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Kenneth Li

Natasha Merali

Columbia University, New York, NY, USA

The ‘Friendship Bridge’ between Khorog (Gorno-Badakshan, Tajikistan) and the village of Shugnan (Afghan Badakshan, Af-ghanistan) stands over the clear rushing water of the Pyanj River, tucked between the snow-capped mountains at the heart of Cen-tral Asia. Since its opening in 2004, the bridge has helped foster plurality and enabled exchange and understanding by opening up local markets and stimulating regional trade. However, it has also served as a medium for the exchange of illicit goods, including narcotics and arms. More specifically, opium drugs are supplied readily from Afghanistan in the form of processed heroin, a de-rivative of opioid, and sold across the bridge in Tajikistan. This consequence is evidenced by the fact that the number of injected opioid drug users (IDUs) in Central Asia has increased exponen-tially over the past decade, making opioid overdose a substantial hurdle to an improved standard of living. In 2009, it was esti-mated that in Tajikistan alone the number of IDUs neared 25,000 in a population of approximately 7.4 million.

Having lived in Tajikistan for six years, I was drawn to get involved with Columbia University’s Global Health Research Center of Central Asia and was assigned to a team of five differ-ent non-governmental organizations (NGOs) in the field to cre-ate a database that would help us better understand drug use in the region. Our findings shed light on the complicated web that intertwines drug use and mental health issues, the latter being particularly taboo in the region.

In Khorog’s only drop-in clinic for IDUs, I met a 19-year-old girl, Nargis (all names in this article were changed), who suffered from a heroin addiction. With the help of a translator, she told me how she and a group of friends had once shared a needle. Soon after, she was diagnosed with HIV. “I am healthier now,” she said, “but my parents will still not speak to me and the owner of the shop I used to work at told me to leave my job.” Her doctor later told me that she had developed signs of depression as a result of her experiences but refused to see a psychologist for fear of further alienation. Sitting with Nargis, we discussed ways that she could better communicate with those who are unaware of what she may be going through and set up a time for her parents to come to the clinic and meet with consultants. Despite our efforts, her hesitant and somewhat unfazed expression told me that it was unlikely to happen.

The following day at the clinic I met Firoz, a 26-year-old man who owned a fruit stall at the local market. He had been di-agnosed with mild schizophrenia as a child. Soon after Firoz was refused entrance to high school. He then became depressed, de-veloped a heroin addiction and attempted suicide. He was turned away by his father, and for a long time could not build up the courage to seek help, dreading more rejection. Firoz had heard about the clinic from a friend who had been an IDU and is now slowly learning how to move past drug use. But Firoz, having been ostracized by his school and friends, still finds it difficult to see the world in a positive way.

Though Nargis and Firoz recalled their personally devastating experiences, to which many other locals could closely relate, the long-term impact of addictive drugs extends beyond the primary drug users, affecting the development and security of the local community and region. When these drugs are acquired in areas such as Khorog, which lacks sufficient educational opportunities, it feeds a cycle of elevated stress, depression and consumption of opioid drugs and alcohol. The doctor at the IDU clinic also high-lighted the fact that opioids themselves have adverse psychological effects such as anxiety and depression, making drugs both a cause and catalyst of psychological distress. Mental illness and drug use have always resulted in high comorbidity, even in developed na-tions, but when this cycle occurs in an impoverished population that lacks an adequate knowledge of the mental health situation, there is little motivation for the government or society to remedy poor mental health. Those who have been labeled as having a psy-chiatric disorder are set aside as incompetent and helpless, further weakening an already fragile infrastructure.

The absence of motivation for remedying the mental health situation only scratches the surface of a problem that is much more deeply rooted. Although health profession- als in hospitals and clinics in Central-Asia recognize the fact that opium injection is a major contributor to HIV/AIDS incidence, they often forget, choose to ignore or stigma-tize the mental health consequences of opium use. The doctor at the IDU clinic explained to me that the few working psychiatrists themselves face prejudice from their family members and community for specializing in the care of those who have been diagnosed with disorders people would rather forget exist. Psychiatrists therefore often burn out following intermittent visits from patients. As clinics are confronted with decreased human and material resources, those suffering from mental illnesses are neglected by their own healthcare system. Even after IDUs have recovered from the physical side effects of drug use, they are mentally scarred by the drastic social and economic changes that result from community estrangement and unemployment. This further plunge in mental health can undermine one’s sense of wellbeing and quality of life, negatively affect societal interactions and lead to increased suicide rates.

