TOWARDS AN OBJECTIVE EVALUATION OF TEACHER PERFORMANCE Website: http://epaa.asu.edu/ojs/ Article received: 8/21/2012 Facebook: /EPAAA Revisions received: 9/24/2012 Twitter: @epaa_aape Accepted: 4/11/2013 education policy analysis archives A peer-reviewed, independent, open access, multilingual journal Arizona State University Volume 21 Number 68 September 16 th , 2013 ISSN 1068-2341 A Lifetime of Trauma: Mental Health Challenges for Higher Education in a Conflict Environment in Afghanistan Mohammed Osman Babury Ministry of Higher Education Afghanistan Fred Manwarren Hayward University of Massachusetts, Amherst United States of America Citation: Babury, M. O. & Hayward, F. M. (2013). A Lifetime of Trauma: Mental Health Challenges for Higher Education in a Conflict Environment in Afghanistan. Education Policy Analysis Archives, 21(68) Retrieved [date], from http://epaa.asu.edu/ojs/article/view/1219 Abstract: More than 30 years of war in Afghanistan have resulted in immense policy challenges to address the resulting mental health issues. The purpose of this policy analysis is to examine the potential role of higher education in addressing the pressing mental health problems in Afghanistan’s public universities and higher education institutions as a major policy challenge. We define and spell out the extent and nature of the mental health problems and policy issues involved, putting them in the context of students in a war environment. We discuss efforts by the leadership of the Ministry of Higher Education to respond to the physical damage of war and the resulting mental health crises in a setting of very scarce human and financial resources. We describe a system of higher education battered by years of war yet seeking to rebuild and raise quality even while the fighting continues. The conditions of the higher education system are described, as well as the scope, complexity and nature of mental health problems, and major challenges faced in trying to rebuild both the system and the lives of the higher education community. We spell out the immense challenges faced in rebuilding a system badly devastated by war while dealing with the tremendous human mental health toll experienced by its students, faculty, and staff. We conclude by setting out http://epaa.asu.edu/ojs/article/view/1219 A Lifetime of Trauma 2 some possible directions, options and recommendations for responding to the mental health problems while recognizing the difficulties higher education faces in trying to respond to them. Keywords: Afghanistan; mental health; higher education; public policy; student services. Toda una vida de Trauma: Retos de Salud Mental para la Educación Superior en un entorno de conflicto en Afganistán. Resumen: Más de 30 años de guerra en Afganistán han dado lugar a enormes desafíos de política para abordar los problemas resultantes de salud mental. El propósito de este análisis de la política consiste en examinar el papel potencial de la educación superior en el tratamiento de los problemas urgentes de salud mental en las universidades públicas y las instituciones de educación superior como un desafío político importante. Definimos y precisar el alcance y la naturaleza de los problemas de salud mental y los problemas políticos implicados, poniéndolos en el contexto de los estudiantes en un ambiente de guerra. Se discuten los esfuerzos de la dirección del Ministerio de Educación Superior para responder a los daños físicos de la guerra y las crisis resultantes de salud mental en un entorno de recursos humanos y financieros muy escasos. Se describe un sistema de educación superior maltratadas por años de guerra todavía tratando de reconstruir y mejorar la calidad incluso mientras la lucha continúa. Los autores describen las condiciones del sistema de educación superior, el alcance, la complejidad y la naturaleza de los problemas de salud mental, y los grandes desafíos que enfrentan al tratar de reconstruir el sistema y la vida de la comunidad de la educación superior. Los autores explican los enormes desafíos que se enfrentan en la reconstrucción de un sistema mal devastado por la guerra en el trato con el tremendo costo humano de la salud mental experimentada por los estudiantes, la facultad y el personal. Se concluye estableciendo algunas posibles direcciones, opciones y recomendaciones para hacer frente a los problemas de salud mental al tiempo que reconoce las dificultades que enfrenta la educación superior en tratar de responder a ellas. Palabras clave: Afganistán; la salud mental; la educación superior; la política pública; los servicios estudiantiles. Uma Vida de Trauma: Desafios de Saúde Mental para a Educação Superior em um ambiente de conflito no Afeganistão. Resumo: Mais de 30 anos de guerra no Afeganistão resultaram em desafios políticos imensos para enfrentar os resultantes problemas de saúde mental. O objetivo desta análise política é a de examinar o papel potencial do ensino superior para enfrentar os urgentes problemas de saúde mental em suas universidades e instituições públicas de ensino superior como um desafio político importante. Nós definir e clarificar a extensão e natureza dos problemas de saúde mental e questões políticas envolvidas, colocando-os no contexto de alunos em um ambiente de guerra. Discutimos os esforços da liderança do Ministério do Ensino Superior para responder ao dano físico de guerra e as crises resultantes de saúde mental em um ambiente de muito escassos recursos humanos e financeiros. Nós descrevemos um sistema de ensino superior atingida por anos de guerra ainda buscando reconstruir e aumentar a qualidade, mesmo quando a luta continua. Os autores descrevem as condições do sistema de ensino superior, o escopo, complexidade e natureza dos problemas de saúde mental, e os principais d esafios enfrentados na tentativa de reconstruir o sistema e as vidas da comunidade de ensino superior. Os autores soletrar os imensos desafios enfrentados na reconstrução de um sistema mal devastado pela guerra enquanto lidam com o pedágio tremendo da saúde mental humana vivida por seus alunos, professores e funcionários. Concluímos, estabelecendo algumas direções possíveis, opções e recomendações para dar resposta aos problemas de saúde mental, reconhecendo as dificuldades rostos de ensino superior na tentativa de responder a elas. Education Policy Analysis Archives Vol. 21 No. 68 3 Palavras-chave: Afeganistão; saúde mental; educação superior; políticas públicas; serviços aos estudantes. Introduction and Problem Definition One of the hidden realities in Afghanistan is the consequence of more than 30 years of war. No one escapes its effects – the death of loved ones, personal injuries, destruction of homes and families, and shattered lives. More than one million Afghans were killed (Ansary, 2012), more than six million Afghans had to flee their homes, with three and one half million spending years in refugee camps in Pakistan, more than three million in Iran and thousands in other countries (Ansary, 2013; Samady, 2001). Many suffered grievously from hunger and poverty during these periods. Some were detained or imprisoned; others lost their jobs and livelihoods. Few escaped unscathed. Added to these are the normal challenges and traumas of ordinary life – illness, separation from families, end of relationships, and serious accidents. These