the crucible of iraq – causes and consequences

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This article was downloaded by: [University of California Davis] On: 21 October 2014, At: 23:07 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Medicine, Conflict and Survival Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/fmcs20 The crucible of Iraq – causes and consequences Jack Piachaud a & Sonali Sharma b a Medact , London b Cornell, USA Published online: 26 Mar 2008. To cite this article: Jack Piachaud & Sonali Sharma (2008) The crucible of Iraq – causes and consequences, Medicine, Conflict and Survival, 24:2, 115-129, DOI: 10.1080/13623690801950419 To link to this article: http://dx.doi.org/10.1080/13623690801950419 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub- licensing, systematic supply, or distribution in any form to anyone is expressly

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Page 1: The crucible of Iraq – causes and consequences

This article was downloaded by: [University of California Davis]On: 21 October 2014, At: 23:07Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

Medicine, Conflict and SurvivalPublication details, including instructions for authorsand subscription information:http://www.tandfonline.com/loi/fmcs20

The crucible of Iraq – causes andconsequencesJack Piachaud a & Sonali Sharma ba Medact , Londonb Cornell, USAPublished online: 26 Mar 2008.

To cite this article: Jack Piachaud & Sonali Sharma (2008) The crucible of Iraq– causes and consequences, Medicine, Conflict and Survival, 24:2, 115-129, DOI:10.1080/13623690801950419

To link to this article: http://dx.doi.org/10.1080/13623690801950419

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all theinformation (the “Content”) contained in the publications on our platform.However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, orsuitability for any purpose of the Content. Any opinions and views expressedin this publication are the opinions and views of the authors, and are not theviews of or endorsed by Taylor & Francis. The accuracy of the Content shouldnot be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions,claims, proceedings, demands, costs, expenses, damages, and other liabilitieswhatsoever or howsoever caused arising directly or indirectly in connectionwith, in relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes.Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly

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forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

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The Crucible of Iraq – causes and consequences

Jack Piachauda* and Sonali Sharmab

aMedact, London; bCornell, USA

(Accepted 14 January 2008)

War can be seen as a crucible in which global geopolitical forces act on apopulation in a transformative manner. The psychological impact ofwar can be described in many ways, from the diagnostic to the narrative,from the intrapersonal to the relational. This paper explores whether theforces driving the conflict relate to the consequent psychologicalprocesses of those caught up in it. Geopolitical drivers, underlyingglobal issues and the consequences on mental well-being are described.The models we use to define the consequences of war determine thedegree to which the causes are seen as relevant to restorative,transformational or therapeutic processes; however a simple modelreducing the consequences to traumatic events and symptoms, whilsthaving some validity, is not a sufficient description of the humanexperience. Understanding the causes and consequences of war is amultidisciplinary venture.

Keywords: globalization; Iraq; psychosocial; mental health; trauma; war

Introduction

Iraq has taken on an iconic meaning in human development and humandestruction. It was a key site for the development of civilization and the firstcities, a wonder of the ancient world in Babylon, the site of the firstuniversities and precursor of the European Renaissance, and now a cruciblein the ‘War on Terror’ and the ‘Clash of Civilizations’.

In its original definition a crucible is a device to transform chemicalsunder great heat; it may also be defined as a place, time, or situationcharacterized by the confluence of powerful intellectual, social, economic, orpolitical forces1. These forces act within the crucible, transforming thenature of society. Iraq has become such a place where these forces have ledto a long period of tyranny, sanctions and wars, which has had a verynegative impact on its people.

*Corresponding author. Email: [email protected]

Medicine, Conflict and SurvivalVol. 24, No. 2, April–June 2008, 115–129

ISSN 1362-3699 print/ISSN 1743-9396 online

� 2008 Taylor & Francis

DOI: 10.1080/13623690801950419

http://www.informaworld.com

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This paper approaches the matter from a mental health perspective andexplores the general question of how the mental suffering created by warmight be related to the causes of the war. Put another way, do the reasonsfor a war have direct bearing on the nature of the consequent psychologicalsuffering, or are the cause and consequence separated by a disruption insocial continuity? From a therapeutic perspective does understanding thecauses of the war have importance in how we respond in our therapeuticendeavours? Do the mental phenomena of the victims tell us anything aboutthe causes of the war?

