Iraq and Mental Health Policy: a Post Invasion Analysis Intervention 2011,Volume 9, Number 3, Page 332 - 344

Iraq and mental health policy: a post invasion analysis Intervention 2011,Volume 9, Number 3, Page 332 - 344

Iraq and mental health policy: a post invasion analysis

Sonali Sharma & Jack Piachaud

The Iraq war, and the subsequent involvement of are estimated to be in Iraq (UNHCR, 2011). various stakeholders in the post con£ict reconstruc- In addition, almost 50% of the total Iraqi tion of the health sector, presented an opportunity population is comprised of those below to learn about mental health policy development, 18years of age, posinga signi¢cant challenge challengesandobstacleswithin apost con£ict context for policy on mental health. Although the in 2003.This paper documents and explores mental overall impact is unknown, the increased health policy in post invasion Iraq, using qualitative mental health burden is high, and demands methodsand a healthpolicyframeworkthat analyses that mental health policymakers adequately context, content and process. Findings indicate that respond to the crisis. there are many challenges, both in repairing an In order to better understand the experi- already weakened health sector, and in maintaining ences faced in the Iraqi context, and to con- mental health as a health priority. In addition to tribute to the dialogue on best practice security issues, fragmentation of power, change of guidelines for other states in transition, this leadership and lack of funding pose signi¢cant pro- paper will examine mental health policy blems. Achievements are evident, though insu⁄cient development in post invasion Iraq. to address the overall mental health burden. The policy process is examined over a four-year period. Methodology Lessons learned are presented as best practice guide- Because the study was initially conducted in lines for post con£ict mental health reconstruction. the autumn of 2007, the period selected for review was 2003 to 2007. For this period, a Keywords: con£ict, Iraq, mental health retrospective qualitative case study method- and complex emergencies, mental health ology was utilised (an intensive analysis of policy, post con£ict reconstruction, war a process which took place in the past using qualitative methods to study it), supported by literature reviews and key informant Introduction interviews, in order to gather data. Over 40 More than 30 years of an oppressive regime, documents from scienti¢c and peer- and the ensuing war in 2003, have devas- reviewed journals, newspapers, various tated Iraqi society and imposed a large pub- institutions (including the World Health lic mental health crisis on the population. Organization (WHO), the U.S. Substance Forced migration of over four million Abuse and Mental Health Services Admin- people, pervasive human rights abuses, and istration (SAMHSA), key nongovernmental years of daily violence since the 2003 inva- organisations (NGOs) such as Medact, and sion, have taken a toll, both on the individual donors, mental health institutions, academic and on the society. Approximately 1.3 institutions and unpublished ‘grey’ policy million internally displaced persons (IDPs) documents were collected and analysed. A

