KABUL, Afghanistan -- The wages of war are starkly visible across Afghanistan, in silhouettes of broken walls, in mounds of pulverized brick. But the most lasting damage can't be seen: the wounds to the minds of Afghans, after 23 years of dread punctuated by moments of terror.
A 4-year-old boy named Hasib grimaces like an animal and repeatedly butts his head on the floor. A young man named Fawad says his father startles awake, terrified, in the middle of every night. An old man, Mohammad, averts his eyes from the rubble of his village; when he looks he is overwhelmed by a flashback vision of dismembered bodies.
Those are three cases encountered recently by a reporter, byproducts of the U.S. bombing campaign. There are millions more, psychiatrists say, after a generation of nonstop war in Afghanistan.
"Most of our people have various grades of mental disorders," said Dr. Fateh Mohammad Sultani, a staff psychiatrist at Kabul's Mental Health Hospital. "I'd say 70 or 80 percent of the population suffer."
Nation's worst health woe
Like much in Afghanistan, hard statistics are lacking, but other psychiatrists agree that most of the country's population of approximately 27 million suffers from some form of mental illness. A report in November by the World Health Organization in Geneva estimated that the illness is serious for one in five Afghans, some 5 million people.
"Afghan specialists are telling us they consider the biggest health problem to be mental health," said the report's author, Loretta Hieber-Girardet of the WHO unit in Kabul.
The U.N. agency and others who want to help scarcely know where to begin. In the latest rounds of multibillion-dollar planning for Afghan relief and development, the WHO has proposed allotting more than $1 million for such basic work in mental health as assessing needs and training doctors to spot symptoms.
"We don't have the experience and expertise in this," acknowledged Dr. Abdullah Fahim, a spokesman for the Afghan Health Ministry. "We need the full support of the world community on this. ... The one hospital in Kabul is the only one in the country."
It wasn't always. Until about 10 years ago, Kabul had three mental health hospitals and an outpatient clinic for therapy sessions, Sultani said. But they all were destroyed in the civil war among Afghan factions in the early 1990s. The current, 50-bed Mental Health Hospital was re-established in one building of a former polyclinic, but the Islamic extremist Taliban, who governed from 1996 until last fall, did not encourage an expansion of the mental health care system.
The WHO report noted that only eight psychiatrists were practicing in all Afghanistan in early 2001. That may have improved only slightly as some professionals have returned from exile since a U.S.-led war ousted the Taliban in December.
The unending wars undermined mental health care in another way as well, by disrupting rural life and sending millions fleeing Afghanistan as refugees, breaking down traditional, informal counseling in the villages, in women's get-togethers, for example.
This cumulative mental health crisis is a huge obstacle to a better future for Afghanistan, experts say.
"If half the population is depressed, you can't rebuild society. The population is vegetative, passive, pushed along, helpless," said Dr. Lynn Amowitz of the U.S. group Physicians for Human Rights. A public health specialist, she has closely studied depression among Afghan women.
The invisible wounds are borne by Afghans who have lost loved ones, lost limbs, their homes, their jobs. Others are traumatized by the deepening poverty, hunger and dislocations of war.
Afghan psychiatrists say the damage often becomes visible in symptoms the American Psychological Association classifies as "post-traumatic stress disorder," or PTSD: traumatic nightmares or waking flashbacks known as "intrusive recollections"; avoidance or "numbing," when an individual withdraws from intimate or social contacts; and rage or edginess known as hyperarousal.
Those afflicted may fear going out, have trouble sleeping, are terrorized at the sound of airplanes, are irritable and argumentative, doctors say. Such disorders do not discriminate by age. A study of Afghan children by UNICEF in 1997 found the majority were severely affected by nightmares, anxiety and concentration problems.
The Afghan specialists know that therapeutic counseling and drugs -- for sleep disorders, for suppressing nightmares and explosive moods -- can help. But in one of the world's poorest countries, with one of the worst health care systems, very few people receive treatment. Even those who find their way to the lone mental health hospital are not always treated.
"We try to give them medications from hospital stocks," Sultani said. "But sometimes we don't have enough. We're appealing for more to the international organizations that help us."
The cheapest two-week course of medicine costs about $20 -- a fortune to Afghans. "People are poor. They can't buy medicine from the bazaar," Sultani said.
Most go untreated
Down the dusty road in Kandahar, others find satisfaction in a dim, cramped room where Dr. Ghulam Mohammad, the city's lone psychiatrist, receives a steady stream of patients -- half with physical, half with psychic complaints. He sometimes charges only 1,000 or 2,000 afghanis per visit, the equivalent of 3 or 6 U.S. cents.
"There's little understanding of all these problems that result from the war. There are so many kinds of stress in this country," said Mohammad, in practice in Afghanistan for almost 40 years.
Afghans are like anyone else, he said, but circumstances conspired against them.
"If they were better educated, if they had jobs, if they had money, if they had peace, no war, then they would be just like Americans," Mohammad said.
Back in Kabul, the overworked mental health specialists see a glimmer of a cure in the hopes for large infusions of aid and plans for economic development in Afghanistan.