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Trauma and Transition: Mental Health in Iraq

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I would put the root cause down to the tyranny of the Ba’ath and, the totalitarian policies of the Ba’ath. Without that there would have been no wars, because the wars were created quite consciously and deliberately by that regime. The regime diverted resources of the State, almost completely towards the military and towards non productive spheres, the services, the welfare services were, again, deliberately starved of funds and neglected. So health and education were completely neglected. In fact there has been no investment in health in Iraq, and I’m not just talking about mental health now, since about 1983-84. So for the last 19 to 20 years of the regime there was no investment at all in the infrastructure of health. Teaching hospitals that were state of the art when I left them in the late 70’s, in 2003 they looked like shells. You know they were crumbling.

This is the transcript of an episode of All in the Mind broadcast on ABC radio (May 1, 2004). ____________________

Natasha Mitchell: And hello welcome to All in the Mind, Natasha Mitchell here with you. Today- the psychological strain of a population under major transition. The people of Iraq. Before the volatility that we’re witnessing today (under the Coalition Provisional Authority) there were three wars, thirteen years of UN sanctions, and the tyrannical rule of Saddam Hussein.

Riadh Abed: I would put the root cause down to the tyranny of the Ba’ath and, the totalitarian policies of the Ba’ath. Without that there would have been no wars, because the wars were created quite consciously and deliberately by that regime. The regime diverted resources of the State, almost completely towards the military and towards non productive spheres, the services, the welfare services were, again, deliberately starved of funds and neglected. So health and education were completely neglected. In fact there has been no investment in health in Iraq, and I’m not just talking about mental health now, since about 1983-84. So for the last 19 to 20 years of the regime there was no investment at all in the infrastructure of health. Teaching hospitals that were state of the art when I left them in the late 70’s, in 2003 they looked like shells. You know they were crumbling.

Lynn Amowitz: We’re talking about torture, killing, hanging, beating, disappearances, rape, being forced to act as a human shield. That’s not even the entire list.

Natasha Mitchell: No, because I mean there’s also ear amputation, people being held hostage.

Lynn Amowitz: Correct. Those are all things that were also documented.


Male character in play, "In Our Name": Why does a man leave his home and friends and all he has created with his life? People think of Iraq as a backward country, but it is not. Not before. Even in time of Saddam people came from all over the Middle East to study in our hospitals and universities. Iraq good country, rich country.

My family lives in Basra in the south of Iraq. We have an electrical store there selling appliances, washing machines. Business is good. But in 1981 things begin to be bad for my family and the people of Iraq. They pull people out of their houses and shoot them like animals in the gutter in front of their children and families. The killing goes on for months, years. In our family my wife’s brother and his son’s were the first to be killed. They sent for her to the place where they threw the bodies.

Female character in play, "In Our Name": For long time we hear nothing, then they come. Say “collect your dogs!”. We go to place for dead, torture place. Blood all over wall and floor. Bodies, so many bodies. Legs, arms, are all mixed up. Then they come for husband, take husband away… not knowing if they torture… not knowing.

Natasha Mitchell: A sobering excerpt from “In our Nam”, a new production by an Australian playwright, Nigel Jamieson, currently playing at Sydney’s Belvoir Street Theatre. It’s a moving dialogue that tells the true story of an Iraqi family who in seeking refugee status after persecution under Saddam Hussein’s Ba’athist regime spent 3½ years in mandatory detention here in Australia.

Later in the show we’ll hear from Physicians for Human Rights who have recently published two major studies documenting human rights abuses in Iraq, including shocking examples of abuse under the hands of medical doctors themselves.

But first to Dr. Riadh Abed who is a consultant psychiatrist and honorary clinical lecturer at the University of Sheffield in the UK. He was born and bred in Baghdad and completed his medical training there. But he left 24 years ago in 1979, only to return to his hometown for the first time mid last year. He left to pursue postgraduate studies in a place safer for him because he’d long been outspoken against the Ba’ath party as a student.

Riadh Abed: It was a very strange feeling. In many ways I returned to a city which I didn’t know. But also the city was in a sorry state. It was clearly rundown, traffic chaos, a lot of burnt out buildings.

Natasha Mitchell: And certainly as a psychiatrist, what were your impressions of some of the mental health services and infrastructure there. What sort of state were they in?

