- Afghan refugees call it "mualagh". Roughly translated, it means a feeling of floating in sad uncertainty, like a leaf held aloft only by gusts of wind. Villagers driven from their homes in Darfur talk about "mondahesh", a sense of shocked surprise.
And when the displaced in East Timor complain of "hanoin barak", they are telling you quite simply that they are thinking too much.
Consider then the Western equivalents. People are burdened with stress, they suffer from depression, and if things get really bad, there is the wide embrace of the mother of all 21st century mental diagnoses, Post Traumatic Stress Disorder (PTSD).
Tempting as it has been to transfer these concepts neatly from Western clinical settings into humanitarian emergency contexts, questions are increasingly being asked of their validity.
In short, are we all feeling the same thing?
Internationalising mental healthEver since the 1994 Rwandan genocide and the Bosnian conflict in the early 1990s, psychiatrists, psychologists and health professionals have been looking for ways to address the mental health needs of victims of humanitarian emergencies.
A conference focusing on the displaced at the Institute of Psychiatry at King&${esc.hash}39;s College London last week heard case studies of vulnerable groups ranging from housewives in Kashmir to trafficked women in London and the chronically mentally ill in tsunami-affected areas of Aceh in Indonesia.
According to International Medical Corps (IMC), a U.S.-based NGO that specialises in mental health interventions, some 450 million people suffer from mental and behavioural disorders worldwide. Yet governments and local authorities often virtually ignore the issue, even more so in areas of armed conflict, and it is often one of the last factors to be considered in humanitarian health programming.
On a pure staffing level, no one is underestimating the extent of the problem. In almost nine out of 10 African countries, for instance, there is statistically less than one psychiatrist for every 100,000 people. Chad and Sierra Leone, with a combined population of almost 16 million, have two psychiatrists between them.
Media reports routinely refer to the "mental scars" that long outlive the physical damage of conflict, natural disaster or displacement, and coverage of so-called "psychosocial" interventions is drawing increasing amounts of donor funding into mental health programmes, especially post-disaster trauma counselling.
Understanding the labelsYet a debate is gathering pace in the world of what has come to be known as International Mental Health over how to identify and treat these scars, if indeed they are scars. Are people as traumatised as we think they are, and if they are, are we truly going to help them by applying Western diagnostics of mental illness?
"PTSD is an anachronism, the discussion is fake," said Dr Joop de Jong, professor of mental health and culture at the Vrije Universiteit in Amsterdam. "There are certain core symptoms, so parts of PTSD can form a valid diagnosis, but it cannot be uniform."
As far as de Jong and many of his colleagues attending the London conference are now concerned, trauma per se is a blunt diagnostic tool, which tells us little about the social and cultural context within which people may experience distress. More importantly, they say it turns human beings into victims by transforming their quite ordinary and understandable distress into a pathological condition.
"There is often an assumption that experience of conflict will automatically traumatise a person," said Janaka Jayawickrama, a research associate at the Disaster and Development Centre at Britain&${esc.hash}39;s Northumbria University. "Yet we often don&${esc.hash}39;t take into consideration the capacities and skills of affected populations."
According to Jayawickrama, a Sri Lankan who has worked extensively with communities in Sudan&${esc.hash}39;s Darfur region, Western practitioners often make the mistake of treating trauma in developing countries as a personal, individual experience when it is in reality viewed primarily as a collective challenge.
It is help with this collective challenge, he says, that beneficiary communities are looking for on both practical and social levels. Isolating individuals for a therapeutic intervention is the last thing they need.
Do no harm?One delegate at the conference, who asked not to identified, ridiculed the belief that Western counselors could possibly understand, measure and treat the distress suffered by residents of far-off humanitarian emergencies according to psychiatric guidelines. (The Harvard Trauma Questionnaire, a checklist of emotional symptoms associated with traumatic stress, is still widely used.)
"Standalone trauma-based interventions are very attractive because the donors like them," he said. "It&${esc.hash}39;s really quite comical."
Aside from base ineffectiveness, others are warning of more damaging consequences, namely that those exposed to trauma counseling will begin to believe they are seriously unwell when traditional - and effective - coping mechanisms, such as seeking out traditional healers, are freely available to them.
"Local people often end up speaking the language of the NGOs, which has a stigmatising effect that fails to capture their own power and resilience," said Dr Derek Summerfield, a consultant psychiatrist at the South London and Maudsley NHS trust, who was worked extensively as a consultant to Oxfam and other aid agencies. "They are not mental cases."
Summerfield stressed that no one was pretending there wasn&${esc.hash}39;t enormous suffering inherent in humanitarian emergencies. "No one is saying that local cultures can always cope, but the ethical response is to start from where they are and not provide responses rooted in a sense of western rationality."
When it comes to the genuine needs of disrupted communities and displaced populations, conference delegates drew clear distinctions between the long-term needs of those who already suffered chronic mental illness and so-called beneficiaries who may or may not be suffering emotionally from post-disaster trauma
"So many people are getting involved in short-term trauma interventions, but given the cultural support that exists, many of those symptoms of distress will dissipate over time," said Dr Andrew Mohanraj, a Malaysian psychiatrist working with International Medical Corps (IMC) in Aceh.
"You&${esc.hash}39;ve got to look at long-term intervention in pre-existing structures to see sustainable development."
As Mohanraj pointed out, patients suffering from conditions such as schizophrenia and epilepsy were found either caged or chained to trees following the tsunami, such was the lack of local investment in formal psychiatric care.
"Mental health services must be improved at the community level," he said. "There is a lack of proper distribution of resources."
According to Atalay Alem, an Ethiopian doctor at the conference, an additional flaw in international interventions was their tendency to poach staff from local mental health structures, who flock to work for trauma NGOs at five times the salary, thus abandoning what little is left of domestic institutions.
A fledgling fieldFor all the mistakes that have been made, mental health is slowly moving into the mainstream of humanitarian aid.
The U.N. formed an inter-agency taskforce on mental health and psychosocial support last year, which has drafted a comprehensive set of guidelines and minimum standards on these kinds of operations. These include the absolute necessity of integrating responses with local social and spiritual practices.
Agencies such Medecins Sans Frontieres now incorporate mental health considerations into all health planning for humanitarian operations. "We culturally validate our programmes by placing far greater emphasis now on the role of national staff in programme design," said MSF&${esc.hash}39;s mental health advisor, Kaz de Jong.
As far the wider aid debate is concerned, experts say it is only to be welcomed that beneficiaries are no longer viewed as anonymous recipients of food, shelter and medical care. International aid organizations have at least cottoned on to one small truth: They have feelings too.
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