Nahid Aziz, PsyD, was 15 years old when she fled Afghanistan. Hiding in villages by day and traveling only at night, she and her father, Mohammad Hossein Nasrat, MD, were smuggled across the border into Pakistan in 1982--part of a wave of 1.5 million people who fled Afghanistan following the Soviet Union's 1979 invasion.

Traveling with five others for more than a week, and risking death, they mostly walked, but sometimes rode pack animals. To avoid suspicion, they dressed like merchants from a cross-border tribe that moved freely back and forth across the border, and carried no identification or personal belongings.

"We left every single thing behind," she says.

The communist-backed government had pressured her father, one of Kabul's few Western-educated physicians, to use his influence as a well-respected doctor and academic to convince other influential people to support the communist regime as it struggled for control.

Opposed to the regime's ideology, he resigned his post as chief of the hospital connected to Kabul University's medical school, risking death for his actions.

Aziz's brother had fled the country with their mother just months before to avoid being drafted into the army, which was attempting to quell a guerilla rebellion.

The family eventually reunited in Germany, and Aziz came to the United States in 1992 to study psychology, earning her doctorate and becoming a clinical psychologist.

In her new American life Aziz, 40, specialized in helping people handle the stresses of immigration and adjust to their adopted country. It's fulfilling work, she says, but she never forgot about the struggles of her countrymen.

"I've always wanted to do something, and to give something back, because we were very lucky to get out," she says.

She got that chance in December 2005, when Winnie Mitchell, who chairs the Afghanistan-focused mental health work group for the Substance Abuse and Mental Health Services Administration (SAMHSA), asked her to join an effort by the Afghanistan government to organize mental health training and treatment.

Aziz jumped at the opportunity because she wanted to use her understanding of Afghanistan's culture and her skills as a U.S.-trained psychologist to bridge the gap between the two sides. And because she grew up speaking Dari, one of the main languages of Afghanistan, Aziz could make communication easier.

The timing was right, as Aziz had just taken a job at nearby Argosy University in Arlington, Va., as an associate professor and assistant director of clinical training. She and her husband had moved to Virginia from California to be closer to Afghanistan reconstruction efforts centered in Washington, D.C.

Afghanistan's minister of public health, S.M. Fatimie, MD, and deputy health minister, Faizullah Kakar, PhD, visited the United States that summer and requested assistance from SAMHSA in rebuilding the country's mental health care system.

Aziz joined the work group set up by SAMHSA following that visit, participating in twice-monthly telephone conference calls with health officials in Afghanistan.

The first goal of the conference calls was organizing a three-day conference in Kabul in May 2006, to bring all the government and nongovernmental organizations (NGOs) together to share information on their work and develop recommendations for integrating behavioral health services into Afghanistan's Basic Package of Health Services (BPHS).

That preparation work came to fruition last spring, when Aziz returned to Kabul for the first time, as a member of a U.S. delegation assisting Afghanistan's Ministry of Public Health (MOPH) in its efforts to organize mental health training and treatment. The conference, co-sponsored by SAMHSA and MOPH, drew representatives from NGOs, the European Union, the World Bank and the World Health Organization.

The meeting gave the Afghan government a chance to start coordinating the efforts of the NGOs, identified ways to include mental health training in the curriculum of the nation's medical schools and suggested strategies to educate community and spiritual leaders in mental health awareness.

Hope amid suffering

Back in her old neighborhood, her childhood home was still standing, but everything else had changed during the 24 years she'd been away. Children and old women begged in the streets, and what she remembered as a city with a half-million residents was now crowded with over 3 million people.

Despite the suffering caused by decades of war, disease and poverty, Aziz saw hopefulness among the people she met, from government officials to children.

"There was such an enthusiasm for learning, such a thirst for normalcy," she says. Afghans are resilient, bound together by close family and community ties, and that gives them a strong foundation on which to rebuild, she says.

But, she says, it's a staggering task helping health officials put together a mental health treatment system in a country beaten down by a generation of civil war and the Taliban's brand of theocratic government.

There are only two psychiatrists in the whole country, and there are no doctoral-level psychologists. The capital has one 60-bed psychiatric hospital, with no treatment area set aside for children or adolescents. And, aside from the efforts of NGOs working in several cities, there is effectively no mental health treatment available across much of the country, Aziz says.

"The main problem is lack of resources, lack of human capacity in any area you can think of, whether it's mental health or education," she says.

While no one has counted the number of people in Afghanistan who are affected by mental illness or dealing with post-traumatic stress disorder, depression and anxiety appear to be widespread, especially among women. For instance, many women have been burning themselves to death, especially those in Herat, the province bordering Iran.

According to one estimate, there have been 250 cases of self-immolation recorded in the past year, says Aziz, noting that those are just the cases brought to the authorities' attention.

Aziz sees that practice as a desperate cry of protest against the second-class status traditionally afforded women in Afghanistan, in everything from forced marriages to lack of education.

Finding new ways to bring mental health awareness and treatment, while still heeding cultural sensitivities within Afghan society, might eventually help women avoid taking such a drastic step, she says.

"We cannot ignore this; it's becoming an epidemic almost," she says.

Signs of progress

At the recent conference, attendees identified several beginning goals, including:

  • Organization. Setting up a mental health coordination section within the Health Ministry to coordinate mental health activities.

  • Coordination. Helping Afghanistan government officials establish links with the NGOs providing mental health services throughout the country, to oversee and coordinate their efforts.

  • Access. Making behavioral health care part of the basic package of health services that the government aims to eventually extend to all Afghans.

  • Education. Encouraging medical schools to include mental health training as part of their curriculum.

  • Awareness. Promoting public awareness of mental issues with an education campaign, through radio spots and outreach efforts to midwives, spiritual leaders and health workers.

Winnie Mitchell, chair of the mental health work group, says Aziz plays a key role in helping U.S. officials and their Afghan counterparts work together, because of the cultural competency she brings to the discussions as a professional psychologist with a deep understanding of Afghanistan's culture.

As Mitchell describes it, Aziz helps match what U.S. experts can contribute, in terms of helping set up training and education, with what Afghan officials see as the nation's most pressing needs and what can actually be achieved on the ground.

"She's just spanned the gulf for all of us," she says.

Ruhullah Nassery, MD, who serves as national mental health services coordinator in Afghanistan, says Aziz's contributions helped both in the planning work for the May 2006 conference, and subsequent efforts to push its recommendations through to reality.

"She played an important role, and she was very helpful in translating training materials," Nassery says.

For her part, Aziz appreciates the opportunity to help people in her homeland. Now that she's back in the United States, she will encourage psychologists to volunteer time in Afghanistan, to help with mental health training. "We need more psychologists to donate time and energy," she says.