Victims of armed conflict in India: psychosocial impact and available support

ABSTRACT

India has been a part of 5 major wars since its independence in 1947 and hosts over 212,413 refugees from Sri Lanka, Tibet and Bangladesh. So, a wide spectrum of trauma survivors, both civilian and military, live in this country and require mental healthcare. We discuss the psychological impact of armed conflict and how the country and culture tint it uniquely. We not only explore the current scene but the resources available and what can be done to make such vulnerable parts of the Indian population feel safer.

HIGHLIGHTS

• The spectrum of victims of armed conflict in India and the impact on their mental health.

• The current deficient governmental and non-governmental psychosocial support available.

• Recommendations for optimum management of these trauma victims through programmes and individual therapy.

India has been a victim of various armed conflicts in its post-independence era, from multiple wars with Pakistan in 1947, 1965, 1971 and 1999, the Indo-China war in 1962 and the skirmish in the Galwan river valley in 2019 (Bose, 2021). Increased conflicts within our neighbouring nations have also increased the refugee inflow significantly, including Tibetans, Sri Lankans and Bangladeshi migrants (Refugee population by country or territory of Asylum – India, no date). In Kashmir, insurgency led to an exodus of 90,000–100,000 Kashmiris in the 1990s, many of whom still reside in refugee camps across the nation (Bose, 2021). In light of this, it is critical to question whether adequate psychological support is available to the people who were engaged or were victims of these conflicts.

As of 1 January 2021, the Ministry of Home Affairs recorded 58,843 Sri Lankans displaced due to Sri Lankan Civil War in 1980–90, and 72,312 Tibetan refugees displaced after China annexed Tibet in 1959, hosted by India (IANS, 2022). Intensive programmes like The Tibetan Rehabilitation Policy, 2014 (Sunder, 2014) and Relief Assistance to Sri Lankan Refugees (Kalaivanan, 2005) support them in aspects of education, land rights, food, cash aid, medical assistance, welfare schemes and employment. Despite governmental efforts through National Health Policy of 2014 (National Mental Health Programme (NMHP) 2014) and NGOs like DANA Foundation (Penttila, 2022) and Children’s Hope India (Supporting refugee mental health: Children's hope India, 2021), the mental healthcare for refugees falls short. Psychological support for victims and soldiers of armed conflict should be considered a prerequisite requirement to ensure that they enjoy their fundamental right to live (Principles for the protection of persons with mental illness and the improvement of Mental Health Care, 1991) with dignity, enshrined in Article 21 (Part III - Fundamental Rights, 1951) of the Constitution of India.

Post-Traumatic Stress Disorder is common after an armed conflict, and multiple studies show its prevalence ranging from 49.81% in directly exposed victims to 3.76% overall in the Kashmir region (Banal et al., 2010; Bhat & Rangaiah, 2015; Crescenzi et al., 2002; Hussain & Bhushan, 2011; Mehta et al., 2005; Servan-Schreiber et al., 1998; Shoib et al., 2014; Yaswi & Haque, 2008). Major depressive episodes or disorder (MDD) (Banal et al., 2010; Holtz, 1998; Servan-Schreiber et al., 1998; Shoib et al., 2014; Yaswi & Haque, 2008), anxiety disorders including General Anxiety Disorder (GAD) (Banal et al., 2010; Crescenzi et al., 2002; Holtz, 1998; Shoib et al., 2014) were also common. Increased association of suicidality (Banal et al., 2010), substance abuse (alcohol and nicotine) (Banal et al., 2010; Shoib et al., 2014), somatization (Shoib et al., 2014) and dissociations is also observed (Shoib et al., 2014). Limited literature focuses on mental health in the Indian Armed Forces, correlating the type of traumatic event and psychological symptomatology. Still, the prevalence of psychiatric diagnoses in the Indian military is difficult to track (Contractor et al., 2020; Dolan et al., 2022).

