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Field report

The impact of war and economic sanctions on the mental

health system in Iraq from 1990 to 2003: a preliminary report
Maha Sulaiman Younis & Azhar Madlom Aswad1
PhD, Professor of Psychiatry, College of Medicine, Baghdad University, Baghdad, Iraq, 1MBChB, MSc, Specialty Psychiatrist, Surrey and
Border Partnership NHS Mental Health Trust, UK

Abstract
This paper explores the effects of war in Iraq in the period between 1991 and 2003, with a focus on the effect of economic sanctions on
mental health services. The authors, Iraqi psychiatrists with direct contact with patients and events during this period, review literature
and reports published contemporaneously. They describe how the mental health system in Iraq was deteriorated, not only by war, but also
by United Nations imposed sanctions during the period between the first and second Iraq war.

Keywords: Iraq, mental health system, sanctions

INTRODUCTION health services, the authors believe they are contributing

Context
As a developing country, Iraq has struggled to re-establish
national mental health services amidst challenges of con-
tinuous civil unrest from regional wars, economic sanc-
tions and an exodus of mental health professionals.
Furthermore, despite various international interventions
to improve Iraq’s national mental health policy, little
has been implemented (Hamada, & Everett, 2007; The
Education for Peace in Iraq Center (EPIC), 2014). While
published literature has primarily focussed on the impacts
on mental health in the aftermath of the American led
invasion of 2003, far less is known about developments in
the decades before the Iraq invasion.
Therefore, this paper begins with a brief historical over-
view of the development of mental health services in Iraq.
This is followed by a description and analysis of the effects
of the first Gulf War, the subsequent period of international
economic sanctions imposed by the United Nations Secu-
rity Council (UNSC) on Iraq in August 1990, until the
American led invasion in 2003 and the civil strife that
followed. Taken together, these factors provide a concise
overview that is necessary to understand the decline of the
mental health system in Iraq over the past few decades.
It is also important to note that most reports on mental
health issues in Iraq are from authors living outside Iraq,
from international agencies, or local officials. As practic-
ing Iraqi psychiatrists during this period, describing the
impact of ongoing hardship and the impact on mental
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a unique and little heard voice.
Historical background
The British occupation authority established the first men-
tal hospital (Dar Al Shefaa) in 1921. As a result, formal
mental healthcare was established much earlier in Iraq than
in neighbouring Arab countries, despite limited facilities
and resources. This institution served as a custodial hospi-
tal with limited facilities, which contributed to generally
poor medical care (Younis, 2009). From 1932 onwards, the
government offered medical graduates of the Iraqi Royal
College of Medicine an opportunity to specialise in mental
health through a scholarship in the UK. An Iraqi physician,
Jack Abood, returned from the UK with a degree in
psychiatry and started the mental health service in Baghdad
in 1934. By 1940, the number of qualified psychiatrists had
increased due to continuous government scholarships,
however, the number was still relatively low.
In 1953, a 1,300 bed psychiatric hospital (Al Shammaiyya)
was established at the periphery of Baghdad, which was
later renamed Al Rashad. At that time, there were only 15
qualified psychiatrists, a ratio of 0.2 per 100,000 popula-
tion (Bazzoui, & Al-Issa, 1966). By 1968, another 70 bed
psychiatric hospital (Ibn Rushid) was established for acute
Address for correspondence: Maha Sulaiman Younis, Baghdad
University, Baghdad, Iraq.
E-mail: Maha.younis@gmail.com
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DOI: How to cite this article: Younis, M. S., & Aswad, A. M. (2018). The
10.1097/WTF.0000000000000144 impact of war and economic sanctions on the mental health system in Iraq
from 1990 to 2003: a preliminary report. Intervention, 16(1), 54-58.

