In addition to the direct effects on ill health previously highlighted, an important characteristic of current conflicts that indirectly impacts on health is the destruction of social networks and cultural institutions that provide populations with a sense of identity. This is particularly relevant in conflicts against particular ethnic groups such as the Iraqi government's targeting of the Kurdish population (Middle East Watch and Physicians for Human Rights, 1993), the Indonesian government's killing of large numbers of East Timorese, and the Serbs' targeting of ethnic Albanians. There has been documentation of the systematic suppression of cultures through the ban of the use of ethnic languages within oppressed groups. Examples are the violent protests in Soweto as a result of the government's insistence on the exclusive use of Afrikaans during the apartheid period in South Africa and the Iraqi assault against the Shia culture and religion (Makiya, 1993).
The intentional destruction of social, economic, and cultural realities has been described as the primary psychic obstacle that needs to be overcome by survivors (Summerfield, 2000). Communities subjected to frequent harassment, particularly in protracted situations, "forget" concepts of trust and innocence and the ability to predict or explain their sociocultural context. Just as traumatic is the destruction of livelihoods, for instance of subsistence farmers that know no other way of life, and other social structures, community networks, and traditional mechanisms that are relied on in times of crisis. Harrell-Bond and Wilson (1990) describe the effects on Sudanese refugees of the inability to perform traditional burial rituals for relatives who lost their lives during the conflict, a critical part of the grieving process. They reported being haunted constantly by the spirits of the dead family members.
The refugee experience is therefore mediated by a wide range of circumstances. How refugees overcome these to rebuild their lives and regain their health and well-being depends to a large extent on the post-conflict outcomes and the opportunity for a stable environment in which "normal" life can resume. Consequently, the opportunities that present through voluntary repatriation or resettlement are critical to long-term outcomes.
Recent repatriation programs have acknowledged the importance of rebuilding all aspects of the country and communities that have been affected by conflict and instability. Program activities for reintegration and resettlement of conflict areas involve not only the returning refugees, but also the local population in areas to which refugees will be returning in order to create and sustain viable social units. There is an increasing focus on active participation, which is important to short-term success and long-term sustainability. In addition, following a recent UN resolution1 on the impact of war on women, findings from studies on gender and empowerment have been incorporated into planning, implementation, and evaluation to ensure women's active participation in the peace and repatriation processes. While the voluntary repatriation of refugees may be the ideal solution, systematic evaluation is fairly recent and therefore "best practice models" by which successful reintegration and re-establishment of livelihoods are not clear. A body of literature is gradually building up from lessons of countries such as Albania, Eritrea, and Ethiopia.
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