To develop this enquiry an analysis of the crucible will be made lookingat the forces at play – the geopolitical context of the crucible and the broadissues that underpin the current conflict – and the contents of the crucible:the people of Iraq and their suffering. This analysis reflects a model commonin the psychological analysis of behavioural problems, to examine theprecipitants, the precursors and the consequences. It is common too to lookat the behaviours themselves, in this case the actual way the war is fought;this will not be examined in this paper, though that is not to deny itsrelevance.

The geopolitical drivers for the war, although related in a variety of waysto the underlying issues, examine the factors of ‘why these combatants atthis place and time’. For example an underlying issue might be the evolvingnature of sovereignty regarding the nation state, and whilst the weakening ofsovereignty may contribute to the emergence of conflict, it is not a directdriver. The sectarianism that emerged after the war may be a long-termunderlying issue, but it was provoked and stoked by the violence and theauthority vacuum, rather than being a direct cause of the war.

These three areas – the geopolitical drivers, the underlying issues and themental effects of the war on the people of Iraq – will be explored, followedby an attempt to draw them together into some continuity of cause andeffect. First there will be a brief look at how a health perspective mightaddress some of these matters of human and international relations.

War in the lens of health

The relationship of health to war is often seen as simply humanitarian,responding to the suffering created by the violence, as health scienceslooking at war dispassionately and carrying out epidemiological surveys andneeds assessments whilst the health services provide for that need. There is along history however of medical professions considering war as somethingto be prevented because of the morbidity and mortality associated with it2.Preventive medicine is not simply about vaccinations or biological matters,but contains an understanding of human behaviours, how to influence thesebehaviours and the political processes that shape the broader determinantsof health and health service delivery.

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Three models of health inform this paper and this analysis. Inunderstanding how policy emerges it is necessary to examine the contextand the content of the policy, as well as the processes and actors involved assuggested by Walt3; although this was originated for health policy it can beapplied to any political actions that impact on health. A public health modelis suggested by Sidel4 to examine political violence at primary, secondaryand tertiary levels of prevention – primary being the prevention of violenceitself, secondary being when violence is emergent but still containable, andtertiary when the violence has erupted and the health consequences must beameliorated. Finally, the bio-psycho-social model used in medicine, thoughby no means restricted to this discipline, allows examination of individualbiological factors, as well the developmental, the psychological and socialissues that determine health, health treatments and health-seekingbehaviours5.

The geopolitical drivers and precipitants of the war

The factors driving the invasion of Iraq cover a wide spectrum from currentglobal relationships in the marketplace to fears of nuclear weapons. It isimpossible to consider either the underlying issues or precipitants withoutconsidering globalization as an expression of the current global relationshipsbetween nations and other significant groupings. Whilst debate exists aboutthe nature of globalization6,7,8 and whether it represents a new phenomenonor an evolution of old practices, there is a general acceptance that newcommunications and markets have reduced the power of sovereign statesand that the transnational organizations, including massive corporationsand intergovernmental organizations such as the UN, the World TradeOrganization, World Bank and the International Monetary Fund, havegreat influence in global matters.

It is also clear that within the new global market there are winners andlosers9, and that one way to lose catastrophically is to become the place ofwar. An examination of several major conflicts such as those in theDemocratic Republic of Congo, Sierra Leone and Angola, suggests stronglythat control of important resources is a significant factor in these wars10. Topossess resources can of course be a boon in the present global markets, butfor poorer countries there is a complex balance: a failure to developsufficient state control is met by civil strife such as in the DRC and SierraLeone. To maintain control of those resources may lead to militaristic andrepressive systems, such as in Uzbekistan and Myanmar. However, attemptsto use those resources to develop power to break out of one’s place in themarket structure can be met with force and condemnation, a situationrelevant to Iraq.

