Tuesday, 19 July 2011

Day 8: Escaping from Heathrow

It’s funny how sometimes you only talk to people in planes in the last few minutes. On the flight to Bahrain, I was next to a Danish NGO worker who was working with a women’s mental health project in Kabul. So I gave her Yousuf’s email. And just landing in Heathrow I made acquaintance with an electronics teacher from Norfolk , who has been doing it for 17 years. Life sounds a bit different there: the King keeps giving his people bonusues and pay rises, and the students aren’t too bothered about learning electronics because the country can pay other people to do it. At least our gang of psychologists and psychiatrists in Kabul are motivated and keen: guess who I’d rather be teaching!

Heathrow is obviously a different world – but a bit like Kabul, it is difficult to esacpe from. I had three plans up my sleeve: taxi, bus and family. Taxi - £xx to Slough, about 5 miles away. Too expensive; next option please. Bus: transfer to Terminal 5, then to Slough Bus Station, then transfer to local hospital bus. Too much luggage for that; next please. Family: all asleep and grumpy, not really possible; back to taxi.
Oh the joys of being home!

Day 7: getting out

Last day
Goodbyes all round, today – I’m quite sad to be leaving and looking forward to the next trip in September, though a lot of organising is going to be needed if it is all going to happen as planned. Lots of warn handshakes, a few hugs and smiles all round.
So not a long entry today, but a few travel tips from my experienced globetrotter colleague:

1.       Luggage weight.
Take it to the local butchers where they weigh the lambs and goats. Only a small tip is required (though if you’re not a local you may be asked for a large one. But resist.) The problem was that my big case was just under 30kg (with my secret purchase) and my borrowed case was nearly 20kg. And the baggage allowance is 35kg. And they charge about $25 per kilogram for excess. And if you can’t pay (probably in used cash plus easements), you have to ditch your stuff or miss the flight. Because at Kabul, nobody else is allowed in to see you off – so they couldn’t take it away for you. But in fact dear Yousuf DID manage to charm his way in, having correctly advised me on item 2, next.

2.       Hand baggage and laptops.
Put all the heavy stuff in your hand baggage (I expect you know that already) – and IN WITH YOUR LAPTOP. A separate laptop bag is always allowed – so use it! I was fortunate in having a large and floppy expandable laptop bag with me. So I ended up with one main bag checked in (34.8kg!), one small wheelie borrowed suitcase (about 12kg with all my clothes mercilessly stuffed in) and my ‘laptop bag’ (about 15kg and fit to burst). Luckily they didn’t spot me before I got away from the check-in desk. Apparently, they can even send you back from the gate to have them weighed (meant to be a maximum of 10kg, and they can charge ‘first class excess’ on anything over) – but they were too preoccupied with other things here, I think. Carting them round the airport was quite a pain, but less so than a whopping excess baggage charge. So far, so good.

3.       Travelling from Kabul airport.
Expect it to be quite a novel process, and look at it like you would an interesting cryptic puzzle. You know that you’re going to be on that plane in the end, so enjoy the struggle of getting there. And cherish the creative new ways they have found to put extra stages and steps into the process of getting on a plane. Keep smiling. I lost count after about seven, there of which happened before we even got the car parked. They did save the best one till last, though. You think it’s like one of those computer  games, as you keep getting onto the next level and thinking you’re winning – and surely you have finally got to safety when you find you’re in the departure lounge with all the planes visible out of the window? Well, no, not here.

In a strange airport where none of the officials speak English, how do you make sure where and when to get your plane? By checking the monitors, maybe? Well, normally yes. But they were all showing that ‘Windows isn’t working’ screen we’ve all seen. And even non-English speaking staff were nowhere to be found: they came and opened the glass doors for each flight, were completely busy with getting everybody through, then disappeared into thin air. But the answer to this level six challenge was the first class lounge, just tucked in behind the man with the prayer mats – where they had a large plasma screen display that you could see from just inside the entrance. Luckily, I soon discovered that the flight was an hour late, so didn’t need to fret while wondering if I’d missed the plane. And was that it? Well, no. There was the small matter of the corridor leading nowhere with no plane in sight and a broken lift. But when you found the staircase tucked away round the corner, it was like winning the jackpot. But when you got to the bottom of the stairs with two ridiculously heavy items of hand luggage, the bus doors were shutting… (to be continued)

Day 6: Group Therapy Afghan-style

Back to work after the weekend – on Saturday-which-feels-like-Monday : it’s going to be a long week as I’m going to have another Monday, starting as soon as I’m back. A very upbeat team meeting – starting just after 0800. The CD (=NGO's country director) is coming every day to hold the reins until a new CoP (=Chief of Party, what an odd expression) arrives to lead and manage the whole mental health project here. There has been a lot of chatter and worry about whether the project is up to scratch, or at least there is for the visible bits of it like whether walls have been painted or electric switches fitted or getting the water turned on when somebody turned it off.  The less tangible products – like better staff attitudes and less grumpy patients at Jangalar – for which I think I have seen and heard  convincing evidence, seem to be to nebulous to be registered clearly on the project tick boxes, though I know we have to try to do just that before we finish.

