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The Royal College of Psychiatrists Improving the lives of people with mental illness

Iraq since IS

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14/04/2015 10:53:00

Iraq

This is a personal blog and in no way represents the views of any organisation. Views expressed are my own.

Yazidi Camp Through Bars


Raw, painful, beyond human endurance...


In the College of Psychiatrists we have established a Syrian Task Force to try and advocate for Syrian refugees in the region.

I have been involved in the Syrian refugee crisis, training in Syria and this was an opportunity to support refugees and displaced people in Iraq.

 

This blog is about a mission to Northern Iraq – Kurdistan in early 2015.

 

 

This was a project that was first proposed last November as a concept but took until February to get off the ground. This was a complex mission involving different UN organisations and health departments in Iraq – Baghdad government and counterparts in Kurdistan.

 

It was a pleasure to be invited to be part of this mission along with my UN colleagues. It was a learning experience for me and a steep learning curve in learning about the refugee and IDP (internally displaced people) issues. I had worked in refugee camps several years before elsewhere and this brought back a lot of memories. However, there, the camp was established and people had established routines and the hopelessness was at a different stage. Also a refugee/IDP situation in Africa is a very different category than in the Middle East.
Erbil to airport


I have been in this country once before less than 2 years ago. At that time I was hearing about the beginning of the refugee problem in Northern Iraq in Dohuk.

 

Now, unbelievably,  there is a new crisis. The arrival of ISIS / ISIL, or Daesh as it is in Arabic, have totally transformed the humanitarian landscape. We were close to ISIL but only on the last day I was told that there was a front line with ISIL 15 minutes from where we were.

 

The purpose of the mission was to support mental health and psychosocial support MHPSS for refugees, IDPs (Internally displaced people) as well as addressing the capacity for local host community.

 

There can be a feeling that refugees and IDPs are very similar. This can be true but I noted marked differences here in Iraq.  IDP populations are fresh in their grief and loss. Refugee camps are established and entrenched in resigned hopelessness.

 

Background

I don't think that anyone is unaware of the catastrophic situation in Iraq, Syria, Lebanon, Jordan and Turkey due. I was in Lebanon last year when they had the 1 millionth refugee from Syria. Now Lebanon has 1.3 million refugees hosted in a country of 4.5 million people. There the refugees have assimilated into local communities and not in camps.

 

Iraq has a population of 33.5 million. About 8 million in Kurdistan. This is the virtually autonomous population of North Iraq. It is no secret that the North and the Baghdad have a strained relationship.

 

Kurdistan has 3 governorates affected by the current crisis; Erbil also called Arbil and Howler in Kurdish, Dohuk and Sulaymaniyah. Erbil and Dohuk were first in line for refugees and Internally displaced people. Now the overflow is moving to Sulaymaniyah close to the Iran border.

 

There are different populations affected:

  • Syrians here the longest
  • Displaced due to ISIL/Daesh
  • Local populations

For myself I was aware that this was Iraq so never secure. However, Kurdistan is pretty safe but, with ISIL 30 minutes down the road and 30Kms from where I am currently writing, it is certainly terrifying. If there are loud noises, planes, helicopters, first thought is what is happening. Have ISIL taken over? They have certainly tried to come to this place even close to Erbil, Capital of Kurdistan-Iraq. Mosul is Iraq’s second city - 30 kms away from Erbil where I am now. What happens if you try and cross over to there now – chances are you will be killed. For foreigners, who knows?  Hence the ubiquitous checkpoints – countless - - literally.

 

The paradox is that you can get a scheduled flight by about 4 or 5 European carriers to Erbil and not far to ISIL / Daesh and IDP/refugee camps. 

 

Day 1

 

Cutting it fine to go from work straight to the airport. And great - have a bad cold. Apprehensive about this new mission.

 

First problem at check in. Check in lady says I can’t travel as no visa for Iraq. In fact I need a visa for Baghdad Iraq but not Kurdistan. Firstly she says “where is that – for Erbil” Then she goes off to check with immigration. Perhaps checking if I am an ISIL member. Who knows? Then final clearance to travel.

 

Full flight to Istanbul. I look around wondering if anyone off to Islamic state as only 3 days before were the 3 UK girls going  to Syria via Turkish airlines.

 

Istanbul has snow on the ground. Don't know how usual this is. Other thing that surprises is people smoking in an airport.

 

Now I meet my lovely colleague who will be with me for the next week from US. I learned a lot from her on development work, report writing and the humanitarian business . Such a pleasure to have some one so skilled and so nice as well to work with.

 

 

DAY 2

 

We arrive at about 3am in Erbil, Kurdistan. No car to meet us. You really don't want to be alone in Erbil in the middle of the night . But fortunately my colleague knew the name of the hotel and we managed to get a taxi.  

