After spending six weeks embedded with British Army war surgeons in Afghanistan in 2011, I figured nothing could be as disturbing as witnessing a boxful of mangled legs delivered by soldiers in the hope that they could be re-attached to the body of a blown-up colleague. Yet I was wrong.
Seeing the impact of violence first-hand on that 2011 embedded tour to Camp Bastion - the mutilated bodies of children and the countless amputations - I returned to Afghanistan in December to better understand how that country's epidemic of violence is impacting on the psyche of its citizens. And while the battlefield injuries were more visceral, the mental health scars left behind by years of brutal violence are in some ways as sad and sobering as that boxful of limbs.
"My liver is bleeding" is a common sentiment expressed by patients at the Alemi Neuro Psychiatric Hospital, Afghanistan's first private clinic, located close to the mountainous Uzbekistan border in the northern city of Mazar-i-Sharif. It's a local expression meaning simply: "I am unhappy."
Following nearly four decades of on-off war, there are plenty of bleeding livers (figuratively) among the people of Afghanistan, as shown by the 80 to 120 people a day who visit Dr. Alemi for consultations that often last only 10 minutes - some traveling 700 kilometres and spending the equivalent of two weeks' household budget on the trip.
"So it is okay for me to cry?" a woman asks from within the solitude of her pale blue frock. "It is good for you to cry," replies Dr. Alemi, who usually works until 11 pm six days a week, and recently moved his family to the hospital's upper floor so his children can at least occasionally see their father. As with this conversation, Dr. Alemi works hard at reassuring patients there is no shame in what they feel, and that their experiences are more common than they might think.
His clientele include rich and poor, psychotic and suicidal, Uzbeks, Turkmen, and even Taliban. Many recount tales of being chained, starved, and beaten by mullahs to drive out demons. One man told me that his brother is "kept chained up or else he destroys everything and everyone", a penchant for violence that began with an altercation years ago with the Taliban over unripe fruit. Many others told similarly atrocious tales of how warfare had left painful psychic wounds.
Curiously, what struck me most after ten days in Dr. Alemi's clinic, was the absence of any diagnosis of Post Traumatic Stress Disorder (PTSD). Official estimates suggest that 42 to 66 per cent of Afghans suffer from PTSD (thought it is not clear how meaningful these figures really are in a country that doesn't even know the size of its population). Yet none of the hundreds of patients during my visit to Dr. Alemi's clinic were ever diagnosed with PTSD, and Mazar's civil hospital rarely offers a formal diagnosis of it. Records of a mental health clinic in the west Afghanistan city of Herat, operated by International Assistance Mission (IAM), suggest that only 1.2 per cent of their patients were diagnosed with the disorder. The question is why not more?
There appear to be several reasons for this diagnostic disconnect.
PTSD isn't more readily diagnosed because some of its symptoms - hyper-arousal, vigilance, and anxiety - are not considered particularly abnormal in Afghanistan, so, perversely, PTSD is nowhere because it is everywhere.
Also, PTSD requires time to diagnose in even the best-resourced clinical environments, so in a country with a paucity of doctors for the number of needy patients such time for proper diagnosis simply doesn't exist. As a result, PTSD and other mental disorders are often treated pharmacologically: by popping pills, as they are generic, cheap, and easy for most patients to come by.
And PTSD isn't considered problematic because it isn't a priority in a country where many struggle to simply survive. "Mental health is part of a bigger challenge and with unemployment having spiked at 40 per cent, poverty is widespread, and so are the bitterness and self-loathing that accompany it," says Jawed Nader, director of the British and Irish Agencies Afghanistan Group (BAAG), which provided funding for our most recent research trip.
Finally, diagnosing PTSD is complicated by the reluctance of many to express how and what they feel and, because of lack of practice they loose fluency. They're ashamed of having such feelings or think it inappropriate to burden others who have plenty to worry about themselves. For this reason, the IAM clinic in Herat introduced emotional vocabulary training. "We ask people to tell others in the room how they feel, the rule being that they cannot re-use an expression already used by someone else," says its clinical psychologist Stephanie Lockery.
Perhaps this is a small but useful start in tackling psychological injury in Afghanistan - because a wider vocabulary of emotional honesty could prove contagious. Yet it's only a start and significant progress will require stability, security, and economic opportunity.
As the British psychiatrist Derek Summerfield observed: "Recovery from trauma happens in people's lives rather than in their psychologies. It is practical and unspectacular, and it is grounded in the resumption of the ordinary rhythms of everyday life."
I hope that, before long, at least some of those ordinary rhythms will return to this beautiful but haunted country.
About the author:
Mark de Rond is associate professor at Judge Business School, Cambridge University. Having deployed with a military surgical team to Camp Bastion in 2011, he returned to Afghanistan in December 2015 to look at the effect of conflict on the mental health of its civilian population. He can be contacted via email at: firstname.lastname@example.org
All photographs by Magda Rakita. Magda is a documentary photographer who focuses on health and social issues, especially those affecting women and children. She can be contacted via email at: www.magdarakita.com