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Intervention16154-5660234 154322
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Abstract
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.
DOI: How to cite this article: Younis, M. S., & Aswad, A. M. (2018). The
10.1097/WTF.0000000000000144 impact of war and economic sanctions on the mental health system in Iraq
from 1990 to 2003: a preliminary report. Intervention, 16(1), 54-58.
54 © 2018 Intervention, Journal of Mental Health and Psychosocial Support in Conflict Affected Areas | Published by Wolters Kluwer - Medknow
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Younis and Aswad: Impact of war and economic sanctions on the mental health system in Iraq from 1990 to 2003
mental health disorders (Abed, 2003; Sharma, & Piachaud, Bank of Iraq (CBI), 2016), resulted in hyperinflation
2011; Younis, 2009). estimated to be 800 times more than in a pre-sanction
era (Al-Nasrawi, 2001; Harvard Study Team, 1991). The
In 1970, the Iraqi Association of Neurologists and Psy-
sanctions targeted the weakest and the most vulnerable
chiatrists was founded by Dr Tariq Hamdi, senior psychi- members of Iraqi society, such as the poor, elderly, women
atrist, with an elected executive committee of distinguished and children (Aziz, 2002; Dreze, & Gazdar, 1992).
psychiatrists, neurologists and neurosurgeons. In 1996 it
was re-named as the ISP in accordance with the bylaws of A few psychiatric centres, like Ibn Rushid Hospital in
an election process. The pioneer members issued a peer- Baghdad continued to function, with only on-call psychia-
reviewed psychiatric journal (AlRaazi) from 1978 until trists and nurses willing to endure continuous bombing,
1993, when production was stopped due to the country’s minimal medication and food donations, as well as severe
financial crises (Younis, 2009). shortages of fuel and total disruption of telecommunica-
tions (personal experience, 1991).
By 1970, an increasing number of psychiatrists were
demanding additional psychiatric clinics in other gover-
norates of Iraq. METHODOLOGY
Although little has been published on mental health issues
While specialised services for somatic patients increased, during the period of 1991–2003, books, peer reviewed
and general hospitals were established in many places in journals and reports of nongovernmental organisations
the country, the number of psychiatric beds remained (NGOs) were studied, including: the United Nations Child-
limited with only a few psychiatric clinics opening in ren’s Emergency Fund (UNICEF), the ICRC and the
the main governorates (Abed, 2003). WHO. PubMed and a commercial search engine were
During the Iran/Iraq war, from 1980 to1988, military searched under the general heading ‘Iraq’, using the fol-
expenditures rose from 19.4% to 38.4% of the gross lowing search terms: ‘sanctions’, ‘mental health’ and ‘Gulf
domestic product (GPD). In that period, the World Bank, War 1991’ in publications from 1991 to 2003. Addition-
together with many other international bodies, described ally, official documents from the Iraqi Board for Medical
the infra and upper structures in Iraq as sophisticated and Specializations (IBMS), and the Iraqi Society for Psychia-
parallel to that of advanced countries (Al-Nasrawi, 2001; trists (ISP) in Baghdad, Iraq were also searched. All
Sharma, & Piachaud, 2011; United Nations Security Coun- publications were reviewed by the senior author, an exec-
cil (UNSC), 1995). The World Health Organization utive member of both aforementioned councils. From over
(WHO) regarded the healthcare system of Iraq to be the 30 documents, the most relevant to the issue of sanctions
best in the region during the Iran/Iraq war, as the rate of were extracted, avoiding assessment of the quality of cited
healthcare coverage was 97% in urban areas and 79% in research studies. Findings are presented below.
rural areas. Further, by initiating a nationwide vaccination
programme, mothers and infants mortality dropped
markedly during the 1980s (Al-Alwan, 2004; Eastern
RESULTS
Mediterranean Regional Office of World Health Organi- Apart from the press and NGO reports, little data on the
zation (EMRO), 2006). psychological effect of the sanctions on Iraqi people is
available. The few published reports mainly discuss nutri-
Four days after the Iraqi army invaded Kuwait on 2 August tional status, maternal and infant mortality rates and
1990, the UNSC implemented a comprehensive trade endemic disease as indicators of serious deterioration of
embargo against Iraq. It was the first sanction of its kind the health care system (Harvard Study Team, 1991; Pilger,
since the foundation of the UN in October, 1945 (Al- 2002).
