The smell of charred flesh clings to the nostrils for days. Putrid and metal-like, it is a nauseating odour sometimes described as a mix of musk and untreated animal hide.

The smell is so sharp it gets etched into the mind, rescue workers say. Even miles away from disaster, these first responders carry the scent of death in their memory. The slightest trigger can bring back images of horror.

Time is often not a great healer.

Like the rescue workers, there are countless victims who have suffered invisible wounds from the violence which has killed more than 50,000 people in Pakistan since 2001.

But the psychological impact of terrorism in the country has largely been ignored, even as it has silently begun to shape the lives of a generation.

A study conducted by the Pakistan Institute of Medical Sciences reveals that the memories of violent incidents continue to reverberate, outliving wars and resulting in higher rates of physical and mental illness.

With a lack of psychiatric care and understanding, victims of violence internalise their experience, falling into denial or depression, while continuing to function on a daily basis.

In Pakistan, the cost of war is judged by statistics only. Death and physical injuries are statistics. Trauma is academic.

Rescue workers, reporters, emergency departments, victims and witnesses are all linked by the chain of trauma often dismissed as ‘part of the job’.

Anger and isolation

First at the scene: The rescue worker

The Ali Raza mosque was pitch dark.

Only a few streaks of light managed to infiltrate through the cracked walls and the mosque's half destroyed dome. Through the collapsed structure and debris rescue workers tried in vain to look for the injured, the dead; any sign of life.

But there was no one on the ground, where were all the bodies?

“My team and I used huge flashlights but found no one. It was only till we looked at the walls that we found them all; bodies plastered straight onto the walls because of the sheer intensity of the blast,” recounts Zafar Abbas, the founder of Jafaria Disaster Cell, while narrating the terrifying blast at the Imambargah on MA Jinnah Road in 2004.

In retaliation to the massive destruction and loss of lives, a clash occurred between an angry mob and police personnel, who resorted to tear gas shelling to disperse the crowd.

“The horror of that night, the reaction of the police, left an everlasting impact on me,” Abbas says, staring blankly at a wall.

But his way of dealing with disasters is what many would term a Pakistani response to tragedy: put on a brave face instead of giving way to emotions.

“If we crumble and break down we would not be doing justice to our job,” he says, quickly gathering himself.

This is the principle that defines Abbas’s work at the Jafaria Disaster Cell (JDC) which took its roots to aid victims of minority communities at a time when terrorist attacks witnessed a surge.

The organisation became active in 2004, when a bombing at the Hyderi mosque claimed 19 lives.

JDC was recognised for its rescue efforts during and after the Abbas town tragedy in Karachi. All affected families were rehabilitated into new homes.

The organisation now provides services to all, not just minorities. But its work has brought it into the crosshairs of terrorists.

“We have been informed by the police that we are under constant threat from terrorists. I know I might not be able to return home today and my family is mentally prepared. But we do not plan on seeking asylum, why should we? We need to stay in the country and fight back,” Abbas says.

Being an aid worker requires a lifetime of endless dedication, it’s a seal for life, he says.

His courage is inspirational and while he puts on a brave face, events of the last few years have steadily cut him off from many of his social circles.

But much of his isolation is not self-imposed.

There are people who flock to him to find solutions to their problems, but there are many from his own community who deride Abbas' profession.

“It is heartbreaking to see that people closest to you tend to break ties once you get into this profession.”

For the unflinching Abbas, the battle is not just on the front lines.

Denial

Tragedy in real time: A reporter's dilemma

Amidst the screeching sirens of rescue vehicles, shell shocked survivors, wailing families, and loud, urgent exchanges between rescue workers, Shahid Hussain had rushed to report on the blast targeting a Yaum-e-Ali procession at Gamay Shah Chowk in Lahore in 2010.

The bloodshed around him was unbearable and the daunting question repeated itself yet again: “Should I help the victims right now instead of reporting?”

His voice was inaudible as he relayed the chaotic scenes around him live to a television audience.

In the middle of the live beeper, an earth-shattering sound pierced the night again.

“We were going live when we heard the ear splitting sound right behind us; I became deaf temporarily after that. The terror that followed cannot be expressed in words. Riots broke out as mobs became violent and attacked a police station and fought with the policemen,” 38-year-old Hussain, a father of two and a reporter associated with the channel Samaa, recalls.

After the two successive blasts, a third bomb detonated five minutes later at the nearby Bhati Chowk. Forty-three people lost their lives that night.

The anger that engulfed the area soon subsided; only grief remained.

