In a land scarred by decades of conflict, people are used to fighting and to being attacked. During these times, lives go on. Living continues.
Daily routines are carved into the framework of war. Tomorrow’s sun is the horizon for the hope of peace.
Yet, when the battle is an internal struggle and there is no peace during the day nor the night, a person cannot rest.
The suffering of mental illness is Afghanistan is a silent war. The causes of such suffering are shrouded in stigma, creating further wounds for the individual, and often their families too.
Understanding the manifestation of psychiatric disorders such as psychosis, schizophrenia, or seizures related to severe depression carries beliefs about weak faiths or curses. In turn, these beliefs de-humanizes the person. Their identities are replaced by associations with the supernatural.
Resources to offer assessment, diagnosis, and treatment for mental illness are severely under-developed and lacking in Afghanistan. A significant yet overlooked consequence of conflict is the impact on health systems.
Infrastructure to accommodate mental health needs has scarcely begun to develop aside from a public psychiatric hospital in Kabul and one private neuro-psychiatric hospital in Mazar-e-Sharif.
Problems exist with both the financial and human resources.
The Afghanistan National Survey on Mental Health 2003–2005 showed that 16.5 percent of the adult population in the country was suffering from mental health disorders and estimated to be significantly higher since the cycle of violence and trauma has continued for a further decade.
Another significant aspect is the cultural shaping of mental illness.
In a recent article “Why there is no PTSD in Afghanistan” by ethnographer, Professor Mark de Rond, it is pointed out that due to the high exposure to trauma, much of the population display traits or symptoms of PTSD. In this sense, it is difficult to identify relatives who may be suffering as well as a shared and collective narrative of suffering that is held tightly together by the culture’s rich tradition of oral story-telling.
However, telling stories of trauma from conflict has resulted in a new generation of Afghans experiencing war in a visceral way and developing secondary or trans generational trauma.
To draw on story-telling further, there is a difference between telling a story of trauma and sharing a story of suffering.
For the unaccustomed listener, the difference is subtle. However, from a professional and academic point of view the difference is crucial.
The question that this article is trying to present is what does suffering mean in contemporary Afghan society? How can the events of a generation who have lived through 40 years of war be reconciled? How can suffering be acknowledged in a health system that is largely being developed from a biomedical framework from an entirely different context to Afghanistan?
The biomedical framework of psychiatry has received criticism for the medicalization of mental illness. For mental distress, as a result of conflict, to be treated with pharmacological means is there a risk of negating the effects of war artificially?
The key for mental health is to ‘suffer better’—placating the mind through artificial methods is a form of nullifying pain that holds a narrative.
Yet without a sufficient mental health infrastructure the support systems that we have come to understand as a crucial element of recovery and management of psychiatric disorders will remain non-existent and pills that sedate will be one of the few available options.
Similarly, for suffering from acute mental illness there needs to be safe, secure and affordable clinical settings for patients to receive care.
The key for mental health is to find stories. These stories must be told.
Some of these stories will highlight and reveal human rights abuses and some of these stories will offer hope and solidarity.
Yet the discussion cannot be carried forward without the exposure of how people are suffering either within themselves or at the hands of others. Hopefully this article can start the telling—and sharing—of stories of suffering.
Dr Ayesha Ahmad is an academic specializing in mental health, culture, and psychological trauma and is a lecturer in Medical Ethics and Law at St Georges University of London and an Honorary Lecturer at the Institute for Global Health, University College London.