March 3rd - Post Traumatic Stress
05 Mar 2004
The Post Traumatic Stress Disorder Programme that Dr Ali and Dr Yousef are trying to run, in spite of all the difficulties. The Ashura bombings and another threat to Happy Family.
So. Yesterday was Ashura. The whole world knows now that yesterday was Ashura because they saw the bodies on TV. Four of Waleed's old school friends, now at college, were killed in the Kadhmiya explosions. The taxi driver asked had we heard. Everyone asked had we heard. And all of them said, "This is the Americans. They are trying to make us fight each other." True or not, perhaps the best hope is that both Shia and Sunni carry on being certain of that and refuse to fight each other.

Ahmed was in Adamiya, the Sunni district next to the Shia area, Kadhmiya, where several of the explosions were. He said lots of people from Adamiya went immediately to give blood at the hospital. He said the western journalists there were the target of rage. The BBC World Service reported that some people blame the Americans for 'letting' the bombings happen. It's stronger than that.

At Safaa's house there were portraits of the Imam Hussein on the stage. They were having a quiet Ashura, except that a brick had been thrown into their garden – better than the last projectile, which was a grenade, but with a message threatening them to stop working with us. It was written in English, Safaa said, which he thought was odd, but he's already destroyed it in disgust.

Damia said we were to ignore it and not dare to stop coming to hang out with her. Safaa said the same: he wouldn't let threats destroy everything we were working on. But how do you arrive, smiling, at someone's gate wondering who's watching, which of the men in the street outside, whose kids are hugging us, shouting our names, asking for this or that trick, is going to say what to whom and what might happen to them in the night after we've gone.

Abu Safaa [Safaa's dad] came in, breaking into a big grin when he saw us. "Hassan Chakuli!" They've nicknamed me Hassan Chakla, after a friend of Mustafa-Poser and Fuad's, now living in Denmark. The pet version of any name is made by adding an –e- to the end and making the last vowel sound into an –oo- instead of whatever it normally is. Hence Khalid becomes Khaloodi, Mohammed becomes Hamoudi, Salam Saloomi and so on.

It was better than being told never to darken his family's door again, better by far, but I still felt like a lump of shit. It's not pleasant to know that your friendship with someone is putting them in danger; still less pleasant, I'm sure, to be the one put in danger. They're angry more than afraid but, at the same time, afraid more than angry.

We went to a park with the boys from the Kurdish House, played football and taught some of them to juggle. They were all in tracksuits or jeans and jumpers, clean, indistinguishable from the other children in the park, shouting and laughing, playing football really athletically, if without much structure. Asmaa, the manager, sat in the sun watching. I think it gave her even more goosebumps than it did me, seeing how they've changed.

Aakan has come back from Baba Sherji, from the gang, who once terrified him so much that he didn't dare leave them, even when Peat and Donna were taking two of the other boys back to the Home. In any group of kids there are one or two that you connect with more than all the rest, however much you like all the rest, and Aakan and I became friends. He sat on my knee in the bus to the park and we set the world to rights.

Ali went back to his family and Laith is going today to live with his grandma. It looks like being a long process, helping him and the extended family to accept one another and settle into living together. Maybe it won't work and he'll end up back in the Kurdish House. Maybe it will.

Last summer the street children constituted an appalling crisis. Kids were sick, injured, high on drugs, malnourished and abused on corners, in basements, on dusty patches of grass. Lots of them had families who were too poor to look after them or with whom they had various problems. The sudden and much needed increase in orphanages, opened by Iraqi and international organisations, got a lot of them into accommodation. The shelter in Baba Sherji more or less solved the problem on the streets around Abu Nawas, although people have started to tell us about groups living in other areas.

The big project now is re-integration: supporting the kids and the families to try and address the problems that led to them living on the streets in the first place, giving economic, psychological or other support.

And on that note, I finally got to meet Dr Ali, the child psychologist who was heading the Post Traumatic Stress Disorder Programme. It was set up a little while after the war and Ali was the only doctor formally assigned to the programme by the Ministry of Health. Several colleagues who helped him were unpaid for their roles.

The doctors believe there is not a single child in Iraq who isn't suffering some degree of post traumatic stress, with a wide variety of symptoms. There is virtually no awareness about the disorder and its symptoms, so bed wetting, for example, is a source of shame rather than a warning signal that the child needs help. Parents are in denial, Dr Yousef says, because of the stigma attached to any kind of mental illness. "Parents think that people will think there's something wrong with the child's mind and say maybe he inherited it from me."

The programme's plans included training play therapists, giving seminars to teachers and others who work with children in identifying symptoms and ways of broaching the subject with parents, a nationwide awareness campaign aimed at parents, setting up of crisis intervention teams and creating centres where parents could bring their kids for diagnosis and rehabilitation.

