Google "Afghanistan" and "post-traumatic stress disorder," and the search results will paint Odyssean portraits of thousands of American war veterans: restless and explosively violent, battling internal monsters, incapable of making the emotional return home years after they have left the physical combat zone. One in five American veterans who have served in Iraq or Afghanistan -- as many as 400,000 men and women -- suffers from severe depression or post-traumatic stress disorder, a noxious bouquet of depression, hopelessness, panic attacks, psychosomatic pains, rage, and insomnia. A recent U.S. Army report found that the suicide rate among active-duty soldiers had ballooned from 9.6 per 100,000 in 2004 to about 24 in 2011. By June of this year, more active-duty troops had died of suicide than in combat. Mental disorder has become the signature injury of Washington's latest wars, which have turned the term and its acronym, PTSD, into household words in the United States.
But can an entire country have PTSD? Can invisible wounds bleed whole societies: failed states like Somalia or the Democratic Republic of the Congo, sadistic dictatorships like Zimbabwe or North Korea, countries trying to recover from fratricidal conflicts like Iraq or Sudan?
Or take Afghanistan, a war zone I know well. What happens when physical and emotional battlefields converge in a land whose people have been eking out an existence amid unending violence for generations? In such war-wrecked countries, the trademark symptoms of individual war trauma -- depression, anguish, and hyperaggression -- leave whole populations envenomed with sectarian and ethnic mistrust, and with the certainty that only violence can end violence.
Like a traumatized veteran who scans a suburban shopping mall for snipers, they see danger even where it may not necessarily exist. Scores of Afghans have told me privately that they defied the 2006 government order to disarm and secretly kept their rifles stashed within easy reach: in shallow pits in their backyards, beneath the earthen floor of their houses, behind knotty poplar rafters holding up wattle-and-daub roofs. One taxi driver explained that his family owned enough rifles to arm an infantry squad. He kept a Luger Parabellum, wrapped in a camel-wool blanket, in his car. He said he felt threatened by government troops, police, Taliban, ethnic militias, and neighbors belonging to different ethnic groups -- in short, by almost everybody who was not his kin. No wonder a 2009 Gallup poll showed that two-thirds of Afghans felt unsafe walking alone outside at night.
In 2002, shortly after the Taliban government fell in Kabul, the U.S. Centers for Disease Control and Prevention dispatched a research team to Afghanistan to study the prevalence of mental trauma among civilians there. That nationwide survey remains the only modern, comprehensive inquiry into the mental health of Afghans. It found that 42 percent of Afghans suffered from post-traumatic stress disorder and 68 percent exhibited signs of major depression. In other words, up to 19 million of the country's 28 million people were suffering from psychological injuries. And that was a full decade of war ago.
In a village about 30 miles south of Mazar-e-Sharif, in northern Afghanistan, I once had lunch in a castle that presided over 15 acres of farmland and belonged to two brothers. I admired the 360-degree view of the valley through the tower's primitive castellations, from behind 4-foot-thick clay walls. The brothers told me they needed the castle, built 60 years earlier by their grandfather, to defend their women, their wealth, and their honor. From whom? I asked. They responded in unison: "Everyone."
"Feelings of hatred and revenge, and the desire of acting on that feeling of revenge, directly affects the peacemaking process," says Barbara Lopes Cardozo, the psychiatrist who oversaw the 2002 mental-health survey in Afghanistan and who has studied mental health of civilians in such war-scarred geographies as Kosovo, Somalia, and Uganda. "We found very high numbers for having those feelings of hatred and revenge -- almost 80 percent -- in Afghanistan."
Post-traumatic stress often spawns domestic violence -- the U.S. Department of Veterans Affairs says returning service members are up to three times more likely to abuse their partners than American civilians -- and Afghanistan is no exception. Time magazine's shocking photograph of Bibi Aisha, the 18-year-old woman whose husband had cut off her nose and ears, became the face of Afghanistan's spousal abuse. Two-thirds of Afghan children surveyed by British anthropologists in 2006 reported traumatic experiences; two years later, a study in the Journal of Marital and Family Therapy found that more than half the children surveyed in Kabul reported witnessing three or more types of domestic violence. Is this the knowledge that had hollowed out the eyes of the children I have met in Afghanistan's villages and towns, that had turned preteen boys into little old men with skeptical down-curved mouths? The generation that will determine the country's future is growing up today with the understanding that nowhere is safe and that cruelty is the norm.
"People get used to using violence to settle their disputes, and it is difficult to find a way to unlearn those behaviors," says Peter Bouckaert, emergencies director at Human Rights Watch, who has worked in war zones around the globe. "You end up with a warlord economy which is incredibly hard to break and which does lead to a constant renewal of conflict -- as it will in Afghanistan."
