Comp. by: C.BALAJI Stage: Proof Chapter No.: 32 Title Name: Okpaku Date:5/11/13 Time:15:29:21 Page Number: 307 Section 6 Chapter 32 Human resources and capacity building Mental health and illness in conflict areas Duncan Pedersen and Hanna Kienzler Introduction It is estimated that since the end of World War II, a total of 240 armed conflicts have been active in 151 locations throughout the world (Harbom & Wallens- teen 2009). While the number of interstate wars has been declining since the early 1990s, the number of intrastate wars, most often fought between ethnic groups or loosely connected networks challenging both poor and underdeveloped states and powerful nation states, has increased both in frequency and in levels of organized violence, inflicted atrocities, and psychological warfare. The largest increase of active intrastate conflicts is being reported in Africa, from nine in 2003 and seven in 2005, to twelve in 2008. If we limit the review to the last two centuries only, wars with a long-lasting – so-called “transform- ational”– effect on the course of world history, leading to important changes in the global order, represent an estimated total of 42 years of conflicts with a conservative estimate of about 95 million deaths, including both combatants and civilians (Smil 2008). The megawars with the largest number of fatalities (over 10 million) were the Taiping War (1851–64), the Second Sino-Japanese War (1937–41), World War I (1914–18), and World War II (1939–45). Contemporary wars and changes in war strategic targets and warfare styles and technologies (e.g., aerial bombing) have led to a significant increase in the number of civilian casualties, now making up approxi- mately 90% of all war-related deaths (Pedersen & Kienzler 2008). In Africa, the style of warfare has shifted dramatically in recent years. Emerging rebel movements are mushrooming, and the continent is now plagued by countless small-scale “dirty wars” with no front lines, no battlefields, and no distinctions between combatants and civilians. Many of the recruits are children and young adolescents who are engaged in a vicious circle of gang-rape, pillage, and crime, leaving behind a trail of mutilation and murder, trauma, despair, and suffering (Reno 2012). The Arab countries have a distinct experience of revolt and rebel- lion against authoritarian regimes and a recent history of violent military repression, with a high death toll among civilians engaged in massive demonstrations and exposed to different forms of organized violence, including jail, torture, and summary executions. Psychological warfare is a devastatingly effective central feature in these contemporary wars, where terror and atrocities, murder and mass executions, disappearances, torture, and rape are the norm (Summerfield 1995, Pedersen 2002). In addition to the mounting number of casualties, these conflicts have resulted in large flows of refugees and internally displaced persons (IDPs). For example, the 2010 United Nations Refugee Agency’s Global Trends report (UNHCR 2011) shows that there were 43.7 million forcibly displaced people worldwide at the end of 2010, the highest number since the mid- 1990s. Of these, 15.4 million were refugees, 27.5 mil- lion were IDPs, and 850 000 were asylum seekers, of whom 15 500 were unaccompanied or separated chil- dren. Although demographic information on dis- placed populations is not always available for all countries, some recent estimates indicate that women represent half of most populations falling under UNHCR’s responsibility. In all, a significant propor- tion of the forcibly displaced populations and victims of genocide and armed conflict in the world involve mostly the poor and politically marginal, so called “Fourth World” peoples (Pedersen 2002). But what are the consequences and main health outcomes experienced among civilian populations affected by endemic conflict, protracted violence, Essentials of Global Mental Health, ed. Samuel O. Okpaku. Published by Cambridge University Press. © Cambridge University Press 2014. 307