Year : 2018 | Volume
: 16 | Issue : 1 | Page : 54--58
The impact of war and economic sanctions on the mental health system in Iraq from 1990 to 2003: a preliminary report
Maha Sulaiman Younis1, Azhar Madlom Aswad2,
1 PhD, Professor of Psychiatry, College of Medicine, Baghdad University, Baghdad, Iraq
2 MBChB, MSc, Specialty Psychiatrist, Surrey and Border Partnership NHS Mental Health Trust, UK
Maha Sulaiman Younis
Baghdad University, Baghdad
This paper explores the effects of war in Iraq in the period between 1991 and 2003, with a focus on the effect of economic sanctions on mental health services. The authors, Iraqi psychiatrists with direct contact with patients and events during this period, review literature and reports published contemporaneously. They describe how the mental health system in Iraq was deteriorated, not only by war, but also by United Nations imposed sanctions during the period between the first and second Iraq war.
|How to cite this article:|
Younis MS, Aswad AM. The impact of war and economic sanctions on the mental health system in Iraq from 1990 to 2003: a preliminary report.Intervention 2018;16:54-58
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Younis MS, Aswad AM. The impact of war and economic sanctions on the mental health system in Iraq from 1990 to 2003: a preliminary report. Intervention [serial online] 2018 [cited 2020 Aug 14 ];16:54-58
Available from: http://www.interventionjournal.org/text.asp?2018/16/1/54/228767
As a developing country, Iraq has struggled to re-establish national mental health services amidst challenges of continuous civil unrest from regional wars, economic sanctions and an exodus of mental health professionals. Furthermore, despite various international interventions to improve Iraq’s national mental health policy, little has been implemented (Hamada, & Everett, 2007; The Education for Peace in Iraq Center (EPIC), 2014). While published literature has primarily focussed on the impacts on mental health in the aftermath of the American led invasion of 2003, far less is known about developments in the decades before the Iraq invasion.
Therefore, this paper begins with a brief historical overview of the development of mental health services in Iraq. This is followed by a description and analysis of the effects of the first Gulf War, the subsequent period of international economic sanctions imposed by the United Nations Security Council (UNSC) on Iraq in August 1990, until the American led invasion in 2003 and the civil strife that followed. Taken together, these factors provide a concise overview that is necessary to understand the decline of the mental health system in Iraq over the past few decades.
It is also important to note that most reports on mental health issues in Iraq are from authors living outside Iraq, from international agencies, or local officials. As practicing Iraqi psychiatrists during this period, describing the impact of ongoing hardship and the impact on mental health services, the authors believe they are contributing a unique and little heard voice.
The British occupation authority established the first mental hospital (Dar Al Shefaa) in 1921. As a result, formal mental healthcare was established much earlier in Iraq than in neighbouring Arab countries, despite limited facilities and resources. This institution served as a custodial hospital with limited facilities, which contributed to generally poor medical care (Younis, 2009). From 1932 onwards, the government offered medical graduates of the Iraqi Royal College of Medicine an opportunity to specialise in mental health through a scholarship in the UK. An Iraqi physician, Jack Abood, returned from the UK with a degree in psychiatry and started the mental health service in Baghdad in 1934. By 1940, the number of qualified psychiatrists had increased due to continuous government scholarships, however, the number was still relatively low.
In 1953, a 1,300 bed psychiatric hospital (Al Shammaiyya) was established at the periphery of Baghdad, which was later renamed Al Rashad. At that time, there were only 15 qualified psychiatrists, a ratio of 0.2 per 100,000 population (Bazzoui, & Al-Issa, 1966). By 1968, another 70 bed psychiatric hospital (Ibn Rushid) was established for acute mental health disorders (Abed, 2003; Sharma, & Piachaud, 2011; Younis, 2009).
In 1970, the Iraqi Association of Neurologists and Psychiatrists was founded by Dr Tariq Hamdi, senior psychiatrist, with an elected executive committee of distinguished psychiatrists, neurologists and neurosurgeons. In 1996 it was re-named as the ISP in accordance with the bylaws of an election process. The pioneer members issued a peer- reviewed psychiatric journal (AlRaazi) from 1978 until 1993, when production was stopped due to the country’s financial crises (Younis, 2009).
By 1970, an increasing number of psychiatrists were demanding additional psychiatric clinics in other governorates of Iraq.