experiences are not visible in people’s daily lives and Afghans do not talk about them. Indeed, the resilience of the people of Afghanistan is remarkable, the ability to rebound in the face of tragedies, to get on with life, to make the best of their situations, to joke with each other, to laugh, to make light of their past. But the consequences of war are real and for many young people these legacies remain just below the surface and find expression in depression, anxiety, and post-traumatic stress disorder. The effects of war and conflict have resulted in immense policy challenges for the nation of Afghanistan that require a comprehensive approach across multiple sectors to begin addressing mental health issues as a national priority. However, part of the challenge is that there are very few qualified mental health professionals in Afghanistan and limited existing mechanisms for producing qualified professionals. In most of the world, the system of higher education has the responsibility for producing qualified mental health professionals to address these needs, but higher education in Afghanistan faces its own significant challenges as the result of decades of neglect and damage caused by years of war and oppression under the Russian occupation and then the Taliban regime. Moreover, universities in Afghanistan are populated by students, faculty, and staff who are themselves victims of the trauma and associated mental health problems related to the war. The higher education system at the end of the civil war and Taliban period was one marked by destruction and decay in which many of the best faculty members had fled, been imprisoned, or killed. The majority of buildings were damaged or in disrepair, equipment ruined or missing, most laboratories inoperative, and libraries stripped. There were virtually no women students or women faculty members as secondary education for girls had been forbidden (Equality for Peace and Democracy [EPD], 2011). Several of the universities had no electricity, one had no water. All had infrastructure that had been damaged by war. Over the last 10 years, with very limited resources, the Afghan Ministry of Higher Education (MoHE) has worked to rebuild facilities, repair buildings, provide dormitories for women students, equip laboratories in science and engineering, and try to provide an effective infrastructure. The MoHE prepared a National Higher Education Strategic Plan: 2010-2014 (NHESP) in 2009 laying out its goals for the next five years. Substantial progress has been made in many areas. Higher education has gone from no women students to 19 percent women in 2013 (EDP, 2011; MoHE, 2013). The Ministry’s goal laid out in the NHESP and reiterated in the National Priority Program in 2012 is that women student will comprise 25 percent of enrollments by 2015 (MoHE, 2012). Student numbers have gone from 7,881 students in 2001 to 135,000 1 in 2013 (Figure 1). Unfortunately, facilities have 1 All student, staff, and faculty data are from MoHE files from 2003 to the present. A Lifetime of Trauma 4 not been expanded commensurately. Thus eight universities are on double session and one on triple sessions. The MoHE has worked hard on quality improvement and inaugurated accreditation during 2012 with institutional self-assessments completed and site visits with peer reviewers underway at twelve universities and the process started at most other public institutions and at eleven private higher education institutions. A major effort is nearly completed to upgrade the curriculum in all public higher education institutions including needs assessments by all programs, improved teaching methods, production of new textbooks, and review of all programs and syllabi by the National Curriculum Commission. Eighteen higher education institutions currently have Internet and four others temporary connects with the Ministry working to provide Internet services to all public tertiary institutions. Modern laboratories have been set up in engineering, pharmacy and several other disciplines. Graduate programs were added in teacher education, public policy and administration, physics, hydrology and mining, and languages. But this is just a start in the recovery process and in meeting national needs. Mental health is also a significant policy challenge that must be addressed by higher education as part of national development (MoHE, 2009). Figure 1. Enrollment at Afghan public universities and higher education institutions, 1992-2013 Source: Ministry of Higher Education (2013) The need for mental health support is recognized in the recent National Higher Education Strategic Plan: 2010-2014 (2009), which specifically mentions mental health. The goal is to set up effective student counseling and academic advising with mental health as one of its components. Yet, to date higher education institutions have not been able to provide much assistance to those in such distress. Resources are scarce and the major emphasis has been on rebuilding shattered institutions and raising the quality of instruction to acceptable levels. Education Policy Analysis Archives Vol. 21 No. 68 5 Method The purpose of this policy analysis is to examine the potential role of higher education in addressing mental health in Afghanistan as a major policy challenge. This paper uses a modified version of Bardach’s (2008) eight-step method 2 for effective problem solving in policy analysis. Bardach’s work was developed to address the complex and data-rich policy environment in the United States. Thus, this approach needs to be simplified and be modified for this particular analysis given the dearth of data and resources in Afghanistan. We combine steps three and four (construct alternatives and select criteria) to simplify the analysis and skip several steps because they are not helpful in the Afghan context. We are not at a stage to deal with trade-offs or project outcomes. The eight steps have been collapsed into the following four steps: 1. Problem Definition - select a particular public policy problem and define the issue or issues clearly. 2. Assembling Evidence - provide a description of the evidence and information needed to address the issue. 3. Constructing Alternatives and Recommendations – using the problems identified above, identify alternatives for addressing the problems and select criteria for evaluating those alternatives and make recommendations based on available evidence. 4. Tell your story - conclusions Assembling Evidence: The Context of Mental Health Afghans have learned to live in an environment of constant war but its toll continues. They see war every day in the armored vehicles, soldiers on the street, attack helicopters overhead, and the constant reminders of war as they pass bullet scarred walls, destroyed buildings and other bomb damage. They live with the occasional suicide bombing or attacks on facilities, and countless other reminders on a regular basis of more than 30 years of war. In spite of demining efforts, an average of 37 people were killed or injured each month by land mines in Afghanistan in 2001, by 2011 it was 52 per month (Lancet Editorial, 2001; RAWA News, 2011). The civilian death toll continues to grow with at least 12,793 civilians killed since 2006 and an unknown numbers wounded. There were 2,412 killed in 2009, 2,790 in 2010, 3,021 killed in 2011 with the number dropping slightly to 2,754 in 2012 (The Guardian, 2013; Yahoo News, 2013) . That same year 3,000 Afghan police and soldiers were killed (Ninemsn, 2013). Thus the trauma of war continues to surround Afghans on a daily basis and touches almost everyone. While the MoHE has made progress in repairing the physical damage to institutions 3 , to date it has not done well in dealing with the ongoing human costs of war, which add to the normal stresses of students and staff life. The Ministry of Public Health estimates that over two million 2 The eight steps are: define problem, assemble some evidence, construct alternatives, select the criteria, project outcomes, confront trade-offs, decide, and tell your story (Bardach, 2008). 