• Why there is no PTSD in Afghanistan

Why there is no PTSD in Afghanistan

01 March 2016

by Mark de Rond

Our Afghanistan Journalism Competition winner shares his surprising findings from Afghanistan

“Is it okay for me to cry?” the woman asks from inside the solitude of her frock.

“It is good for you to cry”, the soft-spoken psychiatrist replies, with a nod to the husband sat alongside. He writes out a prescription and sends her and her husband, handwritten medical file and all, on their way.

Nearly four decades of conflict have bankrupted Afghanistan’s infrastructure, if not also the resilience of its people. Its rudimentary healthcare system – once the poster-child of NATO’s development agenda – is scarcely able to cope with the physically ill, let alone those with mental illness and others left psychologically wounded by a cruel epidemic of violence. Schizophrenia, bipolar disorder, and drug-induced psychosis are common fare here; more commonplace yet are major depressive disorder (MDD) and anxiety. What is surprising is that PTSD, or the trauma that follows exposure to violence, is barely diagnosed at all. The question is why.

Afghanistan’s first-ever private neuro-psychiatric hospital is located in Mazar-e-Sharif, a city tucked into its northern, mountainous border with Uzbekistan. The hospital bears the name of its founder, Doctor Nader Alemi, and can accommodate up to twenty in-patients on two upstairs floors. Its outpatient clinic downstairs caters to anywhere from 80 to 120 people each day, not counting their entourage, meaning it takes some skill to manoeuver from the crowded, dimly lit corridor-cum-waiting area to the doctors’ room midway through. Here patients straddle old-fashioned scales prior to their consultation; if they are overweight, Doctor Alemi tells them so, though never unkindly. Many are embarrassed to be here, and so he works hard at reassuring them that there’s no shame in what they feel; that their experiences are more common than they might think.

The door swings open.

“I forget everything, doctor. I cannot remember whether I’ve said my prayers”, an old man says agitatedly and oblivious to the consultation he’s interrupting. Doctor Alemi, however, is unruffled by the commotion, as are the dozen or so others sat or stood around. If there is one quality Afghans have in abundance, surely it is patience.

Unlike comparable clinics in the West, consultations are public events. The only privacy is that conferred on women by their burkas. The men have no such recourse in a country where demand for psychiatric expertise vastly outstrips supply. Thus, as shades of blue file in ghost-like from the pink corridor outside, others, clutching their prescriptions, file out en route to the dispensing room opposite. Patients are escorted by relatives – most wouldn’t be here if not for exasperated family members – and take their seat as Doctor Alemi eyeballs the handwritten notes of his junior doctors and fixes his gaze on them. The room may be full and the corridor noisy, but for a short, precious moment it is as if the patient were the only one present.

“My liver is bleeding”, one of them replies when asked how he is feeling. It is the most commonly expressed sentiment here. It means he’s unhappy. The next in line tells the doctor her heart is tight, to let him know she is sad; others tell him they’re impatient, to say they’re angry. Occasionally, Alemi will peruse a ticker-tape printout of their ECG or a facial X-ray before offering a diagnosis and prescription. If only he had someone with expertise in reading ECG printouts, he says. As it is, it took him a year-and-a-half to find someone able to interpret X-rays, and only then after he’d sent him to India for a month to qualify. Qualified staff are hard to come by, and harder to retain. There are no local psychotherapists or psychologists in Mazar, and so mental illness is treated pharmacologically: by popping pills. Even if originally designed to provide relief for the well-to-do-and-able-to-pay in the West, Prozac’s real value today may be that of appeasing the Afghan mind. Without it, said one Afghan, he would want to kill every foreigner in sight. Generic versions of it are relatively inexpensive and widely available. Consultations cost around three dollars per patient, with ECGs and X-rays costing another $3.50 and $4 respectively. Serious cases are offered one of the rooms upstairs for observation, though few can afford the fee of 1,500 afghanis ($23) per night, or the inconvenience of yet another day away from work or home.

Lisa hadn’t planned on staying overnight, but seeing the late hour she and her relatives have no choice, for the road back home is long and treacherous. When the Taliban seized nearby Kunduz city in October, she took to the streets and fled, taking nothing but a change of clothing. Since then, she’s been unable to sleep or concentrate, is anxious and angry, and cries for much of the time. Her first port of call was a local mullah who supplied her with an amulet containing a tightly rolled scrap of paper bearing a handwritten verse from the Qur’an, to be boiled and downed with a glass of water. Hers was a similar amulet to those Farkhunda, a 27-year old volunteer teacher, lost her life criticizing as un-Islamic. When, in March 2015, the caretaker of Kabul’s Shah-e Du Shamshira shrine accused her publicly of having burned the Qur’an, presumably in response to her reproach, a crowd rapidly gathered. She was struck down, beaten, stepped on, run over, stoned, and set alight. Forty-nine men were ultimately charged for their role in Farkhunda’s killing though, on appeal, many were let off with relatively light sentences. In the event, having seen no improvement in Lisa’s condition, the family decided to seek treatment  at Alemi’s hospital.

