The following is the text of the keynote address delivered by Jennifer Leaning at the international workshop ‘Beyond “Trauma”: Emergent Agendas in Understanding Mental Health in the Middle East’, held in London on 27 September 2014 (described further in the introduction to this Special Section). An expert in public health rights-based responses to humanitarian crises, Jennifer Leaning is the François-Xavier Bagnoud Professor of the Practice of Health and Human Rights and Director of the François-Xavier Bagnoud Center for Health and Human Rights at Harvard’s T. H. Chan School of Public Health at Harvard University, as well as Associate Professor of Medicine at Harvard Medical School.

Her policy-oriented research has focused on public health, medical ethics, and early warning in response to war and disaster, human rights, and international humanitarian law in crisis settings, and problems of human security in the context of forced migration and conflict. She has documented human rights abuses, provided medical care, and evaluated public health services in a range of crisis situations and humanitarian emergencies in Afghanistan, Albania, Kosovo, Angola, Darfur, the Middle East, the former Soviet Union, Somalia, and the African Great Lakes region. She is a co-founder of Physicians for Human Rights, and serves on the boards of The Humane Society of the United States and the Massachusetts Bay Chapter of the American Red Cross. During 1999 to 2005, Leaning directed the Program on Humanitarian Crises and Human Rights at the FXB Center for Health and Human Rights at the Harvard School of Public Health. She founded the Harvard Humanitarian Initiative and served as its co-director from 2005–2009.  

Dr. Leaning’s perspective enriched our interdisciplinary dialogue by foregrounding pressing issues of practice and policy and bringing them into conversation with anthropological perspectives on and concerns about the future of psychological well-being in Middle East societies.

This is a real honour to have been asked to talk to this group about this topic. I am somewhat staked in current wars from a variety of perspectives. The stance I am taking now is that of a human rights investigator and observer of humanitarian action. I am an outsider without question. The first part of this talk will speak to civilian suffering in war.

Civilian suffering in war

It is believed that civilians have always suffered grievously and died in great numbers during and in the wake of war. Contemporaneous accounts, however, based primarily on military and diplomatic records, have over the centuries focused on battles and military casualties. What occurred to ordinary people during these many conflicts was not considered important and so not worthy of note. Consequently, we collectively know very little about how the wars of the past centuries have affected the lives and prospects of the world’s inhabitants through time.

Most of our limited historical knowledge of how civilians suffered from, adapted to, and survived the wars that had enmeshed their worlds has derived from archaeology, art, poetry, and recorded first-person accounts, such as memoirs or letters. A few narrative historians, in a tradition dating from the ancients (such as Herodotus), and joined in the last 150 years by some social historians, have delved into these sources and others to construct particular depictions of some notable conflicts. In general, however, these records have been constructed or written long after the events of interest have passed. And although most useful, these records reflect the gloss provided by the preoccupations of the age in which they were written, not the concerns of the age in which they were experienced.

In the last seventy years, a number of normative, historical, technological, political, demographic, economic, and environmental trends have converged to raise the scholarly salience of wars of all kinds – and, most especially, to invite analysis of their myriad impacts on civilian populations. In this period, and particularly since the end of the Cold War, an increasing number of academics, human rights investigators, and humanitarian actors have spent their professional lives trying to understand the impact of conflict on noncombatant groups and populations.

In this context, I would advance the following major insights gleaned from my experience:

1) The laws of war leave normative and policy gaps in criminal categorization of what current intrastate wars inflict on large populations.

2) These wars have two major consequences on individuals, groups, and communities:

• They leave ecological wastelands, alien to those who return; and
• They destroy human meaning, sense of agency, and notions of a future – affecting core moral and psychological strengths and identities.
  
  

3) Humanitarian responders and all those who deal with war trauma play essential roles in sustaining a moral compass among people in the midst of conflict or on the long walk back into peace.

2) International humanitarian law and civilian harms

The doctrine of international humanitarian law (IHL), evolving as it has over the last 150 years in close track with perceived military experience of immediately preceding wars, has in the last sixty-five years sought to address observed systematic harms against vulnerable civilian populations. This shift in IHL – from a focus on specifying categories of military personnel that are in need of protection to one distinguishing and thus protecting noncombatant civilians – has deep roots in the politics and technology of mid-twentieth-century wars.

In World War II, civilian populations were seen as the industrial and ideological engines of the war machine (hence the strategic bombing campaigns and use of nuclear weapons) or as stigmatized racial minorities posing a grave risk to the dominant majority (leading to the Holocaust and other mass killings). In the Korean War, the Vietnam War, and many anticolonial wars of the 1950s through 1980s, the civilian population was perceived as a source of support and concealment to armed groups rebelling against an embattled government or contesting colonial authority (resulting in extended insurgency and counterinsurgency campaigns).

