Political Violence and its Effects on Physical and Mental Health

Healing from political violence is not solely an individual project, but a communal process involving reclaiming collective action, trust, and efficacy. Afghanistan faces political conflict for last decades internally as well as externally. Implementation of current international consensus guidelines regarding mental health and psychosocial support in emergencies requires the consideration of findings from both the medical and social sciences. This paper presents a multi-disciplinary review of reported findings regarding the relations between political violence, mental health and physical well being in Afghanistan. Due to scarcity of high quality data and absence of qualified resources it is very difficult for Afghanistan to develop strategies and effective plans to deal with the challenge of compromised (physical and mental) human health. In the Afghanistan, there is very low number of facilities for this purpose and the population is still facing many political conflicts which are affecting the health indicators. Based upon these results, we discuss a number of issues of concern to international researchers and practitioners and present policy and research recommendations. Specifically, we recommend the need for longitudinal multi-disciplinary research into protective and risk factors, including agency, of physical and mental disorders in situations of political violence


Introduction
Within the fields of psychology, and public health, increasing attention is being paid to the deleterious effects of political violence on the mental health of civilian populations (Giacaman et al., 2007;Jordans, 2010). The World Health Organization, 2012) defines political violence as the attempt to achieve political goals through the methodical use of physical force, or manipulation, including the intentional deprivation of basic needs and rights, such as access to food, education, sanitation, healthcare, as well as freedom of speech and association.
While some definitions of political violence are quite diffuse and include events like struggles for independence from colonialism or popular rebellions, political violence is typically conceptualized as a range of acts of violence and repression that occur during wars, armed conflicts, dictatorships, and military occupations (Zwi and Ugalde, 1989). Within this article, we are concerned with two types of political violence: violence and repression perpetrated by states against the populations of their own state and conflicts between states, including ongoing occupations. These types of political violence, in particular, illustrate how political violence is increasingly characterized by a disintegration of barriers between war and everyday civilian life, and the concomitant blurring of lines between combatants and noncombatants, including children and youth (United Nations Research Institute for Social Development (UNRISD), 2005). Mental health is a complete phrase which describes either cognitive or emotional stability level or it can also be described as absence of any mental illness. Mental wellbeing is an expression of one's thoughts and means a good adaptation to a number of requirements. As described by WHO (World health organization) "It is a state of good health in which any individual is able to recognize his/her capabilities, can deal with routine stress of life, can do tasks in a productive manner and have can make significant contribution in the community (Breslau, 2004). Physical health on the other hand is combination of many components including physical activity, diet, and Alcohol use, medical care of self, nutrition, rest and sleep. If a person is healthy (free from disease) and is able to do her routine chores in comfortable way in his/her own body then he/she will be considered as physically healthy person (Buitrago Cuéllar J.E, 2007).

