The mental health dimension.

One of the most pressing issues facing Afghan refugees, especially women, today is their mental health, according to the World Health Organization (WHO) and advocates for women. Although the issue of survival takes priority, more people are recognizing the importance of the mental health of refugees and internally displaced persons.

The common mental disorders found in refugees are post-traumatic stress disorder (PTSD), depression, anxiety and adjustment disorders, and psychosomatic symptoms, say WHO experts. Noting that over 2 million Afghans are estimated to suffer from mental health problems, WHO urged the re-establishment of mental health services to treat them. Afghan refugees suffering from such illness are even worse off because, after decades of war and repression, there are no family or community structures left in Afghanistan from which they can draw psychosocial support.

A WHO fact-finding mission to Pakistan found that 30 per cent of Afghan refugees who seek medical care at local facilities are presenting psychosomatic complaints resulting from psychological illness. "One of the problems right now is the lack of information from Afghan people themselves", said Dr. Shekhar Saxena, Coordinator of the WHO Mental Health and Substance Dependence Department. "All that we have written or talked about is based on past experiences or what is likely, rather than what is actually present."

In early 2001, there were eight psychiatrists, eighteen psychiatric nurses and twenty psychologists for a population of 25 million, according to the WHO Project ATLAS: Mental Health Resources in the World. Facilities for treatment are also limited. There were fifty psychiatric beds available in Kabul (thirty for men and twenty for women). Other psychiatric facilities included two centres in Jalalabad and one in Mazari-Sharif. Patients were reported to include those tortured years ago by Soviet soldiers or later by the Taliban, as well as those traumatized by the recent bombings.

Afghan women, above all, have experienced a dramatic decline in their psychological health over the past decade. Under the Taliban rule, they were excluded from education and employment, but still had to take care of their families. In Kabul, for instance, approximately 60,000 widows had been forced to live without traditional family support. As a result, many have resorted to begging on the street, according to WHO.

An article published in the Journal of the American Medical Association found that among the 160 women interviewed in Kabul and refugee camps in Pakistan, 81 per cent reported a decline in their mental health status. Signs of depression were seen in 97 per cent, and 86 per cent reported symptoms of anxiety disorder.

"Many Afghan women and girls have also suffered atrocities, like kidnapping, forced marriage, rape, amputation, torture and other abuses", said Irena Lieberman, Director of Legal Services at the Tahirih Justice Center, a nonprofit organization in the United States that provides legal aid and social services to protect human rights for women. "Women who have been widowed and girls who have been orphaned are most at risk of suffering from continuing abuses and the lack of access to adequate health care." Most of the women refugee patients of the Center have expressed intense concern for their safety due to past and ongoing ethnic and gender-based violence, which they continue

to endure as refugees. "For these women", Ms. Lieberman said, "repatriation may be the least viable option at this time. Third-country resettlement may be the best way to ensure their immediate survival."

Drs. Saxena, Benedetto Saraceno and Pallab K. Maulik of WHO urged that the management of mental health needs of refugees and internally displaced persons should be integrated with overall health care and be responsive to all kinds and severity of illness. During an emergency phase, they emphasized, a rapid assessment of psychological problems and availability of economic and human resources should be carried out with the help of local authorities. When the initial days or weeks of shock pass, refugees are likely to experience greater frustrations, sadness and anxiety. Memories of fleeing home or the deaths of family members may provoke symptoms of PTSD and depression. The WHO experts recommended interventions in the form of self-help groups, group psychotherapy and provision of activities for youth and children. Medications, especially inexpensive and locally available psychotropics, should be used as much as possible.

For long-term management, consolidation of the initial care and building of new resources should be pursued. Ongoing training and supervision of health professionals and cooperation among various agencies, including local government and international organizations, are also vital.