By Jonathan Finer and Omar Fekeiki
Washington Post Foreign Service
Monday, March 6, 2006
BAGHDAD -- More than 25 years after Saddam Hussein's rise to power ushered in a period of virtually uninterrupted trauma -- three wars, crippling economic sanctions and now a violent insurgency -- the psychological damage to many Iraqis is only now being assessed, psychiatrists and government officials here say.
Even as a grim, though incomplete, picture of the population's mental health has emerged in recent studies, so too has the realization that the country's health care system is ill-equipped to deal with what are likely millions of potential psychiatric patients with conditions born of the hardship of recent years.
One recent study was sparked by one of the country's darkest days in recent memory. Last Aug. 31, nearly 1,000 Shiite Muslim pilgrims died -- some trampled in a crush of humanity, others by drowning -- when a religious procession across a Baghdad bridge became a lethal stampede.
Months after the dead were buried and the wounded had begun to heal, a team of psychiatrists at the Health Ministry established a psychological outreach facility in Sadr City, a teeming Shiite slum in the capital, to assess and treat the damage inflicted on victims, witnesses and their families. What they found surpassed even their worst fears. More than 90 percent of the people surveyed suffered from psychological disorders, including depression, insomnia and post-traumatic stress disorder, or PTSD.
"The people we've identified as troubled are just the tip of the iceberg in terms of the mental health situation in this country," said Ali Abdul Razak, 55, who runs the clinic in a dank corner of Sadr City's Imam Ali Hospital. "I don't consider this post-traumatic, I consider it 'continuous traumatic,' because the trauma they have is ongoing."
Resources for treatment are scarce. Only about 75 psychiatrists remain in a country that has endured a brutal eight-year war with Iran and two wars with the United States, along with crippling economic sanctions in the 1990s and the bloody insurgency today. Many fled along with other professionals to escape kidnappings and threats from insurgents. As a result, there is one psychiatrist for about every 300,000 Iraqis, compared with about one for every 10,000 Americans. There are currently no child psychiatrists in this country of about 25 million, Razak said.
This year the Health Ministry declared mental health a top priority and opened two psychological outreach centers in Baghdad (the second is in the city's main teaching hospital in the predominantly Sunni Muslim neighborhood of Yarmouk). In addition to studying those affected by the bridge collapse, the ministry has begun collecting data on the population as whole.
In a survey of just over 1,000 randomly selected people across five Baghdad neighborhoods, completed this month by psychiatrists at Baghdad's Mustansariyah University, about 890 reported having experienced a violent incident firsthand, including all 27 children under 12 in the sample.
Most alarming, according to the physicians who analyzed the data, was that exposure to trauma has grown dramatically more common since the U.S.-led invasion in 2003. The people in the study recalled 3,504 violent incidents between 1979, when Hussein came to power, and 2003. Since the invasion, they have recorded 6,463.
In the survey, the psychiatrists adapted an Iraqi version of the Harvard Trauma Questionnaire, a research tool once used to evaluate the mental health of Southeast Asian refugees displaced by war.
Among the 42 yes-or-no queries, Iraqi subjects were asked to indicate whether they had been "oppressed because of ethnicity, religion or sect," "witnessed the desecration or destruction of religious shrines," "witnessed mass execution of civilians," been "used as a human shield," "witnessed rotting corpses," or been "forced to pay for a bullet used to kill a family member."
Those at the greatest risk, psychiatrists say, are people who came of age during Hussein's reign and have rarely known a life without trauma.
"For more than 40 years, everything in our country said to be a hero you must be violent. Violence was how we survived, by identifying with aggressors," said Muhammad Lafta, the deputy national adviser for mental health and a psychiatrist at al-Rashid Hospital, one of two dedicated psychiatric hospitals in the country. Under Hussein, he said, elementary school students were made to assemble at least once a week to watch their principals fire AK-47 assault rifles into the air.
The damage to Hussein Ali Saoud's mind is reflected in the molten-looking, purplish scars that rend the skin of both his forearms. An Iraqi soldier during the 2003 invasion, he said he watched two of his platoon mates die from gunshot wounds as U.S. troops invaded Baghdad. Since then, he has sought relief by taking drugs and slicing jagged lines in his flesh with a razor.
"I get nervous and start to feel like someone is suffocating me," said Saoud, 30, joined by his younger brother in a recent visit to the outreach center at the Yarmouk hospital, where doctors diagnosed PTSD. "When I see myself bleeding it helps me relax, even though I know it is wrong."
International advisers and experts say Iraq's mental health system has a long way to go, despite about $25 million in aid, including a $6 million grant from the Japanese government.
"It's pretty small beer, compared to the scope of the problem. You're probably talking about epidemic levels of PTSD," said Keith Humphreys, a psychiatrist and associate professor at Stanford Medical School who is helping train Iraqi doctors in modern practices. "The health system was pretty good, including mental health care. But in the last 25 years or so, they've virtually been kept in the dark. They weren't allowed to go to conferences or even read the medical journals."
Humphreys and other American and European psychiatrists have led conferences for their Iraqi counterparts in the region, although not in Iraq because security is tenuous, a fact he said complicates the psychiatrists' work.
"The thing with psychiatric work, though, is that to make progress you first have to have a functioning society," Humphreys said. "You need to have peace."
Another barrier to progress is a strong stigma attached to psychiatric care in Iraq. "It's unacceptable to say you need mental help, so you have people making appointments with surgeons and then telling them they are depressed," Lafta said.
Muhammed Ata, 44, said he sought treatment at the Yarmouk center only because his sister made him. A policeman, he was patrolling the western Baghdad neighborhood of Khadra three months ago when a pair of improvised bombs exploded, killing two of his fellow officers.
"I looked for my friends, 'Where is Ayad? Where is Fuad?' No Ayad and no Fuad. I just saw a neck here and a hand there," Ata said. "We were like one family, my friends who died and me."
His sister, Nisreen Ata, who attended a recent appointment with him, said he has been too afraid to return to work. "He gazes at police cars and hums," she said.
Most patients are not victims of violence but witnesses to horrific events, Iraqi psychiatrists say.
Khadija Murad's older brother died fighting in the Iran-Iraq war, months before the end of the brutal conflict that consumed nearly a million lives during the 1980s. Her house burned to the ground five years ago, taking with it all her savings at a time when Iraq was under economic sanctions.
Since last January, when a car bomb exploded near an Iraqi army patrol passing by her house, Murad, 40, has been unable to banish from her mind the images of smoke and screaming and charred flesh. Overwhelmed by nightmares and thoughts of suicide, she said, she made her way to the center at Yarmouk Hospital.
"Every other day I feel fine, but then it always comes back," said Murad, clutching her year-old son Hussein, as she described bouts of depression and anxiety that have twice caused her to leave her husband and four children to move in with her parents. "I stop eating. I cry. I just want to go to sleep and not wake up."
Asked how long it would take for the country's collective psyche to recover from the turmoil of recent years, Lafta, the psychiatrist at al-Rashid Hospital, predicted "a generation or more, from the time the fighting here stops."
"The damage was done over a long period," he said, "and it will take decades to heal."
Special correspondents Bassam Sebti and K.I. Ibrahim contributed to this report.