Maha Sulaiman Younis: A personal history of psychiatry in Iraq through war and conflict

The Iraqi government was first established at the end of the period of British occupation (1917–1921). During the subsequent years of political unrest between 1921 and the establishment of the fully independent Iraqi kingdom in 1932, many institutions have laid their foundations, such as the military, the ministry of education and higher educational institutions. Most notable was the establishment of the oldest medical school in the country, Baghdad Medical College. Baghdad Medical College was founded by a British military physician, Sir HC Sanderson, with the assistance from young Iraqi doctors. Shortly after, the first mental hospital (Dar Al-Shefaa) was founded in 1922 to provide custodial services to patients with severe mental illness and poor primitive healthcare. The modern concept of mental health service training and teaching was not introduced until 1934 by the pioneer Jewish psychiatrist, Dr. J Aboad.

The introduction of government-funded scholarships for training and specialisation in psychiatry abroad has increased the number of Iraqi psychiatrists; by 1940, the country had in total 15 specialised psychiatrists, which represented a ratio of 0.2 per 100,000 (Younis, 2009a).

In the following decades, efforts on establishing and developing mental health services had proliferated. This was represented in the establishment of the sizeable 1300-bed psychiatric hospital (Al-Rashad) in 1953 on the periphery of Baghdad, followed by another 70-bed psychiatric hospital (Ibn Rushd) for acute mental disorders (Younis, 2009b). In 1970, the mental health service in Iraq was augmented upon the establishment of the Iraqi Association of Neurologists and Psychiatrists.

The start of the Iran–Iraq war, 1980–1988, marked the beginning of the deterioration of psychiatric development in Iraq; the government scholarship programme to train Iraqi psychiatrists aboard was suspended, and the shortages in the health budget deprived many psychiatric centres of expansion and development. The availability of human resources declined because of the recruitment of many graduate doctors into military service. This decline in mental health care services worsened after the gulf war of 1991. The damage did not only stem from the violence of the short 40-day war but from the years of more severe comprehensive economic sanctions, 1990–2003, which had impacted the poorest segment of the population hardest.

The international sanctions imposed by the United Nations during this period had led to shortages of crucial medicines and brain drained the country of its most experienced psychiatrists. This has markedly disrupted the practice of psychiatry. The destruction of power and service stations, roads and bridges and telecommunications by the continuous bombardment from 17 to 22 February resulted in the paralysis of the healthcare system in general. The number of psychiatric attendees at outpatient clinics increased from 197,000 in 1990 to 220,000 in 1994 and further rose to 507,000 in 1998. The majority of whom suffered post-traumatic stress disorders (WHO, 2005, 2006). The total number of psychiatrists was around 108 in 2001 and dropped to 90 in 2003 (Younis, 2009b, 2008).

A significant blow to the mental health system occurred in March 2003 by the US-led military invasion and occupation of Iraq, when acts of violence, looting and vandalism lead to a new wave of brain drain (Burnham et al., 2006). Around 10% of the Iraqi population were estimated to be affected by psychiatric disorders (WHO, 2006).

The first time I encountered a patient with mental illness was in 1979. I was a fifth-year medical student at the Mosul University, attending my first clinical psychiatric session. During the session, I was introduced to electroconvulsive therapy (ECT). It was administered with intravenous diazepam to an agitated psychotic patient. My tutor, who was a pioneer female psychiatrist, asked: ‘How many of you wish to be a psychiatrist?’ None of us replied, Yes.

In Mosul Medical School, the psychiatric unit was established in the early 1960s by Dr. F Al-Dabbag, who was a pioneer psychiatrist in the city and later became the dean of Mosul Medical School. Through his efforts to develop a modern psychiatric department, he inspired several interns to choose psychiatry as a career. Some of them later secured government-funded scholarships to train in the United Kingdom and obtain FRCPsych (Younis, 2008).

Female doctors rarely pursued psychiatry specialty in Iraq (Younis et al., 2016). However, my tutor, Dr. Najat Al-Saffar, who was the first qualified female psychiatrist in Iraq, was fiercely dedicated to the profession. She inspired me early on to pursue it as a future specialisation.

I graduated from Mosul Medical College in 1981 at the start of the Iraq–Iran war, 1980–1988. As an intern, I witnessed the impact of war-related traumas on families. It is estimated that one million people in Iraq were dead, severely wounded, or imprisoned during this war. The conflict deprived Iraq of young working men, who were recruited for the war, including medical graduates and specialised doctors, some of whom spent 5 years in the military. The recruitment of young medical workforce to the army caused a profound shortage of men in hospitals, especially young doctors and, in turn, increased the workload on female doctors in the country. The newly imposed long duty hours on the interns mounted to 1 day off per week.