Nasrawi, 2001; Aziz, 2002). On 17 January 1991, over
120,000 allied raids were carried out in Iraq, taking the Impact on the healthcare system
lives of around 82,000 Iraqi soldiers during their with-
The Gulf War and the comprehensive trade embargo
drawal from the battlefield. Unfortunately, serious war
caused serious damage to the healthcare system, including
injuries were not well documented. The large scale bomb-
mental health. In 1995, the UNSC established the Oil-for-
ing and ground battles totally destroyed military and civil
Food Programme under Resolution 986 to allow Iraq to sell
structures, including bridges, roads, power stations and
oil on the world market in exchange for food, medicine,
water sanitation plants (Al-Nasrawi, 2001; Harvard Study
health care and other humanitarian needs for ordinary Iraqi
Team, 1991; ICRC, 2001). This invasion was followed by a
citizens, without allowing Iraq to boost its military capa-
civil revolt in Kurdistan, Iraq and the southern governo-
bilities, in order to mitigate the effect of sanctions (UNSC,
rates, leading to increased hospital casualties, lack of
1995). It did help to improve the quality and quantity of the
security and chaotic situations. Consequently, emergency
food ration programme (Dreze, & Gazdar, 1992). Hospital
services in hospitals were seriously hindered due to a lack
admissions had to adjust to this low cost of care in order to
of viable personnel and medicine (EMRO, 2006; the
maintain a basic level of function. The shortage in the
International Committee of the Red Cross (ICRC), 2001).
health budget deprived many psychiatric centres of expan-
Unemployment, food insecurity and dramatic devaluation sion and development. After the 1990s, the Iraq Ministry of
of the local currency, the Iraqi Dinar (ID) valued at 0.3108 Health (MoH) and the state owned pharmaceutical com-
to 1 US$ in 1985, dropped to 3000 for 1$ in 1995 (Central pany, Samara Drug Industry (SDI), were the main
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Younis and Aswad: Impact of war and economic sanctions on the mental health system in Iraq from 1990 to 2003
providers for both imported and locally manufactured basic Al-Ameriyah district of Baghdad showed PTSD symptoms
psychiatric medicines, such as minor tranquillisers, con- following the bombing of a nearby shelter that killed 400
ventional anti-depressants and anti-psychotics (Hamada, & civilians in February 1991. Another study (Ahmad,
Everett, 2007; Sharma, & Piachaud, 2011; WHO, 2006). Mohamed, & Ameen, 1998), showed an alarming 87%
NGOs like ICRC, UNICEF and the Iraq Red Crescent of children and 60% of their care givers presented with
Society (IRCS) donated some basic psychiatric medicines symptoms of PTSD, in a sample of 84 refugees following
within their charity campaigns, however, overall drug military operations in the Kurdistan region of Iraq, while a
supply was irregular and far below the growing need. much lower percentage of 20% was revealed by a similar
Treatment by electro convulsive therapy (ECT) became study (Ahmad, Sofi, Sundelin-Wahlsten, & Von Knorring,
standard for serious presentations of psychotic disorders, 2000). A comparable finding emerged in a study of 116
usually without general aesthesia. The rehabilitation of adult Iraqi refugees who emigrated to the US after 1991
psychiatric units was at a minimum, and plans for estab- (Jamil, Farrag, Hakim-Larson, Kafaji, Abdul Khaleqq, &
lishing new ones were suspended (UNCF, 1997). Due to Hamad, 2007). Anxiety and depressive disorders repre-
the general destruction of important power and service sented 18.9% and 16%, respectively, of 10,101 attendees at
stations during the bombardment, both the healthcare a psychiatry/neurology outpatient clinic in Baghdad in
system and living standards declined significantly. The 1993 (Younis, & Lafta, 2014), while in 2003 subsequently,
Al Rashad Psychiatric Hospital, the only hospital in the 33.4% and 22.2% of 1,315 attendees at the same clinic
country for chronic cases, was affected by looting and suffered from depression and anxiety disorders (Younis, &
vandalism, and many patients escaped or died due to the Al-Naimy, 2006). Similar findings were reported by
collapse of effective administration and lack of proper another study at Al-Kadhimia psychiatric outpatient clinic
medical care. in 2002 (Al-Samarraie, 2002), with depression and anxiety
disorders also found to be comorbid with Benzhexol
A few years later, the ICRC delegate in Baghdad sponsored
misuse in a sample of 354 patients in Al Hilla city from
and supervised a rehabilitation process in cooperation with
1991 to 2000 (Younis, & Moselhy, 2009a). Symptoms of
the Iraq Ministry of Health (MoH), together with few other
impulsivity, depression and raised psychological tension
psychiatric units in general hospitals (ICRC, 2001). Due to
were also associated with para suicide (attempted suicide)
the lack of medical personnel, the psychiatric unit in Al-
and self-poisoning of 58 adults attending the emergency
Karama General Hospital, was closed (Iraq MoH, personal
department of a university hospital in Baghdad (Al-Samar-
communication, 30 May 2015). The ratio of psychiatric
raie, & Huessien, 2000). On the other hand, 91% of service
beds fell to 7 per 100,000 population, psychiatric nurses
men presenting with self-mutilation met the diagnostic
were 0.1 per 100,000 and social workers were 0.02 per
criteria of antisocial personality disorder, according to
100,000 population. There were limited facilities for psy-
DMS-IV (Hassan, 1999). Many patients with schizophre-
chotherapy and rehabilitation (Okasha, Karam, & Okasha,
nia suffered frequent relapses with catatonia, requiring
2012).
ECT as a first-line treatment because of the deprivation
of antipsychotic medication (Younis, & Moselhy, 2009b).
Impact on patients (Al Mokhtar psychiatric hospital, which opened in 1998 in
International studies about mental health services in Iraq Baghdad, was the only private hospital serving 30 psychi-
were mainly extracted from data released by WHO after atric beds and facilities for ECT under general aesthesia.)
