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BMJ. 2007 April 14; 334(7597): 801.
PMCID: PMC1852037
Review of the Week

The scars that won't heal

Reviewed by Robert Hunter, consultant psychiatrist

Afterwards. Rachel Seiffert. William Heinemann, £14.99, pp 336. ISBN 0 4340 1186 X. Rating: ****.

Robert Hunter is impressed by a novel that examines the long term effects of warfare on mental health and relationships

Afterwards gives us an important glimpse of how veterans who are psychologically damaged by their war experiences struggle to cope after returning to civilian society. Seiffert, one of many new writers nurtured by the creative writing course at Glasgow University and whose first novel, The Dark Room (2001), was shortlisted for the Booker prize, has written Afterwards in an understated, almost skeletal style that paradoxically seems to make her work all the more powerful.

At the centre of the story is the developing relationship between Alice, a physiotherapist, and Joseph, a former infantryman who now works as a plasterer and decorator. As the story unfolds it becomes clear that Joseph has been struggling to cope with psychological harm resulting from service with the army in Armagh. Alice, who was abandoned by her father as a baby and is still grieving for her beloved grandmother, enlists Joseph's help to redecorate her grandfather's house. During the redecoration, David, her grandfather, seems to welcome the opportunity to confide in Joseph about his war experiences in Kenya, where as an RAF officer he bombed Mau Mau villages. The effect of this is to rekindle the terrors in Joseph's mind about his own experiences in Armagh.

Since buying himself out of the army Joseph has been trying to come to terms with his own past as a soldier during the “troubles” in the early 1990s. Enlisting in the army had “felt like something real,” allowing him to escape the estate where he grew up; but Seiffert slowly describes the effect on Joseph's mental health of his military experience, and we learn that Joseph had killed a suspected gunman in front of his wife and child. We begin to understand, as the novel develops, how lasting and psychologically scarring the effects of Joseph's military experience have been. Seiffert describes well Joseph's disorientation when he leaves the army and becomes homeless: “It took over everything sometimes and there wasn't anywhere he could settle. Only a few days in any one place, if that. Friends' houses, then friends of friends, sometimes hostels. He was in a place for veterans for over a week once and that was easy at first, familiar . . . but the man in the next bed had screaming nightmares, and the day room was full of bitter talk about compensation and pensions. A lot of Gulf War blokes there, all of them angry.”

As their relationship develops, Alice becomes increasingly aware that Joseph studiously avoids talking about his army past and is prone to “disappear” regularly as a means of trying to cope. She also becomes curious to know what her grandfather and Joseph had discussed together. Seiffert's descriptions of the respective war experiences of David and Joseph, although told in a matter of fact way, are powerful evocations of the effects of war on the lives of those involved and those close to them; there are strong echoes here of Lewis Grassic Gibbon's Sunset Song, where another relationship was blighted by “battle shock” in another “Great” War.

Concern about the quality of care available for injured veterans is increasing in the United States and the United Kingdom. In the US this issue has had a higher media profile, and recently President Bush announced a “wounded warrior” commission to investigate what has been widely considered to be the mistreatment of veterans of the wars in Iraq and Afghanistan. Recent testimony to the Senate's Armed Forces Committee described the struggle of many veterans to have mental health problems taken seriously by military review boards seeking to limit costs. In the UK, the ex-services mental welfare charity Combat Stress (www.combatstress.org.uk) and the Royal British Legion have each reported a significant increase in numbers of returning service personnel with post-traumatic stress disorder and other psychological illnesses.

As described in Afterwards these mental problems often result in anxiety and depression, substance abuse, violence, and homelessness. There has also been concern that the UK's “military covenant”—namely, the historical obligation, recognised since the Napoleonic wars, for the state to care for military personnel who have served their country—is being less than fully honoured or even ignored. Concern that the military covenant is not being honoured has resulted in the publication of an open letter to the prime minister, signed by national figures and relatives of members of the armed forces who have died recently in the Middle East. This follows Ministry of Defence plans to close the UK's only dedicated military hospital at Haslar in Gosport and replace it with a military ward at Selly Oak Hospital, in Birmingham. Throughout the rest of the country NHS services will be expected to provide outpatient services for injured service people.

Whether or not these new services will provide adequate support for the growing number of mentally traumatised veterans from Iraq and Afghanistan remains to be seen; but as Afterwards illustrates, such services will have little or no effect on the many subclinical cases of battle shock. In a recent major speech, Tony Blair expressed a view that UK forces must be able “to be warfighters as well as peacekeepers.” However, there is no doubt that such a policy will result in psychological injury to many servicemen and women and will have a lasting effect on the health of individuals, families, and communities for a generation and perhaps longer. As well as needing a debate about the role of UK armed forces, more research needs to be funded into the health, social, and economic consequences of the ongoing military action in the Middle East. Afterwards is an important and timely new work that avoids political viewpoints but will make readers think beyond the headline figures of war fatalities, terrible as these are, to the effect of war on ordinary lives, relationships, and families.


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