After completing the foundation year in three general hospitals in Baghdad in 1982, I was deployed by the Ministry of Health to work in the rural village of Kubaysah, Anbar province, 180 km west of Baghdad. This was in accordance with the Ministry of Health's regulation of deploying medical residents to work in rural areas for 1 year during their training as general practitioners. Kubaysah village was a natural habitat for jackals and hyenas. Their nightly yowling had caused me insomnia and distress. House amenities, that is, hot water, heating and cooling systems, were inadequate. I worked with two general practitioners in the rural outpatient clinic and was allowed one weekend off per month to travel to my family in Baghdad.

At the end of that year, when my time was nearing to return to Baghdad, I began to contemplate psychiatry as a career. On a surprise visit in 1983 by Iraq's Health Minister Dr. Sadiq Alwash to inspect the quality of healthcare centres in Anbar province, he expressed his admiration at our diligence and dedication to provide quality healthcare in Kubaysah. The commitment to quality service was echoed throughout the country despite the human and financial cost of the ongoing Iraq–Iran war. The World Health Organization (WHO) had acknowledged Iraq's healthcare system as one of the best in the Middle East region at the time (EMRO, 2006). Dr. Alwash asked what my future interest for specialisation and promised to consider my ambition for specialising in psychiatry in the United Kingdom, as part of the government-funded scholarships.

In Baghdad, Ibn Rushd leading mental hospital was founded by the Ministry of Health in Baghdad 1968 and contained 70 beds, including 12 beds for patients with substance misuse disorder. The hospital was adequately equipped and included a consultation clinic for treatment and follow-up. There was a unit specialised for child psychiatry. It also included a special team for modified ECT and a specialised department for social workers and psychologists. There was a special department for patients’ leisure activities and a pharmacy distributing free of charge medicines. There were 10 private rooms in total. By standards of the time in Iraq, this psychiatric hospital was a top-tier treatment centre. I joined Ibn Rushd Mental Hospital to start training in November 1983. On my first day of enrolment, I was disappointed when the administration gave me one of patient's private rooms to reside in, as the hospital only had a dormitory for male doctors. The director told me that I was the first female resident attending the hospital, and there were only four female psychiatrists in the country. I had no choice but to take this patient's residence for the first year.

The workload was distributed between one or two incumbent foundation doctors. The hospital regulation entailed only 1 day off per week. There were only five female and three male nurses serving the patients in the entire hospital. Two of the male nurses were exempted from army service because of their disability, where most male nurses in the country were enrolled for compulsory army service. The rest of the administrative staffs were all female employees with a few old male employees who were spared military service. We used the doctor's hall for inpatient consultation. There were three qualified consultants, who started the rounds early in the morning, accompanied by me, the resident doctor, the nurse, and the social worker. In the evening, I began the rounds with the resident doctor and the nurse. There was no outpatient service after hours, and the hospital administration was assigned to me.

The doctor's hall was used for meals, reading and television entertainment, which was restricted to displaying war news and political events. Our food was limited and rationed. I stayed in this hospital for a year; the last month, I was continuously on duty because the male interns were summoned to the army. I then complained to the manager for 1 day off to see my family, and he helped me by assigning one resident from the nearby OB/GYN hospital to cover my duties for only 12 hours during which I could visit my family. After a while, the Ibn Rushd Hospital had become my home. I stayed in the hospital throughout the week, enjoying my work with the patients and learning the skill of the profession.

At the end of 1984, I moved to Al-Yarmouk Teaching Hospital to continue my training in the psychiatric department for another year. I was happier there because of my private residence in the female doctors’ dormitory. The psychiatric unit had been established in 1977, built for patients psychiatric disorder. It contained 40 beds and an outpatient clinic, a pharmacy and a unit for modified ECT (Younis, 2008). There were four MRC Psych qualified consultants, one intern and myself as the only registrar.