2003 (WHO, 2005; 2006). As expected, mentally ill The overall poor life quality assessed in 579 healthy
patients were among the community groups most affected college students randomly collected from Baghdad, Diala,
by the collapse of family income, with an impact which and Thi-Qarr governorates in 2001 showed psychological
gave rise to different arrays of psychiatric symptomatology distress attributed to the traumatising effects of war com-
(Okasha, & Karam, 1998; Srinivasa, & Lakshminaryana, bined with austerity (Younis, Al-Kaisi, Vasudev, &
2006). The shortage of psychiatric medicines, especially Young, 2003).
the new anti-psychotics and anti-depressants, with poor
services and emigration of many psychiatrists, contributed Impact on psychiatrists
to an increased prevalence of psychiatric disorders
Because of the Iran–Iraq war from 1980 to 1988, junior
(Sharma, & Piachaud, 2011; ISP, personal communication,
doctors in training for psychiatry were enrolled in obliga-
6 April 2001).
tory military service for a maximum period of 5 years as
According to WHO (2006), the number of patients attend- reserve. This caused inconsistency in providing good
ing psychiatric outpatient clinics had enhanced in spite of psychiatric care and continued training for qualifications.
the deterioration in standards of healthcare, which reflects The Iraq Ministry of Higher Education and Scientific
the increase of people’s needs for treatment. For example, Research established the Iraqi Board for Medical Special-
the number of psychiatric attendees at outpatient clinics in izations to set up a specialisation programme for medical
1990 was 197,000, this increased to 220,000 in 1994 and graduates in 1986, based on a similar programme of the
further rose to 507,000 in 1998. It is believed that around Arab Board of Medical Specializations founded few years
10% of the population is affected by different psychiatric earlier. The psychiatric scientific council was then estab-
disorders, especially posttraumatic stress disorders (PTSD) lished in 1988 with a 4-year training and tuition programme
(WHO, 2005; 2006). One local study (Younis, 2003) leading to a fellowship degree. The first batch of psychiat-
revealed that 24–57% of 130 school age children in the ric graduates was of 12 doctors in 1992, appointed to
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Younis and Aswad: Impact of war and economic sanctions on the mental health system in Iraq from 1990 to 2003
Intervention, Journal of Mental Health and Psychosocial Support in Conflict Affected Areas ¦ Volume 16 ¦ Issue 1 ¦ March 2018 57
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Younis and Aswad: Impact of war and economic sanctions on the mental health system in Iraq from 1990 to 2003
Sharma, S., & Piachaud, J. (2011). Iraq and mental health policy: a post Younis, A. A. R., & Moselhy, H. M. (2009b). A nation under siege: The
invasion analysis. Intervention, 9(3), 332-344. 15-year outcome of Iraqi patients with schizophrenia in Babylon,
Srinivasa, R. M., & Lakshminaryana, R. (2006). Mental health con- Iraq. Journal of Mental Health, 18(5), 394-404.
sequences of war: A brief review of research findings. Official Younis, M. S., Al-Kaisi, H., Vasudev, K., & Young, A. (2003). Quality of
Journal of World Psychiatric Association, 5(1), 25-30. life among college students in Iraq. Quality of Life Newsletter, 30, 2-3.
United Nations Security Council (UNSC). (1995). Resolution 986. Younis, M. S. (2003). The psychological impact of Al-Ameriyah bom-
Accessed on 2 June 2016. Retrieved from http://www.securitycoun- bardment on the neighbourhood children. Iraqi Postgraduate Medi-
cilreport.org/undocuments/Iraq%20SRES986.php. cal Journal, 2(2), 191-195.
World Health Organization (WHO) Department of Mental Health and Younis, M. S., & Al-Naimy, A. S. (2006). Cross-sectional study of the
Substance Abuse. (2005). Mental Health Atlas (pp. 442-445). psychiatric outpatient clinic at Baghdad University Hospital in the year
Geneva: WHO Press. www.who.int/mental_health/evidence. 2003. Journal of the Arab Board Medical Specilizations, 8(1), 85-87.
World Health Organization (WHO). (2006). WHO-Aims Report on Younis, M. S. (2009). The foundation of modern psychiatry in Iraq,
Mental Health System in Iraq. Iraq Ministry of Health. (23-26). exploring personal archives. The Arab Journal of Psychiatry, 20(1),
Geneva: WHO Press. 78-83.
Younis, A. A. R., & Moselhy, H. M. (2009a). Benzhexol-dependence Younis, M. S., & Lafta, R. K. (2014). Working in a conflict region: A total
resulting from self medications for intermittent explosive disorders. year work load of a Psychiatry Neurology outpatient clinic in
International Journal of Psychiatry in Clinical Practice, 13(1), Baghdad. American Journal of Bioterrorism, Biosecurity and Bio-
11-15. defense, 1(1), 1-4.
58 Intervention, Journal of Mental Health and Psychosocial Support in Conflict Affected Areas ¦ Volume 16 ¦ Issue 1 ¦ March 2018