Note: This article, although not directly addressing trauma or posttraumatic stress disorder, has been included in this issue because (1) suicide bombing (SB) is an act designed to inflict maximum carnage and the very nature of the act inflicts grievous psychological trauma on those who survive; and (2) SB acts have many analogues to the epidemic of mass shootings (in which the perpetrators often commit suicide afterwards) that have plagued the United States in recent years. Indirectly, these acts affect the mental health of a range of communities in the global village.
The most dramatic increase in suicide mortality in the next decades will be observed not in the developed world but rather in the developing countries. The most potent socio-economic & behaviour factors of suicide risk are already present in a degree considerably higher than in many of the industrialised countries & this discrepancy will probably only continue to grow.1
The causes of suicide bombings lie not in individual psychopathology but in broader social conditions. Understanding and knowledge of these conditions is vital for developing appropriate public policies and responses to protect the public.2
In December 2014, seven terrorists belonging to the Tehreek-e-Taliban entered and attacked the Army Public School (APS) in Peshawar, the capital of Khyber Pakhtunkhwa, one of Pakistan's five provinces, killing more than 140 people, 132 of whom were children between ages 8 and 18 years. In the rescue operation that followed, all seven terrorists were killed by the security forces. The incident galvanized the nation, a military operation was launched against terrorist organizations, military courts were established, and the death penalty was reinstated.3
But long before the APS attack, Pakistan had been in the throes of terrorist acts going as far back as the late 1980s, with the end of the war in Afghanistan that led to the withdrawal of the Soviet Union forces.4 Then, after the terrorist attacks on September 11, 2001 on the World Trade Center Twin Towers in New York City, Pakistan became a front-line country in the “war on terror,” and attacks in Pakistan increased exponentially.4 Over the last 15 years, terrorist attacks have killed thousands of Pakistanis, both civilians and members of the security forces, as well as maimed many more.4 A large majority of these attacks were suicide bombing (SB) acts.
This article looks at the phenomenon of SB. It approaches the topic through models developed to study suicide, the pathway to suicide hypothesis, and the “proximity of factors” framework. The article also highlights the commonalities and differences between suicide and SB acts to answer the question: are there any common factors in the prevention of suicide and suicide terrorism in the context of Pakistan? Both suicide and SB acts cause immense human suffering, they are difficult to study, and empirical data are limited.
Pakistan: A Brief Overview
Pakistan is a developing country in South Asia with an estimated population of 200 million, making it the sixth most populous nation in the world. It has one of the highest population growth rates in South Asia. Religion plays an important part in peoples' daily lives, and 97% of its population are practitioners of the Muslim faith.5 The country suffers from poor social and health indicators, endemic to many developing countries. The literacy rate is <50% and approximately 50% of its population lives under or at the poverty line.6
Since Pakistan's independence from the British in 1947, which led to the division of India, the country has been beset by an unstable political system and under military rule for 32 of its 69 years since independence. Lack of governance and institutional corruption are major issues in Pakistan that impede progress, especially in the social sector.
The breakdown of the educational system has led to the proliferation of “madrassahs” (religious seminaries that offer free tuition and meals) in the country. Some of these seminaries become recruiting centers for potential suicide bombers. There are contradictory reports of the numbers of these seminaries, which vary from 8,000 to more than 35,000, and the student numbers from 500,000 to more than 3.5 million.7,8
For the purposes of this article, a limited review of the available literature on suicide and SB acts/terrorism in Pakistan was conducted. There is a dearth of primary source data on suicide terrorism in Pakistan, understandable given its highly sensitive nature. There is more primary source information available on suicide in Pakistan. In this article, the terms “suicide bombing” and “suicide terrorism” are used interchangeably.
Pakistan and Suicide Terrorism
Historically, suicide terrorism has been used in the following circumstances: demonstrating anger against foreign occupying forces (as in Iraq and Lebanon), struggling for an independent homeland (eg, the Tamil Tigers in Sri Lanka), or in settings where there is “asymmetry of warfare” (as in the Palestine-Israel conflict).9 When looked at critically, none of these objectives apply to Pakistan fully; however, there are broad political agendas that several militant and sectarian groups are pursuing in Pakistan, and SB is used as a means to that end.