These political perceptions, linked to evolving war-fighting strategies and technologies, resulted in many instances of indiscriminate mass killings of civilian populations. Total civilian deaths for all sides are estimated for World War II, Korea, and Vietnam are estimated to be somewhere between 50 and 100 million. No summary data are easily available for civilian deaths from the many anticolonial struggles taking place in Africa and Asia during this period (1950s–1970s) but the numbers easily reach into the millions.

Against this background, the Fourth Geneva Convention of 1949 and the two Additional Protocols (1977), as well as the Convention on Genocide (1948), were conceived and drafted. Highly articulated and far-reaching categories of unlawful acts against civilians were identified and enshrined in international law. Major elements of this international regime have since been adopted into the domestic law of the world’s nations.

The core aims of these later additions to IHL are to establish a contract with civilization: that a key role of the military is to protect civilians from harm and combatants from the commission of atrocities; that reflexivity, training, and discipline of armed forces will integrate rules into good action; that the protection of civilians and combatants from the gross excesses of brutal war is to permit return to stable peace and the re-entry of combatants into civilian life. War should be short and peace should be long. Hence war should not create or perpetuate the conditions for implosion of the next peace, such as bitter partisanship, humiliation, or reprisal and revenge.

Throughout the experience of these wars and the grim analysis that led to ongoing revisions in the then current body of IHL, there was no concerted military or legal attention given to the enormity of human suffering and loss entailed by mass population displacement in the context of armed conflict. It was assumed by the military, and indeed supported by legal doctrine (the duty to warn) that as an instinctive and realistic survival strategy all civilian populations would immediately and intentionally seek to flee the active war zone. It also seems to have been assumed (based on silence in the Geneva texts) that such a survival strategy would prove productive.

And indeed in specific instances during these mid-twentieth-century wars, the record shows that civilians who did not flee combat areas were considered suspect and often killed by warring parties. Hence it appears that in twentieth-century military and legal circles, almost by historical default, the forced flight of civilians occasioned by war between nation states has been viewed as a normative occurrence.

Yet in the intervening years the predominant war pattern has shifted dramatically. The majority of armed conflicts in the last thirty years have been those waged within the boundaries of one nation state. The armed nonstate actors rapidly factionalize; opposing sides lack the funds or command structure to achieve definitive dominance; the conflicts multiply and move across populated terrain; and the fighting drags on for decades.

Crucially, the hostile dynamics and constrained technologies of current internal wars rely directly on forcing large civilian populations to flee their homes and their land. Armed nonstate actors deliberately attack civilian populations in order to capture short-term resources and gain longer-term access to land and mineral wealth. Their tactics of terror and scorched earth are laced with atrocity and fulfil the intent of preventing population return for a very long time. Mass numbers of people are now being torn from their homes and are continually on the run or subsisting, at best, in distant and dismal temporary settlements. The longer they remain away, the less likely is their return.

The ecology of loss

This forced exodus of large populations from home and livelihoods in the context of an interminable internal war inflicts serious, sweeping, and long-lasting harm on the target groups. These harms have not been sufficiently recognized or criminalized in international humanitarian law. Yet these patterns of forced flight are familiar to those who deal with refugees, internally displaced persons, and groups of asylum seekers clambering to leave entire regions or continents.

• The patterns of attack and atrocity include:
• ground attacks on villages and towns in a coordinated sweep
• commission of visible public atrocities, perhaps applied to prominent figures in the community, to strike fear in the population
• encirclement, pillage, and violent pursuit to drive people away in one direction
• the cumulative effect is to cause large populations to flee long distances, often across an important geopolitical boundary, into alien land.
  
  

The immediate harms to people include:

• death in the face of confrontation
• hot pursuit and death or rape (or both) to people overtaken in flight
• capture, imprisonment, torture of high-value individuals
• death or serious illness to people as they flee into harsh or unfamiliar terrain
• separation of family members
• death or serious illness to vulnerable populations – children, elderly, and women in reproductive phases (nursing infant, caring for toddler, pregnant)
• loss of physical assets, stripping of wealth and accumulated personal and group treasure, destruction of prompts for memory (valued items, photographs).
  
  

 The longer-term harms include:

• encampment in formal or informal settings marked by harsh, minimal supports, loss of freedom, tight constraints on economic activity, limited life options
• exposure to ongoing high risk of morbidity and mortality unless and until conditions in these settings improve – often not the case despite humanitarian efforts
• subjugation to ongoing fear, threats, intimidation, sexual violence, hunger, inanition of self and family
• prolonged duration of stay – average now for UNHCR is seventeen years in refugee camps (excluding refugees from Palestine since 1948)
• repatriation usually not an option – these conflicts drag on for generations
• gross impoverishment, long-term exile, diminished life possibilities, pervasive and heavy uncertainty.
  
