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Mental health of Afghan refugees in Pakistan: a qualitative rapid reconnaissance field study

Azaad Kassam & Anar Nanji

For the past 25 years, Afghanshave accountedfor the status, socio-economic disadvantage, poor greatest number of displaced persons in the world. A physical health, collapse of social supports, large proportion of this population has sought psychological distress, and di⁄culty adapt- refuge in neighbouring Pakistan. Many Afghan ing to host cultures (Jablensky, Marsella, refugees have experienced unimaginable su¡ering Ekblad, Levi, & Jansson,1992). Any of these due to war and its consequences. Mental health is factors may in£uence the vulnerability and an essential aspect of the care of refugees, yet the coping abilities of refugee populations. mental health and well-being of Afghan refugees Mental health then, must be considered an has not been well studied. This qualitative ¢eld essential aspect of refugee health. survey endeavours to gain some understanding of collective factors in£uencing mental health in a The Afghan crisis refugee camp in Karachi, Pakistan. We present For the past 25 years, armed con£ict has ways of expressing distress, various sources of stress, a¡ected the people of Afghanistan. The and some of the coping mechanisms utilised by the Sovietoccupation inthe1980’sandthe power refugees in this camp. On basis of these results, some struggles after the fall of communism in recommendations are given. 1992 devastated the country.In1994 theTali- Keywords: Afghan refugees, mental ban movement emerged. This movement health, distress, coping, intervention spread through a large area of Afghanistan, and at the time of this study (1999), the Taliban controlled about two thirds of the Refugees and mental health land. With the introduction of Taliban The World Health Organization (1985) extremism came an abrupt change in social stated that ‘war is the most serious of all norms in Afghanistan (Rasekh, Bauer, threats to health’. War a¡ects all areas Manos, & Lacopino, 1998). Afghan citizens of human existence and often results in were persecuted for a number of o¡ences, the forced migration of populations as including belonging to a minority ethnic refugees. group (for example, Tajik or Hazara). Prior In crisis situations such as disaster-induced to the Taliban movement, women were displacement, relief organizations tend to be included in the work force and free to move preoccupied with emergency relief logistics about. Since the decrees of theTaliban came and mental health issues notoriously receiv- into e¡ect, women havebeen requiredto stay ing low priority status. Refugees are exposed withinthehome (withtheexceptionofhealth to a number of risks that may a¡ect mental care professionals), to be out of male view, health, suchasmarginalizationandminority and to abide by a strict dress code which

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requires them to be covered from head to toe Methods in a Burqa (shroud). Furthermore, violations The rapid reconnaissance method involves of these codes resulted in public beatings. a qualitative, exploratory, ¢eld-oriented ap- Men were persecuted for o¡ences such as proach where the methodology can evolve having a short beard and laughing in public. during the course of the study. It is best Children were beaten in public for o¡ences utilized to gain basic information in a very such as £ying a kite.These changes‘represent short period of time (Patton, 1990). A pro- a striking departure from past religious and posalto conductthisbrief study was accepted cultural practices of Afghanistan’ (Rasekh, by the Department of Community Health etal.,1998).Therefore, itcanbe saidthe social Sciences at the Aga Khan University, fabric of Afghanistanitself underwentdrastic Karachi, Pakistan and Focus Humanitarian assault. Assistance Pakistan. The events following September 11, 2001 The authors conducted thisbrief exploratory have once again changed the socio-political study at one refugee camp in Karachi in landscape of Afghanistan. One of the results May andJune of 19991.The camp was chosen of the Afghan con£icts is the forced displace- because of its accessibility and proximity to ment of over 2.7 million people.‘Afghanistan the Aga Khan University, the institution continues to be by far the largest country under which the study took place.The camp of origin of refugees under UNHCR care’ was meant to be a place of transition prior (United Nations High Commissioner for to ¢nding more permanent housing in Refugees, 2004). This has remained the case Karachi. It was thus known as a Transit forovertwenty years. Pakistanhaswelcomed Centre. over 1.2 million Afghan refugees (UNHCR, During the eight ¢eld visits, e¡orts were 1999,2004).The majority reside inthe North- made by the (male)primary author and a west Frontier Province, Balochistan and the female research assistant to build rapport Punjab. Many have migratedtothe country’s with the community. Con¢dentiality, sensi- largest city, Karachi. Some live within the tivity, and cultural appropriateness were general Karachi area while others remain given the utmost attention. Participants in refugee camps establishedby the UNHCR were selected using convenience-sampling and other organizations. methods including chain sampling (asking Despite this statistic, the published litera- one key informant to identify another)and ture concerning the mental health of Afghan opportunistic sampling (choosing infor- refugees is remarkably sparse. Thus, we mants based on knowledge gained through- set out to explore some of the factors that out the study). Using translators, individual may impact the mental health and well- key informants were interviewed and focus being of Afghan refugees residing in refugee group discussions were conducted in both a camps.Wefocusedonexperiencesconsidered semi-structured and unstructured fashion. to be distressing by the community, and Seven refugee individual informants includ- the ways in which they were coping with ing ¢ve males aged 16^23 and two females their situation. We present our ¢ndings in their early twenties were interviewed. and discuss some of the implications for The ¢rst focus group consisted of ¢ve adoles- mental health work with refugees, especially cent males, aged12^17; the second had eight those living in refugee or displacement males aged 15^23, and the third group had camps. 12 middle-aged men. Two groups of eight