The suggestion that oil was a precipitant for the war in Iraq createsstrong political debate. On one side there is a view that oil was the primary

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determinant for this war and that the essence of the ‘War on Terror’ is abattle between the US market-dominated world and a loose transnationalnetwork called Al Qaeda, that wishes all the oil in the Middle East to beunder the control of a single Islamic State. This is seen to be an asymmetricwar that will rumble on for many years through acts of domination, terrorand insurgency unless there is some political compromise11.

Whilst it is hard to refute this view, it is not all that needs to beconsidered. The emergence of the US as a market state and its use of militarypower to control and contain the globalized market needs recognition. Thecurrent state of the world can be seen as the end product of a ‘long war’ inwhich fascism, communism and market democracy vied for dominance12.Iraq has toyed with all three and at the time of the market democracy’striumph had been a useful client of the US but chose to break the rules byinvading Kuwait, then remained intransigent; maybe Saddam had believedthat in the new world order he would be rewarded by the new superpowerfor his stand against Iran during the 1980s. Iraq then became the example tothe world of what would happen if a sufficiently weak country did not keep tothe rules of the market place, and a period of crippling sanctions wasimposed. In 2001 following the election of GWBush as President, the politicswithin the US shifted to a stronger neo-liberal agenda that wished tostrengthen the political effects of globalization in the post-Cold War era. Inthis sense Iraq then became the scapegoat that was necessary for thesuperpower to establish its new role and global superiority13.

The view that Iraq posed no military threat because it was in fact abroken state has much evidence. Throughout the 1990s Iraq had beenreduced to a poor country, with the health of its people, its social capital,external contacts, freedom and liberty all in serious decline. The control ofsanctions was very great and the roles of weapons inspectors complex,reflecting the power the US exerted within the Security Council (SC) and theUN, even though other members of the SC spoke over the years about theconsequences of the sanctions on the people of Iraq and the need to resolvethe problems14.

A critical question is whether the war would have happened without the9/11 atrocity. For the US, the outrage that its own territory had beenexposed and open to attack was another important factor in its need todemonstrate power. There was an issue of sovereignty, that its ownboundaries had been transgressed; therefore other sovereign boundariesshould be open in any response. The declaration of ‘war’ is about the loss ofsovereignty as a protective device. The view that this is precisely what the AlQaeda leadership wanted warrants some consideration. The events of 9/11amounted to an act of great provocation, which led the US to retaliateand expose one of the current world’s greatest conflicts, that of secularversus spiritual leadership and the battle over which ideology shouldpredominate.

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The existence of a nuclear programme in Iraq is now much in doubt, butthe secrecy of all states is significant. Donald Rumsfeld’s phrase ‘unknownunknowns, the ones we don’t know we don’t know’15 or Tony Blair’s use ofthe ‘Precautionary Principle’16 to justify the war, indicate the level ofparanoia in international relations. The fear that Saddam could be gettingadvantage over those in global power by some secret means could easilyhave played a significant part. And even if there was no known relationshipwith terrorism, the possibility of nuclear material going to Al Qaeda mayhave heightened these paranoid thoughts. It is quite possible that as part ofthe provocation the Al Qaeda leadership would have enhanced thisparanoia.

There was for some the need to remove a tyrant and the wish to bringliberty to a people who had been subjugated for decades. Saddam had risento power and had maintained himself through a brutal regime with littleregard for human rights. There had been long opposition to his tyrannyfrom many global political quarters.

Through our health lens we see these geopolitical issues as representinganalysis of context, content, the actors and processes. From the publichealth perspective this is a secondary level analysis, as violence is emergentand the factors that lead to its actual eruption need to be understood if suchfuture eruptions are to be prevented. Whilst from the bio-psycho-socialperspective the main focus is on social political interactions, the realdecisions being made involve the psychological processes of the key actors,such as Saddam and the Bush Administration. These remain largely hiddenand speculative, though they deserve more consideration if a full under-standing of the path to war is to emerge, as do the biological anddevelopmental factors that might underpin aggressiveness in our politicalleaders.