I don’t have any other experience to compare it with, so I have no idea whether it is a realistic worry or not, but I would think it was quite a morale problem if everybody in the team thought they weren’t doing good enough. With the pervasive paranoia that must be inevitable for anybody living in a war zone, this could surely be enough to break the camel’s back. But what was noticeable was the energetic and infectious enthusiasm of the new CD: she was on top of everything that needed doing, and even willing to start an addictions therapy group herself to get the idea of ‘self-counselling’ off the ground (using expertise from a previous life). So although it lasted till well after 0900, it felt like time together well spent. And with a bit of gentle prompting from Yousuf and I, they even warmed to the idea of possible team awaydays, and relational skills training.

I went straight from this into being an observer in the ‘day hospital’. Now if ‘day hospital’ conjures up images of people sitting around and gently convalescing, in spacious therapeutic surroundings, forget it! This was a slightly shabby room about 15 feet square, with a circle of about 12 chairs. People came into the group once weekly (there were different ones each day) either when they were still in-patients, or in the 12 weeks since they left; there were different groups taking place on each weekday. There were six women and two men in it today, which is less than usual as some of the hospital beds are shut for the refurbishment. Although I had good interpretation of what was being said in Farsi, for most of what was happening,  I didn’t need to know the content. To a strictly trained group analyst, here are the less-than-perfect things that were observable without the language:
  • ·         The conductor (a psychologist) spoke to one person at a time, nobody else spoke until it was the next person’s turn.
  • ·         Nearly all the conversation seemed to be questions (from him) and answers (from the group member)
  • ·         People wandered in and out
  • ·         There were several interruptions for administrative matters
  • ·         A referral was made and accepted while another patient was speaking - a man was brought in with a referral note and sat down
  • ·         During his turn to be asked questions, the man who was admitted to the group during it became rather animated with what he was saying, and hitting his head. Others looked worried and looked to the conductor, and he seemed to indicate that he shouldn’t have been there. In fact he quite soon walked out.
  • ·         Each person was given just over five minutes.
  • ·         When one of them started getting upset, the subject seemed to change and he moved onto the next person.
  • ·         I don’t know if there was a starting time, but there wasn’t a set finishing time and most of them just drifted away when everybody had ‘had their turn’.
  • ·         The two who seemed most troubled by the new man came over to Yousuf and seemed to be imploring him to do something.
  • ·         After that, somebody else from the group came in and had a long, and what looked like quite intense, conversation.

But, oddly enough for somebody who is even obsessional about how far away his group therapy chairs are from each other, and how perfect the circle is, I was strangely encouraged by it. So I wondered why, and came up with this list:
  • ·         It was a group, and a therapy group, and it was happening here in Kabul
  • ·         They were all sat on chairs, in a circle, and talking.
  • ·         There were empty chairs for absent members (though this may have been accidental).
  • ·         It seemed to be valued by the organisation, and its members
  • ·         Not counting myself and yousuf, it had the ‘perfect number’ for an analytic small group – eight members plus the conductor
  • ·         The mix of members’ problems seemed to be very reasonable: one woman talking of domestic violence, another with difficult family rivalries, a man with crippling self-doubt, an agoraphobic woman who was now managing to come in from some distance away after being an inpatient, a woman who appeared very resistant to speaking and would only utter single syllables when questioned by the conductor, and two who had had their turns before we came in. Even the man who was hitting his head appeared more angry and upset than psychotic, so may well have been a suitable member for a longer-term group.
  • ·         It was a mixed group – gender, age and socioeconomic status (one member implied being quite wealthy).
  • ·         It had a clear slow-open format, with members staying for (I think) twelve sessions after discharge from hospital.
  • ·         There was at least a level of trust that enabled the four women wearing bhurkas to show their faces and express emotion in them.
  • ·         The conductor is one of the psychologists who was in the Tuesday morning psychotherapy teaching sessions, and wants to learn more.
  • ·         The room, although not in any way comfortable or well-furnished by our UK standards, was still good enough for conducting group therapy.
  • ·         It happens every week.
  • ·         There are different groups on the other mornings, conducted by different psychologists.
  • ·         It felt like the basic structure for establishing a group therapy culture is in place.
  • ·         I always enjoy groups!

Next, a brief discussion with Yousuf about the training course plans, which had been quietly germinating for a few days. With a couple of rough old diagrams, they sprouted into two courses delivered in six 3-day events. One course will be for 80 people and be called ‘Biopsychosocial Medicine: Awareness Level’, and the other will be a more intensive course, hopefully for training 20 future trainers, called ‘Biopsychosocial Medicine: Foundation Level’. As the 14 psychologists were all assembled in the library for something unrelated, we thought we would try out the idea on them when they finished their meeting. And they liked it, a fact probably not unrelated to the expectation that they will all be expected to do the ‘Foundation’ level, and form the backbone of the new way of doing things. So germination led to sprouting, which seemed to get the warm sunshine it needed – let’s just hope that everything blossoms by next spring!

Bolstered with enthusiasm at this, I resolved to do a quick report for the NGO to gather all this together straight after lunch.  I started about 1.30pm, expecting to finish by about 2.30. In the way of these things, it was finished and emailed off almost exactly 12 hours after I started it: 1.30am. But it is an evidence-based analysis of what needs I have unearthed during the week, and a detailed plan for setting up these two levels of ‘biopsychosocial’ training in the three future visits (late September, late January and April). The details are too much for this blog, but they are uploaded as a pdf resource.