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females, each aged 18^55 and 12^58, as well In two of the male focus groups, the eldest as one group of 20 women aged 14^60 were individual often spoke on behalf of the rest interviewed. Other sources of information of the group. This was not the case within included four Transit Centre volunteers, the female focus group discussions. Com- Transit Centre administrators, a medical munication was challenging, as the inherent o⁄cer and one managerial physician. limitation of using translators was coupled Detailed ¢eld notes were kept and observa- with doubletranslation from Persianto Urdu tions were recorded using paper. No audio to English on several occasions. Also, vague or video recording equipment was used for responses were frequent, possibly due to interviews. After the ¢eldwork was com- remnant fear of persecution by the Taliban pleted, the data were reviewed along with for expressing one’s thoughts and feelings, some literature in the ¢eld of refugee mental concerns about insulting the camp adminis- health, and consultations were with some tration by expressing one’s opinions, and experts in refugeeandculturalmental health. di⁄culty in discussing traumatic events. As Based onthis, we have organized our ¢ndings Rousseau, Drapeau, & Corin, (1997)noted, intothemes, as presented inthe Resultsbelow. this vagueness is often a limitation of trauma research. Results The identity of the researchers may have also Given the methodology utilized in this study, in£uenced what information was revealed. it would be prudent to discuss the limitations Although (Canadian)foreigners, both re- of the study from the outset, as it may in£u- searchers were recognized as members of ence the manner in which the results the same Islamic sect as this Afghan com- are interpreted. A pre-¢eldwork literature munity.Thus, theresearcherswerelikely per- review could not be conducted as access to ceived as both insiders and outsiders by the journals and other references on refugee community. The personal characteristics of health were limited. Also, time constraints the interviewers and interpreters may have limited preparatory work as well as the allowed free access to certain information duration and number of ¢eld visits. This and limited access to other areas. Overall, it was intensi¢ed by extreme heat at the ¢eld was our impression that we were presented site and unfamiliar working conditions. with the collective discourse of the com- However, these conditions also facilitated a munity as a whole, with limited access to greater understanding of the true situation the singular-individual experience. within theTransit Centre. TransitCentrecharacteristics.TheTransit Centre Other inherent limitations in the study housed approximately 1400 refugees. The design included: di⁄culty in choosing the community was Farsi (Persian)speaking, most appropriatekey informants andgroups, Hazara in ethnicity, Shia Muslim, and origi- a limited opportunity for observation, and nated from the Afghan provinces of Mazar- key informant bias coupled with researcher e-Shari¡, Kabul, and Pul-i-Khumry. The bias. Centrewas meant to house refugees forabout Cultural norms in£uenced the selection of three months, and then help them relocate participants. For example, members of the to more permanent housing. However, many community would often join discussions in refugees had been there for longer periods progress. Thus, the sample included a broad of up to 18 months. The community elders range of ages, from teenagers to the elderly. and transit centre administrators expressed

