Sanaullah Khan


During my fieldwork in Pakistan, I had the chance to conduct interviews among Afghan refugees who fled the war in 1979 when the Soviet forces occupied Afghanistan.[1] One day, we sat under a tent where all the workers in the kaarkhana or warehouse slept. On a plot surrounded by walls, there was a corner with a tent where all the men, who I later observed had developed brotherly relations, slept and rested. Right outside the tents were heaps of garbage which were organized by young boys or apprentices and then sold to middlemen involved in the recycling industry. As we sat in the tent and Agha served me Mountain Dew, a rat ran right in front of us. I stood up and moved back in fear, as Agha said, “Don’t worry, this is normal for us. When we sleep, we have rats stepping on our faces. We often keep cats to prey on them.”

As an anthropologist in training, I have been interested in understanding questions of mental illness among marginalized populations who have been displaced due to war. In the context of Afghan refugees, numbness provided a standing language to consider both the experience of bodies being battered by state violence, as well as the use of psychoactive drugs that help in making one’s experiences of psychological trauma somewhat bearable, especially in a place, which was meant to be a sanctuary. Sanctuaries serve as sites where displaced populations are invited and settled, representing humanitarianism and generosity of states, but also sites where new forms of violence are inflicted, in a way that become generative of traumas.

In 2021, the US withdrew forces from Afghanistan. America’s longest war had come to an end. Populations fled the Taliban rule in the fear of persecution. In 2020, the European Union provided 21 million euros for Afghan refugees and host communities which was to be funneled through United Nations High Commissioner for Refugees (UNHCR 2020). Recently, the German foreign minister in her visit to Pakistan, specifically commended Pakistan’s generosity in hosting the refugees. While international donor agencies have invested heavily to safeguard the lives of refugees, the on-ground reality of these communities continues to be bleak. Pakistan currently hosts almost 3 million refugees with almost 100,000 urban Afghans entering Pakistan after US departure, who have been denied the P-2 or the asylum-seeker visa (Gul 2022). The previous Pakistan Tehrik-i-Insaf (PTI) government’s interior minister Sheikh Rashid, also took strict actions against forged IDs among Afghan refugees and gave strict orders about their regulation (Amir 2021). While the Pakistan government has established a temporary camp at Kot Chandna in Mianwali district for Afghan refugees, due to a lack of government interest and poor conditions, refugees have fled to urban centers. In urban conditions, many refugees live protected and isolated lives, cut off from the mainstream society, building makeshift camps on landfills like the one in Lahore.

Afghan Basti, Lahore
Photo by Author

The Biopolitics of Sanctuaries

Much of my work has involved studying the impacts of warfare in Pakistan. In my dissertation fieldwork, I interviewed servicemembers, psychiatrists as well as local healers in Pakistan. During 2021, as I was conducting my dissertation fieldwork among traditional healers providing treatment for mental illnesses in the absence of adequate psychiatric care for cases of bipolar disorder and depression, I also observed Afghan refugees seeking treatment. I wanted to study how mental illness was perceived in pockets of Afghan populations, especially in the absence of basic health and psychiatric services. I observed that mental illness was highly stigmatized, with the subject often provoking laughter toward the person who appeared to be suffering from it, with many men either wholly denying experiencing any problems, or treating it as “normal,” using statements like, “who doesn’t have depression these days?” to refer to the dire conditions of the sanctuary.

The streams of migration from Afghanistan to Pakistan have continued as families draw upon existing networks to successfully move across the border and settle in cities like Karachi, Lahore, Mianwali and Peshawar. Even after almost three decades these refugees are treated as neither Pakistani nor Afghan. Speaking Punjabi like locals, the only thing that distinguishes them is when they instantly start conversing in Pushto or Dari with their relatives. Rates of police brutality remain high, as these groups are construed as harboring terrorists, a paranoia that intensified during the country’s war on terror. The Afghan communities are also portrayed as hotbeds of opium and drug trade. In Afghan Basti, there wasn’t a physician within several miles. One homeopathic practitioner who was part of the government’s anti-narcotics force shared, “The problem is that these people have several marriage partners and don’t use birth control.” The biggest problem for the state, it appeared, was of having large families that continued to be unregistered and outside state surveillance. He suggested that the families also offered a great amount of resistance to polio vaccinations, which resulted in vaccinators coming to households accompanied by police personnel. Any empathy or care toward the vulnerable was missing and health initiatives continued to be construed as punitive actions instead of signs of care. We can now consider the transnational bonds and networks and refoulment of refugees, which although is prohibited in international law, still continues to take place, begging the question about the political stakes and social realities of providing sanctuaries that intensify psychological pressures.

Embodiments of Trauma

Refugees with whom I spent time had specific ways of expressing distress showing the embodiment of kinship obligations, political violence and displacement. Violence back home made it difficult for many to return. In Pakistan, many continued to be viewed with a great deal of suspicion. Partly the suspicion was due to transnational family networks and affiliations of the refugees. The continued refugee status led many to be perceived as temporary residents even if they had resided in the country for over 30 years.

