An update on mental health services in Iraq

In the 1970s, Iraq made strides towards building a comprehensive, well-equipped health system free at the point of delivery. Medical education in Iraq was originally modelled on the British system and started with Baghdad Medical School in 1927. Two more medical schools were founded in Mosul and Basrah, providing Iraq with good numbers of high-calibre medical graduates. After 1968, several other medical schools were set up in various parts of Iraq, including three in Iraqi Kurdistan.

Psychiatry has not been a particularly popular speciality with trainees in Iraq, nor has mental health been well endowed by the Ministry of Health. None the less, in the 1970s there was a considerable expansion in the number of psychiatrists with higher qualifications (mainly MRCPsych) working both in the health service and the Iraqi military. However, given the greater resources of the military under Ba’athist rule, the psychiatrists with higher qualifications in the military outnumbered those in civilian mental health services. This major diversion of medical resources into largely non-therapeutic fields and into the service of state priorities was, of course, a feature of this regime in practically all walks of life and not limited to mental health.

The main centres of treatment for mental illness have essentially remained the same since the mid-1970s when I was a trainee in Iraq. With the exception of a number of essentially medical out-patient facilities in some of the general hospitals in Iraqi cities, which have little multi-disciplinary back-up and no community support, there has been practically no expansion of mental health services in Iraq since then. In contrast, the health services generally saw a major expansion in medical and surgical specialities and to some extent in primary health care services.

The major mental health facilities in Iraq are based in Baghdad, a city with a population of 5 million. Baghdad houses the old asylum (originally Al-Shammaiyya; later renamed Al-Rashad Hospital) with capacity for 1100 patients, as well as an acute 75-bedded psychiatric hospital (Ibn Rushd Hospital). In addition, there are some acute psychiatric beds at the main teaching hospital of Baghdad Medical School (formerly known as Saddam Medical City). One resource that has sadly disappeared is the Directorate of Mental Health, which was part of the Ministry of Health. This was set up by one of the founders of psychiatry in Iraq, Dr Ali Kamal, who was a respected teacher of the subject. He was a widely read academic and a champion of mental health services in Iraq. Although this directorate never achieved its promise and remained an oddly formed body without a clear remit or mandate, it was sad to see its demise following the death of its founder. Outside Baghdad, with the exception of Mosul and Basrah where there are some acute psychiatric beds, the remaining provinces have very little psychiatric resources. During my visit to Iraqi Kurdistan in 2000, there were small numbers of acute psychiatric beds in Sulaimaniyya and Arbil (each covering a district of over a million population), but none in Duhok (with a slightly smaller catchment population).

Following the recent war against the US and UK coalition forces and the fall of the Ba’ath regime, the mental health facilities in Baghdad suffered considerable damage. The Al-Rashad Hospital suffered particularly badly with organised looting leading to the dispersal of its inmates. There are tragic reports of kidnappings and rapes of female patients and the disappearance of scores of both male and female patients. Only 400–600 of the original 1100 patients have since returned. Ibn Rushd Hospital was also partly looted. However, by the time I visited it towards the end of July 2003, it had been re-equipped in some ways to a higher standard than before the war and work was already under way to make further improvements. Basic psychiatric drugs were also available. It was notable that the standard of accommodation and the fabric of the building had changed little from the 1970s. It was also sad to see that in certain ways the standard of care had declined compared with my resident days, with the withdrawal of anaesthetic services for electroconvulsive therapy.

During the 1990s and as a result of the effective bankruptcy of the Iraqi state following the disastrous wars against Iran (1980-1988) and Kuwait (1990-1991), the Iraqi government engaged in a rethink of its policy on health. The originally socialist principle of free health for all was scrapped in favour of a system of self-financing of individual hospitals. This effectively meant the wholesale privatisation of health service delivery, although the hospitals themselves remained the property of the Ministry of Health. Overnight, the health system was converted from a spending ministry into an income-generating enterprise. A largely corrupt system of incentives and payouts accompanied these developments, which created major inequalities in pay among doctors (for example, whereas consultants and medical directors in successful surgical units could expect to be paid hundreds or even thousands of US dollars a month, others working in units generating low income had to make do with US$ 20-30 a month). Nurses and ancillary staff received dismally low pay, sometimes not exceeding US$ 2-3 a month, creating the conditions for a system of informal payments by patients for any item of care they received. As a result of the self-financing initiative, low-income-generating specialities such as mental health suffered further neglect. Mental health services were not only out of favour with the regime's elite - who in any case preferred tribal and folk remedies to modern psychiatry - but also psychiatry was increasingly seen as a pointless burden with little scope for income generation, profiteering or corruption.

Until the early 1980s, Iraq enjoyed reasonably good links with postgraduate centres in Britain (and to a lesser extent the USA) in many medical specialities including psychiatry. However, most such links were severed with the advent of the Arab and Iraqi Board certification process. This qualification is modelled on the American Board model, but is only recognised by the Arab countries that subscribe to the programme. Effectively, however, for an Iraqi psychiatrist who holds the Arab or Iraqi Board certificate this qualification is only recognised within Iraq. This led to the increasing isolation of Iraqi psychiatrists (and doctors generally) from the international medical community. This isolation was later compounded by the economic sanctions that followed the invasion of Kuwait. Under sanctions doctors endured chronic shortages in reference books, medical journals and teaching aids as well as a lack of access to the Internet, which was severely restricted by the Ba’ath regime.

Since the fall of the Ba’ath regime, the pay scales of health service staff have undergone a major enhancement. My meetings with nurses and ancillary staff at Ibn Rushd Hospital showed that their salaries had significantly increased from their previously derisory levels. The new minimum salary was US$ 60–120 monthly, up from $2. Similarly, medical staff had experienced a significant increase in pay. I was told that the practice of expecting patients to pay staff for each item of service had already declined and there were moves to stop it completely. The morale of non-medical staff as a result had improved significantly. Although these rates of pay are still extremely low by international (and even regional) standards, they mean that staff can now at least buy the essentials for themselves and their families without resorting to ethically questionable means. However, for medical and other staff, improved morale due to better pay has been counter-balanced by worries and anxieties related to reduced security, especially during night shifts. Reports of hospital doctors being assaulted and kidnapped for ransom were circulating widely in Baghdad among the doctors I met.

A massive Iraqi diaspora has built up in many Western countries since the late 1970s. It amounts to several million people, among whom are many thousands of doctors. Some estimate that there are more Iraqi doctors outside Iraq than within it. It is quite possible that this is true for psychiatrists, but reliable figures are difficult to come by. The tyrannical nature of the Ba’ath regime, wars, economic sanctions and medical and academic isolation have all played a part in causing this disastrous exodus of medical and other talent. Many now hope that Iraq will have an historic opportunity, once security and basic services are established, to reverse this ‘brain drain’. Psychiatrists working within the Iraqi mental health services will find for the first time in decades that they are able to contact their colleagues abroad and establish professional and educational links without the interference of state security and government bureaucracy. However, even under ideal conditions it will take a decade or more for Iraqi psychiatry to recover to the point where it was a quarter of a century ago. Iraq was one of the pioneers of medical education in the Middle East and it is sad to see it fall so far behind its neighbours in nearly every area of medicine. One important message from the tragic Iraqi experience is: tyranny is bad for health.