HUMANITIES | ENCOUNTERS Yousef’s story n Cite as: CMAJ 2018 August 13;190:E962-3. doi: 10.1503/cmaj.180131 CMAJ Podcasts: audio reading at https://soundcloud.com/cmajpodcasts/180131-enc This is Yousef’s story. He is an 11-year-old boy whose life has changed forever. In 2015, he was the innocent casualty of a mustard gas bomb shell attack while at home with his family in Mosul, Iraq. This narrative describes the details of his tragedy and explains how I came to know his story while working as a physician providing humani- tarian aid in northern Iraq. Yousef has suf- fered terrible sequelae as a result of that bomb, including severe keloid scarring that has resulted in gross disfigurement. The mental anguish of such scarring at that age dominates his physical defacement, and it has pushed him to attempt to take his own life multiple times. Through the privilege of caring for Yousef, I have become aware of the all-too-prevalent use of chemical agents of war in this part of the world, which is unknown to most Westerners. The unac- ceptable consequences for innocent people of exposure to such chemical gases reminds us once again of the urgency to enforce the international treaties that have been signed for an effective termination of the use of chemical weapons for good. The motivation for governments to do so lies in the powerful Tony Bruno among every nation’s people making this a A description of a shelling and the nature of Yousef’s injury led the author to suspect mustard gas global priority. was involved. Sulaymaniyah, Iraqi trict in September 2015. Yousef’s mother The images of Yousef stayed with me Kurdistan, Dec. 5, 2017 brought him to the clinic in August 2017 for days — they would not leave my mind. and explained that Yousef had been Finally, I tracked down his mother, now have just passed the halfway point of sprayed with “unignited kerosene” during back in Mosul, and set up a second inter- a six-month humanitarian mission in the shelling. She assumed that the unig- view by phone. I prepared a set of ques- Kurdistan. My role here is to help nited kerosene had caused her son’s tions and the interview lasted about an Isupervise and instruct Iraqi physicians burns — not the blast itself. hour. My hope was to be sufficiently dili- who care for about 25 000 internally dis- I reviewed the case three weeks later gent and objective to determine the most placed people and refugees in various and quickly began to have doubts that likely cause of Yousef’s burns. Needless camps in the region. unignited kerosene could have burned to say, recounting the attack was During mission handover, a colleague him to any substantial extent unless there extremely difficult for Yousef’s mother. told me about Yousef: an 11-year-old boy was prolonged exposure. After seeing Certain questions led to prolonged with substantial keloid scarring — a result photographs of Yousef, things did not silences — at certain points, she began to of the artillery shelling by ISIL, also known make sense to me. I felt we were missing cry. We paused, then I pressed on, as deli- as ISIS or Daesh, in Mosul’s Wadi Hajar dis- something. cately as I could. E962 CMAJ | AUGUST 13, 2018 | VOLUME 190 | ISSUE 32 © 2018 Joule Inc. or its licensors She explained that Yousef had been the ing World War I were attributed to chemical ers trying to profit from it as it is littered with weapons, yet the Great War has become synony- HUMANITIES only person at the far end of the room landmines. There is gain for those in power mous with their use. The current conflict in Syria when the artillery shell struck and the wall and Iraq depicts a similar picture. ISIL employs a to keep the population poor, ignorant and crumbled right in front of him. Soon the morbidly brilliant psychological warfare, and dependent. And, despite suffering beyond entire family was gasping for air, and those chemical weapons are the ultimate psycho- what most of us can even fathom, these peo- 4 more severely affected vomited. Outside, logical weapon against all their enemies. ple still hope for prosperity and peace one clouds of yellow smoke rose from the earth day. Yousef’s story was simply my awaken- and were carried downwind. Within min- Groups such as the Organization for the ing. It privileged me with spiritual growth. I utes, the family’s eyes began to burn, and Prohibition of Chemical Weapons, a United have been unshackled from the emotional they all lost their vision for hours. Nations chemical weapons watchdog, look apathy that I previously possessed, and from This description — combined with the on helplessly as