A Look at Forced Migration and Mental Health

LIFE AFTER WAR: DISTURBED You’re about to take a close look at the mental turmoil of forced migration that flings survivors far from their centers of gravity, from the places their families have known for generations. Many embark on geographic journeys that move them beyond the terror, but trauma travels, too. The numbers are simply staggering: the World Health Organization (WHO) estimates a billion people around the world are forcibly on the move and the reasons are many: men, women and children “internally displaced” by climate change, natural disasters, repression and conflict within and from outside their own borders; refugees and asylum seekers fleeing dangers at home and unable to return without risking freedom, or their lives; generations of impoverished intent on economic opportunity; families trying to reunite; and the untold numbers of stateless people searching for safe ground. By the close of 2024, the United Nations High Commission of Refugees expects 130 million refugees - masses of humanity who cross borders into mostly low and middle income nations where little to no resources go toward those in need, much whereless non-citizens. 

This year’s migrants and refugees follow the same tailspin as last year’s, their emotional turmoil exacerbated by the unwelcome response they experience from unwilling hosts, conditions bound to exacerbate genetic and environmental mental illnesses. While International groups are only beginning to train their focus on the fallout, with important studies now in their infancy, it is abundantly clear that displacement pushes mental health challenges and trauma to new levels. The World Health Organization last estimated one in five people suffer but since WHO issued this warning, Russia invaded Ukraine and Israel has obliterated Gaza, forcing many millions more from their homes, and impacting entire populations.  

Post-Traumatic Stress Disorder is the assumed baseline, but there is a far greater risk for those who suffer more severe psycho-social afflictions. Victims live among their perpetrators and the silent eyewitnesses of unspeakable atrocities. They are behind high fences of refugee camps, stuffed into detention centers, restricted to the most blighted and overcrowded parts of town or thrust into rural, remote oblivion. For them, life after war often means a dual existence of density and isolation: they’re in close contact, yet unable to communicate. Man, woman, and child suffer anxiety, depression, extreme agitation, and psychosis, yet if cultural norms even recognize psychiatric problems, they fear them or punish them. The norm is individuals and families suppressing and hiding troubles that are simply inescapable, and host countries ignoring cultural sensitivities that are essential to grasp when addressing migrant and refugee mental health.

TRAUMATIZED HAS BECOME A MAJOR DEMOGRAPHIC The many triggers to mental instability often increase for forced migrants. Consider the impact of the most wideaspread weapon of war, savage sexual violence: the brutality, the abuser’s entitlement, the victim’s enduring shame leaving men, women, and children physically and emotionally disabled. Armies and militias rape their way through conflict, while society imposes strict taboos on discussing sex, much less a vulgar form of it. But the same society unleashing systemic and systematic sexual abuse of women and girls, stigmatizes and punishes these very victims as unclean or unworthy of life. Among those fleeing aggression are perpetrators, too, some who have spent their entire lives as killers in captivity. Soldiers conscripted as toddlers and those who joined militias as young teens have shared a common rite of passage: kidnapping, raping, and forcing young girls to wed and bear children. Many of the women and children attempt to escape, and militia members sometimes defect with their families in tow. As radical movements gain and lose steam, nations struggle and mostly refuse to reintegrate former members of groups such as ISIS and Boko Haram. 

Survivors’ mental health needs are beyond measure, yet their resources are abysmal. It’s a mismatch that portends long-term problems. As intra- and extra-regional conflicts continue, the ranks of those damaged and disturbed by war will increase. In sheer numbers, they merit their own world population category. Indeed, “Traumatized” has become a major demographic. 

THE WORK OF THIS GENERATION Restoring balance and averting circumstances leading to turmoil will be the work of many generations to come. Our best and brightest will spring from colleges and universities that strategically respond by turning out graduates equipped to take on these challenges. Nonstop global crises command a fierce line up of medical doctors and nurses, scientists and social workers, child advocates and trauma experts, demographers and development economists, agronomists and food security experts, specialists in the rule of law and conflict resolution, and ever-extending categories of technically-trained professionals in demilitarization, de-mining, ordnance removal, and environmental clean-up. Many schools already offer course work, discrete programs, or devote entire centers of learning to these arenas. A coalition of dedicated learning institutions can become a clearing house for needs, talent prep, and deployment.

Here’s a natural platform for ready, broad-based engagement. Imagine if some of the millions of students studying abroad (upward of 350,000 this year from the US, alone) focused on the deficits in social and economic well-being, and how to practically address them. Imagine if a significant number studied and confronted a public health risk in the field; examined obstacles and ways to boost the number of young girls in school; worked with a local community to reduce ethnic tensions; the list goes on. In well-trod Junior Year Abroad destinations like the UK, France, Germany, and Spain, students in language proficiency will have a much better understanding of their host countries, for example, if they also examine the nationalist underbellies of these societies. There is much to learn from immigration, income inequality, and hate struggles, from witnessing coping mechanisms, and studying lessons learned. By graduation, these liberal arts students will have seen challenging lives and issues, firsthand. At a minimum, experience informs; ideally, it engages.

Nothing confirms the utility of a liberal arts degree faster than matching talent to the world’s most urgent needs. Who has the agency? Colleges and universities are diversifying access to education, adapting their curricula and deploying graduates to tackle problems, mitigate deeper concerns, and convert trouble spots into sources of strength. 

Life After War: Disturbed transports you to over a dozen countries, some decades into their post-war years. The images and storyboards provide historical context, spotlight here and now conditions, and point to horizon concerns for growing populations. These are just some of places around the world where development demands are vast, human engagement is critical, and the investment dollar can go far. Students, professors, practitioners, scholars, activists, anthropologists and future mental health professionals can plug themselves in and help change the equation.

Amy Kaslow   Washington, D.C.   May 31, 2024

S Y R I A N S I N J O R D A N

This is Rana Ersar, boldly confronting sexual violence in the burgeoning Muslim refugee communities of Amman. This is what Arab leadership looks like, rising from families, from entire countries ravaged by war. One of 5.5 million Syrians who managed to escape the decade-long horror next door, Ersar landed here in Jordan’s capital, an ever hot and dusty place where she shares four rooms with sixteen family members. Their neighborhood is filled with a bevy of other nationalities living the same way: Sudanese who survived massacres in Darfur, Somalis who fled al-Shabab’s terror, Iraqis who dodged death from the many wars on their soil. Syrians are the largest group by far. Countrywide, UNHCR says they number 670,000, though Jordan contends they’re double that, while aid groups and diplomats put their total near 2 million.

The list of everyday needs is often blurred by the massive cloud of trauma that's both deeply individual and community wide.

After they scramble for safety, food, and shelter, there is more to fight for: medical care, schools, jobs, family unification. The list of everyday needs is often blurred by the massive cloud of trauma that’s both deeply individual and community wide. The Association of Psychiatrists in the Jordan Medical Association claims one in four people have mental health challenges, while the lament among Jordan’s social workers is absurdly true: there is just one psychologist for every 50,000 people, including millions of refugees badly damaged by what drove them here.

The ratio is obvious in daily life. The director of a decrepit public school in East Amman somehow manages the swell of refugees by serving double shifts for each school day (1,100 in the morning; 1,300 in the afternoon) and cramming sixty students into each classroom. She’s too short-staffed to prevent the “many children who grow up in poor, violent families” from disrupting, bullying, and fighting teachers and classmates alike. Hers is an all-girls school. Worried about gender-based violence that's widely accepted, handed down by one generation to the next and eating into economic growth, the World Bank teamed up with Harvard and the Hashemite Kingdom to survey 1,000 East Amman youth and to innovate solutions.

By this and all international indices, Jordan is a poor country. An aid recipient before its first influx of Palestinians in 1947, it’s been one ever since. Bereft of natural resources, the country has something else highly valuable to donors: peace. Multibillion-dollar foreign assistance is critical to maintaining it. Ever more so now, given the recent masses of refugees whose needs far outsize and outpace Jordan’s capacity to meet them. Average monthly salaries don’t exceed $1,000 and the government’s budget belt tightening leaves even its most loyal tribes financially strapped. Natives (indeed, that category includes millions of Palestinian refugees granted citizenship over the years) show increasing resentment. 

