Jummaghul rests in one of the private rooms at the hospital. In the past, Jammaghul was often beaten by her husband, especially on her head, which her sister believes led to health problems. Jammaghul divorced her husband about 10 years ago, but she rarely sees any of her 5 children, which causes her great distress. She now lives with her brother, who brought her to the hospital. Mazar e Sharif, Afghanistan. December 2015.
Billboard advertising Doctor Alemi’s Hospital on the outskirts of Mazar e Sharif, where it is located. It is the first private hospital in Afghanistan to provide services for patients with neurological and mental health problems. Mazar e Sharif, Afghanistan. December 2015.
With a continuous stream of outpatients to attend to there is little or no privacy. Patients and their relatives are called into the consultation room where diagnosis and treatment are discussed in the presence of others waiting their turn. Doctors use basic tests and X-ray to eliminate other potential causes of health problems. Male patients have their vital signs checked behind the screen. Mazar e Sharif, Afghanistan. December 2015. Photo: Magda Rakita/BAAG
Waiting room for outpatients in Alemi’s hospital. Doctor Alemi and his junior doctors see up to 120 patients a day, 6 days a week. Many travel long distances to be here, some as many as 700 kilometers. Mazar e Sharif, Afghanistan. December 2015.
The main hall of the hospital with a notice board that displays portraits of staff members. Doctor Alemi has on-going problems with recruiting qualified staff. Some of his junior doctors want to leave Afghanistan. He has managed to convince some of his children to take an interest in the hospital, where they now work. Mazar e Sharif, Afghanistan. December 2015.
Doctor Alemi works a shift in the public hospital every morning and sees up to 120 patients in his private clinic every afternoon. During his lunch break, he answers phone calls from patients and their families seeking advice. Many patients who live far away can’t afford frequent visits and rely on this remote advice and locally sourced medicine. Mazar e Sharif, Afghanistan. December 2015.
Najeebullah was diagnosed with schizophrenia and drug-induced psychosis. Prior to coming to the hospital he had become increasingly aggressive and stabbed one of his family members. Chaining those who become aggressive as a result of mental illness is often the only way families without access to treatment can protect themselves against the aggression. However, it does violate patients human rights and doesn't provide long term solution for both patients and their family which can only be achieved by improved access to specialised medical care. Mazar e Sharif, Afghanistan. December 2015.
Mohammad sits on the bed while his mother - Bibi Oghel – rests. Mohammad says she was very worried and unable to communicate. Relatives can stay overnight in the same room as those they accompany. One night stays in the hospital cost 1500 Afghanis (about $23) and some families borrow money to cover these costs. Mazar e Sharif, Afghanistan. December 2015.
Sayed was brought to the hospital by his son. He talks to himself, beats himself, and has night terrors, all of which have had a profound impact on family life. Fearful, the family resorted to keeping him chained up. Sayed was diagnosed with schizophrenia. As long as he takes his medication regularly he should be able to function normally, but there are no pharmacies where the family lives and they spent the equivalent of 2 weeks of the household budget to visit Doctor Alemi. Mazar e Sharif, Afghanistan. December 2015.
With so many patients travelling long distances for consultations with Doctor Alemi, most of the treatments are pharmacological. Generic drugs are imported from India, Pakistan or Iran, and have to be cheap and available in the areas where patients live. If not, patients won’t be able to continue treatment, and many are not able to afford repeat trips to the hospital. Mazar e Sharif, Afghanistan. December 2015.
Dr. Alemi and his colleagues check on patients at the public hospital. Her older sister brought in Rahima for treatment. Rahima’s husband did not have money to pay for the trip and medicine. They struggle financially and their oldest son had to leave school to support the family. He works as a day labourer and gets paid about 200-250 Afghanis a day ($4) if he gets work. They don’t even have a stove at home to heat it during the winter, Rahima says. She believes the financial worries are a reason for her health problems. “When there is nothing at home I worry,” she said. Mazar e Sharif, Afghanistan. December 2015.
