KABUL, 12 February (IRIN) - Standing in a gated cell, Nurallah Herawi wants out. "Open the door. I want to go outside," the former police officer told IRIN. While his request is a simple one, staff members at Afghanistan's only mental hospital, a decrepit and ill-equipped facility in the capital, Kabul, are not so sure.
Brought in five days earlier by his wife, the 45-year-old suffers from acute schizophrenia and is known to lash out. As doctors ponder his treatment, Herawi is confined to room number three, a darkened cell reserved for patients deemed violent.
According to the World Health Organisation (WHO), about four million people, or some 20 percent of the population, suffer from mental health problems or some form of diminished capacity. Depression - particularly amongst women - remains widespread, while thousands of children demonstrate learning or behavioural problems, many the result of war-related trauma. In Afghanistan, devastated by decades of war, poverty and dislocation, cases like Herawi's are hardly uncommon.
What is new, however - over one year after the demise of the Taliban - is the continued lack of resources to meet this challenge. "There is an extreme shortage of expertise with regard to mental health," the WHO mental health officer, Dr Sayed Azimi, told IRIN. "We don't have trained qualified psychiatrists in the country, and the facilities to treat patients are inadequate," the Indian-trained physician - the only trained psychiatrist in the country - observed.
But inadequate is an understatement. Down the hall in a room permeated by the stench of urine, Javid Bydia, a 29-year-old former military officer from the western city of Herat, looks agitated. Brought in for reasons similar to Herawi's, he suffers from hallucinations and bouts of violence. "I have headaches all the time. Sometimes I hear voices," the father-of-three told IRIN.
Meanwhile, in the same room, another former soldier - his legs chained together to prevent escape - mumbles as he sits on his bed. "I'll be good. I promise," he says over and over again.
While conditions within this 40-bed unit are undeniably poor, strangely both of these men are considered lucky. Although there is a small outpatient mental health centre in Sherberghan, the provincial capital of northern Jawzjan Province, the Soviet-built former central clinic in Kabul remains the country's only facility remotely geared to helping those suffering from mental illness and trauma - a fact that baffles Afghan health workers.
"After two decades of war, 95 percent of the population were affected psychologically, and yet there is only one mental hospital for the entire nation," Dr Abdul Ahad Awarah, a former assistant at the hospital, told IRIN. "While we have thousands of regular hospitals, mental health has completely fallen to the wayside."
Deeply frustrated, the clinical psychiatrist maintained that no organisation - including the UN - had demonstrated a real willingness to help. "People aren't interested. It simply isn't a priority for them," he said.
Sadly his contention could be correct. Grossly under-resourced, the unit can barely provide the basics, much less treatment. "Conditions here are very poor," Dr Ahmad Shafi Zia, one of 21 attending doctors and 15 nurses working around the clock, told IRIN. "If any patient comes here, there is little we can do for them," he said. "We just try to keep them from hurting themselves."
To keep warm, patients routinely sleep in their soiled clothes for days on end, while the facility's antiquated heating system stands broken and unused. There are regular power cuts; the water supply remains sporadic and the water pump works for only one hour a day. "There is only one bathroom for 40 people and no hot water," Zia said, adding that food consisted of a meagre dish of rice, beans and water.
Drugs treatment at the centre is nonexistent, and patients are expected to purchase their own medicine on the open market. "Many of these people have no means to do this," Azimi conceded, recalling how until just recently families were given prescriptions for not just the medicine, but also a chain and lock to shackle the patient.
For 2003 alone, just US $100,000 has been allocated for mental health for the whole country. "This isn't enough to provide supplies for this one hospital, much less the whole country," Zia noted.
With limited resources, WHO aims to integrate mental health into primary health care services by providing training to general practitioners working in the various provinces. "So far, we have trained 40 practitioners on mental health," the WHO official said.
But lack of expertise on mental health starts at the top at the hospital. Dr Khetaab Kakar, the current director of the hospital, is actually a surgeon. Though he has received some training from WHO, he is not a trained psychiatrist.
For most of the staff, their training in the field of mental health is even more limited, with much of it conducted on an informal basis only. "We have to improve the knowledge and skills of doctors and nurses first," Azimi said. "The primary emphasis of our activity at the hospital is training," he added, noting that there was little motivation amongst staff to provide care. And with salaries often unpaid and averaging about $40 a month, it is not difficult to understand why.
Equally troubling, however, is the stigma attached to the issue of mental sickness. According to Azimi, it's a taboo subject not just in Afghan society, but also within the health ministry itself. After the ministry was awarded a recent donation of ambulances, it allegedly ignored a request by the mental health facility, leaving it the only hospital in Kabul without an ambulance.
"Their impression of mental health compared with other sectors is quite different," Azimi said, noting that in order to improve conditions at the hospital, they do not only need resources but also the will to do so. "Nobody is interested to work there," he remarked. "The ministry is now forcing some people," he asserted.
Following the overthrow of the Taliban, WHO issued an appeal for help. "Mental disease that one would see in any population has not been attended to for years in Afghanistan," Azimi observed, stressing the urgent need for mental health services to be established throughout Afghanistan.
"During the Taliban time, we never had people coming from rural areas - now we do," Awarah noted, adding that many new arrivals were simply being turned away.
Whereas WHO, given the limited resources, is rightfully addressing the issue of training, and efforts are under way to move patients to a new facility in the near future, it is clear that much more is needed. Reaffirming what he described as widespread neglect when it came to mental health in Afghanistan, Azimi said: "What we are doing is not enough. We can do so much more."
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