The underlying issues

In today’s globalized world the crucible of Iraq has particular relevance tothe underlying themes of global order such as the role of the nation state, theroles of corporations and markets, the roles of transnational organizations,the new communication technologies and the global reaches of the greatpowers. These issues are relevant at a secondary level in our public healthanalysis as the product of political formations. There are however importantunderlying issues at a primary level, such as identity, belonging and beliefs,aspects of human nature that lie beneath the conflict in Iraq and perhaps allconflicts. Wars require soldiers, individuals who will fight and whosecollective efforts can drive political processes as much as the global politicsshape the precipitants of war. In this interaction between the political andthe personal there is debate as to which has precedence, but perhaps this is afalse dichotomy, as both need understanding.

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War, and a crucible, can be seen as a time when certain key themesemerge and come under trial, and the conclusion of this particular war willaffect the future course of the global community, not only in its politics butalso in beliefs, identities and understandings.

In some respects this was a war of globalization. Would sovereigntyprotect the ‘rogue state’, one that was operating outside the usual marketrules? The answer was another example that sovereignty will be overriddenif there is sufficient power to do so. The power of the transnational, the UNversus the corporate world, was also being tested, and the UN was sidelinedin decision-making and in post-conflict reconstruction. The US corporateinterest was enormous, with huge profits to be made, and the impact onhealth was disastrous through an imposed privatized health system with noexperience of managing post-conflict reconstruction17.

The United Nations had been established to ‘rid the world of the scourgeof war’; its failure to do so reflects the power of the transnational corpora-tions in relation to the member states. The wealthiest states are aligned tothese corporations, their wealth arising largely through these corporations;the poorest states are dependant on them for investments and trade. Thereare a few states that have new wealth and can challenge the existing order, butthe lesson of Iraq is that they must do so within certain limits.

A crucial issue in the crucible of Iraq is whether the United Nations cansurvive, reform and take on its original goal of providing global governanceand leadership, or whether it will fall further into being a super aid-agencyand global debating society.

The view that this was a humanitarian war needs some consideration.Sovereignty had also allowed tyrants like Saddam to brutally oppresspeople, and the international community’s responsibilities to protectpopulations had been promoted, even though this meant undermining thepower of the state. The failure to protect in situations such as Rwanda,Somalia and the DRC, and the economic or political self-interests ofinterventions that have taken place, culminating in the invasion if Iraq, haveif anything diminished the focus on this. However, the pressures built up bydecades of human rights abuses have found some expression in the causesand consequences of the war.

The media and communication aspects of this war have significance. Thepost-9/11 control of public awareness in the US and, despite the freedom ofthe press, the capacity for an alternative view to be sidelined in the run-up tothe war, is of crucial importance for future global issues18. The first actionin the war, with its description ‘shock and awe’, was designed not just for theIraqi people but for the world to see. It was the global demonstration ofpower and control with missiles and aircraft travelling half-way round theworld to deliver payload with pinpoint accuracy, with the pictures of thismade available for the world to see; that five or ten per cent of theseweapons failed in their accuracy was of no consequence to the military or

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media impact, though of great human significance. Within days theinfrastructure of a state can be demolished – power, communication,transport, water, sanitation, all swept away.

The control of information is another key trial, as the embedded pressinitially crafted the images coming out of the war. However, as the internetand new communication systems emerged during 2003, this could not becontrolled. Information started coming out through blogs and throughnetworks, and an alternative discourse of suffering rather than militarysuccess emerged. Although the fog of war remained because there was nodiscerning what was the truth, the anarchy of the internet severelychallenged the organized media, and several new websites took dominancesuch as Al Jazeera, finding corporate sponsorship more neutral to the USviewpoint. The power of the internet is on trial, and its capacity toundermine the corporate, state or military view will lead to greater pressurefor its censorship and control.