The few relatives who willingly take up the overnight option often have good reason to. Take twenty-five year old Najeebullah. I find him standing submissively against his unmade bed in an upstairs room, eyes cast down, and his legs chained as a preventative measure. He’d been taken to the hospital by the police, at his father’s request, and was restrained and given an injection to calm him down. Diagnosed with schizophrenia and drug-induced psychosis, his father is evasive when I ask him about the son’s condition. He became increasingly aggressive, he says, and had stabbed his brother in law. The three-month prison sentence that followed did little to assuage his hostility, leaving the father and family to fear the worst. When, in private, I ask Najeebullah why he thinks he’s here, he says his brother accused him of raping one of their cousins while they were visiting – something he says his brother, and not he, is guilty of – and in the ensuing feud, his parents had taken his brother’s side. In anger he had lashed out at his brother in law, and remains convinced he killed him. Why he went after his brother in law rather than brother remains a source of confusion, particularly as he thinks of the former as “not a bad man, and not as bad as the rest of my family”. When I ask him what he will do when released, he is firm: “I will to teach my family a lesson”, he says, “I will do to them what I did to him.” While the brevity of his custodial sentence suggests the victim survived, his family will scarcely be looking forward to Najeebullah’s homecoming. But since Mazar has no insane asylum, and the hospital cannot keep him indefinitely, he must be released within the next few days.

I am here to try and understand how Afghanistan’s epidemic of violence is impacting on the psyche of its everyday citizens. Having seen first-hand the tragic human cost of combat during a deployment with military surgeons in Helmand in 2011, I wondered about the long-term psychological impact of war. We worry about the impact on our soldiers, as we should, but what about those left behind?

Doctor Alemi offered to be my host. His outpatient clinic will remain open until the last of the patients have gone, which is often not until after 11pm. His hospital has never been short of people since it was founded twelve years ago. Such is his reputation that some travel 700 kilometres for what may be no more than a ten-minute consultation with him. His dedication to his profession is legendary, as is his impartiality: his security guards do not carry Kalashnikovs – they carry no arms at all – and his clientele include rich and poor, the neurotic, psychotic and suicidal and, given his fluency in Pashto, the Taliban too. He has treated well over a thousand Taliban, he thinks, a number that is hard to verify but easy to imagine seeing the continuous stream of outpatients every day, six days a week. So long are his working days, in fact, that he moved his family to the upper floor of the hospital such that they get to see their father at least occasionally.

Doctor saib, ma mokhles shoma astom. Khuda tora az ma kam nakona (Respectable doctor, I am sincerely yours. May you always be there for us).” A young man with a bright piece of cloth tied pirate-style around his head, shoots out of bed and embraces the doctor, kissing him repeatedly.

“It’s good to see you too my friend”, Alemi replies with a smile and a kiss, and gently presses him back onto his bed. Amanullah is thirty-four years old and bipolar. His mullah had told him he was possessed by a jin, or demon, and ordered he be chained in a dark room for forty days, his sustenance limited to water, bread, and raw spinach. The mullah made daily visits to flog Amanullah, using a horsewhip, to target, he had said, not him but his jin. When, forty days later, there had been no miraculous recovery, his brother decided to take him to a hospital they could ill afford, where he’d been given an injection to help him sleep.

The impact on the family has been profound. “We keep him chained up or else he destroys everything and everyone. We dare not leave him alone with our mother.” His brother says his wife was beaten repeatedly by Amanullah and, for their protection, he had moved her and their eight-month old daughter out of the family home. The aggression comes and goes, he says, the latest spell set off by a recent spat with the traffic police who had hit him across the head with a baton. Asked when it began, he tells me of an incident when they and their father had been selling fruit from their street cart. A Taliban had purchased a watermelon and, furious at it not being ripe enough to eat, had smashed it over their father’s head. The injustice had so enraged Amanullah that he’d jumped from behind the cart and pushed the Taliban to the ground. Fearing repercussions, his family arranged for him to be taken across the border immediately, into Iran, for his own protection, and ever since then, the brother said, he’s never been the same.

Sayed, a much older in-patient, likewise has a history of violence. While he sleeps off last night’s injection, his son tells of his father’s antics. “He talks to himself and beats himself, and so we have to keep him chained to the ground with four pins.” He says his elderly father has night terrors so frightening that he arranged for his own children to stay with neighbours so as to minimize the impact on them. Diagnosed as schizophrenic, it is imperative that he continues to take his medication. But they ran out, the son says, and there are no pharmacies where they live, and so they spent the equivalent of two weeks’ household budget just on the six-hour road trip to Alemi’s hospital.