But it wasn’t all work and no play, as a certain downtown trip happened, and what a trip it was. In order to not compromise security, I can only portray it by photographs in which the location is not discernable, and the captions are somewhat cryptic…

Just what we need in Slough

Friday, 15 July 2011

Day 5: food and drugs

When I was staying regularly with friends in Nottingham, we used to aspire to having three GIBBs (Great Ideas Before Breakfast) each day, to set us off to work with a spring in our steps. So after talking about expansive and grandiose ideas with Yousuf until late last night, then sleeping on them, I need to carry on the Nottingham tradition, here  in Kabul. So here are today’s GIBBs:
  1. ‘Institute of Biopsychosocial Medicine’ – here in Kabul. Not for the traditional psychiatry of schizophrenia , mania and the organic psychoses – but mostly for PTSD and addictions.
  2. Run on principles of greencare, sustainability and new economics. Small is beautiful, big society, cultural congruence, low-tech, supported from numerous directions.
  3. With backing from David Cameron next time he comes over – as a British legacy to be left after the troops are all withdrawn.
Now I reckon that anybody is doing well if more than 1% of their GIBBs come to anything, so don’t hold your breath!

Back at home Sunday means Sunday Lunch is required – which is the one meal of the week that I always cook. Now we are in the unfortunate position here of having temporarily lost our cook – she got quite seriously burned when the pressure cooker exhaled its superheated steam all over her front a couple of weeks ago. So our cleaner is doing the cooking at the moment – which is fine and nutritious, but not very varied. Breakfast is local bread or UK cereals or eggs; lunch is basmati or pilau rice, fried chicken or casseroled lamb, and okri or spinach; dinner is the same as lunch. But today being Friday (meaning Sunday to us, see yesterday), there’s no food being prepared for us. But Yousuf has the answer up his sleeve – and after we had coffee (which I sprayed all over his day Sunday Best pajamas while trying to get the cafetiere working, in my craving for caffeine) – he went to a relative’s party and brought back two steaming bowls of Sunday lunch which had come from enormous party cauldrons, for feeding several hundred people.

Later in the afternoon, we decided to go and see the state addictions hospital, Jangalar, which is also part of the project. It is in a large building that used to be a car factory: about three quarters of it is used for NGO-run addiction programmes, and less than a quarter is run by the state for detoxification only. The NGO side is better endowed and has a wider range of therapeutic programmes, and the two are run entirely independently with no communication or cooperation.
Entering Jangalar Hospital
The state programme has 40 beds, but the usual number occupied is nearer to 30. Its premises are very dilapidated, although their refurbishment is part of the project. Nearly all the patients are heroin and opium addicts, and they are usually referred by their families. They first attend outpatient motivation groups run by psychologists at the Mental Health Hospital, during which time they reduce their drug use. Then they are admitted to the detox hospital, and prescribed a normal range of sedatives, anti-emetics, anti-diarrhoeals, and other required medication. It always includes ‘cold therapy’ on the prescription sheets, which means cold showers – in a rather unsanitary-looking shower room. They are regularly monitored for signs and symptoms of withdrawal, and when these have subsided (usually over about a week) they are moved to the next room  for up to about a month for rehabilitation, and therapy from the psychologists. One of the patients told me that what they need to wait for is for their families to be ready to take them back. As you might imagine in a poor country like Afghanistan, they are on their own once they are discharged from the hospital.
The Jangalar ward

The 'cold therapy' block (3 'showers')

However, despite the primitive surroundings, the staff seemed cheerful, professional and hopeful – and the patients welcomed us warmly. A facility like this is obviously barely scratching the surface of the country’s drug problem – and the chances of meaningful recovery must be poorer for the lack of any psychosocial follow-up. Another chance for a predominantly self-help model of greencare-based intensive long-term rehabilitation, I would hope: what most of the world knows as TCs. But what I would not hope for is that the research work, done here by overseas agencies, to introduce methadone maintenance regimes, demonstrates that they need to introduce non-abstinence programmes. Afghanistan has the clean slate I mentioned two days ago, and to commit itself to indefinite pharmacological treatment for vast numbers of people in the name of medical science seems to be a backward step to me. It would benefit the pharmaceutical companies, the doctors who prescribe it – and render the addicts lifelong emotional invalids, and spread the belief that the only way to treat addictions is with medicines. A biopsychosocial approach would seem much more culturally congruent, and sustainable way to go.

We asked our driver to take the scenic route home, so I could see a few different areas of Kabul. We made our usual hectic and collision-free way along the very dusty streets which sometimes looked like thick fog in the late afternoon hurly-burly, between the mountains dotted with ramshackle houses (glowing like a tableau of fairy-lights as dusk came upon us), and along the roadsides with all manner of stores selling everything from freshly-killed chickens to chrome car wheels – all illuminated by huge and unfeasibly bright multicoloured low-energy lightbulbs. The most striking places though were Las-Vegas-in-Kabul, and the Afghan version of Surrey-on-Thames.

