Saturday, February 20, 2010

Ethnic Identification


        Even when a country has not existed for years, some people continue to identify themselves as members of that non-existent country. Problems arise when they strive to restore themselves as an independent country. My trips into trauma zones have brought me into contact with a number of these groups, and I have seen the negative consequences of the lack of their integration into the presently existing country. Some examples would be the Tamil Tigers in Sri Lanka, Chechnyans in Russia, and Kurds in Iraq. The pattern seems to indicate that people form an ethnic identity early, see that as who they are, and can find it difficult to or refuse to re-identify as a member of the dominant group.
        My own sense of an almost forgotten early identity came the other day at the old state capital in Tallahassee. We were in the room covering the history of prisons and corrections in the state. One of the stories involved a young man from North Dakota who had been picked up as a vagrant, sent to prison and as was the practice at the time sold to a private company as labor. The young man did something that upset the foreman, who took a dislike to him and gave him a whipping from which he died.
       I had a sense of shock and tears welled up. He had killed one of my people. My people? I hadn’t lived in the state for 60 years and had no desire to go back. But if the boy had been from any other state, I wouldn’t have had that strong of a reaction.
        The story continued. His parents were, as would be expected, incensed and they enlisted the aid of the governor of North Dakota to come to Florida and raise hell with the Florida governor. As a result the practice of selling the prisoners was stopped. My reaction was, “good for my people.”
       My father was brought to the U.S. from Sweden as a child and always identified strongly with being a Swede, to him an obviously superior people. On the other hand he stressed we were now Americans and he and my mother spoke only English to us and used Swedish only when they wanted what they said not to be understood by the children. They spoke negatively about the local Germans who spoke German at home and kept German customs. They weren’t adjusting to the new world. The Germans on the other hand spoke of Swedes as lacking character since they had been so willing to adopt the ways of the new world. In this case the ethnic differences between the two groups seldom broke into open conflict, except maybe at a dance when people were in their cups.
        I would have been upset at the treatment of the young man in Florida regardless of his background, but it was the strength of my response on seeing he was from my home state that surprised me. It was as if my lower, primitive brain had been tapped into. Forget the higher level logical part of the brain, don’t mess with my people.
       My strong emotional response gave me a bit more insight into the strength of the emotional responses of people I have interviewed in various countries where ethnic conflicts are going on.

Monday, February 8, 2010

Iraqi doctors view of the war in Iraq


Report written November, 2004

The culture has grown very dark and very cold in Iraq.
• Few recreational activities are available because of the danger of stepping outside of your home. No one who wants to live breaks the 9:00 p.m. curfew.
• People do not dare to go to the police with complaints because if you are near police your chances of getting blown up or shot increase.
• The Iraqi police and the American troops cannot make themselves safe, so how are they to make the people safe?
• Both sides are trapped in a terrible situation not of their own making.
                                          Observations by Iraqi physicians to UMC trauma team

The Missouri team
       Teams from the UMC International Center for Psychosocial Trauma went to Amman, Jordan, in July to present a program on trauma psychology to 20 Iraqi physicians and in August to Istanbul, Turkey, to work with 26 Iraqi medical professionals. Because of the hazards the UMC teams were not allowed into Iraq.
       Both teams were led by the program’s director, Arshad Husain, UMC child psychiatrist. The first team included Barbara Bauer, Columbia psychologist, Gail Baker, psychologist, and Iyad Khreis, Jordanian psychiatrist, both from Royal Oaks Hospital in Windsor, MO, and Judith Milner, psychiatrist from Seattle. The second team was Dr. Samar Muzaffar, special fellow trauma psychiatrist from UMC, Dr. Barbara Bauer, psychologist, and Rose Proctor, executive director of International Medical and Educational Trust.

The Iraqi physicians
       Much of what is reported here came from comments made by participants in the training program, but in addition Muzaffar and Proctor conducted individual interviews to get more specific examples of problems in war torn Iraq. Participants in the individual interviews were fearful of the consequences of relating their observations and requested that no names or identifying information be used.
       Arshad Husain observed that the professionals in the training sessions were demoralized and in a survivor mode: “How can I survive through this?” This is a terrible time for them and their children, and they had no hope that things would get better in the near future. It is taking all of their psychological strength to live in the present chaos in Iraq.
       They are very dissatisfied with their lives for a number of reasons. There was much anxiety about tanks crushing them or of getting caught in other military action. Their lives are very uncertain, and they can’t control any aspect of their living conditions. These professionals felt powerless under Saddam, and they feel powerless now.
       Even in their work situation they often have little control. Samar Muzaffar interviewed a surgeon who reported the doctors are using old outdated supplies, the basics with nothing modern. They expected improvement when the U.S. came, but basic conditions have gotten worse in their hospitals.
        A psychiatrist interviewed by Rose Proctor reported a serious lack of supplies and medications. Medications are inconsistently available, if they are available at all. A patient may be on six different medications during a month for the same symptom making consistent treatment almost impossible.
       One thing that has improved is the freedom to leave the country. Saddam wouldn’t let them travel, so most of them could not go to conferences to learn the latest medical advances and techniques.
       Some professionals are very frustrated with the new government officials installed by the U.S. They see them as little better than Saddam because they are in power for their own benefit and aren’t improving conditions for Iraqis.
       Muzaffar said listening to the Iraqi doctors talk made her sad because she could do nothing to fix the problem. What they were going through seemed surreal, conditions that we as Americans have never had to experience.

