Throughout Afghanistan, health providers are poised to begin delivering services to the mentally ill and the disabled as three new components—community health, mental health, and disability—are fully introduced into Afghanistan's Basic Package of Health Services (BPHS).

To facilitate implementation of the new BPHS components, REACH held a comprehensive, three-week training course in Kabul for 62 doctors, nurses, and midwives. These Afghan medical professionals, 80% of whom are doctors, are staff from four REACH NGO-grantees that collaborate in conducting standardized clinical training: Agha Khan Development Network (AKDN), Coordination of Humanitarian Assistance (CHA), Ibn Sina, and the International Medical Corps (IMC). The training is provided at eight training centers in seven Afghan provinces: Badakhshan, Baghlan, Bamyan, Faryab, Herat, and Takhar, plus two in Kabul province.

As master trainers, course participants will use reference manuals and teacher and trainee guides in disability, mental illness, and community health. These materials have been developed by REACH to prepare more than 700 other doctors, nurses, and midwives working in basic and comprehensive health centers as well as district and provincial hospitals in the 14 USAID priority provinces to address the needs of Afghanistan's mentally ill and disabled.

More than two decades of war, displacement, and loss have left many Afghans with crippling mental disorders, ranging from severe depression and anxiety to post traumatic stress disorder. The mentally ill sometimes suffer physical disabilities as well.

"The war traumatized so many of our people; many saw family members killed before their eyes, saw them hurt and left with disabilities," said Dr. Ghotay, of CHA Herat, adding that "social problems, such as forced marriages, abuse, and poverty, have especially contributed to depression among women."

The REACH course brought all Afghanistan's mental health professionals together for the first time to teach alongside REACH faculty. Lecturers included Dr. Ruhollah, Afghanistan Ministry of Public Health Mental Health Advisor; Dr. Mohammad Saeed Azimi, WHO Health Advisor; Dr. Mohammad Nader Alemi, a psychiatrist who has opened a psychiatric hospital in Mazar-e-Sharif; Mr. Azizudin Hemat, head of the Afghan Psychological Association; and Dr. Timor Msamem, Director of the Kabul Mental Hospital. The class was also addressed by Dr. Mohammad Azam Dadfar, Afghanistan's Minister for Refugees and Repatriation.

Following discussion and group exercises using case studies, the master trainers observed group therapy sessions and interviewed patients. Seated on chairs at the front of the room, some patients told stories of isolation and physical abuse; others had become addicted to drugs, sometimes as a way to escape fear and physical or mental pain.

"Substance abuse by both sexes is of growing concern," said Dr. Shafiqa Gharawal, Training Coordinator for Ibn Sina in Kabul. "Programs to help the addicted, employment and training centers for the disabled, the mentally ill, and retarded—to many people these are new ideas, and they will need to be encouraged."

An estimated 4% to 10% of the Afghan population have physical disabilities. Those acquired at birth, including mental retardation, reflect the low level of antenatal care, inadequate treatment of infectious diseases, and cultural practices such as the intermarriage of first cousins. Many other disabilities are due to accidents and war-related injury. Land mines have disabled 250,000 Afghans and continue to maim some 480 Afghans a year, many of them children.

Between 2001 and 2004, the number of disabled Afghans receiving physiotherapy, prostheses, or other orthopedic services rose from 48,118 to over 87,000, but a great deal more remains to be done. The disabled encounter discrimination and difficulties in obtaining education and employment; disabled women are often denied the opportunity to marry.

The REACH course supplied training in the detection, screening, and assessment of disabilities. Following an overview of available referral and rehabilitation services, participants visited a school for the deaf as well as several rehabilitation centers in Kabul, including the Community Center for the Disabled in Karte Seh, which holds English and computer classes for the disabled and offers job placement and empowerment programs.

"The course participants were visibly moved as they talked with amputees receiving rehabilitation therapy," observed Dr. Nassim Assefi, REACH Refresher Training Advisor.

The BPHS will now extend services to problems the war-torn country was forced to neglect for many years. On the final day of the REACH course, asked whether she was optimistic, Ms. Medina, a master trainer and midwife from Herat, made a passionate reply: "We must be optimistic! We aren't experts yet, and we'll need to receive—and give—more training, but we've learned how to start removing the stigma from disability and mental illness and ways to provide people the services they need. The doctors, nurses, and midwives that we train will not only work with patients but give hope to their families. They're going to bring a ray of light into what, up to now, has been a very dark room."

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