Wedding halls are an iconic cultural phenomenon here: they are vast buildings, boring and grey by day, but illuminated with neon lights, electric trees and giant lit-up stars and moons at night. They also have lines of cars and hoards of people in their finery going in all directions, outside them. Inside, they host Afghan-size family parties and events – and as I said yesterday, ‘family’ here probably means hundreds, and quite possibly thousands of people. Thursday night is the busiest – but it was pretty hectic tonight too (Friday – like Sunday to us). Although at first it seems a bit unreal – ‘how can a country in this state waste all that money on electricity and parties?’ – I was really cheered up by the thought that they’re having a great time with their enormous families, despite the horrors going on all around.

The Afghan version of Surrey-on-Thames is where very rich people grab land (usually without buying it) and build ostentatious and extremely large houses on it (usually without permission). It was previously the location of disused military buildings like barracks, and is close to the city centre. We reckoned that there are too few people in the whole of Afghanistan who make that amount of money through legitimate business interests to fill these houses (and they would probably have better taste, anyway). So it doesn’t take much reckoning to work out that most are probably built with money from drugs and arms. ‘Why don’t the authorities just demand they are knocked down?’ I naively asked Yousuf; he didn’t quite use his usual ‘there are twenty reasons…’ answer, but top of the list was the fact that many extremely influential people live here, including some who are high in government. Tricky.

Time to go home for our evening meal. As we were stuck in traffic by the roadside stalls, Yousuf pointed out the local cheese (semi-solid, white, about the size and shape of a large squashed orange), as we’d talked about it a couple of days ago. When I said ‘let’s get some’, I was quite surprised at his John Macenroe-type reaction. But as his honoured (and very well-indulged) guest, he generously agreed to buy some. Then he seemed to get a bee in his bonnet, and went off to some other shops before coming back to the car with quite a collection of bags. This is going to be a very special Afghani traditional meal, he explained to me: we are going to eat like the poor people do, like the peasants: bread and cheese and raisins. He had also bought fresh melons and mangos. Well, if the peasants eat like this, I thought, I’m quite happy being a peasant (and often am at home, though it’s usually tomatoes instead of raisins). After an uncertain start, Yousuf decided that it tasted rather good after all – and I wondered if it was just something that he had never tried before. But he soon started reminiscing about how he used to eat it as a small child, and how it brought back the memories of those days – just a few streets away, here in Kabul.

A peasant's meal - not unlike a ploughman's lunch?
It is an Afghani saying that food tastes much better if you are hungry – and a peasant can enjoy his bread and cheese and raisins more than a king enjoys all his fabulous food. So indeed we did eat like kings – although he wasn’t sure he would be able to tell his wife about our ‘special meal’…

Day 4: Thursday = Saturday

The day started on a sad note – a member of staff here was a close friend of a local man whose brother’s family have all just been murdered. Everybody around them feels very traumatised and upset. A few of us talked about it first thing this morning, and we were all affected by the horror of it – especially for those who are closest to the family.

Today is weekend – although it is a Thursday, today and tomorrow are on all the calendars and computers as the two days of rest.  Thursday is traditionally just a half day and Friday is the day for prayers – as in all Islamic countries, of course. Modernisers recently are trying to pass a parliamentary bill to change the weekend to Friday and Saturday, so it would be at least aligned with the western world of commerce and business for four and not three days of the week. The government is trying to support it - but it is a very sensitive and complex matter, and will need a great more discussion before it is agreed. So Saturday remains the first day of the week and Sunday the second: while we are feeling Monday Morning Blues, people here are already nearly half way through their working week. However, like home, many shops and businesses are open at weekends (including the psychiatrists seeing their private patients – see day 2). I wonder if there has ever been a Friday equivalent of the British ‘Keep Sunday Special’ campaign here – I suppose it is an inevitable consequence of global commercialisation that such sentiments do not have the same priority as economic ones.

But in a quirky way, the shifted weekend is an extra ‘disorientator’ that keep humans aware that different places in the world are actually different – however hard we try to homogenise our lifestyles in the name of progress. So alongside the daily and annual astronomical ones (time zones and seasons), we have the cultural one of religious beliefs: the weekly one of weekends, and the annual one of festivals and holidays. So – and perhaps this is getting a little far-fetched – we have the astronomical or cosmic anchors to the land (day and night, winter and summer) and the cultural or spiritual anchors to our fellow humans (weekends and festivals). And anchors like these, I would propose, provide an internal experience of containment through ‘knowing what’s when’ – and keeping the terrors of uncertainty safely at bay. Which is, of course, just what we do with our time boundaries in psychotherapy and therapeutic communities…

But for me, the experience here is definitely of a Saturday – ignoring the alarm clock, getting up for a leisurely breakfast, and not worrying exactly what needed doing today. And the extra bonus of having interesting conversations with my housemates about many things as we just chill out and hang loose, as they say.
And indeed, on that theme, one was language and idioms.  Yousuf’s first language is Persian (also known as, or nearly the same as, Farsi or Dari), and Raymond’s is Swahili. But like most under-educated Brits, my only language is English, so our chewing of the fat had to be in English. Though I did notice that we used quite a lot of hand-gestures to describe nuances and subtle grades of meaning, especially when the English wasn’t quite good enough to express something.