select group of international and Iraqi Stockwell et al.,2005).The frameworkorgan- experts were surveyed, all with experience, isesthematic content into four areas: context, either directly in Iraq or indirectly with post actors, content of policy, and process, and con£ict health reconstruction in low and speci¢cally examines the interaction middle income countries. A snowballing between these four areas. This paper is technique identi¢ed potential interviewees. organised into two sections on context and Of 35 people contacted, 21 responded content/process. The authors utilised this (60%) and were interviewed over a six-week methodology as a means to better under- period in August^September 2007, either stand various in£uences and factors in men- by telephone, or in person where possible. tal health policy development, post invasion. Interviews were conducted in English, using Because this paper was submitted a few years a semi-structured interview tool with 20 after the key informant interviews took open-ended questions divided among the fol- place, an additional review of the literature lowing topics: drivers and in£uences of men- was conducted to analyse the period since tal health policy, planning of services, 2007, in order to have a more comprehensive achievements in mental health, obstacles to and updated view. However, due to budget mental health reform, e¡ect of the war on and time constraints, follow-up interviews the mental health burden, and the role of of respondents were not conducted, and NGOs and other stakeholders. Of the 21 therefore not incorporated into the policy respondents, the group consisted of ¢ve civil analysis. society leaders in mental health service delivery, seven senior experts in policymak- Ethical considerations ing for mental health service delivery, and A description of this project, and a request nine mental health professionals, both from for informed consent, were sent by email to within and outside of Iraq, across six all respondents. Those in insecure environ- countries. Only three of these respondents ments with no internet access were briefed were located (at the time of the study) in about the project by telephone. Personal Iraq, due to security issues. Consumers were information was not collected on partici- contacted, but all declined to participate pants, and all information obtained from due to personal security issues. Data interviews was anonymous, unless otherwise obtained from key informant interviews speci¢ed in the report. For participant pro- was cross-referenced, and substantiated by tection, no protocol approval was needed written literature to ensure accuracy. for this study. Methodology for data analysis consisted of thematic analysis on interview content, grey Limitations of our analyses policy documents, and literature reviewed Limitations of the analysis include lack of usingWalt’s analysis (Walt,1994) as a frame- consumers interviewed due to security issues work for mental health policy analysis.Walt’s and language barrier, under-representation analysis was chosen due to its framing of of Iraq-based respondents due to insecurity health policy within an economic and and poor access to communication, exclu- political perspective in low and middle sion of those who did not speak English; pre- income countries and its use across various dominance of senior leaders and sta¡ countries and areas of health, including rather than mid-level respondents; and mental health (De Vries & Klazinga, 2006; exclusion of those in insecure environments

333 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Iraq and mental health policy: a post invasion analysis Intervention 2011,Volume 9, Number 3, Page 332 - 344

or with poor access to telecommunications. Further con£ict ensued with the Iran/Iraq In addition, observations by respondents war from 1980 to 1988, the invasion by Iraq are based on the period between 2003 and into Kuwait in1990 and1991,and subsequent 2007 and therefore this study does not UN sanctions due to the invasion of Kuwait. examine interviewee observations on Oil revenues, which had generously ¢nanced changes in policy after 2007. much of the social services in Iraq through the 1970s, ceased and health care costs were Background and context of no longer met. The UN Oil for Food Pro- mental health policy gramme began in1996 in response to the cri- development sis, and required that two thirds of oil Following a bloodless military coup in 1968, proceeds were earmarked for humanitarian the Ba’athists came to power in Iraq for needs (UN, 2010). almost four decades of totalitarian rule. By 20 March 2003, when the invasion began, Human rights abuses such as torture, assassi- both from a socio-political and economic nations, disappearances, detentions, forced point of view, the region had weakened. As conscription, and amputations were perva- the invasion proceeded, further destruction sive during this period (Amowitz et al., took place, and internal displacement wor- 2004). sened with 402,000 persons displaced from Although Iraq initially prospered under 2003 to 2005 (IOM, 2007), and another 1.6 Saddam’s rule, the economy and civil society million after a shrine bombing in Samarra weakened with increasing militarisation of (ReliefWeb, 2008) (Table 1). the country. Military expenditure rose from In the1960sand1970s, the health care system 19.4% of GDP in 1975, to 38.4% in 1985, £ourished and was a model for the region peaking at 70.1% in 1981 (Al-Khalil,1989). with mental health services well serving

Table 1. General country information ^ Iraq Geographical area 440,000 square km

Population 30.01million (2008) Population growth rate 2.2% (average over 2005^2010) Population aged 0 to 14 years 41.1% (2009) Main languages Arabic, Kurdish,Turkmens Number of governorates 18 Main religions Muslim 97% Christian, or other 3% Ethnic groups Arab 75^80% Kurdish 15^20% Turkmens, Assyrian, or other 5% Socio-economic: Lower middle income group (World Bank criteria) GDP USD $40.66 billion (2006) Life expectancy at birth 59.1years for males, 63.1years for females Literacy rates 54.9% men, 23.3% women Country Information on Iraq (CIA, 2010). Health care system prior to the 2003 invasion.