these attacks continue. my prejudices. I observe with an altered eye photographs of Yousef — led me to believe Public or political pressure is not going to and listen with an unfamiliar ear these days. that the artillery shell was filled with mus- work on ISIL. And if we consider the horrific This is the magic of missionary work. The tard gas. The cutaneous manifestations chemical weapons attacks by Syrian presi- transformation comes within the journey, that mustard gas may cause include, but dent Bashar al-Assad on his own citizens — whether it is felt or not. are not limited to, skin burning and scar- all with the support of larger, well-known The heartbreaking twist to Yousef’s ring. A moist environment tends to pro- political entities — we find that the West- story is that the extensive scarring on his mote the development of these phenom- ern countries, including Canada, are doing neck has made him the target of teasing by ena. In keeping with this theory, Yousef little to stop these atrocities. We seem to other children. The anguish this has caused had keloid scarring predominantly on his have “a willingness to tolerate the morally him cannot be overstated — Yousef has neck, bilateral axilla and groin region — intolerable.”5 attempted suicide three times. The ques- areas predisposed to sweating. I admit, before my arrival, I had only a tion remains: Will he try again before we However, even with this new evidence, vague notion about what was going on in can get him the help he needs? part of me still refused to accept that Yousef this part of the world. I do not think I am and his family could be victims of a mustard alone in admitting that. If I had come Tony Bruno MD MSc gas attack. I suppose denial was easier on across these images of Yousef while in Can- Iraqi Kurdistan my heart. But even a cursory Internet search ada, I would have been horrified, of course, will confirm that Islamic militants have used but for how long? Probably a few minutes. mustard gas on any number of occasions in Then right back to my day. It is a defence References recent years. On Nov. 21 2016, The New York mechanism. It is easier. 1. Schmitt E. ISIS used chemical arms at least Times reported that ISIL had “used chem- Even being here now, I find myself trying 52 times in Syria and Iraq, report says. The New ical weapons, including chlorine and mus- to keep my emotional distance. Once again: York Times [New York]. Available: www.nytimes. com/2016/11/21/world/middleeast/isis-chemical tard agents, at least 52 times on the battle- self-preservation. Of course, it is a balance. A -weapons-syria-iraq-mosul.html (accessed 2016 field in Syria and Iraq since it had swept to friend of mine recommended that I listen to a Nov. 21). power in 2014.”1 Moreover, “at least 19 of TED Talk by Joan Halifax, who is a Buddhist 2. Chulove M. “My body was burning”: survivors recall 6 horror of Isis mustard gas attack. The Guardian the 52 chemical attacks had taken place in nun. She points out that the way to deal [London (UK)]. Available: www.theguardian.com/ and around Mosul.” with life’s horrors is not by turning away but world/2015/sep/02/syria-mustard-gas-attack-my On Sept. 2, 2015, The Guardian reported by acquiring great strength to leave behind -body-was-burning (accessed 2015 Sept. 2). 3. Van Bergen L. Before My Helpless sight: suffering, on a mustard gas attack by ISIL in Marea, mere pity (which is more about yourself) and dying and military medicine on the Western front, Syria.2 Before readers can scroll through aspire to true compassion. She continues: 1914–1918. Farnham (UK): Ashgate Publishing: the article, they find in bold type: “Warning: 2009;184. In Buddhism, we say, “It takes a strong back and 4. de Bretton-Gordon H. Remembering Halabja this article contains graphic images of inju- chemical attack. Al Jazeera [Doha (Qatar)]. Avail- a soft front.” It takes tremendous strength of the ries caused by mustard gas.” A photograph able: www.aljazeera.com/indepth/opinion back to uphold yourself in the midst of [trying] shows blistering on the back of 31-year-old /2016/03/remembering-halabja-chemical-attack conditions. And that is the quality of mental -1603160612 21074.html (accessed 2016 Mar. 16). Ahmed Latouf — certain patterns are equanimity. But it also takes a soft front — the 5. Geras N. The contract of mutual indifference: political uncannily similar to the scarring patterns capacity to really be open to the world as it is, to philosophy after the Holocaust. Brooklyn (NY): Verso found on Yousef. One photograph could have an undefended heart.6 Books;1998:170.