularly women, as Veena Das (2002, 2007) has ethnographically detailed for victims of the India-Pakistan Partition, have often learned to swallow poisonous knowledge (an old trope of Shiva, the god of destruction and creation anew). Olszewska, in a case study of Afghan refugee poets in Iran, both in her previous work (Olszewska 2009) and in the workshop (this volume) alludes to the role of feminist poets and writers in the struggle for literacy, education, and citizen voice, something detailed also in the work of Fevziye Bahar Johnson (2013), O’Sullivan (2012), Weir (2010), and others.
Al-Ali calls for more fine-grained attention to Islam, and recoils against the violence of the so-called Islamic State in Syria and Iraq that claims scriptural legitimation for beheadings, burning alive, massacres, and abduction of women. There is a need for more inquiry into the (positive and negative) pastoral role of imams, the role of healers, and moral leadership beyond politics and sectarian divisions. In Hezbollah-dominated south Beirut, Saramifar (2015) finds even secularized middle-class women consulting imams about which beaches are appropriate for them, something he observes does not happen in Iran, and he details how even emancipated women pragmatically accept and defend the protection offered by Hezbollah rules.
As Behrouzan (this volume, 2010a, 2013, 2015) demonstrates, the place of dreams and how they are discussed and worked into the psychological regulation of everyday life also requires attention for Iranians both in Iran and in the diaspora. Dreamwork (including nightmares) is how the social is projected, condensed, displaced, and otherwise encrypted or ‘worked through’ with close friends (or via commentaries on blogs on the Internet): working through means to interpret and cope with the stressors not just of daily life, but of generational experiences (Behrouzan and Fischer 2014). Research elsewhere, and prior to widespread Internet access, demonstrates that similar dreamwork was done in poetry and story-telling circles, as described for traditional story-telling nights in Herat in the 1980s by Margaret Mills (1991), and in accounts of the Taliban period of the Golden Needle Sewing School of Herat by Christine Lamb (2004) and Fevziye Bahar Johnson (2013), along with accounts of other efforts to maintain underground schools for girls by the Revolutionary Association of Women of Afghanistan.
Good ethnography spells out the situatedness of moral worlds and ethical decision making. As Al-Ali noted in the workshop, there is no direct relation between forms of violence and trauma or suffering experienced, nor between violence and feelings of guilt or shame (as Josh Oppenheim’s 2013 film The Act of Killing has shown for the perpetrators of the 1965 anti-communist and anti-Chinese massacres and torture in Indonesia). This does not mean that there are no long-lasting legacies of violence (as Robert Lemelson’s extraordinary 2009 film Forty Years of Silence shows about survivors of 1965 in Indonesia who acknowledge being mentally disturbed by what they have been through, including the psychological fears imbibed by their children and continuing discrimination visited upon the children).
Nor is witnessing either a guarantee of truth or a basis for special knowledge and understanding, as generations of war veterans attest. Walter Benjamin’s observation that many World War I soldiers returned home from the front silent – unable and unwilling to narrate – is something that has often been true of veterans of other wars since. Industrialized warfare was introduced in World War I, and like the introduction of the rifle into Ottoman Arabia it contributed to the destruction of charisma in previous narratives of heroic war battles between protagonists who could see each other (Meeker 1979). Fassin and Rechtman’s Empire of Trauma (2009) traces out, through six case studies, including Palestine, how witnessing can be received as unimpeachable or on quite skeptically in different transnational historical periods and in different situations of ‘bureaucraft’.