54 © 2018 Intervention, Journal of Mental Health and Psychosocial Support in Conflict Affected Areas | Published by Wolters Kluwer - Medknow
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Younis and Aswad: Impact of war and economic sanctions on the mental health system in Iraq from 1990 to 2003
mental health disorders (Abed, 2003; Sharma, & Piachaud,
2011; Younis, 2009).
In 1970, the Iraqi Association of Neurologists and Psy-
chiatrists was founded by Dr Tariq Hamdi, senior psychi-
atrist, with an elected executive committee of distinguished
psychiatrists, neurologists and neurosurgeons. In 1996 it
was re-named as the ISP in accordance with the bylaws of
an election process. The pioneer members issued a peer-
reviewed psychiatric journal (AlRaazi) from 1978 until
1993, when production was stopped due to the country’s
financial crises (Younis, 2009).
By 1970, an increasing number of psychiatrists were
demanding additional psychiatric clinics in other gover-
norates of Iraq.
While specialised services for somatic patients increased,
and general hospitals were established in many places in
the country, the number of psychiatric beds remained
limited with only a few psychiatric clinics opening in
the main governorates (Abed, 2003).
During the Iran/Iraq war, from 1980 to1988, military
expenditures rose from 19.4% to 38.4% of the gross
domestic product (GPD). In that period, the World Bank,
together with many other international bodies, described
the infra and upper structures in Iraq as sophisticated and
parallel to that of advanced countries (Al-Nasrawi, 2001;
Sharma, & Piachaud, 2011; United Nations Security Coun-
cil (UNSC), 1995). The World Health Organization
(WHO) regarded the healthcare system of Iraq to be the
best in the region during the Iran/Iraq war, as the rate of
healthcare coverage was 97% in urban areas and 79% in
rural areas. Further, by initiating a nationwide vaccination
programme, mothers and infants mortality dropped
markedly during the 1980s (Al-Alwan, 2004; Eastern
Mediterranean Regional Office of World Health Organi-
zation (EMRO), 2006).
Four days after the Iraqi army invaded Kuwait on 2 August
1990, the UNSC implemented a comprehensive trade
embargo against Iraq. It was the first sanction of its kind
since the foundation of the UN in October, 1945 (Al-
Nasrawi, 2001; Aziz, 2002). On 17 January 1991, over
120,000 allied raids were carried out in Iraq, taking the
lives of around 82,000 Iraqi soldiers during their with-
drawal from the battlefield. Unfortunately, serious war
injuries were not well documented. The large scale bomb-
ing and ground battles totally destroyed military and civil
structures, including bridges, roads, power stations and
water sanitation plants (Al-Nasrawi, 2001; Harvard Study
Team, 1991; ICRC, 2001). This invasion was followed by a
civil revolt in Kurdistan, Iraq and the southern governo-
rates, leading to increased hospital casualties, lack of
security and chaotic situations. Consequently, emergency
services in hospitals were seriously hindered due to a lack
of viable personnel and medicine (EMRO, 2006; the
International Committee of the Red Cross (ICRC), 2001).
Unemployment, food insecurity and dramatic devaluation
of the local currency, the Iraqi Dinar (ID) valued at 0.3108
to 1 US$ in 1985, dropped to 3000 for 1$ in 1995 (Central
Intervention, Journal of Mental Health and Psychosocial Support in Conflict Affected Areas ¦ Volume 16 ¦ Issue 1 ¦ March 2018
Bank of Iraq (CBI), 2016), resulted in hyperinflation
estimated to be 800 times more than in a pre-sanction
era (Al-Nasrawi, 2001; Harvard Study Team, 1991). The
sanctions targeted the weakest and the most vulnerable
members of Iraqi society, such as the poor, elderly, women
and children (Aziz, 2002; Dreze, & Gazdar, 1992).
A few psychiatric centres, like Ibn Rushid Hospital in
Baghdad continued to function, with only on-call psychia-
trists and nurses willing to endure continuous bombing,
minimal medication and food donations, as well as severe
shortages of fuel and total disruption of telecommunica-
tions (personal experience, 1991).
METHODOLOGY
Although little has been published on mental health issues
during the period of 1991–2003, books, peer reviewed
journals and reports of nongovernmental organisations
(NGOs) were studied, including: the United Nations Child-
ren’s Emergency Fund (UNICEF), the ICRC and the
WHO. PubMed and a commercial search engine were
searched under the general heading ‘Iraq’, using the fol-
lowing search terms: ‘sanctions’, ‘mental health’ and ‘Gulf
War 1991’ in publications from 1991 to 2003. Addition-
ally, official documents from the Iraqi Board for Medical
Specializations (IBMS), and the Iraqi Society for Psychia-
trists (ISP) in Baghdad, Iraq were also searched. All
publications were reviewed by the senior author, an exec-
utive member of both aforementioned councils. From over
30 documents, the most relevant to the issue of sanctions
were extracted, avoiding assessment of the quality of cited
research studies. Findings are presented below.
RESULTS
Apart from the press and NGO reports, little data on the
psychological effect of the sanctions on Iraqi people is
available. The few published reports mainly discuss nutri-
tional status, maternal and infant mortality rates and
endemic disease as indicators of serious deterioration of
the health care system (Harvard Study Team, 1991; Pilger,
2002).
Impact on the healthcare system
The Gulf War and the comprehensive trade embargo