This is not to say the Kingdom is an ungracious host. Though Jordan’s dependability as a major humanitarian center may go unnoticed in global media coverage, it is well known to the explosive growth of asylum seekers drawn here. Long stable in a region of utter volatility, this nation houses the world’s second highest number of refugees, per capita. The stressors are many. Jobs are tight and few of the forced migrants are allowed work permits, but some earn money as farmhands and in low-end services. Like immigrants everywhere, they’re blamed for pushing down wages and taking paychecks from locals. And they’re particularly vulnerable to abuse. NGOs and the US State Department are troubled by the escalation in Syrian, Iraqi, and Palestinian child labor. It’s easy for human traffickers to snatch these boys and girls. Females of all ages are at highest risk for indentured servitude, sex trafficking, and most commonly, forced marriage.

While mental healthcare in Jordan is barely beyond the recognition stage, one determined NGO is pushing for momentum. The Center for Victims of Torture trains local Jordanians and refugees to treat traumatized and abused survivors with a holistic approach, from physical therapy to emotional support. Set up in Jordan years ago to help the crush of Iraqi refugees, the Center stayed to assist with Syrians pouring over Jordan’s other border, with a goal to build capacity to diagnose, treat and care for emotionally wrought and mentally disturbed refugees from Iraq, Syria, Sudan, Somalia, and Yemen.

Rania Ersar is among those seeking psycho-social support. Now thirty-seven, she arrived from Damascus in 2016 after her husband abandoned her for a new life with a new woman in Austria. Afraid of losing refugee benefits, he still refuses to give Ersar a divorce. Trapped, she heard about CARE, a global NGO working deep in communities to help women and girls stabilize themselves and cultivate community capacity for self-help. These days, Ersar is also extending support through CARE’s Women’s Leadership Council, as she goes neighborhood to neighborhood building networks, helping others identify, expose and reduce gender-based violence. Ersar says she joined “because we are a link between the community and the decision makers” and she knows the everyday threat of sexual violence. Rape has been the most common weapon of the Syrian war since the beginning of the conflict. Jordan, like the rest of the region, is a male-dominated society where men often conflate aggression with masculinity, especially behind closed doors.

N I G E R I A

Poverty in Sub-Saharan Africa is persistent, profound, and its most populated country is mired in it. Consider these residents of Toge, a village along the major airport road leading to Nigeria’s nearby capital, Abuja. Generations have lived here with no running water. Their floor is packed dirt in the dry season, which turns to mud during the rains. Misery increases by the minute as demographers predict yet another decade of mismanagement and unchecked violence will thrust 120 million more Nigerians into extreme deprivation.

Oil rich, the country should be an economic powerhouse, schooled and self-sufficient. Instead, Nigeria leads the world in the number of children shut out of an education, the majority of whom are girls. HIV-AIDS has been the top killer here since the 1980s and Nigeria still claims the second highest HIV infection penetration, globally. Life expectancy? It’s 61 years, one of the lowest in the world. But Nigeria soars in corruption: not much transpires without a payoff, from greasing teachers’ palms so registered students can access public schools to giving doctors money to enter a hospital where more payola is required inside. The breadth of graft and bribery is a stark picture of public and private sector leaders focusing on raising their own prospects, not the nation's living standards.

Criminal justice is corroded at the most basic level: local police demand bribes from parents brave enough to report the abduction of their child.

What’s also widespread is hopelessness, and it creates a breeding ground for radical groups whose savage attacks have forced millions of Nigerians from their homes. The best known is Boko Haram, the 22 year insurgency exposed for kidnapping and sexually enslaving girls as young as those cradled in this mother’s arms. Invoking Islamic Jihad, it has deployed toddlers as human bombs. Its terror knows no bounds, and spreads to neighboring countries.

While Nigerian forces beat back one insurgency, others emerge, and the chaotic environment proves ideal for snatching with little fear of retribution. Among more entrepreneurial types, kidnap for ransom has become brisk business, too. But it’s only a small part of the robust trade in human beings that goes unchecked in Nigeria, where tens of thousands of citizens are trafficked every year as sex workers, in the construction trades, as farm hands—the entire list of categories is unknown. There is little redress.

Criminal justice is corroded at the most basic level: local police demand bribes from parents brave enough to report the abduction of their child. Preying on desperate women, traffickers lure mothers and daughters into sex work, promising them more than the hunger and squalor they leave behind. Others, they simply abduct. Official Nigerian statistics estimate more than 45,000 women trafficked across international borders each year, a major contributor to the worldwide industry that reaps $5 to $7 billion. Supply and demand position Nigerians as the most trafficked nationality in Europe. And huge numbers go missing. Forced to work off extortionate debts to their traffickers, the women and girls are indentured servants, suffering abuse after abuse: starvation, rape, forced abortions. Returning home is equally nightmarish for those who manage escape: they’re stigmatized as impure and HIV-infected. Seeking psycho-social support risks injury or death.

Nigeria has a long tradition of punishing those with anxiety, depression and greater mental health issues, all still commonly seen as the work of witchcraft and bad spirits. 

Nigeria has a long tradition of punishing those with anxiety, depression, and greater mental health issues—all still commonly seen as the work of witchcraft and bad spirits. The routine community response to the most acute mental health cases: chaining the person to a tree. The community is the key to providing localized care; properly trained and funded, it can help fill the gap between treatment needs and available services, which in Nigeria’s case, is substantial. Like most countries throughout Sub-Saharan Africa, Nigeria has not been active in mental health advocacy until last year. The vast majority of the work and the funding has come from international sources. A twenty-year-retrospective of global financing for mental health contends the efforts and the dollars have been grossly outsized by needs.

Nigeria’s government declared an important law last year that moves the country from its original “Lunacy Act” ordering deviant citizens to be expunged from society through various means to a new mental wellness approach that addresses depression, psychosis, trauma and other afflictions. Nigeria’s uneasy democracy is teetering, and with it, any progressive mental health policies.

K O S O V O

The last of the Balkan wars that shocked with each savage swipe at humanity, Kosovo had its own “ethnic cleansing,” a term coined when Yugoslavia’s 1990s breakup released an unrelenting stream of atrocities. For more than a decade, these were the grounds for Croat, Muslim, and Serb abusers who raped, tortured, and pointedly forced victims to witness brutality. Cities teemed with traumatized people seeking refuge from the madness. Frantic and acting fast, adults placed children in homes, hiding places, even abroad. War-weary parents too damaged to care for their young, cast them aside. Documentation was poor or nonexistent, but those who are known to have survived were mostly warehoused in hastily constructed United Nations camps. 

The last of the Balkan wars that shocked with each savage swipe at humanity, Kosovo had its own “ethnic cleansing,” a term coined when Yugoslavia’s 1990s breakup released an unrelenting stream of atrocities. For more than a decade, these were the grounds for Croat, Muslim, and Serb abusers who raped, tortured, and pointedly forced victims to witness brutality. Cities teemed with traumatized people seeking refuge from the madness. Frantic and acting fast, adults placed children in homes, hiding places, even abroad. War-weary parents too damaged to care for their young, cast them aside. Documentation was poor or nonexistent, but those who are known to have survived were mostly warehoused in hastily constructed United Nations camps. 

Substance abuse and suicide rates climb in tandem as economic prospects sink.

As in Kosovo, forced migrants have long since returned to their hamlets, villages, towns, and cities, but they remain deeply scarred. Fighting in Kosovo, a population of less than 2 million, was often hand to hand and went house to house. Attackers’ identities and their brutality are indelible in a place where mental health specialists contend that depression and anxiety impact, if not personally afflict, society as a whole. Unemployment is epic in Europe’s youngest and poorest country, indeed it’s among the highest worldwide among populations under twenty-five years old. And over half of Kosovars aged twenty-five to twenty-nine are jobless; they’re not in school nor in skills training. Groups of idle young men languish in public squares, smoking, drinking, and brooding. Substance abuse and suicide rates climb in tandem as economic prospects sink. Schools have become a flashpoint, with Kosovar teachers nationwide calling on the government this year to help educators and counselors address the widespread psychological disturbances among students.

