Rebuilding Afghanistan's Mental Health System
By Beryl Lieff Benderly
 |
(Left to right)
Dr. Faizullah Kakar, Afghanistan's Deputy Minister
of Public Health, and Dr. Ruhullah Nassery, Mental
Health Coordinator of Afghanistan's Ministry of
Public Health, prepare to address the Workgroup
on Afghanistan Mental Health recently at the Embassy
of Afghanistan in Washington, DC. Photo by
Meredith Hogan Pond |
Afghanistan has an ambitious vision for bringing mental
health services to its people. Deputy Minister of Public
Health Faizullah Kakar, Ph.D., envisions a country where
"all of our health care services provide the most
essential mental health care," where the various regions
have facilities "to treat patients we can't treat
today," and where there exist "some very good
hospitals" and "enough doctors in proportion
to the population," he told SAMHSA News in
a recent interview.
But making that come true in a nation torn by decades
of war and political oppression will take hard work,
careful planning, and technical expertise. "We would
like SAMHSA to play a strategic role in developing our
mental health care," he said.
Two major challenges stand in the way of attaining Dr.
Kakar's vision. First, because of the people's suffering
during the wartime years, the need for mental health
services is widespread. Second, mental health care traditionally
has not had a high priority within health care in Afghanistan.
But then, in January 2005, these two realities came together
to spark change.
Dr. Kakar was reviewing the national strategy being
developed to guide the rebuilding of the country's health
system. Much of the country's physical infrastructure
has been decimated, and many of Afghanistan's educated
professionals were killed or fled the country during
widespread violence and oppression.
In the midst of this task, Dr. Kakar got the "very
disturbing news that there were young women [in one of
the main cities] committing suicide." Suicide prevention
and other mental health issues, he noticed, did not even
appear among major health care priorities enumerated
in the plan. He immediately realized that they belonged
high on that list.
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A Top Priority
Given that a 2002 nationwide survey documented that
more than 70 percent of women and 60 percent of men suffer
from depression, Dr. Kakar knew that mental health issues
are "a big public health burden in Afghanistan."
Minister of Public Health S. Mohammad Amin Fatimie,
M.D., quickly agreed that mental health deserved high
priority.
Dr. Fatimie called a meeting with the foreign non-governmental
organizations (NGOs) assisting the Ministry. Some donors
objected to including mental health because of the cost.
"If Kakar wants mental health," the Deputy
Minister recalled them saying,
"he needs to find the money." And so
Dr. Kakar came to Washington. "I asked, though it
was not on the agenda, ‘Who is interested in mental
health?' " He "was very surprised" to
receive an immediate, affirmative reply. Prominent among
those encouraging him was SAMHSA.
In December 2005, during a second visit to Washington,
Dr. Kakar told this story during a meeting at the Embassy
of Afghanistan. Seated around the conference table were
members of the Workgroup on Afghanistan Mental Health—a
team of experts from SAMHSA and additional members from
the National Institute of Mental Health, the Office of
Global Health Affairs at the U.S. Department of Health
and Human Services, and the Embassy of Afghanistan.
Also present were Ruhullah Nassery, M.D., Mental Health
Coordinator of Afghanistan's Ministry of Public Health,
and SAMHSA Administrator Charles G. Curie, M.A., A.C.S.W.
Other representatives included the Afghan-American Physicians
Association, the World Health Organization (WHO), and
the Department of Defense.
The Workgroup, inspired by Dr. Kakar's visit earlier
in the year, had already been busy for several months
exploring how U.S. assets could aid in the rebuilding
of the human resources and physical infrastructure needed
to bring mental health services to Afghanistan's population.
Along with this meeting, the schedule for Dr. Kakar's
December visit to the United States included meetings
at the Centers for Disease Control and Prevention in
Atlanta, GA. Dr. Nassery visited a psychiatric hospital
and a community-based mental health center in a Virginia
suburb of Washington, DC.
Mr. Curie expressed SAMHSA's strong support for the
Ministry's focus on mental health as a crucial element
of the overall public health plan. Key to the partnership,
he emphasized, is listening closely to the priorities
developed by Afghanistan, which will guide SAMHSA's efforts
to help the country provide its people with culturally
competent services that become part of their day-to-day
lives.
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A Nation Traumatized
Given Afghanistan's many years of turmoil and destruction,
the number of people suffering from identifiable mental
disorders or substance abuse is "very high and needs
prompt intervention," Dr. Nassery told the meeting.
"War and substance abuse have interacted to produce
more people who are addicted," Dr. Kakar added.
Many families have lost loved ones or are caring for
individuals disabled, either physically or mentally,
by the conflict, causing continuing stress for family
caregivers who lack access to mental health resources.
Because of these pressing needs, mental health now ranks
among the top five essentials in the "Basic Package
of Health Services" designated in the strategic
plan developed by the Ministry of Public Health. The
top four priorities are basics such as newborn health,
child health and immunization, nutrition, and communicable
diseases.
Despite a high priority, however, Afghanistan has a
"severe shortage of mental health professionals,"
according to Dr. Nassery. The WHO's Global Health
Atlas lists the country as having 8 psychiatrists
and 20 psychologists, but Dr. Nassery believes those
numbers are too high.
Even using the WHO statistics, he added, Afghanistan
has substantially fewer psychiatrists, psychologists,
and psychiatric nurses per 100,000 residents than in
neighboring countries such as Pakistan and Iran.
Mental health, Dr. Nassery added, currently receives
little attention in general health care. Overall, mental
health facilities are inadequate and heavily concentrated
in the cities of this predominantly rural country. The
nation's sole psychiatric hospital has 60 beds. In addition,
psychotropic medications are in short supply.
Afghanistan currently lacks the legislation and policies
needed to develop a modern mental health system as well
as the necessary staffing and technical support in the
Ministry of Public Health. Nor does mental health receive
adequate attention in the curricula of the institutions
within Afghanistan that train health care professionals.
In general, public awareness of mental health issues
is low.
 |
Ruins of a building
in downtown Kabul. Photo by Cpl Matthew Roberson,
USMC/USAID |
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