caused serious damage to the healthcare system, including
mental health. In 1995, the UNSC established the Oil-for-
Food Programme under Resolution 986 to allow Iraq to sell
oil on the world market in exchange for food, medicine,
health care and other humanitarian needs for ordinary Iraqi
citizens, without allowing Iraq to boost its military capa-
bilities, in order to mitigate the effect of sanctions (UNSC,
1995). It did help to improve the quality and quantity of the
food ration programme (Dreze, & Gazdar, 1992). Hospital
admissions had to adjust to this low cost of care in order to
maintain a basic level of function. The shortage in the
health budget deprived many psychiatric centres of expan-
sion and development. After the 1990s, the Iraq Ministry of
Health (MoH) and the state owned pharmaceutical com-
pany, Samara Drug Industry (SDI), were the main
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Younis and Aswad: Impact of war and economic sanctions on the mental health system in Iraq from 1990 to 2003
providers for both imported and locally manufactured basic
psychiatric medicines, such as minor tranquillisers, con-
ventional anti-depressants and anti-psychotics (Hamada, &
Everett, 2007; Sharma, & Piachaud, 2011; WHO, 2006).
NGOs like ICRC, UNICEF and the Iraq Red Crescent
Society (IRCS) donated some basic psychiatric medicines
within their charity campaigns, however, overall drug
supply was irregular and far below the growing need.
Treatment by electro convulsive therapy (ECT) became
standard for serious presentations of psychotic disorders,
usually without general aesthesia. The rehabilitation of
psychiatric units was at a minimum, and plans for estab-
lishing new ones were suspended (UNCF, 1997). Due to
the general destruction of important power and service
stations during the bombardment, both the healthcare
system and living standards declined significantly. The
Al Rashad Psychiatric Hospital, the only hospital in the
country for chronic cases, was affected by looting and
vandalism, and many patients escaped or died due to the
collapse of effective administration and lack of proper
medical care.
A few years later, the ICRC delegate in Baghdad sponsored
and supervised a rehabilitation process in cooperation with
the Iraq Ministry of Health (MoH), together with few other
psychiatric units in general hospitals (ICRC, 2001). Due to
the lack of medical personnel, the psychiatric unit in Al-
Karama General Hospital, was closed (Iraq MoH, personal
communication, 30 May 2015). The ratio of psychiatric
beds fell to 7 per 100,000 population, psychiatric nurses
were 0.1 per 100,000 and social workers were 0.02 per
100,000 population. There were limited facilities for psy-
chotherapy and rehabilitation (Okasha, Karam, & Okasha,
2012).
Impact on patients
International studies about mental health services in Iraq
were mainly extracted from data released by WHO after
2003 (WHO, 2005; 2006). As expected, mentally ill
patients were among the community groups most affected
by the collapse of family income, with an impact which
gave rise to different arrays of psychiatric symptomatology
(Okasha, & Karam, 1998; Srinivasa, & Lakshminaryana,
2006). The shortage of psychiatric medicines, especially
the new anti-psychotics and anti-depressants, with poor
services and emigration of many psychiatrists, contributed
to an increased prevalence of psychiatric disorders
(Sharma, & Piachaud, 2011; ISP, personal communication,
6 April 2001).
According to WHO (2006), the number of patients attend-
ing psychiatric outpatient clinics had enhanced in spite of
the deterioration in standards of healthcare, which reflects
the increase of people’s needs for treatment. For example,
the number of psychiatric attendees at outpatient clinics in
1990 was 197,000, this increased to 220,000 in 1994 and
further rose to 507,000 in 1998. It is believed that around
10% of the population is affected by different psychiatric
disorders, especially posttraumatic stress disorders (PTSD)
(WHO, 2005; 2006). One local study (Younis, 2003)
revealed that 24–57% of 130 school age children in the
56 Intervention, Journal of Mental Health and Psychosocial Support in Conflict Affected Areas ¦ Volume 16 ¦ Issue 1 ¦ March 2018
Al-Ameriyah district of Baghdad showed PTSD symptoms
following the bombing of a nearby shelter that killed 400
civilians in February 1991. Another study (Ahmad,
Mohamed, & Ameen, 1998), showed an alarming 87%
of children and 60% of their care givers presented with
symptoms of PTSD, in a sample of 84 refugees following
military operations in the Kurdistan region of Iraq, while a
much lower percentage of 20% was revealed by a similar
study (Ahmad, Sofi, Sundelin-Wahlsten, & Von Knorring,
2000). A comparable finding emerged in a study of 116
adult Iraqi refugees who emigrated to the US after 1991
(Jamil, Farrag, Hakim-Larson, Kafaji, Abdul Khaleqq, &
Hamad, 2007). Anxiety and depressive disorders repre-
sented 18.9% and 16%, respectively, of 10,101 attendees at
a psychiatry/neurology outpatient clinic in Baghdad in
1993 (Younis, & Lafta, 2014), while in 2003 subsequently,
33.4% and 22.2% of 1,315 attendees at the same clinic
suffered from depression and anxiety disorders (Younis, &
Al-Naimy, 2006). Similar findings were reported by
another study at Al-Kadhimia psychiatric outpatient clinic
in 2002 (Al-Samarraie, 2002), with depression and anxiety
disorders also found to be comorbid with Benzhexol
misuse in a sample of 354 patients in Al Hilla city from