Boundaries within and between new nation states, post-Yugoslavia, are largely drawn along linguistic, religious, and cultural lines, but inter-ethnic tensions know no borders. Today. the entire region is marred by memory as victims live alongside their perpetrators and endless questions remain about who did what to whom and when there will be justice. Each year, more mass graves are unearthed and the list of proper burials grows. Anguish mixes with anxiety in a place where cultures cum nations cling to their own historical narratives. The threat of renewed violence is constant.

Corrupt and unimpeded by a toothless legal system, Kosovo's leaders have created a leading re-export platform for the sex trade.

The turbulence looms large in small ethnically Muslim Kosovo, providing cover for opportunists to transform the nascent nation into a major destination for human trafficking victims. Since the migrations and displacement of the 1990s, Balkan sex traffickers have tapped into ample local demand. In Kosovo, it starts at the top: military personnel, international aid workers and peacekeepers, such as the UN Kosovo Force (KFOR), are among the biggest escalators of human trafficking by providing a source of western consumers.

Corrupt and unimpeded by a toothless legal system, Kosovo’s leaders have created a leading re-export platform for the sex trade. Organized crime and less formal networks enslave men, but mostly women and children, and sell them and their services in the Balkans, throughout Europe, and the Middle East. The youngest children are forced to beg until they are old enough to be marketed for sex. Kosovo’s government has set up homes for battered and abused women and girls, but it is this government that so many human rights advocates claim is making a sizable income from trafficking.

V I E T N A M

The streets of Hanoi are an anthropological study in migration. An urban sprawl created by millions of rural transplants in search of work. Vietnam’s capital city bulges with nearly 10 million people on the ground and enormous construction cranes crowd its skyline, beckoning more to come. This metropolis is at capacity, every square inch is occupied, and the density continues.

Lining roads and avenues, women stir cauldrons of piping hot soups and men stoop over tiny grills of meat. Tea time is all day, and Hanoi’s pavement is studded with people crouched over tiny cups at knee-high plastic tables. Everyone rinses dishes in buckets of murky water. Random open faucets provide curbside bathing as suds slide into gutters filled with refuse. Motorbikes become sleeping beds with grown men draped over their saddles. At rush hour, they bounce up and over the curbs, the preferred fast lanes. The air is so thick with gas fumes thrown off by two-stroke engines, riders and walkers wear masks. Even the trees piercing from sidewalks are pressed into service: their gnarled roots and thick trunks become Buddhist shrines, outdoor closets, barbershops, mini-produce stands, super-rigged electrical outlets, and of course, dog urinals. This peddler sells fruit, roots, and seeds, popular among a clientele that misses rural life. As she carefully wraps a purchase in fragrant leaves for one customer, she looks up to the next in line. Clearly, her patrons know where to find her each day.

Reckless industrial contamination and climate change threaten to wipe out vast portions of the country's agriculture and displace millions more Vietnamese.

Rural poverty, lost livelihoods as fishermen and farmers, and severe environmental degradation have forced Vietnam’s population shifts. Scientists and international groups including students and scholars, detail the impact of climate change on the treasured Mekong Delta. A highly productive region, it is among the globe’s most environmentally vulnerable. Reckless industrial contamination and climate change threaten to wipe out vast portions of the country’s agriculture, and displace millions more Vietnamese. 

The race to the cities is a reach for a better life, where women find work in the garment sector and men do construction, production, and delivery. Vietnamese are consumed with trying to make it; indeed they are consummate market capitalists, under strict Communist Party control. That’s at least while the government remains in a decades-long push for economic growth through exports, investment and entrepreneurship. Unlike 1975, when Party dogma crackled nonstop through loudspeakers in every village, town, and city, the demagoguery is greatly throttled back now. “We’re more Communist than Communist over here–we have Marxism, Leninism, and Ho Chi Minhism,” the saying goes, but above all, Vietnam is Communist Practical. There is one basic rule: don’t criticize the government.

The effect on civic society is chilling, of course, a constant reminder about who is in control. If anyone will bristle, it’s the Vietnamese youth and young adults aged fifteen to twenty-nine, numbering a quarter of the population. They are well-aware that the best schools and jobs are reserved for party loyalists, that education costs still far outstrip what many Vietnamese can afford, and that joblessness or low-quality employment await many who manage to graduate. For government planners, it’s about momentum, and they intend to soak up as many youths as possible in low-wage, low-skill assembly line work while the money pours in from South Korea, Singapore, Japan, and Taiwan. As trade wars rage and China’s costs rise, manufacturers are lured by Vietnam’s supply of ready, cheap labor.

Industrial zones throughout the country offer every kind of incentive to construct factories for 20,000 to 30,000 workers. Once built, entire towns are created by and devoted to the efficiency of the production line, be it electrical parts, shoes, or computer chips. Workers are closed in behind security fencing, where complexes house them. Working conditions are often harsh and abuses many. Human trafficking, forced labor, and sex slaves complete the equation. Vietnam brazenly ignores international standards, and has dropped to a low point on the leading index of countries engaged in the purchase, sale, or enslavement of human beings. Given its porous borders and focus on luring workers to industrial areas, the trend will worsen if left unchecked.

It will take serious studies to determine the impact of intensive manufacturing on mental health, as well as the impact of racing urbanization on the psyche.

Communist Party leaders are unbridled in the industrial push, pointing to the millions it employs and the many more it prevented from sinking into poverty. It will take serious studies to determine the ongoing impact of intensive manufacturing on mental health, as well as the ongoing impact of racing urbanization on the psyche. Data is slim, but early assessments are already in, spotlighting high incidences of depression, anxiety and other conditions related to stressful work environments.

NGOs and mental health specialists blame the government for underreporting numbers of Vietnamese confronting mental health issues. Outlying villages and towns have no access to treatment other than what’s considered the norm: banishment, caging, chaining, or worse. By sheer numbers, though, it’s in the cities where mental disorders are greatest, and as urbanization accelerates, the percentages will climb. Both Hanoi and Ho Chi Minh City’s urban sprawl seems as certain as the government’s determination to ignore the psycho-social toll on its citizens.

R W A N D A

In the 30 years since Rwanda redefined intra-national conflict by committing and somehow surviving the fastest genocide in history, it’s made striking progress in realms that have vexed post-war societies: stability, poverty reduction, even economic growth.

The nation managed to quell the terror only after a savage, sustained, and orchestrated Hutu campaign wiped out nearly 800,000 Tutsis and moderate Hutus in just 100 days. Armed with machetes, hatchets, clubs, and spears, Hutu genocidaires moved through their own neighborhoods, searching for “cockroaches” to exterminate. Their gruesome attacks on men, women and children left over 100,000 orphans, hundreds of thousands of rape victims, and a population traumatized for generations. Repressed for decades until  the government acknowledged five years ago, a third of the survivors suffer mental illness. Despite the obvious need for help, most suffering the wide range of mental disorders have spurned offers for treatment, fearing societal shaming that will turn them into outcasts.

Rwanda is the third most imprisoned country in the world, housing tens of thousands of men and women convicted of massacring their neighbors, their friends, even their own families.

It’s simply impossible to escape the psychological legacy of the genocide, despite Rwanda’s stunning success in pivoting from devastation to development. The continent’s second most densely populated country and landlocked in a volatile region, the villages are important, often insular communities, where locals took justice into their own hands, trying some 1.2 million accused in 12,000 local courts. The vast majority of assailants are back in their communities. Many admitted to the crimes, apologized for their actions, were commanded to do community service, and never left home. Others went to the country’s dark prisons, where male and female inmates bear deep emotional scars. They wear fluorescent-colored jumpsuits in shocking solid pink, orange, and yellow, coded according to the severity of their crimes and sentences. Rwanda is the third most imprisoned country in the world, housing tens of thousands of men and women convicted of massacring their neighbors, their friends, even their own families.

Quelling fear and anger, and reversing the exodus of Rwandans was the first order of business for Paul Kagame when he took on the nation’s first presidency after the genocide. He outlawed ethnic division by simply prohibiting advocacy for any group other than “One Rwanda”. It’s an approach that has held this nation together for the last thirty years, but prevented the population from talking, much less teaching about the genocide. Kagame, who  reworked the constitution so he could serve a third seven-year term, contends he is the answer to Rwanda’s continued stability. And he may be right. But Rwandans are so internal about coming to terms with their recent past, that closure is elusive and tensions fester. Here, everyone is a survivor. 