Background
Political violence simultaneously compromises individual, community, and government functioning (Hobfoll et al., 2007;Lykes et al., 2007). Accordingly, healing from political violence is not just an individual imperative, but rather a communal process centered on the reestablishment of collective trust and social and political action (Summerfield, 2002). Indeed, a growing body of empirical research on psychological well-being in the context of political violence suggests that collective-based forms of belonging, action, and meaning-making are essential in recovering from the psychological effects of political violence (Gilligan, 2009;Hobfoll et al., 2007). In Afghanistan last 3 decades were full of Social Chaos, Political Uncertainty and Political destabilization and Mass migration. Curing last decades conflict, more than one million people brutally killed, about two million injured, millions of people displaced or moved from their homes (Saraceno et al. 2007;Ullah, 2020). This war affects nearly every family of the Afghanistan even at least one of their member lost his life in this war. In addition to this, there has been the growing drug industry in Afghanistan which even captivated the youth of Afghanistan in terms of mental growth, Physical Fitness and numerous social problems. According to UNODC (United Nations Office on Drugs & Crime proposed that more than one million Youth addicted to Drugs (Caritas, 2009). Mental Health Disorders and Drug Addiction are interlinked and these conditions worsen by each other. In the world, Afghanistan expressed lowest Health Indices. Maternal mortality is the world's second highest (1600 per 100,000 births), while in low-income countries, infant and child mortality is much higher than the average. High mortality is also observed due to Respiratory Problems and gastric Problems (Miller, 2006). Physical and Mental Health is further entangled due to these general Disease patterns. WHO Reported that physical and mental health problems affected around 2Million people in general, thus resulted in political violence and Household violence to maximum. The Social Violence isn't all about husbands against women, but even brothers against sisters, mother-in-laws against daughter-in-laws and against children forever. Because of the socio-cultural background (extremely low age for marriage, very high fertility), Physical and Mental Health is highest in women, which is presumably due to a higher rate of children and loss of control over their own lives, contributor to the country's high levels of malnutrition among infants. Malnutrition in infants leads to compromised Physical health. (Miller & Kushner 2006). Physical and Mental Health Disorders have been internationally recorded to negatively impact maternal treatment, e.g. breastfeeding, receptive supplementary eating, thereby impacting motor and cognitive performance of infants, and elevated stunting incidence (chronic malnutrition), which is the contributed factor to the underdeveloped Child Growth in Afghanistan. For now, social constraints, societal norms and the absence of women healthcare professional in providing Services is a challenging task (Sanderson, 2004). Healthcare Services, physical and Mental Health were in very bad shape when Government of Afghanistan took up Afghanistan in 2003. The Government of Afghanistan GOA has initiated a range of structural measures to increase access to basic health facilities and improve the health system's efficiency by identifying and improving the Basic Health Services Package (BPHS) for the delivery of primary care services and the Emergency Hospital Services Package (EPHS) for secondary and referral care services. Moreover, in large-scale contracting with non-governmental organizations (NGOs) for the provision of these facilities, the GOA took a bold decision to reinforce identification and management of the results of the HealthCare sector by rational third parties. The Ministry of Public Health (MOPH) has made a policy decision, among several overlapping goals, to focus on Maternal and Infant mortality as its top priority. Physical & Mental Health was the second most prominent Objective (World Health Organization, 2000). In the first tier of goals, mental health services are included. However, due to the absence of consistent implementation guidance, the lack of capacity and expertise among implementing NGOs and health workers, there was not sufficient attention provided to Physical & Mental health related initiatives. The BPHS Guideline was updated in 2009 and, at the basic level; Physical & Mental health programs were incorporated. Fund in Physical & mental health programs will not only help to decrease the suffering of the people, but will also reduce the impact of domestic Violence, alleviating social fragility and ethnic tensions, and thereby helping the country step towards lasting peace and Political prosperity (Weiss, D. , & Mar mar, 2011). Physical & Mental health conditions Constitute a large part of the overall Disease load worldwide and even more in war and post-War Circumstances because of a form of increased severity, increased incidence, progression and impairment. There has been no doubt about the very high prevalence of mental health conditions in Afghanistan, most of this could be due to profound socioeconomic trauma, more than 30 years of armed struggle combined with catastrophes, twofold unemployment, gnawing hunger, lack of institutional resources, and insufficient access to or lack of access to Physical and Mental Health resources. There is a lack of proper details in Afghanistan on Physical & Mental health conditions, both from administrative records and from the Health Management Information System (HMIS), which does not properly classify Physical & Mental Health issues.
Protracted political violence and war in the country have increased the chances of mental disorders. Purpose of the current study is to create awareness about the physical and mental consequences of political instability, find the gaps due to which these challenges are not being tackled properly and finally propose some way forward in the current situation.

Objectives
Following are the objectives of this article: • To create awareness about the physical and mental consequence of political violence.
• To find the gaps due to which these challenges are not being tackled proper in Afghanistan. • To propose some way forward in the current situation for Afghanistan.

Methodology
For accomplishment of research objectives, this research has deployed the given methodology. Literature review is used for better understanding and in depth knowledge of political violence and its effects. In addition, it was suitable technique to know what actual problems or hindrances Afghanistan is facing top cope up the situation. Researches, magazines, newspaper, books, internet and other relevant data have been reviewed for the purpose as used by (Ullah, 2020;Ullah, Afgan, Afridi, 2019).

Results
political violence may cause mental health problems that no doubt warrant treatment on the individual level, at its core, political violence is an attack on the collective polity (Summerfield, 1999), causing not only personal crises, but crises that are social and political in nature (Edelman et al., 2003). Political violence increases isolation, mistrust, and withdrawal, severing peoples' abilities to come together as a people, thus leading to a deterioration of faith in democratic institutions (Dillenburger et al., 2008). Political involvement, collective efficacy, and social engagement are key components of health and well-being (CSDH, 2008); within political violence, these practices are vital for individual and collective health (Farwell and Cole, 2001;Quota et al., 1995;Sousa et al., 2013;Srour, 2005). Demands for justice within as a central part of healing from the suffering of political violence has a rich history; over four decades ago, scholars such as the French Algerian psychiatrist Franz Fanon (1965) and Brazilian educator Paolo Friere (1970) elevated the importance of political engagement for well-being of populations living under oppression and violence. It should not come as a surprise, then, that while mainstream humanitarian response to political violence often asserts neutrality regarding political questions about victim and aggressor, stress and coping research suggests questions of responsibility and justice are central to individual and communal recovery (Hyman, Chisholm, Kessler, Patel, & Whiteford, 2006;Ursano et al., 1994;Ullah, 2020).

Physical and Mental Health Problems in Afghanistan Resulting form Politial Voilence Depression
Depression is the first and foremost effect of political instability and violence. It is clear from the literature review that prolonged political instability in Afghanistan leads to an increased prevalence of depression among individuals of every age. Literature also tells that depression in elders and children is most common side effect and as compared to the middle aged individuals as they are more vulnerable to such conditions. Depression can be treated both by medicine and by cognitive therapies, generally therapies are more useful as compared to medicines but it also depends upon the expertise of therapist. Both treatments can be used in combination to maximize the results.

