MU team helps start healing Afghanistan's refugee children.
In 2003 the Akora-Khattak refugee camp in west-central Pakistan was a teeming slum of 110,000 people. Many of its residents had fled Afghanistan either under Taliban rule or after the U.S. invasion. Many of them, particularly the children, carried the psychological scars that come from witnessing violence and violent upheaval.
Akora-Khattak, had the only mental health clinic in any of the hundreds of refugee camps in Pakistan. It was established under the direction of Arshad Husain, a Columbia psychiatrist and director of the UMC International Center for Psychosocial Trauma.
Every day, more than 30 women, men and children came to the clinic in the camp. Some lived close by, but others traveled great distances by bus and by foot. Sometimes they had to wait for hours, and some until the next day. They all came seeking something to numb the emotional pain that they felt.
Anne Farina, a social worker from St. Louis University who traveled with a team from UMC International Center for Psychosocial Trauma, spent three months interviewing children in a school at Akora-Khattak to make a mental health needs assessment. The research, similar to that previously done by the UMC center in Bosnia and Kosovo, was also being done in Palestine.
Farina studied 141 children between 7 and 15, most of them between 10 and 12. All had been displaced from their homes in Afghanistan, and 37 saw fighting. Part of the study sought to discover the difference in post-trauma reactions based on actually seeing violence such as bombing, torture and dead bodies as compared to simply being displaced from their homes. Of the 37 who saw fighting, 34 met the criteria for post-traumatic stress disorder, 16 of them at the severe level. The needs assessment also studied accompanying psychological problems such as depression, conduct disorders and substance abuse. The UMC team also has a continuing interest in what factors contribute to resiliency or the ability of children to recover from trauma.
The Akora-Khattak refugee camp has existed for many years, but there was a big influx of refugees after the Taliban took over in Afghanistan. In the early days of the camp, many people lived in tents that often became killer ovens in heat that could reach 120 degrees. Open sewers run between buildings, and water is supplied by wells.
The tents had slowly been replaced by adobe homes made with mud. Each house is 13 feet by 16 feet by 11 feet and has a window, door and six ventilation holes near the ceiling. Members of the occupying families are supervised by a master mud mason who helps them mix mud and build their own homes. The doors, windows and other supplies cost $180 and are provided by a nongovernmental organization called Shelter Now.
Farina, living in Peshawar, had a 1½ hour drive each way to Akora-Khattak with 20 staff members crammed into a 15-passenger van. Staff members were not allowed to live in the camp because of the danger of robbers who sometimes shot people.
Farina described the stark conditions in Peshawar, where pollution is heavy and living conditions are poor. “Some nights I go ‘mosquito hunting’ in my room before I go to bed,” she said. “Some nights I find them, but most nights they wake me up at 4 a.m., with big bumps on my face and arms. The other creatures known to lurk in the shadows are lizards. Big fat lizards with big scary eyes. Fortunately, they are actually more scared of me and quickly run and hide when they see me.
“Many Afghans have migrated to Peshawar in the last 20 years. They had learned to drive in Afghanistan using what they call ‘war-driving.’ ‘War-driving’ is driving very quickly from point A to point B, without paying attention to anything but getting there in one piece. Now everyone is driving like them. They continually have close calls with other cars, trucks, rickshaws, horses, people, dogs, wagons and huge potholes in the middle of the street.”
The counseling center
The clinic at Akora-Khattak was financially supported by the Columbia-based International Medical & Educational Foundation, which raises funds to support most of the UMC center’s projects. The clinic was staffed with one psychiatrist, one psychologist, one person in charge of medication and one intake person. The camp once held more than 200,000 Afghan refugees.
The Afghans there had been so traumatized by war, displacement and general poverty that many were suffering from post-traumatic stress disorder. None of the other 200 refugee camps in Pakistan had any psychiatric services. So many patients, including those from other camps, were seeking help that the staff could only give a few minutes to each. Given the culture’s rejection of a psychological basis for disturbance, the doctors were relying heavily on medications to help treat the refugees’ emotional problems. Drugs were a high-budget item in the cost of running the center.