While specialised services for somatic patients increased, and general hospitals were established in many places in the country, the number of psychiatric beds remained limited with only a few psychiatric clinics opening in the main governorates (Abed, 2003).
During the Iran/Iraq war, from 1980 to1988, military expenditures rose from 19.4% to 38.4% of the gross domestic product (GPD). In that period, the World Bank, together with many other international bodies, described the infra and upper structures in Iraq as sophisticated and parallel to that of advanced countries (Al-Nasrawi, 2001; Sharma, & Piachaud, 2011; United Nations Security Council (UNSC), 1995). The World Health Organization (WHO) regarded the healthcare system of Iraq to be the best in the region during the Iran/Iraq war, as the rate of healthcare coverage was 97% in urban areas and 79% in rural areas. Further, by initiating a nationwide vaccination programme, mothers and infants mortality dropped markedly during the 1980s (Al-Alwan, 2004; Eastern Mediterranean Regional Office of World Health Organization (EMRO), 2006).
Four days after the Iraqi army invaded Kuwait on 2 August 1990, the UNSC implemented a comprehensive trade embargo against Iraq. It was the first sanction of its kind since the foundation of the UN in October, 1945 (Al-Nasrawi, 2001; Aziz, 2002). On 17 January 1991, over 120,000 allied raids were carried out in Iraq, taking the lives of around 82,000 Iraqi soldiers during their withdrawal from the battlefield. Unfortunately, serious war injuries were not well documented. The large scale bombing and ground battles totally destroyed military and civil structures, including bridges, roads, power stations and water sanitation plants (Al-Nasrawi, 2001; Harvard Study Team, 1991; ICRC, 2001). This invasion was followed by a civil revolt in Kurdistan, Iraq and the southern governorates, leading to increased hospital casualties, lack of security and chaotic situations. Consequently, emergency services in hospitals were seriously hindered due to a lack of viable personnel and medicine (EMRO, 2006; the International Committee of the Red Cross (ICRC), 2001).
Unemployment, food insecurity and dramatic devaluation of the local currency, the Iraqi Dinar (ID) valued at 0.3108 to 1 US$ in 1985, dropped to 3000 for 1$ in 1995 (Central Bank of Iraq (CBI), 2016), resulted in hyperinflation estimated to be 800 times more than in a pre-sanction era (Al-Nasrawi, 2001; Harvard Study Team, 1991). The sanctions targeted the weakest and the most vulnerable members of Iraqi society, such as the poor, elderly, women and children (Aziz, 2002; Dreze, & Gazdar, 1992).
A few psychiatric centres, like Ibn Rushid Hospital in Baghdad continued to function, with only on-call psychiatrists and nurses willing to endure continuous bombing, minimal medication and food donations, as well as severe shortages of fuel and total disruption of telecommunications (personal experience, 1991).
Although little has been published on mental health issues during the period of 1991–2003, books, peer reviewed journals and reports of nongovernmental organisations (NGOs) were studied, including: the United Nations Children’s Emergency Fund (UNICEF), the ICRC and the WHO. PubMed and a commercial search engine were searched under the general heading ‘Iraq’, using the following search terms: ‘sanctions’, ‘mental health’ and ‘Gulf War 1991’ in publications from 1991 to 2003. Additionally, official documents from the Iraqi Board for Medical Specializations (IBMS), and the Iraqi Society for Psychiatrists (ISP) in Baghdad, Iraq were also searched. All publications were reviewed by the senior author, an executive member of both aforementioned councils. From over 30 documents, the most relevant to the issue of sanctions were extracted, avoiding assessment of the quality of cited research studies. Findings are presented below.
Apart from the press and NGO reports, little data on the psychological effect of the sanctions on Iraqi people is available. The few published reports mainly discuss nutritional status, maternal and infant mortality rates and endemic disease as indicators of serious deterioration of the health care system (Harvard Study Team, 1991; Pilger, 2002).
