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Living in fear

Published on 08 July 2020 Go back to The ACU Review

For communities blighted by terror and violence, fear and dread live on in the mind, long after the immediate threat has passed.

By Salma Siddiqui, National University of Sciences and Technology, Pakistan

In communities across the world, terrorism and prolonged conflict have become the new normal. These communities exist in a constant and sustained state of alarm, with the ever-present threat of violence never far from their minds and experience. Many will have witnessed traumatic events that have threatened their lives and wellbeing, or that of their loved ones. A sense of perpetual fear and insecurity looms large.

In these contexts, we see a widespread increase in post-traumatic stress disorder or PTSD, an anxiety disorder arising from a traumatic event. Its symptoms include vivid flashbacks, nightmares, physical sensations (such as pain, nausea, and trembling), and distressing intrusive thoughts. When first conceptualised, PTSD was understood as a response to events that were outside the range of common experience. But where violence is commonplace and recurrent, traumatic stress can take hold on a mass scale and presents a rising public health challenge.

Anxiety and fear are, of course, natural responses to danger and threat. Many of us will be familiar with the notion of the ‘fight or flight’ response: a stress reaction that enables us to protect ourselves from harm. We call these ‘adaptive responses’. But traumatic events disrupt our adaptive response and leave an imprint on the brain. In other words, the panic, fear and dread continue, long after the immediate threat has passed.

Communities under fire

Worldwide, acts of terrorism take thousands of lives each year. The most recent Global Terrorism Index reported 15,952 deaths from terrorism in 2018 but the figure varies significantly from year to year, reaching its highest in 2014 when the death toll soared to 33,555. Today, 93% of victims of terrorism die in the Middle East, Africa, and South Asia.

Pakistan has a long history of traumatic events due to its geopolitical position, with reports suggesting that 40% of its population suffer from ongoing stress and depression. The Khybar Pakhtunkhwa province on the Afghan border of northwest Pakistan is among the hardest hit in terms of regional terrorism, both political and religious.

The province has been severely affected by continued armed conflict and heavy casualties, as well as violent attacks by militant groups such as the Taliban which emerged after the Soviet invasion of Afghanistan and regrouped in Pakistan.

Towns and cities in the region, such as Peshawar, have endured bomb blasts, shootings, suicide attacks and massacres, with universities, schools and churches all targets. In Parachinar, another terror-hit city, a survey found that 60% of residents were suffering from PTSD.

The devastating impact of these events became starkly clear to me when I joined a team of mental health professionals working in the aftermath of the massacre at Peshawar Army Public School in 2014, in which 132 children and nine teachers lost their lives. Many were shot at point-blank range by gunmen clad in army uniforms and suicide vests, who also detonated bombs around the school buildings. I worked with grief-stricken parents and families, as well as children and teachers who had survived the attack. Many showed signs of trauma: any sight or sound that reminded them of the attack – such as a crash from a building site or even the colour red – brought on intense distress.

Relatives and friends of the children and teachers killed in the Peshawar Army Public School massacre take part in a walk in their memory (Credit: Owais Aslam Ali / Asianet-Pakistan at Alamy Stock Photo) Siddiqui Image 2 (Credit Asianet Pakistan, Alamy Stock Photo) (1)

This traumatic stress damages the social fabric of communities. It robs individuals and communities of their sense of agency, leaving them feeling powerless, terrified and angry. Conflict and terrorism erode the public health infrastructure and systems that are so vital after large-scale traumatic events: support networks unravel, access to healthcare is reduced, social capital eroded, and productivity diminished – all at great cost to society.

Traumatic distress is also contagious and can be experienced vicariously. When a traumatic event is experienced at a community level, distress spreads like an epidemic. For communities raising families in a state of uncertainty or fear, their children become prone not just to traumatic distress but to depression, anxiety, and other mental and physical health issues. This is particularly important for countries like Pakistan where young people form the larger part of population.

A public health approach

Where conflict and violent events are commonplace, there is a risk of over-pathologising traumatic distress – in other words, focusing on it as a disease or abnormal disorder, rather than addressing the factors that underpin and exacerbate it. What is needed instead is a better understanding of the factors that can make a person or community more vulnerable to traumatic distress. Let me draw a parallel here: if you are visiting a place where malaria is common due to poor sanitation, the likelihood of your catching malaria increases. If your health is already poor then your vulnerability increases even further.

In the context of Pakistan and other low income countries, the stigma attached to mental illness, poor access to health services and education, and economic strain all increase an individual’s vulnerability to trauma. Social strife itself is also an outcome of continued exposure to violence and danger, thus creating a vicious cycle.

The World Health Organisation’s Violence Prevention Alliance proposes a four-level model to understand the factors that increase a person’s likelihood of becoming both a victim and perpetrator of violence: individual, relationship, community, and societal. The individual level emphasises personal history and biological factors. The second level – relationships – examines close and influential relationships. The community level looks at the settings in which social relationships happen – schools, universities, workplaces, and neighbourhoods. And the societal  level refers to broader factors which influence whether violence is encouraged or inhibited, such as economic and social policies, the availability of weapons, and cultural norms.

Rather than thinking of traumatic distress as a disease to be treated after it has taken hold, a public health approach shifts the focus towards identifying, understanding, and addressing the underlying risk factors which can help societies to prevent violence before it begins – and that must remain our ultimate goal.


Dr Salma Siddiqui is Head of the Department of Behavioural Sciences at the National University of Sciences and Technology, Pakistan.

Image (top): a candlelight vigil in Peshawar on the first anniversary of Bacha Khan University attack. Credit: Owais Aslam Ali / Asianet-Pakistan at Alamy Stock Photo