Mental Health Consequences of Conflict Neglected

April 1, 2002

In warn-torn Afghanistan, refugees continue to struggle to survive in 20-year-old "temporary" shelters, without proper food and suffering from the psychiatric consequences of trauma. What are psychiatrists doing to help?

It will likely be impossible for Americans of this generation to hear the date September 11 without remembering the emotional pain and sorrow generated by the attacks on the World Trade Center and the Pentagon. The tragic events of that day traumatized this nation's people as they suffered a firsthand initiation into the brutalities of world terrorism.

No more than a month later, U.S. bombers began missions in Afghanistan aimed at toppling the Taliban regime that was accused of harboring Osama bin Laden and his Al Qaeda terrorists. In concert with the indigenous Northern Alliance, U.S. ground troops then made quick work of its objective of removing the Taliban from positions of leadership in most of the country's major cities.

While the United States' "war on terrorism" marked a new direction for its foreign policy, in Afghanistan it brought just more of the same. For over two decades, the ravages of combat have turned much of the country's civilian population into refugees, many of them left to struggle for survival in bordering nations. Psychologically damaged after witnessing destruction of their family homes and atrocities against family members that included deaths, rapes and physical injuries, the refugees have, for the most part, languished in camps -- their trauma untreated and exacerbated by the desperate conditions in which they live.

In Pakistan, for instance, as many as 3 million Afghan refugees have crossed the border in more than 20 years of fighting, many of them still occupying a string of camps along that border. One of those camps, Akora Khattak, has existed since the Soviet invasion of Afghanistan in 1979. Approximately 100 km west of the Afghan border, it occupies a barren desert parcel near the city of Peshawar in Pakistan's Northwest Frontier Province.

Once a tent city, Akora Khattak's row-upon-row of mud huts at times has housed as many as 250,000 people, although its current population is estimated at 15,000 families comprising 110,000 refugees. Deep gullies run between the ramshackle dirt houses carrying away sewage in the open. Wells supply the only water, and food is in short supply. Many children eat only once every 24 hours. Sparse resources mean medical care is often unavailable, and mental health care is, for the most part, nonexistent.

Some of the residents have been in the camp since its creation, while others migrated to it as Afghan warlords fought each other after the Soviets left, or during the national bloodletting that brought the Taliban to power, or to escape the recent battles with the United States. Following each wave of conflict, innocents -- many of them children -- exhibited symptoms of posttraumatic stress disorder; for the most part, however, the depression, anxiety, nightmares and night terrors, sleeplessness, memory loss, and behavioral problems have gone unattended.

Hope Village, a school and social services facility near Akora Khattak, is operated by Human Concern International (HCI), a Canadian human rights organization. Although it has done what it can to help, even its executive director, Kaleem Akhtar, concedes nothing much has changed in 20 years, with refugees surviving at bare subsistence levels. Despite the hoards of journalists who arrive in Pakistan when combat erupts, there has been little, if any, news coverage of the long-term mental health consequences civilians face, he said.

Many of the donor agencies and non-governmental organizations that provide financial support for relief efforts, Akhtar said, "expressed concerns that little awareness has been raised on the psychological effects of the conflict," and some have largely ignored the issue.

In February, HCI helped sponsor a visit by a team of mental health care professionals who offered a two-day training session in trauma psychology. Led by Syed Arshad Husain, M.D., a child and adolescent psychiatrist who heads the International Center for Psychosocial Trauma headquartered at the University of Missouri in Columbia, the team's goal is to equip Afghan physicians, social workers and teachers living in Akora Khattak with the skills to help refugees, especially the children, overcome PTSD symptoms. In addition, a first-time-ever trauma counseling center staffed with two psychiatrists, a social worker and other health care workers will provide ongoing treatment and training.

While adults have their share of problems that must be addressed, Husain explained that the children's suffering is his main emphasis. Food and shelter are the greatest problems, and many children have lost families or work at menial tasks to provide meager, subsistence-level support. Stripped of an environment in which to grow normally, they suffer deficiencies in psychological and cognitive processes often induced by posttraumatic stress, he added.

Among Afghan refugees in Akora Khattak, intractable conflict has produced massive psychological casualties through the years. During the training session at Hope Village, Afghan participants estimated that as many as 80% to 90% of the children and adults living in Akora Khattak exhibited PTSD symptoms. Often induced by witnessing atrocities, the trauma's impact has been magnified by the effects of malnutrition and squalid living conditions.