Motivations for Suicide Terrorism in Pakistan
Motivations for suicide terrorism are complex. Hassan10 states that “humiliation, revenge, and altruism all drive the individual to engage in, and the community to condone, suicide bombing.” Indeed, participating in SB acts can fulfill a range of meanings from the “personal to communal” and that “it is politics more than religious fanaticism that has led terrorists to blow themselves up.”10 Hassan10 discredits a common perception that the personality of people who commit SB acts and their religion are the principal cause, arguing that “though religion can play a vital role in recruiting and motivating potential future suicide bombers, the driving force is not religion.”
According to Iqbal,4 suicide terrorism in Pakistan may be motivated by a range of factors including cultural (revenge, retaliation), religious (desire for a higher place in paradise), social (glorification of the suicide bomber), political (“foreign occupation”), and financial.
Extreme poverty is often cited as a factor in suicide terrorism in Pakistan. In Pakistan, people who commit SB acts tend to be uneducated and often from poor families. According to Pakistani law enforcement personnel, more than 95% of people who have committed SB acts in Pakistan have been from very poor and relatively less-educated families.4
In one of the few primary source articles available, Peracha et al.11 conducted a cross-sectional survey of 135 teenage boys from Sabaoon, a rehabilitation facility in Swat, Pakistan. These teenagers were captured by security forces and were in various stages of training to become suicide bombers. Per the data obtained, the family circumstances of these teenagers were as follows: (1) mean age was 15.5 years (range, age 12 to 17.5 years); (2) 52% were in the middle birth order; (3) 52% came from low socioeconomic status (ie, <$93 per month or $3 per day, according to US currency); (4) 30% were school dropouts; (5) in 65% of the cases, supervising authority figures were absent; and (6) 37% had 5 to 6 siblings and 29.5% had 8 to 9 siblings.
According to Peracha et al,11 militants had abducted 58.5% of the boys, whereas 41.5% had volunteered for militancy. More than 65% of the them had attended madrassahs in various capacities. The authors conclude that poverty, poor quality of life, large family size, illiteracy, and lack of supervision serve as potential demographic risk factors in making children vulnerable to militancy. Therefore, SB acts appear to be motivated by a range of reasons.4 The configuration of these motivations is related to the specific political agenda of the militant or sectarian organization behind the attack.
Suicide in Pakistan
In recent years, suicide has become a major public health problem in Pakistan. The World Health Organization estimates that, in 2012, there were 13,377 suicides (a rate of 7.5 per 100,000) in Pakistan and an increase in suicide rates of 2.6% between 2000 and 2012.12 Risk factors for suicide include male gender, youth (between ages 16 and 30 years), single marital status, poverty, unemployment, lack of education, low socioeconomic class, breakdown of social networks, life events, and depression.13
A case-control psychological autopsy study of 100 people who committed suicide and 100 controls in Karachi, Pakistan, identified nine variables that increased the risk of suicide: male gender, single marital status, youth (younger than age 30 years), low social class, no education or only a primary one, unemployment, disturbed social network, two or more negative life events, and depression.14
Pathway to Suicide
Suicide rarely happens in a vacuum. It is usually preceded by a series of life events, underpinned by multiple social stresses and psychiatric disorders that set the vulnerable individual on the suicidal pathway. Jenkins and Singh15 describe a “pathway to suicide” model through which a person progresses to reach the final tipping point that culminates in a suicide attempt. In this model, at the baseline of the pathway are social, environmental, and biological factors that predispose an individual to depression. Once depression manifests, symptoms such as negative thoughts, hopelessness, suicidal ideations, burdensomeness, increasing isolation, and availability of access to means of suicide become the next steps on the pathway.
