By Ghaith Abdul-AhadGuardian
March 2, 2005
As the violence in Iraq continues, the number of people traumatised by the conflict grows. Yet little or no psychiatric treatment is available to them - and what there is can be terrifyingly crude. Ghaith Abdul-Ahad investigates.
Hafid al-Qadhi is one of the most precarious places in the new Baghdad. Gangs, brothels and piles of rubbish fill its dark, unelectrified alleys, where kids play around lakes of green sewage. It has been known for decades as the crazies' neighbourhood, not only for the eccentricities of its inhabitants, but also because since the late 50s it has been home to the country's most celebrated psychiatrists.
One of Baghdad's best-known shrinks has his clinic in a crumbling, two-storey building there. The stairwell leading to his clinic is a dark, sinister space. Lighters in hand, visitors tread carefully on the steps, plaster falling in big lumps on their shoulders as they climb to the upper floors. The letters on the doctor's nameplate have been lost a long time ago. In the small waiting room, men and women crowd around a small table where a young woman struggles in the darkness to find patients' history in three big volumes of names and details. An old TV sits idle in the corner, and a piece of cloth separates the waiting room from a small, stinking toilet, lit by a candle.
Beneath the doctor's British diploma hanging on the wall, Fatima Aziz, a thin, tall woman in her 40s, is sitting with her sister on a pair of threadbare green armchairs. Her black scarf is falling back from her head, her hand held firmly by her sister and her eyes fixed on the floor. The doctor, an old man in his 60s, pleasant, soft and reassuring, sits behind a big wooden table. The only light in the room comes from the big window behind him, making his white hair glow and giving him the air of a genie. He glances at the white card passed to him by a male nurse and whispers "ECT".
Iraqis these days like to look back and tell each other stories of the good old days when everyone was happy and people weren't at each other's throats over every issue. Clearly the memory is a rosy one, but there is no doubt that depression and psychiatric illness are on the increase in today's Iraq. The worsening security situation has led to more and more people with serious mental health problems, though the withdrawal of the UN and international aid agencies means information about the scale of the problem is elusive; both the International Red Cross and Médecins Sans Frontií¨res say they have no data on the psychiatric effects of the war and its aftermath on Iraq's population. (A 1999 report by MSF into psychological damage in Sierra Leone after a period of intense violence found that 99% of respondents showed levels of disturbance equivalent to severe post-traumatic stress in Europe.)
With limited availability of medicines and counselling therapies, some doctors are increasingly relying on electroconvulsive therapy, or ECT, to treat Iraq's mentally ill. This involves passing an electric current through the brain to induce a fit and in the UK is used, under general anaesthetic, only to treat severe depression and psychiatric illness, and then only after other treatments have failed. The irony is that in Iraqi cities, with their intermittent electricity supplies, even this therapy is not always available.
"So Fatima, tell me what's wrong?" asks the doctor in a fatherly manner. Her sister answers on her behalf. "She is not sleeping very well. She speaks harshly to everyone. She remembers old quarrels and picks fights with everyone." Fatima is looking at the floor.
"My daughter," asks the doctor, "do you feel that people are talking about you? Every time you go to bed do you hear someone whispering in your ears?"
"Yes," says the sister. "She won't have any food cooked in the house, she says we are trying to poison her." Fatima is still looking at the floor.
The doctor starts writing something in a white notepad and says: "She is suffering from an acute depression." He looks at Fatima again. "Fatima, my daughter, do you tell yourself that maybe if I die things will get better?"
Still looking at the floor, she speaks for the first time: "Yes, but then I look at my kids and say no."
"Doctor, every time the door is knocked, she starts screaming and fighting," adds her sister
"Why is that my dear?" asks the doctor in his soft voice.
"It is all these things around us," says Fatima. "The Americans, the booby-traps. No security, I can't let the kids go play outside because of car bombs and fighting." She raises her head for the first time, looks at the doctor and says: "Doctor, you are a learned man. Why can't you stop these car bombs and explosions?" The doctor giggles and looks at the ceiling, raising his palms. "But how can I? I am like you, scared of these things."
Ibn al-Rushud is Iraq's psychiatric hospital, built in the late 70s with oil-boom money. The hospital, a white concrete modernist structure with long slit windows, is squeezed into a cul-de-sac with a Presbyterian church. Dr Hashim Zaini, the hospital's director, is bald, spectacled, slightly eccentric, and clearly a little despairing. "We have 74 beds and two doctors," he says. "We receive 250 to 300 patients a day and we are supposed to serve a nation of 25 million people." He is followed by half a dozen people as he walks to inspect the wards - patients looking for more tranquillizers, a contractor who's here to fix the hospital's generator, a couple of employees asking for leave. They follow him into his office as he continues to sign papers and write prescriptions pushed under his nose by colleagues.
In a conservative society with strict moral codes, visiting a shrink or having any psychiatric consultation is anathema. Having a mentally disturbed person in a household can mark an entire family as damaged, prompting gossip to spread rapidly through extended family networks. People with psychiatric illnesses such as depression or acute anxieties will often be told to read the Qur'an or pray more, or will be threatened by a husband, father or family members. "Psychiatric consultation is so stigmatised here, it is only when the family cannot tolerate the patient any more that he will be brought here," says Zaini. "This is why it will take a long time to figure out the real impact of violence and war on the people."
But according to Zaini and other experts, it is children who are experiencing most acutely the impact of Iraq's descent into violence. "We are witnessing a gradual change in the psychology of the children - they are living in a state of constant fear. When the teacher comes every few days and tells the children, 'Don't come to school tomorrow, there is a terrorist threat,' what do you think will happen to those kids? This is why the best business in town is the market for toy guns.
He would love it, he says, to be able to spend more time listening to his patients and forming a proper diagnosis, instead of turning to electric therapies after five minutes' consultation. "But for us Iraqis, tired and impatient, and especially for the families who want to see a direct result, we can't stop using ECT. For them it is an effective way to calm down the patient, and it is a speedy fix."
And so back in the darkened surgery in Hafid al-Qadhi, the doctor calls to his nurse, "Mustafa, prepare for an ECT." The nurse goes outside, and after a few minutes the muffled roar of a generator comes from the balcony. A faint current of electricity, enough to light only a few bulbs, flickers into life. The nurse comes back and opens a door leading to a small adjacent room smelling of burning plastic. "Doctor, I don't want to go through this again," says a visibly agitated Fatima. "But you want to get well, right?" he says, leading her to the other room as her sister holds her firmly.
They lay her on the leather bench, and take a metal headset from where it has been soaking in an aluminium bowl filled with water. Two wires lead from the headset to a brown wooden box. The doctor switches a plug on the wooden box. Her eyes close tightly as she starts to fit, shaking and trembling. Her sister holds her feet; the nurse puts his thumb under her chin to stop her from biting her tongue.
Back in the room and behind his desk as Fatima lies unconscious next door, the doctor is inspecting the white card of another patient. "The conditions in the surrounding environment, the fear, the anxieties of war and violence and the deteriorating security situation - all work as a pressure factor, that keep chipping away people's resistance." He opens the door to let in the next patient. "Of course, some people are already neurotic and have a low threshold of tolerance. People like Fatima, who break faster than others."
More Information on the Humanitarian Crisis
More Information on Consequences of the War