Riadh Abed: Well when I left, Iraqi mental health services was in a sort of a primitive state, but they were starting to be built up. There were very few psychiatric facilities, but there was an expectation that things were going to get better. Because at that time of course Iraq was a very wealthy country, with the price of oil being quite high and the wealth starting to trickle through to the health service.

When I went back in 2003 things had gone backwards considerably, even from the state that they were in ’79. There were whole services that had vanished. For instance there was no child psychiatry service left in Iraq in 2003. There was a catastrophe that occurred to the big mental hospital in Baghdad, called Al-Rashad Hospital. It had just started to recover from being looted, being largely destroyed through criminal activity.

Natasha Mitchell: Where did the patients go?

Riadh Abed: Well the patients, there was a lot of reports through the Red Cross and other humanitarian agencies to suggest that some of the inmates, especially female inmates, had been kidnapped. Others just roamed the streets. I believe at the fall of the regime it’s said that there were around 900 to 1000 inmates. And in July when I was there only 400 of those had returned. As of last February the report I had was that around 650 patients had returned.

Natasha Mitchell: That’s at the end of perhaps more extreme need. But one review of mental health facilities and services in Iraq has indicated that there are less than 100 psychiatrists and no psychologists across the entire Iraqi population. And we’re talking about a population of somewhere around 24 million people.

Riadh Abed: Yes.

Natasha Mitchell: That doesn’t auger well for mental health services.

Riadh Abed: Well no. I don’t think that really one can consider that Iraq has a mental health service at the present time in the Western sense. In actual fact the public in the sort of public health service there are no more than 45 to 50 psychiatrists, and the rest around the private sector. Iraq now is probably in a worse state than any other Arab country. Even countries that are much poorer than Iraq have a better mental health infrastructure.

Natasha Mitchell: Doctor Riadh Abed, this is despite the fact that another report has suggested that at least 50% of Iraqis could be considered to have Post Traumatic Stress Disorder. I mean how do you see that figure? Does that sound realistic to you?

Riadh Abed: Well, we simply don’t know. There has never been any epidemiological surveys of mental illness in Iraq. Under the old regime the Ba’ath regime never recognised that mental illness, mental distress or post traumatic stress or anything like that actually exists, because it wanted to pump out propaganda that the Iraqi people are resilient and take any amount of suffering and stuff like that. It is possible that there might be such a high figure, but we just simply don’t know.

Natasha Mitchell: And Doctor Riadh Abed, along with colleagues in the UK has recently set up the Iraqi Mental Health Foundation to support exchanges and training for mental health professionals in Iraq. Because of course under the 13 year long UN embargo Iraqi medical professionals couldn’t get access to current textbooks, medical journals, the internet, and even new psychotropic drugs. Medical students learnt from out of date photocopies they tell me.

It’s a reality that Doctor Hussein Haleal, senior psychiatrist at the Nasiraya General Hospital in the south of Iraq knows all too well.

I caught up with him this week on a windy roof in Nasiraya, via a very muddy satellite phone. So I will just bring you a small part of our conversation today. But Doctor Haleal says the most critical mental health issues facing his community and patients has been Post Traumatic Stress Disorder, and also the psychological distress of a generation of children who have witnessed conflict first hand.

Hussein Haleal: Specifically, I saw huge number of Post Traumatic Stress Disorder among the population of Nasiraya. But the problem here is the diagnosis is often confused with depression or with anxiety. So it is misdiagnosed and poorly managed.

Natasha Mitchell: I understand that there are less than 100 psychiatrists in Iraq. Are there enough mental health professions to deliver the therapy that is needed?

**Hussein Haleal**: No, no there are not enough institutions to deal with the cases. There is not. In this big city of Nasiraya there is just one small unit.

Natasha Mitchell: What about amongst young people, because the Iraqi population is a very young population, 50% are under 18. What sort of problems do you see amongst young people?

Hussein Haleal: Yes, I see many cases of addiction, which is previously not in that number. So the young adult people are now homeless, workless, they start to take drugs.

Natasha Mitchell: You are in southern Iraq where there have also been many reports of human rights abuses and torture underneath the Ba’athist regime. Does that form a large part of your work, dealing with the results of that sort of torture and human rights abuse.

Hussein Haleal: Yes yes, I am dealing with them in many varieties, or in the form of depression, anxiety. In various varieties they are presenting to me.

Natasha Mitchell: Are people open about talking about those experiences?

Hussein Haleal: Yes they have told me all the details. There was universal persecution. They used very hard aggressive behaviour, so all of them are severely destroyed, psychologically and physically. So they don’t feel that they are human beings and they need a long time of rehabilitation to return back to normal humanity.

