On a wintry morning in Kabul, the city’s 100-bed mental health hospital, one of only six psychiatric wards in Afghanistan, was heaving with people needing help. The building shows signs that it was established with care, and even hope: The wards are separated by a garden with a fountain at its center, and there is a treadmill and a foosball table. But they are now broken and covered in dust, and the hospital ward’s bright blue walls are peeling, its windows are barred and covered in black tape, as if trying to keep the world out.
Inside, a cook wheeled a trolley with a large saucepan of food and waited for a staff member to ruffle through his pockets for a key to unlock the heavy padlock door, allowing me in to meet Dr. Shafi Azim, a clinical psychiatrist who has worked at the hospital for almost 30 years.
When we met, more than a year had passed since the Taliban’s takeover of Afghanistan in August 2021. Azim was exasperated. He said the numbers of people with mental health issues were too many for his small team. “We need sedatives to calm them. What do I do with a ward full of psychiatric patients and no medication? … There are not enough of us to care for them.”
Azim, who has worked his way up from a student learning on the job to the head of the psychiatry department, has treated thousands of patients, often the same people more than once, over the years. A slim man with a thick moustache and wide grin, it is clear he is well liked among his patients. As he navigates the hospital wards during checkups, he pauses to introduce them to me, before giving them a reassuring squeeze of the shoulder or a handshake.
Decades of conflict and instability have left many Afghans vulnerable to increased rates of anxiety, depression and post-traumatic stress disorder (PTSD). While reliable statistics are hard to come by in a deeply conservative country where social stigma is attached to mental illness, it is estimated that half of Afghanistan’s 40 million people suffer from psychological distress, according to HealthNet TPO, one of the largest health NGOs operating in the country, as of late 2021. According to the United Nations Office on Drug and Crime (UNODC), these are all risk factors for drug use and mental disorders. In 2017, the World Health Organization estimated that 1 million Afghans were suffering from depression and just over 1 million more from anxiety. This can translate into rampant drug use.
Mental health and drug addiction are intertwined, as people attempt to self-medicate with over-the-counter pharmaceutical drugs for psychological relief, a phenomenon that has only worsened since the Taliban takeover, when the international community pulled major funding from a health sector tending to a war-weary population. Now, Afghan doctors are struggling to support an increasingly desperate population with few if any resources. The challenges for the new Taliban government inheriting a major mental health epidemic are enormous.
Azim doesn’t know how long the hospital will be able to operate. It has funding for an additional five months from HealthNet TPO, he told me in December 2022. “Most of our staff have left Afghanistan, even those who had been here for 12 years,” he told New Lines. When the Taliban took control of the country, governmental staff like Azim did not receive their salaries for nearly four months. The female staff have been pressured by the Taliban to give up their hard-earned jobs and stay at home, meaning the women’s ward is unmonitored. Most of the inpatients spend at least two weeks at the hospital — free — treated with a combination of medication, psychotherapy and occupational therapy. Adult patients who can turn aggressive, and are viewed as a danger to others and themselves, are treated with electroconvulsive therapy (ECT).
I first visited the hospital some months before the Taliban takeover. Though the U.S.-backed government was still in control — and a Taliban power grab seemed far-fetched to many – the situation was already desperate. A 45-year-old man named Hafizullah had come with his friend, Amanullah, and the two were waiting to see the admissions nurse. Next to them were dozens of patients, sitting quietly, grasping plastic bags full of medication.
“Hafizullah was in the army for six years, but then something traumatizing happened and his family took him to a hospital here in Kabul,” said Amanullah. Then, Hafizullah spoke, as if recalling a nightmare. “It had hundreds of heads,” he said, staring blankly into space. “I saw this mountain before me fold in half … .” He trailed off.
“He sees things,” Amanullah explained while looking at Hafizullah. “But they don’t make sense. It’s like he is having bad dreams. Today is a good day for him. Other days, he is violent with his family and he cuts himself.” Amanullah pointed at several scars stretched across Hafizullah’s broad jaw. According to Amanullah, Hafizullah’s family found him too difficult and cast him out onto the streets.
“Now all he has is me,” he continued. “But what good am I to him?”