Cultural and religious norms also have their effects. Many of the women lost their husbands during the conflicts or live with men who are too disabled to work. They are prohibited from venturing out alone to take jobs, and only their children can assume the burden of being family breadwinners. Usually employed at physically demanding manufacturing or assembly jobs, or subject to the vagaries of street vending, these children are commonly the targets of physical and sexual abuse. Thousands of children in the camps receive little or no education.

Venetta Whitaker, Ph.D., is an education specialist who provided training in art and storytelling therapies and in dispute-resolution techniques for children during the two-day session at Hope Village. She agreed that the decades-long conflict in the region and the resulting plight of Afghan refugees made their situation more dire than other war-torn areas she has visited.

In contrast, most of the refugees from Kosova who fled to Albania during the conflict in the former Yugoslavia were housed in local homes, either with family, friends or sympathizers, Whitaker said. Those maintained in camps had been there for only a short period of time, and they anticipated a quick repatriation or absorption. Whitaker said this made that situation more like a natural disaster, where the event was traumatic but of finite duration.

In Akora Khattak, however, "There was more of a sense of hopelessness," Whitaker said. Nevertheless, she said mental health interventions can help, particularly among the children. She explained that there are some children who would be more resilient than others and who could overcome their environment with help. That doesn't mean, though, that the camps are without their undermining influences, she added.

"Some of the youngsters whose families have been in the camp for such a very, very long time have a disadvantage in the whole concept of resiliency, because it depends on things they may not have had a chance to experience," Whitaker said. For instance, some children may not have the family structure and security that helps support resiliency.

Mian Iqbal, M.B.B.S., a psychiatrist in Peshawar who will help operate the newly organized mental health counseling center at Hope Village, also conceded that there are limits. "In counseling, we can't change their situation," he said. "We can only try to help them adjust and live with it."

While he is confident that he can help the adults and the children who are trapped in the camps cope with the symptoms of their posttraumatic stress, he said the overwhelming numbers, the lack of resources and the sordid living conditions are near insurmountable obstacles. In addition, with children not at school, teachers and other child care workers will have trouble identifying those suffering from mental illness or psychological symptoms.

At the Hope Village trauma conference, a tentative quiet bred of hesitancy and distrust slowly yielded as participants recognized their symptoms among those listed by the presenters as typical of PTSD. Gradually, they rose to speak. Talking of dead husbands, wives, fathers, mothers and children; rapes and other violent indignities; and years of fear, hunger and desperation, men, women and children unburdened themselves to the presenters. "We are here to help," came the reply.

However, that may be easier said than done. In Pakistan, approximately 250 psychiatrists and half that many psychologists are available to serve a total population of more than 140 million. Stigma, folk beliefs, and cultural and religious norms often put mental health care practitioners in competition with faith healers when it comes to treating mental illness or psychological problems.

Khalid A. Mufti, M.B.B.S., a psychiatrist and professor in the department of psychiatry at Khyber Medical College in Peshawar, is also the president of the Pakistan Psychiatric Society. He said the country was desperate to heighten awareness of trauma and mental health issues that were increasingly generated by conflict and the other social, cultural, economic and political factors that conflict aggravates. For instance, in a recent survey, Mufti and a team of researchers determined that the number of stress-related mental disorders among children increased nine-fold in the last five years.

"The currrent resources are inadequate and insufficient to meet the demand," Mufti said.

M. Lahir Shah, chief executive at the Khyber Teaching Hospital in Peshawar, which includes units for psychiatric services, said that mental health care has taken a back seat to more immediate needs following the influx of refugees. For instance, preventing epidemics of infectious diseases, illnesses related to poor hygiene conditions and outbreaks of polio received top priority.

Government resources, meanwhile, were eaten up by worldwide recession and the demands of the Pakistani military, whose face-off with Indian troops drains substantial portions of the budget. Overwhelming poverty, Shah said, has led to increased family violence and crime and the trauma they produce, as have decreased educational opportunities. "Children are the main targets of all of this," Shah said.

According to Pakistani journalists in Peshawar, people are waiting to see what the United States will do next. After the bombing and troop incursion, they said Pakistanis wonder whether U.S. foreign policy will yield the kind of nation-building aid that will stabilize the region and create an environment where a host of problems, including the psychological consequences of war, can progress toward resolution.

"We come in with hope," said education specialist Whitaker. "It's the hope that makes the people supersede whatever boundaries they may have."