  

If ceasefires and terms of return are eventually negotiated, those populations who go back to their geographic homes enter an unfamiliar wasteland. Their dwellings have been damaged or destroyed; the fields and forests are trampled, cut down, laid to waste; water sources and irrigation structures ruined; livestock long since gone – traded, eaten, succumbed from neglect and hunger. In urban areas, the detritus of conflict lies everywhere – trash, unexploded ordnance, tangles of metal and concrete and military vehicles, remnants of human death. Collapsed structures and rubble signify bridges, roads, apartment complexes, monuments, places of worship, libraries, museums – the built environment that had brought meaning and pleasure to those who used to inhabit the terrain.

The major value of this discussion is to place in the foreground of concern the extent to which this collective harm is being perpetrated under the inattentive gaze of the international policy and legal community. It is there in plain sight, were the eye trained to see it. The cumulative costs of war on civilian populations are enormous, and rendered even more profound for those groups and populations forced to flee their homes and be scattered in distant areas and foreign lands.

These situations are distinct from patterns of movement recognized and categorized in International Humanitarian Law (IHL), which focuses on:

• Groups or large populations, therefore excluding individuals seeking refugee status or asylum.
• The general activity and survival strategies of people fleeing cities or areas because a military campaign is underway in that region. 
• Genocidal actions (Art 2(c)) or ethnic cleansing – where the targeted group is identified on communal characteristics. Inevitably, it becomes hard to be recognized as such when the target group is an undifferentiated mass of civilians who are resident in the enemy state or region.
  
  

International law should attend to the prevalent practice seen now in many nonstate wars where the combatants deliberately act to drive groups of people or populations from their homes and livelihoods, and strip them of wealth and the possibility of return.

The prison of isolation

The functional and geographic distinction between combatants and civilians has been the most prominent feature of modern warfare and the international law of war. The battlefront is the zone of maximum insecurity, where men since time immemorial have fought and died to protect their communities. The home front is a relatively safe zone in the rear that supplies men with fire support and provides moral support, health care, and comfort to worn-out or injured men who have survived the death zone.

When fuller stories of older wars are told through a humanitarian perspective (albeit based on scanty ancient evidence), these assumptions and patterns of war may turn out to have been grounded in a bounded historical reality that held from the Treaty of Westphalia in 1648 to the turn of the twentieth century.

What is abundantly clear now, however, in the second decade of the twenty-first century, is that the primary pattern of war is intrastate, communalized or sectarian. These conflicts are waged by nonstate actors untrained in or dismissive of the laws of war, or are waged by oppressive, brittle, or failing states against stigmatized groups of their own citizens or residents. The secondary and overlapping pattern is the internationalized internal war of insurgency and counterinsurgency, as in Afghanistan, Iraq, and Syria.

The Geneva Conventions have tenets that apply to these wars but they are sparse and underdeveloped in terms of practical jurisprudence. And so it is warranted to declare that today’s conflicts are conducted outside the bright light of established rules, especially those that insist upon military discipline and civilian protection.

Consequently, a dense continuum of suffering marks the existence of civilians in these intrastate or stateless armed conflicts. Protecting civilians from the hostile impacts of war no longer pertains because the norms have broken down and the battles are diffused and pervade the entire lived space of the contested geography. Noncombatants are the main targets; some join the bands of armed nonstate actors. People are not protected from atrocities nor are they protected from committing atrocities. These atrocities are local, intimate, personal.

The breakdown of the moral order of the state and the international community has profound moral and psychological impacts on all people reached by the conflict. There is no common narrative, no collective heroism. A vacuum of authority and accountability, combined with brutality of fighting noncombatants as well as other armed actors, permits – even drives – military fighting groups on all sides to engage in a spiral of increasing violence and cruelty.

The proffered rationales for these conflicts, based on ethnic hatreds or ideological agendas, do not confer meaning or purpose to those outside the relatively small circle of intense adherents – but they do require everyone to take sides – or flee, or be killed. A localized code evolves to which all must adhere. All must become partisan; all must fear or isolate or suppress those who refuse to become so. And since these armed actors cannot protect women and children, since the conflict engulfs everyone, women and children also must become partisans, participants, and to more limited extents, extollers or even perpetrators of violence.

In these ways, a community as a whole may be engulfed by an ecology of fear and hatred, a psychological and social environment in which every aspect of daily life is determined by fear, with no nonviolent option available. As social trust disintegrates and the system of relationships that had given meaning and purpose to everyday life dissolves, the participants in civil or insurgency wars acquire a sense of collective failure and moral bewilderment.

