Conflict Continues to Drive a ‘Mental Health Crisis’ In Afghanistan.

Afghanistan has been plagued by on-going war, violence and terror, for more than 40 years. In 1979, the arrival of Soviet tanks marked only the first chapter in a long and bloody series of conflicts that would keep the country in the grip of war for close to half a century. During this time, Afghanistan has faced a seemingly endless civil war, protracted insurgencies, and an invasion, in October 2001, by the world’s richest and most powerful nation. As we see often in the case of conflict, it has been Afghanistan’s civilian population who have suffered the most. This has been both through direct violence, and the myriad of social and economic impacts war brings. The death toll stands in the millions, with most Afghans having lost at least one family member through conflict. As well as widespread death, conflict has also continually destroyed vital infrastructure, ruined livelihoods and heightened poverty and underdevelopment, leaving millions of Afghans in a constant state of insecurity.

This insecurity, coupled with regular violence, has also fuelled what has been called a ‘mental health crisis’ within Afghanistan. Although less visible, and often poorly documented, it is becoming increasingly clear that forty years of conflict has caused serious psychological impacts to the people of Afghanistan. This is, perhaps, not a surprising revelation. The links between conflict and mental health conditions, particularly post-traumatic stress disorder (PTSD), anxiety and depression, are well documented. However, the extent of this growing crisis is extreme.

Finding accurate data regarding the scope of the mental health crisis is difficult. The World Health Organisation (WHO) has estimated that more than 2 million people in Afghanistan are suffering from depressive and anxiety disorders. The International Psychosocial Organisation (IPSO) has gone further. They suggest that a potential 70% of Afghanistan’s population of 37 million are in need of psychological support. Regardless of the exact figure, it is clear that Afghanistan is facing a serious crisis, and one that it lacks the medical infrastructure and resources to properly address.

Long, drawn-out, conflict has not only brought about and exacerbated mental health disorders in Afghanistan; it has also restricted possibilities for treatment. Wars and conflicts typically destroy hospitals, kill or displace medical staff, create shortages of medical supplies and overwhelm services. Alongside this, Afghanistan has also been ‘plagued by weak coordination and management of service delivery, ineffective policy-making mechanisms, and insufficient information’ in mental health policy planning, according to an article written for PLoS Medicine’s series on ‘Global Mental Health Practice’. In 2001, it was estimated that there were only two psychiatrists in Afghanistan; more recently the picture has not improved drastically. As of 2018, the country had only one psychiatric hospital, and WHO have suggested that there are only 320 hospital beds available for those suffering with mental health problems in both Afghanistan’s public and private sectors. As a result, services are drastically overstretched and finding or receiving clinical support for mental health problems is extremely difficult and, in some places, even impossible.

Very few Afghans are able to receive the care or treatment they require. WHO estimates that Afghanistan has only 0.23 psychiatrists and 0.30 psychologists per 100,000 people. As such, it is no surprise that less than 10% of the population are receiving the treatment they require. Additionally, given the high levels of social stigma attached to mental health conditions, and accessing services, it is possible that this already bleak picture could be far worse.

The lack of sufficient mental health infrastructure, information and resources, means that many sufferers and their families are forced to search for treatments elsewhere, often to the serious detriment of their conditions. One particularly harmful and dangerous practice is the use of religious shrines to house mentally ill individuals in the hope that they will be ‘cured’ by divine intervention. Fast Company has provided accounts of the Amyali Shrine, near Jalalabad, where people suffering from serious mental health conditions were kept in chains for 40 day periods as a result of dangerous misinformation accepted by families desperate for help.

More commonly, however, individuals in Afghanistan are turning to recreational drugs as a form of self-medication. The reciprocal link between drug use and mental health disorders is well documented, with WHO identifying strong causality between depression and the risk of substance use disorders throughout the world. This is particularly problematic in Afghanistan where the prevalence of opium makes accessing harmful opioids and heroin much easier. Afghanistan already has the highest number of opiate users in the world, and this figure is only rising. In 2015, 12.6% of Afghan adults were drug users, compared with a global average of 5.2%. Drug abuse and addiction, typically a problem that disproportionately affects men in most societies, is also becoming more common amongst Afghan women and, in some cases, children. In 2009, at least 3% of women were drug addicted in Afghanistan; by 2015, this figure had risen to 9.5%, according to the United Nations Office on Drugs and Crime (UNODC).