Amanullah has his own problems. At 26, he has been addicted to drugs for nearly half his life. As a teenager, he tried crystal meth. Then he turned to heroin. At one point he managed to kick his habit for four years, only to relapse when he went to look for work in Iran and needed something to help him get through the long hours and bleak conditions as a laborer. When he returned to Afghanistan, he found himself unemployed — and addicted. But then he found he could get high on psychotropic drugs easily bought at one of the many pharmacies lining Kabul’s streets. No prescriptions are required; money is all that is needed for a range of medications, from valium to synthetic opioids. From his pocket, Amanullah pulled out a strip of white pills commonly used to combat anxiety and depression.
When Amanullah’s family would find the pills among his belongings, he would lie and say they weren’t his. He silently flipped the strip between his fingers before his thoughts turned back to his friend. “Hafizullah needs help. I brought him here because I heard this is the only place for him,” he said. “To everyone else, he is a disease.”
Hafizullah and Amanullah are not isolated cases. Addicts — some if not most of them also suffering from mental health issues — blend in among the heaps of trash that flood out of the stagnant Kabul River. Only the whip of a curious stray dog’s tail moves in the landscape.
In January, the Ministry of Public Health said there are more than 3.5 million addicts in Afghanistan. According to the U.N., Afghanistan accounted for about 85% of global opium production in 2020. During the insurgency years, the Taliban profited by taxing traffickers, though they have consistently denied links to the drug trade in public. When the Taliban took control in 2021, ousting the U.S.-backed government and ending America’s longest war, the Taliban spokesman Zabihullah Mujahid said that, going forward, Afghanistan would be “a narcotics-free country.” The new Taliban government vowed to crack down on narcotics production and issued a decree banning opium production and the sale of illicit drugs. Months later, reports emerged of the Taliban rounding up and beating drug users in Kabul and other Afghan cities, as well as forcibly taking them to centers where they were obliged to give up their addictions cold turkey.
Yet the Taliban’s enforcement of their drug ban has proved ineffective. For most of 2022, the trade continued to thrive. While the sight of addicts huddling together under bridges and along the banks of the river has long been common in the Afghan capital, since the Taliban takeover they have now flooded into new parts of the city, sitting in front of malls and restaurants where they get high.
Nor is it only illegal drugs bought on the street that are seeing an uptick in use. It is also the private sector pharmaceuticals market, where importers and unregistered wholesalers are smuggling and selling unregulated pharmaceuticals to people hoping to self-treat their mental health struggles.
According to the Ministry of Public Health, in August last year, about 200,000 patients affected by mental disorders had been brought to mental health centers across Afghanistan within the preceding month. The ministry did not respond to questions from New Lines on the work carried out by the psychosocial counselors at the mental health department, or whether they had continued training them or their plans to address Afghanistan’s mental health epidemic.
Meanwhile, heroin and meth continue to flow out of Afghanistan in large quantities, according to a recent report by the Atlantic Council, supplying markets throughout the immediate region and beyond.
Even under the U.S.-led occupation of Afghanistan, psychology, counseling, psychiatry and psychotherapy were largely neglected professions. In addition to depression and PTSD, the most common disorders people suffer from are psychotic, such as schizophrenia and other so-called delusional disorders. Panic disorders and bipolar disorder, mania, hypermania and major depressive disorder are all common, too.
In place of professional treatment, a chaotic supply of unregulated medication has flooded the country. It is not only desperate people self-medicating, but also the doctors themselves who misprescribe. A shortage of psychiatrists means medical doctors are incorrectly diagnosing people and providing the wrong medications for their diagnoses. “Even the doctors know that what they are prescribing is useless because there are no counselors to work with patients alongside the medication,” said one psychiatrist in Kabul. “If the doctor should refer the patient to a counselor, but there is no counselor, what can he do?” Another psychiatrist in Herat in western Afghanistan, who spoke to New Lines on the condition of anonymity, described situations where “people having anxiety attacks are given seizure medicine that can give them brain damage.” Antipsychotic medication used to treat schizophrenia is “commonly used here for minor ailments,” she said. There are doctors who prescribe medicine that counteracts with other medications and children are given high doses of medication that should only be prescribed to adults, such as the highly addictive sleeping pill Ambien. “Medicines are not regulated,” she added.
There are also a large number of low-quality and counterfeit medicines on the market in Afghanistan. “When you see people’s side effects from taking the medicine, you know it is not acting as it should, so you question what is actually inside it,” she said. Even when medicines have been appropriately prescribed, people may receive fake medicines that contain little or no effective ingredients. Expired medicines are also a concern; many wholesalers and retailers do not store medicines in suitable conditions, and the medication can be damaged by temperature.
