Surrounded by images of war and more recently "liberation" some of us have immersed ourselves in the media barrage of coverage of the Iraq war with the same intensity usually reserved for a football grand final. And ever opportunistic in their promotions and packaging, our commercial TV stations have even offered to send us customised text messages whenever there is a major event (score), or when one side has a major defeat. But as the war enters its denouement and the coverage recedes, within Iraq there are big events occurring at a much deeper level for the Iraqi people - events that will reverberate for many years.
The victims of the brutal Ba'ath Party regime will face particular mental health challenges. For others, coping with disruptive cultural and political change as a part of the war is akin to coping with the top four on the western stress scale - divorce, moving house, death of a close relative and changing jobs all at once. Many will have experienced the horrors of war, torture or imprisonment and may already be suffering from poor social relations, traumatic flashbacks, neurosis, anxiety, depression, phobias and bouts of uncontrollable anger and despondency.
Traumatised Iraqis are distinguished from other Iraqi citizens by their of lack of choice regarding how they became who they are today. Those opposed to Saddam Hussein's regime have, on a daily basis, sought to escape persecution, imprisonment, torture, or even death. Families may have been physically separated for lengthy periods, causing prolonged grief and stress. Those outside prison are often preoccupied with worry about relatives who remain missing or incarcerated.
And the mental health problems of people living in the newly tagged "free" Iraq are not limited to this generation of adults. Children have also experienced a number of losses, separations, persecutions and threats. Younger children are more vulnerable to physical illness and emotional distress than older children, showing increased signs of depression. The mental health effects of war on Iraqi children were the focus of a new report released in Canada in March 2003 before the war began. The report, Our Common Responsibility: The Impact of a New War on Iraqi Children (pdf, 530KB) is based on interviews with more than 100 families in January this year.
It revealed that Iraqi children were more vulnerable and at risk to mental health problems than at any other time. Children were found to have a great fear of war as a looming holocaust they understood to be "hanging over their heads". These children were fretful, anxious, moody and depressed in response to the prospect of the imminent conflict. They reported nightmares and stress, and the report stated that 40 percent did not think that life was worth living.
So what might be the challenges for health services in the wake of regime change? I suggest one major challenge will be that some people in dire need of help and support may never be found. Others may fear being hospitalised against their will if they are found by government authorities to be upset or depressed. This is partly based upon a perception or previous experience of management procedures in Iraq for people who are mentally distressed, or the way in which the treatment of mental ill health is portrayed in the media or popular cinema.
For others there may be even greater challenges when deep inner emotional and spiritual conflicts emerge. This comes into play when certain religious or cultural beliefs or values, which are protective in other circumstances, break down leaving the individual with an overwhelming sense of failure. People who feel this sense of failure are often reticent or ashamed to seek help. In other instances personal hardship may be seen as a way of life with the conditions of mental distress or thoughts of self-harm accepted as fate or destiny. This last point may contribute to some Iraqis assuming the care of vulnerable relatives or individuals, sometimes at a cost to their own health and wellbeing.
These barriers can only be overcome if health professionals and service planners are willing to be innovative and to consult with and listen to the Iraqi people.
In the theatre of war it is the high impact injuries that most often find centre stage - the impact of bullets and bombs are necessarily more immediate priorities. However, it would be misguided to underestimate the long-term impacts of mental ill health, stress, post-traumatic stress and the many other mind impacts of war. In what has been an "I did it my way" war it will not be good enough in the short or long term to impose community and mental health support from this perspective.
As occupying forces dealing with the aftermath of war, one of our goals must be to empower the newly defined Iraqi community.
A sense of belonging to an emerging newly shaped community and being supported by that community will contribute in a positive way to vulnerable people's resilience during times of crisis.
In meeting this goal we will have gone a long way to building partnerships between the Iraqi people, community supports and local health services in a new era. We will also have gone a little way to helping them to heal their own psychological scars.
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