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concern about discussing detailed infor- doctors or healers, and none were observed mation about refugee identity and move- assisting in the clinic. One of the Transit ments, due to security concerns at the time. Centre physicians explained that it would In respecting that concern, we will not dis- be di⁄cult to use Afghan refugee physicians cuss these characteristics further either. since they were not licensed in Pakistan. The Non-Governmental Organization Some women reported that the doctors did (NGO)managing the camp provided all not understand their problems. It was basic survival needs to the community unknown if this was due to language, health including: security, clean water, sanitation, beliefs or for other reasons. food, clothing, child and adult education, Somatic symptoms seemed to be a common and medical care. Community members way of expressing distress. In fact, some of had access to preventive health services, the most common presentations in the local primary health care, and high quality ter- clinic were medically unexplained aches tiary medical facilities. Overall, the con- and pains. There were many anecdotes of ditions of the centre were excellent, but peoplewhohad symptomsundiagnosedafter mental health per se, had not been explored. thorough medical investigations, and unre- Communicating distress. Much of the infor- solved, despite standard medical manage- mation was communicated on a collective ment. Other common presentations were level. That is, the participants tended to dyspepsia (heartburn), diarrhoea, minor convey experiences that echoed those of the dermatological conditions, andupper respir- community as a whole. Participants primar- atory symptoms. Patients often requested ily communicated current hardships. Unless injections of penicillin or ampicillin as a probed, there was relatively little focus on cure-all. This was reported to be common distressing experiences they had su¡ered practice in Afghanistan. No Transit Centre prior to their arrival in Karachi, or on trau- (Pakistani)physicians reported other cultu- matic war experiences. rally-based health beliefs di¡erent from In the interviews and focus groups, the their own. accuracy and cross-cultural translations of Following is a summary of the Refugees’ ‘mental health’and‘mental illness’wasuncer- reported experiences, which can be tain. However, this Afghan community did examined in terms of pre-migration (in not seem to view mental health as aWestern Afghanistan),migration,andpost-migration medical-psychiatric model might suggest. (in the host country)stresses (Rousseau, Only those with severe psychotic illness et al., 1997). Anecdotal examples are also seemed to be conceived of as having mental included. healthproblems. In fact, whentryingto com- Stress before migration. Persecution was a com- municate that we wanted to address mental mon theme among the entire community. health issues, informants identi¢ed only two Theprimary reasonforpersecutionreported young men who probably su¡ered from was a⁄liation with Hazara ethnicity, from severe and persistent mental illness, such which the majority of refugees originated as schizophrenia. (the majority of Taliban were Pushtun in At the on-site medical clinic, a Pakistani ethnic origin). Community members did physician was available who saw about 50 not welcome the extreme social change in patients everyday within a six-hour period. Afghanistan. Women, in particular, felt far There was little recruitment of Afghan more restricted than the norms to which they