 

Rest for a few hours then meet my other colleagues from UN and also local colleagues, I have met before so it was very nice to meet again.

 

We go to the UN compound. This is a walled sprawling compound which looks very much like the Erbil prison from the outside. This is where all the UN organisations sit.  

 

We meet with the local partners, psychiatrists, NGOs, people from Najaf-Kerbala. Nice to see some familiar faces again.

 

People talk about the new situation. One person spoke about all the stress conditions and then mentioned that anyone with headache they sent back to the physician. In reality, headaches and other somatic symptoms are such a hallmark of stress and humanitarian disaster.

 

Dohuk and Erbil have a population of 1.3 million. Now 860,000 internally displaced people – IDPs

 

There are 120,000 Syrians. There are 21 camps. 50% of Syrians have located in host communities outside of camps.

 

IDPs are scattered in derelict or uncompleted buildings or camps. Those with personal resources have rented residences or stay with relatives. 76 different locations identified of IDPS.

 

There are 17 IDP camps 160,000 families, ie 600,000.

 

The figures are staggering when one considers that the population in the area is only 1.3 million. There are major capacity issues. So far there are no tensions between host and refugee/IDP community but one wonders how long that will last. Already one sees beggars around which I didn't see on my last visit to the region.

 

Health services are free in the camps but supply problems. There is limited psychotropic medicines. Only those doctors with some training are allowed to prescribe psychotropics and this is antidepressants. Although there does seem to be over the counter buying of drugs like diazepam, even tramadol.

 

Many of the influx come from Sanjar, Anbar, Nineveh province. These are ISIL held.  

This was from the August 2014 capture by ISIL.

 

The government generally prefer camps to assimilated population so people can return once peace is achieved. A disaster is people staying indefinitely as refugees/ IDPs.

 

The unit of consideration is the family. An issue that does come up is the problems of young single men who are disenfranchised, isolated and goal-less.

 

I heard about Iraq itself as opposed to Kurdistan.

 

Kerbala-Najaf which are provinces South of Baghdad and large pilgrimage places. This is a place to pick up easy pilgrimage work hence the concentration of IDPs here. 250,000 IDPs in government constructed units.

 

Stories the psychiatrist there described were children seeing their father’s killed, nightmares. Sexual violence for girls over 14. So girls are being disguised to look younger or to look like boys. MSF Holland and Spain are present. Medicine supply is a problem. 

 

Children can be aggressive. Some of NGOS such as UPP go to the schools. There are many urban refugees. This is refugees or IDPs who stay with family in the local area, rent places or use disused buildings. 

 

Kurdistan: Dohuk is now synonymous with refugees and IDPS . It borders with Southern Turkey. Each camp there has a primary health care centre and some have psychosocial care. There are very few psychiatrists. Some of these provide some care in the camps but their capacity is stretched.

 

The reduction of oil process is having a direct effect in how the Iraq and Kurdish regional government can support health care. There is a severe shortage of adequate mental health care in relation to the amount of anxiety, depression and stress in the community.

 

A recent analysis of diagnosis at some camps shows that 39% with mental health problems had severe emotional distress, Other conditions 32%, epilepsy 11%, psychosis 9%, medically unexplained symptoms 3%. Alcohol 0.4%. Suspect this is only a small part of the picture.

 

Day 3 

 

We travel to Domiz camp near Dohuk. This is a camp for Syrian refugees. It is actually 3 camps together.

 

Population of main camp is 45,000.  It very much reminded me of camps I have seen before. People have been here for about 3 years. They have gone through anger, despair, hope and they are now past hopeless into helpless resignation. They now get on with things. It looks like a small town, far from anywhere else. People come and go but are registered for camp benefits such as health care and the $19 support. Used to be $30 but low oil prices are hitting.

 

People have set up shops, businesses. The health centre and psychosocial centre is a fixed structure. There are workers from the refugee community working as psychosocial workers, psychologists along with international staff. Mental health is provided but separately from primary care.

 

It is a general principle of mental health care in Low and Middle income countries with poor resources that mental health be delivered in an integrated primary care setting. This is still hard to enact. There are many camps that don’t have specialised mental health psychosocial care so it really does lend itself to an integrated mental health and primary care model.

 

Day 4 - Visit to Shariya camp.

Yazidi Camp Child

This has a population of 18,000. I am writing this a few days later and really this place still haunts me.

This is the camp of the Yazidis. These are the community that ISIL have been systematically destroying. About 95% have fled from their homes in ISIL territory. The women were raped, kidnapped. People were beheaded. We saw on TV news earlier in the year these people fleeing to the mountains where the holy leaders remain still.