3 Laboratories have been established or upgraded in engineering, information and communications technology, pharmacy, agriculture, science; eight new dormitories have been built, though many more for women are needed. New buildings have been constructed at Kabul, Bamyan, Kandahar, Nangarhar, Takhar, Herat, and Albiruni Universities. Libraries were established at Kandahar, Herat, Nangarhar, and many other universities. Laboratory equipment was obtained for Kandahar, Kabul Medical, and Kabul Polytechnic Universities. Computer facilities and professional development centers were established at thirteen universities and institutions of higher education. A Lifetime of Trauma 6 Afghans suffer from mental health problems, noting that “…Mental diseases have not been addressed over the last decades in Afghanistan and little is known about the disease pattern in Afghan society” (Ministry of Public Health [MoPH], 2009, p. 5). Part of the reason for that is that the war continues. There are still people dying, being injured, and displaced on a daily basis. Another part of the problem is the lack of trained specialists in mental health. At the present time there are only 60 psychiatrists, 40 psychiatric nurses, and 45 psychologists in Afghanistan. 4 Furthermore, there is only one mental health facility in the country plus a small number of outpatient facilities (World Health Organization [WHO], 2006). This limited number of personnel, with equally limited facilities, can only begin to provide the basis for mental health care for a population of some 30 million. The same is true in other areas. There are no psychiatric social workers since Social Work is not yet taught at the university level and the number of nurses with such training is low. One of two major issues is lack of funds, which means that little money is available for mental health and there is no such line item in the MoHE budget. The other critical issue is the complexity of the mental health problems. What does one do for mental health with few trained mental health professionals? How does one deal with the very complex gender issues such that a woman cannot be seen by a male practitioner? How do staff members deal with ethnicity and language, which are often serious barriers? Added to that, as we will show in the material that follows, is the fact that there is no real structure of mental health that the MoHE can build upon. Nonetheless, higher education must move forward now to respond to the mental health crises. There are many challenges to doing that successfully. One of the challenges is that the problems go much deeper than the issues of individual students and staff. They include the destruction of the social and family life of many people due to the war and the death, injury, and displacement that has followed from it. These problems are compounded by the problem of adult literacy, which is only 28 percent (Afghanistan Demographic Profile, 2012), and the consequences of limited knowledge and information. A large number of men, as well as women and children, were physically disabled during the war with often profound effects on their mental health. And the young are witnesses to it all. Another challenge has been the very limited health service sector – which was also devastated by war. For women, the problems have been especially acute. In 2001 Afghanistan had the second highest maternal mortality rate in the world – 1,800 out of every 100,000 pregnant women died in childbirth, which was second only to Sierra Leone (Lancet Editorial, 2001). Due to improved access to health facilities, the maternal death rate declined to fewer than 500 of every 100,000 births in 2010 (BBC News, 2011). While Afghanistan’s infant mortality rate has improved in recent years to fewer than 122 per 100,000, it is still one of the highest in the world (Afghanistan Demographics Profile, 2012). Because of limited health facilities, Afghanistan has a high incidence of communicable diseases. For example, 72,000 people a year contract tuberculosis, most of them women (Lancet Editorial, 2009). Yet there has been progress and life expectancy has increased from only 45 years a short time ago to an estimated 62 to 64 years for men and women, respectively (BBC News, 2011). The challenge of dealing with mental health problems is compounded by the fact that opportunities for mental health care treatment in Afghanistan are very limited. As noted in one review: “The mental health situation in Afghanistan is characterized by a highly felt need and an extremely incapacitated mental health care system” (Ventevogel, 2002, p.1). The limited number of personnel can only begin to provide the basis for mental health care for a population of some 30 4 Personal communication from Dr. Wahid, Kabul Medical University, August 2012. Education Policy Analysis Archives Vol. 21 No. 68 7 million. In addition, there are also no social work programs in the universities, an area that in many countries would provide mental health workers through training in psychiatric social work. 5 Depression and anxiety disorders are high, especially among women and children in Afghanistan (Figure 2). One survey in 2008 found that 22 percent of Afghan children met the criteria for the probability of psychiatric disorder (Panter-Brick et al., 2009). A 2002 study by the U.S. Centers for Disease Control of people 15 years and older put the number much higher with symptoms of depression found in 70 percent and of anxiety in 72 percent of their national sample in Afghanistan (Cardozo et al., 2004). This is in contrast to the situation in the U.S. where, according to a recent report, 7 percent of the population had suffered from depression in the past year (Lehrer, 2010). The Panter-Brick et. al. (2009) study reported that post-traumatic stress disorder (PTSD) was found in 24 percent of Afghani students aged 11 to 16 years in their multi-site study. The Centers for Disease Control study put it at 42 percent (Cardozo et al., 2004). While more recent investigations have suggested that PTSD in Afghanistan is not as high as suggested in these studies, and suggest that culturally-biased measures account for the high level of reported cases, there is agreement that depression, anxiety, and other types of mental health problems are very high among young Afghans and twice as high among women as men (Omidian & Miller, 2006). While there are differences in opinion about whether the mental health problems are primarily caused by direct exposure to war (death, injury, destruction of one’s home) or other post-war trauma (refugee status, poverty, malnutrition, loss of employment, rape), the consequences are clear. 