Schools in the area are segregated by gender, and Farina worked in a male-only school. She spent most of her time interviewing the boys, and though she had no time for therapy, it appeared they found her interest in them therapeutic.
She asked questions from several different research measures and had them draw pictures of themselves. She found the interviews overwhelming. “Even though I have read the things that children have been through and seen in Afghanistan, to sit in front of a small child and hear them speak the words is unbelievable.”
One group of 60 boys, all of whose fathers had been killed, lived in a hostel. If they had mothers, the mothers lived some distance away; but it was considered important that the child be in the school to get an education. There was also a girl’s school in camp, but many fathers didn’t want their girls to get an education.
It was expected, given the cultural attitude toward women, that the boys might resist being interviewed by a woman. To the contrary, they were surprised a woman wanted to know what they saw and how they felt about it. They told her they found it difficult to talk to their parents, who often admonished them not to think about what they had seen. They told Farina that, with her questioning, their thoughts had become words. It was calming, they said, to talk about it with a neutral person. They felt they could trust her and that she wouldn’t tell others.
Many of the stories of the 141 boys she interviewed were very sad, especially those of the 37 who saw fighting in Afghanistan.
Short story about a small boy
He lived in a camp with his uncles, three brothers, two sisters and his mother. His father was killed five years previously. His grandfather had taken part in “the war,” and the Taliban came to their home asking about the grandfather and father. The Taliban blamed the father for the grandfather’s actions in the past war, and this made the family afraid. They wanted to leave. One day his father came home late, badly wounded, and he died in the hospital 15 days later. Then the Taliban started asking the boy where his uncle was. Once he thought those asking were friends of his uncle’s, and he told them. Then he learned it was the Taliban and that they wanted to beat his uncle. That is when the family left their home and all of their “equipment” and came to Pakistan.
On the way to Pakistan, the boy saw many dead bodies. Now in the camp, the boy had to work many hours making rugs after school. His family had too little to eat more than one meal a day. He said he has experienced extreme hunger many times, has lost many things because of the war and prays for peace.
“There were some rough days,” Farina said, “and I would ask the interpreter to pick a happy one for me today. Some of the boys were really sad. They lived in bad conditions, and many got only one meal a day, and sometimes that was only bread and tea.” One boy said, “Our country was destroyed. How can I think that the future will be good?” Speaking of the scarcity of food another said, “We are boys. Anything they give us, we eat.”
Despite the traumatic experiences of so many of the children and the poverty they are living with, there were signs they were optimistic about their future. “These were such hopeful kids, looking toward the future and being able to take care of their parents,” Farina said. “They are so concerned about their mothers. They wanted to get an education to make something of their lives. I’ve never seen kids so interested in learning, so focused on their education.”
When asked, “What do you want to be when you grow up?” many said they wanted to be doctors, engineers or teachers. One boy wanted to be the captain of a cricket team, one wanted to grow cucumbers and one wanted to own a general store. Some wanted to continue making rugs. “Where do you want to do this?” she asked. “I want to go home and rebuild my country,” was the answer.
The team from the international trauma center ran training sessions in Peshawar for mental health workers from Afghanistan and Pakistan. Group work is not used much, but those who attended the meetings were interested in starting groups with children. Many people working in the refugee camps are employed by nongovernmental organizations or the United Nations High Commission for Refugees.
Farina and her translator met with a group of Afghan teachers weekly for workshops on mental health. “They are so interested in helping their students through difficult issues, and they are so enthusiastic and willing to share their stories and themselves,” she said.
“Many of the children perceive their greatest ‘need’ is that there is peace in Afghanistan,” Farina said. “Peace is what is on the minds of these children, not toys or money or video games. One boy said what most want: ‘I want to tell the world not to fight. I want to say to all the people in the world not to fight.’
“And one shy boy quietly said that someday he would also like a bike.”