Ahmed Okasha* urges an increased involvement of mental health professionals in Iraq and denounces the psychological and physical damage inflicted on Iraqis by the United States "Every gun that is made, every warship launched, every rocket fired, signifies in the final sense a theft from those who hunger and are not fed, those who are cold and are not clothed." These are not the words of an Iraqi or Palestinian politician denouncing war and occupation in their respective countries. They are the words of former United States President Dwight D Eisenhower, spoken on 16 April 1953. I advise you all to visit www.costofwar.com.A running figure on the top right-hand corner of the webpage indicates the cost of the Iraqi war, not in terms of what the world pays for, but in terms of what the US alone pays. At the time of writing, the figure was a sobering $111,778,777,859, and it is rising by the second. Instead, the US could have paid for 15,803,624 children to attend a year of Head Start -- a programme designed for lower- income preschoolers to gain early access to education. It could have medically insured 47,912,160 children for one year. It could have hired 2,129,125 additional public school teachers for one year. It could have provided 2,835,234 students with four-year scholarships at public universities. Instead, it could have built 1,596,845 additional housing units for US citizens. I will not even start to think what that amount of money could have provided in deprived Third World countries. Nor have I yet borne in mind the Iraqi casualties: the dead, the injured, the disabled, the destroyed infrastructure and the looted universities and cultural centres. But this is how the world is run now. Not by health professionals, whose prime concern is saving and improving the physical and mental life of people, but by politicians whose prime concern is power and more power -- be it political, economic or otherwise. In April 2003 the World Psychiatric Association (WPA) released a statement warning of the consequences of the war on Iraq; the executive committee's profound concerns were included in that statement. It stressed that the humanitarian and health consequences of such a war must not be underestimated, both in terms of their devastating immediate effect on the people of the region and on international relations, and in terms of jeopardising the possibility of a peaceful future for our planet. As psychiatrists we are entrusted with the mental well-being of all people of the world, with no discrimination on the basis of race, religion, colour or gender. The gravity of war in the region -- which has already reaped far-reaching, tragic consequences on life, health and security for all involved, locally and across the world -- should be highlighted. On 10 December 2002, the International Day for Human Rights, the World Health Organisation (WHO) issued a report estimating the likely humanitarian scenarios following a war on Iraq to include massive destruction of infrastructure. "Damage to the electricity network will result in collateral reductions in capacity in all sectors, particularly water and sanitation as well as health," the report read. The report continued: "Direct and indirect health casualties are estimated at 500,000; vulnerable population is estimated at 5.21 million including most pregnant and lactating women and children. Vulnerable groups in need of rehabilitative programs can be foreseen to include 5,000 persons confined to institutions, comprising orphaned children, the severely handicapped and children in detention, 21,000 elderly, 150 million unaccompanied minors and two million internally displaced refugees, most of whom again will be women, children the elderly and the disabled. War traumas and displacements will be but a few of the life events that are awaiting the country's population of 26.5 million citizens." The provision of mental health care through national institutions will probably have to retreat in front of other services deemed to be more vital. In 2002, the WPA executive committee urgently called on all its member societies to exercise their best efforts and contacts to prevent war and resolve the crisis in a peaceful manner, under the leadership of the United Nations and its competent structures. We emphasised the need to do everything possible to prevent such regional and global major psychological and personal trauma. But nobody listened. The invasion was launched. One of the most tragic traits of modern times is that once war breaks out, it does not end. In most wars, one party is responsible for launching war, and another exercises its right to self-defence. War is no longer the one-on-one clash it once was; it is no longer the war between armies, between leaders; it is now a war of leaders against people who were never consulted, whose opinion was not taken, and yet have to suffer while the decision- makers plot in their secure, protected and heavily guarded offices. It is those people that are our concern and responsibility. Indeed, we have tried to fulfill our role. An unprecedented endeavour by the international psychiatric community was launched during an international consultation on mental health and the rehabilitation of psychiatric services in post- conflict and complex emergency situations at the WHO East Mediterranean Regional Office, Cairo from 28 to 30 July 