6 Thus, while the diagnoses may differ, there is agreement that the level of mental health problems is very high. Girls and young women suffer from mental health problems in greater numbers than men partly because of discrimination, lack of opportunities, lower levels of education, and the fact that some girls are required to stay at home most of the time. In one study of young Afghani people 11 to 16 years of age, girls showed a two-fold higher risk of psychopathology than boys (Panter-Brick et al., 2009, Table 1). These studies also give credence to the risk accumulation model (Garbarino & Kostelny, 1996), which suggests that mental health problems in children increase substantially when children are exposed to more than five traumatic events, including non-war related experiences (Dawes & Flisher, 2009), which is the case for a significant number of young people in Afghanistan. Then there are the normal problems of growing up – illness, accidents, stress, divorce, a new environment (de Berry et al., 2003). Almost 64 percent of children in one survey reported exposure to some traumatic event – about half of which were war related including witnessing severe violence to another person (14 percent) or being displaced by force (9 percent) (Panter-Brick et al., 2009).7 5 A social work program was initiated at Kabul University in 2011 by Hunter College and Boston University, but had to be suspended when funding from UNICEF was eliminated. 6 For an excellent discussion of the two views see Miller and Rasussen (2010). 7 “Severe physical injury” includes: traffic and other accidents; beaten by a relative; beaten by a neighbor; frightening medical treatment; no access to medical care; war-related injury. “Witnessed severe violence to another person” includes: killing or beating by Taliban; saw a dead body; community violence; death from rocket explosion; domestic violence; accidental death or injury. “Death or loss of a close relative” includes: due to acts of war; accidental death; criminal acts; missing person. A Lifetime of Trauma 8 Figure 2. Most distressing lifetime event from Afghan school-based survey Source: Panter-Brick et al., (2009). The problems of mental health are further complicated by the easy availability of tranquilizers and other drugs in the markets, which leads to self-medication and abuse. There is also easy access to other drugs such as opium in parts of the country leading to high levels of substance abuse in some places. It is estimated that there are 800,000 drug users in Afghanistan including 6,000 children. Sixty percent use opium while others use tranquilizers, painkillers, cannabis, and other drugs (Palan, 2012). The magnitude of the mental health problems and the lack of facilities for treatment have led some people to turn to traditional methods of dealing with mental health problems such as being chained to a wall or put in a cell in a shrine often with tragic results (Arnold, 2009). Most people, including students attending higher education institutions, have no access to mental health services. The MoHE would like to remedy that. Assembling Evidence: Challenges for Higher Education in Responding to Mental Health Needs There have been no studies of mental health issues among university students in Afghanistan. However, given the data from studies of young people in general we know that mental health problems among Afghan youth exist and there is evidence of it on university campuses. For example, there is a high level of violence on campuses especially among male students. There are far too frequent acts of aggression and acting out especially by men. Some of this may reflect the kind of findings of Cardozo and colleagues (2004) of a high percentage of respondents feelings “a lot” of hatred or feeling the need for revenge with levels averaging 81 percent to 84 percent at that time. There is a certain lack of civility among many students as well as inappropriate behavior including in Education Policy Analysis Archives Vol. 21 No. 68 9 classes. 8 The years of conflict have also seen a loss of self-reliance and patriotism. Depression and anxiety among students are serious problems although we do not have data because of lack of treatment facilities or referrals. We surmise that mental health issues also increase the drop-out rate of students and lead to poor performance by some students. Added to these challenges is a lack of funding. In 2011, the MoHE oversaw 26 public higher education institutions with an operating budget of $45 million (United States Agency for International Development [USAID], 2012). That number will soon be expanded to 31 institutions. In 2011, Afghanistan spent only $431 per student, very low even for a developing country. By 2012 it had increased to $517 per student, still very low. About half of higher education funding is spent on dormitories and meals for students. After staff salaries, this leaves very little funding for instruction. Of the country’s total education budget in 2011, only 10 percent went to higher education in contrast to a 20 percent average in the region and for comparable developing countries (USAID, 2012). One rule of thumb suggests that the minimum cost for a quality higher education is $1,000 per student. Thus, in addition to the other challenges, there is that of very limited funding available to organize a mental health program. In the context of these challenges, the National Higher Education Strategic Plan calls for the MoHE to begin to address these problems by adding mental health to its recently established student services centers established by the Higher Education Project (HEP) with support from USAID. Student services are now available in twelve of the 31 higher education institutions (Figure 3). They are to be expanded to seventeen institutions with financial support from the World Bank through the Strengthen Higher Education Project (SHEP). These centers were established to provide student advising, placement assistance, help with accommodations, and other related issues of students. At the time student services were started, mental health for higher education was not among the major concerns of officials. It was only in early 2010 that the authors and a few others began to focus on the issue. That led to the realization that there was a crisis that needed MoHE attention. At that point, the logical vehicle for such an effort was the recently established student centers. The MoHE plan was to expand them to include mental health if suitable staff could be found given the lack of social work programs and the limited number of psychiatrists. At that point the senior staff involved in looking at mental health had no idea of the difficulties that would be faced. 8 Based on observations and interviews with student and faculty members by the authors who attributed them to mental health issues. A Lifetime of Trauma 10 Figure 3. University student service offices across Afghanistan, 2012 Source: Adapted from map prepared by the Ministry of Higher Education and printed with their permission. There is no tradition of student services or advising in Afghan higher education so that in itself was a major challenge. Student needs in addition to mental health are enormous and had become the focus of the initial set up of student services. Among the initial concerns were student retention and degree completion. In the Afghan higher education system, once a student drops out for reasons other than illness or pregnancy, it is almost impossible for him or her to be readmitted. 