Himson often dreamed of going home. Twenty years had passed since he lived in his village, but Ranuata was always there for hm. A vision persisted, behind the present moment, of woven sago and people sitting on the swept earth. He took off his heavy police boots, intending to remain at his desk and think about village life. Tattered manila folders, documents, padlocks, he ignored. The other men worked, writing, making phonecalls. Outside, the air was perfectly still, and the sun was hot. Coconut palms stood tall and motionless beside a glassy sea. A chicken clucked. Children shouted on the beach.

The young Tolai bloke came in from the duty room. He had copper skin and a baby face with fuzzy eyelashes. Himson warmed to his ready smile. Himson was Tolai too, so this was his wantok or clansman. He had even once looked somewhat the same, when he was fit and young. His workmates called him Midnight Fox and had stuck a comic book drawing on the wall behind his seat of a gaunt fox silhouetted by the moon. But nowadays this was a joke against his fat neck and pot belly. He smiled back at his young counterpart.

‘Bloody, fucking Bougainville,’ the young man said as he presented some routine problem.

Himson did not like their current posting either and accepted the tone of the remark, though he would not have spoken in the same way himself. He accepted too that the young bloke wore a dirty t-shirt despite being on duty. Young blokes should be allowed to do things the modern way, he thought, even if the modern way was a bit slovenly. He accepted that everything was a bit slovenly now. The longer we go from getting independence the more slovenly we become in New Guinea, he knew and accepted. He gave the young bloke some information and the keys to a police vehicle, and then tried to think of his home again.

This Bougainville posting was bad luck, he thought instead. Too many of his postings felt like bad luck. You might expect that as a new recruit, since police force policy determined that younger men should not work close to home. They should discharge their duties without clan-related bias. But Himson was not new and was still getting moved from one foreign district to another. It puzzled him to have so little power over his life, how other men got promotions and privileges. People moved so freely around New Guinea nowadays that he found wantoks everywhere anyway. He went out of his way to favour them, just to thwart the system. Not that it gave him much satisfaction. He discharged his duties with increasing carelessness, as so many of his colleagues did. At least he still had his mother’s land at Ranuata to go back to, and his sister’s children there. He had savings too, but he was getting tired. 

He was tired of unfamiliar men and their unfamiliar women and children. These men and women would not look him in the eye when they spoke to him and pretended not to understand his reply. In particular he was tired of men he did not care for, shouting in their own language and stinking of alcohol.

He heard shouting now. A fellow policeman was making heavy weather of a conversation on the phone. There was a fight at a road block on the Arawa Road, the man finally announced. Furthermore he was not going to the incident as there were guns involved. Then everyone decided to go.

 No use thinking about home now. Himson pulled on his boots again and made his way to Security to get fresh incident forms. As usual he thought of his money there, well hidden in one of the Security files. On a whim, while everyone was preoccupied elsewhere, he took it and locked it in the drawer of his desk instead, before going out to the cars.

The Army manned the road block to which they had been summoned, and of course there were guns involved for this reason. The war in Bougainville was supposed to be over, but you would not know it. Were policemen needed too? Then Himson noticed one police vehicle already there. It had been abandoned, blocked by a crowd of local people who stood sullenly on either side of the army barricade with their own vehicles laden, as usual, with market produce. None of them was doing much, but if anyone was out of control it was the soldiers, some of whom gesticulated wildly with anger or excitement.

‘Stupid bastards,’ the policemen said to each other. ‘And look at your wantok,’ one of them said to HImson.

The young Tolai policeman was on top of the cabin of an army truck, in the company of two Tolai soldiers. He had taken off his shirt and was sporting an army rifle. Himson felt humiliated on their behalf, by the blatancy of the racial get together. He had erred along these lines himself, but never so publicly. He had done worse, perhaps, but never so dangerously. In Moresby once he had stolen his boss’s car to visit his cousins, but afterwards had turned up at the boss’s house to drive his missus to market. That turned it into a great joke. He was handsome then, too, and the missus liked him. But this was no joke. No-one like to see these young Tolai blokes together with guns on the army truck roof.

It was impossible to reach them, or even attract their attention. The policemen watched events unfold from behind the crowd that blocked their way. Other soldiers were rough-handling two local men on the back of the same truck. The men kept breaking free and shouting to the impassive crowd, until a young woman carrying an infant came forward and attempted to talk to the soldiers. Then she tried to talk to the young ones on the truck roof. Then the young Tolai policemen on the roof fired his army rifle at her, striking her in the arm and narrowly missing her baby.

A great wail went up from the crowd. Himson wailed too, in shock. He and other policemen struggled on foot through the mass of people. The wailing was mixed with angry shouting now. Himson knew they had to get their young colleague away from here, before he was killed. They found him huddled behind the truck. Himson handcuffed him, and a group of them surrounded him and got him back to their car.

‘Let me take him to the station,’ Himson said.

The others agreed. ‘Your wantok,’ they said angrily.

‘Something no good,’ he said. ‘No good.’

They wanted to stay to see what the crowd would do next, while Himson and his prisoner left.

‘Something no good,’ Himson said again to his captive, on the drive back to the station, angry too. His mind struggled to grasp what had happened. They passed the airstrip on their way along the palm-fringed coast.

At the station they sat on either side of Himson’s desk, avoiding each other’s eyes. The young one, bare-chested, sullen, looked even more of a boy now.

‘What can we do?’ Himson asked him.

‘Bloody Bougainville,’ the boy said. ‘I want to go.’

‘Go where?’

‘I want to go home.’

Himson thought hard about this. He wanted to go home too, more than ever. Eventually he opened his desk drawer and took out the money. He unlocked his wantok’s handcuffs. Then he gave the young bloke his money.

We arrived for our excursion at the worst time of day. It was noon when we parked the car, and the air was hot. To make matters worse, the car-park proved to be some distance from the rock paintings at Oberi. Green melaleucas burned against a cloudless sky.

Sweat trickled inside my clothes as we picked our way along the path of crumbling stone.  I saw that Mother’s face was flushed with blotchy red on cheeks and forehead.

‘You all right?’ I asked.

‘Look.’ She pointed ahead.

A rustling in the thin grass might have been a lizard or a snake. Then I saw little birds, miniature parakeets, scuttling through the undergrowth. We are on an adventure, after all, I thought. This might have been a walk on our own hill at Yarrambat, thousands of miles away, years ago.

We pressed on stolidly.

‘And there’s the Rainbow Serpent,’ Mother said some time later, pointing to a smooth rock face, and the first of the Aboriginal paintings.

‘How do you know?’

‘Of course it is, Tim.’

A notice-board informed us of other things. Paintings are widespread in this area, some dating from up to ten thousand years in age.

The walk required a steeper climb after that, over slabs of fallen rock. It would have been difficult for anyone, and the unprotected skin of Mother’s leg proved thin as paper.

‘Too old,’ she apologised, as pricklets of blood started from her scraped calf. She panted, and stared vacantly for a moment.

I cleaned the graze as best I could with some of our drinking water and a tissue.

‘There’s the Rainbow Serpent in that one,’ Mother said again, pointing to another painting up ahead.

‘No, not in that one.’

‘Of course it is, Tim.’

Then there were more paintings – so many we may have both felt overwhelmed. Some were easy to discern, others almost lost in the natural markings of the rock: lichen stains, or the splash of bird droppings, or the wearing of a tree branch with the wind. Newer paintings overlay the old, their orientations and relationships confused. Some were difficult to reach. There was no relief from the sun.

‘It might be easier to look at a book of reproductions,’ I complained. ‘And we could do with an account of what the paintings mean.’

We made out men and birds. We saw a thylacine, now extinct. I knew that. Reptiles and fish sometimes included the skeleton within. I made a joke to Mother about ‘old bones’.

‘Were these done by the Aborigines, Tim?’ she asked.

I should be used to Mother’s lapses by now, but this one caught me off guard. “Yes,’ I said carefully. ‘Careful where you step.’

Once she might have told me much about the paintings herself. She would have read up in advance. Now she had forgotten what we had come to see. Once she would have prepared meticulously, and I would have relied on her to tell me about what we were doing. She might have recounted the myths, and what was known of the artists’ intentions.

I exaggerated what she was once like, out of dismay perhaps? The heat was taking its toll on both of us. Yet I could not spare myself the awfulness of how she was becoming, like fingering a wound.

She’ll come good after a bit, I reminded myself. Her attention waxed and waned these days, though it had been worse lately. For the time being I ignored her, hovering at my elbow, and examined the paintings more intensely than before. I would get what I could from the occasion, I told myself. No longer bothered by discomforts, I tried to imagine what these pictures looked like to their ancient guardians over the centuries that had gone before. A sort of language declared itself by degrees, I thought, in the repeating patterns, the particular strangeness of the style, the recurring images. I saw a language foreign to us but familiar to this place.

I may be trying too hard, I thought, but only briefly. I was trying to conceive of ten thousand years passing, and people living out their span here, with these paintings an enduring aspect of their lives.