Natasha Mitchell: Doctor Hussein Haleal speaking to me on a very muddy satellite phone from a roof in Nasiraya. And you’re tuned to All in the Mind here on ABC Radio National and Radio Australia and the net with me, Natasha Mitchell.

Harvard based Dr Lynn Amowitz in the senior medical researcher with Physicians for Human Rights. They’re an organisation which aims to promote health by protecting human rights and documenting violations across the world. Dr Amowitz has worked in some of the world’s real hot spots including Pakistan, Afghanistan, Sierra Leone, Nigeria, and last year she travelled to Iraq after the fall of Saddam Hussein.

She’s one of the authors of two major studies just published in the Journal of the American Medical Association, revealing the extent of abuse under Saddam Hussein and his paramilitary force, the Fedayeen. His so-called ‘Men of Sacrifice’.

Lynn Amowitz: At the time that Physicians for Human Rights was in Iraq we were concerned about any type of ongoing human rights abuses that may be going on during the campaign that had started.

We were also very interested in what had happened in the South from 1991 until the present. Because for a great deal of time Physicians for Human Rights had been documenting the human rights abuses that had happened since 1988. We were the first to document what gas was used against the Kurds, and then we raised concern about the uprising in 1991. But because we were unable to get access to the South nothing was known about what had happened in the South other than few reports that were not detailed enough. So we decided to conduct a study in Southern Iraq.

Natasha Mitchell: Can you give me some impressions of what you found on the ground in Iraq, because you were there right after the bombing had occurred. We’re talking about the middle of last year.

Lynn Amowitz: Correct. When we first went in, in late March, early April people were very suspicious and quiet. You didn’t see people in the markets. As time went on and we continued to sort of move up towards Baghdad as the troops moved on, you started to see things coming back to some type of near normal where the market was open, the booksellers were selling books, music was being sold, and there was a certain sense of somewhat security.

It was interesting, I left for two weeks, and when I came back after those two weeks I was shocked when I came into Najaf which was the holy city, and there were lights, neon lights in the cafes in Najaf. And there was electricity and they were cooking kebab on the streets, and it was completely different from when I had been there previously where I had stayed in tents in the desert, and now could stay in a hotel which had electricity for maybe 2 hours a day.

Natasha Mitchell: I’m also interested in your impressions in spending time with individuals, individual men and women and perhaps children. How does the trauma of 30 years of awfulness reveal itself?

Lynn Amowitz: I mean there were so many individuals. What our study showed was that 47% of households, which is basically every other household in the area that we surveyed, had been subject to an abuse. And most abuses had occurred within the household. What I mean by that is the Fedayeen or the Ba’ath Party affiliates came into the house and killed a household member in front of all of these household members.

So not only did you have stunned victims who may have survived, but you had an incredibly stunned household, stunned family members who lived side by side these houses, and may have also suffered the abuses. When I interviewed victims who had survived torture there was one in particular who was just haunting. He was maybe 90lbs and he was an average height man. He sat with his shirt over his knees and he sat in front of a window and you could count his ribs as he was sitting in front of this window. And he had this sort of vacant stare and he looked at me and he rocked back and forth as he would tell me everything that had happened to him in the torture center.

Natasha Mitchell: What you are referring to there is rather incredible study what you did while you were there which involved surveying thousands of residents in the south, in three major cities in the south. What were you probing in particular?

Lynn Amowitz: We were looking at many different things, but the things that we were mostly looking for were the number of abuses to figure out how many households had suffered abuses under the regime and during the regime…

Natasha Mitchell: But no one has really documented that before had they? And what we’ve seen is something like 150 mass graves being revealed across Iraq in recent months.

Lynn Amowitz: Right. There’s now more than 250 mass graves and 300,000 missing. And the question is how many households and how many people does that equate to? And these were the numbers that we were trying to get at as well as the stories of what happened to these households, particularly in the south. And what our study showed was that more than half of the abuses occurred during the 1991 uprising.

But there was also a spike between 2000 and 2003 which we think was probably due to international pressure that was starting to be placed on the regime and the regime then went back and started repressing groups that it thought may be allied with groups that were putting pressure on the regime.

Natasha Mitchell: Your survey also painted a picture of a fairly high suicide rate compared to say the U.S or Australia. And also spousal abuse, so - abuse within families.

