From Health to Peace in Afghanistan – the Story So Far

This is an unusual story of working from health toward peace in a country particularly severely affected by multiple wars. The work to be described has been carried out during several phases of war in Afghanistan – the end of the mujaheddin wars, the invasion by the United States and its allies, and the current guerilla war in the south of the country. The story exemplifies the merits of holding to an informed vision of peace while beginning work in mental health, of seizing opportunities to act at increasing levels of political influence as they arose, applying knowledge of peace processes whenever possible, and of working with a team with high levels of knowledge in both health and peace.

Mental health deficits in Afghanistan

We might consider these in terms of two factors. One is about expected levels in any population of mental illnesses, such as the major psychoses, anxiety and depressive disorders, substance abuse disorders, and mental disorders usually diagnosed in childhood. There are no epidemiological data on levels of illness in Afghanistan, and in particular, none in the pre-war phase prior to 1979. Mental health care at the beginning of this work was near to non-existent. In 2002, for 23 million Afghan people, there were 8 psychiatrists and 18 psychiatric nurses (1). Availability of modern drugs was very limited.

The second is about psychological disturbances as a result of war – posttraumatic symptoms, depression, anxiety, anger, violent behavior, and suicide. Several surveys, carried out under difficult conditions, suggest that levels of suffering are very high. Physicians for Human Rights – USA carried out a survey in 1998 in Kabul, showing that 42% of 160 women reported symptoms that met the diagnostic criteria for posttraumatic stress disorder, 97% had evidence of major depression, and 86% had severe symptoms of anxiety (2). Ninety per cent of 300 children interviewed in Kabul in 1997 said they suffered from intrusive memories and 40% said they often thought life was not worth living (3).

Peace deficits in Afghanistan

Peace deficits were extreme at all times of the work to be described. When the project began in 1999, the mujaheddin conflict persisted, having coalesced largely into two groupings – the Taliban on one side and the Northern Alliance on the other. The US-UK invasion of 2001 brought the latter faction to ascendance, and in the following year resulted in cessation of violence around the capital city, Kabul. Violent conflict, waged by the supporters of the Taliban, continued in various parts of the country and, at the time of writing this essay is seriously increasing in the south.

Afghans engaged in this project identified other peace deficits – conflict between Afghans of various orientations and the political and military agencies of those western countries intervening in Afghanistan; conflict between moderate and fundamentalist Moslems; and the gender conflict in its various manifestations, including high domestic violence and female suicide. More recently, as national governance struggles to emerge, there is conflict between its promoters and certain powerful men with militias at their command, and conflict between those who would suppress and those who profit from the opium trade. Throughout all phases of the wars, there has been conflict with those neighbors of Afghanistan pursuing their own interests through interference in Afghanistan, especially through support of armed factions.

Project evolution

In the light of this enormous array of problems, the choice of entry point was determined by the team’s capacities, its framework of operation and its potential Afghan partners. The team centered on an Afghan-Canadian, Seddiq Weera, who had trained and worked as a physician in Afghanistan. He had fought against the Russian invasion and been imprisoned for this. After working in public health as a refugee in Pakistan, he migrated to Canada, trained in epidemiology, and connected with the group working on Peace through Health at McMaster University. The team he assembled came to comprise expertise in mental health, with some focus on children, and in peace processes. A relationship with peace researcher Johan Galtung of TRANSCEND, a peace and development organization, was forged, to further strengthen capacity in the area of peace processes. The work was funded in its early phases by the Canadian International Development Agency and in later phases by minor private contributions and by hundreds of hours of volunteer work by dedicated team members.

Early phase

In preliminary field trips, Dr Weera had been impressed by the avid uptake of input on coping with anger, grief, and stress of living under war and refugee conditions. The team was encouraged to develop a manual (4) for adults on maintaining mental health and good relationships under the extremely stressful conditions of people’s lives. They also began work on a children’s version of similar material, incorporating these and other themes in stories (5). The workshops and the manual were delivered to women’s groups and to Afghans working under difficult conditions in nongovernmental organizations, some of them attempting to carry out peace education in Afghanistan during Taliban rule. Participants benefited from the mental health input and wanted to work on understanding the violent conflicts of Afghanistan and on possible ways to address them. Dr Weera, with knowledge of conflict analysis and of conflict transformation, was an ideal guide through these explorations. Participants urged him to take his methodology to politicians and other influential people, as well as to people working in mass media.

The team set about to meet this expressed need. As it was not possible to bring this work into Afghanistan itself during the time of Taliban rule, the team, together with Johan Galtung, visited Peshawar, the home of millions of Afghan refugees, in early 2001. Their visit was hosted by the Afghan University, a university-in-exile.