This model is based on research from around the world (with some exceptions) that show >90% of those who commit suicide are suffering from a diagnosable psychiatric disorder (depression, substance abuse, psychosis, or comorbidity of disorders) at the time of death.15,16 Studies have also highlighted the role of social stress and adversity, particularly low social class, poverty, and unemployment, for Pakistani people who are depressed.17,18
Distal and Proximal Factors
Another useful approach to study suicide terrorism is the “proximity of factors” framework used in suicide studies, both for studying risk factors as well as for prevention strategies.19 Distal risk factors operate at a distance from the act, at both individual and environmental levels. They include social factors (poverty, unemployment, deprivation, injustice), psychiatric disorders (particularly depression, alcohol abuse, and personality disorders), family history of psychiatric and suicidal behaviors, early traumatic life events, personality characteristics (eg, impulsivity and aggression), and disturbed serotonergic activity.19
Proximal risk factors are those that are more closely associated with and act as precipitants to the suicidal event. Some examples include sudden stressful life events (eg, loss of job or break in significant relationship), psychosocial crisis (loss of prestige or honor), exposure to suicidal behavior (through media or direct), and availability of means of suicide (eg, guns, pesticides in home).19
Distal factors do not directly lead to suicide but form the groundwork on which the proximal factors act. The presence of either distal or proximal factors alone is insufficient to precipitate the suicidal behavior. Rather, it is the combined effect of both that puts the person at risk of suicidal behavior.
Suicide and Suicide Bombing in Pakistan: Commonalities and Differences
In Pakistan, both suicide and SB acts are predominantly perpetrated by young, single men with little to no education, who are on the low-socioeconomic strata, unemployed, and may have disrupted social networks, and recent negative life events (Table 1).11,13
Commonalities Between Suicide and Suicide Bombing Acts
Many of these variables form the distal (macro-level) factors on which the more proximal (micro-level) factors act. In both cases, it leads to a sense of alienation as the person embarks on the suicidal pathway. Once alienation sets in, the suicidal person internalizes feelings that feed into a sense of hopelessness and depression that eventually ends up in a self-harm act.
On the other hand, the person committing the SB act may be affected by the same distal factors and may also end up with a sense of alienation making him or her vulnerable for recruitment. Once recruited, one's individual identity is lessened and he or she adopts the group identity, giving the person a sense of belonging; the process of indoctrination follows20 (Figure 1).
Pathways hypothesis for suicide and suicide bombing.
There is research to support the above.20,21 For example, Post et al.20 states, “if suicide terrorism is the result of a complex psychosocial pathway, it is imperative to institute programs to inhibit individuals from entering that path in the first place and to facilitate exit from that pathway.” Volkan21 asserts that “the typical technique of creating suicide bombers includes two basic steps: first, the ‘teachers’ find young people whose personal identity is already disturbed and who are seeking an outer ‘element’ to internalize so they can stabilize their internal world. Second, they develop a ‘teaching method’ that ‘forces’ the large-group identity, ethnic and/or religious, into the ‘cracks’ of the person's damaged or subjugated individual identity.” According to Volkan,21 killing one's self (and one's personal identity) and “others” (enemies) is of no consequence—what matters is that the act of bombing (terrorism) brings self-esteem and attention to the large-group identity. Table 2 lists some important differences between suicide and SB.
Differences Between Suicide and Suicide Bombing Acts
Suicide and suicide terrorism are highly complex and multidimensional problems that require complex and multidimensional approaches for their prevention. Over the last 60 years, research on suicide has provided significant insights that have informed policy and led to many prevention programs, with encouraging results. For example, in many countries, including Denmark, Germany, Sweden, the United Kingdom and many others, that have invested in evidence-based national suicide prevention programs suicide rates have decreased.22
However, suicide prevention continues to be a challenge for many other countries, particularly developing countries. Similarly, suicide terrorism has become a challenge for researchers, public health professionals, policymakers, security agencies, and governments in many countries. If suicide terrorism is to be controlled and prevented, then an approach like suicide prevention may need to be applied.