9 Thus dropout prevention is an important need. Several of the student service programs are already making a difference in this area. For example, at the University of Herat the dropout rate was reduced 60 percent in 2010 through the efforts of the counseling services. 10 Students also need help in career advising. Higher education institutions do not have the capacity at the present time to carry out aptitude testing. Faculty members generally do not assist with student advising beyond their work with students on specific projects or papers for their classes. For these reasons the MoHE has encouraged the expansion of student services to help students think about careers early in their studies and to link them to internships, help prepare them for job interviews, and connect employers with students who will be graduating soon. These services should help reduce students’ stress about employment and generally improve student well being. The World Declaration on Higher Education states that every nation has an obligation to provide guidance and counseling services (World Conference on Higher Education, 2008, Article 10) and 9 The lack of a credit system makes it hard to track prior work as does the lack of a transfer system. The credit system is currently being introduced and that may help resolve this problem. 10 Personal communication with the director of the student services program at HEP, January 2011. Education Policy Analysis Archives Vol. 21 No. 68 11 recognized the importance of finding new ways to assist students with mental health needs noting that this was a critical future direction for counseling services (Ludeman, Osfield, Hidalgo, Oste, & Wong, 2009). When the MoHE recognized these mental health needs it began searching for ways to support the kinds of student counseling and intervention that could be effective in giving balance and new meaning to students with mental health problems. Young people have proven to be amazingly resilient, and it is this that has helped them deal with mental health issues in spite of limited mental health services. As the NGO, Save the Children, found in a study of children in Kabul, “Children in Kabul are not, however, completely overwhelmed by the difficulties they face. Instead, they and their families have many strengths and resources, which they employ to cope with challenges, lessen the negative impact of those challenges, and reduce suffering” (de Berry, 2003, p. ii). Among the strengths are the strong bonds of the extended family and friends. Their study suggests that this resilience comes from a particular kind of social ecology – “the nurturing physical and emotional environment that includes, and extends beyond, the immediate family to peer, school and community settings, and to cultural and political belief systems” (Betancourt & Khan, 2008, p. 3). While many young people have benefited from this nurturing environment, for far too many young people that nurturing environment has been disrupted by war: breaking up families through destruction of their homes, the need to find refuge elsewhere – for many abroad – and the dispersion of friends, relatives, and classmates. As a Ministry of Public Health study notes, “Many families have been rendered dysfunctional or partially so as a result of continued stress, exposure to traumatizing events, loss, drug abuse, and poverty. Those psychological and psychosocial stressors make people vulnerable to psychological and social dysfunction. Mental disorders are highly prevalent and highly disabling” (MoPH, 2009, p. 6). Thus the need to help rebuild the social ecology of their environment with part of that support coming from the university community. Yet, as the Ministry of Public Health states in its recent National Mental Health Strategy 2009-2014, mental health is only just now beginning to be available and links with higher education have not yet been put in place. They note: “…despite sometimes significant funding being committed to ad hoc projects, mental health is only just becoming mainstreamed into primary health care service delivery” (MoPH, 2009, p. 9). The challenge for the MoHE is how to help restore the damaged social ecology – a process that “is fundamental to improving prevention and rehabilitative interventions for war-affected children” (Betancourt & Khan, 2008, p. 3). Counseling is one mechanism for providing social support to those students who need it. The university, after all, is a community and we know that schools and communities can play a vital role in creating a sense of well-being and ensuring a positive mental outcome by “mitigating trauma’s effects” and providing social supports (Betancourt & Khan, 2008). What the MoHE envisions for student counseling in the next five years in Afghanistan, as part of the Strategic Plan, is to build on the small number of student service programs now underway with additional programs that focus on mental health problems. An initial part of that has been to encourage recreation as part of the rehabilitation process because of the difficulties in staffing mental health efforts and the many other complexities they pose in Afghanistan including issues of gender, language, region, and ethnicity. The MoHE has also been working on improving access and conditions for women students as part of its goal to achieve gender equity in the not too distant future (MoHE, 2013) that has included construction of additional dormitories for women to add 4,000 places for women and emphasis on women’s safety and inclusion in all campus activities. The most pressing problem, as noted earlier, is the shortage of trained staff. In the meantime the MoHE needs to organize a mental health strategy (see recommendations). To a limited extent complementary assistance is provided to students through other student services A Lifetime of Trauma 12 including: academic advising drawing on faculty expertise; assistance to students as they develop education plans and with career development in keeping with their goals; assistance to overcome educational and personal problems; to reduce student drop-out rates and enhance their performance; to help students with job planning and job placement; and to provide the university with a better understanding of student needs, problems, and expectations (Blaney et al., 2008). We concur with UNESCO, which has suggested that higher education student services: “… are designed to provide access to higher education, enhance student retention and graduation rates, develop global citizenship skills, and provide society with new human capital and potential that can help everyone as we move forward toward a true family of nations” (UNESCO, 1998, p. 8). Yet, as emphasized earlier, in Afghanistan the MoHE is faced with additional problems related to the traumas of war, and it does not yet have the funding or the personnel to establish effective programs to deal with them. Part of setting the groundwork for such programs is the MoHE’s push to have a student academic advising and