Sa’ed Atshan (2013, 2014) nicely deploys ‘bureaucraft’ describing it in James’s (2010, 28) terms as a node for ‘generating social, political, legal, economic, symbolic, and even spiritual power and capital for the recipient of aid … [as well as] multiple forms of power and capital for the provider of aid’. He deploys the term as a lens to examine the undecidability and skepticism about whether a ‘solidarity’ march in a refugee camp was really ‘tadamun’, solidarity with victims, or ‘tadakhul’, a political intervention to accumulate power. The march, in any case, made the bureaucraft apparent, exposing the less-than-altruistic motivations behind the competition among NGOs in Bethlehem for building up their trauma portfolios. The story about donors only wanting to set up yet more (there are already eight) psychosocial support organizations in largely Christian Bethlehem is equally telling, both of the Christian interests of the donors, but also of the visibility and thus public relations value of Bethlehem. It is helpful, however, not to think of bureaucraft merely as corruption, in-fighting, or distorting patronage, though it may be all of those things, but rather (or also) as the social infrastructure that needs to be acknowledged and worked through into new forms that might be more supportive to more local lives. Summud (persistence) is not enough by itself. And it is not only a Palestinian moral virtue, but a general Islamic one as well (the patience lauded in the Qur’an, the Shi’ite injunction in the Karbala Paradigm to struggle for justice no matter that the world is unjust and the likelihood that the immediate struggle will fail), as well as having its counterparts in many other ‘this worldly ethics’ (such as the role of karma in Buddhism, or deferral of gratification in the Protestant work ethic, of which both Max Weber and Karl Marx wrote).
Atshan is excellent in acknowledging binocular or double-voiced perspectives in conflict. Somehow we need to get further, to at least a three-eyed, or more-than-two sides, perspective (Fischer 2006), not to Al-Ali’s (unlikely) gloss for the postmodern condition as nihilism, but on the contrary to larger collective, inclusive, and diversity-nurturing commons, to a postmodernism, if Al-Ali likes the word, of postings back and forth between different modernities for examples of new ways of doing things.
The resilience of West Bank Palestinians to the daily adversities of occupation is perhaps nowhere more ethnographically detailed than in Liva Wick’s (2006) work on childbirth under occupation and Sa’ed Atshan’s work on humanitarianism (2013). Wick details the pulling apart of the medical referral system (focused in Jerusalem both in the Palestinian Moqaddasa Hospital and the Israeli Haddasah Hospital) and its replacement with a flexible, community-supported, decentralized one, a process that included ostracizing Palestinian doctors (including female ones) felt to be uncaring or too authoritarian (or just too stressed). She also details the tensions and political struggles between local needs and foreign donor agendas, and between Eastern European-trained physicians who were more inclined toward centralized control, and Western-trained ones who were more inclined toward decentralized flexibility. Wick managed much of her access to her research community via the networks of Birzeit’s Public Health School and her mother’s work there in the Midwifery Department, as well as via her own networks from having grown up in Ramallah and attending a Quaker school.
Atshan’s work (2013) also draws upon Quaker networks, and particularly on his remarkable blind aunt Laila Atshan, who worked for the United Nations and to set up psychosocial emergency teams in each of the governates of the West Bank. One of the extraordinary strengths of Atshan’s work is his willingness to condemn violence against Israelis as well as against Palestinians. He is also able to consistently acknowledge divergent understandings of reality as told from Palestinians and Israelis in his story about the killing of a family in an Israeli settler village on the West Bank. According to the Israelis the family was killed by two Palestinian brothers; according to the Palestinians, aggrieved Thai workers (whom the Palestinians, he laments, describe in similar denigrating racist terms as Palestinians are described by many Israelis) were responsible. Such complexities have important ramifications and require good ethnography to untangle the threads of connection. Why, for instance, are there Thai people working in Israeli enterprises in the first place, when once those jobs went to Palestinians? Why is the same wall described as an ‘Apartheid Wall’ on one side and on the other, as a ‘Separation Wall’ that stopped suicide bombers entering Israel during the Second Intifada?
Structural transformations: Displacements, rights, psychiatric selves
Omar Dewachi (this volume) brings us back to a dilemma that the modern world first faced after World War II: massive displacement, people without citizenship, temporary camps, and desperate efforts to find placements in countries that would take them and offer a chance for rebuilding lives and families. This was the world that Hannah Arendt wrote about. Today, instead of escape from Europe, we see massive efforts to get into Europe, Canada, the United States, and Australia, with camps of refugees ringing Europe. Palestinian refugees are the longest refugee legacy of the post-World War II period, with their own special status that under United Nations Welfare Relief Agency rather than the United Nations High Commission for Refugees. Today there are millions of Iraqis and Syrians tented in camps in Jordan and Lebanon. For a time the three million-plus Afghans in Iran made up the world’s largest refugee population, a number comparable to the number of Afghan refugees living in Pakistan.
