WTF/8; Total nos of Pages: 9; Azaad Kassam & Anar Nanji 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 1 WTF/8; Total nos of Pages: 9; Mental health of Afghan refugees in Pakistan: a qualitative rapid reconnaissance field study Intervention 2006, Volume 0, Number 0, Page 1 - 9 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 2 WTF/8; Total nos of Pages: 9; Azaad Kassam & Anar Nanji 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,