counseling center at each of the 31 public higher education institutions and to encourage private higher education institutions to do the same. The recently started accreditation process (MoHE, 2011), which will include an assessment of student services at each institution, will be one of the ways in which the MoHE will encourage both public and private institutions to provide and improve counseling and academic advising services and be able to review their effectiveness in the long run. 11 Nonetheless, the MoHE has not yet been able to develop the mental health programs and the appropriately trained staff to run them. Constructing Alternatives and Recommendations: Possible Directions for Higher Education Mental Health in Afghanistan The two most critical problems facing the MoHE in setting future directions for mental health in Afghan higher education are the acute shortage of qualified mental health workers and the shortage of funds. This is in a context in which student numbers in higher education have grown 147 percent between 2008 and 2012, including 33 percent in 2012 and 31 percent in 2013. At the same time funding was basically flat for several years until 2012 when it increased 30 percent. There is now hope for additional funding through the MoHE’s funding proposal to the National Priority Program (NPP). As noted earlier, those funds have not yet been allocated but part will be used for mental health services to the student service offices. In the meantime, in consultation with the Ministry of Public Health (MoPH) and Ministry of Education (MoE), the MoHE will begin to work on a strategy and measures to tackle the mental health problems with the limited staff available. If funds from the NPP or other sources become available, the MoHE will bring in mental health specialists who have experience in conflict areas to help put together a team to explore the kinds of interventions that might be put in place in the near future and what can be done to alleviate the critical shortage of qualified mental health professionals. A pilot program should be started as soon as possible thereafter. The MoHE needs to move quickly using student services as a platform for this effort. We recommend that work be resumed to establish a social work program in higher education. Social work programs are a frequent source of trained mental health staff in other countries, but social work is not offered in higher education institutions in Afghanistan at the present time. Those called social workers in Afghanistan have in most cases only taken a few weeks of 11 For a list of criteria for quality assurance see: Ministry of Higher Education. 2009. Self-Assessment Protocol for Institutional and Faculty Reviews. Education Policy Analysis Archives Vol. 21 No. 68 13 short courses. To meet the need for professional staff, the MoHE worked with UNICEF, Hunter College, and Boston University during 2011 and 2012 to establish the first social work programs at Kabul University. This was to be a major step in providing staff not only for mental health in student services, but for mental health generally, as well as other health and social service programs in many other areas. Unfortunately, the UNICEF budget was cut in 2012 and this funding disappeared before the program could be fully established although initial work on the curriculum was underway. The MoHE is currently looking for alternative funding to continue this effort. 12 A critical part of the process of getting trained mental health professionals is dependent on the development of social work (including psychiatric social work) at Kabul University and other mental health programs. Studies of student services in conflict areas have suggested that there are several areas in which special focus is needed, including: the “…environment; organizational issues; essential skills and competencies; professional development; future directions; especially the current environment” (Shea & Baghirova, 2009, p. 59). The authors emphasize the importance of being student-centered. They suggest a number of useful topics for student workshops including: “mediation, crisis prevention/intervention, conflict resolution, performance appraisal, student and professional career development, mental and physical health, self-care, and leadership” (Shea & Baghirova, 2009, p. 61). They also point out the importance of providing support to student service professionals for their continued growth and development, an effort the MoHE has started in Afghanistan working with HEP, and hopes to continue with the advent of social work programs. These are major tasks that must be prioritized. From our perspective, the first priority is to create a supportive environment for students suffering from mental health problems and then to provide professional interventions that helps them develop coping mechanisms and other practical skills that assist them in getting past, or dealing with, the traumatic experiences. Several studies in other parts of the world suggest types of services that can be especially cost effective in providing mental health assistance. Studies by Panter-Brick and others have shown the value of working with schools and higher education institutions to identify problems and provide intervention (e.g. Panter-Brick et al., 2009). Research in the United States (Tedeschi et al., 1998) also suggests the utility of group work in dealing with mental health issues. Group work includes both the work of a mental health specialist or specialists with a group suffering from depression, post-traumatic stress disorder, or other problems, and groups that provide mutual support. Group work has a number of advantages including lower cost than individual intervention, it requires fewer staff members, and it provides the potential to change the dynamic from the individual to the group, which often becomes a support group that helps initiate beneficial change. Other work on mental health in the U.S. is encouraging in suggesting that there can be substantial growth after traumatic events that lead to depression and mental health problems – what Tedeschi and Calhous (2008) have called post-traumatic growth. Group work has also been shown to reduce costs and be quite effective. One study in Afghanistan has shown the value and effectiveness of group work in programs to help women deal with suffering from depression and other mental health issues in Herat on suicide prevention in an area in which self-immolation had become a problem (Canadian Women for Women in Afghanistan, 2012). Similarly, experience in the Kabul area showed the value of group work in a 12 The MoHE hopes to use some funding from the recently approved (but not yet allocated) donor commitments to the National Priority Program (including Higher Education’s NPP3) to continue to develop social work programs at both the undergraduate and Master’s level. UNICEF will also provide some assistance to resume work on the undergraduate Social Work curriculum, though not enough to complete it. A Lifetime of Trauma 14 program called “Balance of Blessings,” which focused on group activity that was “…aimed at increasing social support and helping women come to terms with difficult life experiences” (Omidian & Miller, 2006, p. 20). In both cases group work, coupled with practical support such as vocational training, helped enhance social support and strengthened women’s ability to cope with their problems. These experiences suggest possible avenues to provide mental health services on university campuses and the positive effects such interventions can achieve. Reaching a point where the MoHE can do so on higher education campuses will be a tremendous task in a context in which mental health has been a neglected problem not only in higher education but nationally (MoHE, 2009). Evidence from other parts of the world based on work with children affected by political violence in the West Bank, Gaza, Uganda, Bosnia, and Sudan has shown good results. 