 

It is an ancient religion that ISIL considers as pagan. It is a somewhat secretive religion which is perceived as devil worship but is actually more about a protection against the devil-keeping the devil close as a protection.

 

Here the grief and loss were raw and painful. They are very much in the phase of hopelessness, distress and raw grief at their losses.

 

We spoke to some health workers. It was clear these health workers who came from this Yazidi community were at breaking point themselves. They had the respect of the community whence they came. Sometimes the patients knew the doctors and health workers from their own villages.

 

We spoke to one old man whom I will never forget. He told us that he had left his home. He had lost 2 members of his family. He had seen women kidnapped.  He had been in the army before and served with the Iraqi army in several missions. Now he felt that all the world had abandoned the Yazidi community. They say –“we are devil worshipers so they kill us, rape us and let us die. They behead us and leave us in this camp. We have nothing to do all day except think, think and think about what has happened. We have no future. We are hopeless”.

 

This is really what a refugee camp looks like although an IDP camp - internally displaced people. It is a bleak, desolate environment.  There are tents and temporary residence structures . They are in military rows. The latrines are situated far from the tents, which leaves the women particularly fearful.  

 

There is a rudimentary portakabin health centre. There were many people around but no smiles, no laughs just a stony sad expression of painful, angstfull grief mixed with hopelessness and giving up on any hope of help from outside. Those expressions stay with me. Raw, painful beyond human endurance. A health worker told me about her cousin who was raped 10 times in one night and stays at home all day. Many women were raped and kidnapped and now in the camp. There are many with suicidal feelings.

 

Women tend to stay in the tents. This is cultural. They spend all day thinking and in loss. Similarly for the men but they move about. We did see a group of men playing a game together on the ground.

 

A woman spoke to my colleague about her situation “ You know I am a clean person and my children and now we have scabies and it comes back again and again. We cant get rid of it in this place. We are ashamed as you will think we are dirty but we are clean”.

 

However Children are playing and there are actually schools.

 

So when people say IDP and refugee camps are the same they aren’t here. There is a deep emotional distress in this IDP camp. The losses are severe. This is possibly a temporal effect.

 

Now the camps are full and new influx goes to the east to Sulaymaniyyah. 

 

DAY 5

 

Meetings and discussions.

 

Interesting to talk to local people here who are very interested in UK. Many have family members overseas. Heard a few stories of people smuggling and horrendous journeys to get to UK from this area.

 

Travel to east to Sulaymaniyah

 

Day 6

 

Sulaymaniyah.

 

Stakeholder workshop.

 

Seems like a lot of work being done here .

 

Less camps and most people here IDP. Refugees have assimilated into host community raising issues of access and picking up mental disorder and psychosocial problems.

 

They are beginning to have influx of people here from ISIL territory.

 

Now with new fighting there is every likelihood of a huge rise of IDPs 

 

We stop in the equivalent of a motorway rest stop en route. My female colleague asks –‘is this place usually got women in it”.  Answer was never. As men we hadn’t noticed but for her she could feel stared at by about 30 men and she was the only woman. Made me realise that a woman’s perspective can be different and how blind us men can be to what is in front of us.

 

Day 7

 

Friday rest day.

Alone as all my colleagues have now left.

 

Day 8

 

Arrival in Dohuk.

 

Journey here was on the main road as was in a private vehicle as opposed to the UN vehicles when we had to use back roads.

 

On the left was the ISIL or Daesh (as it is in Arabic) area and we skirted around their area.

 

Dohuk is a small town surrounded by barren mountains. Has a bit of a frontier town feel to it.

 

Day 9

Training in Dohuk

 

Today was a training day in Dohuk. The first day of training. This was attended by a number of people and professions from the camps and town including some internally displaced Yazidis. We ran the day with interpreters. We worked on the new WHO UNHCR (World Health Organisation United Nations High Commissioner for Refugees) mental health gap humanitarian version.

 

 

 

 

The participants described seeing cases with common themes of stress and being affected by loss and sexual violence. The venue was a beautiful modern children’s centre in Erbil.

 

It was a lively discussion across different languages. It took just about most of the day to cover communication skills.

 

Fascinating conversation with a senior doctor from Mosul now under ISIL control. The first two months of ISIL occupation were fine and then the persecution of Christians happened. Executions are frequent even for using a phone if the leaders catch you. There are shortages of most things. It is now impossible to travel or from Mosul and life threatening to cross the border. This doctor had to leave as he feared he would be killed as he worked for the government. He is an internally displaced person so ironically his salary has been preserved from central government in Baghdad. It is distressing for him to think of what has happened and an uncertain future. He has family back there but can barely get in touch with them and any contact is dangerous for them. Mosul is the second largest city of Iraq. 

