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SAMHSA News - January/February 2006, Volume 14, Number 1

Rebuilding Afghanistan's Mental Health System

photo of Dr. Faizullah Kakar and Dr. Ruhullah Nassery preparing to address the Workgroup on Afghanistan Mental Health at the Embassy of Afghanistan in Washington, DC

(Left to right) Dr. Faizullah Kakar, Afghanistan's Deputy Minister of Public Health, and Dr. Ruhullah Nassery, Mental Health Coordinator of Afghanistan's Ministry of Public Health, prepare to address the Workgroup on Afghanistan Mental Health recently at the Embassy of Afghanistan in Washington, DC. Photo by Meredith Hogan Pond

Afghanistan has an ambitious vision for bringing mental health services to its people. Deputy Minister of Public Health Faizullah Kakar, Ph.D., envisions a country where "all of our health care services provide the most essential mental health care," where the various regions have facilities "to treat patients we can't treat today," and where there exist "some very good hospitals" and "enough doctors in proportion to the population," he told SAMHSA News in a recent interview.

But making that come true in a nation torn by decades of war and political oppression will take hard work, careful planning, and technical expertise. "We would like SAMHSA to play a strategic role in developing our mental health care," he said.

Two major challenges stand in the way of attaining Dr. Kakar's vision. First, because of the people's suffering during the wartime years, the need for mental health services is widespread. Second, mental health care traditionally has not had a high priority within health care in Afghanistan. But then, in January 2005, these two realities came together to spark change.

Dr. Kakar was reviewing the national strategy being developed to guide the rebuilding of the country's health system. Much of the country's physical infrastructure has been decimated, and many of Afghanistan's educated professionals were killed or fled the country during widespread violence and oppression.

In the midst of this task, Dr. Kakar got the "very disturbing news that there were young women [in one of the main cities] committing suicide." Suicide prevention and other mental health issues, he noticed, did not even appear among major health care priorities enumerated in the plan. He immediately realized that they belonged high on that list.

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A Top Priority

Given that a 2002 nationwide survey documented that more than 70 percent of women and 60 percent of men suffer from depression, Dr. Kakar knew that mental health issues are "a big public health burden in Afghanistan."

Minister of Public Health S. Mohammad Amin Fatimie, M.D., quickly agreed that mental health deserved high priority.

Dr. Fatimie called a meeting with the foreign non-governmental organizations (NGOs) assisting the Ministry. Some donors objected to including mental health because of the cost. "If Kakar wants mental health," the Deputy Minister recalled them saying, "he needs to find the money." And so Dr. Kakar came to Washington. "I asked, though it was not on the agenda, ‘Who is interested in mental health?' " He "was very surprised" to receive an immediate, affirmative reply. Prominent among those encouraging him was SAMHSA.

In December 2005, during a second visit to Washington, Dr. Kakar told this story during a meeting at the Embassy of Afghanistan. Seated around the conference table were members of the Workgroup on Afghanistan Mental Health—a team of experts from SAMHSA and additional members from the National Institute of Mental Health, the Office of Global Health Affairs at the U.S. Department of Health and Human Services, and the Embassy of Afghanistan.

Also present were Ruhullah Nassery, M.D., Mental Health Coordinator of Afghanistan's Ministry of Public Health, and SAMHSA Administrator Charles G. Curie, M.A., A.C.S.W. Other representatives included the Afghan-American Physicians Association, the World Health Organization (WHO), and the Department of Defense.

The Workgroup, inspired by Dr. Kakar's visit earlier in the year, had already been busy for several months exploring how U.S. assets could aid in the rebuilding of the human resources and physical infrastructure needed to bring mental health services to Afghanistan's population.

Along with this meeting, the schedule for Dr. Kakar's December visit to the United States included meetings at the Centers for Disease Control and Prevention in Atlanta, GA. Dr. Nassery visited a psychiatric hospital and a community-based mental health center in a Virginia suburb of Washington, DC.

Mr. Curie expressed SAMHSA's strong support for the Ministry's focus on mental health as a crucial element of the overall public health plan. Key to the partnership, he emphasized, is listening closely to the priorities developed by Afghanistan, which will guide SAMHSA's efforts to help the country provide its people with culturally competent services that become part of their day-to-day lives.

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A Nation Traumatized

Given Afghanistan's many years of turmoil and destruction, the number of people suffering from identifiable mental disorders or substance abuse is "very high and needs prompt intervention," Dr. Nassery told the meeting.

"War and substance abuse have interacted to produce more people who are addicted," Dr. Kakar added. Many families have lost loved ones or are caring for individuals disabled, either physically or mentally, by the conflict, causing continuing stress for family caregivers who lack access to mental health resources.

Because of these pressing needs, mental health now ranks among the top five essentials in the "Basic Package of Health Services" designated in the strategic plan developed by the Ministry of Public Health. The top four priorities are basics such as newborn health, child health and immunization, nutrition, and communicable diseases.

Despite a high priority, however, Afghanistan has a "severe shortage of mental health professionals," according to Dr. Nassery. The WHO's Global Health Atlas lists the country as having 8 psychiatrists and 20 psychologists, but Dr. Nassery believes those numbers are too high.

Even using the WHO statistics, he added, Afghanistan has substantially fewer psychiatrists, psychologists, and psychiatric nurses per 100,000 residents than in neighboring countries such as Pakistan and Iran.

Mental health, Dr. Nassery added, currently receives little attention in general health care. Overall, mental health facilities are inadequate and heavily concentrated in the cities of this predominantly rural country. The nation's sole psychiatric hospital has 60 beds. In addition, psychotropic medications are in short supply.

Afghanistan currently lacks the legislation and policies needed to develop a modern mental health system as well as the necessary staffing and technical support in the Ministry of Public Health. Nor does mental health receive adequate attention in the curricula of the institutions within Afghanistan that train health care professionals. In general, public awareness of mental health issues is low.

photo of ruins of a building in Kabul, Afghanistan

Ruins of a building in downtown Kabul. Photo by Cpl Matthew Roberson, USMC/USAID

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SAMHSA News Information

SAMHSA News - January/February 2006, Volume 14, Number 1

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