Impact on the healthcare system
The Gulf War and the comprehensive trade embargo caused serious damage to the healthcare system, including mental health. In 1995, the UNSC established the Oil-for-Food Programme under Resolution 986 to allow Iraq to sell oil on the world market in exchange for food, medicine, health care and other humanitarian needs for ordinary Iraqi citizens, without allowing Iraq to boost its military capabilities, in order to mitigate the effect of sanctions (UNSC, 1995). It did help to improve the quality and quantity of the food ration programme (Dreze, & Gazdar, 1992). Hospital admissions had to adjust to this low cost of care in order to maintain a basic level of function. The shortage in the health budget deprived many psychiatric centres of expansion and development. After the 1990s, the Iraq Ministry of Health (MoH) and the state owned pharmaceutical company, Samara Drug Industry (SDI), were the main providers for both imported and locally manufactured basic psychiatric medicines, such as minor tranquillisers, conventional anti-depressants and anti-psychotics (Hamada, & Everett, 2007; Sharma, & Piachaud, 2011; WHO, 2006). NGOs like ICRC, UNICEF and the Iraq Red Crescent Society (IRCS) donated some basic psychiatric medicines within their charity campaigns, however, overall drug supply was irregular and far below the growing need. Treatment by electro convulsive therapy (ECT) became standard for serious presentations of psychotic disorders, usually without general aesthesia. The rehabilitation of psychiatric units was at a minimum, and plans for establishing new ones were suspended (UNCF, 1997). Due to the general destruction of important power and service stations during the bombardment, both the healthcare system and living standards declined significantly. The Al Rashad Psychiatric Hospital, the only hospital in the country for chronic cases, was affected by looting and vandalism, and many patients escaped or died due to the collapse of effective administration and lack of proper medical care.
A few years later, the ICRC delegate in Baghdad sponsored and supervised a rehabilitation process in cooperation with the Iraq Ministry of Health (MoH), together with few other psychiatric units in general hospitals (ICRC, 2001). Due to the lack of medical personnel, the psychiatric unit in Al-Karama General Hospital, was closed (Iraq MoH, personal communication, 30 May 2015). The ratio of psychiatric beds fell to 7 per 100,000 population, psychiatric nurses were 0.1 per 100,000 and social workers were 0.02 per 100,000 population. There were limited facilities for psychotherapy and rehabilitation (Okasha, Karam, & Okasha, 2012).
Impact on patients
International studies about mental health services in Iraq were mainly extracted from data released by WHO after 2003 (WHO, 2005; 2006). As expected, mentally ill patients were among the community groups most affected by the collapse of family income, with an impact which gave rise to different arrays of psychiatric symptomatology (Okasha, & Karam, 1998; Srinivasa, & Lakshminaryana, 2006). The shortage of psychiatric medicines, especially the new anti-psychotics and anti-depressants, with poor services and emigration of many psychiatrists, contributed to an increased prevalence of psychiatric disorders (Sharma, & Piachaud, 2011; ISP, personal communication, 6 April 2001).
According to WHO (2006), the number of patients attending psychiatric outpatient clinics had enhanced in spite of the deterioration in standards of healthcare, which reflects the increase of people’s needs for treatment. For example, the number of psychiatric attendees at outpatient clinics in 1990 was 197,000, this increased to 220,000 in 1994 and further rose to 507,000 in 1998. It is believed that around 10% of the population is affected by different psychiatric disorders, especially posttraumatic stress disorders (PTSD) (WHO, 2005; 2006). One local study (Younis, 2003) revealed that 24–57% of 130 school age children in the Al-Ameriyah district of Baghdad showed PTSD symptoms following the bombing of a nearby shelter that killed 400 civilians in February 1991. Another study (Ahmad, Mohamed, & Ameen, 1998), showed an alarming 87% of children and 60% of their care givers presented with symptoms of PTSD, in a sample of 84 refugees following military operations in the Kurdistan region of Iraq, while a much lower percentage of 20% was revealed by a similar study (Ahmad, Sofi, Sundelin-Wahlsten, & Von Knorring, 2000). A comparable finding emerged in a study of 116 adult Iraqi refugees who emigrated to the US after 1991 (Jamil, Farrag, Hakim-Larson, Kafaji, Abdul Khaleqq, & Hamad, 2007). Anxiety and depressive disorders represented 18.9% and 16%, respectively, of 10,101 attendees at a psychiatry/neurology outpatient clinic in Baghdad in 1993 (Younis, & Lafta, 2014), while in 2003 subsequently, 33.4% and 22.2% of 1,315 attendees at the same clinic suffered from depression and anxiety disorders (Younis, & Al-Naimy, 2006). Similar findings were reported by another study at Al-Kadhimia psychiatric outpatient clinic in 2002 (Al-Samarraie, 2002), with depression and anxiety disorders also found to be comorbid with Benzhexol misuse in a sample of 354 patients in Al Hilla city from 1991 to 2000 (Younis, & Moselhy, 2009a). Symptoms of impulsivity, depression and raised psychological tension were also associated with para suicide (attempted suicide) and self-poisoning of 58 adults attending the emergency department of a university hospital in Baghdad (Al-Samarraie, & Huessien, 2000). On the other hand, 91% of service men presenting with self-mutilation met the diagnostic criteria of antisocial personality disorder, according to DMS-IV (Hassan, 1999). Many patients with schizophrenia suffered frequent relapses with catatonia, requiring ECT as a first-line treatment because of the deprivation of antipsychotic medication (Younis, & Moselhy, 2009b). (Al Mokhtar psychiatric hospital, which opened in 1998 in Baghdad, was the only private hospital serving 30 psychiatric beds and facilities for ECT under general aesthesia.) The overall poor life quality assessed in 579 healthy college students randomly collected from Baghdad, Diala, and Thi-Qarr governorates in 2001 showed psychological distress attributed to the traumatising effects of war combined with austerity (Younis, Al-Kaisi, Vasudev, & Young, 2003).