The "Safe to Play" and "Back to Play" programmes with UNICEF, for six to twelve year olds, came to an end when the UN withdrew most of its international staff after the bombing of their HQ. There are manuals and kits for training play therapists and for carrying out the therapy, but they're all in Jordan.

Dr Ali explained, "We were doing workshops, an awareness programme, we trained 120 teachers to look out for symptoms and talk to parents, funded by the Ministry of Health. We had everything ready for a huge campaign: Dr Yousef translated a lot of things from the internet and we made pamphlets and letters. We talked with the Sheikhs and the Imams and all the community places. We had the whole distribution infrastructure ready.

"After only a few weeks they were asking for my results. The senior advisor in the Minsitry of Health is an American man called Jim Haveman. He is not even a doctor. I wonder what did he want? The details of how many centres I have built, in only a few weeks? How much office stationery I have bought? I explained that this is a project which will take years.

"Then I got an e mail from him to say the funding was suspended and I could not spend any more money from November 2nd. You can imagine the magnitude of frustration. Everything was ready. We were writing a letter to go out with the ration cards, because every family would receive a new ration card within a few months. We would have given out one and a half million letters. He was enthusiastic at the start. He said yes, let's do it, but in the end he wouldn't let us."

Dr Ali has been transferred away from the programme and Dr Yousef assigned in his place but the two say they need to work together. Still there is no funding. A psychology centre for torture victims has been opened with funding from the Ministry of Health. No one would dispute that torture victims need support and healing as well, but one might speculate about the politics of a decision to prioritise the victims of the last regime over the victims of the traumas of sanctions and war inflicted by the present one.

UNICEF requested a detailed proposal specifying the aim, timescale, number of children and personnel requirements for the programme and asked them to find an internationally recognised NGO through which the funding could be channelled. "I was relieved," Yousef smiled. "It eases the headache if the money goes to someone else. Money is trouble. There is so much mistrust."

He says they'd prefer to work through a European or Australian organisation than a US one. "The American NGO people are nice and they mean well but now, even people who were happy when the Americans got Saddam out are frustrated. They don't want anything to do with Americans any more. They don't trust them. They were happy that Saddam was gone but the Americans treat people harshly."

Dr Ali had his own example: "My little boy, Haider, was playing in the street with his plastic toy walkie talkie and the troops came and said what's that? Why are you playing with that? Where's your home? He pointed to our house and 24 soldiers pushed in and for two hours they searched my house."

The doctors believe that play therapy is the best, perhaps the only, way of diagnosing and rehabilitating kids with PTSD but there are no trainers in Iraq. "There are less than a hundred psychiatrists in Iraq, but more than three hundred Iraqi psychiatrists in the UK."
Training for psychologists and play therapists is a priority. Effective play therapy needs to include some sort of symbolic representation of the trauma the child has suffered, Yousef says, and there is no one in the country who can give the training. Far more people can be trained if some play therapy specialists come to Iraq than by taking people out of the country for training.

The teacher-training programme that was underway needs to be restarted as well. Teachers' salaries are low, so the programme would need to pay their expenses for attending seminars: travel to the venue, the venue itself, the lecturers and so on. They would hope to use a room in the Ministry of Health or one of the hospitals, perhaps in a school. The Minister of Education is a doctor, apparently sympathetic to the programme. Yousef estimated that 3-day seminars for thirty teachers could be run for less than $2000. They wouldn't need any manuals and they could start with a pilot seminar, rather than needing the money for ten right away.

Crisis Intervention Teams are urgently needed. "Two or three months ago, when there were lots of bombings near schools, parents were scared to send their children to school and teachers were afraid to go to work. There were no psychologists working around the schools to get the kids back in and deal with everyone's fears. In other countries as soon a something happens near a school the support teams are there. We need crisis intervention teams as bases for multidisciplinary teams that can go where they're needed."

There's a need for a mental health network, using telecoms and the internet so that doctors all over the country have access to advice, filling the huge gaps which exist at the moment. The network would play a central part in creating a national mental health database and screening for post traumatic stress disorder and other kinds of trauma.

They'd have to get permission to distribute the pamphlets officially, but if printing costs can be found, so can ways to get them out. If anyone out there has contacts in the Iraqi media, it would be good to be able to get some information out about the nature of PTSD, its symptoms and how parents can talk to their kids about it.

As always, any ideas or offers of help, I'll pass them on. I don't know: I don't want to gush, but Ali and Yousef are good men, extremely committed, well-educated, intelligent and compassionate, who have taken on an enormous task with, at the moment, little support and apparent political obstruction. After they criticised coalition conduct for making the fear and trauma worse for the kids, their funding was stopped.