In Iraq, depression and psychiatric illness are disregarded although they affect large sections of the population. They are even associated with shame and weakness. The rare medical structures present in the country do not offer suitable treatments to the men and women traumatized by the violence in society.
Near Sadr City, barbed wires can be seen for hundreds of meters. Armed men are positioned at the main entrance of the Al-Rashid psychiatric hospital. Their night shift over in the morning, they let other security officers replace them. Inside, birds are chirping and bathing in little swamps. Rusty car structures are scattered in the courtyard. In the distance, a few fenced buildings appear loosely in the distance behind creeping vegetation. Two silhouettes appear in the distance, they head shaven, staggering and wearing gray dressing gowns tainted with filth.One of them starts to urinate on the floor. The other one launches into an epic chant. “These are our Iran-Iraq war veterans”, explains Hassan*, an intern working in the hospital. “Here, we have all types of patients. Some are former soldiers with PTSD, while others have serious psychiatric pathologies, or are also affected with post traumatic shocks following terrorist attacks”, Hassan detailed.
One flew over a cuckoo’s nest
The young intern waves at a guard to ask him to open the gate leading to a little courtyard. Men appear, their faces disfigured by madness, and quickly get agitated as the door opens. They flock together slowly, their arms passively lined against their body, their heads leaning down. Hassan is quickly surrounded. Patients ceaselessly beg him for cigarets. Some try to kiss his hands. One of them throws himself at his feet to beg him. A strong smell of urine emanates from the crowd. Some piercing shouts escape from the rows of the most serious cases.
Iraq’s Al-Rashid psychiatric hospital is one of the only medical facilities to be exclusively dedicated to mental health issues. Patients from all over Iraq live there, some for several decades. Despite his position as head of the establishment, Ali Al-Rikaby, 58 years old, does not remember precisely if Al-Rashid hospital hosts 1200 or 1400 patients. He certifies that two thirds of them are men. “We only have nine social workers and twelve psychiatrists for the whole institution. It’s too little. We would need at least a hundred more”, he complains. “The issue is that young medical graduates are not really interested in psychiatry. They go more towards medical specialties that are more economically rewarding, hence there is a deficit of volunteers working here”, Ali admitte.
In his wide and empty office, Mr. Al-Rikabi nonetheless praised his musical, theater and sports therapies, as well as oral group sessions intended to reduce physical violence and encourage dialogue between patients. A colleague suddenly stumbles inside the office, ready to guide us through the facility. The therapy rooms are decrepit, the cultural and sports equipment seems to be decades old. But the staff enunciates the proposed activities like automatons.In the section reserved to women, female patients roam the corridors. Facial expressions are empty, jaws wide open. A nurse discreetly confessed “[hoping] to get the hell out of there as soon as possible” as soon as her job is done. “I don’t feel safe here. We lack every possible medicine necessary to calm patients”. In the operating room, only one woman dressed in black has the ability to speak… but the old lady is in fact only able to recite surahs from the Coran.
Outside the room, in the mess, a social worker is shaving the hair of a patient. A chariot is then brought in front of the rows of tables and chairs. Lunch meals sealed in plastic boxes include an apple and yogurt. “Working conditions are bad and the patients are left in limbos, but it’s always better for them than to be left in their poor families”, Hassan admits. These men and women are not abused here, he certifies.
Psychiatric pathologies: Iraq’s societal taboo
Al-Rashid hospital’s director says he receives around 400 millions Iraqi dinars (250 000 euros) of annual budget, which amounts to around environ 330 000 Iraqi dinars (200 euros) per patient each year. A ridiculously low sum. Obviously, the Iraqi government and its Ministry of Health do not take mental health problems seriously, as do many Iraqis. In Iraq, mental pathologies are a taboo. According to a study published on October 11th 2010 entitled Public perception of mental health in Iraq, 65% of a sample of 500 Iraqis estimated that psychological problems were due to “personal weaknesses” and 80% claimed that people with mental health problems were partly responsible for their situation. On top of this, more than half of the questioned persons admitted they would be ashamed if a member of their family had a psychological condition.
According to a study by Médecin sans Frontière (MSF), Iraq had only four practicing psychologists as of 2012. A less catastrophic estimate dating back to 2010 brings forth the number of around a hundred psychologists for a population of around 32 million Iraqis. In comparison, France, with a larger population (67 millions) has around ten thousand of them. While the quantity is lacking, the level of treatment offered is just as disastrous. “Our psychiatric rooms were refurbished and transformed into additional operating rooms. Since then, we do not receive mentally ill patients. Why is that? Because they were always empty. […] The population is generally hostile toward mental illnesses and lacks information on the matter. A patient seeking treatment for mental health issues risks serious social stigma” angrily explained Ahmed Khalid, the head of the emergency room of an Iraqi hospital. The doctor also confessed that Iraq has a severe lack of specialized medicine: “There is a void between the treatments we are able to propose and the actual needs of the population, which is further aggravated by the people’s defiance toward specialized treatments. Honestly, there is a lack of literally everything in our infrastructures. You mentioned a deficit in mental health medicine, but here, we’re even out of paracetamol”, he added. An Iraqi pharmacist with eleven years of experience, Karam Mahmoud, supports this claim: “It would be easier for me to enumerate the medicine that we have then the one we are missing. Most patients suffering from hysteria or severe panic attacks are regularly treated with… electric wave therapies.”