I spoke to Mother again. ‘We are looking across an enormous gulf of time,’ I told her.

‘Two little girls in blue, they called us,’ she replied, referring to herself as a child and to her friend Peggy who had lived next door.

The ceiling of one shallow cave teemed with the flying shapes of birds and fishes, captured in a net of intersecting lines. Each alone would have wielded slight effect, but the overall display of haphazard overlappings, of part obliteration, of resistance to obliteration, spoke to me, at any rate, of comings and goings, of reworkings, of reknowings.

Mother limped on our way back to the car. I continued to brood over my imaginings.

‘Enjoying yourself, Tim?’ she said.

‘Yes, I am. Sort of.’

‘I thought you’d like it.’

‘How’s that?’

“When I brought you on this holiday.’

‘Mother, it was me who brought you.’

‘No. Did you, Tim?’

I went round to the passenger side to unlock Mother’s door. I helped her in and did up her seat belt for her. The buckle was almost too hot to touch.

‘Careful,’ I said again

I got in, fixed my own belt, and began to drive. I held the hot steering-wheel with my finger tips, waiting for the air-conditioning to take effect. We bounced over the rutted gravel surface then came round a corner and found ourselves hurtling towards a group of Aboriginal people, who scattered before us. They had been walking in the middle of the road.

Back at the Kakadu Motor Inn I chatted to the keeper of the souvenir and book shop. I had bought a guide to the rock-art, a soft-covered Archaeology of the Dreamtime.

‘Will this tell me,’ I asked him, ‘what the paintings mean to the Aborigines themselves?’

He looked a good-humoured man, though a bit large and restless for his line of work. ‘No,’ he said, to my surprise. ‘No way you can find that out.’

‘You’re joking. There must be,’ I said.

‘The Aborigines themselves won’t tell you,’ he said, ‘so how can a book?’

‘Yes, they will,’  I said. ‘We have only to ask them, and I’m sure their myths have been recorded by researchers. Their myths and the paintings must match each other somehow .’

‘A pictorial guide, you reckon?’

‘I think so.’

‘More likely the paintings are their myths,’ he said.

I did not know what he meant by that.

I came back to him later, having looked around the shop. ‘There must have been research done,’ I said again. ‘Haven’t some white people won the Aborigines’ trust?’

‘Nothing to do with trust, mate,’ he persisted. ‘There’s one white man had that for sure. Bill Hartley? You heard of him? He was a kind of honorary Abo in these parts a few years back, and he reckoned it was important to get all the stories from the old men, before it was too late, and to match the pictures to each one, as you say.’

‘That’s right.’

‘So he took a few of them around your Oberi Rock area, discussing each painting, writing it all down.’

He paused to sell postcards to another customer.

‘Then he went back with the same old fellows a few months later, just to check on the finer points, and, what do you know, the stories were all different.’

‘How come?’

‘You tell me,’ he said. ‘Maybe they mean something different every time you look.’

I found Mother examining bark paintings hung along the back wall of the shop. They looked a lot like the rock art, and I decided to buy one. The elongated shapes of lizards, and men, and native geese, overlaid one another in the same way, like fallen leaves, though the sharpness of the angles and clarity of the outlines gave out a more nervous energy.

I tackled the shop-keeper again as I was paying. ‘It says on the back that these are of Mimi and Namorodo spirits of the Gunwinngu tribe,’ I told him.

‘That’s what they tell the tourists,’ he grunted.

‘Like me. I’m a tourist and I’m your customer,’ I said.

‘Oh yes,’ he said. ‘So you are, mate. I must have forgotten.’ He smiled for the first time.

‘I like all the paintings,’ Mother said. ‘They are all lovely. So Australian.’

When we got outside we came face to face with a family of Aborigines bringing more paintings to the shop. They made their way awkwardly across the motel grounds, holding multiple slabs of bark tied together with long grass. I tried not to stare, but I was truly startled by their appearance. I have spent my life in Australia but, like many white people, have seen few full-blood Aborigines. The postage-stamp familiarity of their features surprised me. They were live people looking as old as the landscape. They turned their eyes away, and the man hurried past us lithely, despite the discomfort of our encounter. The woman and children shrank back, keeping close to one another. One small boy peeped up from beneath his heavy brows, only to withdraw his glance when I tried to smile at him. That was all. We exchanged no greetings.

Mother and I went for a swim next, in the motel pool. She was game for that, despite her years, and we were both refreshed. She must have been all right again, at that stage, and I was slightly elated by my purchases from the shop. I went down the water-slide, taking turns with boisterous children, and a young Scandinavian couple probably on their honeymoon, and one other man too drunk, as far as I could tell, to know what he was doing.

Later, back in our room, I told Mum she was a good old soul, and she said I was a good boy. I am fifty-two, and we both laughed at that.

‘It’s funny,’ I said, ’how this place does make me remember childhood in Yarrambat all those years ago. Were we more like the Aborigines ourselves then?’

‘We lived off the land, anyway.’

‘And loved the land better than we do now,’ I said, ‘didn’t we Mother?’

I remembered how a great throng of us had once gone on an outing up our hill. We had hurled ourselves into a wild run down again, through the untouched bush towards our farm. I remembered the feeling of abandonment to the steep slope, flying faster than I could normally run, my legs working automatically, compelled by the descent. I remembered my chest heaving, my feet thudding on the soft earth, and flinging myself from side to side to weave between the trees. Below lay the flat valley floor of fenced paddocks crosscut with rabbit runs, and home.

We had all left Yarrambat now, trapping ourselves in the bland complexities of city life. But we had not forgotten.

Mother and I went for our tea in the Kakadu Kafe. In the centre of the room glowed an octagonal aquarium large enough to hold twenty or thirty gliding barramundi, some half a meter in length, the colour of polished pewter in the green water. Wooden beams supported the tank, and between them the brightly lit panels flickered with the fishes’ movements, like television screens.

I got up from the table to look more closely. The clarity of the fishes’ outlines, and the detail and complexity of their markings, seemed to increase as I gazed. Something about the way the aquarium was lit emphasised the fact that the fishes lived and moved in three-dimensional space. Languidly they rose and fell, ancient creatures intertwining swim-paths, their fish-eyes revolving, their  mouths agape without words. Yet they were contained here. They turned abruptly as they neared the glass.

‘Wonderful,’ I said. ‘I wish I could take one of these tanks home too.’

‘Fish!’ said Mother in mock disgust. Her face quivered in the ensuing pause.

I still watched the drifting, silver shapes.

‘They look like ghosts,’ she said.

‘They’re alive.’

‘They look like they are in their coffin.’

I realised then that they might be there to be eaten by the customers. We ordered something else.

As we waited for the food to be brought, we talked about Yarrambat again, and our hill, and the creek, and times before I was born.

‘Mary Keep and I …’ said Mother, naming another of her childhood friends . She mumbled as she continued.

I had heard the story before, anyway, many times. It had fascinated me when I was small to hear these repeated tales of my mother’s early life.

‘Two little girls in blue …’ she told me again.

But did she really picture that now, as she spoke? Seventy years had gone by of telling it. Did I really listen anew? Or only recall what I had imagined from her past descriptions? Did I remember my own memory of it more than hers? I saw the little girls in a backyard much as our backyard had been, though with a special look, perhaps, of being hers, a look of proper, old-fashioned family life.

‘… and that’s how I broke it,’ she said.

‘How you broke what, Mother?’

‘My wrist. don’t you remember?’

‘What?’ I knew she had broken her wrist only last year. I lost control of the situation after that, and we argued pointlessly. I still expected her to be able to sort out her jumbled thoughts.

‘You’re not worth talking to,’ I said.

‘Tim!’

‘You’re not worth being with.’

She would not look at me then. She pressed her lips together and stared past me.

‘We shouldn’t get like this,’ I said. ‘We’re both angry.’

‘Not me,’ she said. ‘I’m ashamed. I’m ashamed of you.’

‘But I’m the one left, having to think for both of us.’

‘So I should just drop dead, should I?’

She would die soon, I knew. I felt ashamed too, thinking how well she had always treated me. ‘I’m sorry,’ I said.

‘Oh, go and look at your fish again!’

‘I said I’m sorry, Mother.’

‘Go and look at your fish, and leave me alone.’

Later, getting ready for bed, I pretended nothing had happened, though I felt upset. Even when she went to clean her teeth in the communal bathroom and did not return, I pretended everything was fine. I looked at my painting and my Dreamtime book, and felt annoyed again by the shop-keeper’s remarks. Eventually I realised she must be lost.

At first I tried to find her on my own, without success. I felt embarrassed having to get help.

‘You and the wife had a bit of a domestic, have we?’ the man on reception asked impertinently when I finally reported the problem to him.

I explained that I was talking about my mother, and that she was old.

‘So what’s she doing here if she’s not up to it?’ he said, just as rudely.

‘She still has the right!’ I was angry with him too, now.