The vulnerabilities were noted to be the female gender (Banal et al., 2010; Hussain & Bhushan, 2011; Shoib et al., 2014), unemployment (Banal et al., 2010), frequency of traumatic events, first-hand exposure, media coverage of the conflict (Bhat & Rangaiah, 2015), number of dependents and refugee status (George & Jettner, 2014). Conversely, Bhat et al. and Yaswi et al. did not find any gender predominance (Bhat & Rangaiah, 2015; Yaswi & Haque, 2008). Migrants and refugees seem at higher risk for GAD due to their alienation from a new culture and society, making them feel inferior (Banal et al., 2010). In children under 12 years, diagnosing depression was a challenge due to atypical symptomatology and decreased expression tools (Servan-Schreiber et al., 1998). Another elusive group was women who underreported sexual assault experienced during imprisonment, inhibited by sociocultural stigma. A high disparity between endorsement of the item ‘being kept naked’ vs ‘rape and sexual abuse’ was noted, making us infer that females were hesitant in admitting to the latter despite its high possibility (Crescenzi et al., 2002).

Women, despite being vulnerable, showed higher post-traumatic growth through resilience (Hussain & Bhushan, 2011). Religion also seems to be a strong protective factor against PTSD. When comparing Sri Lankan and Kashmiri migrants to Tibetans, the latter accepted their fate readily because of their unique Buddhist beliefs, facilitating post-traumatic growth. The Buddhist monks and nuns were additionally provided social-cultural support and a purpose by monasteries, enhancing collective coping through spirituality (Crescenzi et al., 2002; Holtz, 1998; Servan-Schreiber et al., 1998). Other factors that helped combat post-traumatic stress were familial involvement, security, active community support and the patriotic spirit of struggling against their national oppressor (Servan-Schreiber et al., 1998). Kashmir has been persistently involved in wars, traumatic events and armed conflicts. Surprisingly, the PTSD prevalence is low due to the resilience of the residents unless they directly experienced the trauma (Shoib et al., 2014).

India remains deficient in an adequate structure to provide mental health support to the victims in the conflict-stricken regions. This is attributed to the double jeopardy of still being a developing country while hosting the second largest population globally (Yaswi & Haque, 2008). Another challenge is tackling the social stigma around mental health so sufferers readily seek clinical care and support. On the level of the Government and NGOs, we recommend:

• Overall strengthening of psychiatric services and socio-economic status in Kashmir and Kashmiri refugee camps across the nation, as the region is a hotspot of territorial disputes and armed conflicts between India, Pakistan and China (Banal et al., 2010).

• Mental health services in educational settings, with the establishment of counselling cells and crisis intervention centres, providing tailored treatment to the suffering population (Bhat & Rangaiah, 2015).

• Insisting governmental and non-governmental organizations focus on implementing existing schemes to narrow the huge gap between the on-paper and in-field scenarios (Bhat & Rangaiah, 2015).

• Potentially involve international support like the World Health Organization if national programmes are overwhelmed (Yaswi & Haque, 2008).

• Include cultural and community-based therapies and tailor the programmes to an individual’s experiences, behaviours and perceptions (George & Jettner, 2014).

• Promoting mental health at the community level to combat stigma and initiate support groups, religious and cultural activities, re-establish educational institutes and involve the community in the psychosocial support system (Hussain & Bhushan, 2011).

• Recruit and train additional lower-level mental health providers in areas prone to armed conflict (Gilmoor et al., 2019).

As a group of predominantly doctors, we would like to suggest physicians encountering such patients include local languages and vernacular terms, along with the gold standard of DSM-5, for diagnosing psychiatric disorders in an accessible way (Gilmoor et al., 2019). Tailoring individual therapies around the culture, religion, behaviour and perceptions of the migrant population increases their effectiveness (George & Jettner, 2014). Maternal involvement in paediatric patient therapy is highly beneficial as it provides a warm, comforting environment (Servan-Schreiber et al., 1998). There is also a dire need to qualitatively investigate the perceptions and trauma experienced by vulnerable populations (women, children and unemployed groups) where post-traumatic stress is underreported and neglected (Gilmoor et al., 2019).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability

All data underlying the results are available as part of the article and no additional source data are required.