Human Rights Watch has raised alarms over the lack of mental health support in wartorn Afghanistan, where more than half of the population is experiencing psychological distress.
The advocacy group said that, despite the high prevalence of psychological and mental health conditions, the Afghan government is failing to provide adequate help, with fewer than 10% of the country’s population receiving assistance.
HRW cited a 2018 EU survey that said the overwhelming majority of the country’s population (85%) have seen or been involved in at least one traumatic event in their lives.
In a country that has been at war for more than 40 years, difficult experiences are all too common – but help to deal with the trauma is not.
When Afghan journalist Maryam Shahi survived a twin bombing in Kabul’s Deh Mazang Square three years ago, she didn’t expect the traumatic event to continue to haunt her later in life.
But, last year, while working on her university dissertation, the 33-year-old started to feel stress and experience panic attacks.
“I witnessed horrific bombings,” said Shahi. “They were all killed in front of my eyes. I survived miraculously. I am usually a relaxed person in life but, no matter how relaxed I am, this event took its toll on me.”
Government documents show that fewer than 10% of the country’s population is receiving help. Women and girls, in particular, face extra obstacles. Their access to health services is “often determined by male members of their household and may be conditioned on the availability of segregated services with female staff and segregated infrastructure, such as separate gates and waiting areas”, said HRW.
In Shahi’s case, however, the issue was mainly the lack of services. Doctors failed to refer her to a mental health professional.
“I had stress and panic attacks and I went to see a doctor in Kabul, but they said I have no issues. I couldn’t breathe properly, I felt as if I was about to have a heart attack,” she said. “They said I have psychological problems but they couldn’t do anything about it. They didn’t refer me to a psychiatrist, they didn’t give me any address for one.”
Shahi was forced to go to neighbouring Iran for treatment. There, a psychiatrist started a treatment plan that she later continued by phone and online through Telegram, a messaging app, when she returned to Afghanistan. She finally started to get better.
“In Afghanistan, psychiatrists and psychologists are not easily available. That’s why I had to travel to Iran. Afghans with health problems usually travel to Pakistan or India,” she said.
“Poverty is increasing and people are targeted with violence. This has taken hope away from people. The real figure of people struggling with mental health in Afghanistan is even more than what’s been announced. This is the reality. People don’t know if they’ll be alive tomorrow or not.”
Anxiety is a daily experience, said Shahi. “Today I was at home resting and my sister said she was going to take the public transport to her university. I got anxious and thought: ‘What if there’s an explosion on her way to university?’ This is just one example of stress. The stress you’re facing here is not just about you and your life, it’s also about people surrounding you.”
Shahi said her biggest stress these days is not yet having got married. “Girls like me have a hard time dealing with a traditional society [while unmarried]. Because of political circumstances, you can’t foresee a future in this country.”
In an already weak health system, the government spends as little as $0.26 (21p) a person on mental health – far below the $3-4 a person recommended by the World Health Organization. There is just one psychiatrist for every 435,000 people, and one psychologist for every 333,000, while in public mental health facilities there are as few as 200 beds available, equating to one bed for every 172,500 people.
“Decades of violence have left many Afghans experiencing deep psychological wounds, as well as physical ones,” said Jonathan Pedneault, HRW’s conflict and crisis researcher.
“There is an urgent need for expanded psychosocial services to support Afghans exposed to violence, suicide bombings and airstrikes, and [to] prevent the long-term effects that can be debilitating to survivors, families, and entire communities.”
Afghans face a range of obstacles to access mental health services, from poverty to health literacy, social exclusion to stigma.
According to Hasan Rezaee, an Afghan academic and government adviser on social affairs, a major problem facing mental health in Afghanistan is cultural.
“In a conservative and traditional country like Afghanistan, a lot of mental health conditions are not being seen as disease,” he said.
“When figures were released a while ago, people were dismissive and they couldn’t believe the figures, they thought the figures were untrue and propagated by western countries. People, and a lot officials as well, don’t take mental health diseases seriously.”
Rezaee added: “Both the government and the health sector are not yet mentally and culturally ready to give priority to the mental health problems. The priority is given to sectors that are considered tangible, such as patients facing death or physical diseases.”