He ignored my tone. ‘We’ll all have to look for her, then,’ he said.

And all the night staff did just that. They grumbled about it, but a dozen men relinquished their television watching, and the staff-room pool table, to make a torchlight search. Intersecting walkways connecting the various blocks of the Motor Inn, and adjacent caravan site, presented something of a maze by night. I just hoped Mother had stayed within the system. But she was not on any of the paths.

We found her in the Aboriginal camp. She must have walked through the bush to the dim light from their spirit lamps. She was sitting on the bare earth. An old man had his arm around her. In the other hand he held the bottle of beer he was drinking.

‘She all right, Mister,’ he said.

‘I’m all right, Tim,’ she said.

An Australian psychiatrist’s experiences in the Middle East in 2009

Introduction

It happened quite suddenly. For many years I had loved my work as an analytic psychotherapist in Melbourne, and I was content.  My patients, it seemed to me, were more thoughtful than other people, their lives more deeply intriguing, more tragic, more courageous, inventive and surprising. I knew how to listen to them as no-one else could – how gentle and yet unyielding I should be, if they were to leave past traumas behind – if they were to be free without asking why. A multitude of precious and delicate tasks filled my days. How could I abandon such a life? Why would I want to?

Extricating myself took time, thought and care, like ending a multitude of little love affairs, leaving one’s lovers hurt but equipped to love again. I diminished my practice daily until my consulting rooms were empty, lit blankly by the sun, waiting for their future occupants without me. I longed now for participation in the outside world; not only to know others but to interact and be known; to work alongside people I admired, or perhaps did not admire, and make my contribution to a working team.

So it was that I joined an international humanitarian organisation and became responsible, for six months in 2009, for the psychiatric care of the patients on an acute burns unit in northern Iraq. I was afraid, of course, as I set out, knowing what everyone did about Iraq. I also had my particular health concerns. I had an atypical and undiagnosed lung condition. I had had a heart attack and recovered. My right knee was prone to give way, and my neck to get stiff, and I was subject to bouts of melancholy and anxiety which I could manage but not avoid. I was also subject to bouts of intense excitement, still young at sixty-two. I decided, in fact, to write a journal of my experience, partly as therapy for myself.

The Kurds, who were to be my patients and colleagues in the northern city of Sulaimaniyah, are only secondarily Iraqis. They have every reason to regret their inclusion in that country, against their wishes; every reason to be disaffected with the Arab majority there. As an ethnic group their domain extends well outside Iraq anyway, across borders drawn by European powers less than a hundred years ago. The generally mountainous region they call Kurdistan spans parts of what we designate Iraq, but also parts of Iran, Syria, and Turkey. The Kurds display maps of their purported homeland on office walls, though it has never existed as a country. Central to it is Lake Van in eastern Turkey, the memory of which, in ancient times, is sometimes thought to have provided the story of the Garden of Eden – a story which later spread throughout the Middle East. Among the many testaments to the antiquity of the region are the remains of an eleven-thousand-year-old stone temple in the Kurdish part of Turkey, six thousand years older than the pyramids of Egypt. Elaborate animal carvings decorate its gigantic pillars, the earliest of their kind ever found in modern times.

Kurdistan is situated midway along the ‘fertile crescent’, extending from the Arabian Gulf to Egypt, which supported the beginning of Western civilization. Humans cultivated wheat for the first time in Kurdistan and herded the first sheep. Wild wheat still grows in the region, wild sheep still roam, and Kurdish shepherds still lead their flocks on the mountainsides. Kurdish people were also the first in the Middle East to ride horses, and Kurdish mountain horsemen in traditional dress remain an impressive sight. They are said to have taught horsemanship to the Ancient Assyrians, and the breed of horse known as ‘Arabian’ comes from them.

Of the forty-five million Kurds of today – the fourth largest group of Middle Eastern people and the biggest without a state – the majority still live in Iraq, Iran, Turkey and Syria, but with a significant diaspora in the cities of western Turkey, Armenia, Georgia, Israel, Azerbaijan, Russia, Lebanon and, in recent decades, some European countries, chiefly Germany and the United States. As regards the term ‘Kurdish’, it appears in Arabic sources in the early Middle Ages, referring to an amalgam of nomadic western Iranic tribes, who were distinct from Persians, and who wandered this vast area with their sheep and their horses. The idea of a single Kurdish people gradually materialised with clear evidence of the Kurdish ethnic identity and solidarity in texts of the Twelfth and Thirteenth Centuries. They speak the Kurdish languages, which are related to those of Iran, Afghanistan and Pakistan, rather than to Arabic or Hebrew, and which are members of the Iranian branch of Indo-European languages, rather than Semitic.

In the modern country of Iraq, with its reluctant collection of diverse peoples, six million Kurds make up approximately seventeen percent of the population. They occupy mainly the three northern provinces, now known as the Autonomous Region of  Kurdistan. No similar autonomous region is available to Kurds in Turkey, Syria or Iran, and nor was it in Iraq until recently. As in Syria and Turkey, the Kurds in Iraq have suffered long-running persecution by the majority. From 1960 until the 1990s the Iraqi Kurds engaged in heavy fighting to protect themselves from successive Arab regimes in Baghdad. In1970, Iraq announced a peace plan, but also started an ‘Arabisation’ program in the oil-rich Kurdish regions of Kirkuk and Khanaqin, displacing Kurds from their homes in order that Arabs could lay claim to the oil. Such a ‘peace agreement’ did not last long, for obvious reasons, and in 1974 the Iraqi government began a new offensive against Kurdish objections to their displacement from oil rich areas. In 1975, an Iraqi government accord with Iran cut supplies to Iraqi Kurds, and started another wave of ‘Arabisation’, with more Arabs moving to the oil fields, particularly those around Kirkuk, and more Kurds being deported to other parts of the country.

In the 1980s, during the Iran-Iraq War, the Iraqi regime’s anti-Kurdish policies meant that a de facto civil war broke out. The Baghdad regime was verbally condemned by the international community, but was not held to account at the time, for oppressive measures against the Kurds, such as the mass murder of civilians, the destruction of villages and the forced deportation of thousands of them to southern and central Iraq. This genocidal campaign, called the Anfal (‘Spoils of War’), led to the destruction of over two thousand villages and the killing of 182,000 Kurdish civilians. The villages have since been rebuilt in concrete, but without visual evidence of their extraordinary antiquity, and the current population of Kurds includes the absence of a large proportion of one whole generation of males. The waging of the Anfal also involved the use of torture prisons, mass firing squads and the infamous attack on the Kurdish town of Halabja in 1988, using chemical weapons supplied by the United States, killing five thousand civilians. In Sulaimaniyah, where I spent my time, Azadi Park (‘Freedom Park’) had been the site of a mass slaughter of Kurdish men, commemorated by gruesome sculptures set among the flowerbeds of today. The international community did little to help them, choosing in their actions to support Saddam Hussein’s regime and continuing to supply it with the military equipment and weapons used in the Anfal.

A Kurdish uprising succeeded in throwing off this oppression for a while, but in March 1991, Iraqi troops recaptured most of the areas the Kurds had claimed. One-and-a-half million Kurds abandoned their homes and fled to the Turkish and Iranian borders. Again, the international community offered no immediate help. It is estimated that close to another twenty thousand Kurds died of exhaustion, lack of food, and exposure to cold and disease. Citizens of Sulaimaniyah I got to know in 2009 remembered this well. The United Nations Security Council eventually passed Resolution 688 condemning the repression of Iraqi Kurdish civilians and demanding that Iraq allow immediate access to international humanitarian organisations. Kurdish guerrillas also re-captured Erbil and Sulaimaniyah from Iraqi troops. The Iraqi government retaliated by imposing a food and fuel embargo on the Kurds, and by stopping pay to civil servants in the Kurdish region. These measures backfired, however. The Kurds held parliamentary elections in 1992 and established the Kurdistan Regional Government (KRG).

Meanwhile the Arabs of the Iraq region have their own long and illustrious history. It has been a troubled history, but, viewed long term, no more so than the history of other parts of the world, including Europe. Modern Iraq corresponds to the area the ancient Greeks called Mesopotamia and was the site of the earliest developments of the Neolithic Revolution from around 10,000 BC. It has been identified as having inspired some of the most important developments in human history including the invention of the wheel, the planting of the first cereal crops and the development of cursive script, mathematics, astronomy and agriculture.

The Sumerians and Akkadians (including Assyrians and Babylonians) dominated Mesopotamia from the beginning of written history (c. 3100 BC) until the fall of Babylon in 539 BC. They invented metal-working, glass making, textile weaving, flood control, water storage, and irrigation. They were also one of the first Bronze Age societies in the world, developing from copper, bronze, and gold on to iron. They decorated palaces with hundreds of kilograms of these very expensive metals, as well as using copper, bronze and iron for weapons and armour. Libraries were extant in towns and temples during the Babylonian Empire, women as well as men learned to read and write and many Babylonian literary works are still studied today. One of the most famous of these is the Epic of Gilgamesh, which they inherited from the Sumerians. Civilisations of the area influenced the Abrahamic religions too, especially the Hebrew Bible; their cultural values and literary influence are said to be especially evident in the Book of Genesis.