Now, as Afghanistan faces a series of unprecedented economic and humanitarian crises, the situation has only worsened. The country feels the economic strain brought on by the Taliban takeover. According to Brown University’s Cost of War project, 92% of Afghans are facing food insecurity and 97% are living in poverty. Afghanistan still lacks a functioning central banking system and, in February 2022, the U.S. Federal Reserve froze $7 billion in assets belonging to Afghanistan’s central bank. (In September, the U.S. said it would move $3.5 billion to a new “Afghan Fund,” but there has been no update since then on when the money will be released and to whom.)
Afghans have long struggled to access mental health care, largely because those services simply do not exist. Only 3% of people visiting health centers are offered help for psychological issues. In October 2022, a Save the Children report estimated that 4,460,000 children and adults in Afghanistan need mental health and psychosocial support. But when the report was published, only around 29% were able to access services and treatment.
While the Taliban-run Ministry of Public Health is tasked with regulating the pharmaceuticals market and deciding which medicines are allowed for use in public health facilities, it lacks the capacity to regulate the wholesale, retail and particularly the import of medicines that are brought into the country both through legal and illegal means. While privately imported medicines are nominally limited by a list of medicines licensed for use in Afghanistan, the sheer quantity of unregulated pharmaceuticals brought into the country greatly outweighs the capacity of both the ministry and the customs and border guards who are supposed to control them.
The ministry did not respond to questions as to what the Taliban government is doing to monitor the flow of illegal pharmaceuticals that arrive on the Afghan market.
In January 2020, I found myself herded between the heavy blast walls at the Ministry of Public Health in the center of Kabul. Inside stands an imposing concrete building at odds with the warm morning sun streaking across its dirty windows. On the third floor, I met Dr. Bashir Ahmad Sarwari, a psychiatrist who oversaw the department of mental health and substance abuse, a position he had held for a decade until the Taliban took control of the country.
Since mental health is rarely discussed in public in Afghanistan, Sarwari knew he had his work cut out in trying to stop Afghans from turning to cheap pharmaceuticals, especially when they are being smuggled into the market at rapid speed. Most are imported directly from Pakistan and India, with Iran and China also significant sources, he added. “They are producing medication to meet Afghanistan’s demand but there is no way to regulate the medication or check the quality of each tablet in each pharmacy.”
New brands of pharmaceutical medicines are constantly appearing on the market, but the country’s current inspection, sampling and testing facilities are inadequate to ensure basic standards of medicines and there are no adequate testing facilities at border points. Landlocked Afghanistan’s long, porous borders, especially those with Iran and Pakistan, allow counterfeit medicines to be smuggled in, avoiding border inspection altogether. “Do you know how many kilometers of the border we do not have control of?” Sarwari asked rhetorically.
From the 1970s until the early 1990s, Afghanistan was a producer of pharmaceuticals and was working on developing its own export market. However, there was also a large uncontrolled drug trade from Pakistan and Iran in the areas controlled by mujahideen guerrillas. When the communist, Moscow-allied government system began to collapse 30 years ago, private individuals moved in to capitalize on the pharmaceutical imports. A 2005 report noted how Afghanistan was never able to build up its domestic production to eliminate its reliance on imports because the country lacked a significant manufacturing capacity or its own chemical industry to produce active raw ingredients for medicines.
During the time of the U.S.-backed previous government, hospitals and clinics relied on donor supplies for medicine and overall funding — 75% of total public health expenditure came from external aid, including funds granted by the U.S. Agency for International Development (USAID) to the International Committee for the Red Cross. In 2004, the government budget for mental health was a tiny 0.1% of the total health budget. By 2020, it had increased to 3.4% of the total health budget, used to train 850 psychosocial counselors in 400 clinics nationwide. This meant that basic services for psychosocial support could be provided, but there were no specialists to deal with deep-rooted trauma.
Sarwari said that corruption also allowed medicines donated by global aid organizations to be seized at border points and sold in private pharmacies in the country or exported for sale in neighboring Pakistan. But after the Taliban seized power a year and a half later, aid largely stopped flowing into the country. The World Bank and other international donors froze $600 million in health care aid. The WHO warned that two-thirds of the roughly 2,300 health care facilities it supports had run out of essential medicines. Only about 400 were functioning, with some medical professionals working without pay for up to five months.