the population (Sadik & Al-Jadiry, 2006). unknown, due to scarcity of data on Good access to roads, sanitation, water, psychiatric epidemiology. transportation and communications sup- When the invasion occurred in 2003, the ported the health care system. The health mental health care system was already care system penetrated both urban and rural severely constrained in regard to public populations, providing access to 97% and resources and human capital, and limited 79% of Iraqis respectively, before 1991 in its capacity to meet the demands ahead (WHO, 2005). Infant mortality rates were (Table 2). low. Health care was ¢nanced through the government, with services free of charge to Socio-cultural context the public. The stigma attached to mental disorders has The Iran/Iraq war, and the invasion into remained consistent over time in Iraq. Con- KuwaitbyIraq,increasinglyconstrainedpub- text analysis reveals: 1) the large degree of lic spending on health care, and by 1991total stigma leads users to seek care from primary expenditure on health had declined, health care doctors, internists and neurologists, care indicators worsened and health infra- rather than psychiatrists; 2) most users of structure had deteriorated. Health expendi- the mental health care system are primarily ture plummeted from 3.72% of the GDP, the severely mentally ill; 3) there is great before the 1990s, to 0.81% of the GDP after reliance on local religious and cultural heal- 1997 (Iraq MoH,2004).Infantmortality rates ers for assistance; and 4) family and commu- increased in the 1990s, with estimates of nities, rather than the system of care, often 500,000 child deaths (Lehmann,2004). assume responsibility for treating mental ill- In 1997, the system changed from a govern- ness. Furthermore, according to Sadik ment funded scheme to a self-¢nancing sys- (2010), negative attitudes towards treatment, tem in which the cost of care is shifted to work, marriage and recovery from mental the patient. Free health care ceased to the illness impact the degree of social inclusion, public (WHO, 2005). Despite hospital own- despite the fact that most of the Iraqi public ership by the Ministry of Health, health care understand the scienti¢c underpinning of became increasingly privatised. mental disorders. According to aWHO report (2003),‘rural life Mental health system prior to the 2003 invasion in Iraqisstrongly in£uencedbytribaltraditions,long Mental health in Iraq during the Ba’athist held norms and religious teachings.’Iraqi civilians period was a hospital-based, public model often seek assistance from local and religious with an emphasis on long term institutional healers as the ¢rst point of contact. Coordi- care. The government initially ¢nanced nation is poor between traditional and mental health care until the self-¢nancing allopathic systems. system was introduced in 1997. Many practitioners were forced into the private system, The mental health system post 2003 invasion or £ed as funding declined. Sincethe2003invasionofIraq,theexactmen- Mental health care was a low priority on the talhealthburdenisunknown.Lifetimepreva- health agenda. Outside of the hospital-based lence of any mental disorder is reported at system of care, psychiatrists had limited 18.8% (Alhasnawi et al., 2009). High rates of in£uence on national policy.The total men- anxiety, depression and posttraumatic stress tal health care burden prior to 2003 is syndrome (PTSD) (Hussein & Sa’adoon,

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Table 2. History of Mental Health Services:Timeline (pre) 2003 705 AD First mental hospital in the world established in Baghdad 1927 Baghdad Medical School established and modelled on UK system Early1950’s Mental health services established in Iraq with two psychiatric hospitals established, both in Baghdad; Al-Rashad Hospital, a 1,200 bed chronic care facility and Al-Rashid Hospital (now Ibn-Rushid Hospital), a 74 bed facility for acute psychiatric care 1960s^1970s Establishment of mental health centres and mental health units in hospitals, school mental health programmes and mental health promotion e¡orts 1980s to 2003 Wars and UN imposed sanctions; General decline in health services, many psychiatrists and other doctors £ee Iraq, plans for mental health strategies blocked by regime in power 2003 (pre) invasion A few weeks before the war in 2003, ex-regime released convicted forensic prisoners (people with mental disorder who were in jail) into streets Immediately post invasion, 2003 Violence, looting, and destruction of health infrastructure further undermines health services; Al-Rashid Hospital, the 1,200 bed chronic care psychiatric facility, was hit particularly hard Many international NGOs entered the scene out of goodwill to assist with humanitarian needs From: Sadik & Al-Jadiry,2006; U.S. SubstanceAbuse and Mental Health Services Administration (SAMHSA),2005.