Another aspect of language which is more directly relevant to our mental health work is analysis of the qualitative data on our teaching evaluation forms. The numerical data is simpler – one can either cheat with the analysis, or do it correctly; and we all trust our staff to not cheat when entering the quantitative data into spreadsheets. However, in mental health, it is often the qualitative data that gives more information about meanings and relationships: and here, even the process of translation may introduce bias. For example, the evaluation forms have comments on them which are written in Persian, but need analysing in English. Our interpreter is a member of the team, but also a local young woman, and both English and Persian are second languages to her. To help with some of the trickier written responses, she discusses them with one of the psychiatrists who has good English. At least three sources of bias come in here: (i) she goes to ask different people, who all tell her slightly different things; (ii) the psychiatrist is senior to her, so she is culturally unable to disagree with any of his or her opinions; (iii) both of them may, probably unconsciously, choose wording which does not offend local or national sensitivities. This is a life and death problem in the war – as deliberately distorted interpretations are known to have caused fatalities. To prevent the danger of this, the British forces now train their own interpreters and translators – and recruit, for example, Afghanis resident in the UK to translate between the local languages (Persian, Pashto and Uzbecki, mostly). I heard that the British forces run a ‘training village’ in the UK to replicate many of the cultural and religious factors, to help accuracy of understanding for translators who are learning the subtleties and nuances of the three main local languages.

We had quite a scare after lunch today, when we were at the NGO offices: Yousuf received a phone call from his wife in England telling him that there had been a suicide bombing in Kandahar Red Mosque, where the President’s brother’s memorial service was happening – and one of Yousuf’s close family members was with the Presidential party. Although President Karzai was known to have left and flown back to Kabul after the funeral and before the memorial service, there was confusion as to whether the family member was still in Kandahar, or had also come back to Kabul. The fact he could not be reached by mobile phone made it more worrying and reassurances from officials on the phone were not convincing, and only when Yousuf had directly spoken to him on the phone an hour or so later (the phone also kept getting jammed by the ‘blockers’ – see day 1) did he feel able to relax. We later learned that four people died and he was indeed in the mosque at the time – but at the other side from the entrance. Also, most Afghans normally wear turbans – which are never searched, and it was the turban in which the bomb was hidden, which we thought was a new thing – so this will probably lead to routine searching of turbans from now on. Like the shoe bomber being responsible for us having to take our shoes off at airport security nowadays.

There was also a ‘minor scare’ from the security staff in the HQ office, who said that they had just had a report that our way back to the house was blocked by a large demonstration – and we wondered if we were marooned in the office, just as everybody was due to go home. However, a conversation with a native man on the security staff soon established that it was a group of female university students who were objecting to sexist remarks made by their male passers-by. Their slogan was 'This is my street too' - so they could walk along the street without being harassed or abused. We would have gone and joined them if we were allowed!

But this illustrates how the ‘being in a war zone’ is more dangerous to mental well-being than it is to physical health. With the protection and regulation imposed on us, it takes no great statistical analysis to say ‘I am more likely to get killed as a cyclist on the Euston Road to Paddington station (which I do most weeks) than I am to be murdered as an expatriot in Kabul’: several cyclists get killed in London each month, and nobody here can remember when an NGO expatriot was last murdered. But what does happen nearly every day are these ‘anxiety bombs’ – which transmit their shock waves like electricity through all the personnel here: often with personal worries about loved ones, or colleagues. And they are used very effectively by the security staff to keep us in line – and obeying the rules of where we can go (our NGO's premises and projects, and the places on the safe list) and where we can’t (everywhere else). At least one of those anxiety bombs, of different severity, has gone off each day I have been here. And it’s OK for me – because I’m going home on Sunday: but what effect must it be having on the mental health of all the permanent staff, people like Yousuf who know so many people here, and even more on the residents of Kabul, who know no other home –and surely can never feel safe from this anxiety and dread?

There is a real, and I think insoluble, muddle about ‘us and them’ in discussion of ethnicity over here. At first, I kept hearing words like Tajik, Hazara, Dari, Uzbeck and even Sunni and Shia without understanding whether they were religious, tribal or linguistic. So I asked a few questions and concocted the following ‘idiot’s guide’ to help me through conversations without putting my metaphorical foot in it (and feet are another sensitive matter – my iPhone etiquette app told me that it is extremely insulting to use them for anything except walking - but Yousuf tells me he has never heard of such rubbish! Or is it that comes from a different Afghani group, or is somebody trying to start a silly urban myth, or just make me paranoid?). But then we had a long and complicated discussion about what you can and cannot do with your feet, and decided it meant sitting on the floor with your legs out (they should be crossed) or touching other people with your feet - both of which are very rude.


Facial appearance
Varies, but is quite distinct from Uzbecks and Hazaras
Iranian or Tajikstanian
Area of Afghanistan
S and SE
S and SE
N & W
Geographical origin
Southern Asia
Southern Asia
Central Asia
Pashto & Persian
Persian (mainly)
Persian (mainly)
Type of Islam
Others (including non-Islam)
(all figures are seriously disputed)
Less than 40%
Includes most  of the Taliban (but most are NOT Taliban)
About 25%
About 10%
Less than 10%
About 5%

Families are extended and huge, and often the line between who is family and who is tribe becomes indistinct – especially in matters like job application and recruitment. In our Western ‘we can manage anything’ style, beloved of arrogant clinicians and authoritarian managers alike, Raymond and I soon had it sorted out. We said – ‘don’t you just need to agree an equal opportunities policy, so all the tribal factions and ethnicities are fairly represented? Surely it’s not beyond the wit of man to find something that is fair and agreed by everybody?’.  But no, said Yousuf, what we casually call ‘equal opportunities’ would be seen here as encouraging racism at home – and certainly if it is written down or spoken on the public record. It would publicly question an Afghani's integruty that they are one people. The collective cultural sensitivities are seriously offended, and although it may happen ‘in private’ – any such behaviour would never tolerate public exposure. Publicly, all Afghanis will profess that “we are all brothers together in Afghanistan” – but in private, and out of media or ousiders’ gaze, they will gently joke with each other about their differences, poke fun at their different characteristics, and be friendly or less friendly rivals. There is a paradox here: that to respect everybody equally actually results in some others feeling disrespected, and that their collective cohesion is being disrespected.