Among the most notable architectural remains from early Mesopotamia are the temple complexes at Uruk from the 4th millennium BC, and the Arabic name of Babylonia, al-ʿIrāq, derives from the name Uruk

In 636AD, the Caliphate seized control of Mesopotamia and built a new Islamic empire. Baghdad became the hub of a huge dominion extending from North Africa to the Indian subcontinent and an important centre of learning, culture and science. In 1258, the Mongols destroyed Baghdad. Three hundred years later Mesopotamia became part of the Ottoman Empire, and continued in decline until the beginning of the 20th century. During World War I, Britain took over what is now Iraq, establishing its current borders. Iraq gained independence in 1932, though Britain re-occupied it briefly during World War II.

In 1958, the military ousted the monarchy there, and, in 1968, the Baathists seized power, promoting the concept of one secular Arab nation with health care and education for all. Baghdad now became a centre of Arab nationalism, and Saddam Hussein assumed office in this context in 1979. His regime provoked successive revolts inside Iraq, however, in particular in the Kurdish north but also in the Shia south, and the regime conducted one military operation after another to brutally suppress these. In the south, the defeat of Iraq in the Gulf War triggered a Shia uprising in 1991, eventually crushed by the army, but reinstated by the Americans after the 2003 invasion. Iraq has since descended into chaos, with increasing resentment of the US invasion and occupation, and its results. A subsequent lack of political progress, or social cohesion, has increased and continues unabated.

The Kurdish population initially welcomed the Americans, not surprisingly, holding celebrations of their new freedom. The Pesh Merga (‘ready to die’) freedom fighters expanded their area of control, and Kurds gained effective jurisdiction in Kirkuk and parts of Mosul. In 2005 a new Iraqi constitution recognized the authority of the Kurdistan Regional Government and the legality of its laws and regulations, and, in 2006, the two Kurdish administrations of Erbil and Sulaimaniyah were unified.

The American presence did not remain a blessing for the Kurds, however. As the occupying US forces removed educators and administrators from public services throughout Iraq, for being members of the previously ruling Baath party, and replaced them with former freedom fighters and others, not necessarily competent to do these jobs, life became increasingly difficult for Kurds in the north as it did for everyone else. Governments and government departments throughout Iraq proved frequently more corrupt and more self-serving than their predecessors had been, and the previously helpful role of tribal leaders was negated. In addition, the US occupation favoured one religious group over another throughout the country. Opposition to the US was chiefly Sunni – this was called the ‘insurgency’ – and those benefitting from the American presence were chiefly Shia . The US recruited the newly-empowered Shias to assist with the ‘counterinsurgency’ in persecution of the previously ruling Sunnis. This included assisting Shias to kill and torture Sunnis, dramatically increasing existing sectarian hostilities. Shias also attacked the long-suffering Kurds. A series of bombings of Yazidi Kurds in Nineveh became the deadliest suicide attacks since the war had begun, killing eight hundred civilians and wounding one-and-a-half thousand more.

By 2009, when I was there, medical services, and the health of the population of Iraq, had been greatly impeded by all of the above. Hundreds of thousands of Iraqis had been killed as a result of the invasion and occupation, and hundreds of thousands of others left with life-long disabilities and disfigurements, largely untreated, as well as severe psychological scars, mainly not treated at all. The once high-functioning health service had been decimated in many parts of the country, with untold additional consequences. Chronic illnesses, such as diabetes, hypertension, or chronic mental illnesses, also went largely untreated. Very few new doctors and nurses had been trained for many years, a large number of medical students had abandoned their studies, and a large proportion of trained personnel had left the country. The respected medical schools and teaching hospitals in Baghdad has become a shadow of what was once in place. The remaining health care services had also become largely privatised and much more expensive, making them out of the reach of many. Loss of infrastructure, electricity, safe water, sanitation, and housing added to these health consequences. Nor had these problems been addressed to any extent by the invaders, nor by the dysfunctional new governments of Iraq. Nor had doctors globally paid sufficient attention to this situation to make much difference. International organisations, such as the International Red Cross, and various others, helped treat a small number of the victims of armed conflict – and continued to do so – and contributed a very small amount to restoring disrupted health services. For the most part, however, these matters went unheeded by the global community, and ineptly addressed within the country. As far as I know, this remains the case.

In addition, in 2009, trying to pursue a career in health services, or of any other kind, or to run a business, was fraught with difficulties for the citizens of Iraq, unimaginable to us in the Western World. Young people’s efforts to advance themselves by studying for qualifications, or doing their job well, went unrewarded compared to the advantages of having parents in positions of influence, or being a member of the right political party. And the population in Iraq is mostly young people. More than fifty percent are younger than 20 years of age, while a self-serving older generation now maintained this dysfunctional organisation of public affairs. Nothing seemed to work as it should, when I was there.

Kurdistan is theoretically wealthy because of its rich oil deposits, but its cities, at that time, looked like those in some of the poorest countries in the world, and life for ordinary people was grossly impoverished. Added to this, the destruction of the former social order throughout Iraq, including the destruction of centres of excellence that had been established in Baghdad in various fields of endeavour, had left intelligent and ambitious young Kurdish people with nowhere to pursue excellence in their own country, and little chance of going elsewhere. No other country was likely to give them a visa, apparently for fear they would apply for asylum once abroad. Extreme sectarian violence that had developed during the US occupation continued, as well as uncurbed criminal activities of all kinds. This included frequent kidnapping of people from all walks of life, to be tortured and killed, or held for ransom.

So great was their frustration and grief at this outcome that, despite Saddam Hussein’s attempted genocide and their gratitude for his removal from power, by 2009, when I was there, many Kurds were of the opinion that the American invasion had cost them so much they could not bear to talk about it. That is to say, the wholesale disruption of the status quo in Iraq had, in the long run, made life so much harder for everyone, not better. This is pretty unbearable for us, in the West, to think about too.

Some expressed long standing mistrust of the West, anyway. Britain had repeatedly betrayed them in the past, and had directly attacked them under Churchill’s orders in the 1920s. Others expressed contempt for the ignorance and ineptitude of the Americans since the 2003 invasion, in dismissing good people and placing criminals in positions of power, they said. Yet no-one I met expressed a desire for violent revenge against the West. They would be unlikely to say this to me, however. The main object of their anger remained the Arabs in general. Interestingly, when Israel was mentioned, their feelings about it were of indifference, neither for nor against the Israeli state, though I once heard one describe the Palestinians as ‘trouble makers’.

Many Kurds continued to think in terms of establishing their own country independent of the Arabs, taking their rich oil deposits with them. A great restlessness of this kind was apparent among them while I was there. Others were profoundly disappointed by the treatment they were receiving from fellow Kurds in positions of power, even though they had their Kurdish autonomy within Iraq. They warned that only rich and powerful Kurds would benefit from a Kurdish breakaway, anyway, who would engineer to keep the oil money for themselves. We might as well remain part of Iraq, they said. Although I heard both points of view in 2009, I do not know how prevalent either of them was at that time.

I must admit I knew little of any of this before I set out. Foolish as this may sound, my initial ignorance was part of the adventure. Less foolish, perhaps, was my desire to see things for myself.

My Arrival in Jordan and Iraq

I am startled to find, not for the first time in my life, just how many people there are in the world, and how like me they are, after all. From the upstairs window of my apartment in teeming Amman, where I am to spend a few days in transit, I watch children play in a dusty courtyard below my window. A boy of about nine years has only an older girl of about twelve to play with, his sister I suppose, and a little boy of five. They have devised a game with a ball, a bush, a clothesline, and a pile of bricks. I realise, watching the boy play, how familiar to me is that unavoidable conflict between wanting to be together with the others, and loved, and to do things as taught, versus wanting to be the one who matters, who wins at any cost, and not the other one, who does not matter. I cannot remember being nine specifically, yet I know how that is for the Ammani boy. They play another game in which he carries first his younger brother, on his back, from the grass on one side of a wide path to the other, then his big sister, but shouts at her when she will not carry him. Other children arrive, and they forget this disagreement.

I have no prior thoughts on how Amman might look. It is built on a cluster of rocky hills, and its builders have carved quarries out of these, even in the middle of town, to get the stones, I presume, for the buildings on the hilltops, down the remaining slopes, and along the valleys. They have also made cuttings for some of the roads. The place is all rock faces and stone town combined. The buildings are mainly not high – three or four stories –  similar to one another and square, mainly cream-coloured, like the streets, though some are grey, and some pale coral pink. Some are eye-pleasing in themselves, in the disposition of windows and arches and solid balconies. Others are inoffensively cubic. Dusty olive trees and cypress line some streets, with occasionally a scrawny lemon tree. The people wear mainly black or grey or white, and drive dark-coloured cars. Signboards, and even advertisements, are in pale colors, or black, or grey. The overall uniformity, the muted tones, the buildings marching up and down the cut-up slopes, makes it seem more like a picture of a place than anywhere real. Or perhaps that is an effect of my jet-lag, coming only yesterday from the other side of the world.

