in2mentalhealth

This is the 8th story in the Global Mental Health Inside Stories series. In this series I want to collect and spread information/ideas from people active in mental health from all over the world and specially from low resource settings or fragile countries.
I hope this series contributes to more insight in the challenges and wishes from people active in these settings and adds to a more bottom up movement in global mental health.
Haitham Assim Abd Alrazak answered the 10 interview questions follows:

Work location and some background information:
I’m Haitham Assim Abd Alrazak, living and working in Baghdad, Iraq, born in 1969 and psychiatrist by profession.

Brief country profile:

From Wikipedia: Iraq borders Turkey to the north, Iran to the east, Kuwait to the southeast, Saudi Arabia to the south, Jordan to the southwest, and Syria to the west. Iraq has a narrow section of coastline measuring 58 km (36 mi) on the northern Persian Gulf. The capital city, Baghdad is in the center-east of the country. Two major rivers, the Tigris and Euphrates, run through the center of Iraq, flowing from northwest to southeast. These provide Iraq with agriculturally capable land and contrast with the steppe and desert landscape that covers most of Western Asia. Iraq has very rich oil reserves.
Iraq was controlled by the Ba’ath Party (Iraqi-led faction) from 1968 until 2003. After an invasion led by the USA and multinational forces, the Ba’ath Party and its leader Saddam Hussein were removed from power and multi-party parliamentary elections were held. The American presence in Iraq ended in 2011. In the years following the invasion until now, insurgency against Coalition and government troops as well as intense violence between Sunnis and Shias dominate the country.

According to a MSF (Médecins Sans Frontières, Doctors Without Borders) report, 2013 between 2003 and 2011, the total recorded number of violent Iraqi civilian deaths was 116,788.5, but the number of people impacted by these deaths, through injury, losing loved ones, and/or witnessing violent events is many times higher. Iraq and Iraqi society has been devastated by violence.

Around 33 million people live in Iraq. Although it is a very rich country, due to the violence and the political turmoil there are more than 6 million people now living below the poverty line. The politics in Iraq are very religious in nature and Iraq is characterized by the presence of many ethnic groups and races. Unfortunately an improvement in the situation in Iraq is not expected in the near future and there are weekly reports of suicide attacks and bombings.

(wikipedia:) In 2010, spending on healthcare accounted for 6.84% of the country’s GDP. In 2008, there were 6.96 physicians and 13.92 nurses per 10,000 inhabitants. The life expectancy at birth was 68.49 years in 2010. This is down from a peak life expectancy of 71.31 years in 1996.
Iraq had developed a centralized free health care system in the 1970s using a hospital based, capital-intensive model of curative care. The country depended on large-scale imports of medicines, medical equipment and even nurses, paid for with oil export income, according to a ‘Watching Brief’ report issued jointly by the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO), 2003. Unlike other poorer countries, which focused on mass health care using primary care practitioners, Iraq developed a Westernized system of sophisticated hospitals with advanced medical procedures, provided by specialist physicians. The UNICEF/WHO report noted that prior to 1990, 97% of the urban dwellers and 71% of the rural population had access to free primary health care; just 2% of hospital beds were privately managed.

According to the WHO (World Health Organization) Mental health Atlas 2011 there are currently 85 psychiatrists, 279 nurses and 47 psychologists working in Iraq’s mental health care. There are 3 mental hospitals with a total of 1340 beds. In 350 psychiatric beds in general hospitals and 34 mental health outpatient facilities.

