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Iraq: Healing the psychological wounds of conflict
Syrian psychologist Mahmud describes how he and his team have provided more than 18,000 mental health consultations in Erbil this year
The sky is almost white at noon. The reflection of the sun on the beige rocks of the camp alley is blinding us.
The heat in this part of Iraq is extreme, reaching sometimes 50 degrees Celsius. Hundreds of tents are sizzling in the direct midday sun in Hasan Sham - M2 Camp, which has become a temporary shelter for 28,000 of the nearly one million Iraqis displaced by 10 months of fighting in and around Mosul.
Mahmoud welcomes us with his gentle and friendly smile and invites us to a an air-conditioned consultation room in one of the two prefabricated ‘units’ of the MSF clinic in the camp.
Immense psychological scars
“The environment has improved since we arrived,” he says. “Now we receive patients with more privacy, and more comfort. But we still have difficulties providing support to all the patients who require it because they are so numerous and it’s difficult to find good staff with experience in psychology and trauma.”
At the beginning, in 2012, the team was working with Syrian refugees. Then the first wave of displaced Iraqi people came in 2014. And, after the start of the battle for Mosul last October, MSF received an influx of patients.
Although awareness about mental health is growing, most people do not spontaneously request these services, nor know where to find them.
Besides, mental health services in Iraq are mainly centralised in hospitals around psychiatry, many of which lack appropriate drugs, and psychological support is not widespread in the community.
But, after years of the so-called Islamic State (IS) control over large parts of Iraq, and over a year of heavy fighting between Iraqi Security Forces and IS to retake cities in northern Iraq, the psychological and emotional scars of war are immense. Thousands of people are in need of assistance.
Even after escaping the frontlines, many still fear for their safety and worry about the future.
“The people who come here have lost everything,” says Mahmud. “We see men, women and children of all ages. Trauma-related distress is a very difficult condition to recover from. It comes with symptoms like depression and anxiety... We sit with them, we listen to them, we speak with them and after several therapeutic sessions they can feel better and see the future, find hope.
“It helps them find a meaning for their life after all these troubles. They lost trust in everyone and here they meet people who care about them, who give them time and support to deal with them as human beings. With us they recover their humanity. It’s good to see light in this darkness. And it’s good for me too, as a refugee, to be able to help other people.”
Mahmud sees on average 25 patients every week
Since the beginning of this year, our teams in Erbil provided more than 18,000 mental health consultations and more than 23,000 medical consultations, including consultations for non-communicable diseases (mainly diabetes, epilepsy, asthma, hypertension).
Mahmud sees on average 25 patients every week. “Each person is different,” he says. “Their capacity to recover depends on their personality, their resilience, the support they have in the camp. We usually follow their cases for three to five months. We see them either in individual sessions, as husband and wife or as families with children, or sometimes in group therapy.
“We have lots of severe cases. I remember a man who was under medication before the conflict but couldn’t receive his drugs for quite some time. As part of the treatment, the psychiatrist provided him with the drugs, but he would not take it.
“So we – the community health workers and me - had to visit him several times, to gain trust, bring him to open up to us. Now he has a small shop and he can take care of his family,” Mahmud explains.
In Iraq, like in most conflict contexts, men arrive with their families in the camps where they find a safer place to live after having sustained injuries or trauma and after a long and perilous journey. But then they have no work, often they cannot go out of the camp and they cannot sustain their position of the family carer. So they lose a sense of social utility and self-confidence.
"The djinns have left my head"
Women are also facing tough situations and additional responsibilities. Many women are widowed or their husband is missing and they may have several children and elderly relatives to take care of, bearing the weight of the household alone.
“There was a woman with three children,” remembers Mahmud. “She was severely depressed. She couldn’t sleep or eat, she lost interest in life. She was isolated and even suicidal. She was referred by another organisation that was working in the camp, because they knew she needed medication but they couldn’t provide it.
“The first time I met her she told me: ‘I lost my son. I don’t know what is happening in my head.’ When she was discharged, after three months follow-up with anti-depressants, she said: ‘I still have the pain in my heart, but now I can go ahead and live my life, all the djinns (evil spirits) have left my head.’”
Lots of children have been traumatised by the fighting, the displacement, losing their roots. They suffer anxiety, and have nightmares regularly. But children can heal more easily than adults if they receive good care and are in a safe environment.
There are some schools in the camp, but many children didn’t go to school before the conflict.
Today, the MSF team is seeing people going back to their homes. But many return to the camp, either because their home areas remain unsafe, or their homes simply don’t exist anymore. Returning home can help people to recover, but then comes the difficulty of continuing treatment.
Those who have left the camp are often out of reach of MSF teams for follow-up, and have limited access to mental health services near their homes.
In September, around 90,000 internally displaced people (IDPs) were living in camps where MSF works between Erbil and Mosul.
In these camps, MSF is the only NGO providing psychiatric care to the most severely affected patients, and to all patients who previously had psychiatric disorders and were left without care because of the conflict.
Because the needs are huge, MSF has a significant team consisting of more than 20 psychiatrists, psychologists, mental health doctors and counsellors who take care of severe and moderate cases.