At the end of 1985, I was transferred to Ba’qoba General Hospital in Diala province, 70 km east of Baghdad, where I worked as a psychiatric practitioner. After 2 years, I was assigned the role of a specialist psychiatrist. My daily work was in a walk-in psychiatric outpatient clinic with no night duty. Emergency cases were referred to the general hospital. I stayed there until the end of 1988 when the war finally stopped, and the ceasefire declared on 8 August 1988. I was overwhelmed, as everyone was, for this news. This represented the possibility of obtaining a qualification in psychiatry abroad as borders would open, and the government-imposed travel ban will be lifted.

The Ministry of Higher Education and Scientific Research founded the Iraqi Council for Medical Specializations (ICMS) in 1986 to start a national postgraduate training programme as an alternative strategy for overseas education. In October 1988, I joined the first batch of 10 trainees to obtain the degree of the Iraqi Fellowship (FICM Psych), the programme involved rotation in four teaching hospitals in Baghdad, and we were enthusiastic about being educated in this specialty. Our hospital duties became more scheduled and more organised with weekly seminars and tutorials, and I was assigned to edit a research work for the first time in my life (Al Jadiry et al., 1994).

After 2 years, Our training in this programme was disrupted by Iraq's invasion of Kuwait on 1 August 1990. A few days later, the United Nations Security Council (UNSC) imposed a comprehensive trade embargo on Iraq as a political punishment, which was a unique measure in its history (UNSC, 1995). A new wave of military recruitment started, and the travel ban was imposed again. The economic sanctions caused the severe collapse of the Iraqi currency, Iraqi Dinar, debasing the currency to 1/800th of its original value (The Harvard Study Team, 1991). The sanctions affected all sectors of life, in general, targeting the necessary needs of people, food and medicines (Al-Nasrawi, 2001). Our monthly wages had dropped to what would be equal to $1–2 US dollars at the time, 3000 Iraqi Dinars in 1991. People were struck economically, and there was a shortage of psychiatric drugs causing deterioration of the mental health system. Supply of new and imported psychiatric medications stopped, and the only source of medicines came through the state's drug factory, Sammeraa Drug Industry (SDI), with some donations from international organisations (Younis and Aswad, 2017). Because of the financial hardships, some consultant psychiatrists chose to leave Iraq for a better life elsewhere. The number of psychiatrists per general population dropped from 0.5/100,000 population before 1990 to 0.1/100,000 population in 1998. Furthermore, per 100,000 population, there were seven psychiatric beds in hospitals, 0.1 nurses and 0.02 psychologists and social workers (Okasha et al., 2012).

Psychiatrists were burdened by the resultant workload of an increased number of war traumatised patients. This is also reflected by the WHO reporting an increased number of attendees to the psychiatric clinics in the state hospitals from 197,000 patients in 1990 to 507,000 in 1998 (Okasha et al., 2012). In my study, the total number of patients attending the Neuropsychiatric Outpatient Clinic in the Medical City Teaching Hospital during the year 1993 was 10,200, which reflects a considerable number during sanction's years (Younis and Lafta, 2014).

On 17 January 1991, the US-led allied forces carried out a military invasion to expel the Iraqi army from Kuwait, killing an estimated number of 82,000 military and civilian personnel and destroying many infrastructure establishments: bridges, roads, power and water stations. Thus, the health system was severely affected. There was continuous bombardment on Baghdad and other governorates with an estimated total of 120,000 raids (Younis and Aswad, 2017). During this tumultuous time, I was reallocated to Ibn Rushd Hospital again, where I first trained for specialisation 8 years before. We were firmly instructed to stay inside the hospital to deal with all incoming emergencies. There was no electricity, and no telecommunication, food quality was poor and rationed. We received assistance from the International Committee of the Red Cross (ICRC) for food and medicine delivery.

Following the truce between the allied forces and the government officials on February 22, public uprisings began to erupt, which increased the chaos and human casualties (Younis, 2003a). I was struggling to concentrate on my studies and training under these insecure circumstances. However, only 2 months later, life became quiescent again, and the government began efforts to replenish hospitals; I was allowed to continue my postgraduate training at Al-Rashad long-stay mental hospital.

Al-Rashad Mental Hospital was established in 1953, containing 1300 beds; some 100 of them were for the detainees for forensic assessment (Younis, 2009b). Then I enrolled in the Neuropsychiatric Department in the Medical City Teaching Hospital for another 6 months. By then, I finished my training and obtained the fellowship (FICM Psych) in September 1992, I was appointed as a psychiatric specialist in my former hospital once more, Ibn Rushd Hospital.

