Afghanistan

The impact of the conflict in Afghanistan on civilian mental health

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By Meera Thoompail and Jake Tacchi

"The doctors wanted to discharge me...I begged them to keep me in longer."

These are the words of Faridon, a 40-year-old man from Afghanistan's Baghlan Province, who was held in a hospital for mental health issues for just over one week. But Faridon's desperation to receive help is indicative of a much wider problem in Afghanistan. There is a psychological epidemic plaguing the Afghani people, and it is fast becoming increasingly apparent that it is largely a result of forty years of uninterrupted war there.

Afghanistan continually ranks among the most dangerous places in the world to be a civilian, with casualties caused by explosive violence rising from 4,268 in 2018 to 4,630 in 2019. 2020 so far has been no different. Afghanistan was the country worst impacted by explosive weapons in August 2020, with 353 civilian casualties recorded by AOAV. And although peace talks between the Afghan government and the Taliban commenced last month, explosive violence in the country shows no sign of abating.

The impact of this violence on the population's mental health is becoming shockingly clear. There has been a surge in post-traumatic stress disorder (PTSD) and other psychological conditions linked to armed conflict throughout the country, with the International Psychosocial Organisation (IPSO) estimating that 70% of Afghanistan's 37 million people are in need of psychological support. Afghanistan has been called a 'trauma state'; according to this theory, trauma caused by war fuels more war, in turn causing more trauma--and the cycle continues.

One study, conducted following the Soviet occupation and subsequent years of violence in Afghanistan, found that the most common trauma events experienced by nondisabled respondents triggering the onset of mental health problems included shelling or rocket attacks (40.8%), and bombardments by Coalition forces (34.9%). This study revealed that out of the 699 nondisabled respondents in the survey, 67.7% had symptoms of depression, 72.2% had symptoms of anxiety, and 42% suffered from PTSD.

This brief report by AOAV seeks to sheds light on the scale of mental health impacts triggered by armed violence in Afghanistan. It examines how the nation is currently handling this widespread issue with regards to its healthcare resources and social contexts as well as the consequences this issue has on some of the nation's most vulnerable groups.

**Lack of medical infrastructure and social awareness **\ There is a significant lack throughout Afghanistan's medical infrastructure in terms of psychological support. The World Health Organisation estimates that per 100,000 people in Afghanistan there are only 0.23 and 0.30 psychiatrists and psychologists, respectively. The 2019-2023 National Mental Health Strategy concluded that less than 10% of the population is getting the medical services necessary to treat their psychological disorders.

Jonathan Pedneault, conflict and crisis researcher at Human Rights Watch, has argued that "there is an urgent need for expanded psychosocial services to support Afghans exposed to violence, suicide bombings, and airstrikes, and prevent the long-term effects that can be debilitating to survivors, families, and entire communities."

The result of this shortage of resources and infrastructure is that Afghanis either don't seek the help they need, or they are simply sent home with a prescription for psychotropic drugs. This is done in order to keep the 320 hospital beds available for mental health patients free for the most serious cases. In addition, a lack of mental health literacy among the population at large helps fuel the use of psychologically harmful illicit drugs in a country with the highest number of opiate users in the world.

The stigma associated with mental health in Afghanistan has reportedly prevented many Afghanis from seeking medical help for psychological issues. Common pseudo-therapies include being chained inside religious shrines for extended periods of time in the hope that divine intervention will cure conditions. Clearly, this method of treatment endangers exacerbating psychological conditions and reinforcing the stigma associated with mental health issues.

The impact on children\ Children are disproportionately affected by explosive devices, particularly in terms of psychological effects. According to a study by the United Nations, in 2017, 81% of casualties arising from the explosive remnants of war were children. Injuries caused by blasts and bullets resulted in the most common form of trauma for children in Afghanistan, with the effects leaving a lasting impact on their livelihoods.

Children who have been exposed to armed violence are more likely to experience depression, night terrors, difficulty concentrating, aggressive behaviour, muteness and even sleepwalking. A 2019 report by Save the Children in Afghanistan showed that 73% of parents interviewed stated that their children experienced fearfulness and anxiety as a result of conflict and 38% reported that their children self-harm.

The impact on women

Alongside children, women are also at a higher risk of experiencing mental health issues stemming from conflict. One study found that one in five women out of 1,463 in the trial had been exposed to a traumatic event by witnessing an armed attack. These women were found to be more likely to develop depressive and PTSD symptoms.

The trauma experienced by women in conflict is exacerbated further by intimate partner violence (IPV) that occurs in domestic settings. IPV has been shown to increase in conflict and post-conflict periods, with domestic violence against women often arising out of the trauma suffered by men. According to the same study, women who experience both war trauma and IPV are shown to be more likely to engage in domestic violence towards their own children, which consequently contributes to the low psychological wellbeing in children, creating a cycle of cross-generational mental health problems.

Women also face greater difficulty in accessing mental health services in Afghanistan, as a joint report from AOAV and Chatham House has shown. Often this is the result of cultural factors, where women are highly unlikely to accept treatment from male doctors. This creates particular problems in rural areas, where a lack of freedom of movement prevents women from travelling to districts where female practitioners are available. Furthermore, the country's patriarchal society often requires women to seek permission from a male family member to access health services.

Conclusion

This brief report highlights that the psychological impacts of armed violence are very evident in Afghanistan, a society experiencing the effects of decades of violence. As this report shows, conflict and explosive violence not only increase the prevalence of mental health conditions in a population but also serve to damage and destroy health infrastructure designed to treat such conditions. It is clear that efforts must be made to improve mental health services and awareness of these issues so as to treat victims effectively and tackle stigma.

The Afghan Ministry of Public Health's 'National Strategy for Mental Health' sets out ambitious targets to strengthen leadership and governance in mental health, as well as information systems, evidence and research. However, these efforts will not be sustainable if there is no end to violence and the use of explosive weapons in the country. The on-going talks between the government and the Taliban will prove crucial to the long-term mental and physical wellbeing of this country's civilian population.