1991 to 2000 (Younis, & Moselhy, 2009a). Symptoms of
impulsivity, depression and raised psychological tension
were also associated with para suicide (attempted suicide)
and self-poisoning of 58 adults attending the emergency
department of a university hospital in Baghdad (Al-Samar-
raie, & Huessien, 2000). On the other hand, 91% of service
men presenting with self-mutilation met the diagnostic
criteria of antisocial personality disorder, according to
DMS-IV (Hassan, 1999). Many patients with schizophre-
nia suffered frequent relapses with catatonia, requiring
ECT as a first-line treatment because of the deprivation
of antipsychotic medication (Younis, & Moselhy, 2009b).
(Al Mokhtar psychiatric hospital, which opened in 1998 in
Baghdad, was the only private hospital serving 30 psychi-
atric beds and facilities for ECT under general aesthesia.)
The overall poor life quality assessed in 579 healthy
college students randomly collected from Baghdad, Diala,
and Thi-Qarr governorates in 2001 showed psychological
distress attributed to the traumatising effects of war com-
bined with austerity (Younis, Al-Kaisi, Vasudev, &
Young, 2003).
Impact on psychiatrists
Because of the Iran–Iraq war from 1980 to 1988, junior
doctors in training for psychiatry were enrolled in obliga-
tory military service for a maximum period of 5 years as
reserve. This caused inconsistency in providing good
psychiatric care and continued training for qualifications.
The Iraq Ministry of Higher Education and Scientific
Research established the Iraqi Board for Medical Special-
izations to set up a specialisation programme for medical
graduates in 1986, based on a similar programme of the
Arab Board of Medical Specializations founded few years
earlier. The psychiatric scientific council was then estab-
lished in 1988 with a 4-year training and tuition programme
leading to a fellowship degree. The first batch of psychiat-
ric graduates was of 12 doctors in 1992, appointed to
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Younis and Aswad: Impact of war and economic sanctions on the mental health system in Iraq from 1990 to 2003
replace the emigrated specialists. Eventually the number of
qualified psychiatrists grew to 86 between 1992 and 2007
(IBMS, personal communication, 12 May 2015).
Due to the minimal wages offered after 1991 sanctions for
professionals and auxiliaries, psychiatric units in hospitals
suffered medical and therapeutic decline. The financial
strain of the sanctions and the stringent restrictions on
traveling and communications with the outside world led to
lack of access of educational materials and global medical
advances. This, in turn, hindered the quantity and quality of
the psychiatrists (Afifi, 2005).
The total number of psychiatrists was around 108 in 2001
(ISP, personal communication, 2 April 2001), which
dropped to 90 in 2003 (WHO, 2006). The pre-sanction
ration of 0.5 psychiatrists per 100,000 population
decreased to 0.1 per 100,000 populations during 1998
(Okasha, Karam, & Okasha, 2012), and accordingly, psy-
chiatrists were overwhelmed by the workload with an
increasing number of traumatised patients.
CONCLUSIONS
Mental health services in Iraq, in spite of a long history
beginning in the late 1920s, did not receive enough atten-
tion nor development from successive governments. It did,
however, flourish during the early 1970s with improved
economic conditions in the country and the availability of
government scholarships for training abroad. When the
Iran–Iraq war began in the 1980s government funds were
reduced, and no more scholarships were offered. The Gulf
War of 1991, and the long years of comprehensive eco-
nomic sanctions caused marked deterioration of psychiatric
services and trained mental health workers and people’s
mental health. The collapsed country’s economy caused
shortages of medicines and emigration of many experi-
enced psychiatrists, disrupting the practice of psychiatry
and preventing development of a mental health care sys-
tem. With a growing need for psychiatric services and the
increased demand of people resulting from psychiatric war
traumas, the Iraqi Council for Medical Specializations
established the psychiatric council for specialisation of a
4-year programme of clinical training and tuition, leading
to the degree of fellowship in psychiatry. The first group of
12 specialists graduated in 1992, and this has stimulated the
practice of psychiatry in the country.
This study shows that economic sanctions have had a huge
impact on the mental health of people in general: of the
people who are already known as a mental health patients
and on the mental health care; on the availability of
psychiatric health workers and education of psychiatrists,
as well as the number and quality of mental hospitals and
the availability of medication. It is important for a
clear understanding of the mental health situation that
mental health professionals in conflict affected settings
document the effects of international sanctions on mental
health care systems. These documents can, in turn, support
mental health professionals to inform the international
community about the results of sanctions for mental health
patients.
Intervention, Journal of Mental Health and Psychosocial Support in Conflict Affected Areas ¦ Volume 16 ¦ Issue 1 ¦ March 2018
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58 Intervention, Journal of Mental Health and Psychosocial Support in Conflict Affected Areas ¦ Volume 16 ¦ Issue 1 ¦ March 2018