Such large populations inevitably result in a range of efforts to stem the tide; a kind of triage or bureaucraft is deployed, replete with injustices, arbitrariness, strategizing. There is a wonderful Iranian short story about the refugee in Paris who was refused asylum repeatedly, but for a different reason each time he applies. He hires a short story writer to figure out how to craft his appeal so it will work. The refugee tries to give the writer just enough true information to be credible but not too much to stifle his creativity and thus run afoul of the inscrutable bureaucrats. Under such conditions, as Dewachi points out, people get divorced if a woman-headed household is more likely to get a visa or asylum, and strive to tell stories about torture in a way that is just gruesome enough. One can become deranged by the process, assuming one wasn’t already.
The triage is not unlike that described by Petryna (2001) in the post-Chernobyl era. For refugees today, the more vulnerable you seem, the more likely you are to receive support and access, and perhaps even asylum and a visa. As Dewachi puts it in the case of Hussein, the most important aspect of his ‘humanitarian package’ was being declared a victim of torture. With it came financial and other benefits. This is a form of ‘biological citizenship’, as Petryna (2001) calls it in her monograph on the Ukrainian welfare system after Chernobyl, and it is what Fassin and Pandolfi (2010) call the mobile sovereignties of humanitarianism, making decisions in the first world for events in war-destroyed settings (a pattern also described by Wick for the tussle between local needs and donor agency directions for use of their funds).
Dewachi makes the case that while the stories told by asylum seekers can become inscrutable for their veracity, they do expose the structures of recognition/triage, skepticism/arbitrary rulings, and politics of bureaucraft. Similar to Dewachi’s Hussein is the autobiographical account by anthropologist Shahram Khosravi (2010) of his journey as a stateless person from Iran into Pakistan and then eventually to Sweden. There are thousands of such cases. In Israel, Sarah Willen (2006) has done detailed ethnography with Sudanese, West Africans, and Filipinos who enter Israeli illegally in order to get into Europe and the West.
Al-Ali suggests that all these stories constitute a continuum of violence that is simultaneously gendered, diagnosed, and war-related. The case of Hussein leaves us wondering not only what is true, but where the line is between dysfunction or delusional mental illness and what might be seen as a pragmatic scramble for resources, recognition, and resilience.
Rights, RAWA, and shattered men
Afghanistan, the site of three decades of war and massive population displacement into Iran and Pakistan, with also much migration outside the region to Europe, Australia, and North America, is now drawing more attention from anthropologists of mental health and social reconstruction. Zuzanna Olszewska’s (this volume) case study draws attention to the central role of poetry as an expressive medium for literate and illiterate alike, and to the way the poetics of ambiguity draws upon the sweetness of sorrow for meditative detachment on the one hand and the ‘black dog’ of depression on the other. Churchill might not have known that his canine metaphor comes from a long line of Persian psychiatric attention back to the medical texts of Ibn Sina (Avicenna) and Ali ibn al-Majusi (d. 982–984 [Behrouzan and Fischer 2015]). The figure of inner darkness combined with an outer appearance of joy is a transformation of the old Persian trope of trying to keep inner purity while doing what is necessary to survive in the corrupt outer world (batin/zaher) explored by Bateson et al. (1977). Olszewska draws attention not just to the poetic texts as expressions of emotion or inner feelings, but also to the social support networks (circles of recitation, Internet blogs) that accompany the sharing of poetry.
As noted above, the Revolutionary Association of Women of Afghanistan (RAWA) is among the networks of feminist political activists that have supported underground schools, literacy work, as well as creative writing production (poetry, but also short stories and even novels), which in turn often can provide ethnographic-like accounts of local ways of thinking about mental health, accounts of local ways of dealing with depression and resilience, and accounts of various forms of coping strategies in disordered worlds.