I share my accommodation with a big Iraqi man from Baghdad, Hadj Ashalaf, who spends a long time in our bathroom, makes a lot of loud, disconcerting noises in there, leaving everything waterlogged and steamed-up. He is very friendly, on the other hand, enjoys my stories, laughs at my jokes, and tells me the people of Amman are extremely boring, they are so rule-bound, make so little fuss of one another, laugh so little, and have no community, compared to the people of Baghdad, despite their troubles. A well-dressed, very formal Iraqi surgeon, who shows me round the plastic-surgery project at the hospital next day, says the same thing, and that there are large numbers of Iraqis stuck in Jordan, longing for the liveliness of their former home. Iraqi people can joke about anything, he says, including even the Americans, and send each other many funny emails. He tells me a joke about an Englishman, an American, and an Iraqi, who have died and gone to Hell: the Englishman asks the angel there if he can phone home, is allowed to do so for five minutes and is charged one million pounds because of the difficulty of ringing from Hell; the American makes a similar request, gets to speak for one minute, and has to pay ten million US dollars; then the Iraqi rings home, speaks for an hour, and pays only ten Iraqi dinars. When the others complain, the angel explains that for an Iraqi telephoning from Hell is a local call.

The surgeon also tells me that people in the rest of Iraq make jokes about the Kurds, in the north of the country, as being very countrified and mentally impaired – like English jokes about the Irish, I suppose. Since I am on my way to Kurdistan I do not find this encouraging. Then, getting on the plane to go there, a day later, I notice some very slow-moving stolid folk with large faces. Some have magnificent, long noses, with a prominent bridge, perhaps a bit like their sheep. I find later, however, that most Kurds are good-looking, lively, friendly people, though they wear some far-out clothes.

I have some idea of what my destination, the city of Sulaimaniyah, will be like, having looked it up on the internet, seen pictures, and read an introductory report – though not how to spell the name correctly. It seems to be spelled differently every time it is written, even in official documents, or on official signs.

I do not, however, anticipate the magnificence of its setting. The surrounding mountains are spectacularly high and snow-capped. Viewing them from the air, I do not recognise them from the pictures, nor as being like other great mountain ranges I have seen. They form a vast bowl, with Sulaimaniyah a splatter of tiny human constructions in the bottom. The plain is very green – it is early Spring – but once on the ground, I do not recognise it either as like other green places, mainly because it is so dusty despite the green surface. There are few trees, except for scattered Australian eucalypts near to houses and in the town parks, and these with dust-coated leaves. Azadi Park, in the centre of town, is pleasant, nonetheless, with Spring blossoms and Kurdish men in pairs, or groups, out for a stroll, or lounging at the kiosks that sell strange wares, or Sprite, or Coca Cola. Young men are in jeans, but the older men wear baggy woolen trousers with long lengths of cloth wound round their waists. Their brown faces are more European than I expected – some look like my English granddad when he was very old.

During the post-World War I British occupation of the newly created state of Iraq, Sulaymaniyah was the center of nascent Kurdish nationalism, I discover, and the main street is named after a freedom fighter who died in a British massacre here. With Kurdistan’s subsequent inclusion in Arab Iraq, it enjoyed a few further years of greater autonomy than other western Kurdish cities like Erbil and Mosul, and the city serves as one of the metropolis of Iraqi Kurdistan  under the Kurdistan Regional Government. Since 2005, the two major political groups among Iraqi Kurds, the KDP and the PUK have set aside rivalries and manage to occupy strategic position on the Iraqi political chessboard, by actively participating in the establishment of a central government and providing military forces (Peshmergas) to the US-led coalition. But internal Kurdish tensions remain and the region is de facto separated between PUK/Sulaimaniyah governorate and PDK/Erbil/Dohuk governorates. Sulaymaniyah is also known for its strong economic ties with Iran, and, being close to the border, many Kurdish families have relatives there.

It was not Arabised in the past, presumably because it has no oil, but since 2005 many Arab Iraqis running away from unsecured areas in the south of the country have resettled in Kurdistan region, including Sulaymaniyah, which is considered as a relatively safe place. The population of this city remains largely Kurdish, nevertheless. It has also become a tourist attraction for Iraqis and other Middle Easterners, due to its relative security and natural beauty and also its monuments to Kurdish suffering.

On my first walk through Azardi park I see groups of boys climbing happily on public monuments commemorating the massacre, in Saddam Hussein’s time, of thousands of their kind. Not many women are out walking. Occasionally there is a young couple, and sometimes a young family. I see a wedding party, with the men in pale gray suits, the bride in voluminous white with a veil, and the other women in traditional Kurdish dress of purple, green and orange, and much gold. They communicate with me in gestures, wanting me either to take a photograph of them – though I do not have my camera – or to join them in being photographed – which I prefer not to. The little children, I notice, are really nice, with black hair, clear skin and bright eyes.

The town itself has the busy, confused air of Asian cities I have been to, with many different things happening, or being sold, or being made on the streets, or in open workshops – hammering, welding, grinding, next to racks of clothes, next to sweet shops, next to produce stalls. The fruit and vegetables are diverse, large and healthy-looking, and things generally cleaner and sweeter-smelling than Asian cities tend to be. Kurdish music, heard everywhere people gather, is heartfelt and tuneful. The solid buildings are brick, or stucco of brown, yellow, pink or blue.

The houses in the quality suburb where I live with expatriate colleagues are similarly coloured and quite grand, with a strange combination of architectural features and ornaments – columns, arches, geometric patterns of tiles, elaborate window panes. I have a large upstairs room with a good view – out one window anyway – of town and mountains. My room contains two large double beds, two large wardrobes and a plastic table and chairs, leaving little space to move about. My curtains are cream-coloured, with red roses and streaming ribbons, and my two unmatched bedspreads all sorts of colours. I wish I could move some of the furniture elsewhere, but the other rooms have the same oversupply. I decide to sleep on the edge of one bed and to use the other to spread papers and books. ‘This is where you are for six months,’ I remind myself. ‘Make yourself at home.’

The bathroom is intimidating at first, with water jets instead of toilet paper, and my housemates like the heating on high, while I keep opening windows. Once I have got to know them better I will re-arrange the furniture in the large living area downstairs, at least, I decide, which could be more comfortable than it is. One housemate, Ken, a logistician from Liberia, tells me he is also new and has just come from establishing the physical supports for a huge feeding project in southern Sudan assisting thousands of starving people. He has come here, to this more-established project, for an easier time. Because of his African accent I do not understood a lot of what he says, but can see he knows a lot about plumbing, or electrics, or computers, or bath plugs. Another housemate, Darren from southern England, is one of two nurses responsible for infection control on the burns unit where we work. He is tall and thin, and likes rugby, but gets inordinately offended when I ask, on my first morning, why he takes so long taking a shower. It takes some days for us to re-establish friendly relations after that. Then there is Jameel, a nurse from Afghanistan, who talks constantly about women despite their extraordinary unavailability to young men in Sulaymaniyah. This scarcity will not be a problem for me, but I talk at length to Jameel about it. He is intelligent, playful and vain, wears stylish clothes, and seems likely to become my best friend here.

I arrived on this project on Thursday March 26^th, 2009. My predecessor, Lotte, an Austrian psychiatrist, told me she had loved the job. She gave a handover and introduction, over the next few days, to the work of the Mental Health team and to its other two members. She had stayed on, after her term had ended, for this purpose. I am sure she was well liked in return. I liked her too.

I take on the role of heading the Mental Health team myself from Monday March 30^th, 2009. Everyone I have dealt with along the way, in Australia, in Amman, and in Sulaimaniyah, has been welcoming and helpful and efficient. I am well-pleased. The burns unit is very busy, however, the patients very young, and very severely burned, the mortality rate high. I do not know how much I can help.

April 2009

A fine dust hangs in the air here, which varies from day to day. Some mornings the view from my window is clear and bright, and I see the surrounding mountains cut out cleanly against a blue sky. On other days, through the dust, the sun looks like a silver moon, and we cannot open the windows anywhere in the house without getting everything dusty. Sometimes I wake in the middle of the night, unable to breathe through my nose. There is a lot of lightning and thunder. The brown rain makes the cars dirty, and the man living opposite us is forever washing and polishing his to gleaming white again. I tell him it looks beautiful, and he smiles with very white teeth.

I manage, by hook or by crook, to clear my room of excess furniture, and to feel at home in it now. I have a dusty plant in a plastic pot, and have seen sumptuous Persian rugs for sale in the market for less than a hundred dollars.

