Haider A. Naqvi ( Department of Psychiatry, The Aga Khan University, Karachi. )
Syed Faraz Kazim ( Department of Surgery, Aga Khan University Hospital, Karachi. )
Shafqat Huma ( Department of Psychiatry, Aga Khan University Hospital, Karachi. )
In contemporary times loss of skilled health care staff by suicide-terrorism is a matter of grave concern. The prime example of this tragedy is death of Surgeon General Pakistan, General Mukhtar Ahmed Baig, in an incidence of Suicide Bombing.1 No place is immune from such incidences; acts of suicide bombing have been carried out in hospitals, private clinics and places of worships. According to most widely accepted definition, suicide attacks are "an operational method in which the very act of attack is dependent on the death of the perpetrator".2
Pakistan has seen a steady rise in the incidence of suicide bombing. Various government departments give contradictory statistics on suicide bombings. According to Federal Investigation Agency (FIA), in 2007 there were 32 suicide attacks, while the Interior Ministry claimed there had been 43 attacks.3 According to data released by the US government, 1,335 Pakistanis and 19 US citizens lost their lives in terrorist attacks in 2007. This number is the third highest after Iraq and Afghanistan.4 SB attacks increased from 22 between 2002 and 2006 to 71 in 2007 alone. Though the number was less in 2008 (67) the mortality statistics was higher; there were 973 deaths related to incidences of suicide bombing.5 2009 saw the highest incidence of SB in which around 1,286 individuals were killed across the country involving 171 events of suicide-terrorism.6
In a periodical, scientific American, Susser et al. writes \'Terror does not always come out of the barrel of a gun or in the shape of a bomb or grenade. Intimidation, harassment, threat of violence or the creation of an environment of imminent violence can be enough to paralyze civil life and kill enterprise and creativity. Such tactics can also lead to violent retaliation by those oppressed.\'7 Suicide-terrorism is a multifaceted problem; it has various social, psychological and geo-political determinants.8 Islam as a religion has nothing to do with sponsoring terrorism while Muslims have everything to do with it. They are the victims as well as the perpetrators of this terrible form of violence. Statistics would bear out the fact that more Muslims are killed then Christians, Jews or individuals from other faiths. This is applicable to Iraq, Afghanistan or United States of America.9 Why then Islam is credited with the rising trend of suicide terrorism? There are certain common denominators which should be kept in mind while reviewing the scholarly work in this area.
Suicide bombing is a symptom of a disorder. There is a dire need to treat the cause rather than control the symptoms alone. Fighting terrorism with force is an exercise in futility. Lack of education and development are a breeding ground for extremist ideologies. There is a dearth of Education in most of the Muslim countries. Consider Pakistan as a case scenario. Education is not a priority when it comes to budgetary allocation. A mere 1.8 per cent of Pakistan\'s GDP is spent on government schools. The statistics are dire: 15 per cent of these schools are without a proper building; 52 per cent without a boundary wall; 40 per cent without water; 71 per cent without electricity.10 There is frequent absenteeism of teachers; indeed, many of these schools exist only on paper. The rise in religious extremism has affected health related initiatives in many ways.