This university had assembled about 100 people for a workshop, comprising politicians of all parties, academics, judges, and school principals. More people applied than could be admitted. This huge workshop dealt first with generalized concepts of understanding and transforming conflict, and then applied the ideas to Afghanistan. The men and women participating produced a long list of ideas to end or mitigate the violent conflict in their country, and pleaded for more peace education. In a separate meeting with university faculty, there was also a plea for assistance with peace education.

This early phase of work also involved work with journalists, propagating the idea of peace journalism – probing causes as well as describing effects of violence, presenting multiple sides of issues, and looking for solutions.

Those nongovernmental organizations working on mental health and peace education received the manual enthusiastically, and proceeded to use it. The team developing the children’s stories engaged Afghan artists to illustrate the stories and went on to create puppets for the main characters in the saga, to animate the use of the stories in schools. The stories were carefully filtered for cultural appropriateness, religious acceptability, mental health validity, literary excellence after translation into Dari and Pashto, and interest to children. Dozens of women volunteered hundreds of hours making the puppets for Afghan children.

Middle phase

While the mental health component of the project created its initial entry, its peace education component moved it into deeper engagement with Afghan society. Requests for more peace education led to a program of training peace educators with a formal curriculum. For this purpose, a basic manual of peace studies (6) was developed. Several of those who went through this training are now ministers of the government in Afghanistan. By this time, the Taliban were out of power, and it was possible to work in those parts of Afghanistan free from violent conflict. Further large workshops were held in Kabul, Jalalabad, and other cities. One was attended by the whole of the Ministry of Education, and there was interest from the Ministry of Higher Education. Dr Weera held a succession of consultant positions in the Ministry of Education. He developed large components of the new curricula for primary education, with a focus on peace and social skills education. He now heads the Departments of Peace Education and Religious Education in the ministry. Another team member, Susan Wardak, has also worked on curriculum development for several years, with a focus on women’s education.

The Canadian side of the team has been working on methodology of evaluation of the mental health and peace education components with school children.

Later phase

From the earliest workshops, the theme of reconciliation had been included, dealing with this at all levels, interpersonal to national. Several proposals for national reconciliation were put forward. As a result of this focus, Dr Weera was appointed to the Independent National Commission on Strengthening Peace, a proto-reconciliation commission, and has played a particular role in the reconciliation into mainstream society of former Taliban fighters. He has continued to press, however, for large-scale reconciliation processes. For the last several years, he has warned of the importance of inclusion, rather than exclusion, of those Afghans disaffected from the formation of the government with a predominance of the victors over the Taliban. He predicted that, if these important processes were ignored, there will be a worsening of violence from a minority who would feel they must take to arms to make their needs known. His predictions have, unfortunately, come to pass.

In recent months, Dr Weera has made informal probes to the leaders of Taliban and other parties and has ascertained a serious interest in a political rather than a military solution to the current conflict. He has also determined that ten or so members of cabinet in the government wish to pursue this option, and is working to widen this support for peaceful means of ending the violence. Meanwhile the Canadian team has been working to try to engage their government to support such processes and in ending the waging of war in Afghanistan.

Overview of this work

From the beginning, the work was conceived as aiming to improve both peace and health. Humanitarian needs impelled attention to health, but it was clear to the team that attainment of peace would be the highest priority contribution to population health. Accordingly, the team included both areas of expertise. In devising the initial intervention, the team linked psychological health with healing of social relationships, a concept that made sense to the participants. The team was also well-prepared to respond to participants’ need to analyze their destructive conflicts and to devise ways of acting constructively on them. The knowledge and prestige of an internationally renowned peace researcher supported the team in this function.

The non-Afghan members of the team worked hard at understanding and respecting the culture in which they were working and adapting their input to it. While matching their input to the culture, and drawing from its resources, they also introduced less familiar ideas in the areas of reconciliation and nonviolence in settings where dialogue was encouraged. The team also attempted to include women as much as possible, pushing inclusion to limits which met resistance in early phases of its work.

Undoubtedly, achievements have been enhanced by the particular attributes of one team member, Dr Weera, who has proved his capacity to engage with people at all points of the political spectrum, and at high levels of political influence, to master complex new areas of knowledge and to cope with certain levels of risk to his life. Sheer hard work on behalf of Afghans by Seddiq Weera and Susan Wardak has been part of the success of these endeavors. At a less dramatic and demanding level, dedicated support from the Canadian part of the team has been important.

Evaluation of effectiveness of this work is challenging. Some of it involves unique actions, such as quietly arranging dialogues with Taliban leaders. The most easily evaluated aspect is the mental health and peace education work in schools (Figure 1). This is proceeding.

Figure 1.

Facilities are poor in Afghan schools. Many “classrooms” are out-of-doors.

The achievements so far would suggest that others should consider involving those with peace expertise in health work in war zones.