Small progress… thanks to militias
The paradox of these last five years is that all progress made in terms of psychiatric infrastructures in Iraq did not come from the government, but from militias associated with the Ministry of Armies. As the Islamic State organization (ISIS) threatened the very existence of the Iraqi state during the summer 2014, 20 000 Hashed al Shaabi volunteers coming from Basra answered Ayatollah Ali Al-Sistani’s call to defend the country against it. From this war, 8000 of them returned wounded, 3000 amputated from at least one body part while 1580 died in action, according to the Hashed’s numbers. Once back home, the survivors are not the same. “Families were calling us for help day and night. Our wounded fighters were out of control. They had become violent” remembers a member of the volunteer’s force wishing to remain anonymous.
Unemployed, construction workers, young graduates, petty criminals, engineers, professors… Most of them had no experience of war. War-shattered bodies from the war also leave the soul in shambles. In order to confront the issue of “living Martyrs” and the accumulation of social problems related to it, the Hashed Al-Shaabi opened two psychiatric facilities. Commanders selected two former presidential palaces that belonged to Saddam Hussein. The first one is located in Baghdad (Al-Rasool Al’adam), on the banks of the Tigris river while the other one is located in the outskirts of Basra (Jaafar al-Tayyer).
These palaces were initially built to welcome the dictator’s families and his guests. After the 2003 invasion, they either became military bases for the international coalition or open houses where curious Iraqis can witness the opulence of their fallen Raïs. Today, these two palaces shelter the wheelchairs of men wearing prosthesis away from any sight. In Jaafer al-Tayyer, where Talbi was sectioned for a long period, hundreds of calligraphic inscriptions of Saddam Hussein’s name were systematically removed by Hashed militiamen. Inside, the looted renaissance disappeared only to be replaced by crude chipboard furniture, falsely luxurious chandeliers and plastic dividing walls separating treatment rooms in the immense living room of the palace. Three years after its opening, the palace turned hospital resembles a squatted war bounty.
self-proclaimed psychologist and Hashed Al-Shaabi veteran Jaber Hussein welcomes us in a bright and large empty room. On the right of a desk and a chair still in its bubble wrap lies a large and black leatherette massage seat is reserved for patients. Behind the large windows, electric wires hang and swing. The sound of wind coming from the Arab gulf could easily follow the arrival of a spooky ghost like in a low budget horror movie. A seedy atmosphere fills the room.
“This hall is reserved for my psychiatric therapies. My patients are all veterans of the war against ISIS. What are my methods? I mention the names of those who sacrificed their lives like Abu Mahdi al-Muhandis (former militia leader and director of the Hashed Al-Shaabi who was assassinated by the United States in January 2020) in order to neutralize the depression of my patient”, Jaber detailed. The man explains that he received a psychiatric training and an additional course on PTSD without being able to mention where or how long his training lasted. “I don’t know how many patients I follow. I don’t have a specific list. I’d say ten or more”, Jaber explained while lighting a cigarette, apparently annoyed by all these questions. After long minutes of discussions about trauma caused by violence experienced by his combat comrades, the self-proclaimed psychologist loses his nerves and answers unequivocally: “When we went to fight, we enrolled for our country. We, the Hashed Al-Shaabi, we are so courageous that after facing death, we came back home without developing any paranoia or any other PTSD or depression. Do you know why? That’s because in Iraq, we do not have the same conception of death as in France for example. Here, in certain circumstances, we are glad to die. It’s the concept of Jihad”. As absurd as it may sound, Jaber does not believe in the discipline he practices. He is not the only one in Iraq: psychiatry is there for weak souls, for cowards or for mad people.