Olszewska’s contribution is one of several recent, similar accounts and analyses. Young men in highly masculinized societies, perhaps among the most difficult of subjects to talk to about deep motivations, intentions, and feelings, were the focus of concern in both Suleiman-Khel’s (2013) dissertation about his work (with psychiatric backup) among Pashtu-speaking outpatients in a hospital in Peshawar and in Andrea Chiovenda’s (2013) long-term psychoanalytic interviewing of a young Afghan Pashtun in the Jalalabad and Kabul region constantly negotiating back and forth between very different expectations of masculinity. Drawing on Peter Lock’s (2009) notion of ‘complicated grief’ (prolonged maladaptive grief reactions with symptoms of intense yearning/longing, feeling bitter over loss, hopelessness and emptiness, denial, numbing, agitation, intrusive preoccupations), Suleiman-Khel explores the impossibilities or failures of overly rigid masculinist codes (badal akhistal:taking revenge; defending zan, zar, zamin, women, wealth and land; izzat and namus or self-respect, honor), and the (weak?) solace sought in other men’s company sitting and talking in a hujra (men’s guestroom), compared with women’s involvement in religious ceremonies as coping mechanisms. Olszewska also helpfully reviews much of the fragmented literature on mental distress and coping in the Middle East. Part of the message perhaps is the attention to distress – not just for the individual but for the destruction of the social fabric, with the implication that RAWA and other such networks are important beyond just their immediate pragmatic work. (See also the BBC report on ‘The Taliban’s Psychiatrist’, Qadiri 2014.)
A larger transformation in discursive structures is traced over decades in the ethnographic and historical work of Orkideh Behrouzan (2015) and what she calls the ‘rise of the psychiatric self’ in Iran, and also in her call for attention to the after-effects of war on civilian populations (2013; this volume). The case studies in this special section begin to address these after-effects.
Behrouzan writes (this volume):
Epidemiological studies conducted by health professionals have shed light on the often-overlapping physical and psychological conditions among veterans and civilians, particularly those exposed to mustard gas and those who struggle with chronic illness and long-term psychological conditions (Hashemian et al. 2006; Khateri et al. 2003; Falahati et al. 2010; Razavi et al. 2014). Studies suggest that in the decades since Saddam Hussein’s brutal use of chemical weapons on Iran’s civilian population, fertility has been hampered and the risk of congenital and developmental conditions has increased (Abolghasemi et al. 2010). There is also evidence of increased psychological symptoms among all civilians affected by war (Karami et al. 2013; Roshan et al. 2013).
She also warns: ‘The clinical encounter and the universal paradigm of trauma in biomedical psychiatry inevitably fall short of capturing historical and generational sensibilities, in part because they individualize loss without concern for its sociocultural context and meaning, and in part because they universalize trauma and take for granted a form of pathology (for example, PTSD or depression) that privileges only certain forms of therapeutic intervention’.
Like Iran, Iraq has been subject to multiple wars as well as an earlier regime of sanctions (the Iran-Iraq war from 1980 to 1988, the 1991 Gulf War, and the 2003 US-led invasion against Saddam Hussein and its continuing aftermath of civil war spilling over into Syria). The situation is extreme: there are 2.9 million displaced Iraqis internally or abroad; one in twelve Iraqi families have fled their homes and not returned; 90 percent have no plans to return (Dewachi 2011). About half of Iraqi doctors have left the country (Dewachi 2008). As with all such crises, the rhetoric is always that it is ‘unprecedented’. Unfortunately that seems not to be the case, and we need to learn from the various cases of massive displacement.
In the case of Iran, Behrouzan’s earlier work (2010a, 2013, 2015) focused on the aftermath of revolution and the eight-year Iran-Iraq war. A dramatic discursive change has occurred. In the past, traditional tropes of philosophical melancholia and the poetic sweetness of sadness were used in nuanced contexts to talk about mental health problems and to appeal for social support. In recent decades this has changed dramatically to a psychiatric discourse that still cannot speak openly about sociopolitical causalities or contexts for people’s mental states. Behrouzan flags this silencing and rerouting into psychological discourse as possible ‘depoliticization’. However, as her work shows, and as such struggles as that of RAWA or the Golden Needle Sewing Circle of Herat, or indeed the work of El-Sarraj and L. Atshan demonstrate, the everyday politics does go on. One of the most impressive examples of such everyday politics is the effort of physicians in Iran to get a national program for HIV/AIDS in place through the use of triangular clinics (that deal with other issues so as not to identify and stigmatize HIV patients) and about which Behrouzan has written elsewhere (2010b).