In January 1995, I was elected to join the academic staff of Baghdad College of Medicine, and I was the first woman tutoring psychiatry in the college. I enjoyed my job, especially teaching medical students and doing my clinical practice in the department. I married a gynaecologist in 1994 and had two daughters.

In October 2000, I went to Cairo to attend examination of the Arab Board of Psychiatry, the journey proceeded through road travel to Jordan and then flight from Amman to Cairo, because air travel was banned in Iraq. I passed the examination and was awarded the degree (CABM Psych). I then rejoined my academic department and started research on the quality of life amongst college students in Iraq. I was then renowned by the university to be promoted to assistant professor in 2002 (Younis, 2003b).

On 21 March 2003, Iraq was invaded by the US-led allied forces, and the country was struck by bombardment, killing and injuring tens of thousands of military and civil personnel (Burnham et al., 2006; Sharma and Piachaud, 2011). During that extensive bombardment, I confined myself at home with my family, the most memorable times of this campaign was the first time we had seen invading US tank entering our street and stationed at our entrance. It was a hard time for my family and me to endure. Hospitals were closed except for emergency calls. We realised then that Baghdad had ‘fallen’ and the government was toppled.

There occurred a generalised disruption of law and order. The Iraqi forces were dismantled, creating a security vacuum. Following this, violence and armed conflict swept the country, taking away hundreds of thousands of lives. Vandalism, theft and kidnap prevailed in Baghdad and many other cities (Iraq Family Health Survey Study Group, 2008). Amongst the lost lives, there was an estimate of 140 doctors assassinated, including 5 psychiatrists (Younis, 2008; Al-Kinde, 2014). This situation cited many doctors leaving the country abroad, depriving the medical workforce in hospitals (Donaldson et al., 2012).

The situation of armed conflict and civil war continued for the following years. The high number of casualties had taken a toll on the health system's ability to cope. In one incident in June 2006, corpses were being transferred to the mortuary adjoining the medical college building where I worked; these bodies were left to be claimed by their relatives. A cut in electric power caused the fridges where the bodies were stored to stop working. The corpses rotted because of the lack of electricity, and the foul smell permeated through the college building. I was attending the student's examination in the lecture theatre, and all of us were suddenly made uncomfortable by this foul smell.

During this period, my brother, an eye surgeon, was kidnapped, along with two cousins of mine for ransom. I was overcome by stress and decided to leave Baghdad for a safer place. I travelled with my two children to Jordan on a road journey, leaving my husband to his duties behind. In Jordan, I worked as a senior lecturer in the psychiatric department at Jordan University of Science and Technology, attending the outpatient clinic and tutoring the fifth-year medical students 2006–2008.

At the end of 2008, the situation in Baghdad had relatively improved, and sectarian violence diminished; I returned to Baghdad, rejoining my academic department and organising my home back in order again. Psychiatric services in Iraq deteriorated after 2003 because of the brain drain and corruption (Calisi, 2013) but gradually improved again after the war and armed conflict stopped. The total number of patients attending the psychiatric outpatient clinic in the Medical City Teaching Hospital decreased to a minimum of 1,310 in 2003 compared to 10,200 and 2,979 patients in 1993 and 2010, respectively (Younis & Al-Nuaimi, 2006; Younis et al., 2013).

The most recent civil war against the Islamic State in Iraq and Syria (ISIS), 2014–2017, caused a tragic influx of wartraumatised patients and forcibly displaced families who needed psychiatric and social care (Horton, 2015). This created a need for re-organising women's mental health services because of the mounting number of widows and orphans, preferring women psychiatrists for cultural beliefs. The number of women psychiatrists increased from 8 (7%) of 110 psychiatrists in 2001 to 44 (29%) of 160 psychiatrists in 2014 in Iraq.

Owing to the increased number of female trainees enrolled in psychiatry, as I addressed in my published paper (Younis, 2015) selected as one of the top six psychiatry articles from around the web (Psychiatric Times, 2015), I was promoted to a professorship in 2012 after publishing 36 papers in local and international journals and attending about 40 local and international conferences as a speaker.

This biography has been a summary of my journey in psychiatric specialisation, from medical school to professorship. As I am nearing my retirement, I hope I have exemplified the model of woman psychiatrist to the younger generation of medical students in Iraq, and the dedication of providing high-quality healthcare during war and conflict. I hope I had paved the way for more women to enrol in psychiatry, both locally and internationally. Reflecting on personal history in scientific journals is always a positive and unusual way to motivate people to overcome life's difficulties in achieving their goals (Bhugra, 2019).