Among many men, not being able to raise enough money for marriage was often perceived as emasculating and as common causes of udaasi (sadness or dejection). This was especially the case given the pressure to accumulate enough money to successfully pay bride-price for marriage. Yet this money could only be raised outside of the formal economy given the structural inequalities that prevented access to education and led to heightened xenophobia against refugees. This led many to exclude themselves altogether from the formal market. Bride-prices back home in Afghanistan were much lower because of the war. Daud, another interlocutor shared that this was a product of the desperation families experienced to marry their daughters out of the war-torn country. The bride-price in Pakistan on the other hand was often much higher, which meant that many men, who were excluded from the formal economy strove to somehow gather 10 to 12 lac rupees ($5-6000) to successfully get married. Agha would often equate the bride-price paid to the families of women to the loyalty of women, as his own wife had been missing for many years. He wondered whether she had escaped or been kidnapped. Others shared that they lived away from families in urban centers to make enough money. Thus, marriage itself and the responsibilities it entailed involved transnational ties, which were often fragile, given the high rates of poverty and violence. Men explained the pressures to marry and maintain marriages as the primary cause of psychological stress.

What intrigued me as an ethnographer was the rapid movement of families between several countries like Pakistan, India, Turkey and Iran, often by being smuggled across borders, as many would share with me. Movement across borders had high stakes for families, with risks such as being caught by the state or becoming injured or losing life during the arduous journeys due to suffocation in containers or by drowning in boats. This of course also included the risk of getting caught and repatriated. Meanwhile, the war on terror has led the Pakistan Army to pursue a policy of “shoot to kill” for anyone entering the border without authorization (Oztig 2018), just as the Pakistani state has sought to make temporary visit visas accessible for many, in an attempt to show its generosity. In Pakistan, many refugees faced a range of problems related to lack of basic medical services. Further many avoided medical services because of the fear of getting deported. Agha once even said that Covid-19 vaccines were meant to kill the Afghans off. Ihsan, another interlocuter, had once shared that he was recently repatriated from Turkey after he was injured from falling from the second story at the construction site. This explained the fear of accessing medical services. Ihsan complained of having “headaches” due to temperature changes because of his injury, but felt that no one fully understood the root cause of his problems. The repatriation of Afghan refugees from the countries who host them, as in the case of Ihsan, show the medical costs of repatriation, which remain unaddressed and are compounded by newer forms of violence in the host communities.

 Body, Political Violence and the Sanctuary

Apart from transnational movements and transactions, there were medical costs of routine police violence as well. Some of the men I interviewed had been deported from Turkey and now returned to Pakistan. Within the waste recycling economy, these men living on waste disposal sites, started gathering plastic bottles as soon as they left their homes. These men gathered enough bottles to help them sustain their daily needs. Plastic bottles were the main currency – a kilogram of plastic bottles, collected from a day’s labor, would pay a few hundred rupees (4-5 USD). In many homes, one could find many hundreds of bottles where families hoped to use them as assets to sell in times of desperation. At the same time, the movement of Afghan refugees was also increasingly limited due to the high incidence of police violence. Agha shared, “The police arbitrarily arrest us and keeps us in prisons for a day or two and we need to bribe our way out. I disappeared because I was arrested.” The mark of punishment was carried in the form of aches.

He shared that his ID card had recently been stolen by a man he had considered his brother. Within conditions of immense surveillance, there was no assurance about when the hearsay of a friend, in the form of a complaint to the police, would result in one being imprisoned. Agha had referred to his friend as a brother to signify their shared history as refugees having been raised in the absence of parents in refugee camps in Pakistan. Agha had only heard from elders that his father had died during the jihad (armed struggle) against Soviet occupation. This brother had been a heroin user, and had supposedly reported against his so-called sibling in order that he could himself appear as innocent in the eyes of the law enforcement. Only a few days before Agha’s imprisonment, he had commented out of sympathy for his brother, “look at my poor brother. Look at the marks of syringe on his hand. Look what nasha(addiction) has done to him.” This was one example in many that showed how in the absence of any medical support, there were several problems related to addiction in which caregivers were involved. We can thus consider the social experiences of addiction fully within conditions that make the welcome of sanctuaries temporary and conditional at best. However, this trust and relationship of care between the two friends was broken due to the friend reporting Agha’s involvement in the local drug economy to the police.