Overview of work activities:
I’m a psychiatrist since 2006 and graduated from the University of Baghdad.
Since 2008 I was the coordinator of the MSF (Médecins Sans Frontières, Doctors without Borders) counseling project in the Imam Ali Hospital, Baghdad.
Recently MSF handed the whole counseling project over to the Iraqi Ministry of Health (IMoH) and currently I’m the head of the supervisors and trainers at the IMoH in Baghdad.
In 2009 MSF, in collaboration with the IMoH, launched this counseling program focused on non-pharmaceutical approaches to address the anxiety and depressive disorders. Research shows that these are the most common of the mental health disorders experienced by the Iraqi population (see The prevalence and correlates of DSM-IV disorders in the Iraq Mental Health Survey (IMHS), 2009) and are considered highly amenable to psychological counseling approaches as well.
Between 2009 and 2012, over 25,000 counseling sessions were provided by MSF-trained IMoH counselors in Mental Health Units in Baghdad (the Imam Ali Hospital and the Yarmouk Hospital) and Fallujah, and the teams currently carry out around 600 counseling sessions a month.
Teams of counselors have been trained using a training module developed together with the IMoH which can continue to be used by the IMoH for future training of counselors. While the security circumstances of Iraq have often complicated implementation, the challenges have also brought out innovative solutions which may help sustain services in future. For example, video conference links between Baghdad and Jordan were trialled and then used extensively for training, technical support through case discussions and clinical supervision.
Telephone helplines are another initiative created to raise awareness and increase access to care. Technically supported by MSF, the IMoH established a telephone help-line in Yarmouk Hospital to provide information about counseling services and to facilitate referral to the Yarmouk Mental Health Unit. Experience with the service so far shows it to be valuable for clients who cannot access the counselors in person. Uptake is increasing and this method has potential to reach a group of people – including women unable to leave their homes or their duties – who may otherwise be unable to access care.
And together with the IMoH, MSF has produced a 6:49 minutes film, 2012 to be distributed on Iraqi TV and in hospitals, explaining what counseling is and showing available services.
As with many countries with underdeveloped mental health systems of care, the main component of Iraq’s mental health service has been institutionalized care for those suffering chronic psychiatric disorders such as schizophrenia. So, MSF started the counseling services from level zero and we can say that they were really pioneers in rather difficult circumstances.

I’m also lecturer in the International Medical Corps (IMC) mental health promotion program in Iraq since 2010.
I’m interested in mental health and especially in thought-processes in the coping with difficult situations.
I’m conducting research on the effects of counseling on survivors of violence in secondary school students in Iraq.

The main challenges personally in work/study/life:
First of all is the security issue. It is very hard to live in dangerous place with every day explosions, killings, kidnappings, and corruption. And traveling around in the city is difficult due to traffic jam and check points.

The main challenges for the organization(s)/colleagues/clients:
Safety and corruption are important issues.
And we have only a few resources and lack of specialized staff in the mental health field like psychiatrist, psychologist and psychiatric nurses.
And of course there is still a huge stigma surrounding mental health and seeking help.

The main challenges for the country regarding mental health care:
In Iraq there is a low mental health awareness, a limited mental health infrastructure, a lot of stigma and a low access to mental health care although there are a lot of beneficiaries. I see an increased prevalence of neurotic and psychotic cases, due to the increased life stresses.

What should be changed in mental health care on a local or national level:
There are some vaccinations for some medical diseases, but unfortunately there is no such thing for mental health issues. It is a human right issue to supply such vaccinations and I think mental health should have such privilege in my country and globally in terms of personal growth and changing of attitudes and awareness .

What is the right direction for the global mental health movements:
There is a lot of suffering and there are a lot of mental health diseases but the whole bulk is concentrated on treatment of these diseases. The future direction should be on prevention because that gives better results and proper cost\benefits.

What can ICT, mhealth and e-learning contribute to mental health care:
In such a fast century where time is becoming very critical I think there will be increasing use of ICT applications. It is easy to use and has a wide reach. You can share updated and feedback information in very short time. It can connect professionals, beneficiaries, learners at one time, and it can be part of mental awareness campaigns.

Other links and contact information:
mail address: dr_haitham1969@yahoo.com

With many thanks to Haitham Assim Abd Alrazak!
Roos Korste, psychologist, international trainer and blogger.