2006; WHO, 2007) are documented. Among poor border control), weak oversight of children, 47% experienced traumatic events pharmaceutical system resulting in a high from 2004^2006 (Razokhi et al., 2006) and rate of prescription drug abuse (Aqrawi & highexposurelevelstotraumaticeventscorre- Humphreys, 2009). Opiates are widely used. late with mental, behavioural and emotional Cocaine and cannabis are also available. issues, with prevalence rates of 10^30% for Alcohol, although historically banned, is on posttraumatic stress disorder (Dimitry,2011). the rise as well. In Mosul, 37.4% of children and adolescents Thementalhealthsystemremainstwo-tiered, in primary care centres were found to have with 92% of psychiatrists working both in mental disorders (Al-Jawadi, 2007). Suicide publicandprivateservices,2%ingovernment rates among young women in Kurdistan are only, and 5% solely in private practice increasing.Substanceabusehasescalatedwith (WHO,2006).The public systemtransitioned lifetime prevalence at 0.9% (Al-Hasnawi from a self-¢nancing model to a centralised et al., 2009). Reasons cited include: con£ict, one. Fewer than 100 psychiatrists, and mini- economic strain, geographical location (bor- malancillarysta¡,servetheentirepopulation dering countries with high rates of abuse and of 27 million, or 1.6 professionals in mental

health facilities per 100,000 (WHO, 2006). and sectarian violence, lack of coordination, Multi-disciplinary practice is virtually non- competing models of mental health, corrup- existent. There is no social insurance and no tion, stigma and culture, posed grave di⁄- community residential facilities. The avail- culties in moving the agenda forward. Key ability of mental health services for children points, both with respect to content and pro- and adolescents is very limited (Al-Obaidi, cess, will be discussed below. Budosan & Je¡ery 2010). Most inpatient psychiatric treatment is for Political transitions challenging the mental health severe and persistent mental illness. Mood agenda disorders are treated on an outpatient basis. Political transitions of power within Iraq, A biomedical model of treatment is in use. from 2003 to 2007, a¡ected both the pace Mental health in primary care is limited. and timing of mental health policy develop- No support exists for consumer groups or ment after the invasion. The four phases of families (WHO, 2006). Medications are government: 1) Coalition Provisional frequently unavailable. Authority (CPA) post invasion in 2003; 2) U.S.-led Iraq Interim Government from 28 Mental health policy June 2004; 3) IraqTransitional Government development: content and from 3 May 2005; and 4) ¢rst elections on process post 2003 invasion 15 December 2005, leading to an Iraqi cabi- Theanalysisrevealsthatthecontentofmental net and a four year government in March health policy development remained fairly 2006; led to changes in leadership and lack constant over time, but the process was conti- of continuity of the mental health care nually challenged and thwarted by obstacles. agenda. The impact on government planning, action and policymaking is often an indirect con- Health and public mental health leadership sequence of con£ict (Ugalde et al.,2000). Varied leadership within the health sector Key components of mental health policy played a large role in both propagating and development in Iraq, post 2003, include: delaying a national strategy and imple- mentation of mental health policies. Lobbying, strategy and planning at the During the CPA’s tenure, power struggles Health Ministry level, between USAID and the Pentagon initially Prioritisation of mental health care onthe led to a quick change of health leadership health agenda, and delays. According to respondents, from Shift away from long term institutional the onset, there were missed opportunities, care towards public and primary mental poor health sector planning, and lack of post health care, con£ict and regional expertise among Equitable distribution of access to care, management of the CPA (Medact, 2008, Emphasis on capacity building, and Chandrasekaran, 2006). Reliance on international collaborations. The ¢rst Iraqi Interim Health Minister and the CPA declared mental health care a key The process of mental health policy develop- priority area in 2004 (Fleck, 2004). This ment depends strongly on the governing declaration led to speci¢c appointments, body in power, public mental health leader- committees and achievements within the ship, and foreign support. Security issues mental health care arena. The ¢rst mental