Participants of all kinds in these wars realize that they are being suffocated by their loss of agency, by their sense of betrayal that they are left alone to experience the horrors of war, the grief, the rage. No one can take care of them. They cannot take care of those they love. They are humiliated by their failures to protect their families and by the dark choices they are forced to make.

They see these wars as occurring in violation of their basic expectations regarding social contracts with the state, the society, the armed actors, their erstwhile neighbours. They are demoralized by their sense of isolation from the moral universe, what used to be the rules and norms of the established collective order, the common tenets of humanity.

People trapped in these settings are uniquely isolated by their own fear, oppression, and personal and group jeopardy. The values of their own world are disrupted by the violence and brutality they are forced to endure or even participate in. A breakdown of their own moral order takes place around them – and a local, contingent morality intervenes. Survival becomes paramount. Boundaries of sympathy constrict.

The role of the outsider

The fate of civilian populations forced to move by war or by its terms of settlement has become a topic of significant and abiding interest in the international community. A wide range of people, disciplines, and institutions has burgeoned in the past few decades, marshalled despite the lacunae in the law to provide minimum sustenance and relief to the millions of war-affected people.

The route I have travelled is informed by my training in clinical medicine and public health, my engagement with disaster response, and my experience investigating violations of human rights in settings of conflict and oppression.

A common theme emerges from these ways of looking at the world. Despite the infinite diversity in how humans experience suffering and struggle to survive, conflict-based assaults on their well-being can be generally catalogued, and their behaviour in the face of these assaults can be largely described. Physicians are taught to think in terms of syndromes, associations, and biological mechanisms. Public health is organized by the methods of epidemiology and biostatistics, a search for patterns and probabilities across a vast array of data points. Disasters throughout the world can be modelled and predicted as functions of risks and vulnerabilities, resilience and coping strategies. Violations of human rights in situations of chronic or acute oppression, or in outright conflict, have appreciable impacts on individuals and groups and cause or force them to react in discernible ways.

In other words, the external world of human suffering, adaptation, and survival is not unknowable or outside the scope of descriptive and analytic understanding. It is from that vantage point and with this background that I would make three main points about the role of the humanitarian community in these terrible wars of our times.

1) The humanitarian enterprise is still necessary though deeply flawed.

This enterprise is continually laced with fallibility and error; always very dependent on individuals; always weak in systems and accountability; always hampered by a lack of political sophistication, historical knowledge, and cultural understanding; weakened by a lack of reflection and consolidation of what has been learned; very slow to embrace the concepts of best practices and evidence-based assessments; always undermined by lack of consistent training and mentorship; and terrible at holding on to its best and its brightest participants.

Yet this enterprise remains absolutely essential because of the immediate help it can deliver to those in reach. Much more can be said on this point. It is also essential in that the people who enter the conflict zones, often at some risk, are there to bear witness as well as ease the suffering of others. This action is of unparalleled significance to the polity living in safety far away – because without their own youth and a few seasoned veterans from the zone of stability getting so involved in these areas of death and entrapment, very little would be known about what is happening on their watch to so many people elsewhere.

2) Human rights investigators, relief workers, and all those who deal with the war trauma of individuals and populations provide an external eye to the moral order that has been crushed for those who survive in these conflicts. This activity is potentially of great significance to the people who are engulfed in suffering. This insight I have gained in large measure because I have stood somewhat apart from the main trajectory of humanitarian relief – not consumed by trying to make something happen, but privileged and obligated to try to understand what is going on.

Many consequences flow from this intervention. The arrival of the outside world, even clumsy and irritating and ineffectual, brings with it a moral good. To those who are trapped, it is intensely important – morally, psychologically, and often politically – to know that they are not alone.

It is evident through these encounters that there is a human morality, a rule-based as well as a psychological and social order, that when violated or vitiated creates great pain. This pain appears to cross cultures and traditions.

People demand the right to be protected from rapacious state and nonstate actors; they seek a package of rights and freedoms that extend beyond those afforded in international humanitarian law. Human rights law has not fully entered the realm of war. But this is what people demand:

                         Recognition of dignity
                         Protection from torture, arbitrary killings, systematic rape
                         Right not to be forced to move
                         Right to move
                         Right to be helped to survive when under attack
                         Right to maintain a family and build a livelihood
                         Right to have the international community act earlier rather than later.

Globalization of norms and expectations has taken place. The international community comes late and inadequately to the implementation of these norms, the maintenance of these expectations. Voices from within the war zones and those of us outside will play a role in bridging this gap, in large measure because as people still suffer, they are also demanding that the world outside speak to them about their humanity, and ours.