Following is the text of the WHO Special Report:

World Health Organization (WHO)

6 Nov 2001

WHO SPECIAL REPORT Central Asia Crisis Unit

The invisible wounds: The mental health crisis in Afghanistan

In the remote central highlands of Hazarajat, Afghanistan, one of the most prevalent reasons patients visit the local health center is fear.

Dr. Leena Kaartinen of the NGO Healthnet International first started treating patients in this isolated region in 1985. She says the greatest health problem facing the people, who are primarily Hazaras, is psychosocial distress.

"The community is very protective, but the population lives in fear. They worry about everyday survival. They are terrified of military attacks. They come to the clinics with pain that isn't linked to any physical condition. I just listen to them carefully and they are relieved," says Dr. Kaartinen.

Twenty-three years of war have ravaged the mental health and psychosocial functioning of the people in Afghanistan. Killing, executions, massive persecution, forced internal displacement, fear associated with living in mined areas, and the latest escalation of violence have left an indelible mark on the population. In addition, the psychological impact of living in uncertainty affects at least three million Afghan refugees.

Not only does Afghanistan hold the unenviable position of one of the worst health care situations in the world, it is also grappling with a hidden medical crisis: severe mental suffering resulting from decades of conflict and repression.

Women, in particular, have seen a dramatic deterioration in their psychological, family and social life over the past decade. Excluded from education, and employment, they have enormous difficulties accessing health care while still having to care for other family members. Widows, pregnant women, and survivors of sexual violence are particularly vulnerable. In Kabul alone, an estimated 60,000 widows are forced to subsist without traditional family support. Many suffer the humiliation of having to beg, yet are punished for roaming the streets without male accompaniment.

Updated statistical data about mental health care in Afghanistan doesn't exist. Over-all world statistics in normal circumstances suggest that more than 3% of the population suffer from a grave mental disorder at any point of time. This means that hundreds of thousands of Afghans are likely to be suffering from severe mental illness with no opportunity for any treatment under the current circumstances.

Research shows that in conflicts, 10% of people who experience traumatic experiences will have serious mental health problems and another 10% will develop behavior that will hinder their ability to function efficiently. In Afghanistan, some five million people are very likely to be affected by psychosocial distress. The most common conditions are depression, anxiety and psychosomatic problems, such as insomnia, or back and stomach aches. Traditionally, people suffering from the consequences of trauma are able to benefit from the support of the family and the community. But communities in Afghanistan have been destroyed by decades of fighting, and such support systems are very rare.

The opportunities for psychosocial support are almost non-existent in Afghanistan. First, there is an extreme shortage of trained mental health professionals. WHO's Project ATLAS revealed that early in 2001, for a population of 25 million, the reported number of psychiatrists was just eight in the entire country. There were only 18 psychiatric nurses and 20 psychologists.

Facilities for treatment are also extremely limited. There are 50 psychiatric beds available in Kabul: 30 for men, and 20 for women. Other facilities include two [ReliefWeb]centers in Jalalabad, and one in Mazar-I-Sharif. There [ReliefWeb] is no way of knowing whether these centers are still functioning today and whether the psychiatrists are still in Afghanistan.

"Mental health resources in most countries are grossly insufficient, but the lack of available care in countries in conflict, such as Afghanistan, is especially alarming," says Dr. Shekhar Saxena, Coordinator in the WHO Mental Health and Substance Abuse Department.

Already in the 1980s during the war against the Soviet Union, medical groups such as Medecins sans Frontieres and Aide Medicale Internationale warned of growing numbers of young fighters suffering from psychological problems. They also reported that many refugees who had seen family members killed or executed in front of them were suffering from mental distress.

Five years ago, research carried out in Afghanistan pointed to an increasingly dire mental health crisis, especially among women. An article published in the Journal of the American Medical Association highlighted the deteriorating mental health situation of women in Kabul and refugee camps in Pakistan. Of 160 women interviewed, 81% reported a decline in their mental health status; 97% showed signs of depression, while 86% had significant anxiety symptoms.

The grave vulnerability of children in Afghanistan was revealed in 1997 through a survey carried out by UNICEF. Three hundred children in Kabul were interviewed: the results indicated that 40% had lost a parent; 2/3rds of them had seen dead bodies or parts of bodies and 90% believed they would die during the conflict.

A WHO fact-finding mission to Pakistan recently found that 30% of the Afghan refugees who seek medical care at local health care facilities are presenting psychosomatic complaints resulting from psychological problems. The harsh evolution of the Afghan conflict is leading health officials to warn of a large-scale mental health crisis in Afghanistan.

"This catastrophic situation calls out for an immediate and comprehensive response," says Mary Petevi, psychosocial specialist at WHO's Emergency and Humanitarian Action Department. "The international community must consider psychosocial health as urgent as physical health problems."

Given the magnitude of the problem and the scarcity of resources, WHO appeals for greater international awareness and financial support for psychosocial programs. Emphasis must be placed on carrying out rapid assessments and training trainers in psychiatric care and psychosocial action. Mobilization, empowerment and active participation of the affected community in its survival is critical. Even if such support in Afghanistan may be currently too complex to implement, all efforts should be made to provide emergency psychosocial support to refugees in neighboring countries.