Of the more fundamental issues, identity, belonging and beliefs are ontrial in what some have called a clash of civilizations19, though this is toosimplistic a view and leads to examination of difference rather thancommonalities. The risk of going down this path is concerning, and somepolitical forces would welcome this type of rallying cry. The misuse of theword ‘crusade’ by Bush was leapt on by the media; whilst some thought this‘unthinking’, others perceived it as deliberate, to denote the Christianstruggle against Islam. There is little doubt that elements of radical Islam seethe battle in these terms and that individuals have powerful beliefs whichlead them to take violent actions, but to describe this war as a battle betweenthe Christian and the Islamic civilizations is far from the truth.

Whilst underlying issues do include the sanctity of Islam in a worlddominated by Christian market countries, the role of secular versus spiritualpower and longstanding divisions and interpretations of Islam, theglobal picture is far from a simple clash between two religions. Western-based transnational organizations and corporate entities have strong ties inMuslim-dominant states such as Indonesia and Malaysia and fully integrateoil-rich Arab States into the marketplace. Despite the purported religiousdivide that the fundamentalists see in the world, there is integration of thetwo paradigms, that of the western corporate world which is dominated bylargely secular/western states and that of countries which may be more Arabor Muslim but which participate and are integrated into the western,corporate endeavours. More importantly both Christianity and Islam arereligions that promote peace and condemn wanton killing; though both havetheir notions of just war, both have been used for violent political purposesand during these clashes elements within each accuse the other of beingwarlike.

These personal issues of identity and belief have more obvious relevanceto individuals caught up in the crucible. Whatever we may believe in this

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academic and globalized discourse, there are those caught up in this strugglefor whom it is principally a just war and a jihad against an aggressor. Thereare those caught up in a sectarian divide, some with passionate belief of theircorrectness, others with divided loyalties and even a divided sense of self,with parents from different sides of the divide. Secularism is also on trial inIraq as an often forgotten third element of sectarianism in addition to theSunni and Shi’a principles.

Through the health lens we see here some of the primary drivers ofconflict between human beings. The emergence of identity, as a develop-mental process, can create sides and divisions; belonging can be definedthrough exclusion of others. In a country so ravaged by war and violence forover thirty years there are risks of children emerging into adult identificationwith violence. There are some who see the biological innate human drivesfor violence as most important; others see the developmental and thepsychological as paramount; for others it is the social and political issues. Agreater understanding will emerge from a synthesis of the biological,psychological and the social factors at work.

The contents – the consequences of war

What then of the people in the crucible, those who are paying the price inhuman costs for this war? Through the health lens this is the tertiary level,when violence has erupted, and there have been several reports in the lastyear on the health consequences in Iraq20,21,22. The poor health and healthsystems are best understood in broad historical terms that reflect the driversand the issues, including the war with Iran during the 1980s, the long periodof poverty brought about by sanctions, failures to plan and invest, failuresof post-conflict reconstruction, poor human security, the exodus ofprofessional people who could escape the violence, as well the direct effectsof the war on injuries. In 30 years Iraq has moved from an aspiring middleranking economy with one of the best health services in the region23 to adamaged and all but failed state where 80% of people do not have access toeffective sanitation, 70% are without access to clean water and 40% with noaccess to the public food distribution system, 43% face absolute poverty andmore than 50% are without work22.

The mental well-being of Iraqi people must also be understood in termsof this history. For many there is a profound sense of loss, sadness andanger that their country has been destroyed in the battleground for globalforces that have little to do with the well-being of their people. The impact oftyranny includes direct and indirect effects on mental health24, throughtorture, brutality and bereavement as well as through the loss of socialcapital, the increase in paranoia and reductions in social trust. A householdsurvey in three southern Iraq cities demonstrates that since 1991approximately half (47%) of those households reported one or more abuses

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including torture, killings, disappearance, forced conscription, beating,gunshot wounds, kidnappings, being held hostage, bodily mutilation andothers, with 30% taking place between 2000 and mid-2003 and 70% ofabuses occurring in homes25.