I continue to like my housemates very much. Ken, the African from Liberia, has the face of a baby, but is a wise baby, I find. He shouts a lot, even in ordinary conversation, and in language I cannot always comprehend. What I do follow is interesting and informative, about Africa, and about his work as a logistician on this and many other humanitarian projects. He shows me pictures of his four little daughters in Freetown, two of whom look exactly like him. He also makes a speech when Lotte, the psychiatrist working in my post before me, is leaving,  that has everyone in tears.

Darren, the English nurse, comes from rural Dorset where he sings in a choir. He has St Matthew’s Passion on his computer, I notice. He continues to spend too long in the shower in the morning, and makes me late for work once or twice. I now get up earlier than him.

As for the handsome and neatly-shaped Jameel, the infection control nurse from Afghanistan, he has no car to polish, as our neighbour does, but shines his shoes daily. He has brilliant computer hardware, as far as I can judge, and expensive socks and underwear, and speaks eight different Eastern languages, he tells me. In English he says intelligent things about our work here – matching my thoughts, anyway – and I am finding him to be a good sounding board as I become acquainted with my role. He continues to talk about women and wants someone to go out hunting for them with him. But who? Not me. I tell him that I am enjoying the life of a monk, with only a small room to live in, and only the possessions from Australia I brought here by plane.

It is Jameel who helps me to clear the surplus furniture from my room, by showing me a secret space full of furniture under the house. He also offers his assistance in moving large items, but we get stuck with a wardrobe halfway out the door of my room, unable to turn it on the landing to take it downstairs. The more we manoeuver, the more wedged it becomes, until our arms ache with exhaustion and we collapse in laughter on the floor, knowing no-one can get to any upstairs room now, or even to the bathroom. Ken comes to see what we were doing and shouts at us, which makes us laugh more, which makes him shout more. Finally he does whatever is needed to solve the problem, and that is that. We are like a bunch of schoolboys sometimes.

I suffer another schoolboy mishap the next day, which does not make me laugh, and which I tell no-one about.  My walk to and from work takes me across Azadi Park  twice daily, where the foliage on the spindly trees is becoming every day denser and greener, and more and more flowers are blooming. Despite the history of violence and fighting to survive, the streets of Sulaymaniyah give the impression that I could not have found a gentler place, in which Azadi Park, despite being the site of a massacre, is the gentlest spot. In the busy centre of this city of one-and-a-half million, people are friendly and helpful, cars stop for me when I go to cross the road to the park, shopkeepers give me the right change without question when I buy bread on the way home, and, in the evening, café-owners run after me to return the money I leave as a tip. Much of the city is built of poor-quality, crumbling concrete, and everywhere looks down-at-heel, but nowhere do you see groups of surly people, or even aggressively-dressed young people, or graffiti, or evidence of vandalism. Women in public avoid all contact, but older men often greet me and say ‘welcome’ in English, and young men meet my eye with a shy smile, rather than ignore me, as they might do elsewhere. And from the very centre you see the background of the mountains in all directions, and have the sense of being cradled in Nature, even if it is a bit dusty.

The first few times I walk to and from work, I do so with at least one of my housemates. Then, on one particular evening, I finish work later than the others and set off for home alone. From the hospital to the park, the walk is fine. Nor is the walk across the park any problem. But between the park and our house I lose my way. We have an agreement to have our mobile phones with us at all times, for security purposes, but I do not have mine. I know the name of our street, but meet no-one who speaks English. Nor can I read the Kurdish street names in Arabic script, nor even work out how they would be pronounced.  I decide to retrace my steps to the park and try again, but am unable to find my way back either. Nor are there any taxis. I cannot believe what a predicament I had got into, so quickly and so hopelessly. I become panicky, hurrying along unfamiliar streets, turning this way and that. Suddenly I come across a kebab shop I went to with my housemates a few days earlier, and my way home is simple from there.

At the hospital, the Kurdish junior plastic surgeons are gracious and knowledgeable, and present case reports well at the daily morning meetings. They discuss the physical problems intelligently and, apparently, with due concern. One of them, Dr Abdulrachman, tells me proudly that his name in Arabic means servant to Allah’s compassion. I notice, however, that they have remarkably little personal relationship with their patients compared to Australian doctors. I wonder if part of my job might be to encourage this, since I am here to support the patients’ mental wellbeing. They write up the patients’ notes each day after a very brief round with one of the senior consultants, and after checking the results of blood tests and bacteriological examinations, but rarely speak to the patients in person.  Even when called back to the wards later in the day, or in the evening, as problems arise, they deal with these by speaking only to the nurses, I find, and possibly changing the medication or nursing instructions, but usually without actually examining the patient concerned, let alone having a conversation with him or her. Nor do they see why a psychiatrist should be involved in caring for people with severe burns, even though Lotte was here before me, doing the same job. They say how much they liked her, and that they are very pleased to have me here too, even if I am of no use. So that surprises me : the friendliness on the streets, the friendliness and courtesy of the young doctors, coupled with the indifference of those young doctors towards their patients as people, and their ignorance of possible psychological aspects of their patients’ care, and what my role might be.

Lotte informed me during her handover that my job is fourfold. She divided the tasks into psychiatric care of patients, plus facilitating a helpful relationship between doctors, nurses and patients, plus providing emotional support to the staff in general, in view of the stressful nature of their work, plus providing training in basic psychiatry and psychotherapy to the mental health team. Ok, I told her, I can do that. I will divide up my working day accordingly. She also advised me, to attend the meeting, at the start of each, between the consultants, junior doctors, project coordinator, project medical officer and representatives of the nursing staff, physiotherapists and laboratory technicians. At this meeting the junior doctor who has been on duty the night before, or over the weekend, runs through all the patients, very briefly, mentioning new admissions, discharges and deaths, and particular problems in the management of some established patients. Whichever consultants are present, usually only one or two of them, and everyone else, give some feed-back and advice. Another junior doctors, or occasionally a consultant,  then gives a prepared talk, sometimes in the form of a detailed account of a past patient’s presentation, management and outcome, and sometimes a report and discussion on a topic relevant to the unit. They expect me to provide this talk on some occasions.

Lotte also advised me to go on the junior doctors’ morning ward round, usually with just one of the consultants, which follows this meeting, to take members of my team, and to contribute to the discussion of individual cases. The ward round is conducted by a different consultant each day, and amounts to a quick dash past all the patients on five wards. There is little discussion, in fact, apart from the consultant for that day issuing orders to junior doctors in Kurdish. Many of the orders are received with sighs and rolling of the eyes by juniors who have a more detailed knowledge of the cases anyway. If there is anything useful I can contribute, I have to interrupt in English, and get little response from anyone. The nurses and physiotherapists generally say nothing and are never addressed.

I think initially, after experiencing the first few such meetings and rounds, that there must be some other occasions on which the admitting doctors present each new case in detail to their seniors, as is the custom in Australia. This is when the consultants would provide comments on the junior doctors’ assessment and management plan, as part of their training and supervision. This is when all concerned would further plan and coordinate the ongoing care of each patients. I soon learn otherwise, however. The morning meeting handovers and hasty ward rounds are all the consultants provide. I wonder if they might give additional teaching and training to juniors during wound care and skin grafting in the operating theatres, but soon learn that this is not the case either. Nor are the junior doctors allocated to particular consultants, as in Australia. Nor are the patients themselves allocated to particular consultants, or particular juniors, responsible for their care. Everyone looks after all of them part-time, when on duty, without having opportunities for communication with the others. Nor are the patients’ notes a source of detailed information either.

This makes my job of assisting in patient care, by offering psychiatric advice, particularly difficult. No-one in particular is going to refer a case to me and my team for psychiatric help, and there is no one in particular to whom we can report our findings and advice. How can this work?

Visiting the wards is also a distressing experience for me at first, for other reasons. Our patients’ burns are severe and extensive. When their dressings have been removed for the morning round, it is like walking through a butcher’s shop with skinned carcasses everywhere. Without dressings to protect their skinless flesh, the patients cannot rest their arms and legs on the bed, or even allow them to touch one another. They hold their red-raw limbs aloft as best they can, above their red-raw torsos, shaking with the prolonged effort of doing so. Sometimes the doctors by-pass them, or barely look at them, anyway. The majority of patients are young women, burned by flames in gas explosions in their kitchens or bathrooms at home, or by having their long, loose clothes catch fire. The men also have flame burns usually, due to industrial accidents, and some electrical burns. The children are more likely to have been scalded by upset boiling water or tea. A small number of men, women and children have burns caused by market-place bombs, but most injuries are not directly related to the war.

The burns hospital complex comprises separate buildings for each ward plus a utility and administration block, all set in pleasant gardens. I am told it was once a primary school. We have an admissions and outpatient area, separate wards for men, women and children, and an intensive-care ward for the most severe cases of all kinds. The regimen on the intensive-care ward, where the patients are nursed in individual rooms, restricts visitors to one or two close relatives for each, and requires all staff members to change from street clothes, before entering, to freshly-laundered hospital gowns, masks and shoe-coverings.