 

Day 10,11,12

 

Training days

 

The driver points out the vehicle is armour plated which made me realise how insecure this place is. Countless checkpoints to Erbil. Probably over 20. We are skirting around ISIL territory. We stopped in one place which I know on UK foreign office site is marked as red (ISIL) but now seems free to travel in. 

 

Day 13.

 

Kurdish holiday day.

 

In 1991 the Kurds of North Iraq –Kurdistan started a revolt against the Baghdad government. This was eventually crushed. However Kurdistan is independent in all but name . The Baghdad government has been involved in the camps but clear that KRG is leading in these affairs.

 

What strikes me about this humanitarian work is how it stretches the concept of mental illness.  Even in training people’s concept of mental health is drugs and psychotherapy. What comes up is a much broader approach needed. It includes day activities, religion, families being together. It is also about a humane approach where people can be sympathetic, listen and help problem solving. No fancy psychotherapy or counselling just simple being with someone in a humane way. Listening and sharing person’s feelings of grief and pain is as important as CBT in these types of humanitarian circumstances. What happens though is not enough time to spend with people. Prescribing vitamins, benzodiazepines etc.

 

One example that occurred in the training was about bed wetting which is a big problem. Women punish their children perpetuating the problem. The women are stressed. What is a solution that affects psychosocial health is getting a washing machine or more washing capacity for bed clothes. I could see that one of the NGO coordinators wrote in her notebook,  Get extra washing machine. That isn’t mental health but that is what is helpful. Other ideas such as toy workshop. Getting women to make toys for their children is a therapeutic activity. Recreation is therapeutic.

 

Day 14

Rest – Erbil

 

Day 15. First day of training in Erbil.

 

Venue is psychiatric unit at general hospital. This is close to centre of town. There is a beautiful new mosque across the road.  We got lost in the compound. I suggested to the driver that the mental health unit would be at the extreme end and isolated. And it was. It was actually around the back through a back entrance. This is the acute unit and another larger, longer term unit elsewhere .

 

Much as this is all interesting to me I must keep the focus to the mhGAP (Mental Health Gap Action Programme) ideal which includes de-institutionalisation and small units attached to general hospital. This seemed pretty close to this. Had a walk around. Saw some patients at some sports equipment. Seemed like a large unit.

 

A large group of participants at training including doctors, psychiatrists. A psychologist spoke to me in Arabic. She came from Mosul last year when ISIL took over. She left all her certificates behind and this stops her tracks. It was clearly very painful for her to talk about her experience of moving from her home and life to Erbil.  I asked for people to write clinical cases. I realised that some had written about their own personal losses through conflict.

 

Last day of training today.

 

Really was a pleasure to have such an engaged group. Some very skilled and knowledgeable people. Might have been some confusion when I asked for cases that they had seen to be written down as examples. One person had written about being suicidal as a result of feeling so alienated after having to move away from ISIL. They felt now like a second class citizen in the host community. Another participant told me he left Syria a year before from the Northern area. Before this he had been placed in Prison by the government for 2 months for political reasons. Life is so tough for these people. He has had to make a living in a new sometimes unfriendly society.

 

I spoke to someone today on the way to the airport en route to Baghdad. With the Tikrit offensive there will be a large amount of displaced people. He is an international staff so cant travel freely. He lives in the green zone in Baghdad. He describes it as a prison. Security is huge for foreigners and a lot of clearance to leave the green zone. His work takes him North now with the huge humanitarian situation. 

 

I now write at the airport. There are flights coming in from Baghdad, Najaf. Places now famous for explosions. I will have been at the airport over 11 hours once I get through this marathon.

 

It has been a good trip and the feeling that I have been able to help train people in some new skills in mental health and psychosocial support that might help this dreadful, human misery. I know that I can go not that far to find hideous IDP and refugee camps. It makes it very surreal that it is so close by to the real world.

 

I am haunted as I leave by the Yazidi people I saw and their blank, haunting, pained faces. This is unimaginable suffering that we seem to be just in the middle of. I have moved over the past few overseas assignments from being a psychiatrist to something else where common, human misery is a legitimate area of concern. Simple interventions can make a big difference and is about listening, being with people unconditionally rather than anything more complex. I really hope that this situation can sort itself out in some kind of way. The alternatives are not to be imagined. It will be all to easy for these refugees and displaced people to move forward in a life of permanent alienation and hopelessness as I have seen elsewhere.

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  Dr Peter Hughes, RCPsych Blog Editor
 


RCPsych Blog Editor, Dr Peter Hughes, is a consultant psychiatrist based at Springfield University Hospital, London. He has an interest in international psychiatry and has been travelling to Africa over the last five years doing short-term assignments in mental health.

If you would like to contribute to this series, please email an outline of your blog to: jburnside@rcpsych.ac.uk