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were accustomed. The vast majority inter- away.They were concerned about the hosti- viewed had been exposed to violence, either lity of their new environment and had fears directly or indirectly. Prior to migration, for their safety. manyoftheadultandteenagemaleshadbeen Some hadtravelled long distancesby vehicle, involved in armed combat. Others usually while others came by foot without access to had a family member who had been engaged food, hygiene, or shelter. Taliban o⁄cials in combat. The loss of loved ones was very stopped many refugees at the border. One common, either by death, detainment or 17 year old boy had been sent by his father migration. For example, one 17 year old boy to Pakistan and was travelling with a Push- interviewed had witnessed his mother being tun (but notTaliban)familybycar. ATaliban killed by a landmine. Witnessing extreme soldier stopped them at the border and the violence was a common phenomenon. boy was asked about his ethnic origin. He There were numerous accounts of detain- denied being Hazara but the soldier, suspi- ment and torture. For example, one teenage cious of the boy, threatened to shoot him boy reported that his father had been cap- unless a signi¢cant amount of money was tured and jailed by the Taliban three times paid. because he was suspected of being a govern- Stress after migration. The community ment o⁄cial. The man was interrogated, expressed hardship that occurred with the verbally abused, beaten with a weapon to changes in their physical, social and cultural the point of unconsciousness, and refused environment. Karachi was much warmer access to toilet facilities. than Northern Afghanistan and participants Although women were not asked individu- alsoreporteddi⁄cultyacclimatizing.In fact, ally or directly about rape, it was known to one of the most common paediatric medical frequently occur and has been a de¢nite problems wasblisters caused by extreme heat threat. One female focus group reported that and humidity,‘prickly heat’,or malaria. Also, many women would disguise themselves as the necessary layout of the makeshift homes older to avoid rape because, as one woman had caused crowding and a loss of privacy. stated, ‘Taliban like pretty women’. One of According to one informant, most Afghans the most horri¢c experiences reported was had been accustomed to ample living space thatof ateenage girlwhose mother wasbeing in their homeland. raped by aTaliban soldier, and then witnes- The Pakistani language, customs, and rituals sing her father shooting both the soldier and were similarlyexperiencedas quite di¡erent. her mother during the act. There were di⁄culties in communication Stress during migration. Participants reported between the Afghans and the Pakistanis, similar experiences during the process not only due to language barriers, but also of forced migration. Families had been intermsofculturalnorms. Forexample, some uprooted from their land and their homes. women reported that the typical Karachi- They had lost their possessions, jobs, and style dress provided to them was shameful schooling. Separation from family, friends, and embarrassing because the top was and neighbours seemed to be a particularly shorter than the traditional Afghan top and stressful loss. Most informants had feltagreat it had slits, which was unacceptable in their sense of uncertainty in respect to entering culture. Additionally, communicating these the host country. Most had not known their feelings to the administration was perceived ¢nal destination, or if they would be turned as potentially insulting.

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The Transit Centre was a very safe environ- cians, traditional healers, and others, were ment for refugees. In exchange for safety, not utilized as NGO sta¡ and volunteers security, refuge, and freedom from persecu- served these functions. Much of the com- tion, however, the Afghan refugee com- munity remained idle with little purposeful munity had put itself in the hands of the activity. host country and its institutions. One might Coping mechanisms. There were a number of describe their predicament as disempower- ways in which the refugees were coping ment.That is, the community had sacri¢ced with their circumstances. Faith and religion their autonomy, authority and freedom to seemed to be a common bond of strength choose. Due to security reasons, most of the among the entire community.The makeshift refugees were con¢ned to theTransit Centre, prayer hall and daily ceremonies provided a and as a result many felt trapped there. The centre for worship as a congregation. Com- living quarters, for example, consisted of a munity and family were considered to be large hall with bed sheets separating each important sources of support. Women, in family. This feeling of entrapment, then, particular, formed small informal support was only reinforced by the lack of privacy groups where they could discuss their di⁄- and almost non-existent individual physical culties. Transit Centre volunteers endea- space. Simultaneously, however, the anti- voured to keep families together and reunify cipated hardship of life outside the Transit separated families, an e¡ort which the Centrewas one of the mostcommonly voiced community appreciated. concerns among all the informants. The Asmentionedabove, activityandoccupation community’s primary concerns were about was a signi¢cant, but under utilized strategy. income, housing, language, and medicalcare. A small minority of refugees, particularly There were numerous anecdotes about the young men, had found work in factories and impoverished living conditions in Karachi in the textile industry. A few refugees had neighbourhoods where many refugees found been employed by the Transit Centre for permanent housing. Also, most felt that they cooking or cleaning duties. However, these hadnotgainedenoughlanguageskillsinUrdu activities seemed to be sporadic. Engaging to function properly in the Pakistani com- the community in purposeful activity would munity. Therefore, although the Transit appear to be a signi¢cant challenge. Recrea- Centre was a di⁄cult place to live in, there tional facilities were inappropriate for foot- was also a resistance to leave. Most of the key ball (soccer), the preferred sporting activity. informants interviewed, however, did have Teenage males were able to play volleyball, hope for changes in future circumstances. and some of the older and middle-age males Some wished to return home to Afghanistan, occupied themselves with the game of chess. others wanted to migrate to theWest. According to female informants, women Having lost their livelihood and placed could not engage in games, sport, song or themselves in a disempowered position had dance because there was no private space given rise to one of the community’smost sig- for them. It was culturally unacceptable for ni¢cant issues: lack of activity and occupa- them to engage in such activities in the pre- tion. As all basic necessities were provided, sence of men. Most women spent their days mostwerenotrequiredtowork.Astherewere caring for children but had little else. Thus, no houses, there was little housework. Skilled idleness was common. Anecdotally, the Afghans such as teachers, interpreters, physi- e¡ects of purposeful activity were striking.