Witnessing such incidents on a regular basis, Hussain feels he cannot mourn any tragedy for more than a day. His job requires him to snap out of his misery.

For Hussain, the only way to survive through the psychological stress is to believe nothing would happen to him or those around him.

“You can call it blind faith but that’s what all reporters need to keep reassuring themselves with.”

The organisation Hussain works for promises a hefty compensation, in case a reporter loses his life on the field.

“The financial support to my family is what keeps me sane, I just want to be sure they would be taken care of after me.”

Enduring grief

The invisible wounds of the hospital staff

It is practically dizzying to observe the influx of patients at the emergency ward of Jinnah Post Medical Centre (JPMC).

More than 1,200 people from Karachi and across Sindh come in everyday to the emergency department of JPMC, a staggering number for a single facility.

But for head nurse Daisy Nasreen, these are peaceful days compared to the times when the already frenzied wards were filled with bodies of blast victims.

Daisy is on call 24 hours a day, living on campus in the premises of JMPC with her family.

She has witnessed a number of incidents in her 28 years of being a nurse, but the worst for her was the October 18, 2007 bombing which targeted Benazir Bhutto’s motorcade. One hundred and thirty nine people died and 450 were injured.

“There was a long line of bodies lying on top of each other at the mortuary. There was no place to keep them. It was truly a horrifying sight,” Daisy tells Dawn.

During 2010 and 2011, the city saw a surge in violence and the sheer magnitude of the devastation left a mark on the nurse.

“After a blast, a lot of people are brought in who have already died. But when their families arrive, there is a sense of denial. They all have the same demand: “un ko uthao” (Wake them up!). What can we do then? It is a heart-wrenching experience and leads to many sleepless nights.”

No counselling is available to deal with post traumatic stress for the team at JPMC, their head Dr Seemin Jamali is their only pillar of support.

“Dr Seemin often says a few words to reassure us when we are all shaken to the core. She keeps reminding us that it’s alright to give in to emotions at times,” Daisy says.

But this resilience faltered when the hospital came under attack in 2012.

Twin blasts occurred at the Shahrah-i-Quaideen flyover targeting the Chehlum procession on MA Jinnah Road, followed by a blast outside the emergency department at JPMC. Thirty-four people were killed and over 100 injured.

“I was right here when it happened,” Dr Seemin says, pointing to the entrance of the hospital.

“I had a brain hemorrhage because of the intensity of the blast. I should not be able to remember anything but I can recall everything that happened that day. It’s unforgettable.”

The ward was up and running only hours after the blast occurred, and none of the staff took a day off. The emergency ward worked around the clock to save the injured and dying.

With the increasing number of terror attacks in the city, it is assumed that a doctor in the emergency ward of a government hospital would lose track of the events.

On the contrary, Dr Seemin can recall every incident on her fingertips.

As she converses, her eyes keep a look out on the CCTV cameras inside the hospital and the tickers flashing on the news channels.

“Only a few words of condolence are a source of comfort for the grieving family. But who will be our tower of strength?” Dr Seemin questions.

It is not only the gruesome state of the bodies, the agony and the pressure that takes a toll on the staff, the doctors are victimised and abused as well.

“Listening to attendees curse and hurl abuses at us is an everyday routine but personal assault is becoming common too. A patient’s brother tried to hit me once. He broke the entrance door out of anger, and we called in the Rangers to handle him. An attendee once tried to beat a nurse.

“The very people who are trying to help are being assaulted; ambulances, media, hospital staff.”

Hopelessness

A family torn apart

Mehreen Kausar's demeanour is increasingly deceptive; the petite 23-year-old's ever-smiling face, soft voice and shy exterior suggests a life that has been carefree, peaceful and protected.

But beneath this calm surface is a plethora of repressed thoughts, a darkened past and broken dreams that haunt her consciousness.

She lives in Quetta’s Hazara Town, which houses a population of more than half a million approximately. Hazaras remain confined to this locality, and do not venture out even for basic commodities.

Mehreen’s life revolves at home, looking after household responsibilities and her father. But life was completely different just a year ago.

“January 21, 2014, I was in a bus with my mother and sister. We were coming back from Iran and were parked on Quetta’s Taftan Highway. I was eager to get home, tired from a long journey. We were waiting for a second bus at the stop. I was in the middle of a conversation with my father when the bus arrived and everything changed forever.”

What ensued is a dark memory filled with smoke, fire and death.

“It was doomsday for me,” says Mehreen, her voice lowering as she draws an image in her head.