13 Research by Betancourt and Williams (2008) indicates that “high quality mental health services are possible in low resource and war affected settings…” (p. 52). There is also substantial evidence that group focused interventions, which are much less costly than individual interventions, can have markedly positive effects on lowering the effects of PTSD and other war-related mental health problems and are one mechanism to be explored in Afghanistan. The MoHE will try to build on these findings. Interventions tried in Afghanistan and elsewhere in high-conflict regions show promise for dealing both with the issue of cost and the critical shortages of trained specialists in mental health or facilities that specialize in its treatment. Nonetheless, the loss of funding to establish a program in social work at Kabul University is a major blow to the MoHE’s effort to train and employ appropriately qualified staff. This is neither a job for amateurs nor one for untrained staff members. The MoHE is under no illusions about the magnitude of the task ahead. There has been little research on mental health in higher education in Afghanistan, although there has been some work on mental health issues of young children by one working group of the Education Development Board of the MoE, which is focused on primary and secondary education in emergency areas. A few NGOs have concentrated on the mental health of children but in general the mental health issues and problems of young adults are basically uncharted ground in Afghanistan. It is important to emphasize that not all the problems found among young people in Afghanistan are the result of war. Students suffering from post-traumatic stress disorder, anxiety, and depression are found in significant numbers as a result of non-war situations such as car accidents, loss of family members due to illness, crime, work related injuries, break-up of relationships, pending unemployment, and other traumas. These add to the magnitude of the problems in Afghanistan. The next steps for the MoHE are to develop a new approach and strategy for dealing with issues of mental health. As noted, there are not enough psychiatrists or other mental health professionals in Afghanistan to draw on that area and less than 1 percent of the training for medical doctors in Afghanistan focuses on mental health (World Health Organization [WHO], 2006). The MoHE will cooperate with the MoPH and MoE as it moves forward in this effort. The new approach will require a careful look at cost-effective methods such as the group interventions noted earlier, decisions about and identification of appropriate professional staff, planning the program, and a pilot phase to test its effectiveness. All this must be done in the cultural contexts of Afghanistan and in the face of the realities created by years of war – one that seems likely to continue for some time. It will also require careful attention to issues of gender and ethnicity. A 13 A particularly interesting article by Betancourt and Williams (2008) surveys a number of studies of interventions for war-effected children in these and other conflict countries examining the effects of different kinds of interventions. They conclude that the prospects for group intervention were mostly very positive and a cost-effective way of dealing with PTSD and other war-related mental health problems. Education Policy Analysis Archives Vol. 21 No. 68 15 second step must be to find the funding needed for appropriate interventions, building on the new student service centers as a starting point for intervention. In the short term the MoHE will also need to identify well-qualified local or expatriate professionals to help inaugurate a mental health program in higher education as part of student services. Finally there will be the enormous task of building a program that has the confidence of students, staff, and the community and provides the intervention and treatment that addresses the mental health problems of the higher education community in Afghanistan. Conclusions The MoHE is laying the groundwork to create the kind of effective, supportive university environment needed to help students not only with mental health needs, but with academic advising, job placement, and other student counseling requirements. Afghanistan has a long tradition of high quality education that was largely destroyed by more than 30 years of war. The MoHE is fully committed to rebuilding higher education and to reestablishing a high quality higher education system complete with updated curricula, effective student counseling, academic advising, and mental health services for all students. The MoHE is at the very early stages of efforts to establish effective student programs in higher education to deal with the traumas of war and is just starting to work on strategies to include mental health as an integral part of its student services – an addition that is badly needed in any university community but even more so in a war environment. While the MoHE is aware of the tremendous mental health problems faced by students and some staff, it is just beginning to be able to respond to these needs. In a war-ravaged country, with pressing needs in almost every area, the demand for funds is enormous and the ability to meet them is limited. The MoHE has received assistance from several donors over the last eight years and hopes that support will continue. In the short run, in the current context of war, without substantial outside assistance it will be difficult for the MoHE to do what needs to be done to meet the mental health challenges in higher education. The MoHE recognizes that higher education must not only produce students who will have the training, knowledge, creativity, entrepreneurial talents, and citizenship skills to provide for their own well-being and help foster national development, but also ensure that the traumas and other legacies of the violence and carnage of war are adequately addressed. The MoHE is committed to realizing these goals. References Ansary, T. (2012). The Often Interrupted History of Afghanistan: Games without Rules, New York: Public Affairs. 