Afghanistan is in urgent need of a 'mental health first aid' programme

An Afghan woman begs on the snow in Kabul, Afghanistan. AP

The world watches with heartbreak and horror as women disappear from the public sphere in Afghanistan. This happens as the Taliban impose increasingly stringent regulations over their education, employment, leisure and movement. They justify this as response to women not wearing hijab properly.

Other Muslim countries remonstrate amid worldwide outrage, with some leaders labelling such treatment of women as gender apartheid and even crimes against humanity. But two years on, the criticism appears to be of no avail.

Meanwhile, long-standing sanctions targeting Taliban individuals and enterprises have isolated and crippled the whole country, with nearly a third of its republic-era GDP having disappeared. Perversely, even humanitarian provision is severely impaired.

The UN has declared Afghanistan to be the world’s largest humanitarian crisis, with 28.3 million people requiring urgent help. But only 27 per cent of its $3.23 billion appeal for 2023 has been funded, with delivery compromised by complicated financial transfers and restrictions on women aid workers.

How do increasingly impoverished and hungry Afghans manage? Amazingly, despite the perils, some remain defiant. However admirable that is, their resilience only goes so far.

Many Afghans have left: over 5.6 million – a staggering 13 per cent of the population. Afghanistan is the third-largest source of refugees (after Syria and Ukraine). Other migrant categories add to an estimated 8 million Afghans scattered across more than 100 countries.

Afghans abroad are famously enterprising, wanting nothing more than to make safe, self-sufficient lives. But the life of an exile is no bed of roses. Those fleeing take mind-boggling risks only to be trapped in bureaucratic quagmires or suffer mundane knock-backs.

Taking chances in our callous world requires strength and means, and most forced Afghan migrants are men. Women are left behind – encumbered by children, family obligations, social traditions and plain coercion. Their impossible situation was highlighted when female students were prevented from taking up UAE university scholarships.

The women left behind are more likely to encounter violence than their sisters in other countries. According to UN data, eight in 10 Afghan women have been victims of sexual, physical, or psychological violence, with forced marriages and domestic violence most prominent.

The outcome of Afghanistan’s trauma, and its outsized impact on women, is unbearably tragic. According to the World Health Organisation, suicides are globally twice more common among males than females. But Afghanistan has long been the only place in the world where the suicide rate for women is higher than for men – since even before the Taliban came to power. It is thought that up to 80 per cent of suicide attempts in the country are by women. It appears that the gender war on women has become internalised as a war by women on their own selves.

I recall that the most distressing part of my past work as a hospital doctor in Britain was admitting people attempting suicide. I logged around 300 heart-rending cases over six months, of which three died on my watch, while 25 were not rescued in time to be brought to hospital. That conforms with global figures that nine out of 10 suicide attempts do not end in death. They may be cries for help.

How many of those cries are heard in Afghanistan? We don’t know for certain, and not just because of the shattered country’s data systems. Suicide is prohibited in Islam – and other religions. Even in my own extended family in India, our elders feel ashamed to talk about the relative who killed herself some years ago.

Additional misconceptions and stigma put pressure on medics to avoid suicide death certification, and spare further distress to families. Also to consider are legal implications, for example, for insurance pay-outs, inheritances or even intrusive police investigations.

Thus, suicide is under-reported globally. Nevertheless, it shows a stable or slowly declining trend over the past two decades. But not so in Afghanistan, where recent hospital surveys suggest a grim uptick for women.

The testimony of self-harming survivors suggests why they are driven to take extreme measures. “Our lives are an empty shell. What is there to live for?” they assert. The driving of so many women into their homes by excluding them from public life should find resonance in everyone who was locked down for months during the Covid-19 pandemic. That led to a 25 per cent increase in anxiety and depression including suicidal ideation especially in young women, according to WHO.

That is not all. Female despair feeds on longstanding mental health vulnerabilities that precede the Taliban. Afghanistan has known little but conflict and disruption compounded by poverty and disaster over several decades. Researchers estimate that half the population have experienced some form of mental illness including post-traumatic stress.

Findings across countries in prolonged crises indicate the intergenerational transfer and magnification of population-wide trauma. An especially sinister effect is increased violence against women in domestic and community settings.

Mental illness is neglected worldwide. Even more so In Afghanistan, where the little aid it gets is driven by day-to-day physical survival needs. But people can’t live on bread alone.

The modest mental health services the country once had have withered away. And draconian access restrictions mean that mentally distressed females needing women counsellors can’t find them quickly. The pipeline of future women psychologists and psychiatrists is also empty.

This is a mental health crisis of unprecedented proportions, topped up by an epidemic of female self-harm. While advocating for changing the Taliban’s treatment of women remains essential, it is unlikely to bear fruit anytime soon. Neither is it sufficient to invest a small share of the humanitarian cake in repairing mental health services. This will always be too little and late.

Instead, a public health approach is essential through a mass programme of low-cost mental first aid. Like physical first aid that saves countless lives in wars and accidents, this is about community skills to handle psychological trauma through awareness of risk factors, alertness to warning signs, especially around self-harm, communicating with empathy and respect, and building non-judgemental solidarity networks that strengthen coping capacities.

Many countries offer mental health first aid services with techniques that rely on established science. They are also available online. Why not in Afghanistan?

Afghans will take their own time to find solutions to their many complex problems. But healthier minds – in women and men – are a pre-requisite for that and for constructing a society that works for all.

It is never too late for Afghanistan to embark on the long journey towards better mental health. And it could also save precious lives along the way.