2003. The WPA executive committee collaborated closely in the preparation of this meeting with 15 WPA member societies, including the two largest societies -- the American Psychiatric Association (APA) and the Royal College -- as well as the two zonal representatives from the Middle East and North Africa. The objectives of the meeting were to develop a coordinated strategy, methodology and approaches for, first, a rapid assessment and identification of the most immediate needs; second, a comprehensive needs assessment and situation analysis; third, a plan of action for the remainder of the year 2003; fourth, planning for the preparation of a strategic programme and plan of action for 2004-2005; and fifth, the identification of the financial implications of the strategies and fund raising. The meeting concluded with a number of comprehensive recommendations. First, that mental health should be given priority in the National Health Plan and be integrated into primary health care services. Second, the Poverty Reduction Strategy should be tailored to suit the cultural context. Third, a needs assessment should take into consideration the needs of the population, infrastructure, facilities and supplies and available human resources. Fourth, human resource development in mental health at different levels is of critical importance. Fifth, the empowerment of patients and families of the mentally ill should be a priority. Finally, that teachers, religious leaders and voluntary agencies should be involved in health education and in building on people's initiatives. We were promised a reconstruction phase and we had planned to use it to ensure that our recommendations were appropriately integrated, despite the constraints imposed by security concerns and demoralisation. However, this phase never came. Non-governmental organisations visiting Iraq have tried to forge a space for intervention. An Egyptian NGO working on the rehabilitation of victims of violence visited Iraq and was torn between addressing traumas left by the regime of deposed Iraqi President Saddam Hussein, the traumas of the 13-year period of sanctions, and the traumas of the US-led occupation. Children are sleepless, enuretic, terrified, lacking all sense of security and left with no answers to basic, legitimate questions of why are those troops still there, why the bombing is continuing, why raids are being carried out and why their homes are being destroyed. Adults live caught between the options of submission and resistance, neither of which spares them from being targetted by missiles. For Iraqi children and the elderly, men and women, it is a no-win situation. A recent report released on 8 April by the international organisation Occupation Watch states that in Falluja alone, over 300 Iraqis were killed and hundreds more injured since attacks began on Sunday 4 April. In Falluja, hospitals have been surrounded by soldiers forcing doctors to set up field hospitals in private homes. Blood donors are not allowed to enter; consequently, mosques in both Baghdad and Falluja are collecting blood for the injured. Water and electricity were cut off for days. One needs to be familiar with Arab culture to understand how a state of hopelessness affects the choices of the people, especially when they feel violated. Part of that culture is to avenge defeat, a matter that can cut across generations. Arabs will continue to fight for as long as they feel that their dignity is injured, for as long as they feel violated. They will only stop if the aggressor will publicly acknowledge guilt and assume responsibility for the aggression. Then, and only then are they ready to reconcile. The US army went into Iraq to overthrow Saddam Hussein and allegedly to search for weapons of mass destruction. The weapons were never found. We should not forget: Hussein was backed by the US and supplied with weapons of mass destruction to fight Iran. Similarly, Osama Bin Laden himself was on the payroll of the Central Intelligence Agency, fighting the invading Soviet troops in Afghanistan. US presence in Iraq has been and remains an occupation. This is not simply our claim: this is the way the international community describes the situation in Iraq. The Arab people cannot live under occupation -- it is too humiliating. They have come to learn that negotiations do not end occupations. Though it may be true that fighting does not end occupations either, at least it gives them a sense of being, a sense of not giving up. Certainly, it is in response to such situations that altruistic phenomena such as suicide bombings take place. One could describe the act in Orwellian terms: "You want to live. We want to die." This phrase hints at the bombers' helplessness, hopelessness and despair. Ideology and worldview certainly come into play, but there remains the question of how much the proponents of a particular ideology actually believe it rather than manipulate it in order to use it as a fundamental tool in their fight. For suicide bombing is an act of absolute despair, far more than one inspired by ideological commitment. It creates a sense of achievement: it is seen as the achievement of a "victory" against the "enemy", and it is coupled with the achievement of a state of martyrdom that is rewarded in heaven -- in another life. Both are great rewards for a people whose "here and now" is strongly