Subject: Lancet: Torture & trauma in post-conflict East Timor

Lancet Volume 356, Number 9243 18 November 2000

Health and human rights Torture and trauma in post-conflict East Timor

The 25 years of Indonesian military occupation of East Timor were characterised by repeated allegations of human-rights atrocities, few of which were ever investigated or prosecuted by the Indonesian authorities. Following the August 1999 referendum, pro-Indonesian militias, supported in part by the Indonesian military, embarked on a wide scale and largely indiscriminate programme of organised violence and destruction of infrastructure, which required a major international peace-keeping and relief operation.

An inherent part of the response to such humanitarian crises must include assessment of the prevalence of torture and extreme trauma, and attention to the rehabilitation needs of victims. If people do not have the opportunity to process the mental consequences of their traumatic experiences, and to obtain an integrated, balanced perception of their history, social reconstruction becomes extremely difficult if not impossible. Although spontaneous recovery is acknowledged, previous studies of treated and untreated patients with post-traumatic stress disorder (PTSD) have found a doubling of the average time needed to achieve significant remission of symptoms for those who did not receive treatment. Treatment is a critical process that must be incorporated early in the emergency phase of a post-conflict situation.

The International Rehabilitation Council for Torture Victims (IRCT), an independent international health professional organisation, carried out a national psychosocial needs assessment in East Timor in June and July this year. We aimed to assess the extent of `torture and trauma and the health impact it had on the population. The study results have provided the basis for the proposed National Psychosocial Rehabilitation Program.

1033 households in 13 districts of East Timor, an estimated 750 000 individuals, were interviewed. One respondent was selected from each household who was considered to be a reliable informant. A community trauma mapping activity was carried out, with the aim of generating a picture of each district's health system, and of identifying and establishing potential partners and support systems. The questionnaire was designed to ascertain trauma and torture history, PTSD symptomatology, self-perception of health, potential for recovery, and help-seeking behaviour.

Respondents had a median age of 35·5 years and 873 (85%) individuals were aged 14-59 years. 998 (97%) respondents said they had experienced at least one traumatic event. The five most common events were: direct exposure to combat situation (785 [76%]), lack of shelter (658 [64%]), and ill health with no access to medical care (623 [60%]).

351 (34%) were classified as having PTSD, based on a cut-off score of 2·5 or greater in the Harvard trauma questionnaire symptoms checklist. Death of the father or mother was a common occurrence, reported by 320 (31%) and 248 (24%) respondents respectively, and 142 (14%) had lost their spouse during the conflict period. For women, grieving the death of a loved one was often compounded by the dilemma of taking over the sole responsibility for the family.

To get an indirect measure of the effect of trauma on children, respondents were asked if they had children who were either injured or from whom they had been separated. 227 (22%) said yes, and a further 125 (12%) said that they had children who died as a result of political violence. In several provinces there were reports of children having been raped by the militia.

Torture appears to have been widespread. 400 (39%) respondents said that they had been tortured, but a larger number, 587 (57%), said they had experienced at least one of the six forms of torture included in our study instrument. Psychological torture (411 [40%]), physical beating or mauling (336 [33%]), and beating the head with or without a helmet (267 [26%]) were the most common forms reported, and other forms of torture included submersion in water (126 [12%]), electric shock (124 [12%]), crushing of hands (102 [10%]), and rape or sexual abuse (54 [5%]). Many respondents described having been threatened at gunpoint, especially during interrogation by the Indonesian military. 227 (22%) witnessed the murder of a family member or friend. 207 (20%) respondents believed that they would never recover from their experiences, and a further 424 (41%) believed they would only recover with some help.

The problem of under-reporting of torture in population surveys was clearly seen in this study. Asking directly whether the interviewee had been exposed to torture yielded 39% affirmative, whereas the summation over only six specific forms of torture raised the estimate to 57%. This discrepancy may be explained by the reluctance of many victims to raise the subject at all unless asked about it directly. Future studies to assess the prevalence of torture should use instruments that specifically address particular experiences of torture.

Our study also found that East Timorese people look primarily to family members, the church, and the local community for assistance, although they are willing to approach a doctor or community nurse for problems that they perceive as being health related. Psychosocial and rehabilitation programmes are therefore likely to be most effective if they are family and community oriented.

With this in mind, the IRCT is working closely with other organisations to educate primary-school teachers in basic concepts of trauma and psychosocial recovery in children, and to provide support to children and their families. We aim to carry out the programme nationwide during the next 12 months. Giving priority to the treatment of children acknowledges that they are the population group in which the impact of conflict and disaster is greatest. Children can recover rapidly if they receive prompt treatment. By assessing traumatic events and their health sequelae epidemiological studies can play a crucial role in the collective response to humanitarian crises.

*J Modvig, J Pagaduan-Lopez, J Rodenburg, C M D Salud, R V Cabigon, C I A Panelo

International Rehabilitation Council for Torture Victims, Copenhagen K, Denmark (e-mail:

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