A family gathers around a patient in the neuro-psychiatric ward in Mazar’s public hospital. Patients with mental health issues often share rooms with patients with neurologic problems as they are treated in the same hospital ward. Mazar e Sharif, Afghanistan. December 2015.
Her children brought Zahra to Mazar’s public hospital after her depression got worse. They said she has taken medication for as long as they can remember. Zahra believes her problems began when she was very young when she was often scared at night whilst looking after cattle in the desert. Mazar e Sharif, Afghanistan. December 2015.
Amanullah was diagnosed with bipolar disorder. He became aggressive towards family members, who chained him and later took him to the local mullah who ordered him locked up in a dark room for 40 days. He stills bears scars on his hands following daily whipping by the mullah, using a horsewhip, as part of the ‘treatment’ to scare out the bad ‘jin’ blamed for his behaviour. Mazar e Sharif, Afghanistan. December 2015.
Mullah Sakhi Jan says a prayer over a 13-year-old girl who was hit by a car the day before and had injured her leg. Many come to mullahs for guidance and help with medical problems, including those with mental health issues. While some mullahs, after offering traditional prayer and amulets, tell their clients to go see a doctor, not all are as progressive. Mazar e Sharif, Afghanistan. December 2015.
Raesa comforts her daughter Lisa while waiting to see a doctor. Since an attack on their house in Kunduz in October, when they had to escape with only a change of clothes, Lisa has difficulties sleeping and focusing, and often cries. They visited a mullah, who insisted she was just a little scared. The mother says “Every minute we think about war. What if they come? We don’t have money and means to escape. Until the war ends, this disease will be everywhere.”
The taxi driver no longer plays music. It doesn't fit the mood of his customers as everyone’s grown more silent and worried, he says as he drives me around city of Mazar-e-Sahrif in northern Afghanistan.
He knows the places I visit – Dr. Alemi’s Hospital – the first private hospital to specialise in neurological and psychological disorders in Afghanistan, or Mullah Sakhi Jan, a religious leader. Many of his clients go to either or both for help with mental health issues. I want to talk to them to get a better understanding of how they deal with psychological injury.
Afghanistan and its people have endured over three decades of uninterrupted war. We typically learn about just one side of that conflict through stories of returning soldiers who show symptoms of war-related trauma. We understand that war has an effect on people’s wellbeing, even years afterwards. But for people here in Afghanistan conflict it is the only way of life they know. So how are they affected by it psychologically? Some estimate 40-60% of Afghanistan’s civilian population to suffer from Post Traumatic Stress Disorder. Yet few of those who seek treatment are actually diagnosed with it. Symptoms of PTSD, like flashbacks, hyper-vigilance, or being suspicious of afraid to leave the house, are not considered particularly abnormal. What is considered abnormal in a communal society where large families often live under the same roof is for people to withdraw socially, or to suffer angry outbursts. Thus, typically, people will be diagnosed with, and treated for, major depressive disorder or anxiety.
Another reason why PTSD isn’t more commonly diagnosed is that people are often reluctant to burden others with their problems. They have, after all, plenty problems of their own. As a result, people loose fluency in the ability to express themselves emotionally. They might say that their liver is bleeding, to indicate they are sad, or that their throat is tight to tell others they are feeling anxious or afraid. It is up to the psychiatrist or mullah to probe deeper for clues to their ailments, and depression and anxiety are often more quickly diagnosed than PTSD. Besides by treating these one alleviates many of PTSD’s symptoms in any event. For Doctor Alemi, treatments are typically pharmacological: people are given a pill to pop. This serves patients well, particularly those who travel for up to 700 kilometers to see him.
Many patients tell stories of experiencing conflict first-hand, even within the home environment. Relatives talk of how they struggle to live with those who are mentally unstable, and how chaining them is often the only way they can protect themselves. That said, and as many will admit, the underlying cause of so much misery is often endemic poverty and joblessness. With unemployment at an all-time high, and with so many NGOs withdrawing from Afghanistan, their prospects are unlikely to improve any time soon.