There are some specifically vulnerable groups. With regard to women,the same study25 reports that 53% of those surveyed were in favour ofrestricting women’s pursuit of education and 50% in favour of restrictingwomen from working. 54% of women and 50% of male respondentsbelieved in the wife being beaten if she disobeys her husband. This raisesconcerns about human-rights abuses for women and also goes to the issuesof belief and identity on trial and how such matters might expressthemselves after this war.

Iraqi children and adolescents form more than 55% of the Iraqipopulation. Over the last two decades they have experienced high levels ofpsychological trauma, such as loss of parents due to imprisonment or death,dislocation of families, exposure to violence and conflict, and the witnessingof scenes of carnage; many have suffered religious and political persecution,detention and torture.

The sheer volume of Iraqis fleeing their homes is overwhelming innumber, including both internally displaced persons within Iraq andrefugees to neighbouring countries. The movement has placed undue stressupon the social and economic infrastructure of neighbouring countries andof particular regions in Iraq. Concurrently individuals are affected with thestresses placed upon them. Studies conducted among Iraqi refugees andasylum seekers may shed some light on mental health issues particular to theIraqi population.

Attempts to describe the effect that these noxious social environmentshave on people have led to a complex and difficult debate26, essentiallybetween those who see the social aspects of context, cause and rehabilitationas paramount and those who are drawn to the psychological sense ofsuffering and the search for an individual ‘cure’. The recent guidelines of theInter-Agency Standing Committee27 try to draw together these differentstrands by using the term ‘psychosocial’ for concepts and interventions thatrevolve around external circumstances and ‘mental disorder’ for those whichrevolve around individual problems. It also allows recognition that thosewith serious mental disorders, chronic illness and disability are a vulnerablegroup who require some specific attention.

One discourse allows symptoms to be identified, clustered and fordiagnoses to flow from this. For example, a study in Baghdad in 2006 showedthat 47% of children reported exposure to a major traumatic event during theprevious two years and 14% suffered post-traumatic stress disorder (PTSD).In a second study in Mosul, 30% of adolescents had symptoms of PTSD28.There will be a number of studies flowing out of Iraq now with data ofthis type, rates of depression, post-traumatic stress disorder and anxiety.

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These will be linked to life experiences, defined as traumatic events, andprogrammes will emerge to provide treatment for those with more severesymptoms. This views people as having similar basic responses to violence/bereavement/threat and is interested in describing the form rather than thecontent of their thoughts and emotions.

This approach describes the link between the symptoms of mentaldisorder and the war in a behaviourist manner, in that untoward events areseen as leading to symptom formation. This does not deny the humancultural context or subjective meaning, but does not identify it either. In thissense whether a bomb comes from one or other side, whether the sovereigntyis under threat or the corporations are transcendent, has no particularrelevance. These are precursors of the traumatic event, but it is the event notits precursors that creates the symptoms.

A range of therapies emerge focused on individual well-being, which maybe seen loosely within the bio-psycho-social framework. Biologicalinterventions are essentially drug-based and there is some evidence ofcertain antidepressants helping PTSD; in this model there is little need toexplore the content as the focus is on the symptom. Cognitive andbehavioural treatment strategies might look at the content of distress inorder to help individuals take control of distressing images and thoughts,but do not need to explore the personal meaning. Other psychotherapeuticresponses, however, may spend time exploring personal meaning, andconsider for example that a threat by a criminal group may have a differentimpact than a threat by a group intent on destroying the victim’s ethnicidentity, or that threats from invading forces might have different meaningfrom threats from local militias. In this way issues driving the war such aspolitical and ethnic tensions, sense of identity, belonging, the role andrelationship of the individual to the state and authority will have relevanceto the psychological injury and recovery.

