The next time excessive paperwork, difficult managed care negotiations, and uncertain funding streams make you feel that you have the hardest job in the world, consider the situation of your colleagues in another country. Approximately 75 psychiatrists are available to care for 26 million people. Group homes, Assertive Community Treatment teams, and community-based care exist neither in reality nor in concept. Needed medications are in short supply, and many psychiatric facilities are understaffed and dilapidated. Some of your colleagues have been threatened or targeted by kidnappers. Meanwhile, daily bombings and economic insecurity continue to undermine the mental health of a people who already have endured decades of dictatorship, wars, and economic sanctions. Welcome to today's Iraq.
It was not always like this. What were probably the world's first medical schools and mental hospitals were established in what is now Iraq by the Sumerian and Abbasid civilizations. More recently, in the 1960s and 1970s, some of the best healthcare (including psychiatric care) facilities and training in the region were available in Baghdad. This same period witnessed the development of mental health centers, public awareness programs, school-based programs, and psychiatric units in general hospitals. Until the beginning of the Iran-Iraq War in the 1980s, Iraq's spending on healthcare was on the upper end of nations in the developing world.
Saddam Hussein destroyed this healthcare system over the next two decades. He reduced healthcare spending to a third-world level for all persons not in his inner circle. He also undermined the confidence and skills of health professionals through intimidation, deprivation of control, and restrictions on travel and education. Many mental health professionals left the country; those that stayed saw their skills erode as their access to journals, conferences, continuing education, and colleagues was inexorably cut off.
Since the fall of the old regime, we have been privileged to work with a remarkable group of colleagues attempting to build quality mental health and addiction services in Iraq. One author (S.S.) was asked by the newly formed Iraqi government to serve as the lead mental health advisor to the Iraqi Ministry of Health in September 2003 and started extended work in Baghdad in March 2004 (after a preliminary visit in December 2003).
The other author (K.H.) joined the project in late 2004 as part of a growing network of professionals outside of Iraq who wished to aid the effort. Such individuals come from Italy, Slovenia, Sweden, the United Kingdom, and the United States; a number of them were born in and received some of their education in Iraq.
The international team's work has benefited from support from governments (e.g., a large donation from the government of Japan, as well as support for training from the U.S. Substance Abuse and Mental Health Services Administration, along with the Kent and Medway National Health Service and Social Care Partnership Trust in the United Kingdom). Professional societies (e.g., the U.K. Royal College of Psychiatrists and the American Psychiatric Association) also have provided support. And the team has benefited from strong collaborative relationships with the World Health Organization (WHO) and the World Bank.
Our work is coordinated through Iraq's National Council for Mental Health and Substance Abuse, which brings together representatives from a range of ministries to address mental health needs in the country. The challenges at the moment are, of course, considerable, not just because of the security situation but also because the mental health system was deprived of resources and of outside contact for several decades.
The current Iraqi mental health system has a “fly trapped in amber” quality, being like systems of another era in emphasizing long-term institutional care for many disorders and lacking developed mental health professionals outside of psychiatry, notably psychiatric nursing and clinical psychology. Furthermore, although the national formulary has been updated substantially since the fall of the old regime, the system suffers from a serious diversion problem, particularly for abuse-prone medications such as benzodiazepines and anticholinergics.
The vision we pursue might be called a “wrinkle in time” approach. Rather than upgrade the mental health system from a 1970s-style to a 1980s-style model, we hope to go directly into a primary care–oriented, public health–driven approach. In the United States in the 1980s, many specialty institutions for psychiatric and addiction care grew up independent of the rest of the healthcare system; many of us have spent the subsequent decades struggling to reintegrate them. Starting at that end point without the intervening period of uncoordinated silos of care would be a major achievement in Iraq.
Our colleagues in Iraq and around the world are striving to build a mental health system supported by a range of developed health professions (e.g., not just psychiatry), as well as strong alliances with educators, community groups, and religious groups. We also intend to overcome the former regime's policy of refusing to collect information on mental health by developing a modern patient record and epidemiologic database. As another sharp break from the policies of Saddam's regime, we have been offering advice on the development of compassionate laws concerning the treatment of mentally ill and addicted individuals.