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One young woman had experienced medi- the most helpful. Studies within various cally unexplained pain for several months populations suggest that supporting a com- and did not respond to any medical treat- munity’s inherent coping mechanisms is ment. When she began making carpets, her important. Several studies also support the complaints of pain disappeared quite soon. idea that better mental health outcomes Education was also an important coping result from keeping family and community strategy. Many adults and all children networks intact (Desjarlais, Eisenberg, attended daily classes. It is the one activity Good, & Kleinman, 1995; Summer¢eld, that kept them occupied in a very fruitful 1996; Summer¢eld, 1999). Family and com- way, and was thought by many informants munity cohesion was important to this to be necessary for their survival as a com- community.TheTransit Centre environment munity. A few teenagers were fortunate providing common areas for worship, meals enough to be sent to college and, according and social interaction, as well as e¡orts to to these students, it enhanced their career keep families intact, facilitatedthis collective opportunities and gave them a sense of pride, strength. However, this close-knit shared purpose, and hope. Along with their aca- space, in turn, may have limited the singular demic education, younger children were also space available to the individual. Perhaps it given the opportunity for structured group is a trade-o¡ of one for the other. play and art activities. Several studies support the notion of com- Physical escape from theTransit Centre may munity and individual empowerment. In have also been a coping mechanism. Phys- one study of Cambodian refugees, (Mollica, icians working at theTransit Centre reported Cui, McInnes, & Massagli, 2002)demon- that many refugees demanded to be sent to strated that refugees that were working were the nearby hospital, despite no medical less likely to su¡er depression, compared to indication for such a referral. Since the con- those unemployed. In the same study those ditions atthehospitalwereimpressivelycom- engaged in religious practice had signi¢- fortable, the physicians suspected that this cantly fewer mental health problems. The was a form of temporary escape and a way authors conclude: ‘This study suggests the of coping with the feelings of entrapment extraordinary capacity of refugees to protect arising from the di⁄cult environment. themselves against mental illness despite Prior to the ¢eldwork, it was suspected that experiencing horri¢c life experiences and opiate abuse might be a maladaptive coping ongoing poverty and violence.’ strategy for some refugees. No one, however, Another area of importance is education, reported use of opium (hafeem)or other which has also been shown to improve drugs, and there did not seem to be any cause mental health. In fact, it is becoming appar- for concern at this Transit Centre. Some key ent in the ¢eld of international health informants reported however that opium that the education of women seems to be addiction might be found in refugees from the single most important determinant of the province of Badakshan, where the crop health worldwide. This may be equally true is commonly grown. of mental health and there is evidence to support this view in refugees (Mollica et al., Discussion and conclusions 2002). The existing literature suggests that social The issues prioritized by the community in and community based interventions may be this study were di⁄culties encountered after