Rwandans are so internal about coming to terms with their recent past, that closure is elusive and tensions fester. Here, everyone is a survivor.

Chantal Murekatete stands next to the Ntarama Memorial Church, an orange brick structure pock-marked by gunfire and grenade explosions. A congregant here, her world was torn apart as Hutus raped and slaughtered their way through nearby Kigali and areas surrounding the church. Panicked by the violence that pitted neighbors against neighbors, and friends against friends, Murekatete joined five thousand other Tutsis from the region’s villages in the scramble for refuge. They filled the church, and those who could not fit inside, swelled just outside, hoping that huddling next to this place of worship would afford them some protection, some place closer to God.

Once a critical mass of Tutsis assembled, Church leaders called in Hutus who ignited the building with explosives, then butchered nearly everyone in and around the environs. The Church elders’ collusion with the attackers was a scene repeated across Rwanda's lush green landscape, known as “Land of a Thousand Hills.”

Hacked in the face and left for dead, Murekatete was piled on top of slaughtered bodies and underneath others. Victims endured unspeakable violations, including the disembodiment of pregnant women. Murekatete crawled out of the massacre, and quickly learned she lost her entire family. Twenty years later, she returned to the church to commemorate the anniversary of the genocide. It is now a memorial of blood-soaked clothing, dried and weathered, stuffed into the blasted-out windows and strewn across the crude wooden pews. Cracked skulls line shelves along the back walls. Murekatete's gaze seems focused on something very far away. She is silent.

E L S A L V A D O R

Daily inter- and intra- gang battles, just five years ago, thrust El Salvador atop the list of most murderous places on earth. The government of Nayib Bukele was ushered in by voters demanding a public response, and it made demonstrable change, fast. In the most abject area of San Salvador, he cleaned up gang occupied houses, restored them to locals, and stationed both the police and the military there to protect. For hopeful Salvadorans, what the new president accomplished in the bleakest part of the capital city, they see for the rest of El Salvador. Beating back the hyper violence requires force and follow through, fortitude no government has ever shown until now.

Throughout the country, terrified bus commuters long-avoided eye contact, lest they attract the attention of gang members preying on riders for cell phones, watches, and wallets. Thugs divided up territory to shakedown businesses, from modest papusa street carts to upscale professional offices, and they delivered on their promise to harm those who refused. Every school, every neighborhood, and every commercial establishment able to afford it, had installed high walls, barbed wire, and security guards armed with submachine guns. 

In a corrugated metal labyrinth of houses slapped together along a busy San Salvador highway in 2015, young Enri hung onto the front door. His mother left for her nearly five-hour round trip commute to clean houses, and the six-year-old was not allowed to go outside. Gang leaders lived next door and across the street. Like most Salvadorans, his family would not take the chance to venture beyond the house after dark.

Almost half of Salvadorans are under twenty-four years old, and had only known risk and violence in a country where machismo crushed weakness and where mental health care is out of reach for the vast majority. 

Five years ago, more than 60,000 Salvadoran youth had already joined gangs. Since, the government’s bold pushback on terror may have changed the future for Enri’s generation. Almost half of the country’s citizens are under the age of twenty-four and they had only known risk and violence. Rural areas and towns offer slim prospects, so unaccompanied youth moved to urban areas and became even more vulnerable to abuse. And as they advanced in age, these victims often became perpetrators themselves. The unmet mental health challenges are incalculable in a country where machismo crushes weakness and where mental health care is poor and out of reach for the vast majority.

More than a million people cram into the environs of San Salvador, where just five years ago they scrambled for jobs in an economy crippled by government corruption, endemic extortion, and endless security challenges. On the ground researchers and regional security experts are optimistic about the country once considered the most extortionist economy in the Northern Triangle, where previous state mano dura policies — mass detentions, incarceration, militarized policing — had been showy and self-serving.

Women and children are human trafficking targets whose lives are stolen and then sold for gang-controlled day labor and sex, big business in El Salvador, in Mexico, and the United States.

The anemic, even absent rule of law that allowed gangs to act with impunity. deterred foreign investment and economic growth. Gangs became the gravitational pull for idle Salvadorian teens and twenty-somethings. Belonging gave them a sense of place, of purpose and protection, and it also gave organized crime a wide and efficient stranglehold over society. In El Salvador’s gang warfare, children were actively recruited, trained, and armed to assassinate, extort and traffic drugs. Women and girls were easy human trafficking targets whose lives are stolen and then sold for gang-controlled day labor and sex, big business in El Salvador, in Mexico, and the United States. The savagery sent the female suicide rate to an alarming level, prompting half the population to set its sights  outside the country. El Salvador once only trailed  Haiti, the poorest nation in the Western Hemisphere, in the percentage of citizens wishing to emigrate. Today’s views are markedly changed, with local pride restored and planeloads of Salvadorans returning home.

W E S T B A N K

Economic life for West Bank Palestinian women has always been marginal, even as increasing numbers of young females enrolled in higher education. Female labor force participation limps here, one of the lowest in the world. Greater access, more jobs and cultural acceptance of women at work could change the course of Palestinian females, even given the severe limitations Israel’s occupation means for Palestinian life. Within the West Bank community, it’s all about agency, how to brave a culture thick with thorns for any female looking for mobility. This entrepreneur breeds songbirds for sale in remote villages of the Nablus Hills. She started her business with UNRWA’s micro financing, built enclosures in her backyard, and soon became a wholesaler to area pet stores. Her earnings have been critical for the family budget, and she has gained hard-won respect at home and in the community. As she gives a tour of her cages, her husband and children beam with pride. 

The mechanics of it look simple, but a complex layer of impediments stand in the way of similar successes. Among the external inhibitors: closed borders with Israel, limitations on travel within the occupied territories, and the daily restrictions, humiliations and public fears of occupation. Also formidable are internal constraints created by a long legacy of pervasive Arab male resistance. In this largely conservative Muslim society, the great majority of fathers, brothers, and sons forbid their family’s females to attend school, to take public transportation, to use community childcare, and to work outside the home. Women and girls often assume subservience, no matter their desires or needs, and the psychological barriers they must push through can prove insurmountable. Emotionally destabilizing and physical degrading, gender marginalization compounds problems for females across a broad swath of the Palestinian population.

The World Health Organization and the Palestinian Authority did a mapping of mental health resources for West Bankers, but the taboos against seeking it are powerful. Médecins Sans Frontières, decades deep into treating the escalating mental health needs on the West Bank, has called mental anguish and disability so stigmatized, it’s a silent crisis. But the Palestinian Authority’s top mental health professional, Sawah Jabr, cautions against WHO’s broad strokes in diagnosing, and balks at the notion that PTSD plagues Palestinians. For West Bankers and Gazans who face uncertainty and violence on a daily basis, there is nothing “post” about their disturbing experiences and fears. And she makes a distinction between what she calls “justified misery and clinical depression.”

Deteriorating economic conditions portend more challenges for Palestinian women and children where the largely conservative Muslim society eschews public discussion of sexual abuse and the repression of females is a cultural norm.

Deteriorating economic conditions portend more challenges for Palestinian women and children where eschewing public discussion of sexual abuse and the repression of females is a cultural norm. The Jerusalem-based Palestinian women’s organization, Sawa, works here to fight sex trafficking’s enslavement of women and early teens. It has detailed prostitution rings and identified perpetrators and worked to reverse a crude Palestinian law allowing contrite rapists to avoid punishment if they marry their victims. As frustrations mount, abuse and neglect of women and children worsen. To reach the most vulnerable, Sawa and other community activists must chip away at deeply entrenched traditions of conservative Arab households: the psychological and physical blocks erected by men and boys to resist females’ efforts to appear in public. Even if it’s just to visit the nearby community center.

