On October 18. 2(X)I, just weeks following the 9/11 attacks on New York. NY, and Washington, DC. US District Judge Leonard B. Sand sentenced four associates of Osama bin Laden to life in prison for their roles in the August 7. 1998, bombing of the US embassies in Nairobi. Kenya, and Dar es Salaam, Tanzania.1 Many people have forgotten the extent of those bombings, which occurred 8,(XX) miles from the United States and in an area of the world unfamiliar to most Americans.
Yet these bombings, especially the one in Nairobi, were deadly and created a degree of psychological and physical destruction not experienced before in that particular way in that pail of the world. East Africa is an area well acquainted with manmade and natural disasters. In Rwanda, just to the southwest of Kenya, 800.000 people had been butchered by their neighbors 4 years before the embassy bombing. Still, the bombing was devastating and had a terrible effect on the Kenyan community.
On August 7. 1998. a LO(X)-Ib truck bomb exploded in an alley behind the US embassy in Nairobi. Kenya, killing 213 people, most of them Kenyan, and injuring 5,(XX). Within minutes, another virtually identical truck bomb was detonated in Dar es Salaam, Tanzania; it killed 12 people and injured 85. Within hours, Osama bin Laden was identified as the chief suspect in the bombings, and his involvement and the involvement of the al Qaeda terrorist organization were established during the trial of the bombers in the spring of 2001 .2
The Nairobi blast caused more damage for a variety of reasons. Although the Dar es Salaam bombing was devastating, the damage wrought by the Nairobi bombing was orders of magnitude greater. In Dar es Salaam, a nearby water truck absorbed a great deal of the blast (in fact, the truck was thrown into the air by the blast). In Nairobi, the main blast was preceded 8 seconds earlier by the sound of a flash grenade one of the terrorists had thrown at an embassy guard to force him to allow entry into the embassy's underground parking lot. The noise from this grenade attracted the interest of many of the Kenyans in the downtown Nairobi office buildings; those who gathered curiously at their office windows were injured by the flying debris created by the main blast.
The VS embassy in Nairobi is a larger mission than the one in Dar es Salaam and, therefore, the damage affected the operations of the US government more substantially. Although I dealt with bombing victims from both events, this paper focuses on Nairobi.
INJURIES AND AFTERMATH
The bombing inflicted serious injuries on the survivors. Eye injuries were especially common because of the large number of curious people who had gathered near windows to find out what had caused the first blast. The 5,(XX) injured patients rapidly overwhelmed the eight major hospitals in Nairobi. Many other victims were treated at local hospitals by Kenyan physicians: no systematic record of the treatment of those victims exists.
Among the Americans, most of the injured had various kinds of lacerations, penetrations, fractures, and amputations (Sidebar).1 All of those who died had sustained unsurvivable injuries; the best assessment is that none died as a result of delayed or improper care. Arrangements were made to evacuate 26 injured patients to facilities with more advanced capabilities.
US Mission staff made repeated visits to local hospitals to identify missing employees. One of the dead Americans was misidentified and therefore not confirmed dead for more than 2 days. Although the chancery building was unusable, the embassy continued functioning at the US Agency for International Development headquarters, located in a suburb of Nairobi.
The immediate aftermath of the bombing was complicated in several ways. First, when security personnel secured the perimeter of the embassy following the bombing, as they had been trained to do, they were criticized as being selfish or hostile. Thousands of panicked and curious people congregated in front of the building.4 While many Kenyans wanted to help the embassy victims, some took advantage of the situation to loot. One survivor saw a Kenyan stealing jewelry from a dead American. Another embassy official reported rescuers from a third nation who had been sent to "assist" in the rescue were photographing classified documents.
American rescue teams did not arrive until the following morning, so the victims of the bombing also found themselves acting as first responders. The scene was chaotic and hellish. One survivor said that one minute he had been looking out a window at the city, and the next second he was staring at "the apocalypse." Unaware of the devastation and numbers of casualties inside the chancery building and dismayed by the security cordon of US Marines and other personnel, the Kenyan press launched a barrage of criticism.