In immunization programmes, the refusals of polio vaccines have been a recent source of concern. Self-styled clerics in North West Frontier Province (NWFP) of Pakistan have passed a religious decree boycotting the immunization campaign launched by the government. They believe that vaccines have been donated by "western" countries with the covert agenda of harming the "faith" of their future generation. It is of prime importance that officials in the ministry of health, Government of Pakistan, initiate a dialogue with these religious leaders in order to find an impasse.11 The child health related indices in Pakistan read a sorry picture; the neonatal mortality of 57 per 1000 live births and infant mortality rate (under one) of 78 per 1000 live births is a source of persistent concern.12
In terms of burden of disease, Pakistan is beleaguered with a double burden of Infectious and Non-communicable diseases. In terms of economic resources we are classified as a Low- Middle Income Country while health related variables are at par with Sub-Saharan Low Income Countries.13 Community based studies report prevalence estimates of depression and anxiety disorders to be around 30%.14 This estimate is almost double the figures reported from the industrialized western countries. Armed conflicts lead to migration and internal displacement of population, pushing marginalized individuals towards mental illness. Post Traumatic Stress Disorder (PTSD) is one of the common conditions in such instances. Though there are no representative figures, of 1020 Afghan refugees presenting to a psychiatric clinic in Peshawar, North West Frontier Province, Pakistan, 76.1% (n=776) met DSM-III-R diagnostic criteria of PTSD.15
Suicide bombing and terrorist activities are particularly more devastating in the context of restricted Medical resources of Pakistan.16 Unfortunately, an organized Emergency Medical Services (EMS) does not exist in Pakistan. The initial help to such trauma victims is usually provided by people at the scene of the terrorist activity, which mostly is nothing more than sending the victims to the nearby hospital in any available transportation. Transportation of these victims to the hospitals is also delayed by the traffic congestion; though the situation has improved in major cities due to the combined efforts of government and NGOs. In-patient care for suicide bombing victims is also not very effective. The doctors and paramedical staff in the emergency department across the country, even in tertiary care hospitals, are not well trained for the care of suicide bombing victims. The situation of medical services is even worse in less developed, rural areas. Training and education in the field of EMS is quite nascent in Pakistan. Additionally hospital accident and emergency sections are staffed by generalists rather than specialists. Only handful of centers have skilled trauma teams.
Recent development in terms of conflicts is use of "non-lethal" weapons. Trauma surgeons and Emergency care staff has been outraged with its use. It is difficult if not impossible to draw a distinction between lethal and non-lethal weapons. The term non-lethal implies zero fatalities, but such an objective is acknowledged to be unrealistic. The development of this new generation of weapons incorporates knowledge from the remarkable advances made in medical science. A buried antipersonnel mine containing explosives is designed to blow off or disrupt the foot; few victims die from this injury if treatment is available. Eye attack laser weapons and other optical ammunitions have been produced in line with the non-lethal concept, supported by the argument that it is better to blind enemy soldiers than to kill them. It is the responsibility of the scientists to be proactive in unveiling the dangerous consequences of such weapon system and not be dissuaded by the terms like non-lethal or sub-lethal.17
The gravest issue with terrorism is that it impedes development in all facets of life, health care sector in not an exception. Terrorism also affects the mental health of the masses direct as well indirectly. The stress of uncertainty leads to state of compromised functioning among those who are vulnerable. In a larger frame of reference, the lack of development - in terms of human capital - is the biggest loss inflicted by terrorism.
In the twenty first century, when stem cell research has opened new avenues of research and inquiry, we cannot afford relegation to deep waters of ignorance. Clinicians and researchers need to initiate dialogue on public health issues. Universities need to play their part in bringing all the stakeholders together. Leadership in academia should step out of their traditional roles and confront the bigger issues. Noam Chomsky, the famous American cognitive scientist, linguist and philosopher in his famed essay, \'The Responsibility of the Intellectuals\', commented on the prevailing situation after the second World War: "…Only those who are willing to resist authority themselves when it conflicts too intolerably with their personal moral code, only they have the right to condemn the death-camp paymaster." The question, "What have I done?" is one that we may well ask ourselves, as we read each day of fresh atrocities…as we create, or mouth, or tolerate the deceptions that will be used to justify the next defense of freedom\'.18 The same question confronts many intellectuals in this country beleaguered by suicide-terrorism.
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3.Human Rights Commission of Pakistan. The Annual Report. (Online) 2010. [Cited 2009 March 2]. Available from URL: http://www.hrcp-web.org.
4.2007 Report on Terrorism: National Counterterrorism Center, US Govt; 30 April 2008.
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18.Chomsky N. In: The Responsibility of the Intellectuals. The New York Review of Books, 1967; 8:7.