M O Z A M B I Q U E 

Global warming, a war humans have waged on the earth, wreaks havoc on Africa’s southeast coast. This is Kongolote Refugee Camp, a few miles from Mozambique’s capital of Maputo, and a few months after a cyclone struck with its savage rains. Nature’s wrath is familiar to the lowlands along this southeastern coast, unleashing here every couple of years. When the water reaches impossibly high levels, desperate locals cling to trees, climb to rooftops, and hope that boats and recovery helicopters spot them in time. After washing away lives, tropical storms leave people languishing in camps for months, usually years, where endless lines of canvas tents are caked in dried mud and the hot air is thick with dust. These restless children are among many millions forced from flooded areas to dry patches of land. This is circa 2000; today they’re probably parents, even grandparents. Once again, they’re under water as Mozambique staggers from the most deadly, most costly cyclone that’s ever swept across this part of the Indian Ocean’s coastline.

 A leading indicator of economic development—the education of girls—barely registers in Mozambique. 

Aid groups know this country as the epicenter for the region’s storms and geo hazards that level enormous swaths of land, stripping survivors of homes they’ll never replace. Wracked by a sixteen-year civil war that left a million dead and the people divided, 70 percent of Mozambicans today live in poverty, most of it extreme. Storm after storm breaks up families, leaving women and children vulnerable to raw street life where the police do little to thwart roaming gangs, violent crime, sexual abuse and human trafficking.

Migrant physical health is a vexing problem in Southeastern Africa, where HIV and TB infection rates are the world’s worst. The natural disasters quickly spread communicable diseases that command immediate responses. The storms also wreak havoc on mental health; indeed migrants and internally displaced are more prone to mental illness. What makes the situation dire for young migrants here is the exploitation of children, escalating alarmingly fast, and in the dark. Labor and human rights groups detail widespread abuses in an economy that’s more than 80 percent informal, which means no oversight and no accountability. They estimate some 30 percent of the country’s children, as young as these boys here, are forced into labor. Unchecked, this trend could overtake the percentage of boys and girls attending school. A leading indicator of economic development—the education of girls—barely registers in Mozambique. Nearly half the country’s females aged fifteen years and older are illiterate. Clearly, the country’s problems extend far beyond the short term.

Some 30 percent of the country’s youth, aged five to fifteen are forced into labor. Unchecked, this trend could overtake the percentage of boys and girls attending school. 

2019’s back-to-back cyclones obliterated the nation’s harvests and farms, and the human toll is still unknown. The torrential rains collapsed infrastructure and intensified challenges to meet emergency needs. Major health groups like UNICEF, WHO, and Médecins Sans Frontières scrambled to beat back deadly cholera outbreaks, with each day a higher death toll.

Mozambique’s responses to these urgencies never address the population’s attending emotional trauma. Indeed, the latest onsite look and literature review contends that mental health care in Mozambique is as deficient as it is needed: massively. The nation needs homegrown capabilities, a strong medical community with schools, doctors, clinics, and hospitals that not only treat post-disaster trauma but also engage the public in ways to blunt its impact. The repeated and untreated shock, or PTSD, compounds physical and mental illness. Yet broader society further marginalizes the afflicted; Mozambicans view mental disorders with fear and suspicion.

Unable to stop climate change in its tracks, the government expects income from its vast gas fields will pull the people out of devastation and poverty. The deposits are along the northeastern coast, where Islamic radicals tap into local frustrations. The main grievance against the government: its brutal land grabs that upended the entire landscape and emptied out longtime residents. Economic prospects are so bad, humiliated men cannot afford to pay the “marriage fee” for prospective brides. The conditions are ripe for Islamic radicals to pluck young men from the streets.

Among the NGOs with the staying power on the ground, CARE is a standout given its ability to help troubleshoot immediate shortages like clean water, nutrition, sanitation, shelter and cultivate longer term solutions to send girls to school, train and employ women, and mitigate the impact of successive natural disasters.

G U A T E M A L A

Drugs, violence, and profiteering governments have crushed Guatemala’s society. At the very bottom are women and girls. In a region long-defined by lawlessness and abject poverty, this Central American nation is a standout. An assessment released by the UN-backed corruption monitor crystalizes the impact: Guatemalans are caught in a world where criminals run with impunity while elected leaders collude, mafia-style, dealing with ruthless gangs and the burgeoning ruthless narcotics trade. The toxicity is stark, with a quarter of the population suffering neuropsychiatric disorders in their lifetime. 

Mothers stunted in their own growth struggle to feed themselves and their children. Generations are borne of sexual violence.

Made destitute by government land grabs and fearing farming in fertile areas where terror reigns, Guatemalans go hungry. Famine hits indigenous tribes hard as does the legacy of the nation’s thirty-six-year civil war when militias gang-raped and murdered entire native communities in the highlands. Numbering nearly half of the country’s population, two thirds of indigenous people are malnourished. Mothers stunted in their own growth struggle to feed themselves and their children. Generations are borne of sexual violence.

In and outside of families, a culture of impunity normalizes sexual assaults. Femicide is among the highest rates in the world. It’s all in the dark: a staggering 90 percent of domestic violence cases go unreported, while only 2 percent of murder cases prosecuted result in a conviction. Progress is one step forward and two steps back, because de jure and de facto are two separate realities. Although the legal age for marriage was increased from fourteen to eighteen in 2015, in practice, almost a quarter of female minors married. Misogyny’s grip on Guatemala means males control whether girls can attend school and if women can leave the house. A staggering 82 percent of Guatemalan men surveyed nearly a decade ago denied the women in their lives had any authority. Laws may have changed since then, but practices haven’t, especially among native populations. Fathers still force daughters to marry before puberty. Female illiteracy is high, strikingly so among the indigenous. The country has seen a surge in incest and births among ten to fourteen-year-olds. Bearing children at high risk to their own bodies and to those of the newborns, young teens care for large families well before they have learned to care for themselves. This, while Guatemala moves to further criminalize abortion and restrict access to sexual and reproductive services. Guatemala is savagely making its way up to the number one spot as the most sexually violent and murderous place for women on earth.

Where in the chaos can ailing child mothers find and safely access psycho-social support? What are the prospects for escaping aggression, so firmly rooted in the nation’s culture? The tens of thousands of Guatemalans who leave their homes each month, desperate for a better life beyond their borders, already know the answers to those questions. Emigration is a highly gendered phenomenon as degradation and survival push women out of the country. For those who remain, psycho-social services are minimal and out of reach.

Here, on the cobblestone streets of Antigua, mothers and their young arrive each morning from far outside the city to peddle vibrant woven goods, leather products, assorted fruit, and vegetables. They come from the rural areas and highlands where the country's indigenous population is dominant and new mothers are pre-adolescent. Non-governmental organization (NGO) aid groups attend to the basics by helping to beat back hunger with strategic livestock and farm production; by shoring up the schools with reading and financial literacy initiatives; and countering the spread of disease with clean water and hygiene projects.

Guatemalan women are pushing back on commonplace public sexual assault in libraries, at schools, inside parks, bathrooms, near national monuments… and on virtually every bus. 

Female education and employment are leading indicators of economic growth in developing countries, but all of this is confounded in Guatemala, where abusing and subjugating females is the norm. With UN support, Guatemalan women are pushing back on commonplace public sexual assault in libraries, at schools, inside parks, bathrooms, near national monuments…and on virtually every bus. The most effective NGOs in the country know that female agency is essential for change. Among them is Multicolores, a local NGO with a vivid view into how women are changing the equation for beating back poverty in this most neglected part of the world. Its template — a literal “how to” for social and economic growth — originated deep in the mountains where every mother faces challenges just securing drinking water, much less protecting herself and her children from sexual violence and kidnapping.

Woman by woman, Multicolores reaches the remote and high-risk. Tapping into their generations of Mayan designs and their explosive sense of color, the NGO taught women to hook rugs. They rip and tear through Salvation Army clothing donations to create artful and high-priced floor and wall coverings, and the artisans’ sales have elevated the status of women. One mother used $500 of her overseas sales to purchase faucets so six families could tap into the main pipe of a potable water project several hours from the nearest city. Another saved enough to purchase the only refrigerator in the village. The economic returns convinced more to join, and Multicolores now has a program to train new local teachers; it’s a scalable way to prepare Guatemala’s least likely entrepreneurs to become profitable. The NGO’s latest push: health insurance coverage for their weavers, at modest cost, which they pay for with a small portion of their output. In rug hooking circles, women share in each other’s struggles and successes. Where the needs are great and access is poor, the multiplier effect is strong.