Lynn Amowitz: Correct. The suicide rate was actually extraordinarily high, and particularly for the area. Our interviews were one on one. So we were able to get numbers, which are probably under-estimated. Remember these are the people who survived the suicide. There is no way to really document those who manage to kill themselves. And so we looked at who had tried to kill themselves over the last year, and we got figures somewhere between 5 to 7% of the 3 million people that we can say that our survey reached. Which is about 210,000 people.

Natasha Mitchell: Did you get a sense that people hadn’t wanted to talk about this? I mean was there an apprehension about revealing the experiences of torture and abuse within their communities and under the hands of the Ba’athist regime?

Lynn Amowitz: You know we didn’t find that at all. And I have not found that in other countries where we have surveyed in the past either. You know as we would go into these neighbourhoods and we were doing this in a scientific manner, so it wasn’t that we could go to anybody who wanted to talk to us. We had to go by a system that we had set up so every other household or every fourth household – depending on the size of the community – and people would come up to us and say, listen I have a story as well. You need to hear my story.

And some of these stories are stories that I went in to listen to, and they were not reticent to tell us what had happened or to tell us the details of the story. And some people told us that they even felt better after they had talked to us about it. And when we then said you know, how would you feel about having to talk to others who this has happened to?, because we know that many of your neighbours have had this happen to them, they agreed that this would be a reasonable way of dealing with the issues that had happened over the last 35 years.

Natasha Mitchell: Let’s give some specifics here. What sorts of human rights abuses are we talking about here?

Lynn Amowitz: We’re talking about torture, killings, hangings, beatings, disappearances, rape, being forced to act as a human shield. That’s not even the entire list, that’s the most common ones.

Natasha Mitchell: No, because there’s also ear amputation, people being held hostage…

Lynn Amowitz: Correct. Those are all things that were also documented.

Natasha Mitchell: In another study that you also undertook at the same time, you looked at the involvement of Iraqi physicians in human rights abuses, and you anonymously surveyed doctors in two cities in southern Iraq. I mean some of the results that that study revealed are extraordinary, but perhaps not surprising.

Lynn Amowitz: No it’s not surprising. Wherever you have a totalitarian regime there are people that will be co-opted forcibly into doing things that they don’t want to do. And it’s not uncommon for them to go after the pillar of society, which usually includes doctors. And we’ve seen this in many countries where doctors have been forced to do horrendous things, or be killed themselves if they don’t co-operate.

Natasha Mitchell: The majority of the doctors you surveyed indicated that torture and human rights abuses were an extreme problem in Iraq. But how did they account for their own involvement, because they did indicate that physician involvement was also an extreme problem?

Lynn Amowitz: The majority of these were forced involvement. You know they had, with the stories that we have, are that the Fedayeen come with someone who needed an ear amputation as per the Fedayeen, and they would with a gun say: “you will cut off this person’s ear or we will kill you or we will kill your family”. They really were in a big dilemma, and I’m not sure that you know if you’re not standing in their shoes you would know what to do either. And many of them were forced to participate or lose their lives.

Natasha Mitchell: You refer to the non-therapeutic amputation of the ears. What other human rights abuses did they nominate physicians had been involved in?

Lynn Amowitz: Some of the things included falsification of death certificates to say that it may have been related to either the sanctions or that it didn’t happen under torture. They were also forced to do mercy bullets, meaning that the Fedayeen had tortured a victim to the point that they weren’t completely dead yet and they would bring them to the physician and tell the physician to finish them off, as opposed to them doing it.

Other things included branding…removal of corneas from patients who were either dead or not dead; particularly prisoners, and various other horrible things.

Natasha Mitchell: And in that survey Lynn Amowitz, did you have any accounts or reports of what happened to physicians who refused to partake in torture?

Lynn Amowitz: There were physicians who were killed for not obeying. Either shot on the spot or they ran away and were captured later and killed. And there are many second hand reports of doctors saying that some of these doctors disappeared. Several doctors who actually refused were sent to some of the torture centres. And we have testimony from these doctors about the abuses that they suffered and the torture that they suffered, just like the Iraqi civilians.

Natasha Mitchell: To what extent do you think a functioning Iraqi democracy will need to be based on psychological wellbeing as much as anything else, as much as the health of the infrastructure?