Sanctuaries, Self-Prescription and Opium Intimacies

There were several problems related to drug-use, which one may understand as shaped by past violence and the precarious existence in countries that tout themselves for hosting refugees with generosity. For instance, one local big man, referred to as Baba Jee, had a son who was suffering from methamphetamine use. He thought that his son was about to die. Agha, had secretly been smuggling some opium to keep him alive, without letting the father know. The father thought that under his supervision, he would be able to keep the son from returning to drugs. In the past, anthropologists have shown how the use of psychopharmaceuticals can create new dependencies among users (Chua 2020). Similarly, my ethnographic observations too showed how drug-use created new forms of care, in the absence of psychiatric services, that often edged on forms of physical control and violence as Baba once mentioned, “I keep my son under constant supervision to make sure he does not go close to drugs – He does not fear anyone but me, there is nothing else stopping him…” Among those experiencing addiction, questions of what it means to care may also vary, as this may involve ensuring that the severity of withdrawal symptoms is reduced, instead of making a loved one quit (Meldrum 2010), something Agha had also been doing for Baba Jee’s son. In the absence of any medical care, the form of control Baba Jee exerted over his son could also impact his son’s self-esteem often viewed as necessary to successfully reduce dependence.

The father claimed that the son continued to have waswasa which roughly translates to an inclination to commit a sin. His used the word to describe his son’s desire for drugs. Many like the big man, thought that it was best to institutionalize people suffering from such problems, as it was impossible to quit cold turkey especially when access was easy. In Pakistan, I observed that among those from low-income households, attitudes toward institutionalization in psychiatric hospitals were positive because of the burden on household resources placed by requirements of caregiving. However as one interlocutor shared, it was impossible to get admitted without a national ID which is why Afghans often sought the help of Pakistani citizens. The refugees try to secure access to institutions and to evade punishment by what Roberto Beneduce (2015) has referred to as the “moral economy of lying” among asylum-seekers. The ease of access to drugs led another person struggling with opium addiction to share that he suffered from extreme night sweats, diarrhea and insomnia when he did not take his daily dose. He shared that he wanted to be a good father for his children, but desperately needed medical assistance. A psychiatrist had recommended Tramadol in small amounts to make the withdrawals bearable, but the problem remained that many had already experimented with Tramadol illegally in attempts to overcome their addiction.

Conclusion: Toward the Politics of Generosity

Scholars have now suggested that Afghan refugees are being incentivized to return to their home countries, especially those residing in European countries. Although these schemes do not force refugees and migrants to return, they show that the new countries in which refugees try to find a sanctuary, cannot fully integrate them as equal citizens even after they have spent many decades, as in the case of Afghan refugees in Pakistan. Meanwhile, basic healthcare services are being denied to these people. Given the psychological pressures, forms of state-brutality and tensions in social relations become generative of “numbness” as a form of social metaphor showing abjection toward social realities and the effects of drugs used to erase traumatic memories and to make the life of precarity and violence somewhat bearable, as we have seen above.

Perhaps it is time to think about political realities of sites we refer to as sanctuaries and consider how, just as they are sites of care, they may also inflict various forms of violence on the bodies of those seeking asylum. It is time that we view concepts like humanitarianism that come to represent sanctuaries not as value neutral – or categories with which the actual practices of the state closely align – even if they are enshrined in international and local law – but think concretely about the co-imbrication of care and punishment that come the highlight the daily experiences of those seeking sanctuaries (Fassin 2011).


(2020) “UNHCR welcomes EU’s humanitarian aid of 21 million euros for Afghan Refugees and host communities,”UNHCR Pakistan.

(2022) “German Foreign Minister Annalena Baerbock visits Pakistan,” DW.

Beneduce, Roberto (2015) The Moral Economy of Lying: Subjectcraft, Narrative Capital, and Uncertainty in the Politics of Asylum, Medical Anthropology, 34(6), 551-571, DOI: 10.1080/01459740.2015.1074576

Chua, J. L. (2020) “Pharmaceutical Creep: U.S. Military Power and the Global and Transnational Mobility of Psychopharmaceuticals,” Medical Anthropology Quarterly, 34: 41-58.

Fassin, Didier (2011) Humanitarian Reason: A Moral History of the Present, University of California Press.

Gul, Ayaz (2022) “Pakistan rules out refugee status for Afghan Asylum-Seekers,” Voice of America.

Meldrum, Marcia (2010), “’The Long Walk to the Counter’:  Opioid Pain-Relievers and the Prescription as Stigma.”  In Elizabeth Watkins and Jeremy Greene, editors, Prescribed:  Writing, Filling, Using and Abusing the Prescription in Modern America.  Johns Hopkins Press, 2012:  184-206.

Oztig, Lacin Idil (2018) “Pakistan’s Border Politics and Security Dynamics along the Pakistan-Afghanistan,” Journal of Borderland Studies 35(2).

Yasin, Aamir (2021) “200,000 CNICs fraudulently obtained by Afghans cancelled.” Dawn.

Sanaullah Khan is an advanced doctoral candidate in the department of anthropology at Johns Hopkins University and an adjunct faculty in medical anthropology at the University of Delaware. He has been interested in questions of violence, militarization and mental illness in Pakistan and the US.