Google "Afghanistan" and "post-traumatic stress disorder," and the search results will paint Odyssean portraits of thousands of American war veterans: restless and explosively violent, battling internal monsters, incapable of making the emotional return home years after they have left the physical combat zone. One in five American veterans who have served in Iraq or Afghanistan -- as many as 400,000 men and women -- suffers from severe depression or post-traumatic stress disorder, a noxious bouquet of depression, hopelessness, panic attacks, psychosomatic pains, rage, and insomnia. A recent U.S. Army report found that the suicide rate among active-duty soldiers had ballooned from 9.6 per 100,000 in 2004 to about 24 in 2011. By June of this year, more active-duty troops had died of suicide than in combat. Mental disorder has become the signature injury of Washington's latest wars, which have turned the term and its acronym, PTSD, into household words in the United States.
But can an entire country have PTSD? Can invisible wounds bleed whole societies: failed states like Somalia or the Democratic Republic of the Congo, sadistic dictatorships like Zimbabwe or North Korea, countries trying to recover from fratricidal conflicts like Iraq or Sudan?
Or take Afghanistan, a war zone I know well. What happens when physical and emotional battlefields converge in a land whose people have been eking out an existence amid unending violence for generations? In such war-wrecked countries, the trademark symptoms of individual war trauma -- depression, anguish, and hyperaggression -- leave whole populations envenomed with sectarian and ethnic mistrust, and with the certainty that only violence can end violence.
Like a traumatized veteran who scans a suburban shopping mall for snipers, they see danger even where it may not necessarily exist. Scores of Afghans have told me privately that they defied the 2006 government order to disarm and secretly kept their rifles stashed within easy reach: in shallow pits in their backyards, beneath the earthen floor of their houses, behind knotty poplar rafters holding up wattle-and-daub roofs. One taxi driver explained that his family owned enough rifles to arm an infantry squad. He kept a Luger Parabellum, wrapped in a camel-wool blanket, in his car. He said he felt threatened by government troops, police, Taliban, ethnic militias, and neighbors belonging to different ethnic groups -- in short, by almost everybody who was not his kin. No wonder a 2009 Gallup poll showed that two-thirds of Afghans felt unsafe walking alone outside at night.
In 2002, shortly after the Taliban government fell in Kabul, the U.S. Centers for Disease Control and Prevention dispatched a research team to Afghanistan to study the prevalence of mental trauma among civilians there. That nationwide survey remains the only modern, comprehensive inquiry into the mental health of Afghans. It found that 42 percent of Afghans suffered from post-traumatic stress disorder and 68 percent exhibited signs of major depression. In other words, up to 19 million of the country's 28 million people were suffering from psychological injuries. And that was a full decade of war ago.
In a village about 30 miles south of Mazar-e-Sharif, in northern Afghanistan, I once had lunch in a castle that presided over 15 acres of farmland and belonged to two brothers. I admired the 360-degree view of the valley through the tower's primitive castellations, from behind 4-foot-thick clay walls. The brothers told me they needed the castle, built 60 years earlier by their grandfather, to defend their women, their wealth, and their honor. From whom? I asked. They responded in unison: "Everyone."
"Feelings of hatred and revenge, and the desire of acting on that feeling of revenge, directly affects the peacemaking process," says Barbara Lopes Cardozo, the psychiatrist who oversaw the 2002 mental-health survey in Afghanistan and who has studied mental health of civilians in such war-scarred geographies as Kosovo, Somalia, and Uganda. "We found very high numbers for having those feelings of hatred and revenge -- almost 80 percent -- in Afghanistan."
Post-traumatic stress often spawns domestic violence -- the U.S. Department of Veterans Affairs says returning service members are up to three times more likely to abuse their partners than American civilians -- and Afghanistan is no exception. Time magazine's shocking photograph of Bibi Aisha, the 18-year-old woman whose husband had cut off her nose and ears, became the face of Afghanistan's spousal abuse. Two-thirds of Afghan children surveyed by British anthropologists in 2006 reported traumatic experiences; two years later, a study in the Journal of Marital and Family Therapy found that more than half the children surveyed in Kabul reported witnessing three or more types of domestic violence. Is this the knowledge that had hollowed out the eyes of the children I have met in Afghanistan's villages and towns, that had turned preteen boys into little old men with skeptical down-curved mouths? The generation that will determine the country's future is growing up today with the understanding that nowhere is safe and that cruelty is the norm.
"People get used to using violence to settle their disputes, and it is difficult to find a way to unlearn those behaviors," says Peter Bouckaert, emergencies director at Human Rights Watch, who has worked in war zones around the globe. "You end up with a warlord economy which is incredibly hard to break and which does lead to a constant renewal of conflict -- as it will in Afghanistan."
A few years ago, researchers in northern Uganda -- where the Lord's Resistance Army of the self-proclaimed messiah Joseph Kony had killed and mutilated tens of thousands of civilians and abducted countless children into servitude before fleeing into the jungles of the Central African Republic in 2006 -- conducted a survey designed to determine the emotional effect of violence on residents. The study, published in the Journal of the American Medical Association in 2007, established that civilians who were suffering from post-traumatic stress disorder -- about 74 percent of the Ugandans surveyed by University of California/Berkeley scholar Eric Stover and his colleagues -- were "more likely to favor violent means to end the conflict" than civilians who were not. Trauma begets trauma -- and violence.
Compared with research into the effects of conflict on U.S. war veterans, studies of combat trauma among civilians are few. But there is a growing understanding among medical scientists and conflict experts that the emotional toll of war on noncombatants is more significant than had been assumed. During World War I, when military physicians described soldiers' traumatic reactions to war as "shell shock," about nine out of 10 war casualties were fighters. But after nearly 50 years of the Cold War and more than 10 years of the war on terror, the way we wage war is more personal. Terrorism battlefields recognize no front lines. Vicious sectarian rampages pit neighbor against neighbor. Victims of genocidal campaigns often know their attackers by name. In the most current conflicts, at least nine out of 10 war casualties are believed to be civilians, writes psychologist Stanley Krippner in his book The Psychological Impact of War Trauma on Civilians. In Iraq, where as many as 1 million people may have died since 2003, the rate might be even higher. No one kept track of civilian casualties in Afghanistan between 2001 and 2007, and estimates vary widely; given the United Nations' tally of almost 12,000 civilian deaths since the beginning of 2007, a rough guess of between 20,000 and 30,000 civilian casualties since 2001 seems reasonable.