A sequence of brutal wars since 1978 has had a profound impact on Afghanistan’s psychology. It is estimated that 42 to 66 per cent of Afghans suffer from PTSD, though it is not clear how meaningful these figures really are. Reliable data on PTSD is hard to come by in a country that doesn’t even know the size of its population. None of the patients during my two-week visit were diagnosed with PTSD. In fact, Mazar’s civil hospital and Alemi’s neuro-psychiatric hospital very rarely offer a formal diagnosis of PTSD. Records of a mental health clinic in Herat, operated by International Assistance Mission (IAM), suggest that only 1.2 per cent of their patients were diagnosed with the disorder. So why isn’t there more of it?

One reason why PTSD isn’t more readily diagnosed is that some of its symptoms – hyper-arousal, vigilance, and anxiety – are not considered particularly abnormal here. PTSD is nowhere because it is everywhere. By contrast, a 2004 survey, the last available, found 68 per cent of respondents to suffer from depression, and 72 per cent from anxiety. Each of these causes people to withdraw from social situations, and given that, culturally, Afghans are community and family orientated, the wish to be left alone is seen as the real outlier, and one that relatives may decide needs treating. Moreover, by treating MDD (major depressive disorder) and anxiety with a generic variant of Prozac or other serotonin reuptake inhibitor, you likely ease the symptoms of PTSD in any event. And, besides, PTSD requires time to diagnose in a world where patients outstrip doctors by a large margin, meaning time comes at a premium.

Diagnosing PTSD is also complicated by the inability of many patients to express how and what they feel in a nuanced way. It is uncommon nowadays for Afghans to talk openly about their feelings to others, either because they don’t trust even those closest or because they are ashamed of having such feelings. Or they think it inappropriate to burden others with problems seeing they have plenty to worry about themselves, and so why heap misery upon misery. Not talking about how they feel means they lose fluency in expressing themselves emotionally. Thus, ironically, the harshness of life has made it difficult to articulate how difficult living here can be.

“By keeping things to themselves, people lose the ability to express themselves”, says clinical psychologist Stephanie Lockery. Use it or lose it, is the argument, and it is for this reason that IAM’s Mental Health Training Centre in Herat introduced emotional vocabulary training. “We ask people to tell others in the room how they feel, the rule being that they cannot re-use an expression already used by someone else.” While talking about emotions may be difficult, recounting experiences isn’t. Stories of Taliban occupation are passed on through the generations such that Mazar-e-Sharif now has a generation of 13 year olds that never experienced war first-hand yet talk about it as if they did. Theirs is a vicarious trauma.

Or perhaps PTSD isn’t considered problematic because it isn’t a priority. Poverty and joblessness are. As Jawed Nader, director of the British and Irish Agencies Afghanistan Group (BAAG), put it: “Mental health is part of a bigger challenge and with unemployment having spiked at 40 per cent, poverty is widespread, and so are the bitterness and self-loathing that accompany it”. At no point did interviewees speak of PTSD or ideology, though they had much to say about instability, insecurity, and joblessness, and more yet of the violence it breeds – not just on the outside but inside the family home.

At the end of the day, what Afghans want is no different from what we would want were we to find ourselves in the same circumstances. As the British psychiatrist Derek Summerfield observed, “the question of how people recover from the catastrophe of war is profound, but the lesson of history is straightforward … recovery from trauma happens in people’s lives rather than in their psychologies. It is practical and unspectacular, and it is grounded in the resumption of the ordinary rhythms of everyday life.” To provide Afghans with the means, security, opportunity, and freedom to rebuild the social structures that make their lives intelligible and meaningful is essential. One year on from the withdrawal of international combat troops, it is clear such change is not yet on the horizon. If Doctor Alemi, IAM and others are to play their part in supporting Afghanistan’s war-weary population, international support focused on sustainable self-reliance must continue for many years to come.   

About the author

Mark de Rond is associate professor at Judge Business School, Cambridge University. Having deployed with a military surgical team to Camp Bastion in 2011, he returned to Afghanistan in early December for two weeks to look at the effects of conflict on the mental health of its civilian population. A shorter article about this trip was published by The Huffington Post UK

Photograph by Magda Rakita, who travelled to Mazar e Sharif with Mark de Rond and BAAG.  It shows Raesa comforting her daughter Lisa. Since an attack on their house in Kunduz in October, when they had to escape with only a change of clothes, Lisa has difficulties sleeping and focusing, and often cries. The mother says “Every minute we think about war. What if they come? We don’t have money and means to escape. Until the war ends, this disease will be everywhere”

A gallery of Magda's photographs from Mazar e Sharif has been published on The Guardian's Development website