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health budget was written for US $2.5 has played an instrumental role in support- million, or 0.32% of the total health budget ing the Health Ministry, convening expert from the CPA(Jones et al.,2006).Funds were consultations in Cairo in 2003 and 2005, put into mental health care training, psy- and conducting epidemiological studies to chiatric units in hospitals, and site visits. better understand the mental health burden An Iraqi (expatriated) psychiatrist assumed (Alhasnawi et al., 2009).WHO and partner the ¢rst position of National Advisor in Men- agencies ensured that each Governorate tal Health in February 2004. International had a refurbished mental health centre. collaboration, inauguration of a National The U.S. SAMHSA collaborated with the Mental Health Council, and formulation of CPA in early 2004, prioritised mental health a comprehensive National Strategy ensued. on the health agenda, and mobilised By October 2004, a draft Mental Health SAMHSA resources (Curie, 2006). Act was submitted and approved by the SAMHSA took the lead in convening two Cabinet. Although limited in its content, it Action Planning Meetings in 2005 in put mental health care onthe map as an inte- Amman, Jordan (SAMHSA, 2006), and in gral public health priority. March 2006 in Cairo, Egypt (Benderly, After the one-year appointment of the 2006). A multi-agency Iraq Planning Group National Advisor, the hands of leadership was still in operation in 2007, with weekly changed again and signi¢cant e¡ort was conference calls and activities. required to keep mental health care on the In the United Kingdom, the Royal College agenda. High turnover of Health Ministers of Psychiatry convened an Iraq Sub-Com- from 2004 to 2007, further fragmented men- mittee in 2005, Annual Fringe Meetings tal health care policy e¡orts. The approved and a volunteer scheme to bring mid-career Mental Health Act was stalled. Receptivity level psychiatrists to Iraq for capacity build- was tested each time a new Health Minister ing. A delegation to Iraq’s Kurdistan region came into power, and mental health care took place in July 2007 and established a was not sustained as a consistent priority formal link between the Royal College over time. Volunteer Scheme and the Kurdistan The current Minister of Health, Salih Regional Governorate. Al-Hasnawi, is a psychiatrist and he has Many groups organised around the impend- maintained mental health care as a priority, ing demand for mental health care and psy- with a particular focus on integration of chosocial services. Disenfranchised Iraqis, mental health into primary care, as re£ected who had long standing concerns about the in the 2009^2011Health Strategy. health sector, saw the invasion as an opportunity to help their country in the absence International collaboration and the role of foreign of an oppressive regime.There was an oppor- in£uence tunity for free action that had not existed Immediately post invasion, there was an out- before. Iraqi psychiatrists in the UK estab- pouring of support and goodwill from the lished the Iraqi Mental Health Forum to international community and the Iraqi Dia- provide supervisory and technical assist- spora. The International Red Cross came ance, programme development expertise to the rescue of the Al-Rashad Hospital, and supervision to young providers in Iraq. which was looted and damaged following According to the nongovernmental organis- the invasion (Humaidi, 2006). The WHO ation (NGO), Coordination Committee on

