Contemporary wars and changes in war strategic targets and warfare styles and technologies, such as aerial bombing and unmanned aerial vehicles (UAV), known as ‘drones’, have led to a significant increase in the number of civilian casualties, now making up approximately 90 % of all war-related deaths (Pedersen and Kienzler 2008).³ The global impact in numbers of accumulated civilian deaths is thus considerable. Psychological warfare is a devastatingly effective central feature in these contemporary wars, where terror is infused and atrocities are committed, including massacres and mass executions, desecration of corpses, disappearances, torture and gang rape are the norm (Summerfield 1995, 1998; Pedersen 2002).

These new forms of warfare and their devastating consequences can be observed across all regions of the world. 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, deaths, despair and suffering (Reno 2012).

The Arab league countries also have a distinct experience of revolt and rebellion 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 organised violence. The siege and bombardment of cities and the use of heavy artillery and aerial bombing, chemical weapons and other abusive and repressive measures, including harassment, jail, torture, suicide bombings and summary executions, are common occurrence in countries such as Syria, Libya, Yemen, Egypt and the occupied Palestinian territories, among others, resulting in large numbers of civilians killed and wounded, yet the total number of fatalities remains unknown. According to recent UNHCR estimates, the number of refugees from the Syrian long-standing civil war is now over 2.5 million peoples, which is one of the highest numbers of refugees in the region’s recorded history.

In South and Central Asia, apart from the two major wars being fought in Iraq and Afghanistan which are responsible for thousands of lives lost and millions of displaced populations and refugees, numerous protracted ethnic conflicts have erupted and continue to engulf the region in organised violence, resulting in high death tolls, particularly among civilians and enrolled militias, resulting in massive population internal displacements and increasing numbers of refugees. Prime examples of these are the ongoing ethnic conflicts in the Kashmir region between India and Pakistan, Tibet in southern China, Bhutan, Nepal and Sri Lanka. In the case of Nepal, there were more than 10,000 people killed and an estimated 100,000 suffered torture (CVICT 2008), rape and other form of physical and psychological abuse. Sri Lanka has been shaken by a long-standing ethnic conflict between the Sri Lankan Sinhalese majority government forces and the Liberation Tigers of Tamil Eelam (LTTE) which divided the country in a brutal conflict and war that lasted well over two decades (1983–2009). The conflict ended with more than 300,000 Tamils held hostage in the northeastern part of the island, in what became for a few months one of the largest concentration camps in recorded history, where systematic violations of human rights were enforced by government forces.

In the Latin American region, there are many recent examples of ethnic conflicts and internal wars resulting in high death tolls, particularly among indigenous peoples: the almost four decades of violent conflict and massive killing of more than 200,000 civilians, mostly of Mayan origins in Guatemala; the extrajudicial executions of Miskito Indians in Nicaragua; the murder of Tzotzils in Chiapas, Mexico, and Yanomami Indians along the border between Venezuela and Brazil; and the annihilation and disappearance of 70,000 civilians, mostly Quechua-speaking peasants in the Peruvian highlands, undertaken by Shining Path guerrillas and the military repression (Pedersen et al. 2003), are some of the exemplary cases in point.

Despite a decreasing trend of armed conflict and wars and the mounting number of civilian war casualties, the post-cold era is characterised for growing and significant global flows of refugees and internally displaced persons (IDPs). For example, the UNHCR Global Trends Report (2011) shows that globally there were 43.7 million forcibly displaced people at the end of 2010. The global number of people affected by conflict-induced international displacement increased from 24.4 to 26 million, and available information suggests that a total of 67 million people had been forcibly displaced at the end of 2007. The number of IDPs keeps growing – mostly because the ongoing Syrian civil war now responsible for over 2.5 million refugees – and has been more recently estimated at 54 million worldwide, where about 30 million were displaced as a result of armed conflict and war and another 24 million by natural disasters. In addition, while often not considered as being displaced per se, it is estimated that there are some 12 million stateless people worldwide (UNHCR 2011). Although demographic information on displaced populations is not always available for all countries, the available data by sex indicates that women represent about half (47 %) of most populations falling under UNHCR’s responsibility.

Furthermore, around one third of all refugees are residing in countries in the Asia and Pacific region, with 80 % of them being Afghans. The Middle East and North Africa regions are host to more than a quarter of all refugees, primarily from Iraq and Syria, while Africa and Europe hosted, respectively, 20 and 14 % of the world’s refugees. The Americas region had the smallest share of refugees (9 %), with Colombians constituting the largest number for this region (UNHCR 2009).

Whether internally or cross-nationally, the majority of refugees are clearly made up of women, children and the elderly. They are often subject to various forms of social exclusion, exploitation, rape and sexual abuse and are exposed to political violence and torture. The conditions found in sheltered zones, in larger cities or across the border in neighbouring countries are not necessarily better than the ones left behind. The lack of sanitation, food and water shortages, loss of family and social support networks, crowding and overall deprivation experienced in refugee camps impose additional health risks and increased mortality and morbidity and inflict further distress and suffering among survivors. Outbreaks of cholera, dysentery, tuberculosis, acute respiratory infections and other viral diseases, such as measles, are common occurrence in most refugee camps. Pregnancy, sexually transmitted diseases and AIDS are also on the increase among refugee women and young adolescents who have experienced sexual abuse. According to UNICEF (1996), in Rwanda virtually every adolescent girl who had survived the genocide of 1994 was subsequently raped. Rape and commercial sex is also widespread in refugee camps, often resulting in unsafe abortions and the spread of sexually transmitted diseases, including AIDS. The displaced are usually deprived from social, material and emotional support systems, which may make them more fragile and vulnerable to environmental adversities and social distress.

To close this chapter, we would like to discuss briefly the nature and content of humanitarian interventions being used in civilian populations in the aftermath of organised violence, armed conflict and war-related adversities.

The aftermath of contemporary wars is partly characterised by the overall reordering of post-conflict post-war politics and the emergence of what has been called a ‘therapeutic moral order’, which is largely driven by the false premise that not only combatants but entire civilian populations exposed to the adversities of endemic violence and armed conflict are traumatised and would require therapeutic management of one kind or the other (Moon 2009). That is, in the post-conflict and post-disaster operations, psychiatric teams or trauma counsellors are often mobilised under the assumption that trauma-related disorders will necessarily affect most if not all of the exposed.

At the same time, it is acknowledged that states recently emerging from armed conflict or under endemic and protracted organised violence have inadequate mental health resources due to a lack of funding, reduced health budgets and a shortage and inequitable distribution of mental health professionals (Allden et al. 2009; Al-Obaidi et al. 2010). In order to ameliorate this situation, the funding and delivery of humanitarian assistance is increasingly organised by bilateral aid, as well as international and local NGOs, and most current therapeutic interventions are exported from Western countries and adopted by the recipients from to war-torn societies worldwide with little adaptation if any.

While various forms of mental health intervention may have a role to play in post-conflict or post-disaster recovery, the medicalisation of psychosocial intervention programmes in terms of PTSD and related constructs often leads to the uncritical application of symptom check lists and provision of ‘trauma counselling’ (Dwyer and Santikarma 2007). This approach reflects our limited understanding of the relationships among the range of possible health outcomes after exposure to catastrophic and traumatic events (Young 1995, 2000). Moreover, at a clinical level, we know little of who should (or should not) receive individual intervention and still less about how and why it may work in some cases and not in others. Most ongoing efforts and humanitarian interventions carried out by government agencies and NGOs have not been assessed in terms of health outcomes and overall impact in the quality of life and well-being of local communities and potential beneficiaries.