Although other factors are at play, increasing drug use can be seen, in part, as another consequence of  Afghanistan’s growing mental health crisis. This is deeply harmful, as drug addiction can exacerbate psychological conditions, creating a vicious cycle, which places even more pressure on the country’s sparse mental health services. Furthermore, a 2014 UNODC report on Afghanistan highlighted how drug users are far more likely to inflict psychological, sexual or physical abuse on their spouses and children, another factor that is only likely to increase the prevalence of mental health problems.

Despite this bleak picture, attempts are being made by both the Afghan government and international organisations to curb the crisis. The Afghan Ministry of Public Health recently published its comprehensive ‘National Strategy for Mental Health (2019-2023)’ reflecting a willingness amongst Afghan authorities to address the on-going issues. The strategy sets in place a rigorous set of measures, with a strong focus on monitoring and evaluation, to improve mental health care provisions and to integrate them into the wider healthcare service by 2022. These steps are in line with the WHO Mental Health Global Action Plan, which places an emphasis on improving leadership and governance within mental health services, proliferating community-based approaches, strengthening information systems and implementing prevention strategies.

The impetus for change and improvement in mental health provision clearly exists within Afghanistan. What is more, a growing commitment from bodies like the EU, WHO and USAID, providing training, funding and technical assistance, make a lack of resources less of a limiting factor. However, the effectiveness of this national strategy is not assured, and must be seen as merely a stepping stone in a long and difficult process.

There is also a need for a growing understanding of the complex web that helps to formulate the country’s mental health crisis. Government attention and international funds cannot rest solely on improvements to medical infrastructure and personnel. Instead, authorities should recognize the ways in which drug abuse interplays with mental health and psychological concerns, and that without addressing both issues, advances are unlikely to be made in either.

Interventions and improvements in services also need to be properly balanced throughout Afghanistan and its population. In a 2019 report, Save The Children highlighted how the availability of mental health services in Kabul was significantly higher than in rural areas. This is especially problematic given that, unlike most other countries, drug use in rural areas is 2.5 times higher than in urban centres. Money and resources need to be evenly distributed amongst Afghanistan’s urban and rural communities in order to combat this issue.

Efforts must also be made to address the gender imbalance at the heart of Afghanistan’s mental health crisis. Unlike most Western countries, suicides in Afghanistan are far more prevalent amongst women. Therefore, a particular focus must rest on female care and services, and attempts should be made to better understand this imbalance. This may need to come from a greater influence from local, community-based knowledge, and a resistance to tacitly accepting the methods and blueprints of large international organisations typically developed in vastly different social, cultural and economic climates. Foreign interventions in the past have sometimes exacerbated gendered issues within mental health services. It has not always been realized that Afghan women are unlikely to take treatment from male healthcare workers due to cultural factors at play. Therefore, a balance must be struck between international support and local knowledge in a way that allows services to effectively assimilate within the specific context of Afghanistan.

Finally, however, we must acknowledge that if the on-going conflict does not come to an end, no amount of money, training and culturally specific consideration will drastically curb Afghanistan’s mental health crisis. If fighting, explosive violence, and terror are not reduced, mental health services will face a growing wave of statistics. Without an end to 40 years of conflict, Afghan mental health services and the Afghan people lack the security required to address these issues. The talks between the Afghan government and the Taliban, currently taking place in Qatar, have the potential to be epochal for Afghanistan and the mental health crisis it faces. This being said, the extent to which these talks will bring about a lasting peace are constantly called into question. Since their commencement on 12th September, 2020, violence and bombings have remained highly prevalent throughout the country, resulting in large numbers of civilian casualties. Until a sustainable peaceful solution can be found to the on-going conflict, there is little hope that the growing mental health crisis will be curbed.

Jake Tacchi

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