At least 22 people were killed and 32 were injured in the blast that targeted a bus carrying Shia pilgrims in the restive Mastung district’s Dringhar area, some 50 kilometres southwest of Quetta.

Mehreen was severely injured in the blast but lost her mother and sister in the attack.

“I have nightmares of that day every night. Every time I close my eyes, the horrific memories flash in front of me and it is impossible to forget them.”

This was not the first time Mehreen had survived a terrorist attack. In 2013, her university bus was blown up resulting in the death of 14 students.

She was supposed to be on the same bus, but survived as she had skipped classes that day.

She was a second year student of Botany at Sardar Bahadur Khan Women's University. But after the successive traumatic incidents, dropped out of university.

“Family members or friends do not force others into resuming their education or going out of Hazara Town. If something happens to their children, or friends, how will they be able to live with themselves?” states 29-year-old Ali Zaidi who hails from Quetta but has moved to Karachi in pursuit of a better life, education and to support the Hazaras in Karachi.

It is easy to put the experience into words and find theoretical solutions for it, but overcoming the agony that has become embedded in Hazara Town is a herculean task for the survivors.

“Drug abuse is becoming common in the area. The youth are increasingly indulging in drugs to keep themselves calm. Dysfunctional relationships between married couples are on the rise,” Zaidi adds.

“The degree of traumatic stress is poisoning family life, and hence there is a constant feeling amongst the entire community, young or old of their life being in constant jeopardy.”

Guilt

Surviving the Peshawar school attack

What happened at Peshawar's Army Public School (APS) on December 16, 2014, was unprecedented in terms of the feelings of disbelief, horror and helplessness that it evoked not just in Pakistan but around the world.

More than 130 children lost their lives when seven gunmen belonging to the Tehrik-i-Taliban attacked the school. Over seven months have passed since the gruesome events of that day but fear still engulfs the students of the school.

They think their school can come under attack anytime.

“This is a mental health epidemic,” says Sharmeen Khan, a Karachi-based psychiatrist who, along with a team of therapists, visited Peshawar after the APS attack.

“When such trauma is not dealt with in an appropriate manner, it can lead to mass psychological disorders in the long-run. To protect against this eventuality, psychological first-aid is required in the short-run.”

While some victims suffer from survivor’s guilt, the rest are struggling with post traumatic stress.

For 16-year-old Talha, survivor of the APS attack, emotions have paved way for a whole new level of strength. At least overtly. What he feels internally is hard to gauge.

“In the beginning I was injured and I did not realise the severity of my injuries. When I came back home from the hospital I realised that this was the true face of the demon known as extremism. It filled me with sadness but I eventually overcame it and did not exaggerate my grief,” narrates Talha, recalling the day three bullets struck him, one of which pierced his jaw.

For some, the flashback of the incident is unbearably thorny while others, such as Talha, have become noticeably immune to it.

“When I came back home I told myself it is alright and then everything slowly became normal.”

“I have definitely become stronger after this incident. Initially, when I came home I had this constant fear but slowly I realised I’m safe now.”

In a sharp voice he reflects upon life after the incident.

“My parents stood as a huge support system for me. I have a large social circle and I am also mentally and physically strong so it wasn’t that big of a problem for me,” he says casually.

But his posture lowers as he clasps his hands to recount the events of December 16.

“We were sitting in our class when we were asked to go to the auditorium. A doctor was setting up charts and apparatus, and he had just started his lecture when we heard gunshots outside. They barged in through the auditorium door, with guns pointed at us,” says Talha.

“There was a hail of gunfire, and we could feel the heat of the bullets as they whizzed past us. We ran to take cover behind the auditorium seats. I was shot at directly, but was conscious. All of a sudden we heard them scream ‘Allah O Akbar’, and we took this second of respite from the gunfire to run towards one of the doors. We exited the door and went to an adjacent school wing. We waited there for 10-15 minutes before soldiers from the Pakistan Army came and rescued us.”

Talha has had sleepless nights thinking of the attack. But more than the blood and gore, there is something that constantly wears him down despite assurances that he is all right.

“When I was shot at, I got up and ran. I saw my friends breathing their last breath and gasping for air, drenched in blood. I was torn between helping my friends and saving my own life but I heard my teacher yell my name asking me to leave the building immediately.”

Upon discussing the impact of the incident, he makes it a point to clarify that the incident has affected him in a way that he is not scared anymore.

“I can fight these things again. All these things are normal now for me,” he says with much certainty.

“I was even called in for psychological therapy but I did not go. I do not need it. I am sure I don’t need any sort of psychological help. We discuss this with our friends daily and it has become a part of our every day conversations,” he says.

