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SAMHSA News - January/February 2005, Volume 13, Number 1

Across Borders: Rebuilding Iraq

In 1979, Sabah Sadik, MBCHB, FRCPsych, DPM, a doctor with 3 years of experience in general practice and 1 year in psychiatry, left his native country of Iraq. Twenty-five years later, in December 2003, he returned to visit relatives in Najaf, 100 miles south of Baghdad. What he saw saddened him profoundly, and he resolved to do all he could to assist in restoring mental health and rebuilding the country's mental health service system.

Three months later, Dr. Sadik was appointed National Advisor for Mental Health to the Iraqi Ministry of Health.

photo of (left to right) Jim Haveman, SAMHSA Administrator Charles Curie; Dr. Sabah Sadik, and Jon Wilkes
Members of the planning group met in December at SAMHSA. (L to R) Jim Haveman, who served as Senior Advisor to Iraq's Coalition Provisional Authority; SAMHSA Administrator Charles Curie; Dr. Sabah Sadik, National Mental Health Advisor, Iraq; and Jon Wilkes, West Kent Trust, England.

This past December, Dr. Sadik attended a meeting of the Planning Group on Iraq Mental Health, chaired by SAMHSA as part of its commitment to help rebuild Iraq's health care system for mental and addictive disorders. In addition to SAMHSA staff,
Dr. Sadik, and other Iraqi officials, the ongoing planning group includes representatives from the National Institute of Mental Health at the National Institutes of Health, the U.S. Department of Defense, and the U.S. Army.

Members of the planning group met in December at SAMHSA. (L to R) Jim Haveman, who served as Senior Advisor to Iraq's Coalition Provisional Authority; SAMHSA Administrator Charles Curie; Dr. Sabah Sadik, National Mental Health Advisor, Iraq; and Jon Wilkes, West Kent Trust, England.

The meeting built on the process initiated when SAMHSA Administrator Charles G. Curie, M.A., A.C.S.W., accompanied the U.S. Secretary of Health and Human Services on a visit to Iraq in February 2004 (See SAMHSA News, May/June 2004). The purpose of the meeting was to plan for an international conference in Amman, Jordan, on ways to strengthen Iraq's mental health system. At the meeting, Dr. Sadik discussed the work that he and colleagues from Iraq, England, and throughout the world have undertaken.

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Dr. Sadik described the deterioration of mental health services in the country since the mid-1980s, when an "exodus of psychiatrists" occurred "due to poor and intimidating working environments, shortages of medication, poor quality information systems, and a lack of access to up-to-date knowledge and education."

An initial tally of mental health staff in Iraq—a country with a population of roughly 25 million—produced just 154 psychiatrists, 20 clinical psychologists (of whom only 3 had appropriate training), 25 social workers (none of whom were trained in mental health), and 45 nurses (also not properly trained in mental health). The few existing mental health facilities had antiquated ECT machines over 20 years old and very limited medication.

In addition to these meager resources and the instability and shortages due to three disastrous wars, 12 years of international sanctions, and ongoing violence, Dr. Sadik noticed more insidious problems as well upon his return.

"Iraqi society changed during the previous regime," he said, "primarily correlated to the way the individual and communities have been oppressed. There is a noticeable lack of confidence in one's self and one's abilities, an indecisiveness, and a lack of initiative for fear of mistakes and fear of reprisals." He likened the phenomenon to that of refugees from concentration camps after World War II, suddenly liberated but simultaneously paralyzed by inaction.

Fortunately, Dr. Sadik said, he also found that "Iraqis quickly embrace new ideas and remain enthusiastic and willing to work on issues and services for the new country."

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Mental Health

Under Dr. Sadik's leadership, a National Council for Mental Health was formed with representatives from other government ministries as well as from mental health disciplines outside the government.

The National Council's first priority was to draft national plans for mental health. The plans are based on several underlying principles. The first is the concept of universal coverage of essential mental health care for the population.