influenced by religion and a belief that those chosen for martyrdom by God are honoured. Let us consider what happens in countries that breed suicide operations and so-called terrorism. They have political systems -- usually US- backed -- characterised by despotism, atrocities, oppression and corruption. Their populations are poor. Poverty leads the individual to lose faith in the system, in their leaders, in the world. They turn to faith, religion and ultimately fundamentalism, and because of their helplessness and hopelessness, they chose to be martyrs in their conviction, freedom fighters or terrorists. This is not meant to be a political presentation about Iraq. It merely seeks to explore the background to the situation in which we have tried to become a party. We might plan as much as we want, and make the most rational and comprehensive recommendations. But we shall not be able to implement any of them so long as the war in Iraq does not stop, if those in charge in Iraq are not made to bear their responsibility of the well-being -- both physical and mental -- of that people. A generation that sees nothing but death, blood and disability is hardly capable of reconstructing a nation. A generation tormented by post-traumatic stress disorders is a generation drowning in images of the horrible past, rather than one planning for the future. Unfortunately, we psychiatrists have to deal with disasters initiated by policy makers. Our job is to help the sufferers and to try and minimise the consequences on mental health. On previous occasions, we did not do enough. We did not do enough for Rwanda -- where one million died -- nor for Bosnia or Kosovo, nor for occupied Palestine, Somalia or Sudan. We must find a way to prevent mental ill health, regardless of political conflicts. As psychiatrists we should transcend political, racial, religious conflicts for the welfare of our patients. Yet, how can we draw a line of demarcation between the consequences of decisions of policy makers and looking after the victims of their decisions? To put it simply, how can we gain access considering that one needs a permit to help afflicted patients in regions of conflict? As professionals, we have to tell the world that in such desperate situations -- where you can lose your child to hunger or missiles, where there is no guarantee that your home will remain intact, where your hours and days are either times of military raids or of waiting for raids -- martyrdom is legitimate, for it is the only way for people to offer a sacrifice, even if it entails death itself. We have the resources and the volunteers who are ready to help improve mental health in Iraq. What we do not have is a guarantee of their security. In June last year, the president of the APA and I wrote to US Civil Administrator in Iraq Paul Bremer about the mental health hazards implicit in Iraq and the professional need for our intervention. Until this very day we have not received a reply. The international community cannot claim that it did not know of the problems that Iraqis are experiencing, for we -- among many other humanitarian and health organisations -- warned of the consequences of the US-led invasion. Now, we are simply reiterating what we have previously said. We need to go to Iraq in order to identify the needs of the people. We need to have access to patients and the traumatised. We need to abide by the first provision of the Madrid Declaration, that ours is a medical discipline concerned with the provision of the best treatment for mental disorders, with the rehabilitation of individuals suffering from mental illness and with the promotion of mental health. It is clear that the only solution is to collaborate with NGOs and human rights activists, and to disentangle ourselves from the ideology of selected world leaders. We may even need to address those leaders publicly, and denounce their actions by exposing the damage they have inflicted on the mental ill health of a whole nation. Maybe we should send our own professional messages to the leaders, to the media, to the UN. In short, lobbying may be what is needed before we can hope for intervention. If we want our efforts to be of use, if we want it to go down in history as those who lobbied leaders to take mental health into their consideration, we should be more outspoken. In that respect the APA and the Royal College of Psychiatrists are in an especially good position to take the lead in addressing their respective governments to give priority to the mental health of the people of Iraq. The British and American public strongly sympathises with the traumatised women and children of Iraq; this is a strong element that can work in the favour of our mission. Needless to say, the WPA will be an essential actor in this endeavour. For now, we must continue emphasising the hazardous implications of the war on the mental health of the people of Iraq. We have to be innovative in our work, even if that means transcending the boundaries usually imposed on our profession. At best we might make some change. At worst we would spare ourselves the guilt of having stood on the sidelines of a disaster while we could have been agents of prevention. * The writer is president of the World Psychiatric Association and director of the World Health Organisation's Coordinating Centre for Research and Training in Mental Health.