A few years ago, researchers in northern Uganda -- where the Lord's Resistance Army of the self-proclaimed messiah Joseph Kony had killed and mutilated tens of thousands of civilians and abducted countless children into servitude before fleeing into the jungles of the Central African Republic in 2006 -- conducted a survey designed to determine the emotional effect of violence on residents. The study, published in the Journal of the American Medical Association in 2007, established that civilians who were suffering from post-traumatic stress disorder -- about 74 percent of the Ugandans surveyed by University of California/Berkeley scholar Eric Stover and his colleagues -- were "more likely to favor violent means to end the conflict" than civilians who were not. Trauma begets trauma -- and violence.
Compared with research into the effects of conflict on U.S. war veterans, studies of combat trauma among civilians are few. But there is a growing understanding among medical scientists and conflict experts that the emotional toll of war on noncombatants is more significant than had been assumed. During World War I, when military physicians described soldiers' traumatic reactions to war as "shell shock," about nine out of 10 war casualties were fighters. But after nearly 50 years of the Cold War and more than 10 years of the war on terror, the way we wage war is more personal. Terrorism battlefields recognize no front lines. Vicious sectarian rampages pit neighbor against neighbor. Victims of genocidal campaigns often know their attackers by name. In the most current conflicts, at least nine out of 10 war casualties are believed to be civilians, writes psychologist Stanley Krippner in his book The Psychological Impact of War Trauma on Civilians. In Iraq, where as many as 1 million people may have died since 2003, the rate might be even higher. No one kept track of civilian casualties in Afghanistan between 2001 and 2007, and estimates vary widely; given the United Nations' tally of almost 12,000 civilian deaths since the beginning of 2007, a rough guess of between 20,000 and 30,000 civilian casualties since 2001 seems reasonable.
COMMUNAL PSYCHOLOGICAL WOUNDS -- what medical anthropologist Arthur Kleinman has called "social suffering" -- permeate the lives of survivors scraping by in unimaginable poverty amid collapsed infrastructure, the common afterbirth of modern combat. According to the Centers for Disease Control and Prevention, between 30 and 70 percent of people who have lived in war zones bear the scars of post-traumatic stress disorder and depression.
They are people like Farida, a wasted mother of three from northern Afghanistan. She was 2 years old when the mujahideen drove Afghanistan's communist government out of Kabul and plunged the country into fratricide. She was 6 when Taliban tanks rolled into Khanabad, her hometown of dusty poplar alleys. She was 11 when a series of U.S. air raids pummeled the town, targeting Taliban fortifications and killing nearly 150 civilians. Soon a ragtag mujahideen army once more dragged its howitzers through town, executing Taliban fighters who had not fled in time. Five years later, the Taliban were back. There were ambushes, beheadings, roadside bombs, acts of unspeakable brutality. By the time she was 20, Farida could no longer summon the energy to boil rice for dinner or pin wet laundry to the lines that sagged along the hand-slapped mud walls of her family compound. Her days brought tidal surges of panic attacks. Her nights brought no sleep. Headaches tormented her. The shrill voices of her three small children sawed through her skull. She could not eat. Inside her farmhouse, Farida found no peace.
I met Farida at one of Afghanistan's few psychiatric clinics, in Mazar-e-Sharif, a day's journey from Khanabad. Her husband had scraped together some $50 for transportation and treatment to take her there. She sat in a stuffy third-floor room on some rug-covered planks fixed to a metal frame that passed for a cot, her arms folded around her knees, rocking lightly. Her old calico dress, now several sizes too large, hung off her wasted shoulders. Flies landed on her twig-like collarbones. Farida just rocked.
"Panic attacks and depression," explained Mohammad Nader Alemi, the clinic's owner and head doctor. "And conversion disorder." Most of Alemi's clients -- more than 6,000 since he opened his hospital seven years ago -- suffer from the same symptoms, all common manifestations of mental trauma.
Scholars who study conflict say that it is as important to address the effects of war trauma on the psyche as to provide survivors with food, shelter, and physical health care. Extending behavioral help to the millions of people who raise their children, graze their livestock, tend their fields, and go to school every day against the macabre backdrop of mass rape, air raids, gunfights, minefields, torture, and political executions is becoming "a major issue for national security, public health, and reconstruction of a traumatized society," says Richard Mollica, a psychiatry professor at Harvard Medical School and one of the pioneers of the notion that mental healing is essential for postwar recovery.
But how does one help heal a country that has been forged in millennia of almost incessant conflict? There is no such thing as a Marshall Plan for the mind. Most mental-health professionals agree that war injures the psyche, but not everybody thinks that the diagnosis of post-traumatic stress disorder, formally recognized by the American Psychiatric Association in 1980, can be applied to people from non-Western cultures, who may perceive and experience grief and shock differently. Weekly counseling sessions may be appropriate for a platoon sergeant from Arkansas, but imagine trying to get a grizzled shepherd from the Hindu Kush to open up about his nightmares.