Iraq (2007),80 international NGOs and 200 disciplinary teams, and links to community Iraqi NGOs were present as of 2007. A small based care (Humphreys & Sadik, 2006). proportion focused on mental health care. Furthermore, the Iraq Ministry of Health Unfortunately, many NGOs had to with- Strategy, 2009 ^ 2011, emphasises primary draw from Iraq, as a result of security issues, health care as a main priority, with mental including death threats and killings of those health care as one of the core initiatives (Iraq providing services. MoH, 2008). Capacity building through short term train- Special populations at high risk for develop- ing was conducted outside of Iraq in collab- ing mental health issues, such as refugees, oration with the UK, Kuwait and Jordan, IDPs, children, women, and the disabled, in 2004 and 2005. have speci¢c needs that shouldbe considered Financial contributions supplemented the in policy formulation for an appropriate Ministry of Health budget. In May of 2004, model of mental health care. Child and ado- Japan donated USD $6 million for mental lescent mental health care is virtually non- health care services. The CPA requested existent, for example, and advocacy e¡orts from Congress USD $850 million for health, aroundthese issues call for increased support with $100million earmarked for ambulatory and policy steps (Al-Obaidi, 2010). care (Gar¢eld, 2003). More recently, the Ministry of Health, with the support of Sectarian violence in the health sector USAID and IMC-Iraq, has been systemati- Respondents repeatedly cite security as the cally supporting the integration of mental major obstacle within the health sector. health care into primary care in 20% of Sectarian violence and discrimination by basic health facilities (Sadik et al., 2011). political a⁄liation are widely pervasive Because of the success of the programme throughout the health sector. Death threats and the in£uence of donors, the Ministry against doctors, kidnappings, extortion and will continue to fund and expand the pro- murders, posed a signi¢cant threat to the gramme to the rest of the country. healthworkforce. Of the 34,000 doctors regis- tered in Iraq before 2003, 17,000 £ed, 2,000 Competing models of mental health care were murdered and 250 were kidnapped In response to a survey question on models of (O’Hanlon & Campbell, 2007).The number mental health care, respondents indicated of psychiatrists is purported to be below 30 that competing models of care were a source for a population of 27 million. Postgraduate of power struggles within andbetween stake- quali¢cations and training programmes in holders. Health maintenance organisations psychiatry su¡er due to the severe shortage (HMOs), centralised and self-¢nancing of mental health professionals. models were considered. Policymakers Newspaper reports and respondents consist- endorsed reform and deinstitutionalisation ently allude to the Ministry of Health as a of the inpatient psychiatric hospital, Al sectarian monopoly, teeming with corrup- Rashad. In general, there was a lack of tion and involvement in alleged human emphasis on the existing Iraqi health infra- rights abuses. structure and using local capacity to rebuild the system. The consensus for Iraq’s model Corruption was a public mental health model with Mismanagement of funding and private an emphasis on primary care, multi- contracts thwarted reconstruction e¡orts.

339 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Iraq and mental health policy: a post invasion analysis Intervention 2011,Volume 9, Number 3, Page 332 - 344

Ine⁄cient use of fundsby private contractors survive changes in leadership. Lobbying has been well documented (Chatterjee, of ministers, politicalwill, a clear national 2007; U.S. Senate, 2006). Lack of transpar- mental health plan and budget, as well as ency, funding misappropriations and diver- support from the international com- sion of supplies to the black market are munity, can all aid in this process. The among the key issues contributing to further strategy should include activities such as: drains of the public system. integration of mental health care into primary care, building specialist mental Stigma of mental health health care, community-based mental The stigma attached to mental illness in health, and mental health promotion Iraqi society is a barrier to mental health and outreach activities. policy making. It in£uences the position of Coordinated mental health planning and pro- psychiatry within medicine, and a¡ects gramming is necessary using international demand for psychiatric services. guidelines (e.g. IASC, 2007) and a mini- mum set of activities immediately post Implications of culture invasion, in additionto rapid needs assess- Respondents stated that Iraqi culture is an ments, multi-disciplinary teams, strat- obstacle in reaching consensus, working on egies based on need, and ensuring that teamsandcollaboratingacrossethnicfactions. all stakeholders are coordinated and Political a⁄liation, past historical tensions working to support Ministry priorities. and the removal of Ba’ath party members Localcapacity,resourcesandknowledgeshouldbe from positions within the Iraqi government harnessed to formulate a system that meets after the invasion promulgated mistrust. cultural needs and regional demands. Further ethnographic research is needed to Post con£ict and regional experts should examine culture as an obstacle in detail. be consulted. Increased collaboration with the traditional community will Policy recommendations enhance access and early identi¢cation. Policy recommendations can be elucidated Improved governance and management is recom- from this analysis in post invasion Iraq, con- mended, notonly for mental health o⁄cers, sistent with international guidelines and but also for the overall health sector. Gov- expert opinion. Presented below are a series ernment performance standards, of recommendations for post con£ict mental improved accountability and increased health care, taking into consideration the transparency measures should be put into context, content and process of policy devel- place to the extent possible. opment in Iraq. The mental health workforceshould beexpanded so that mental health services are maximally Security is the ¢rst priority in ensuring sound scaledup.Targeting primarycareproviders policy development. Insecurity fragmen- to identify, treat and refer persons with ted the process in Iraq, and constantly mentaldisorderswillprovide directaccess posed a challenge. to a great number of people. Workforce Mentalhealthcareshouldbeanintegratedpartof expansion should include mental health theoverallhealthstrategyand focusedonpub- training for primary care providers and lic mental health. A sustainable mental support sta¡, including: psychologists, health care strategy is required that will clinical social workers, psychiatric nurses,