“Someone seeking treatment from a specialist is necessarily crazy”
Amal Muheen Zowid, 28 years old, does not hold the same opinion. She welcomes us in her office. The young lady thanks a patient showing tattoos on his arms moving on an electric wheelchair and holding a urine bag next to his brake pedal. She was hired in 2018 after graduating from a Masters in psychology. She claims to have followed 266 patients since, “former Hashed Al-Shaabi who had been amputated”. Even though she struggles to explain her therapy techniques, she described resorting to picnics, swimming pool sessions while building mutual trust while asserting that psychologists must dissociate every Man’s characteristics with his potential mental pathologies. In other words, PTSD can happen to anyone. As her colleague Jaber, she has to manage the skepticism of her patients and their relatives. “Some families lock their husbands or brothers in imam Ali and Hussein’s shrines in the hope of getting them cured. This means society does not understand very well what psychiatric trauma really is about. A man coming back from the frontline who weeps alone, is depressed and doesn’t want to work anymore is generally considered weak among society. You know, psychiatry or psychology are not widespread in Iraq due to the weight of traditions who claim that someone seeking treatment from a specialist is necessarily crazy”, the psychologist continued. Furthermore, the stigma of madness associated with psychiatry prevents any marriage or social perspective for a young man or woman.
Ancient commander of the Al-Muntazar brigade (part of the Kataeb Sayyid al Shuhada), Jawad Ruhaif Fuleh al-Daraji welcomes us in his organization’s reception hall in Basra. Battle fatigues on, the man with a long white beard is surrounded by his sons with whom he fought against ISIS. Old pictures on the wall of the militiaman standing with his weapon in hands, looking focused, have whitened with time. Jawad himself seems to have lost his colors. The man is missing his right leg and fear he might lose his left foot that keeps getting darker since shrapnel is still inlayed in his flesh. “He is nervous and sometimes appears violent for no apparent reason. Just like when you put a lit match next to a barrel of petrol. It can explode. He shouts and sometimes beats his children”, his son Ali admitted with an embarrassed smile. “My kids make noise! I can’t stand their noise anymore”, answers his father, suddenly nervous. The man went through Jaafer al-Tayyer’s hospital but refused to continue consulting a doctor. “I don’t need psychiatric care! If ISIS came back, I asked my son to carry me to the battlefront right away and to leave me there. I await my destiny”, he shouted under the gaze of his comrades fallen on the battlefield, all immortalized on a banner hanging on a wall of the room.
Gardening and severe depression
In Baghdad, the al-Rasool Al’adam hospital for Hashed Al-Shaabi fighters has the same conceited architectural features than its Basran counterpart. Impressive moldings on its ceilings and walls decorate bright rooms made of marble. Zahra al-Shahristani, a 46 year old counselor, just finished a painting workshop with her patients. Some drew portraits of the two iconic figures of the Hashed Al-Shaabi, Qasem Soleimani and Abu Mahdi Al-Muhandis. The drawn features are flattering but quite realistic. “We started with patients that couldn’t even hold a paintbrush… and look at the result after nine weeks of therapy! Our veterans have a lot of talent even though most of them left school very early.” Zahra’s specialty is physiotherapy and psychiatric rehabilitation. She teaches amputated and disabled patients how to dress, brush their teeth, use a key slot as well as painting and gardening. “Our veterans have psychiatric issues, that’s for sure. They are paranoid, violent, and depressed. This is due to PTSD. It’s not well understood here in Iraq as are most aspects of psychology. Hence we do significant work with patients and their families to put words and explain what their trauma is all about.”
Her 57 year old psychiatrist colleague Maaida al-Nuab, 57 ans, is desperate. “We have more than 5000 wounded in Baghdad, 5000 more in Basra and we can’t receive all those veterans because we lack medicine and psychiatrists.”, she explains, adding that several of her patients saw their comrades get their throats slit while one recently tried to immolate himself with his whole family. Suddenly, a veteran enters the consultation room. His hair is long, his appearance unkempt and his speech is unclear. He begs Maaida to prescribe him medicine to help him sleep: “Give me the strongest.” His psychiatrist opens a drawer and lifts a bag full of boxes from it before selecting the right ones. “So, this is for bipolar disorder; that’s for severe depression phases. But please do not exceed the prescribed doses! ”. The shadowy man disappears, apparently satisfied. “Medical students rarely choose this specialization where there are very few job opportunities. Before, I had my own psychiatry cabinet and I had to close it because I didn’t have enough clients. Iraqis are afraid of us and do not understand what psychiatry or psychology are really about. For example, young couples would come to me asking advice before their marriage”, added the psychiatrist, visibly annoyed by this experience.
The resurgence of ISIS in some Iraqi areas can only mean one thing: The country will need more psychiatric assistance than ever in the future, which might, paradoxically, fille Saddam Hussein’s palaces even more in the years to come.
1. Post traumatic stress disorder, caused by a shock which occurred during a violent event
2. A militia notorious for its activities in Syria where it fought alongside Bashar Al-Assad’s forces and Iran’s Revolutionary Guard Corps.
3. Former leader of the external branch of the IRGC. He was the mastermind of Iraq’s pro-Iran militia front and one of Iran’s most powerful military leader until his assassination in January 2020 alongside Abu Mahdi Al-Muhandis.