The plans also emphasize primary care at the community level and integration of mental health care with general primary care services. This includes the establishment of mental health services in the 150 primary health centers to be built or renovated throughout the country. Dr. Sadik noted that currently, Iraq does not distinguish between primary and secondary health care, and yet primary health care providers are seeing many people with somatization, overt depression, and anxiety.

The plans address the following areas: primary care services (mental health services provided in the primary care setting); secondary care (traditional mental health services for persons with mental illnesses); mental health training and education/human resource development; building scientific programs and research capacity; and policies and support for mental health programs.

To decrease stigma and meet service needs, the plans include education efforts for members of the public and health care personnel. Community initiatives are encouraged by offering support to families and organizations. The plans urge more research on mental health problems in Iraq, as well as appropriate legislation and administrative structure to support the program.

Several efforts have already been launched. For example, for the last 20 years Iraq has lacked proper mental health legislation that would establish such things as a code of practice and relevant training standards. In October 2004, the Iraqi cabinet approved such a plan drafted by the National Council for Mental Health together with the Iraqi Ministry of Justice.

The National Council also has supported activities by Nongovernmental Organizations (NGOs) from several different countries. For example, an NGO from Italy, Movimondo, sponsored a project for children in Baghdad. The organization "Together," from Slovenia, sponsored a psychosocial support effort for children and families in Babylon. Diakonia of Sweden offered psychotherapy and services for children in Duhook, Erbil, and Suleymania.

Japan also ran a training course for 40 senior Iraqi nurses in Egypt in September and November 2004.

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Substance Abuse

Dr. Sadik said that there are indications of an emerging drug abuse problem in Iraq, although the exact extent is unclear due to the limited resources for monitoring the situation. He suggested several contributing factors, including the instability and lack of law enforcement coupled with a rapidly changing social and economic situation. Unemployment is prevalent, he said, especially among youth. The geographic location of Iraq, the lack of border controls, and the proximity to countries that traffic in opium and heroin, have also increased the availability of drugs, he added. Finally, he noted that thousands of criminals imprisoned during the previous period had been released.

"The previous regime claimed that there was no substance abuse problem in Iraq," said Dr. Sadik, "so people providing treatment had to work in secrecy." Because of this, there is an urgent need to build expertise and establish programs. Currently, substance abuse treatment in Iraq is limited mostly to detoxification and not rehabilitation.

A plan to address the issue of drug misuse was recently finalized in collaboration with the regional World Health Organization team. Five broad strategies guide the development of drug abuse services in Iraq:

  • Understand the dimension of the problem through surveys and rapid assessment studies.

  • Organize services and integrate them with general health care and community care services.

  • Develop human resources and provide needed training.

  • Launch prevention programs, especially in schools.

  • Provide administrative support.

Noting the similarities in strategies and principles, Dr. Sadik said, "Planning for both mental health and substance abuse services is proceeding hand in hand."

Looking to the future, he added, "I remain optimistic in spite of all the difficulties. The idea of returning to Iraq came out of love for the country and for the Iraqi people. The Iraqi population has been very resilient. I think a great asset to them has been the achievements of the past, and that it is possible to rebuild once there is stability, clear lines of accountability, and funding. Added to that, there is a great asset in the Iraqi professionals outside the country and what they can offer in terms of the process of cross-fertilization."

Speaking about his visit to the United States, Dr. Sadik added, "Seeing colleagues from various parts of the world who are committed to supporting Iraq and have worked so hard in putting ideas and proposals together has enhanced my hope. It says a lot about the goodwill that exists." End of Article

Key Elements of Iraq's Plans for Mental Health

  • Mental Health Services: primary, secondary, specialty care

  • Mental Health Training and Education

  • Scientific Programs and Research

  • Policies and Support for Mental Health Programs. End of Article

« See Also—Previous Article

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SAMHSA News - January/February 2005, Volume 13, Number 1

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