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Kabul, Afghanistan: WHO http://www.rawa.org/temp/runews/2011/04/06/landmines-kill-almost-52-civilians-per-month-last-afghan-year.html http://www.rawa.org/temp/runews/2011/04/06/landmines-kill-almost-52-civilians-per-month-last-afghan-year.html http://www.ayubmed.edu.pk/JAMC/PAST/14-4/Peter.htm A Lifetime of Trauma 18 About the Authors Mohammad Osman Babury Ministry of Higher Education, Afghanistan mobabury@hotmail.com Professor Mohammad Osman Babury is Deputy Minister for Academic Affairs at the Ministry of Higher Education in Kabul, Afghanistan and Professor of Pharmacognosy at Kabul University. He received his BA and Master’s in Pharmacy from Pyatigorsk Pharmaceutical Institute in Russia. He has worked in the Department of Pharmacognosy, Faculty of Pharmacy at Kabul University and currently holds the position of Professor. He because Deputy Minister for Academic Affairs in the Ministry of Higher Education with oversight of 31 higher education institutions in 2007. He has been Head of Department at Kabul University, General Director of Pharmaceutical Directorate at the Ministry of Public Health, Vice Chancellor of Academic Affairs of Kabul University, and Chief of the Governing Board, South Asian University in 2011. He has published twenty-two articles in the field of Pharmacognosy and herbal medicine and is author of the first Dari textbook in the field entitled Pharmacognosy. His most recent scientific research focused on the study of mumie which is well known in traditional medicine in Afghanistan. Fred M. Hayward University of Massachusetts, Amherst haywardfred@hotmail.com Dr. Fred M. Hayward is Senior Higher Education Advisor to the Ministry of Higher Education, and works for the University of Massachusetts, Amherst, Center for International Education. He is a specialist on higher education with more than 30 years of experience as an educator, scholar, senior administrator and higher education consultant. He has a Ph.D. from Princeton University and a B.A. from the University of California. He has taught at the University of Ghana, Fourah Bay College in Sierra Leone, and the University of Wisconsin-Madison where he was Professor of Political Science, department chair, and Dean of International Programs. He was Executive Vice President of the Council on Higher Education Accreditation and Senior Associate for the American Council on Education for more than ten years. He has been a higher education consultant for the World Bank, Carnegie Corporation, Ford Foundation, Academy for Educational Development, USAID, and Ministries of Education, focusing on higher education change, governance, strategic planning, and accreditation. Dr. Hayward has written extensively on development issues and higher education. education policy analysis archives Volume 21 Number 68 September 16th, 2013 ISSN 1068-2341 Readers are free to copy, display, and distribute this article, as long as the work is attributed to the author(s) and Education Policy Analysis Archives, it is distributed for non- commercial purposes only, and no alteration or transformation is made in the work. More mailto:mobabury@hotmail.com mailto:haywardfred@hotmail.com Education Policy Analysis Archives Vol. 21 No. 68 19 details of this Creative Commons license are available at http://creativecommons.org/licenses/by-nc-sa/3.0/. All other uses must be approved by the author(s) or EPAA. 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Sanders The Pennsylvania State University Christopher Joseph Frey Bowling Green State University Janelle Scott University of California, Berkeley Melissa Lynn Freeman* Adams State College Kimberly Scott Arizona State University Amy Garrett Dikkers University of Minnesota Dorothy Shipps Baruch College/CUNY Gene V Glass Arizona State University Maria Teresa Tatto Michigan State University Ronald Glass University of California, Santa Cruz Larisa Warhol University of Connecticut Harvey Goldstein Bristol University Cally Waite Social Science Research Council Jacob P. K. Gross Indiana University John Weathers University of Colorado, Colorado Springs Eric M. Haas WestEd Kevin Welner University of Colorado, Boulder Kimberly Joy Howard* University of Southern California Ed Wiley University of Colorado, Boulder Aimee Howley Ohio University Terrence G. 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Pereyra Universidad de Granada, España Jose Joaquin Brunner Universidad Diego Portales, Chile Monica Pini Universidad Nacional de San Martín, Argentina Damián Canales Sánchez Instituto Nacional para la Evaluación de la Educación, México Paula Razquin UNESCO, Francia María Caridad García Universidad Católica del Norte, Chile Ignacio Rivas Flores Universidad de Málaga, España Raimundo Cuesta Fernández IES Fray Luis de León, España Daniel Schugurensky Arizona State University Marco Antonio Delgado Fuentes Universidad Iberoamericana, México Orlando Pulido Chaves Universidad Pedagógica Nacional, Colombia Inés Dussel FLACSO, Argentina José Gregorio Rodríguez Universidad Nacional de Colombia Rafael Feito Alonso Universidad Complutense de Madrid, España Miriam Rodríguez Vargas Universidad Autónoma de Tamaulipas, México Pedro Flores Crespo Universidad Iberoamericana, México Mario Rueda Beltrán Instituto de Investigaciones sobre la Universidad y la Educación, UNAM México Verónica García Martínez Universidad Juárez Autónoma de Tabasco, México José Luis San Fabián Maroto Universidad de Oviedo, España Francisco F. García Pérez Universidad de Sevilla, España Yengny Marisol Silva Laya Universidad Iberoamericana, México Edna Luna Serrano Universidad Autónoma de Baja California, México Aida Terrón Bañuelos Universidad de Oviedo, España Alma Maldonado Departamento de Investigaciones Educativas, Centro de Investigación y de Estudios Avanzados, México Jurjo Torres Santomé Universidad de la Coruña, España Alejandro Márquez Jiménez Instituto de Investigaciones sobre la Universidad y la Educación, UNAM México Antoni Verger Planells University of Amsterdam, Holanda José Felipe Martínez Fernández University of California Los Angeles, USA Mario Yapu Universidad Para la Investigación Estratégica, Bolivia A Lifetime of Trauma 22 arquivos analíticos de políticas educativas conselho editorial Editor: Gustavo E. Fischman (Arizona State University) Editores Associados: Rosa Maria Bueno Fisher e Luis A. Gandin (Universidade Federal do Rio Grande do Sul) Dalila Andrade de Oliveira Universidade Federal de Minas Gerais, Brasil Jefferson Mainardes Universidade Estadual de Ponta Grossa, Brasil Paulo Carrano Universidade Federal Fluminense, Brasil Luciano Mendes de Faria Filho Universidade Federal de Minas Gerais, Brasil Alicia Maria Catalano de Bonamino Pontificia Universidade Católica-Rio, Brasil Lia Raquel Moreira Oliveira Universidade do Minho, Portugal Fabiana de Amorim Marcello Universidade Luterana do Brasil, Canoas, Brasil Belmira Oliveira Bueno Universidade de São Paulo, Brasil Alexandre Fernandez Vaz Universidade Federal de Santa Catarina, Brasil António Teodoro Universidade Lusófona, Portugal Gaudêncio Frigotto Universidade do Estado do Rio de Janeiro, Brasil Pia L. Wong California State University Sacramento, U.S.A Alfredo M Gomes Universidade Federal de Pernambuco, Brasil Sandra Regina Sales Universidade Federal Rural do Rio de Janeiro, Brasil Petronilha Beatriz Gonçalves e Silva Universidade Federal de São Carlos, Brasil Elba Siqueira Sá Barreto Fundação Carlos Chagas, Brasil Nadja Herman Pontificia Universidade Católica –Rio Grande do Sul, Brasil Manuela Terrasêca Universidade do Porto, Portugal José Machado Pais Instituto de Ciências Sociais da Universidade de Lisboa, Portugal Robert Verhine Universidade Federal da Bahia, Brasil Wenceslao Machado de Oliveira Jr. Universidade Estadual de Campinas, Brasil Antônio A. S. Zuin Universidade Federal de São Carlos, Brasil