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migration.Inparticular,theissuesofempow- OneTransit Centre volunteer suggested ¢eld erment, purposeful activity and anticipated trips to various sites in Karachi (such as a hardship were the most salient concerns market or a school)in order to demystify elicited. the fears of life outside the Transit Centre. Numerous Pakistani volunteers tried to meet Employment or schooling outside theTransit the needs of this refugee community. It Centre seemed to be helpful and could also seemed, however, that this generosity might beutilized.Theunderlyinggoalistofacilitate have also contributed to removing autonomy the extension of the refugees’networkoutside and control from the refugees. Summer¢eld theTransit Centre; that is, to promote an in- (1996)emphasizes that interventions should out situation where the community has a enhance refugees capacity to reinstate con- more graded integration into their host trol of their own lives. However, refugee society. In summary, social and community camps, with their emphasis on con¢nement, based approaches that address natural cop- control and minimal involvement of resi- ing strategies; family cohesion, education dents in decision-making, too often breach and empowerment are likely to be the most this basic principle. helpful interventions. Simmonds (1983)emphasizes the mobiliza- tion of community resources. There could be greater involvement of Afghans in daily References Transit Centre activities such as cooking, Desjarlais, R., Eisenberg, L., Good, B. & maintenance, and other tasks. Afghan pro- Kleinman, A. (Eds.)(1995)Executive Sum- fessionals could be utilized to assist Pakistani mary from World Mental Health: Problems professionals in areas such as education and and Priorities in Low-Income Countries. health care. This would enhance the use of Oxford University Press, pp.1-20. purposeful activity as a coping strategy in its own right. Jablensky, A, Marsella, AJ, Ekblad, S, Levi, L, & Simple adjustments to the Transit Centre, Jansson, B. (1992). The International Confer- such as the creation of a separate space for ence on the Mental Health and Well-being of women to engage in recreation separately the World’s Refugees and Displaced Persons, from men, may also facilitate more activity. Stockholm, Sweden, 6^11October,1991. Jour- Such interventions might serve to share nal of Refugee Studies, 5(2), 73-183. responsibility and engage refugees in the active participation of their management, Mollica, RF, Cui, X, McInnes, K, & Massagli, ratherthanbeingthepassiverecipientsofaid. MP. (2002). Science-based Policy for Psycho- The uncertainty and anticipated hardship of social Interventions in Refugee Camps: A living in Karachi outside the Transit Centre Cambodian Example. Journal of Nervous was one of the most distressing and anxiety- and Mental Disease, 190(3), 158-166. provoking issues.The community’s concerns about housing, employment, health care, Patton, M. (1990). Qualitative Evaluation and and language are quite justi¢ed. There is no Research Methods, second edition. London, ideal solution but programs that focus on U.K. Sage Publications. practical skills such as Urdu language, voca- tional skills, or, simply, how to use the public Rasekh, R, Bauer, H, Manos, M, & Lacopino,V. transport system, forexample, maybe useful. (1998).Women’s Health and Human Rights in

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Afghanistan.Journal of the American Medical of Concern to UNHCR. http://www.unhcr.ch/ Association, 280(5),449-455. statistics

Rousseau, C, Drapeau, A, & Corin, E. (1997). World Health Organization. (1985)Targets for The In£uence of Culture and Context on Health for All. Copenhagen: WHO Regional the Pre- and Post-Migration Experience of O⁄ce, pp.14-15. School-Aged Refugees From Central America andSoutheastAsiainCanada.Social Sciences 1 A proposal to conduct this brief study was and Medicine, 44(8), 1115 -1127. accepted by the Department of Community Health Sciences at the Aga Khan University, Simmonds, S., et al. (1983). Refugee Community Karachi, Pakistan and Focus Humanitarian Health Care. New York/Toronto:Oxford Uni- Assistance Pakistan. We would like to express versity Press. our gratitude to Focus Humanitarian Assistance Pakistan, Dr. Fahrin Shari¡, Dr. Cecile Rousseau, Summer¢eld, D. (1996)The Impact of War and Dr. Franklin White, Dr. Shams Kassim-Lakha, Atrocity on Civilian Populations: Basic Prin- Dr. Anil Khamis, Dr. Tashi Khamis, Dr. Faruk ciples for NGO Interventions and a Critique Ghouri, and the residents in Community Medi- of Psychosocial Trauma Projects. Relief and cine at the Aga Khan University for their assist- Rehabilitation Network Paper 14. London. ance and dedicated support of this project. Overseas Development Initiative.

Summer¢eld, D. (1999). Boznia and Herzegovina Azaad Kassam, psychiatrist, is attached to and Croatia: The Medicalisation of the McGill University, Montreal, Canada, The Experience of War. The Lancet, 354,771. Northern Ontario School of Medicine, The Northeast Mental Health Centre and The Aga UNHCR (United Nations High Commissioner Khan University, Karachi, Pakistan. for Refugees)(2004). 2003 Global RefugeeTrends: Anar Nanji is attached to Focus Humanitarian Overview of Refugee Populations, New Arrivals, Assistance International. E-mail: azaad. Durable Solutions,Asylum-seekersand Other Persons [email protected]

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