I R A Q

Once the bastion of secularism in the Arab world, where women advanced in their careers and highly educated youth were the nation’s great promise, Iraq’s elevation has been leveled, war after war. Conflict has eroded families, along with a society protecting childhood as sacred and recognizing women as essential. After an eight-year battle with Iran, much of it hand-to-hand combat, soldiers returning from the front were edged out by a replacement workforce: females and foreign labor. Gender violence escalated, poverty quickly spread, and anguished parents began to deploy their young sons and daughters as income earners. 

An alarming number of children have been dispatched to stave off family hunger: they peddle cigarettes, petrol, pornography and themselves.

Along the banks of the Tigris River, a moonlit beggar boy tries to hustle a passerby with card tricks. He was a rare sight in 1989. But during the thirty-five years of invasions and many insurgencies since, an alarming number of children have been dispatched to stave off family hunger. They peddle cigarettes, petrol, pornography, and themselves.

Today, millions of Iraqis are displaced across the country, and refugee camps are exploding. Instability is the best breeding ground for human traffickers, and in Iraq, there have been many competitors in the market: ISIS-trained, Iran-backed militias, and tribal forces. They abduct women and children to deploy them in combat, as ordnance makers, human shields, suicide bombers, and indentured servants. They pluck eight-year-olds from their homes, force youth from refugee camps, and have targeted entire ethnic populations like Yazidi women for sexual slavery. As Iraq attempts to restore some semblance of order to the land and the occupied people ISIS left in its wake, the survivors’ mental disorders command attention and resources. 

Iraq’s psychological fallout from a continuum of crises simply overwhelms any local professional capacity. 

Iraq’s psychological fallout from a continuum of crises simply overwhelms any local professional capacity. Mental disorders are the fourth leading cause of ill health in Iraqis over the age of five, asserts Médecins Sans Frontières, the global NGO that has fanned out across Iraq with psychosocial support and training. Hospital beds are at capacity, and international attention is waning. Data is sketchy, but a most troubling barometer of Iraqis’ mental status is suicide among women. The International Organization of Migration visits refugee and displaced persons camps to de-stigmatize discussion about mental health and major stressors, including domestic violence, joblessness, and marginalization. Hundreds of NGOs are on the ground in Iraq; their work is essential as the government mulls a national effort to diagnose and treat trauma, depression, and psychosis.

The land where Arab women had unparalleled agency and where parents once pampered, even insulated their young, is gratuitously violent. Iraq is now a global destination point for sex tourists seeking children and a leading marketplace for human slavery.

R U S S I A

Outside the Chamah soup kitchen in Moscow, elderly and indigent Jewish patrons line up in the falling snow. Some ride two hours each way on the city’s crime infested metro for nutrition that’s become critical to their survival. Once they arrive, they find a whirl of activity where cooks and volunteers turn out piping hot pots of stew, plates piled with meat, and buttered rolls straight from the oven. The lunchroom is filled with diners who peel off layers of clothing before they tuck into their serving.

Russia’s aging citizens struggle on minimal resources. Since the fall of the Soviet Union in 1991, pensions shriveled, government assistance vanished, and the aged found food and fuel prices far out of reach. For the group at Chamah, deprivation was just the latest in a succession of horrors they survived over many decades: anti-Jewish pogroms, the Holocaust, Stalin's forced labor camps, refused emigration, banishment to Siberia, vicious anti-Semitic attacks, the wrath of skinheads, and ever-increasing Russian xenophobia. And now? Insecurity is the norm. President Vladimir Putin’s xenophobic nationalism often cites Jews and other minorities as suspicious groups, further marginalizing them. 

While lackluster about using psychiatry to treat the mentally ill, the government regularly deploys it as a political punishment, and it’s notorious for its “forensic tests” of its opponents. 

Today, the Chamah soup kitchen serves hundreds of destitute Jews. Most are isolated, living in decrepit apartments and houses, some with no running water or adequate heat. After they push back from their noontime meal here, the men and women often linger at cloth-covered lunch tables, telling stories and gossiping while others settle quietly in the library. They come from different parts of the vast city, and this is their sense of community, much of it funded by overseas aid organizations. Russia ranks the seventh lowest in the world in psychological and mental wellbeing, with no specialized care for geriatrics, a glaring omission for this aging society.

The Russian government controls the country’s entire mental health landscape, administering service characterized by Russian psychiatric professionals as once poor, now abysmal. The Kremlin slashes funds, drastically reduces hospital beds, and ignores acutely needed outpatient services. It’s made few gains in this arena since it crudely warehoused patients in former barracks, remote monasteries, even old slave labor and concentration camps. Russian xenophobic culture is often suspicious of difference, and dismissive of weakness. While lackluster about using psychiatry to treat the mentally ill, the government regularly deploys it as a political punishment. A noted Dutch-based NGO released a damning assessment of Russia’s abuse of psychiatry for political purposes, case studies of government critics, members of the opposition, and more. Victims are seized, tortured, tested, diagnosed and incarcerated in asylums, labeled with the wide array of fabricated mental illnesses.

Integrating mental health into mainstream medicine, much less as a form of geriatric care, is far from Russia’s reality. 

Integrating mental health into mainstream medicine, much less as a form of geriatric care, is far from Russia’s reality. NGOs do what they can to fill the gaping holes in coverage. Chamah dispatches doctors for home visits and casts a wide net with its meals and ways to attend to elderly who would otherwise die from neglect.

The soup kitchen is a destination for those who are isolated, and the sustenance is beyond food. Patrons here wear their very best clothing for their lunch together. Men arrive in old suits and neckties, and women in brightly colored scarves. Social workers here say the conversation and camaraderie over daily meals is as much about dignity as it is survival.

T H E D O M

This young Dom girl was found playing in one of Amman’s many rambling and decrepit areas where have-not Jordanians share space with millions of other poverty-stricken immigrants. There are the Palestinians who fled Israel, the Iraqis and Syrians who poured in from wars next door, the Africans drawn by Jordan’s open door to refugees. And there are increasing numbers of Dom. Largely unknown, the minority lives on society’s edge in almost every country of the region. Called Gypsies, the Dom, like the Roma, trace their roots back to the Punjab’s castes of migrating artisans and entertainers who left the subcontinent some 1000 years ago. Once they reached Persia or thereabouts, the Roma went on to Europe, and the lower status Dom continued deep into the Middle East. All have been stuck at the intersection of social isolation, poverty, and political instability, ever since. Stigmatized and severely ostracized, Dom have little to no access to public facilities. Safe water, adequate nourishment, education, employment and medical attention all elude them. Virtually non-existent for this group: mental health care for afflictions caused or exacerbated by their rough conditions. 

Stigmatized and severely ostracized, Dom have little to no access to public facilities.

Dom families have been here since Jordan was founded, their encampments the only sign of life along an otherwise barren desert-scape. The caravans are all but gone, those tending livestock are increasingly rare and Dom everywhere scramble for water, food and power sources. Regional wars, violence, and destitution forced many clans to break up. Most have gone urban: their largely nomadic lifestyle has given way to life in small, substandard structures on the blighted outskirts of cities and towns. Some cling to tent life, scraping to pay rent for a small area, wedged in between buildings, or in an open, abandoned lot.

Their lives are hardly stable, or secure. It is a rare national host that affords them what the general citizenry enjoys: energy, water, schooling, sanitation, healthcare, and police protection. In Jordan, as elsewhere, Dom are marginalized, stateless, left to fend for their own communities. Even as wars displace them across the region, United Nations Camps turn them away for inadequate personal documentation. Here, in Jordan’s capital city, school teachers claim that Dom are class bullies, unruly, and dishonest. They start fights in the hallways, complains one overworked administrator. She contends Dom children are more aggressive because of family violence.

Public disdain for the minority is so profound, Dom must hide their identity and “pass” for another ethnicity.

Public disdain for the minority is so profound, Dom who do become professionals must hide their identity and “pass” for another ethnicity. This, while Dom youth do what they do: they try to fit in. They want to lose what they call the Gypsy dress, the Domari speech, the markers of belonging to the group at the bottom.

Children drop out of school early. Boys train for carpentry and textile jobs that will go to Jordanians and other refugees, first. And this child, found playing on the steps, will likely marry in a couple of years. Dom girls become brides by age fifteen, caring for their own babies before growing up themselves. They will try to stay with their clan, for support. But societal pressures and urbanization mean Dom are detached from their own customs, minimizing their traditions and their language.