Impact on psychiatrists
Because of the Iran–Iraq war from 1980 to 1988, junior doctors in training for psychiatry were enrolled in obligatory military service for a maximum period of 5 years as reserve. This caused inconsistency in providing good psychiatric care and continued training for qualifications. The Iraq Ministry of Higher Education and Scientific Research established the Iraqi Board for Medical Specializations to set up a specialisation programme for medical graduates in 1986, based on a similar programme of the Arab Board of Medical Specializations founded few years earlier. The psychiatric scientific council was then established in 1988 with a 4-year training and tuition programme leading to a fellowship degree. The first batch of psychiatric graduates was of 12 doctors in 1992, appointed to replace the emigrated specialists. Eventually the number of qualified psychiatrists grew to 86 between 1992 and 2007 (IBMS, personal communication, 12 May 2015).
Due to the minimal wages offered after 1991 sanctions for professionals and auxiliaries, psychiatric units in hospitals suffered medical and therapeutic decline. The financial strain of the sanctions and the stringent restrictions on traveling and communications with the outside world led to lack of access of educational materials and global medical advances. This, in turn, hindered the quantity and quality of the psychiatrists (Afifi, 2005).
The total number of psychiatrists was around 108 in 2001 (ISP, personal communication, 2 April 2001), which dropped to 90 in 2003 (WHO, 2006). The pre-sanction ration of 0.5 psychiatrists per 100,000 population decreased to 0.1 per 100,000 populations during 1998 (Okasha, Karam, & Okasha, 2012), and accordingly, psychiatrists were overwhelmed by the workload with an increasing number of traumatised patients.
Mental health services in Iraq, in spite of a long history beginning in the late 1920s, did not receive enough attention nor development from successive governments. It did, however, flourish during the early 1970s with improved economic conditions in the country and the availability of government scholarships for training abroad. When the Iran–Iraq war began in the 1980s government funds were reduced, and no more scholarships were offered. The Gulf War of 1991, and the long years of comprehensive economic sanctions caused marked deterioration of psychiatric services and trained mental health workers and people’s mental health. The collapsed country’s economy caused shortages of medicines and emigration of many experienced psychiatrists, disrupting the practice of psychiatry and preventing development of a mental health care system. With a growing need for psychiatric services and the increased demand of people resulting from psychiatric war traumas, the Iraqi Council for Medical Specializations established the psychiatric council for specialisation of a 4-year programme of clinical training and tuition, leading to the degree of fellowship in psychiatry. The first group of 12 specialists graduated in 1992, and this has stimulated the practice of psychiatry in the country.
This study shows that economic sanctions have had a huge impact on the mental health of people in general: of the people who are already known as a mental health patients and on the mental health care; on the availability of psychiatric health workers and education of psychiatrists, as well as the number and quality of mental hospitals and the availability of medication. It is important for a clear understanding of the mental health situation that mental health professionals in conflict affected settings document the effects of international sanctions on mental health care systems. These documents can, in turn, support mental health professionals to inform the international community about the results of sanctions for mental health patients.
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