Nearly 42 years of violent conflict is driving a growing mental health crisis in Afghanistan.
I am an Afghan doctor currently working as a Psychiatrist in the NHS. I am also the co-founder and ex-chair of the Association of Afghan Healthcare Professionals-UK. I fled Afghanistan almost 20 years ago but I have never cut ties with my country.
I am actively involved in improving the healthcare system in Afghanistan. In April 2019, I attended a one-week intensive training in ‘Professional Healthcare Regulation Consultancy’. The training was delivered by the General Medical Council of the UK in the GMC offices in London and Manchester on behalf of the Afghanistan Medical Council (AMC). AMC is a newly established regulatory body for doctors and dentists in Afghanistan.
In July 2019, I went to Afghanistan where I spent two weeks and provided AMC staff with training on “Medical Registration, Licensing and Fitness to Practice”, I am now a formal trainer to AMC.
Overall, I visited Afghanistan at least once a year. During my visits, I ran free clinics for poor people in my home town. Besides seeing patients, I visited hospitals where I gave presentations and shared my knowledge with colleagues. During these visits, I learned a lot about the healthcare services in Afghanistan in particular about mental health services.
This was the tragic situation before the current events.
While accurate data on mental health issues is not available in Afghanistan, according to the International Psychosocial Organisation (IPSO), as of 2019, about 70% of Afghans suffer from various forms of mental health problems. The mental health toll signifies a hidden consequence of war that is often overshadowed by bombed-out buildings and loss of life.
During the last 20 years Afghan governmental and medical centres have made some medical achievements, but they are still not capable of providing patients with specialized services; consequently, many Afghans who need specialized treatment travel to other countries such as India, Pakistan, Turkey and Iran.
The Kabul hospital is the only mental health hospital for all of Afghanistan and is supposed to serve the needs of all psychiatric patients in the country. This facility is organizationally integrated with the mental health outpatient facilities. None of the beds in the mental health hospital are reserved for children or adolescents, and 18% of users are female. The patients admitted to mental health hospitals belong primarily to the following two diagnostic groups: psychoactive substance use (58%) and schizophrenia (24%). There are no long-stay patients (more than a year) in the mental health hospital. This data was collected from Kabul Psychiatric Hospital.
In Afghanistan, mentally ill patients are generally looked after by their families. Some people still consider mental illness a punishment from God, possession by a djinn (devil) or black magic. They take the patients to shrines and mullahs (Imams) for treatment. Those patients who do not have family either end up on the streets or if lucky in a Marastoon (asylum house).
During my visits to Afghanistan, I found that depression, anxiety and PTSD are alien terms there; people, and especially women, are more likely to present to a doctor complaining of somatic symptoms, which on further inquiry, it happens to be an undiagnosed mental health condition.
Psychosomatic illness features commonly in general medical outpatient clinics and access to a psychiatrist is practically non-existent. I have found that treatments are generally medical and there are only a handful of psychologists who have received their training outside Afghanistan. I have found that Afghanistan is unequipped, unqualified and unprepared to deal with its mental health crisis. The country’s only mental health hospital in Kabul is in bad condition due to war damage and lack of maintenance. All other provincial hospitals only offer counselling services and no real mental health care; the counselling centres are staffed by partially retrained nurses.
The European Union has supported the rehabilitation of the mental health hospital in Kabul and has paid for the construction of new building within it; the capacity of the hospital remains at 60 beds, however. Counselling is available in small clinics thinly distributed around the country. Even in Kabul they are few.
Some international NGOs offered training and help to the Afghan mental health service. Greek NGO Klimaka, for example, provided some equipment, translated a training manual into local languages, renovated facilities and provided 8-week training courses. HealthNet is the largest NGO involved in mental health care in Afghanistan, but their impact has so far been limited; their main contribution was the supply of some medicines. According to a WHO report, “psychosocial interventions centres were established in 2005 by some international NGOs in the capital but they have not been implemented in rural areas”.
The long-stay homeless patients reside in Marastoons (asylum houses) which are available only in four major cities of Afghanistan, including Kabul, Jalalabad, Heart and Kandahar Provinces. These Marastoons have limited capacity, the biggest of all is Kabul Marastoon with 78 female patients. There is no Marastoon for male patients in Kabul. Most of the residents are there for more than 5 years without any psychiatric care.
I last went to Afghanistan in July 2019, during this visit I spent three days in the Red Crescent Society’s Marastoon in Kabul. They call this place a Qala (fortress): the gate is always locked for their protection. As soon as the door was opened for us, we were surrounded by a dozen patients greeting us in Pashto and Dari and touching us. I noticed that all patients’ heads were shaved, it was later explained to me this was for hygienic reasons (headlice).
I was given a tour of the Marastoon. I noticed that between 12 and 16 patients were sleeping in one bedroom in bunk beds. The situation was heartbreaking and I could not control my emotion and broke into tears. I cut the tour short and asked the staff member to show me the clinic room they have prepared for me as I wanted to make the most of my time and see as many patients as possible.
I managed to assess 32 out of 78 patients in three days. I let a psychologist, a nurse and a family medicine doctor sit with me during the assessments to learn how we assess mentally ill patients in the UK. There was a physical health clinic attached to this Marastoon but none of the patients had been seen by a psychiatrist before me, and some patients had been there for more than five years. Some patients in the shelter showed symptoms of mental health problems since their early life, the majority of them were there because they have developed psychological problems during the war.
I also found that some people should not have been there, but because there are no social services and due to the lack of adequate outpatient mental health services, they remain.
Psychiatry and mental health services were already limited and inadequate to meet the need of the population. Without a doubt, the current situation in Afghanistan is very bad. The humanitarian consequences will be severe.
Conditions have been deteriorating for some time due to violence, natural disaster, and the COVID-19 pandemic. Already, half the population — some 18.4 million Afghans — need aid. Almost 17 million people are experiencing serious food insecurity. If the International community cut their ties with Afghanistan and stop their financial support the current fragile healthcare system will deteriorate further.
If the Taliban can hold together and construct a viable, long-serving government, then the longer-term prognosis is better. The Taliban has already stated they intend to govern Afghanistan in a manner ‘that is good for Afghanistan’ although it remains to be seen how far this extends to extremist Islamic tendencies, at the expense of commerce and trade.