While refugee demands continue to surge here in Amman and throughout the country, the competition for resources leaves Jordan’s Dom at the end of the list. There is one group after them: the Syrian Dom, refugees who fled next door in search of a better life. The outlook for the Dom as an ethnic group looks grim, perhaps imperiled. Prejudice against them is so powerful, it even puts humanitarian assistance out of reach. The lack of organizations with information on the Dom indicates they're not even on the radar of mainstream aid groups.

L E B A N O N

Down a short hill from Lebanon’s storied American University of Beirut, an old broom seller hawks his wares, street side. He’s perched on an overturned bucket right at the hairpin turn where drivers are forced to slow down long enough to glance at his collection of mops and brushes. He waits. Business is slow for this octogenarian, a Palestinian refugee from Jerusalem. His family escaped the violence of “the Nakba,” what Palestinians call 1948 when Arabs both fled and were expelled from the new state of Israel. He’s anxious to talk about why he’s still sitting with so many items near the end of the day. It’s a string of common complaints: there are no jobs for Lebanese he says, and Palestinian work permits are even harder to come by, the government has no money, people are getting more desperate, and there is growing anger toward refugees. 

It’s a string of common complaints: there are no jobs for Lebanese and Palestinian work permits are even harder to come by, the government has no money, people are getting more desperate, and there is growing anger toward refugees.

Still staggering from its own protracted civil war that ended in 1990, Lebanon has long been the go-to for survivors and fighters from neighboring conflicts. The trend started a century ago with an influx of Armenians fleeing their homeland. A destination point for Palestinians from their earliest scuttles with Israel and a landing pad for their leaders after Jordan expelled them, the country is now under Shia-Islamicist Hezbollah control. Add onto that millions of Syrians who have crossed into Lebanon since Assad turned on his people in 2011, and the country earns the dubious distinction as host to the largest refugee population, per capita, worldwide. All this, in a territory the size of the state of Connecticut.

Lebanon has long lived as a world-class debtor, but it simply can’t bear the current financial pressure. Divided along sectarian lines, government payroll is all about patriarchy and covers ten percent of the entire population, including rosters of “ghost workers” who collect income but don’t work. Donor fatigue means diminished aid for refugees while Lebanon’s treasury scrambles to pay salaries. Financial pressures explode into street demonstrations as the country is torn up over possible cuts in military pensions, university funding, utilities, and all sorts of other critical services. Public attacks on Syrians are more frequent. The foreign minister, also leader of Parliament’s largest political party, ratchets up popular resentment blaming refugees for Lebanese job losses and demanding that they return home.

Transparency International’s watchdogs have monitored violations here ranging from election fraud to diverting international aid intended for Syrian refugees, and contend robust reforms are essential to regain public confidence.It’s a view broadly shared by Lebanese themselves, who maintain epic distrust of their government. The latest Gallup poll puts the misery index high. Remarkably, the profound lack of public confidence is matched by strong civic engagement. Perhaps the place with the single largest engagement of NGOs, worldwide, Lebanese society has a long history of community and extra-community responsibility, with thousands of groups positioned to help the needy. The government has teamed up with dozens of local humanitarian organizations and many more internationally to critically assess Lebanon’s mental health environment and to develop a strategic plan for the nation’s pressing mental health needs. 

Remarkably, Lebanon’s lack of public confidence is matched by its strong civic engagement. Perhaps the place with the single largest engagement of NGOs, worldwide, Lebanese society has a long history of community and extra-community responsibility, with thousands of groups positioned to help the needy.

And the future? Up-and-coming Lebanese talent worry about underemployment and shrinking wages across the spectrum. The surge of refugees accepting lower pay and dangerous working conditions has pushed more citizens into poverty. The legions of jobless Lebanese college grads are part of a disturbing brain drain of the nation’s youth who want to work as the engineer or accountant they trained to be, not in the waitress or bus driving job they’ve managed to find. And they are exhausted by the relentless corruption.

Palestinians like this broom seller face far greater challenges as they compete with Syrians for limited resources. The poor are growing poorer, and many who thought they “made it” are falling from the coveted entrepreneurial middle class into poverty. They call it 'the neglected crisis:’ new, steep economic divisions more profound than ethnic, religious, and political differences.

In Beirut, the divide is inescapably visual. Consider the gleaming new downtown area, a welcome relief to those anxious to clean up the post-war eyesore. Former billionaire Prime Minister Rafik Hariri showed characteristic hubris by leading the razing and re-developing of iconic real estate along the harbor, before he was killed by a car bomb in 2005. His legacy: massive limestone buildings affordable to super rich, mostly Gulf Arabs who buy sprawling addresses and leave them unoccupied. Lined with absentee investments, the streets are empty and quiet, save the construction cranes operating nearby. A wooden plank wall shielding the construction site in a prime seaside area is sprayed with "You Stink but you don’t do sh*t” in big, black angry letters. Graffiti artists have been spreading the "You Stink" movement's message since 2015’s trash crisis, when garbage piled high on the streets, dumps were beyond capacity, and the public raged against government incompetence. The crisis spurred a powerful wave of homegrown advocacy for better living standards. A whopping 44 percent of the population lives poverty, according to a new World Bank report.

Across the city at the Burj Barajneh Refugee Camp, Palestinian men return from a day’s work. Wearing soiled white shirts with “window cleaner” in large black letters across their backs, they walk through a dusty haze of heat and diesel emissions, passing waist-high piles of trash and industrial refuse. Their home is just beyond the 40-foot-high metal fencing. It’s a place teeming with men in open-air metal works, repair shops, and fruit stands, groups of them walking to mosques, and others gossiping over tea. Children dart in and out of makeshift houses with corrugated metal roofs. Women peer out of windows and from behind curtains. Lebanon is home to hundreds of thousands of Palestinians like these. Many have integrated into villages and cities over the decades, while others remain in sprawling camps-cum-urban ghettos.

The country won’t allow more recent Syrian arrivals this illusion of stability. Lebanese authorities force them to break down the hard structures they erect to weather the punishing winds and rains. Nothing permanent, the government warns; the Syrians aren’t staying.

R E P U B L I K A S R P S K A

This is the face of grief. Hers is one among hundreds of thousands of anguished Muslims who make the mountainous memorial trek to Srebrenica. In this Bosnian town nearly 30 years ago, Serbs unleashed their most savage attack of the Balkan wars. Raiding a “safe enclave” for Muslims, they rounded up men and boys, warehoused them in a battery factory, tortured and slaughtered them. Serbs coined the phrase “ethnic cleansing” as they erased males from virtually every family in Srebrenica and for miles around. The death toll neared 8,000. 

Every year, Bosnians lay more fully assembled relatives to rest. Dozens of graves are closed each summer. A thousand more skeletons are still missing, leaving the entire population waiting for closure.  

Serbs feared mass graves could lead to war crimes charges, so they drove earthmoving equipment through the carnage to quickly spread the corpses wide and far. For the past three decades, forensic investigators and average citizens have unearthed human bones in this mountaintop town, just miles from the Serbian border. The work continues, and every year, Bosnian Muslims lay more fully assembled relatives to rest. Dozens of graves are closed each summer. A thousand more victims are still missing, leaving the entire population waiting for closure and still in aftershock. A new repository for bones and personal effects, including clothing, will house these partial remains until their burials can be complete.

Srebrenica remains a Muslim majority in Bosnia’s Serb-dominated Republika Srpska, as remnants of families return to slowly repair their lives. Stone stairways crumble into tall weeds; the houses they once led to are blackened ruble. From a distance, stacked red brick and corrugated roofing sheets appear to be a promising new beginning, but a closer look reveals long-weathered materials crusted with rubbish and the stains of time. There are as many unfinished new houses as there are those destroyed. 

All of Bosnia still wears the conflict that incinerated populated areas, along with the infrastructure and housing stock supporting them. Cites and rural hamlets alike are pockmarked from shelling, their streets still marred by mortar fire. Billboards rise from large swaths of fenced-off land, warning of mines, and unexploded ordnance. 