Lynn Amowitz: I think you can’t move forward without dealing with the past, and without feeling mentally healthy and dealing with what the unknown is. The fact that there are so many mass grave sites, and an inability to identify those who are missing is going to weigh heavily on whether the country can move forward. There’s this huge need that has to be covered. And how that’s going to be covered is going to be difficult. It needs to be in a culturally appropriate model. It needs to be community based. It shouldn’t be done in hospitals. And there needs to be a lot more of the sort of mid level trained health care providers who can do that type of treatment.

Natasha Mitchell: Doctor Lynn Amowitz, keep up the good work and thanks for joining me on the program today.

Lynn Amowitz: Thank you very much, it’s my pleasure.

Natasha Mitchell: Doctor Lynn Amowitz there from Physicians for Human Rights. And it certainly sounds like what might be needed in Iraq is a ‘Truth and Reconciliation Commission’ similar to the powerfully cathartic process embraced by South Africans who of course are this week celebrating the 10th anniversary of the end of apartheid.

But if 50% of the Iraqi population is under the age of 18 what hope is there for a generation that has known little more than tyranny and war. Doctor Riadh Abed.

Riadh Abed: It’s a bad omen for their mental health, but also for the psycho- social adjustment of Iraqis as well. We don’t know how much of the current social unrest that seems to be destructive beyond belief - it is possible there has been a severely damaging effect on many people’s personalities resulting in people engaging in irresponsible and destructive behaviour, which at times seems to be entirely irrational. My interest is not only in the effect of tyranny on mental health, and obviously there are direct effects, but also there are wider effects, totalitarian states destroy people’s ability to co-operate with each other. The profound distrust that people feel towards each other because the State encourages people to inform on each other, to inform on their neighbours, which can actually destroy the fabric of society.

Natasha Mitchell: We’re witnessing some horrible scenes on the ground across Iraq right now. And I just wonder at times like this do the mental health needs of a population fall by the wayside when there are much more immediate physical and security needs?

Riadh Abed: Well I mean I think it’s inevitable that in situations where the very survival of people is at stake - there are gunfights, mini wars occurring in Baghdad neighbourhoods - up until two weeks ago people were scared of going out in their own roads and streets, they were just cooped up at home, I suppose when there are situations like that mental health services take a back seat.

Natasha Mitchell: Even so, where do you start with an entire population, at least half of which is suffering probably some fairly deep trauma?

Riadh Abed: Well it’s a daunting task. What is happening now in Iraq is there is a beginning of a nucleus of mental health services. And in fact there is now a commission charged with planning and overseeing mental health services, based in the Ministry of Health. I mean the list of things that need to be done is really endless, but the hopeful thing is that some of these things are being thought about. For instance, the Interim Governing Council in Baghdad is now considering formulating or suggesting a Mental Health Act. This is the first time in Iraqi history. Also for instance there was a centre for the victims of torture opened in Baghdad in January. This centre now receives about 10 to 15 people a week who are victims of torture. So there are small steps.

Natasha Mitchell: Doctor Riadh Abed, an Iraqi born psychiatrist joining me from Sheffield in the UK. And there’s plenty more to follow up on there for us. And I’ve put details about today’s program, including links to the two Physicians for Human Rights papers on our website. (see below).

And if you haven’t trekked to our website before, it’s at http// and then click on “All in the Mind” under the list of programs. Audio transcripts and references aplenty, including our email address too.

Thanks today to Sue Clark and Jenny Parsonage for production. I’m Natasha Mitchell, and cheerio from me until we coincide next week. You take care.


Guests on this program:

  • Dr. Riadh Abed Consultant Psychiatrist

Rotherham District General Hospital

Honorary clinical lecturer, University of Sheffield

Sheffield, UK

  • Dr Lynn Amowitz

Senior Medical Researcher, Physicians for Human Rights (PHR).

Director, Initiative in Global Women's Health at Brigham and Women's Hospital and Harvard Medical School.

  • Dr. Hussein Haleal


Nasiriya General Hospital

Nasiriya, Iraq

  • Publications:

Human Rights Abuses and Concerns About Women's Health and Human Rights in Southern Iraq

Author: Lynn L. Amowitz, Glen Kim, Chen Reis, Jana L. Asher, and Vincent Iacopino. Journal of the American Medical Association (JAMA) 2004;291:1471-1479

Physician Participation in Human Rights Abuses in Southern Iraq

Author: Chen Reis, Ameena T. Ahmed, Lynn L. Amowitz, Adam L. Kushner, Maryam Elahi, and Vincent Iacopino

Publisher: Journal of the American Medical Association (JAMA) 2004;291:1480-1486.


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