The blast, like most terrorist attacks, came as a surprise. Although Prudence Bushnell, the US ambassador to Kenya at the time of the blast, had made well known her security concerns regarding the embassy, she was largely unheeded.5 Most considered economic crime, not international terrorism, the chief threat in Nairobi. The chancery building was viewed as impregnable, especially by the Kenyans working there. They felt that, once they entered the building, they were protected from the hectic life of downtown Nairobi. Once they realized that the embassy had been not only bombed but effectively destroyed, this sense of invulnerability vanished.
Although the bombing had targeted Americans, thousands more Kenyans were killed and injured by the blast. Although Kenya, like many countries in the developing world, does not have a well-developed mental healthcare system, there is in the country a strong interest on the part of mental healthcare providers to offer psychiatric services.6
Kenya has a number of mental health professionals, including a substantial number of knowledgeable, experienced psychiatrists. One of these, Frank Njenga. quickly recognized that the bombing victims would need education and psychological support. With the support of the Kenya Medical Association, he organized "Operation Recovery," which trained approximately 700 counselors and treated approximately 7,(XX) people.7
Because few Kenyans use outpatient psychiatric services for any reason, the Kenyan psychiatrists made substantial efforts to educate the public about the psychological effects of trauma through radio and television.8,9 The public education and counseling outreach seemed to have been appreciated by victims, but what effect these measures had on individuals has not been assessed adequately. In fact, Kigamwa and colleagues (Kigamwa P, Njenga F, Ny amai C, unpublished data, 2(XK)) surveyed 52 Kenyans who had sustained injures during the blast, 85% of whom had undergone counseling. They found most said "religion, prayer, and faith in God" were of most help (20%), followed by support from family (12%). group therapy (9%). counseling (6%), and "personal resourcefulness" (6%). These results, al though based on a convenience sample, are among the few data available about the response of the Africans to interventions and indicate that religion was a helpful factor for many victims, as well as that the interventions used so frequently in the industrialized world may have more limited applicability than might be suspected in the sub-Saharan Africa setting.
In a study of 49 Kenyan employees of the US government completed 2 years after the bombing, 1 8% had a score of 65 or above on the Impact of Events ScaleRevised, which is used to assess posttraumatic stress (Thielnian SB, Pfefferbaum B. North C, Doughty DE, unpublished data. 2004). This indicates a continuing high level of posttrauma psychological symptoms. In the study, 26% of respondents also had a score of 17 or above on the Beck Depression Inventory, a score that is in the moderate or above range of depression. Futher, 74% reported "other things provoke thoughts of the bombing." 62% reported they thought of the bombing unintentionally, and 56% reported they stayed away from reminders of the bombing.
One particularly interesting finding of American researchers studying the bombing was that Kenyan children who had been affected had frequently been victims of other traumas and were more likely to be functionally impaired after the US Embassy bombing.10
Although victims themselves, the Americans who survived the bombing became the object of intense local anger. The ambassador's assertion that looters had entered the chancery building minutes after the explosion was soundly rejected. "Nobody was interested in looting at that tragic hour," one Kenyan politician asserted, demanding that the ambassador withdraw her defense of security personnel." Kenyans also accused the Americans of racial discrimination in their efforts to evacuate Americans who had been badly injured in the bombing. The portrayal of Americans as racist bullies was devastating to the American survivors.
Bushnell, an experienced diplomat in her first ambassadorial assignment, was injured by the blast as she sat in a meeting with the Kenyan Trade Minister in the Co-op Bank Building, a large structure that was adjacent to the embassy. After the attacks, Bushnell described herself as "devastated."4 A passionate advocate for diplomatic safety and one of the lone voices in the US government calling for intervention during the 1994 Rwandan genocide. Bushnell. a humanitarian and independent-minded diplomat, repeatedly noted security concerns before the bombing. As chief of mission, responsible for the security of mission personnel and their families, she was reported to have viewed the tragic events of the bombing as a personal failure.4
Three days after the bombing. Bushnell sent a memo to all mission personnel asking employees to attend debriefings. Debriefings were organized according to four types of groups: people at the site of the blast, people not at the site, family members of embassy personnel, and children. During the next 2 weeks, most participated in one of these groups, each subdivided into sections of 20 to 25 people each.12 These groups generated a variety of feelings. A few people refused to participate. A number of those who participated expressed discomfort with the procedure that mixed Kenyan employees with American supervisors. Few of those leading the debriefings had had formal training, although the model used was that of Jeffrey Mitchell, whose debriefing model has been popular with the US military.