Most Afghans turn for comfort to religious shrines -- small mausoleums or simply fenced, coffin-sized ziggurats, painted green and laced with shreds of shiny cloth that sparkle along country roads and hillsides like jewels. Pilgrims come to kneel or lie prostrate next to the metal palisades, seeking delivery from the djinns that possess them -- evil spirits that trigger sudden violent outbursts and long bouts of melancholia, that bedevil their sleepless nights with nightmares and turn their days into lethargic slogs. On some roads, a traveler can pass a half dozen such shrines during an hour-long drive.
One shrine popular among people who suffer from emotional disorders squats at the base of Zadyan Minaret, Afghanistan's oldest, whose intricate brickwork rises 60 cylindrical feet from the dun desert floor, two hours by car from Mazar-e-Sharif. Beneath the shrine's vaulted ceilings, pale lizards dart over folds of heavy green velvet that shrouds a tomb believed to belong to Saleh, a pre-Islamic prophet. An eerie albino creeper sprouts from the wall near the door, the shrine's only source of light. Outside, knobbly roots of mulberry trees grab onto the side of a jade-colored, perfectly round pond.
Mohammad Yusuf, the eighth-generation keeper of the shrine, said that its 4-foot-thick cob walls are an infallible cure for the djinns that haunt many of the pilgrims who travel to this remote oasis.
"We put the crazy man in here. We lock the door. When the crazy man comes in, the djinns can't go inside with him," Yusuf explained.
Afghans seeking more conventional therapy have fewer choices. Much of Afghanistan is too unsafe for mental-health-care professionals to operate effectively -- or at all. In the entire country there are only 200 beds for mental-health patients.
"Everyone in Afghanistan has been mentally affected by war," an official with Afghanistan's cash-strapped Health Ministry once told me. The ministry, he said, had no resources to comfort the afflicted. "Everybody needs help, and very few can get it."
Twenty of the country's psychiatric beds are at Alemi's Neuro-psychiatric Hospital in Mazar-e-Sharif, the four-story brick ward where Farida had traveled from Khanabad. Alemi, the head doctor, who for years had rented a house for his clinic, built the hospital in 2011 with savings and money he had borrowed from wealthy friends. "It's a growth industry," the doctor half-joked. Inside the clinic, an underpaid team of two psychologists, five psychiatrists, four nurses, a pharmacist, and a lab technician, armed with generic equivalents of Zoloft, Paxil, Lithonate, and Prozac from Iran, India, and Pakistan, treats about 100 patients daily.
One day last year, two dozen or so men and women sat quietly waiting. Most had journeyed to Mazar for days on dangerous, unpaved roads. They were battling unexplained fatigue, panic attacks, abiding headaches, chronic stomach pain. For most, the $3 the hospital charged for a consultation was maybe a week's wages. A typical wait was 10 days.
"Our facility is not sufficient for their needs," Alemi said in the precise, accented English he had learned as a medical student at Kabul University in the 1980s. "You have to have social workers, psychiatrists, social psychologists, psychotherapists, psychiatric nurses. We do not have psychotherapists. We do not have psychiatric nurses. I am sorry."
Alemi -- who is in his mid-50s, wears a neatly trimmed beard and glasses, and looks like an escapee from a New Yorker shrink cartoon -- apologized constantly. He apologized for his hospital's lack of staff. For the rudimentary conditions at his inpatient ward, with its flies and its bare cots. For the absence of staff to perform cognitive therapy. For what he called, in English, his "paltry knowledge of English." He apologized not to anyone in particular but, it seemed, to his own sense of rectitude.
As he spoke, the lights in the clinic went out. In Mazar-e-Sharif, the state-run power plants rotate electricity through neighborhoods for several hours on alternate days. On that day, the hospital's quota of state-issued power was up by noon.
"I am sorry," Alemi said again.
The doctor made rounds. He checked on a 20-year-old patient whose tidal surges of panic attacks had left her incapable of performing the most basic housework. He checked on an old woman curled up in a silent ball on a makeshift cot in a room next door. He checked on a 19-year-old whose mother had brought her from Jowzjan province, about 100 miles away. She, too, suffered from panic attacks: sudden, inexplicable animal fears that made her think she was dying. She was hiding under a blue blanket. Only the pale soles of her bare feet were visible.
"A lot of PTSD cases are coming here," Alemi explained. "I'm sorry, but we don't have a lot of staff. But we are able to listen to them. We are receiving them with empathy."
The doctor's Afghan accent clipped the last word. He pronounced it "empty": "We are receiving them with empty."