Perhaps this very deeply ingrained process becomes entirely understandable when we think of it not as a matter of individual rights or conscious and rational decision-making, but more as a phenomenon of the collective unconscious – where decisions and actions necessarily come about through a complex and emergent process most of which is conducted at a level where words fail, and logic is largely that of the limbic system, or primary process. And this could then be framed as actually being more respectful , but of cultural, collective, emotional, social and relational values – rather than our own predominantly mechanistic, operationalised, materialialistic, reductionist and individualised ones. And who is in a position to say which of those two positions is more ethically, morally or philosophically right? I have only been in the country for a few days - and these are merely personal ruminations - I’m sure somebody will have done research and a great deal of thinking about this somewhere, but it is so far out of my own field of understanding that I wouldn’t know where to start looking. Has anybody any ideas?

[Photos today are random ones taken from the car while we were driving to and from the city centre. Through the windows of course!]

Wednesday, 13 July 2011

Day 3: Kabul Medical University

Yousuf has arranged for us to go and meet the Chancellor of Kabul Medical University today, and we were planning to go this afternoon - but the Chancellor has to go to an urgent meeting at the Ministry of Health, so we have been asked to go at 0830. We wonder if the urgent meeting is anything to do with the yesterday's murder of Ahmad Wali Karzi, the President's brother.

Usual routine, bundle in the car, check doors and windows, gates open, off we go. It's about two miles down a single long road: noisy, bustling, chickens in cages, market stalls, people wandering everywhere (amidst the traffic too), swerving to overtake cars, buses, rickshaws, pedestrians, lorries, donkeys or horses and carts -  followed by immediate violent swerve to avoid being hit by an oncoming car or bus or rickshaw or pedestrian or pedestrian or lorry or donkey or horse or cart. You soon get used to it - I just assume that they are good at it by now as I've not seen any collisions yet, and even if we did it would only be at about 10 mph.
Obstacles in the road
We drove through the tree-filled park of the other university, where elegant faculty buildings stood in well kept gardens, and multitudes of students sat below the trees - talking, reading or just chilling out. And the rumour is that, even on the hottest day (its about 33C today, it can get a few degrees hotter) when you go and sit under a tree you'll get cold and need a jumper or scarf. Sadly, the security precautions don't allow us to try it out.
Kabul University Campus
There were two armed policemen at the gate to the Medical University, and they wanted to see our ID - but waved us straight through. Once inside, Yousuf seemed to know and be warmly greeted by every second person - and he was clearly transported back 30-odd years to his time there, at the time of the Russian invasion.
Memory Lane
The first impression was of a modern building teeming with students, inside and outside. Outside there were less trees that the non-medical university (which is a completely separate organisation), but very well laid-out gardens and a modern marble-floored square with plants and chairs and tables. Inside was much like any other hot country: wide corridors with all hard surfaces, floor-to-ceiling glass windows, then small, medium and huge lecture theatres - and an online computer room for a least 100 students. Every so often, though, the corridors would widen into seating areas with dozens, possibly even hundreds, of elaborately made large armchairs covered in what looked like hand-embroidered cushions. Their purpose was like the trees at the other university - for sitting, reading, thinking, chatting - and all the other things that go with learning. A pretty civilized environment, considering we're in a war zone, we thought.

Even more of an island oasis was the Chancellor's office: furnished with oriental carpets and voluminous heavy curtains, we went through two plush ante-chambers, the first with two assistants and the second with a very large and formal committee table, to arrive - almost like a Bond movie - at the command centre of a very powerful man. The desk was the size and style of a large luxury car; there were five very large and very soft ornate sofas  leading down each side of the room from the desk, with carved wood and glass tables low in front of them. The only item in English I saw on the vast desk was the spine of a book - "War Surgery - Working with Limited Resources in Armed Conflict: Volume 1". Oh yes, that, of course - which felt a million miles away from here. You certainly wouldn't have seen anything to indicate that was going on, at least from the moment we passed the armed guard and entered the gates of the university.
The Inner Sanctum

The Outer Anteroom

The Chancellor's place on the sofas was discreetly identified by the presence of his wireless bell-push, to call his assistants. We were gracefully ushered to our seats on the sofas, with the position of each, I think, reflecting our position and esteem in the social order - as a foreign guest, I was opposite him, with the Daimler-of-a-desk on one side and Yousuf on the other. And indeed, honoured I was - indeed somewhat over-awed and anxious to boot. We had about five minutes notice of his arrival, and were served green tea in octagonal glass cups while we were waiting.