I cannot help noticing on the morning ward rounds, however, that even on the intensive care ward, in contradiction of the gowning precautions, the doctors go from patient to patient, touching the wounds of some, touching the bed clothes or the clip-board notes of others, without wearing gloves or washing their hands. Yet I know, as all doctors do, that infection control is half the battle in caring for burns. Is it my concern, however? Lotte did not mention worrying about the patients’ physical care too.

Apart from the four burns wards, there is also an additional ‘special ward’ in the complex, to which the consultant plastic surgeons can admit some other non-burns plastic surgery cases from their private rooms, free of charge. Are these my concern?

Upstairs in the utility and administration building, above the laboratory, store rooms, kitchen and cafeteria, are the offices of the project co-ordinator, project medical officer, administration, logistics and finance staff and the head of nursing. Everyone else complains about how rarely any of these descends to ground level to see what is actually going on. I worry about this too.

Detached, in the centre of the complex and surrounded by lawns and gardens, is a single-roomed hut allocated to the three-person psychiatric team – me, a female interpreter experienced in psychiatric work, Alya, and a male social worker, Baktiah. Lotte secured these separate premises for us through long, hard negotiations with the project administration, the other two tell me. She also furnished the single room ‘like a little bit of Europe’, as the patients describe it, and equipped it with toys and activities for the children. We also keep our patient files and other records here, use it to interview ambulant patients and staff members in confidence, and to run children’s play groups and adult psychotherapy groups.

My first impression of the two other mental health team members, Alya and Baktiah, recruited by Lotte, is that they are both remarkable for their good looks. They were chosen from a large number of applicants, and I presume, at first, that Lotte must have had an eye for beauty in making her selection. Later, I find that had nothing to do with it, but enjoy working with such striking individuals nevertheless. Alya, a former medical student in Baghdad, whose studies there ended with the American invasion, became a physiotherapist at this hospital in her home town subsequently. Our organisation allocated her to the mental health team as interpreter because of her linguistic abilities and good sense. She likes the role very much, she says, but it puts her in a precarious position, I am told by others, with regard to being employed in future by anyone else. She is not continuing with the physiotherapy for which she is qualified and has no formal qualifications for the work she is currently doing.  She is single, in her thirties and dresses in European style. I soon come to see her, in addition, as the most intelligent and astute person in the hospital, a fountain of information, good advice and wise insights, as well as having a beautiful face. How lucky I am to have her. She is familiar with the hospital environment and the nature of burns care, has worked with Lotte before me, is naturally gifted as a counselor herself and is aware of other organisations in Sulaymaniah that might assist our patients on discharge. Her contribution goes far beyond that of an interpreter. I later find she also respects the patients’ confidentiality in a way that few others working here do.

Baktiah, a black-eyed young man in his early twenties, got the job, he says, because he was the only one of many social work applicants, male and female, who felt able to cope with the confronting appearance of the burns patients he would be caring for. Baktiah has familiarised himself with the nature of burns patient care, and has also been trained in mental health work by my predecessor. I am pleased to have him too. So are the children, all of whom love Baktiah. Lotte allocated him to work on the children’s ward in particular, and I continue this. The male head nurse on the children’s ward is also Baktiah’s best friend at the hospital.

That young men here get on well with children is not surprising. Half the population is under eighteen years of age and there are children everywhere. Almost all adults, male and female, have daily responsibilities caring for one or more of them. Baktiah has both older and younger brothers and sisters, and many young nieces, nephews and cousins, he tells me.

His employment prospects are also possibly jeopardised by working for our organisation. The Department of Health does not employ social workers and would not employ Baktiah in health care if we did not do so. Nor will we be here forever. In Kurdistan at present, all social workers must work for the Ministry of Social Affairs which then allocates them to schools or other services, without giving the individual much choice in this. The Kurdish Ministry of Social Affairs has a particularly bad reputation for being disorganised and for rejecting qualified social worker applications for scant reason. Baktiah tells me he has no need to worry, however, since his father is in the military.

After the morning meeting and ward round, my team and I re-visit each of the wards every day, including the ‘special’ ward for non-burns patients, to talk with both patients and their relatives at greater length, and also with the staff on each ward. Some former patients also come to see us in our hut, after attending the hospital outpatients department for dressings. Patients and relatives speak mainly Kurdish, and a few speak Arabic, both of which Alya can interpret. Most of the staff speak some English They speak in Kurdish to one another and in English to me.

Initially I decide not to learn Kurdish myself, since it is such a rare language, spoken by only a few million people. I find, however, that it is closely related to Farsi, spoken in Iran, to Pashto and Dari, spoken in Afghanistan, and to Urdu, spoken in Pakistan and northern India. Jameel, my house mate from Afghanistan, for example, finds it easy to understand. This distribution of related languages corresponds to the area once covered by the ancient Persian Empire, and several hundred million people speak them. So I am learning a little Kurdish after all, taught mainly by Baktiah. The children find it amusing hearing me trying to count, ek, du, chey, shwa…, and race ahead counting to twenty before I can.

Baktiah sometimes accompanies Alya and me on our ward visits, and sometimes sees patients on his own. He discusses their difficulties with me later, and what he might do to help. In the early afternoons we welcome the children, with their mothers to our little hut, to play with the toys and to talk to us there. Baktiah supervises the children’s play, Alya talks to the mothers, and I write up notes and complete statistics. Later we discuss the work together, and I teach them some basic psychiatry and psychotherapy, building on what they learned from Lotte.  Towards the end of the day, when Alya and Baktiah have gone, some individual staff members come to discuss their personal problems with me in confidence.

Almost all the patients love just telling us a little bit about themselves, they are so bereft of conversation and friendships. A lot suffer from acute post traumatic stress related to the occasion on which they were burned, and have flash backs and nightmares of the gas explosion, or their clothes catching fire, or the samovar falling over. We can help them a lot simply by giving them an opportunity to talk about the event. When this is not effective, we encourage them to develop an alternative fantasy account in which someone who loves them saves them from the flames or the hot water. This works surprisingly well in enabling them to forget the horror of what happened. With the children, it helps if they draw us a picture of their accident and explain to us who was there and exactly what occurred. We then throw the picture away ceremoniously. Some patients are seriously depressed and beyond these simple measures, in which case I prescribe antidepressant medication in addition to the talking. Others benefit from night sedation which they are not given routinely.

Lotte found that about twenty percent of the patients suffer from a serious psychiatric disorder in addition to their burns, and that the remaining eighty percent demonstrate varying levels of normal distress in response to their injuries and the inevitable hardship of burns treatment. These benefit from psychological intervention, nevertheless, particularly since this ‘normal distress’ tends to be aggravated, rather than eased, by the local doctors’ lack of personal interest in them. Nor are they helped by the demoralised attitude of nursing and other ward staff, who sometimes treat them in a callous and insensitive way, Lotte said.

My encouraging staff to better see the patients’ point of view, and to talk to them more, is intended to help with this. As will helping staff members with their own psychological difficulties, I hope. As will training members of my own team in the provision of counseling support. This is what I wanted, I remind myself a bit hesitantly now, when I left my solo psychotherapy practice in Melbourne for the challenges and rewards of a multi-facetted team job far from home.

The job description I was given did not mention the half of it, but does require me to fill in a computerised statistics document, to be sent to the headquarters of our organisation each month with my written report, giving data on all the patients my team sees. This includes assigning a psychiatric diagnosis to each person we see, broadening the psychiatric diagnoses for most patients, beyond what I would normally do, by calling normal distress ‘an acute adjustment disorder’ or something of the kind. Initially I comply. Eventually I decide not to, and to give no diagnosis to most of them, unless I am satisfied that they do actually have a psychiatric condition. Pathologising normal emotions, classing them as psychiatric disorders, I reason, obscures their nature and what really needs to be done to help. But who am I saying this to? I wonder. Who looks at the statistics and reads the report? I expect to be asked to explain the absent diagnoses, but get no response.

Still I want someone to know that all doctors and nurses can provide comfort for normal distress, without requiring mental health specialists. This has fallen to the lot of the mental health service here, by default, I want to say. How many other uncomforted, emotionally distressed patients are there throughout Iraq? Whose responsibility are they? Are we going to send psychiatrists to help all of them?  Lotte, at least, understood the problem. She drew up, for general use, a comprehensive first person account of what the normal distress of the normal patient might entail:-

I am on this Unit because I have suffered severe damage to my body, and from which I can never fully recover. I feel sorrow and anger.

My wounds look and smell badly, and so do the wounds of other patients; I try not to look at them. I feel disgusted and disgusting.

I am in pain much of the time. I fear being showered and having my wounds cleaned and dressed, or having physiotherapy, because the pain is worse. I cannot get comfortable and dread the night when the pain also gets worse and I have difficulty sleeping. The persistent pain exhausts me.

I see other patients die and am unsure of my own recovery. I am afraid.

I cannot do everyday things for myself. I am totally dependent on others’ help, like a small child. This humiliates me.

Sometimes my naked body is exposed to many eyes without my consent, and I am unable to cover myself. I feel shame.