Social responses in the personal suffering approach tend to focus onrehabilitation by providing group activities: work-based vocational pro-grammes focused on rehabilitation and encouraging social interactions.However, there is a different social discourse that does not make the indi-vidual the focus, but rather the social fabric that sustains people within theculture they inhabit. War is seen as damaging this social fabric, which in turnmay undermine informal and local networks, ultimately causing individualsto suffer. Attempts by outside agencies to heal only at an individual levelmay draw attention and resources away from repairing the social fabric andmay weaken, even destroy, local processes to develop social capital byfocusing on incapacity and treatments outside of the local culture.

Iraq is a society at the crossroads of many dilemmas, one being theadoption of western approaches versus traditional, reflecting the struggleswith globalizing influences. The solution proposed by the IASC is thatpsychosocial programmes aimed at helping recovery after conflict must

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include local actors and ideas and must look at what would develop well-being from the viewpoint of the participants. The more symptom-orientatedapproaches would establish mental health programmes, also with localdialogue, and offer treatments to those who had become more clearlyincapacitated. Within the IASC framework the social and symptom-orientated approaches are not mutually incompatible; it is a question ofbalance.

Engagement with the traditional sector in Iraq needs consideration, andat present little is being made of it, though it is important to note that themental-health planning groups set up by the Ministry of Health weremultidisciplinary and included Imams of both Sunni and Shi’a denomina-tions as well as other religions. However, traditions in this respect includenot only the roles of key leaders or matters of the spirit, but also practicesthat deal with grief and loss; notions of mourning and communityinvolvement will be important to understand, as will their regional andsectarian variations.

Within the social discourse, issues of justice and truth are fundamental toindividual well-being as well as political reconciliation, such matters relatingdirectly to the drivers of the conflict29. Research from a mental-healthperspective in Iraq,25 Kosovo30 and East Timor31 show that the wish forjustice remains prominent in people’s minds and that hatred and the desirefor revenge bear only a loose association with symptoms of mental disorder.For some the actions of courts such as the International Criminal Tribunalfor the former Yugoslavia (ICTY) may have punished the prominent figuresbut did nothing to solve the local feelings of injustice, whilst for others, aTruth Commission process may satisfy some part of community need butallows others who are thought to be guilty to walk free. The question ‘why’is important. Can the reasons for the loss and suffering be accepted or dothey represent injustice? This must depend in part on a person’s view of thecauses. There is also evidence that people with strong beliefs, whetherpolitical or religious, have greater resilience in dealing with the traumas ofwar.

The notion of resilience, that most people seem to come through theseevents, after time, without ‘symptoms’ or mental disorders, is important tobear in mind as it is all too easy to imagine that all people caught up in warbecome disabled in some way. To discount resilience leads to approachesthat do not enable populations and that deal with everyone as if they aredysfunctional.

The relationship between well-being and mental disorder needs furtherinvestigation. The more individual discourse tends to see them as separate,whilst the social discourse suggests that the focus on symptoms misses thesekey concerns for communities in conflict or post conflict. In terms ofrelationship between the mental phenomena, the issues and the drivers ofwar, the notions of justice might range from local disputes, sectarian divides

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to the role of corporations and the ownership of oil. For some their mentalanguish may be tied to a local matter, for others their anguish may only beresolved when justice over global matters has been achieved.

Conclusion

This paper uses the notion of a crucible as a metaphor for war, as a placewhere powerful forces act in a transformative manner on the contents. Thesepowerful forces are the drivers of the war in Iraq and underlying global andhuman issues leading to conflict, whilst the contents are the people of Iraqand the mental health consequences of the war. The question being exploredis how these might be related to each other. It looks at the issues through ahealth lens, loosely using three models of analysis of health and healthsystems that consider politics and process, different stages in the emergenceof human violence and a recognition that biological, psychological andsocial science all have a role to play in understanding these matters. Thereare connections between the drivers and the underlying issues to do withglobalization such as the dominance of Western ideas, the ways thatcorporations have come to dominate other global institutions, such as theUN and national sovereignty, and the need for the superpower todemonstrate its control of the global system. These link with thepsychological consequences in the minds of some through the need toexplain the loss and the suffering. When there is close personal loss and thereasons for the violence are seen as unjust, then anger, hatred and the desirefor revenge may overwhelm mental processes.