Once he arrived, and had signed his way through a pile of papers which one of his assistants had brought in ('we will keep being interrupted by people if I do not do this first'), he welcomed us in English (by now including about about five other senior academics) and let Yousuf describe what we were there for, in Farsi. He was very receptive to our ideas for 'modernised psychiatry' integrated about three axes:

  • throughout the biopsychosocial curriculum, 
  • across the medical and non-medical disciplines, 
  • througout the training pathway (undergraduate, postgraduate, continuing professional development and leadership training).
So the upshot was a lot of work for Yousuf in collaborating with various curriculum committees, support for including (or at least negotiating) with the other Kabul mental hospital (an academic neuropsychiatry clinic, where some of the senior staff have a particular aversion to Yousuf's plans for rigorous training and assessment), and willingness to include medical students in our forthcoming intensive psychosocial (living-learning) experiential courses over here, and my agreement to talk to somebody at IMH in Nottingham about possible exchange programmes, and help with designing, delivering and researching PTSD treatment programmes. He thought that the current friendly British Consul would be helpful with initiating things. Probably several other things too - as, by now, most of the talk was not in English, so impenetrable to my ear. The Chancellor gave his apologies, and disappeared to the Ministry. The rest of us carried on several impromptu conversations which broke out amidst the sofas, and we said our goodbyes a good while later - after the octagonal glass tea cups were taken away. Presumably a signal, and to ensure that Mission Control was ready for Mr Bond's next set of visitors, in his Inner Sanctum.

Yousuf treated myself and a psychologically-minded neurosurgeon, Dr Pirzad, to a walk down memory lane by showing us round the medical school - including the numbered seats in which they sat in lectures (and at which he has often subsequently lectured). The numbers are printed in a large size numeral, and on the seats at the top of the FRONT, not the back. This is so that the lecturers can make a note of all the empty seats - and woe betide those whose numbers are visible! A lovely low-tech way to opt out of lectures rather than opt in - and reduce paperwork in the bargain. Memory lane for all of us probably includes final exams, and we were treated to the interesting experience of finding our way through crowds of several hundred anxious young medics queuing up to get to the lecture halls (where the exams were held).
Waiting for the off
 It looked to me as if the genders were separated - but Yousuf assured me that was no longer true. They were however separated by punctuality: the first ones there got seats in the lecture theatres, and the last few had to sit on the floor in the corridor for their two hours of mental torture...
The swift or lucky ones got seats 

... while the rest did not
The final event of the visit was tea in Dr Pirzad's office, with him telling us interesting tales of meningiomas, and how do do neurosurgery with inexpensive ultrasound location rather than fabulously expensive scans. Clearly a man for mastery of gadgets and gizmos, I introduced him and Yousuf to the idea of using Prezi instead of Powerpoint - and we swopped notes on tricks with digital cameras and other boys' talk. I was also given a book in Farsi to examine - which is a bit of a non-starter for me anyway - but it was perhaps the largest ever book with the smallest number of words for its size. We decided the author (one of Dr Pirzad's acquaintances, who had given the book for his collection) had deliberately chosen a vast font size to win the biggest book in the library prize...

A heavy read (2005pp)
Then the two of them explained and discussed how they are going to revolutionise medical ethics in Afghanistan through regulation and registration of training. And I believe them!

Tuesday, 12 July 2011

Day 2: the hospital and the psychiatrists

The days starts at 7.30 here - meet for a cup of tea before being driven off the hospital for a 8am briefing.
One of our ever-present drivers, always waiting for us
The briefing was for the whole NGO team, and about eight were there for it this morning: surrounded by flipcharts, to-do lists, everybody with at least one laptop on their lap. Tasks for the day, snags, people coming and going, important meetings - and a warm welcome for a newly arrived psychiatrist from Europe who doesn't speak Farsi. But thankfully Nadia the team interpreter was available for most of the day; she is a local young doctor who wants to train in obstetrics - but is doing this job for an NGO while things are so chaotic in Kabul.

Then to the nicely refurbished library - with a large and a small teaching room, and a few small shelves of books (mostly donated from UK, but quite a number in Arabic script too). Bright blue walls, sun playing on the vertical blinds, projector bolted to the ceiling, a familiar-looking circle of about 25 new chairs and people trickling in for the seminar. As good as most postgrad teaching rooms back home, and better than many; the circle soon filled up with psychiatrists (all men) and psychologists (mostly women, all sat together) and anybody more than five minutes late was not allowed in.
The door to learning
The new education centre

The small seminar room

The teaching plans and timetables

The planned session on Kleinian theory was postponed so that I could have a conversation with them all about how things worked in the hospital, and how they thought the training programme might help. I made some complicated comments about using therapeutic relationships to improve understanding and clinical effectiveness - and was surprised how many of them got the point straight away and agreed. I warmed to my theme, and explained how the future visits will be for training events that will give them an intensive experience of being in groups themselves - and why this will help them, and how it can be quite challenging. Again, even more surprisingly, general agreement. Now my guide book says that Afghanis tend to be very polite and would generally try being agreeable rather than upset a guest - so I'll have to wait to see if they know what they are letting themselves in for. And when I later talked Yousuf through the normal format for these 3-day courses, he gave me a list of things that might be different in this culture:

  • sensitivity to gender issues - fair enough about having completely separate sleeping quarters, but I'm determined to get those men cooking for each other (and he assures me that none of them will ever have cooked anything before).
  • prayer times - which need to be religiously observed (boom-boom) and therefore timetabled - but would expose fascinating dynamics, as he knew the range of religious belief to be very wide - and never openly discussed.
  • overwhelming exposure to trauma. Most people here have experienced family and personal loss as a result of the wars, and are generally open about discussing it. But to do so in a therapeutic space where feelings could be overwhelming needs careful thought about containment - especially small group conductors and interpretation.
  • humour can sometimes be extreme - but in a defensive way to avoid discussing 'serious' matters. And most Afghanis are long-practiced and expert at it.
  • gay relationships are sometimes disapproved of and can be the subject of the jokes - and projected onto various ne'er-do-wells.
The doctors and psychologists at Kabul Mental Health Hospital
We also thought language exercises could be devised - and that it might be very eye-opening for their professionals to experience the power dynamics of having an expert by experience in our staff team. We shall have to see what we can arrange!

The work discussion group was reassuringly familiar - which is enough said for those who know about such things, and probably quite inexplicable for those who don't. I was charmingly invited to lunch by two of the female psychologists, and - being somewhat confused by how this isn't even mentioned as a possibility in my etiquette guide - was rather relieved when I realised that it was against the security rules to go anywhere with any locals without the NGO cars, driver, security person and all. So I gracefully apologised - and later learned that this is exactly the right thing to do anyway - even if I was able and keen to go.

At lunchtime one of the other NGO staff came over to tell us about the murder of the President's brother - a powerful political presence in Kandahar, one of the least safe areas. It was by a trusted bodyguard, so the conversation turned to how it is increasingly difficult to identify who is Taliban - and how sophisticated and long-term their planning is becoming. We also wondered if it would increase the restrictions on us and our movements - which are already close to the maximum without having to stay in our house all day every day. And after that, its just the safe room, then emergency evacuation.

The afternoon tour of the hospital was both better and worse than I had imagined. The bad news is that yes, they do chain people to the beds (in some hospitals they have to raise the cost of their own chains); there are ten patients in a small room (all day - with nowhere else to go), sat on beds which almost touch  each other; nobody is admitted unless their relatives come too to look after them; nurses are almost non-existent; efficient psychiatrists can see sixty patients in little over an hour; the forensic ward is only different because it has more chains.
The hospital kitchen (as seen on YouTube)

Dr Rahimi is very upset with the state of the buildings

Dr Haigh believes ECT should only be a very last resort
BUT the patients do talk together, appear generally well fed and clothed, seem to care about each other, sometimes include spiritual healing in their treatment, receive medication efficiently, and only have a 5 second waiting time for psychological treatment. The last one is not a test to see if you are still awake, but the way the outpatient clinic works: 1-2 minutes with the doctor and nurse (sat at the left and centre tables, below - the doctor interviewing, diagnosing and prescribing and the nurse completing the notes) then along to the next table with a psychologist as soon as you have finished, if the psychiatrist thinks it will help (by the window on the far right). You might not get very long for your session, though, and none of it all is exactly confidential...
The Kabul Mental Hospital Outpatient Clinic

A little later in the day we had a detailed discussion with nearly all the senior doctors in the hospital, plus the head of psychology and a representative from the trainee psychiatrists. Which made seven - not a large number for a psychiatric hospital covering about half the souls of Kabul (pop 3.89m). Interestingly, they are all TV celebrity doctors, too - with about 40 local channels now, they are all signed up to be the 'television psychiatrist' for at least three or four of them. However, they were all committed to learning better ways of running their practice, being more psychologically-minded, and becoming less professionally isolated. Unfortunately, just like many psychiatrists in England who are not now managers, they have no power to make any of it happen: apart from the unimaginable skimpiness of the resources - the management are not very interested in change (which is perhaps different to England where they are interested in change but too much of it and in the wrong directions). So my own prescription is for some heavy-duty reflective consultation exercises. But as the insidious and probably unconscious undermining has already started ('forgetting' meetings, slipping back into old command & control ways, and other things), don't hold your breath that it will happen.
Refurbishment under way

The psychiatrist and his bright green newly painted female ward

My most optimistic thoughts are that such a tabula rasa gives wonderful opportunity for the development of a  truly commnunity-based network of self-help non-residential therapeutic commuities: ideally one for each of the proposed five community teams, in the same buildings as them (rumour has it that many military and other buildings will be vacant soon, as troops move out), and with both mental health programmes and addictions: forming the heart and hubs of all the city's mental health services. And they could be run as cooperatives between the professional staff, service users (always "patients" here), volunteers, families and friends. The psychiatrists would only need to look in once a week, and the rest of the time they could be seeing their private patients who do not like the thought of groups, or are too psychotic or organically ill to be attend them.

The private patients are simply those who actively choose to see one of the psychiatrists, rather than just be taken to the state hospital - they do not get treatment that is much different from the state hospital outpatient clinics (ie very quick mental state assessment, diagnosis and prescription). The working day here for the psychiatrists is mornings at the state hospital then afternoons seeing literally dozens of these private patients (which they also do at weekends).  Now, of course, they are also expected to go to the new psychiatry courses which Yousuf has set up to improve the clinical standards - and I suppose they squeeze the TV appearances in between times.