Two years after the bombing, a survey of Kenyans who had participated in the debriefings revealed thai 86% felt the sessions had been "somewhat" or "very" helpful. Still, a substantial number of people continued to have posttraumatic psychological symptoms 2 years later, despite the broad participation (Thielnian SB, Pfefferbaum B, North C, Doughty DE, unpublished data. 2004).
How Americans fared as a group after the bombing has been difficult to document. To receive security clearances. Foreign Service employees aie asked about mental health issues, and many bombing victims were reluctant even to present themselves for clinical caie, much less to allow themselves to be studied in a clinical research protocol. Despite assurances that seeking psychiatric care would not jeopardize medical or security clearances, many people resisted mental health care intervention of any kind. Nonetheless, Pfefferbaum et al.13 were able to obtain information from a small number of injured survivors and found that injury during the bombing predicted posttraumatic stress, intrusion symptoms, and arousal.
Despite the initial reluctance to seek caie, many American victims did, in fact, eventually come to psychiaüic attention. I treated a number of them and talked with others who were being treated by other clinicians. As a result, several general observations are possible.
First, the effect of this event on the lives of those who experienced it was monumental. Almost everyone affected seems to have had some post-irauma reaction, and many have symptoms that persist even to this day. Not only were many of those who experienced the blast affected, but a significant number of those working at the US Agency for International Development mission (located some distance from the main embassy) were also affected because of their involvement in the rescue effort.
One woman who assisted in the rescue effort found the bombing reawakened memories of her childhood in the foreign service, when she had lived overseas and observed bombings and war. Even though she had not been present at the time of the blast, the scene of destruction, the ensuing chaos, and the loss of valued friends and co-workers produced a devastating effect. She sought counseling from a local therapist early on and subsequently obtained significant relief, after trials of various medications, from a combination of an antidepressant, psychotherapy, and eye movement desensitization and reprocessing therapy, a desensitization technique that has been used to reduce the symptoms of posttraumatic stress disorder.
Another rescuer, who had assisted in clearing human remains from the blast site, although not present at the precise time of the bombing, was profoundly disturbed by memories of the event. He reported that he filled biohazard bags with human body parts, blood-soaked clothing, and other items. At the time I saw him, 2 years later, he had for many months had difficulty with awakening at night with images of picking up human remains, which was very disconcerting to him. He found bad memories were triggered by putrid smells or seeing a dead animal on the road. He began to remember distressing memories of childhood. He had had some increased use of alcohol in the previous 2 years, and at the time I saw him was drinking four beers or half a bottle of wine a day. He received psychotherapy and an antidepressant and improved dramatically in terms of depression and intrusive thoughts.
Children who had not been present at the bombing but whose parents were deeply affected also exhibited psychological symptoms. One pre-adolescent girl was brought by her mother for evaluation because of misbehavior and sad mood. During the interview, the girl reported that she had wanted to kill herself and had actually attempted to do so by jumping, without effect, from a wardrobe in her home. She was treated with psychotherapy and a selective serotonin reuptake inhibitor and improved somewhat in terms of suicidality but continued to have academic problems in at school and behavioral problems at home.
Another pre-adolescent child was presented for clinical care 3 years after the bombing. His father and mother, although associated with the US mission in Nairobi, were not in the building during the bombing. His father was, however, one of those instrumental in coordinating the response. The child had become depressed and reported suicidal fantasies involving drowning himself. Following the bombing, he had begun to feel very unsafe and to fear that he might be attacked by a madman who would throw a grenade into the house. He responded positively to psychotherapy and improved somewhat in terms of his tearfulness, but he had a fluctuating course during the year following his initial treatment and has continued to receive psychiatric care intermittently since his initial visit.
The Nairobi bombing highlights the complexities of providing psychiatric care to traumatized people in an overseas setting. The fact that the victims of the bombing were both Americans and Kenyans created special problems in terms of the delivery of care but also provided an opportunity for two very different cultures to interact with each other at the doctorpatient level, peer-to-peer level (for the survivors), and professional level (for the providers). The persistence of symptoms among both American and Kenyan survivors suggests both the intensity of exposure to a terrorist event and the intensity of disruption of the lives of the survivors may have contributed to the chronicity of the symptoms we observed. Clearly, additional study of the response to trauma in nonWestern settings will be helpful to understanding the nature of post-trauma psychological reactions.
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