There are connections between underlying issues such as belief systemsand identity and the content of mental anguish related to the war, beliefsand identity themselves being under threat and changing due to globalprocesses. Changes in the media and speed of communication are likely toaffect how it feels to be caught up in a war, for some elements of thepopulation. For others, perhaps the most vulnerable, internally displaced orin refugee camps, the global matters may have little significance for theirpsychological states, except in how the global community responds to this interms of finance, resources and understanding. It is hard to see how specificissues such as Western fear and dissemblance regarding nuclear weaponsbear a direct relationship to the psychological state of people in Iraq.

Looking at the consequences of war elicits two major views, thesymptomatic and the social. Those views that tend towards the moreindividual and the bio-psychological find models that see violence as the keyfactor, creating traumatic events, whilst the reasons for the violence seem ofless importance. In this model there is a discontinuity; the social processesdetermining the actions have little bearing on the mental phenomena. Ananalogy is that the bullet causes physical harm, regardless of the intention ofthe shooter.

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However the mind is not the province of the body, and in consideringmental phenomena there is a direct connection with the social environment.For a range of psychological treatments the focus is on the relationshipbetween the self and the world, so the meanings within the conflict willemerge. Issues of identity, relationship to the cause of suffering, personalmeanings and understandings of why the violence occurred, and moral andspiritual beliefs will all have relevance. In this way, this discourse reflectssome of the underlying issues.

The social discourse, with the emphasis on justice and truth, inevitablyrelates matters of well-being to the issues that caused the war, the drivers ofthe war and the needs for restitution. The injustice that some have profitedfrom the war, the wish to bring those who perpetrated dreadful crimes tojustice, are ideas that may intrude into the minds of some, causinganguish and suffering; though the opinion of what constitutes a crime will behighly personal. The issue of casualties, currently hotly debated as anepidemiological matter32, is of great personal importance; who died and atwhose hands remains critical, and directly contributes to politicalreconciliation efforts and post-conflict reconstruction. Work in Bosnia hasshown how important these matters are for reconciliation processes andalso for the emotional recovery of those bereaved; not only who caused thedeath but ‘why’ remains a vital question and clearly links with the causes ofthe war33.

In conclusion, the relationship between mental health, the underlyingcauses and drivers of war is determined to a large extent by the model ofunderstanding of mental health, as from one perspective, however importantthe causes are to international relations, it is the violence itself, the traumaticevents that cause the mental problems, and these are independent from thepolitics. This reduction has some validity, but this paper essentially arguesthat it cannot be the whole picture. Also, whether one takes a broad socialunderstanding of mental health or a focused individual view, issues ofprevention are important. The drivers and the underlying themes, whilstprimarily in the political and economic spheres, are deeply relevant to healthand therefore within the province of health professionals. These are mattersof Global Health and of Human Security which demand a multidisciplinaryapproach in research and practice.

At individual and societal levels there will be huge variations inexperiences, knowledge and understanding, as well as the degree to whichthe violence affects mental health. The personal meanings and socialconstructions have importance. One strand of the multidisciplinary workwill be to consider more closely the words and views of those caught up inthe crucible and how these relate to the global drivers and underlying issues,as well as to the personal experience. The exploration of the question ‘why’is not only to resolve feelings at a personal level but also to consider howsuch suffering can be prevented.

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Notes on contributors

Jack Piachaud is a psychiatrist and member of the Medact Conflict and Healthgroup. He also works at the Medical Foundation for the Care of Victims of Tortureand is Editor ofMedicine Conflict and Survival. He is an Honorary Senior Lecturer atImperial College London.

Sonali Sharma is a resident psychiatrist at the New York Presbyterian Hospital,Payne Whitney Clinic, and a post-graduate student at Cornell University, New York.She spent a research elective at Medact in August and September 2007 to studymental health policy in Iraq.

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