Anxiety
Anxiety is another common consequence of political instability in the country. A large proportion of Afghanistan population suffered from anxiety and face periodic anxiety attacks. This mental illness is less severe form of depression. It is less severe because it is not constant and also its effects are less adverse. Again both, medicines and cognitive behavioral therapies can be used to treat the anxiety but therapies are more effective in children and adolescents. WHO recommends some basic psychological interventions for the treatment of anxiety.

Post-traumatic Stress Disorder
Review of different literature researches indicate that PTSD are very common and can be treated only by psychological interventions. These interventions should be customized for every person depending upon his/her individual symptoms and level of severity o9f disease.

Gaps and Challenges to Deal with Physical and Mental Health Challenges in Afghanistan
Afghanistan, due to its political instability and war situation face many challenges of physical and mental health and Country is still facing such problems at lesser level. Persistent level of stress and limited access to healthcare facilities makes it more difficult to cope with the situations. Review of the literature indicates some critical hindrances/gaps including:

Limited Number of Health Services
Very important hindrance in the provision of physical and mental care in Afghanistan is that there are only a limited number of health facilities available as compared to the population. Many people in far villages even don't have access to these health care centers.

Low Quality of Available Healthcare Services
On one hand people do not have access to healthcare facilities and on the other hand people who have access are even not getting a good quality services. According to the Literature people in Afghanistan are even unaware of the whole setup of healthcare. Only representative of the healthcare people know and interact with is the doctor so they just have to believe what he is saying and act according to his will either it's right or wrong.

Lack of Trained Staff
This is hindrance due to which Afghanistan is not able to help its people in complete recovery. There is no proper trained staff in the healthcare facilities that can provide services according to the required standards. Specifically for mental health problems, Afghanistan lack trained and qualified psychologist who can treat and provide counseling sessions to the people who are in ill mental health condition.

Lack of Competent Leadership
Review of literature provides sufficient evidence that health care system in Afghanistan lack sufficient competent leadership. Because even the available resources in healthcare are not being utilized properly.

Lack of proper Evaluation and Monitoring
Literature also supports the evidence that no proper system of evaluation is present in Afghanistan health care system which ultimately leads to poor performance of the authorities. In summary, present vertical facility of healthcare is not sufficient to provide the required health services to \the residents of Afghanistan. Children and adolescents are more vulnerable and at the same time fewer facilities are available for them in the country.

Way Forward for Future
Evidences suggest that to help the physically and mentally ill patients and to maximize their reach to healthcare facilities in a politically instable country like Afghanistan following approaches can be of great help for authorities

Community based Approaches
Community based approach is very helpful and relevant for the people in Afghanistan. Different Awareness session can be done in different communities by the local trained personals of the community e.g. females of far villages who are isolated and are not able to visit available health facilities in cities if trained by any female of the community who herself got training and knowledge from a qualified person, it would be very helpful for them. They can discuss their problems, issue and experiences more freely and can get stick to the treatment of follow-up more easily. Facility based approach would not work in Afghanistan because it is very difficult to reach at the available facility and then availability of healthcare professionals is also a problem so community based approach is helpful and workable but it can be used in combination with facility based approaches.

Service Delivery
If we want this community based plan to benefit the society then major icons of heath care should contribute in terms of financial and required technical support. In addition different community levels trainings should be provided for self-care and assessment by the professionals. Also at every BPHS, EPHS should have a ward specified for mentally ill patients and there should be a therapist to deal with them.

Conclusion
From the current research, it is concluded that Afghanistan faces political conflict since decades internally as well as externally. This prolonged political violence and civil war results in millions mortalities, thousands disabilities and enormous populace uprooting. The circumstances has affected adversely to each part of the country and society because most of the population of the country has been traumatized by this constant political conflict and cataclysmic events. Adequate proofs are present that these calamities have added to an increase in physical and mental health problems. Due to scarcity of high quality data and absence of qualified resources it is very difficult for Afghanistan to develop strategies and effective plans to deal with the challenge of compromised (physical and mental) human health. People in Afghanistan face many physical and mental health problems in Afghanistan resulting from political violence including depression, anxiety, STDS etc. On one hand people do not have access to healthcare facilities and on the other hand people who have access are even not getting a good quality services. According to the Literature people in Afghanistan are even unaware of the whole setup of healthcare. Only representative of the healthcare people know and interact with is the doctor so they just have to believe what he is saying and act according to his will either it's right or wrong. Lack of trained staff, competent leadership, low quality of services etc is some of the important hindrances due to which Afghanistan can't cope up with the situation. Evidences suggest that to help the physically and mentally ill patients and to maximize their reach to healthcare facilities in a politically instable country like Afghanistan role of authorities is very important.

Imran Zafarzai
Associate Professor Forensic medicine department Medical faculty Nangarhar University, Afghanistan Email: Imranzafarzai22@gmail.com Aimal Amiri Assistant Professor Forensic medicine department Medical faculty Nangarhar University, Afghanistan Email: Aimalhospital1@gmail.com