Afghanistan mental health: Treatment caught between ancient and modern worlds

Noorzai knows of at least four other shrines taking patients in the geographically scattered provinces of Paktia, Parwan, Sar-e Pol, and Ghazni. Meanwhile, major cities like Jalalabad, Herat, and Mazar-e Sharif now have mental health wards in hospitals.

The shrine in Samar Khel lies a few miles outside the city of Jalalabad. It houses the tomb of Mia Ali Sayed, a 17th-century Sufi sage whose descendants take turns tending to patients.

Mia Sahib, one of the shrine-keepers, explains that his patients are possessed by demons known as djinns. For some, he offers a taweez - a Koranic verse written on a slip of paper. Others require 40 days of confinement.

"A mental patient doesn't know himself," explains Mia Sahib. "In 40 days, he is going to know himself fast. He will know he has some djinn inside. Once he knows he has a djinn inside, he will clean himself. And once he cleans himself, he will know Allah."

He claims some successes, but says he cannot help patients who are addicted to opium or are faking illness to avoid work. (That said, one drug addict named Waseem from Pakistan was locked up in his shrine.)

Afghanistan's health officials have tried to get the media to tell people not to send patients to shrines. And they have enlisted religious leaders to speak out against cultural practices that stricter Sunni interpretations of Islam reject.

"High-profile mullahs and religious scholars are against all these [practices]. They are all the time on TV coming out against taweez as not in Islam," says Noorzai.

But one television journalist, Ahmad Fahim Kohdamani, spent nearly a month in prison this year after he offended some clerics with a report critical of taweez.

The sensitivities leave some international organizations treading lightly.

"Many people use these taweez and people believe that it helps. We won't say it doesn't help," says Bibiane van Mierlo, technical adviser for HealthNet TPO, an Amsterdam-based nonprofit organization working on mental health in Afghanistan. "To deprive somebody for 40 days - that is not a healthy practice. But if some people want to hand this taweez out, that is not a problem - that can go hand in hand with other treatment."

HealthNet tries to offer an alternative by spreading mental healthcare into areas beyond the cities. Many villages already have community health posts, so the group is training some 4,000 to 5,000 of these local health workers to flag mental problems. Then, at the provincial level, the group is training 500 to 600 doctors and nurses on basic psychiatric treatment with drugs and on when to refer harder cases to specialists.

The training courses are short - several days for community workers, several weeks for doctors. But in a country where the immediate need is great and where highly educated doctors often quit for more lucrative careers, less can be more.

Raising the rural levels of education may also, over time, put an end to the shrine treatments.

"My sons secretly say they won't do this," says Mia Sahib. One son is a teacher, another graduated from university. "I will be the last person [in my family] who does this."

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