The challenges of replacing Afghanistan’s long-standing dependency on medication with virtually non-existent psychological support are huge. This has created incentives for private hospitals to attract and treat more paying patients, although the country’s dire economic situation means that even these will not last long.
Toward the end of 2020, I visited a female psychiatric ward in Herat’s regional hospital, where I spoke to one of the women psychiatrists on duty. Her slight frame disappeared into groups of relatives as she bustled about, pausing to make notes in patients’ charts and check IVs. The patients were silent, stretched out on bright blue mattresses. Curious children peered through the barred windows of the ward. The psychiatrist, who has since told me she wishes to remain anonymous given the Taliban takeover of the country, told me stories of “women suffering from family violence, self-immolation, gender violence and rape.”
The prospects for women and girls needing mental health treatment were always harder than the situation for their male counterparts. Indeed, due to the fact many women stay at home, the scale of their need is not even known. This has undoubtedly worsened since the Taliban takeover. They have systematically erased Afghan women from public life, depriving them of basic rights including education and imposing restrictions on their employment, clothing and freedom of movement. A report from October last year by Save the Children found that one in four Afghan girls shows signs of depression or anxiety. The female psychiatrist in Herat is no longer working, pressured by the Taliban.
She is now trying to leave the country. “There is no future for me here. Without my freedom to work, I cannot help my patients,” she said dolefully.
In the outpatient department at the Kabul mental health hospital, staff and psychologists check patients’ medical history, diagnose them and, if needed, prescribe medication. Then, there are supposed to be regular follow-ups with the patient at home.
However, this is more difficult for patients who have come from outside the capital, often because they cannot afford to keep coming back. Patients are frequently given one month of medication when they are discharged, because they need evaluation each month to see if the medication is working. “But many families cannot afford the transportation fees to bring them back for their evaluation,” Azim added, “or the patients don’t come back and instead purchase the medication themselves, including antipsychotics that aren’t very expensive.”
He stressed that it is important for patients’ families to support them while they recover.
“Our psychologists explain the patient’s condition and how to care for the patient but, unfortunately, many families just don’t have money to buy the medicine or they don’t have time to follow our prescription timetable,” he said. “Other times, they cannot convince them to take their medication, and so we see the patients returning to us.”
Azim sees many patients with chronic conditions returning over the years. “They know me; I know them.” Other times, multiple members of a family come to the hospital with the same disorders. When he met Hafizullah and Amanullah in the hallway, he immediately recognized Hafizullah.
“He brought his schizophrenic brother here,” he told me, smiling sadly. “Now, he is the one coming in.”
Azim described a father who was bipolar who was brought into the hospital by his sons. Months later, one of the sons came in. “We have so many cases like this, but there are few studies on generational trauma and generational mental disorders in Afghanistan.”
Looked at more broadly, there are consistent indications that decades of occupation by foreign forces lead to increased psychological stress, said Jan Kizhilan, a German Yazidi psychotherapist who specializes in trauma and works with war victims in Iraq and Syria. “In each generation, there are individual, collective and historical traumas that have been passed on to subsequent generations,” he told New Lines.
“If treatment is not done in time, it is likely that other mental illnesses will develop,” he added.
Four months on from the Taliban takeover, the mental health hospital in Kabul was struggling. “We are trying to keep the hospital open but we are running out of food for our patients and staff,” said Dr. Ahmad Khetab Kakar, who has been the hospital’s director for four years.
Kakar’s office at the front of the hospital building is decorated with an array of framed certificates, tokens of his achievements over the years. He sits down behind his large desk, adjusting his glasses, to look over a stack of folders a staff member had brought in and piled up in front of him.
Efforts by the Ministry of Public Health to do outreach, promoting mental health awareness and training staff in the provinces are gone now, he said.
“Unfortunately, the number of mentally ill has not decreased; the mental health issues have become more severe, particularly among women,” he told New Lines. When the Taliban took over, the center established to train mental health professionals ceased activities. Now, some funding makes its way into the country, but international NGOs direct it straight to the hospitals, bypassing the Taliban-run ministry. Kakar said his hospital is running out of fuel.
At the end of last year, after Afghanistan had been under Taliban control for a year and four months, I reached out to Azim again. He told me Kakar had been replaced as director of the hospital. Azim was still working.
“We have saved lives here,” he said. “It is possible to help people. This is the one thought I hold onto.”
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