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Afghanistan, Iraq: SAMHSA Supports Mental Health Efforts

By Beryl Lieff Benderly

When Nahid Aziz, Psy.D., returned to her native Afghanistan this past May for the first time since she fled the Russian invasion at age 12, the most moving moment came during a visit to the reconstructed School of Medicine at Kabul University.

She well remembered her many childhood visits there with her late father, a professor of medicine and one of Afghanistan's first Western-trained physicians. The school had since been heavily damaged, and in the Taliban era, women had been excluded.

But this spring, nearly half the students on the rebuilt campus were women. A class of 300 new physicians was about to graduate. In the auditorium stands a commemorative wall listing the pioneers of modern medical care in Afghanistan. With deep emotion, Dr. Aziz saw among them the name of her father, Dr. Mohammad Hossein Nasrat.

But her return to Kabul was no mere sentimental journey. Dr. Aziz, a clinical psychologist and associate professor at Argosy University in Washington, DC, regards it as continuing her family's tradition of working for better health care for the Afghan people.

She traveled there as a member of SAMHSA's delegation to an international conference, cosponsored by Afghanistan's Ministry of Public Health and SAMHSA. The conference focused on the continuing process of planning for the reconstruction of the nation's mental health system.

SAMHSA cosponsored two such conferences this spring. In addition to the one in Kabul, SAMHSA convened a meeting in Cairo for Iraqi health professionals. Other participants at that meeting included colleagues from Egypt's Ministry of Health and representatives from the World Health Organization (WHO).

The WHO has played a significant role in the mental health training provided to Iraqis over the last several years.

The Cairo conference tracked the progress made since last year's similar, smaller meeting on Iraq in Amman, Jordan (see SAMHSA News, May/June 2005). All the meetings underscore SAMHSA's commitment to support the expansion of mental health services in both Iraq and Afghanistan.

At the only mental health hospital in all of Afghanistan, SAMHSA Administrator Charles G. Curie visited the kindergarten/day care center established for the children of employees. Some of the children are wearing traditional tribal garb.

Afghanistan

"Mental health is crucial to fostering a constructive relationship between health and development," Afghanistan's Minister of Public Health, S. Mohammad Amin Fatamie, M.D., told the more than 70 mental health professionals who gathered in Kabul from around the country.

The 3-day meeting provided an opportunity to gather together representatives of several ministries of the Afghan government; international agencies including USAID, the WHO, and the United Nations; and the non-governmental organizations (NGOs) involved in providing mental health services.

"The Afghans are really looking at a time when the NGOs will [leave] and the Afghans will be providing services," said Winnie Mitchell, M.P.A., International Officer at SAMHSA. Much of the discussion in Kabul, therefore, centered on how the NGOs could train community health workers and staff, and also, in the longer term, on the curriculum and education needed at the Kabul medical school.

Training emerged as a crucial need of Afghanistan's mental health system because of the country's severe lack of mental health personnel, including, for example, "not one practicing psychiatrist," said Hussain Tuma, Ph.D., a consultant to SAMHSA who attended both the Kabul and Cairo conferences.

Of the two qualified psychiatrists in the country, one works at a ministry and the other with an NGO. "The top people that we met are first rate," Dr. Tuma said, but far too few Afghans have had the opportunity to receive mental health training.

Formal presentations in Kabul focused on mental health services, substance abuse programs and—probably most significant—capacity building for mental health services.

A major accomplishment of the conference, and of the breakout groups that did the work, was prioritizing the strategies within Afghanistan's National Mental Health Plan and discussing specific next steps.

Participants emphasized that the entire Afghan population has been exposed to violence but that women and children are most vulnerable.

They also identified a need to develop screening methods for mental health and substance abuse problems and to define quality standards for psychosocial interventions.

Despite these challenges, participants emphasized that Afghan society possesses significant strengths in regard to mental health, especially the nation's strong faith and close-knit families.

Particularly in times of trauma and loss, Dr. Aziz told SAMHSA News, Afghanistan's tradition of close and vigorous extended families provides bereaved or traumatized individuals far more emotional and practical support than is typically available elsewhere. The strength of this support has been a major element in the people's resilience over years of violence and oppression, she said.

click to view larger image

In this Afghan government antidrug poster, poppies growing in a field are mowed down by a tractor. Because heroin and opium are derived from poppies, they are portrayed under a "devil" image with horns, claws, and black clothing.

Iraq

The effects of violence and trauma in Iraq were evident at the Cairo conference, participants told SAMHSA News. One could sense "hopelessness among the Iraqis at the beginning of the conference because of the challenges they are facing," said Husam Alathari, M.D., staff psychiatrist at the Northern Virginia Mental Health Institute in Falls Church, VA.

An expatriate Iraqi, Dr. Alathari attended the conference as part of the SAMHSA delegation. "You can really sense that the Iraqis are very stressed out. On top of this, physicians have been a target for the insurgents." But as the week progressed, "everyone was very impressed by the amount of energy that was generated by the conference. There is a lot determination. They are not losing hope."

The keynote address by Iraq's National Advisor for Mental Health Sabah Sadik, MBCHB, FRCPsych, DPM, opened with a report on services, training, and research and policy accomplishments during the previous 12 to 18 months.

These included finalizing Iraq's National Strategy for Mental Health; drafting and submitting to the government a much-needed national mental health law; aiding the establishment of a Child Mental Health Association; establishing a number of mental health clinics; arranging for the return to professional work of numerous experienced psychiatrists, psychologists, and social workers who had for a variety of reasons stopped working; and conducting a course for trainers of nurses in mental health, 1 of more than 50 training events involving more than 2,000 individuals.

"It was very impressive to see what people had achieved," Dr. Alathari told SAMHSA News. "Absolutely, progress had been made [that] was beyond our expectations." These accomplishments, he added, are "even more impressive given all these challenges" that Iraqi health professionals face.

Dr. Sadik's talk enumerated some of the challenges, including the need to encourage greater teamwork, re-establish professional and service standards, develop collaboration with institutions of higher learning that will enhance competence in the mental health professions, develop leadership training, and build an effective information system. "Sadly," he observed, the need to function in a poor security situation has "hindered" international support and contributions.

Nonetheless, optimism about the future of mental health care was high among the Iraqis present, said Dr. Alathari, who was last in Iraq in the early 1990s. At the conference, he spoke with a number of former colleagues and classmates from the days when he was receiving his education there.

"They said, ‘Fortunately, we have the best opportunity of any health system in the world. We can look at all the models, and we can design our own, starting from scratch.' At the same time, they have the opportunity to look at all the other challenges that other health systems have gone through and not repeat the mistakes."

After "15 years of intellectual isolation, they want to catch up," Dr. Alathari continued. They relished "the opportunity to attend an international conference and interact with professional organizations."

"It was very evident that [the Iraqi participants] have a clear idea of how to re-establish mental health services in Iraq," Ms. Mitchell added.

Once the security situation improves, Dr. Tuma believes, progress on rebuilding Iraq's mental health system will be rapid.

In support of that process, "the conference has been very effective in enhancing team work, partnership, and collaboration," Dr. Sadik told SAMHSA News. "Delegates were relaxed, participated actively, and felt valued as colleagues and contributors. I am confident that the skills they acquired and the networking they established will make a significant impact in the short and long term."

Spending time in safety among supportive international colleagues proved a "sanctuary" for the Iraqi health professionals and provided them tremendous emotional support, said Dr. Tuma. "When you're working under stress, you don't know whether you want to go on. . . . But what these doctors and mental health professionals are doing in Iraq is important. As a group, we wanted to let them know that."

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