Struggle and post-traumatic growth

The massacre of masterpieces: A teacher’s lament

“The militants checked classroom after classroom for students hiding under desks…” the newscaster revealed on Pakistan's longest day.

As Jennifer Marshall sat in front of her television screen in Karachi, an unfamiliar terror gripped her.

The impact of the Peshawar school attack had paralysed the entire nation. But the grisly assault and its aftermath made Marshall tremble.

She is a teacher.

For over 30 years, the Karachi resident has educated some of the brightest minds in Pakistan in her various postings. She has taken great care to nurture each student individually.

Peshawar's blood-soaked uniforms filled her head with images of her own pupil.

“It’s when I heard that the militants rampaged through the school, classroom by classroom that my mind restlessly wandered through the long hall at the school where I teach. It has long rows of rooms lined up on either side,” Marshall says.

“In each child at APS, I could see the numerous students I have taught over the 30 years of my career.”

Eight months after the attack, unlike many Pakistanis who, as a coping mechanism, keep suppressing the toll of terrorism, teachers continue to bear the same inundating fears they experienced on that cold, fated December morning.

“While being cautious is a general way of life in the country now, the entrance of every school has changed in a way it never should have,” she says.

Barbed wire, roadblocks and metal detectors greet the innocent minds coming to school everyday, she adds.

Parents trust teachers to nurture their children, to influence them and guide them. Schools represent innocence and wisdom. But, all of that has changed now.

Several doctors have raised concerns over a lack of psychological support and treatment for citizens affected by acts of terrorism in the country, however, there has been no mechanism to help Pakistanis deal with the enduring cost of human lives.

In the weeks and months proceeding the Peshawar attack, the government should have set up psychological rehabilitation programs in schools throughout the country. Private schools adopted security measures but ignored the mental effects of the events in Peshawar.

Teachers and students were left to deal with their fears themselves.

Trauma has multiple components: events, experience, effects.

The 'effects' of a particular 'event' have never been fully understood or addressed in Pakistan. Panic attacks, anticipatory anxiety, hyper-vigilance are terms never explored in dealing with the aftermath of terrorism. An individual does not have to be physically a part of an 'event' to suffer the traumatic outcomes of it.

Marshall recalls falling physically ill on hearing the news of the APS 10th grader Ishaq Ameen, who succumbed to his injuries two months after the attack.

“I had been praying for Ishaq. He had to pull through.”

“It’s hard to explain how we teachers feel towards our students; these precious blank canvases are brought to us with great trust. We use different hues, different strokes to define and amplify each child’s potential. And with resolute commitment, we begin the task of creating a masterpiece. Ishaq Ameen was a teacher’s masterpiece too,” she says.

The state of education in Pakistan is by no means satisfactory. A teacher often has to play multiple roles to fill the void left by the government.

“In an environment where education is so fragile, a teacher has her work cut out. Our relationships with our students thrive on mutual learning, it thrives on discourse and ideas and dreams. A teacher is eternally marked by each students' individuality,” she states.

Marshall's voice grows steady with conviction as shes cites the example of Tahira Qazi, the headmistress, and Saeed Khan, a teacher at APS.

The two individuals paid with their lives attempting to rescue their students. Survivors of the APS attack have stated on record multiple times that all 900 students present in the schools at the time would have been killed, had Mrs Qazi and Mr Khan not braved the militants.

“I wasn’t surprised to hear about the bravery of the two. It’s hard not to see your students much like you do your own children; long after we retire, we remember their names. The pranks they play on us. We’re often amused by their over confidence and we’re ever ready to catch them when they trip over it. We are the first witnesses of their journey into the real world. Our students remain our most profound accomplishments,” she says with pride.

“Staying true to their profession, Mrs. Qazi and Mr Khan did what was most natural thing to them; protecting the children they had nurtured.”

Recalling her first day back at school after the APS attack, she says there was a renewed determination at how she looked at life now.

“As I entered the classroom, 32 blank canvases greeted me with respectful anticipation. My heart ached as I realised the monumental task that lay ahead for every teacher of this nation. The task of bringing back our children from the terror of APS; the task of rebuilding the shattered dreams that we, both student and teacher, collectively shared in.”

Credits

Reporter

Yumna Rafi

Writers

Yumna Rafi

Momina Khan

Zeresh John

Research

Taimur Sikander

Photos

AP

AFP

Reuters

Hussain Ali

Nadir Siddiqui

Shameen Khan

Creative

Shameen Khan

Timsaal Bukhari

Producers

Shameen Khan

Taimur Sikander