Despite such grave consequences, psychiatric care and mental health still remain very low priorities compared to other sectors of health care in Central Asia. In most regions, mental health does not hold legislative urgency and a minimal number of community-based services are available. In 2008, it was reported that the number of recorded patients with mental health disorders was 59,010, although the total number is estimated to be much higher. In Tajikistan, as of 2009, the percentage of the Government Health Department expen-diture put towards mental health was merely 1%. Of that 1%, the majority (84%) was directed towards mental health hospitals leaving only three community-based inpatient facilities in operation. More-over, only 14 hospitals out of the approximately 500 hospitals in Tajikistan were reported to administer mental health treatment and the number of psychiatrists per 100,000 people was 1.8. As of to-day, Tajikistan’s Ministry of Health still does not have a department of mental health, and the nation’s primary health care staff do not receive training in mental health treatment.4 Tajikistan already faces unyielding corruption and poverty, limited local access to education and the perpet-ual problem of brain drain; the medical school in Kho-rog continues to attract stu-dents but graduate retention remains a problem as health workers seek the prospect of higher wages abroad. So how does one convince the coun-try that mental health care is a worthy investment? Currently, one of the biggest hurdles in over-coming the lack of attention paid to mental health care is the preju-dice against and stigmatization of those suffering from psychiatric disorders. Not only do patients receive insufficient care, but their illnesses are also inadequately recognized, which only exacerbates the problem. Because people refuse to see doctors or therapists, the data that is collected misrepresents the true nature of the situation. In reality, the number of mental health patients that is recorded is insignificant in comparison to the number of people who suffer from these disorders and do not receive treatment. Subsequently, national information on the mental health system is not readily available, and reports that do exist are often outdated or have substantial gaps and inconsistencies. Before attempting to obtain reliable and systematic data, efforts are first needed to raise awareness and lift the veil that prevents people from coming forward about mental health issues—an effort that applies equally to doctors and patients. Governmental and health authorities also need to be reminded that mental health and the well being of the population go hand-in-hand with the eco-nomic health and development of their country. Only then do coun-tries like Tajikistan stand a chance of implementing effective mental health legislation.

Although financial barriers play a part in deterring the advance-ment of the mental health system in Tajikistan, they are secondary compared to the role local people have in addressing the subject. Governments have a higher chance of responding to mental health if the issue at hand matters to their people. While in the long run, the implementation of a strong foundation in mental health profes-sionals and facilities would be the preferable course of action, in the short-term, addressing the social barriers that exist for those who need treatment is just as important. If traditional attitudes and prac-tices are first overcome by individuals, forward thinking can be uti-lized as a contagious force to slowly spread awareness and tolerance throughout communities.

There is a preliminary need for those suffering from mental illness to gain self-confidence before being able to effectively communicate with those who may initially be ignorant of their condition. People diagnosed with mental health illnesses in Tajikistan perceive them-selves as inept because society has decreased expectations for them. If a person has been rejected in a community for being “unable,” he or she first needs to realize the poten-tial in him- or herself before others can do the same. One of the main reasons people do not speak up against the stigma associated with mental health issues is that they fear that no one will be able to grasp or relate to their side of the story. This segregation can be eliminated if an opportunity is given to meet others in similar circumstances. Existing IDU clinics and community-based services can implement phone helplines and hold frequent group therapy sessions for people to share familiarities and opinions as well as to discuss ways to approach those who may not comprehend the subject. Through these sessions, patients can gain insight into the prevalence of the situation in their community and build self-confidence to express their experiences openly, knowing that people are there to listen and understand.

A challenging, but particularly crucial, step in combatting stig-ma is better informing those who have rejected people who needed psychiatric care and helping them to understand that the words “dis-order” and “illness” are not synonymous with incapability. Society is partially responsible for the decline in the wellbeing of those who have experienced discrimination. This sequence of events comes to a halt once individuals see themselves as having self-worth; it opens the door to their family’s acceptance and allows employers to give them another chance to prove their competency. Treating people who have experienced a downfall in their mental health as full members of so-ciety, with equal privileges and responsibili-ties, is essential in order for a community to accept that the state of one’s mental health is a shared liability and not the fault of an individual.

Undoubtedly, solutions should include preventative measures in addition to treat-ment. Education lies at the heart of motivat-ing society to eliminate gaps in the mental health system and preventing further igno-rance. This strategy includes implementing training centers for local volunteers who can then hold mandatory mental health in-formation sessions at schools for teachers, parents and children. Such teaching would explain how to recognize signs of depression and emphasize that mental health issues are not the fault of the person who experiences them but instead due to their genes and environment. In classes, students can be given scenarios depicting people with men-tal health disorders and then be asked how they would respond. This will ease young kids into talking openly about such subjects and prepare them to respond positively and knowledgably to similar issues in the future. For those who do not attend school, volun-teers can also make presentations in commu-nity or religious centers. At the macro level of this educational process, once volunteers have received sufficient training, they can serve as community health promoters and train others to do the same. Such educators must be local people if the effect of minimiz-ing stigma is to be long-term. As for teachers in further education, psychology and men-tal health should be incorporated into the medical school curriculum. Education, both at a micro and macro level, will not only empower people and enable them to speak about mental health with confidence and openness but also enable them to approach treatment with better understanding.


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