In this context, both the “pathways to suicide” model and “proximity of factors” framework provide valuable insights. Distal factors such as social stress that form the groundwork on which proximal factors act need to be addressed. For example, poverty and lack of education feature prominently in suicide terrorism in Pakistan and there is evidence that educational attainment as well as greater income discourages support for SB acts in Pakistan.23
Since the advent of suicide terrorism in Pakistan, the country has been spending a colossal amount of money on its security apparatus. After the APS attack in December 2014, all schools in Pakistan were ordered to raise their walls, put razor wire on them, install security cameras, and hire armed security guards. The costs have been passed on to the families of the students. Similar security measures have taken place within the government, costing the taxpayers millions of dollars.24 Unfortunately, all this is at the expense of development in the social sector such as housing, education, health, jobs, and civic facilities (distal factors that contribute to disenchantment and frustration among the population).
Pakistan continues to struggle with poverty alleviation, low literacy rates, and high population growth. There is high prevalence of both communicable as well as noncommunicable diseases. Crucially, Pakistan does not have a viable political process, which underpins progress in social and health sectors. Good governance continues to be a major challenge for the country. Whatever slight budget is allotted for social development programs is further reduced by massive corruption and poor governance—factors that have beset the country since its independence.25
Knapp's26 assertion that as long as societal conditions remain poor with unresponsive governments, terrorist groups “will continue to attract recruits and financial support” is highly relevant for Pakistan, and policymakers, in my view, should heed it. There is a need for social policies that are equitable and address the real needs of the population. Such policies would speak to the distal factors that contribute to both suicide and suicide terrorism in Pakistan. There is also need for further research in this area. Methods developed by suicide researchers, such as the psychological autopsy, could help increase understanding of individual and group factors that underpin suicide terrorism.27
- Diekstra RF. The epidemiology of suicide and parasuicide. Acta Psychiatri Scand Suppl. 1993;371:9–20. doi:10.1111/j.1600-0447.1993.tb05368.x [CrossRef]
- Hassan R. What motivates the suicide bombers? Study of a comprehensive database gives a surprising answer. http://yaleglobal.yale.edu/content/what-motivates-suicide-bombers. Accessed February 14, 2017.
- 132 children killed in Peshawar school attack. The Express Tribune. https://tribune.com.pk/story/807564/gunmen-target-school-in-peshawar/. Accessed February 21, 2017.
- Iqbal K. Evolution of suicide terrorism in Pakistan and counter-strategies. The Pakistan Institute of Peace Studies. http://www.academia.edu/9234090/Evolution_of_Suicide_Terrorism_in_Pakistan_and_Counter-Strategies. Accessed February 14, 2017.
- Pakistan Demographic Profile 2016. Index Mundi (Source: CIA World Factbook, 2016). http://www.indexmundi.com/pakistan/demographics_profile.html. Accessed February 21, 2017.
- Rana S. 40% of Pakistanis live in poverty. The Express Tribune. https://tribune.com.pk/story/1126706/40-pakistanis-live-poverty/. Accessed February 21, 2017.
- Rashid A. Taliban: Militant Islam, Oil and Fundamentalism in Central Asia. New Haven, CT: Yale University Press; 2000.
- Gishkori Z. Reforming madrassas: the revolution within. https://tribune.com.pk/story/825216/the-revolution-within/. Accessed February 14, 2017.
- Overton I, Dodd H. A short history of suicide bombing. https://aoav.org.uk/2013/a-short-history-of-suicide-bombings/. Accessed February 14, 2017
- Hassan R. Life as a Weapon. The Global Rise of Suicide Bombings. New York, NY: Routledge; 2014.
- Peracha FN, Khan RR, Ahmad A, Khan SJ, Hussein S, Choudry HR. Socio demographic variables in the vulnerable youth predisposed towards militancy (Swat, Pakistan). Psychiatr Psychol Law. 2012;19(3):439–447. doi:10.1080/13218719.2011.598635 [CrossRef]
- World Health Organization. Preventing suicide. A global imperative. http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf. Accessed February 14, 2017.
