Afghanistan mental health: Treatment caught between ancient and modern worlds

While Afghanistan mental health treatment has improved in cities, many rural residents still opt to send the ill to shrines, where they may be chained and poorly fed. Aid workers are trying to expand training for community health workers.

Hamidullah Khan says he went insane after he fell down a well. The chatty young man spends his days alone with his right foot chained to the wall of a windowless cell of the Mia Ali Shrine, a religious site that, for centuries, has taken in the mentally ill.

The shrine-keeper feeds Mr. Khan and three other patients a strict diet of bread and black pepper. The chains and the close walls dictate the position they will sleep on the ground. Sanitation is nonexistent. They use uncollected trash in each cell to fling their waste out the doorway.

Earlier, Khan spent 40 days chained to an ancient tree in the dirt courtyard. The shrine-keeper says that's the usual treatment when the weather isn't too chilly. Some people don't survive the regimen and are buried in earthen mounds scattered around the shrine.

Shrines offering this draconian approach to mental illness exist today in Afghanistan alongside a modernizing mental health system supported by Western donors. The two approaches epitomize the two Afghanistans - one a developing nation emerging in the cities, the other an archaic countryside cut off by illiteracy, tradition, and insurgency. Linking the two involves basic training in villages as well as debates over tradition and religion.

And the need is urgent. A 2004 survey published in the Journal of the American Medical Association found symptoms of depression in nearly 70 percent of respondents and of post-traumatic stress disorder in more than 40 percent. Those numbers are "high, even when compared with other communities traumatized by war," noted the authors.

Neuropsychiatrist Mustafa Noorzai heads a mental ward at the Ali-Abad Hospital in Kabul. With more than 70 beds and a dozen trained neuropsyciatrists, the facility has plenty of capacity, he says, and the services are free.

One patient, a university student named Ghulam Nabi, arrived four days ago and was diagnosed with psychosis. On the first day he broke windows, but now he is walking calmly around his light-filled room. Mr. Nabi says he is "getting better" and is "treated well."

A few years ago, says neuropsychiatrist Sayed Abdullah, the hospital would have chained up Nabi. But an ongoing World Health Organization effort called the Chains Free Initiative has educated doctors in Afghanistan to rely on alternatives instead.

"Now we increase the relief medications," says Dr. Abdullah. "Sometimes we tie with a belt, in old times we tied with a chain. But that ... affects their psychology."

Despite the improvements, the hospital has had families remove relatives once they learn of the shrines.

"We come here and find no patient, and when we ask, they say he has been taken to the shrine," says Noorzai. He notes: "I don't think it is the last generation of these [shrines] because they are linking some of their own traditions with Islam."

Noorzai knows of at least four other shrines taking patients in the geographically scattered provinces of Paktia, Parwan, Sar-e Pol, and Ghazni. Meanwhile, major cities like Jalalabad, Herat, and Mazar-e Sharif now have mental health wards in hospitals.

The shrine in Samar Khel lies a few miles outside the city of Jalalabad. It houses the tomb of Mia Ali Sayed, a 17th-century Sufi sage whose descendants take turns tending to patients.

Mia Sahib, one of the shrine-keepers, explains that his patients are possessed by demons known as djinns. For some, he offers a taweez - a Koranic verse written on a slip of paper. Others require 40 days of confinement.

"A mental patient doesn't know himself," explains Mia Sahib. "In 40 days, he is going to know himself fast. He will know he has some djinn inside. Once he knows he has a djinn inside, he will clean himself. And once he cleans himself, he will know Allah."

He claims some successes, but says he cannot help patients who are addicted to opium or are faking illness to avoid work. (That said, one drug addict named Waseem from Pakistan was locked up in his shrine.)

Afghanistan's health officials have tried to get the media to tell people not to send patients to shrines. And they have enlisted religious leaders to speak out against cultural practices that stricter Sunni interpretations of Islam reject.

"High-profile mullahs and religious scholars are against all these [practices]. They are all the time on TV coming out against taweez as not in Islam," says Noorzai.

But one television journalist, Ahmad Fahim Kohdamani, spent nearly a month in prison this year after he offended some clerics with a report critical of taweez.

The sensitivities leave some international organizations treading lightly.

"Many people use these taweez and people believe that it helps. We won't say it doesn't help," says Bibiane van Mierlo, technical adviser for HealthNet TPO, an Amsterdam-based nonprofit organization working on mental health in Afghanistan. "To deprive somebody for 40 days - that is not a healthy practice. But if some people want to hand this taweez out, that is not a problem - that can go hand in hand with other treatment."

HealthNet tries to offer an alternative by spreading mental healthcare into areas beyond the cities. Many villages already have community health posts, so the group is training some 4,000 to 5,000 of these local health workers to flag mental problems. Then, at the provincial level, the group is training 500 to 600 doctors and nurses on basic psychiatric treatment with drugs and on when to refer harder cases to specialists.

The training courses are short - several days for community workers, several weeks for doctors. But in a country where the immediate need is great and where highly educated doctors often quit for more lucrative careers, less can be more.

Raising the rural levels of education may also, over time, put an end to the shrine treatments.

"My sons secretly say they won't do this," says Mia Sahib. One son is a teacher, another graduated from university. "I will be the last person [in my family] who does this."