War, cultural beliefs and a lack of infrastructure all have combined in Afghanistan to create a virtual maelstrom for families dealing with mental illness. There is only one hospital in the country with a psychiatric ward, and it has a mere 60 beds, 20 of which are dedicated to treating drug abuse.  (A variety of other hospitals in the country have beds for treating people dealing with mental illness, but the focus in those is rarely on treatment.)  With the lack of governmental or privatized supports, families who have a member dealing with mental illness often opt instead to bring their mentally ill to shrines around the country where the clients are chained outside when it is hot, inside when it is cold.  They are left at these shrines for 40 days and 40 nights and the belief is that God will cure them.  In spite of the few improvements that outsiders see, such as lowered blood pressure because of the minimal diet, the people who run the shrines and the families that utilize them report miracles.  Individuals are cured regularly the legends report; statistics and observation seem to speak otherwise.  In the context of this paradox, 68% of the country is probably dealing with some sort of Axis I disorder.

Wali Sutani in a shrine for the mentally ill. (Photo from Chicago Tribune)

Wali Sutani in a shrine for the mentally ill. (Photo from Chicago Tribune)

This article makes me think a lot about the challenges implementing effective medical care of any kind can have within cross-cultural contexts.  A year ago or so, I read the book The Spirit Catches You and You Fall Down by Anne Fadiman, a book about a Hmong family in central California whose daughter had epilepsy.  It covers the work the doctors, social services, and family went through to cope with their three year old daughter’s illness.  According to the Hmong worldview, epilepsy was a blessing, a sign that she was gifted and was going to eventually become a shaman.  According to most of the doctors’ view, epilepsy was an illness that needed treating.  According to the social services system view, it was the families right to practice their cultural beliefs however they wanted, as long as they were compliant with her medications.  Each system wanted what the best for the child; each system believed that best was something dramatically different.  Due to a variety of factors, the child eventually passed away.  Throughout the course of the book, the author speaks about individuals in the various systems and one doctor’s appraisal in particular appealed to me.  He was the one doctor in the area that the Hmong families most often went to out of choice.  When asked why he was so successful with their families, his reply was simple.  “Their lives are not my own.”

The lives of the people dealing with mental illness in Afghanistan are not my own.  Their plight is not my own.  Their problem is not mine, and their solution in all likelihood, cannot come from me.  When I first read this article, solutions started to pop into my mind, but am I really even correctly identifying the problem?  If the culture in which the people live does not identify a problem, is there one?  By the same token, I believe that there are some rights that all people should have access to, regardless of cultural orientation, ethnicity, religious beliefs, or even actual physical availability.  In my heart of hearts, I believe myself to be somewhat of an idealist.  Medical care is one of the rights that I believe all people should have access to; I believe that mental health coverage is one aspect of that basic right.  With that set of biases on the table, I would like to purpose some ideas.

For the situation in Afghanistan, I wonder how effective starting at the ground level would be.  Sunni Muslims don’t agree with the use of the shrines talked about in the article, but the article doesn’t cover what the Sunni majority thinks about mental illness in general.  I wonder if using Afghani community leaders to educate their own people about mental illness and the effectiveness of treating many of the Axis I disorders the population seems to be dealing with would be effective in curbing the use of the shrines.  Perhaps working with the people who run the shrines to develop more humane conditions for the inhabitants would be effective.  I would also like to see a systemic study of the effectiveness of the shrines in treating what the families perceive to be the major treatment issues.  (If the family’s main issue is violent behavior, how well does 40 days and nights at the shrine effect violent behavior upon return?)  Ideally, I would like to see Afghani people doing most of this work as well because I think it would have more credence for the population.  What do you think?

American Psychological Association (2008, December 26).  Mentally ill suffer in Afghanistan: Afghanistan lacks system to treat them. PsychPort. Retrieved December 29, 2008, from http://www.psycport.com/showArticle.cfm?xmlFile=knightridder_2008_12_26__0000-0231-TB-Mentally-ill-suffer-in-Afghanistan-1226.xml&provider=