Reactions of Iraqi Civilians
       Iraqi professionals reported that when the Americans first arrived the civilians were very welcoming. At first the soldiers would play soccer with them and bring gifts to the children. When the insurgents starting killing members of the coalition, the whole scene changed. Now civilians feel the members of the coalition are indifferent or actively hostile toward them, no longer talking or interacting with them making it obvious that the coalition doesn’t trust anybody.
       Families traveling in cars must avoid coalition vehicles or face the possibility of being fired at. The coalition has become an ever present threat to their families. The troops cannot tell the good guys from the bad guys who want to kill them, so the policy is to shoot first and ask questions afterwards. They understand this need for extreme precautions, but they don’t like it.
       Many of the Iraqi men who were in the military under Saddam now have no jobs, resulting in a loss of identity. This has left them with feelings of shame and guilt, because without a role to play their lives have no meaning. With the men unemployed a heavier burden has fallen on the women to provide for and keep the family together. They as a group are showing many somatic symptoms from keeping their frustrations bottled up.
       There is much concern about the welfare and the future of the children and despondency as a result of not being able to make plans for them. Some children are adapting to the violent environment by becoming violent themselves. For example, two boys, 13 and 14, who had failed an important exam, threatened the teacher that they would bomb her home if she didn’t change their grades. She reported their threats. As a way to get their “problems gone,” they bombed her home and killed her.
       Without an effective police system the streets have become very dangerous, and children are frequently held for ransom. Criminals have some way of selecting those whose parents can pay. The physicians raised the question of how much do you warn children about the possibility that they will be kidnapped: Will it make them unduly fearful? Arshad Husain felt it was like preparing a child for fire or bomb attacks and encouraged adults to help the children make plans for this possibility.

The Training
       There was a marked difference between the July program in Jordan and the August program in Istanbul. In Jordan the Iraqi psychiatrists were very subdued. Most of them had not been out of Iraq in 25 years. They talked in low whispering voices as if they would get into trouble if they were overheard. They chose not to talk about what is happening in Iraq.
       The group in Jordan shared no personal stories and focused on learning what the team had to offer. It was obvious to the team that they were very traumatized and depressed. Some had brought their own children with them to see Husain, and others sought out Bauer for help with their own trauma reactions.
       Mental health treatment and facilities are very rudimentary in Iraq, and only one psychiatrist in the group had a child psychiatric clinic. They wanted to learn practical ways to deal with trauma and were appreciative of the training the team gave them. Many of them are looking for opportunities to come to the U.S. to study and be updated. Although they are concerned about their professions, they are more worried about their families and children, and if the opportunity arose they sent their children to the U.S.
       The second team’s training program in Istanbul was held in conjunction with the 21st meeting of the Arab Medical Association, a medical union of Arab physicians working in Europe. The association invited 30 professionals from Iraq and 70 showed up, many with their families expecting to have their expenses covered. The World Health Organization managed to find funding for them. Similar to the group in Jordan, this was the first time many of them had been allowed out of the country in 25 years. Because it was in conjunction with an international conference, the team had only two days for the trauma sessions.
        These physicians represented many disciplines, surgeons, pediatricians, general practitioners, but they all saw the relevance of trauma psychology and were very active participants.
         Bauer ran sessions on structured groups and individual techniques for trauma treatment, and Husain covered recent advances in child psychiatric diagnoses and treatment. In contrast to the previous group in Jordan the six psychiatrists and 19 other M.D.s who participated in the sessions were very open and willing to share. The members of this group were highly placed professors, deans and administrators.
         They wanted to vent their feelings about their common experience and how it is affecting education and their practices. In the sessions they focused on ways to protect and help their children. All spoke English and seemed ready to soak up information.
          The UMC team’s training approach is highly interactive calling for the practice of new skills by the participants and the involvement of the group in modifying treatment techniques to fit their particular patient population. The participants liked the hands-on techniques which they had a chance to practice and that they could make the material culturally specific.
          Although this form of training was new to them, both groups were highly appreciative of this approach and commented upon the team’s encouraging attitude and treatment of them as experts and being willing also to learn from them.
          As much as possible under the circumstances the UMC team members provided logical professional explanations for participants’ post-traumatic stress symptoms. This concern for their mental health on the part of the team was much appreciated.
         Just as the team was leaving Istanbul, two hotels in the city were bombed. The Kurdish Liberation group claimed responsibility. Since they had just been in Turkey, team members had to prove their identity when getting on the plane in Amsterdam.

Summing up the doctor’s attitude
        Our government officials have failed to see the situation in Iraq through the eyes of Muslims. We need to be aware of how Iraqis (and Muslims in general) are interpreting what we are doing, not only what we see as our intention. We feel our intention was to bring democracy to the Iraqis, but they do not see it that way. Our intention in their eyes was to establish a foothold in the Muslim world and control oil supplies. To do this we were willing to destroy Iraq’s infrastructure and kill a large number of Iraqis, both military and civilian. To get cooperation in rebuilding the nation this view needs to be considered as relevant in negotiations.