In conclusion: A note on mixing methods and moving forward
During the Lebanese civil war, psychologists and psychiatric researchers reported that the burden of mental health did not increase, presumably because the adrenaline rush of staying alert and the sharpness of communal solidarities gave heightened meaning to everyday life. Hezbollah leader Hassan Nasrullah has repeatedly claimed in the latter case that Shi’ite faith and persistence (sabr) in the mode of the Karbala Paradigm (Fischer 1980) protected the psychological resilience of the Lebanese Shi’ite population (albeit with a lot of social support supplied to victims by Hezbollah), while non-Shi’ites accused Hezbollah of a culture of death. This is the claim – that proper faith protects believers against psychological problems – that the Islamic Republic in Iran has made repeatedly over the course of the Iran-Iraq War and its long aftermath. Even the Islamic Republic (as detailed by Behrouzan 2010a, 2015) has been forced to admit that an enforced thirty years of philosophical melancholia and sweet sadness plus faith has produced problems, and that a new culture of happiness needs to be ‘engineered’.
However one takes these claims of faith and the meaning given to stressful life by ideological commitment, a number of researchers have warned against excessive application of trauma models for PTSD. Not everyone is traumatized by the same events, people have different modes of coping, and these should be canvassed for different idioms and more helpful approaches to dealing with the effects of war and other potentially traumatizing events and contexts. The workshop ‘Beyond Trauma’ suggested coming back to the social to ask what kinds of wounds scar the body and how such wounds organize the social fabric of everyday life, a suggestion that implies a methodological turn to the ethnographic and the everyday.
The literatures on the aftermath of war need to employ a wide range of empirical methods. These include long-term ethnographic research combined with a focus on migrants’ room for maneuver (Dewachi 2008; Khosrovi 2010), poetic forms of expression and social settings for that expression (Olszewska 2009, this volume; Mills 1991), networks of psychosocial facilitation (Atshan 2013, 2014; Behrouzan 2010b), gendered violence (Al-Ali 2007; Al-Ali and Pratt 2009), international NGO aid organizations (Kienzler and Amro 2014), hospital and ministry of health data on expenditures for psychiatric drugs (Behrouzan 2010a), and new genres and discourses of expression on the Internet and in mass media, as well as interpersonally.
To remind readers of the depth behind these case studies, I have both drawn on the earlier work of these ethnographers and highlighted the parallel work of others, which together demonstrate the wide-ranging mix of methods and objects, including mental health community centers (El-Sarraj et al. 1996; Afana 2003; Afana et al. 2002a; Afana et al. 2002b; Afana and Neda 2003); following out networks of midwives (Wick 2006); multiyear psychosocial surveys in war-torn areas with follow-up psychiatric interviews, medication, and provision of new mental health capacity in community clinics (Good, Good, Grayman, and Lokoma 2006); in-depth first-person interviews over many sessions (Chiovenda 2013; Crapanzano 1980); one- to two-hour-long life histories of many persons selecting contrasting cases for presentation (Weir 2010); outpatient interviews in clinical settings with psychiatrist on call (Suleiman-Khel 2013); analysis of public acting out such as hostage holding by individuals rather than by politically motivated organizations (Lotfalian 1996); attention to ritual processes of reintegration (Theidon 2013); and one might add creation of new rituals and reburials (Kiensler 2010; Davis forthcoming).
A concrete result of this ‘Beyond Trauma’ workshop, with its ambitious agenda, is that it has begun building a new network and stimulating a new conversation that should grow and connect with other networks and nodes of researchers, bringing together patient life histories, genres of expression, and new discursive formations to address transformations in the lives of everyone touched by these wars. Because of these events, life histories, and modes of expression, the world is changing and will look different in the near future, and our mix of methods and approaches need to evolve as well.
About the author
Michael M. J. Fischer is Andrew W. Mellon Professor in the Humanities and Professor of Anthropology and Science and Technology Studies at the Massachusetts Institute of Technology, and Lecturer in the Department of Global Health and Social Medicine, Harvard Medical School. He is the author of several books including Iran: From Religious Dispute to Revolution (Harvard University Press, 1980; 2nd ed. University of Wisconsin Press, 2003); Anthropology as Cultural Critique: An Experimental Moment in the Human Sciences (with George Marcus, University of Chicago Press, 1986, 2nd ed., University of Chicago Press, 1999); Debating Muslims: Cultural Dialogues in Postmodernity and Tradition (with Mehdi Abedi, University of Wisconsin Press, 1990); and Mute Dreams, Blind Owls, and Dispersed Knowledges: Persian Poesis in the Transnational Circuitry (Duke University Press, 2004).
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