Survivors here, and throughout Bosnia, resent the US-brokered agreement that pushed combatants into an uneasy peace and offered little more than the template for separateness: Serb governance in the north and northeast (called Republika Srpska) with a Bosnian Muslim and Croat federation covering the rest of the landscape. Bosnians agree on one thing: their self-serving government is a failure. Leaders tap into bitter memories and stereotypes to maximize their support; inter-ethnic hatred is arguably more profound today than it was during the war. 

Srebrenica’s only relief from the inescapable history of conflict is that tragedy has been normalized, perhaps because it’s literally part of the landscape. This is where ten thousand men fled into the thick of the forest while women and children hid among dense shrubs and trees, living on whatever roots and berries they could collect. Like other Balkan combatants, Serbs used rape as a weapon of war, leaving Srebrenica’s Muslim women to suffer enormous shame with babies born from sexual attack. Families transfer trauma from one generation to the next. An essential part of stabilizing the region is addressing surging mental health needs of the survivors; the government seems to recognize this, but the real work is done on the municipal level where the large NGO community tries to reduce the cultural stigma on seeking mental health treatment and sets up local clinics. But practitioners in the field warn that the government’s poor response to the alarming post-traumatic stress disorders among citizens, post COVID, post Russia invasion of Ukraine, puts citizens at great risk. 

Men beat and sexually assault women at an alarming rate, the juvenile delinquency rate is soaring, and youth are leaving in droves.

Anger festers. Thirty years after men put down arms, few have picked up jobs. The legacy of 350,000 restless and unemployed ex-soldiers, their schooling interrupted by war, casts a pall on society. Men beat and sexually assault women at an alarming rate, juvenile delinquency is soaring, and youth are leaving in droves. The IMF says Bosnia’s brain drain of young, educated talent portends a tough future for a country that bears deep scars of war. Among those who remain, antidepressant use, much of it self-dosing, has risen precipitously, spurring greater attention to the efficacy of treatments. 

While many government and non-government groups try to defuse tensions, ease trauma, and mame strides with community-based health, the outlook looks grim. Outside intervention promises to keep Bosnia’s society on edge: Moscow’s meddling is opportunistic, taking advantage of a people in turmoil, and consistent with its jarring penetration in almost every major political news development, worldwide. It’s particularly dangerous here in the Balkans as it rips open old wounds. Vladimir Putin made sure that his favored Serb nationalist Milorad Dodik secured the ethnically allotted seat in Bosnia’s inter-ethnic presidency. Russia’s public endorsements of Dodik emboldened the Serb leader’s calls for Republika Srpska’s right to a land grab and its own statehood. In turn, Dodik pushed Bosnia’s recognition of Russia’s illegal annexation of Crimea. Dodik harbors the same yearning for ethnic purity, for a separate state of Serbs and only Serbs. He has agitated for his own military force, and warns Serbs are under threat.

Russia understands that Bosnians harbor the same hatred, the same suspicions of decades, even centuries ago. Russia knows the entire Balkans were marked by tribal wars, slaughters, and mass graves. Encouraging Greater Serbia is to scramble any effort to move past that ethnic hatred. But Putin intends to keep Bosnia off balance to give Russia an unquestioning ally in the middle of Europe. Again, Bosnia teeters on the treacherous. Here, and throughout the region, almost everyone wrestles with trauma. For anguished mourners like this woman in Srebrenica, reconciliation is beyond reach. The new political landscape all but guarantees it.

P A N A M A

This is Panama, where armed traffickers will move over 750,000 migrants through the Darién Gap in 2024, trampling one of earth’s most critically endangered ecosystems. This is Sara Omi, an indigenous Emberá community leader in its Choco region, where sixty percent of her people have fled the human and environmental disaster. Daily intrusions drive out indigenous, long protecting and sustaining one of the globe’s most important old growth forests. The species-rich tropics has plant life known only to Panama (twenty percent of what grows here only grows here), all under an enormous mature canopy called the “natural lung” of the Americas, where Omi’s Emberá have thrived with Mother Nature for centuries.

The constant crush of humanity through its delicate rainforest hasn’t generated much response from Panama’s government, but scientists worldwide are bracing for the fallout. Among them, the Smithsonian Institution, the world’s largest museum with its only home outside the US in Panama. Here, it has a century drawing world class specialists to study local fauna and flora, the oceans and paleontology. Today, the Smithsonian Tropical Research Institute is frantic to protect the unparalleled biodiversity from human destruction. It puts a premium on the Emberá’s natural restoration of the forest, as intruders trample and recklessly poach logs, illegal mines and clearcut.

The invasive attack on humans and nature unfolds in a 100-mile long, 30-mile wide stretch between Colombia and Panama, an undeveloped, lush green density, interrupting the otherwise paved Pan-American Highway from Alaska to Patagonia. There are no roads in the Darién, just mountainous jungle punctuated by rivers, swamps and wetlands that often become deadly human sinkholes. Impossible to penetrate without skilled guidance, travelers fall victim to cartels of vicious crossers who navigate, but also beat, rob and rape them en route. Eyewitnesses contend the savage behavior is worse on the Panamanian side. Violently controlled, the entire forest has given way to a “transnational criminal economy” that Insight Crime tracks with vigor.

Largely ignored by Panamanian and Colombian authorities, the criminality keeps pace with migration. Roving gangs and paramilitary groups leading refugees run roughshod through this rich ecosystem and poison a once pristine environment for the Emberá, Wounaan and other native communities along the water’s edge. Distinct, isolated peoples who speak different languages, they live in open stilt houses along banks of rivers that flow to the Pacific ocean. In the past two years, indigenous have seen their ancestral grounds overrun by refugees from every corner of the world. The back stories of Venezuelans, Haitians, Sub Saharan Africans, Chinese and more fleeing repression, poverty and conflict – these are documented, data-rich “push factors” driving people to embark on a terror-filled journey to reach safety. Last year’s wave of 535,000 people doubled the number in 2022; the sheer volume soiled the land, the water, and the essentials of indigenous life.

Omi is President of the Emberá Congress in the Darién Gap (last year Forbes Magazine once again named her among the 100 most influential women in Central America). She wants to stop flows of smuggled humans who “make their necessities everywhere'' defecating all over the forest floor. She frowns: “They pollute everything. Dead bodies of drowned migrants float in rivers and contaminate the water for drinking and fishing. Tribal people are getting sick.”

Everyone is at risk. Emberá men disappear as hunters, soil tillers, and palm leaf slashers, now drawn to fast money as forest guides or worse. Women, overrun by migrant demands for meals, have no time to distill natural color and weave the intricate designs that have set the standard for the region's finest folk art. Indigenous hunger is a new problem and likely to worsen as natives stop growing and collecting food. Forest protection's future looks dim as do the prospects for indigenous youth. Parents pulling children from school to help serve migrants is what most concerns Omi. “In our community the greatest value has been on access to education,” She laments losing that, and even civility, with some indigenous men joining local Panamanian gangs to rob and sexually assault migrants crossing from Colombia. It is wiping out their way of life. Just over a third of Omi’s own community remains. Cartels and savage treatment of females and children in this jungle threaten to destroy what’s left, as detailed in the International Crisis Group’s sobering account.

The daughter of the Emberá first female chief, Omi resists, as she was taught to do. Giving voice to local women comes naturally, but her political rise grates against the ingrained machismo culture that sees female leaders “as menacing” she says, and the entire gender as prey.

She looks out for her people and for those passing through. "It's all local,” explains Omi, the sexual violence “increasing against migrant women and children,” impacts natives, too. Human Rights Watch asserts the government’s stance allows “crimes against migrants and sexual violence against women” to occur with impunity. Indeed, the Panamanian government has yet to step in. It simply lacks the resources to hear from victims: Panama’s National Migration Service’s appointed prosecutor has no staff interpreters to translate for Haitians, Africans, and other non-Spanish speakers who have been attacked.

Deeply disturbed by the sharp increase in brutal sexual assaults and government inaction, the organization with special expertise in treating victims of Darién’s sexual violence, Médicins Sans Frontiers, recently publicly prodded Panama to do more, Government officials did act; they summarily shut MSF down. Now there is no accountability, no security and no careful treatment for those brutalized, while daily, often deadly intrusions through here go unchecked.