This is a personal blog and in no way represents the views of
any organisation. Views expressed are my own.
Raw, painful, beyond human
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.
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
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
- Syrians here
- 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.
Cutting it fine to go from work straight to
the airport. And great - have a bad cold. Apprehensive about this
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
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
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
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
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
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
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
Many of the influx come from Sanjar, Anbar,
Nineveh province. These are ISIL held.
This was from the August 2014 capture by
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
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.
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
Day 4 - Visit to Shariya camp.
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
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
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
Now the camps are full and new influx goes to
the east to Sulaymaniyyah.
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
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
Friday rest day.
Alone as all my colleagues have now
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
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.
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
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
It was a lively discussion across different
languages. It took just about most of the day to cover
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
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
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
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
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.