- Khan MM. Suicide prevention in Pakistan: an impossible challenge?J Pak Med Assoc. 2007;57(10):478–480.
- Khan MM, Mahmud S, Karim MS, Zaman M, Prince M. Case-control study of suicide in Karachi, Pakistan. Br J Psychiatry. 2008;193(5):402–405. doi:10.1192/bjp.bp.107.042069 [CrossRef]
- Jenkins R, Singh B. General population strategies of suicide prevention. In: Hawton K, Heeringen VK, eds. The International Handbook of Suicide and Attempted Suicide. Chichester, England: John Wiley & Sons, Ltd; 2000. doi:10.1002/9780470698976.ch34 [CrossRef]
- Henriksson MM, Aro HM, Marttunen MJ, Heikkinen ME, Isometsa ET, Kuoppasalmi KI, et al. Mental disorders and comorbidity in suicide. Am J Psychiatry. 1993;150:935–940. doi:10.1176/ajp.150.6.935 [CrossRef]
- Husain N, Gater R, Tomenson B, Creed F. Social factors associated with chronic depression among a population-based sample of women in rural Pakistan. Soc Psychiatry Psychiatr Epidemiol. 2004;39:618–624. doi:10.1007/s00127-004-0781-1 [CrossRef]
- Mumford DB, Minhas FA, Akhtar I, Akhter S, Mubbashar MH. Stress and psychiatric disorder in urban Rawalpindi. Community survey. Br J Psychiatry. 2000;177:557–562. doi:10.1192/bjp.177.6.557 [CrossRef]
- Moscicki EK. Epidemiology of completed and attempted suicide: toward a framework for prevention. Clin Neurosci Res. 2001;1:310–323. doi:10.1016/S1566-2772(01)00032-9 [CrossRef]
- Post JM, Ali F, Henderson SW, Shanfield S, Victoroff J, Weine S. The psychology of suicide terrorism. Psychiatry. 2009;72(1):13–31. doi:10.1521/psyc.2009.72.1.13 [CrossRef]
- Volkan VD. Suicide bombers. http://cc.oulu.fi/~hsoini/luentomateriaali/Kasvatuspsykologia%202012/artikkelit/Volkan%20%20Suicide%20Bombers.pdf. Accessed February 14, 2017.
- Matsubayashi T, Ueda M. The effect of national suicide prevention programs on suicide rates in 21 OECD nations. Soc Sci Med. 2011;73(9):1395–1400. doi:10.1016/j.socscimed.2011.08.022 [CrossRef]
- Shafiq MN, Sinno AH. Education, income, and support for suicide bombings: evidence from six Muslim countries. J Confl Res. 2010;54(1):146–178. doi:10.1177/0022002709351411 [CrossRef]
- Ain QU. APS Peshawar incident – an appraisal. ISSRA Papers. http://www.ndu.edu.pk/issra/issra_pub/articles/issra-paper/Issra-papers-1st-Half-15/10-APS-Peshawar-Incident.pdf. Accessed February 21, 2017.
- Javaid U. Corruption and its deep impact on good governance in Pakistan. http://pu.edu.pk/images/journal/pesr/PDF-FILES/7%20JAVAID%20Corruption%20and%20its%20Deep%20Impact%20on%20Good%20Governance%2085.pdf. Accessed February 21, 2017.
- Knapp MG. The concept and practice on Jihad in Islam. http://strategicstudiesinstitute.army.mil/pubs/parameters/Articles/03spring/knapp.pdf. Accessed February 14, 2017.
- Townsend E. Suicide terrorists: are they suicidal?Suicide Life Threat Behav. 2007;37(1):35–49. doi:10.1521/suli.2007.37.1.35 [CrossRef]
Commonalities Between Suicide and Suicide Bombing Acts
Young, single, male gender
Low socioeconomic class
Low or no education
Breakdown of social networks
Negative life events (two or more)
Differences Between Suicide and Suicide Bombing Acts
||Suicide Bombing Acts
|Deeply personal act
||Act on behalf of group
||Motivation: mainly political