midwives and paraprofessionals. Clinical to promote an environment of teamwork, psychiatrists can contribute by transition- collaboration and trust. ing their role fromclinicalworktotraining The use of global networks and international and building capacity of basic service pro- expertise can be harnessed in resource poor viders. Capacity building with clinical settings, however, in good coordination supervision should be the role of specialist with the new government in power. teams. If capacity is limited, policymakers Links should be made with religious and must be creative with local, regional or traditionalhealers. Capacitybuilding, invol- international expert supervisory teams. vement in stakeholder meetings and edu- Coordination with other Ministries to cation are some of the recommended makeaninvestmentineducation,integrate activities among community leaders mental health into pre service and in ser- and healers. vice training curricula, and to provide The recommendations above are speci¢c to research opportunities, is recommended. this analysis of Iraq, and are also in line with Investment from within the country is essential. expert opinion and international guidelines. Transitional governments should enable This study demonstrates the di⁄culties of and support local leadership, facilitate mental health policy development in a external experts working in conjunction fragile state, but also highlights that progress withlocalexpertise,andharnessavailable can occur with a core set of activities and resources within the country to promote priorities. It is the author’s hope that this the most culturally sensitive and appro- analysis will provide insight to policymakers priate solutions. and practitioners in post con£ict settings, E¡orts to reduce stigma, and a focus on mental and contribute to the development of mental health advocacy, should be integral to the overall health care in the most vulnerable settings. health promotion strategy. This can be achieved through mass media edu- Acknowledgements cational campaigns, awareness-raising This analysis was ﬁnancially supported by a activities, emphasis on primary health research honorarium, the Perry Award, received care and education and links with com- through the Psychiatry Residency programme munity stakeholders. Advocacy for men- of Cornell University’s Payne Whitney Clinic at tal health care should come from all New York Hospital in 2008, and in part through sectors, and should focus on human rights. Medact [www.medact.org] in the UK. Development of consumer groups and This paper is dedicated to the late Jack family/caretaker coalitions can be advan- Piachaud, and could not have been written with- tageous in providing support. out the guidance of Marion Birch (Medact), Mental health care includes not only treatment of Vikram Patel (who introduced me to Jack), people with mental disorders, but also a deeper participating respondents, the Iraqi Diaspora, understandingof localrisk and protectivefactors, and Dr. David Hamburg (for his invaluable and the development of targeted com- mentorship). munity and psychosocial interventions. Although cited speci¢c to the Iraqi con- References text, the culture of hierarchy within medicine Alhasnawi S., Sadik S., Rasheed M., Baban A., and across all disciplines relevant to Al-Alak M.M., Othman A.Y., Othman Y., health and wellbeing must be addressed Ismet N., Shawani O., Murthy S., Aljadiry

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