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The crisis following the 2003 war in Iraq has had a major negative impact on Iraqi society. One of these adverse effects has been massive civilian displacement, both within and beyond the Iraqi borders. An estimated four million Iraqis, nearly 15% of the total population, have fled their homes; 50% of these refugees are children. Among these refugees are many highly qualified professionals and academics who have escaped death threats only to find that their qualifications are not accepted by authorities in the host countries (Giles, 2007).
High rates of mental health problems and a history of multiple traumatic experiences among Iraqis have been documented in the literature (Murthy, 2007). Iraqi refugees face additional challenges; for example, in Egypt, between 2003 and 2007, between 100,000 to 150,000 Iraqis resettled to Egypt (Colville, 2007), but they have no access to free governmental health services. Iraqi refugees in Egypt have to pay private fees for healthcare, with the exception of limited services provided by NGO’s, such as CARITAS, Catholic Relief Services, AMERA and Refugee Egypt. With few or no legal rights, and extreme economic hardship, life for Iraqi refugees is difficult. Children are usually out of school and parents struggle to find jobs to support their families. Moreover, the families are plagued by memories of violence. Mental health problems are ubiquitous. Under these difficult circumstances, concern is raised that the collective Iraqi trauma will continue and even intensify (AlObaidi, 2009).
Children who are refugees of war are exposed to traumatic stressors in premigration, flight, and resettlement that affect their psychological well-being and development. These stressors include direct exposure to war time violence and combat experience, displacement and loss of home, malnutrition, separation from caregivers, detention and torture, and a multitude of other traumatic circumstances that detrimentally affect children’s health, mental health and general well being (NCTSNET, 2005).
This article is a report of my experiences as an Iraqi child psychiatrist living in Egypt since 2007, seeing first hand mentally disturbed Iraqi refugee children and adults. Working in non-clinical settings, such as my private accommodation and public cafes and/or gardens, providing services at no cost on a volunteer basis, my family and I endeavoured to provide assistance and in the tradition of Iraqi hospitality the refreshment of courtesy, concern and often food and drinks.
The children we encountered, aged 3 to l8 years of age, were displaying diverse emotional and behavioural problems following exposure to war, violence and traumatic displacement experiences. We were involved in managing children with various complaints, including increased bedwetting, separation anxiety, obsessive compulsive anxiety (triggered or exacerbated by trauma), drug abuse and conduct problems. We observed that Iraqi refugees fleeing violence and instability in their home country often continued to face health and psychological challenges, including difficulties in accessing health services, little social support, and psychosocial problems.
Our management plan focused upon a behavioral and supportive approach, but with no medication. Psychoeducation and some behavioral techniques to control symptoms were implemented, in addition to family and parenting therapy. Group therapy was used with some youths to help them through their traumatic experiences and to increase their psychosocial awareness. In consultation with licensed Egyptian physicans, I occasionally recommended the use of psychotropic medications when appropriate for adults or children.
The topic of Iraqi refugee mental health has not been thoroughly researched in the seven years that have elapsed since 2003. The Iraqi mental health treatment has been disrupted and many Iraqi health and mental health professionals have been displaced mainly to countries nearby Iraq. The systems of care available to Iraqi refugees in host countries have been ill-prepared to provide even the basic level of coverage.
It is difficult for Iraqi health and mental health professionals to work with Iraqi refugees in foreign countries. However, it is still possible for them to use their training and abilities in non-formal ways to help their fellow expatriates. In circumstances of crisis and conflict, there is often a need to create short-term solutions to provide immediate assistance to affected people, for example by using informal settings and/or private houses to offer both clinical and educational services to the population in need (Jones & Shahini, 2004).
Humanitarian efforts are at times too narrowly focused and removed from the needs of the most needy and should be re-designed to provide some basic infrastructure to facilitate the mobilization of the expertise of the refugee Iraqi health and mental professionals to serve the dire needs of Iraqi refugees. Instead of costly and unsustainable direct professional help, humanitarian efforts should make efficient use of the refugee’s own expertise.
Within the last year or so, it seems that western media attention has shifted away from Iraq to other more “newsworthy” global conflicts; the plight of the expatriated refugee population is not a high priority as well for the Iraqi government. In this sense they are the victims of this double neglect. Hopefully this brief letter will remind everyone not to forget.