Living through interminable adversity: the mental health of the Afghan people

The return of the Taliban regime to power after twenty years of war represents yet another crisis in the long history of armed conflict and invasions in Afghanistan. Successive generations of Afghans have been exposed to systemic violence resulting in widespread human rights violations and mass displacement. Adding to these stressors are country‐wide conditions of adversity related to poverty, drought, food shortages and the COVID‐19 pandemic. There are compelling reasons for concern, therefore, that these cumulative experiences of threat and stress will have lasting impacts on the mental health of the population.

Five million Afghans are currently displaced from their homes, three million within their own country and over two million to neighbouring Pakistan and Iran. There is a long history of Afghans seeking asylum in Western countries, the largest group of some 170,000 having settled in Germany. During the turmoil of 2021, 120,000 Afghans were airlifted from Kabul, and more than 60,000 fled to neighbouring countries. According to the United Nations High Commissioner for Refugees, up to half a million additional Afghans could flee the country in the near future ¹ .

Mental health services in resettlement countries should expect an increased demand for assistance from both long settled and newly arrived Afghan refugees, presenting with a range of common mental disorders related to traumatic stress, loss and grief. Services in many countries have built important expertise in engaging with Afghan persons, and in some countries there is a substantial cadre of trained and experienced Afghan professionals and community workers who can ensure that services are sensitive to the culture and history of persons from their homeland ² . Host governments should be proactive in supplying enhanced funding and training to service providers to meet the inevitable increase in mental health needs of Afghan refugee communities. Strategic support should also be given to community agencies led by Afghans who can assist newly arrived refugees in adapting and resettling in their new environments.

Based on international data, it can be expected that approximately 10% of populations exposed to mass violence and/or forced displacement need immediate mental health treatment, and an additional 20% require psychosocial support ³ . These figures represent only averages, however, and studies conducted in Afghanistan prior to the current crisis revealed remarkably high rates of common mental health symptoms amongst adults and children across the country. It seems probable that this pattern of elevated symptoms was related to the cumulative effects of stress associated with repeated periods of conflict and social disruptions experienced by the population over several decades4, 5. High levels of pre‐existing distress within the population in turn increases the risk that many Afghans will manifest frank symptoms of mental disorders such as post‐traumatic stress disorder (PTSD), anxiety and depression after being confronted with the challenges of the contemporary crisis. At a population level, repeated social disruptions, losses and dislocations undermine cohesion at the community, kinship group and family levels, potentially exacerbating psychosocial problems such as intimate partner violence and childhood abuse and neglect.

Women are at high risk of psychosocial distress in Afghanistan, as indicated by the findings of successive mental health surveys. Over many decades, women have been excluded from higher education, professional training, employment opportunities, and participation in the social and political life of the country. The previous government made some progress in addressing gender inequalities, but early signs, such as restricting girls from attending high school, suggest that these advances may be reversed by the new regime. This major setback will greatly undermine the morale of women, increasing their risk of developing mental disorders such as depression. International advocacy is urgently needed to defend and promote the human rights of women in Afghanistan, an initiative that should be strongly supported by international psychiatric and mental health organizations.

There has been a long history of discrimination and victimization of ethnic and religious minority groups in Afghanistan. The previous government has had some success in curtailing prejudice against minorities by promoting their access to education, employment and roles in government. Reports of atrocities and acts of reprisal against minorities in past months raise concerns that harsh forms of discrimination will be imposed on these groups. If this trend continues, it is likely that there will be an escalation in the number of minority group members fleeing the country to join compatriots in neighbouring and Western nations. Mental health interventions provided to these minorities must be sensitive to the culture and religion of these groups, and to dealing with the legacy of mistrust and avoidance that they have developed in interacting with government services. Involving leaders and representatives of each community in the planning and delivery of services is essential in overcoming understandable initial hesitancies in accessing and utilizing mental health services.

Conditions of armed conflict and social upheaval have greatly limited efforts to establish durable mental health services in Afghanistan. In addition, stigma, lack of awareness, and geographical constraints on access continue to present difficulties to ensuring the equitable utilization of services. Nevertheless, important progress has been made in recent times. A milestone was the inclusion of mental health in the Basic Package of Health Services and the Essential Package of Hospital Services ⁶ in Afghanistan in recent years. Hundreds of psychosocial counsellors were deployed in governmental health facilities throughout the country ⁷ . In addition, training was provided to primary health community professionals to enable them to provide basic mental health assessments and treatment ⁸ .

A recent survey suggested that modest but meaningful gains were made during the early phase of this program in providing care for persons with severe mental illnesses, and to a limited extent to those with common mental disorders ⁹ . It would be a major setback if this momentum was lost now that the new regime has assumed power. There are compelling reasons, therefore, for the international community to continue supporting local and international agencies already operating mental health and psychosocial support services in the country.

Afghanistan has often been referred to as the “graveyard” of empires, a label likely to be reinforced by the recent crisis, and one that generates an attitude of pessimism about the value of supporting service development in the country. At the same time, international agencies in mental health have a long history of working under adverse conditions in politically challenging environments. An important principle to uphold is that sound mental health is fundamental to building a strong and resilient society whatever the conditions of adversity that may exist in the country at the time.

In relation to policies of resettlement of Afghan refugees, some simple lessons from the past should be kept in mind. Confining displaced peoples in refugee camps or under conditions of protracted insecurity only serves to prolong their mental health and psychosocial problems. Rapid resettlement and early support by providing culturally‐relevant mental health services offer the best insurance of integration of displaced persons into host countries.

Afghan refugees have already demonstrated the positive contributions they can make to strengthening their own communities and those in which they have sought asylum. The indomitable spirit of the Afghan people continues to inspire those who work with them in the mental health field by demonstrating in practice the power of mutual support and community‐mindedness that refugees can exhibit even after experiencing long periods of adversity.