I am in a strange environment, cut off from familiar surroundings, subject to a new routine, unable to engage in usual activities. I am spoken to by many new people and am unable to see most people I know. This total change causes me to feel lost and anxious.

Most people who treat me here seem uninterested in who I am, what my life is like normally, what are my hopes and fears, what I think about, and how I am faring from day to day. Many just give me physical care without talking to me or considering my feelings. I feel hurt and devalued.

I am always being treated by different doctors, changing every day, and by different nurses. I am not sure who they all are. I feel confused, lonely and frustrated.

Treating doctors and nurses often fail to tell me what is happening, what medicine I am being given and why. They do not tell me why I am going to theatre, how my treatment is going, how long it will take, or answer my questions. They do not listen to my own suggestions, or hear my special concerns. This also devalues me.

I am confined to a plain room with long days and weeks to wait to get better, a television set that does not work well, and monotonous food to eat. I feel bored and irritable.

Sometimes I am left for long periods uncomfortable or unable to think about anything other than my pain. Sometimes I get reprimanded when I complain or plead for help. I get angry.

I miss my family and friends and my familiar life. I feel so sad.

Yet the ‘normal distress’ is not so normal really. Many of the young women patients have been burned through setting fire to themselves. They do not say directly that they have done this to themselves. Lotte maintained that almost all the young women’s burns were of this kind. She spoke vehemently in condemnation of the men’s attitude to women in the Kurdish culture, describing a life of desperation for young Kurdish women. Alya concurred at the time with equal vehemence. I was suspicious, I must admit, of their insistence, and decide to keep an open mind on this. The patients, young and old, male and female, all tell me their burns are accidental. My Afghani male confidant, Jameel, on the other hand, says of course the young women’s burns are not accidental, whatever they say. If this is anything like Afghanistan, many have been set on fire by others – fathers, husbands or mothers-in-law, who doused them in kerosene. I do not find evidence for this either. Yet there is a predominance of young women among our patients. The extreme rage implied, and the cruel treatment, I find strangely unexpected among such pleasant people. The predominantly male doctors do not voice an opinion on this matter one way or the other. Most do not even discuss the possibility. Nor does anyone among the project administrators.

Is this something only the psychiatric team, and Jameel, acknowledge? And what if it is true? Lotte is no fool. Nor is Jameel.

One of the junior doctors also admits that this occurs. He says that self immolation among young women has increased greatly since the invasion and occupation of Iraq, as has violent crime among men. I am not sure how he knows, but maybe this is so too. Maybe both are expressions of the level of distress in this invaded and occupied society. There are no systematic studies.

Another big problem apparently left to the psychiatric team to worry about, is that about a quarter of the patients do not survive more than a few weeks – of the twenty-two patients admitted in March with fifty percent or more of body surface burned, for example, twenty-one are now dead, and the last one is about to die. Yet how they should be treated as dying patients is something the doctors and administrators have not addressed. At the morning doctors’ meeting all the patients are presented briefly in terms of the technical treatments they are receiving, and mention is made of the one or two who have ‘passed’ during the night, without saying their names. I have to ask for the names afterwards for my own records. There is no review of these deaths, whether they were preventable or inevitable, for example, or what was achieved in caring for them during their dying days.

The number who die does not surprise me in itself, since the hospital is not equipped to provide Western-style intensive care, and most of the burns are by flame, rather than scalds, and consequently severe. The technical care and infection control is probably of a fair standard, as far as I can tell, with some reservations, and nothing that needs to be hidden, in itself. What I also observe, however, is that not acknowledging the plight of those whose injuries are obviously fatal means that they continue to receive repeated wound-cleanings and dressings-changes, and to have bloods taken, and to go to theatre for wound debridements, like everyone else, regardless. In addition, since these severe cases are all kept in the ‘intensive care’ ward, most of their friends and relatives are excluded from visiting them in case they bring infection. I see weeping fathers and brothers standing on flower-pots gathered from the garden, to glimpse their dying family-member through the windows of the ward. Yet infection-control measures are futile and irrelevant. Why make the dying spend their final weeks in isolation? In a kind of torture, in fact? Painful procedures are continued, though also futile and irrelevant, and pain-management controlled by the doctors and nurses is haphazard. No discussion of all this, also means that the strain this must have on the staff – of the futile work, and of the deaths they witness – is not much considered either.

I speak to our project medical officer, Sven, from Sweden, about my dismay at the sight of relatives struggling to look in the windows. He maintains that the local attitude to dying is a cultural matter in which we, as European outsiders, should not interfere. By no means do I agree. The idea that burns victims should be cared for in isolation came from us, not them. Nor has Sven researched the traditional treatment of the dying in Kurdistan. So what is he saying? I later learn from others that he never visits any of the wards anyway, because he finds it too distressing. Sven certainly distresses me.

I do my best to encourage everyone else to talk about the problem too, in all its aspects, and to think what they would like to have happen to them if they were dying. What is actually culturally appropriate for dying people? I ask. If it was up to me, I would send the doomed patients home to their own families, having cleaned and dressed their wounds once, and with a supply of morphine for self-administration. But it is not up to me. The local staff need to decide what is appropriate. I also know that terrible things have happened to Kurdish people and that they are, in fact, too well acquainted with death. Maybe their pretending people are not dying is linked to that. I encourage everyone to talk, but I bear this general pain in mind.

Meanwhile our mental health team makes its own rounds, as I have described, without having patients referred to us by anyone in particular, and without any formal opportunity for communicating our findings and our interventions to anyone in particular in response, or for asking the other doctors to assist with this aspect of their patients’ care. We gather information from the sparse notes in the patients’ files, with no-one available to answer additional questions. The notes contain no general medical history or treatment plan anyway, only an account of the degree and distribution of the burns, their physiological consequences and physical treatments prescribed. Concomitant illnesses, both physical and psychological, tend to be ignored or given rudimentary attention. We take our own general histories from patients, often finding important physical problems that have gone unnoticed, as well as psychological ones. I write our findings, and an account of our interventions, in the notes without knowing if anyone will read them. I talk to any, or all, the doctors about what we find, and what we are doing, whenever I can. I curse the stupid way in which the project has been set up without cases being allocated. The delivery of pain relief is also often deficient, and sometimes grossly inhumane. I try to remedy this too.

Initiating new treatments for the patients we see without discussion with other responsible doctors would be considered impolite, and possibly risky, in other hospitals where I have worked. Nor can I be sure that other doctors will not discontinue my drug treatments without informing me, or discharge patients I have seen without prescriptions for psychotropic drugs I would like them to continue, or advice to see the mental health team again as an outpatient. I raise these matters with the junior doctor who happens to be on call at any time, or at the brief morning doctors’ meeting, or during the equally brief consultant’s round, or simply ‘on the run’. But only some of the doctors come to each meeting, or attend each ward round, and different ones each time. I repeat myself many times. I also get the nursing staff to keep me informed on the progress of patients I am particularly concerned about, when the doctors do not, or to pass on messages to the next doctor to see the patient, on my behalf.

Some of the doctors tell me I do not need to come to everything, that I talk too much and that I send too many messages. Is this is the kind of reason we psychiatrists get told we are as mad as our patients? I do feel unhinged at times. Or that I am struggling in quicksand. Others find what I have to say of increasing interest, however. One of the juniors tells me I was the most thorough doctor he had ever met, and that he would like to be like me. We are all like this where I come from, I say. He does not believe me, and nor do I, to be honest.

There are too many doctors employed by our organisation on this project anyway, I gradually realise – three consultants and twelve juniors for forty patients. The system wastes a lot of the effort of all them, not just mine, with so many people making independent assessments and decisions about the same patients. What a waste of money. What haphazard and inconsistent treatment. I am not unhinged. The system is. I never realised before how important the co-ordination of the medical team was.

I have raised these dangers, and this inefficiency, at the morning doctors’ meeting, with the Medical Director of the project, and at the weekly project team meeting, without getting much response anywhere. I have also expressed my dismay that the other doctors do not take a general medical history, do not make a general physical examination and do not formulate a general management plan, let alone record these, before starting treatment, also without getting a response from anyone in authority. I never meet the anaeshetists, but have learned that even they do not take a general history or examine their patients before anaesthetising them, and we have already had one unexplained operating theatre death this month.

Though only some of the juniors acknowledge the validity of my concerns, they all agree that they did learn in medical school to take a history, to examine their patient and to formulate a plan, even if they did not learn about effective team work. But for Sven, and the local consultants, and the expatriate administrators, I am becoming a trouble maker. Why not? I did not give up my practice in Mebourne and come all the way to Iraq to turn a blind eye.

Among all local staff working on the project there appears to be a high level of discontent too, not just in me. They tell me about it. Lotte must have established a tradition of responsiveness to staff-members’ concerns as one way of dealing with this, since the mental health team is approached daily by members of one staff group or another with requests for support. This may be with the difficulties with the clinical work itself, which I think is appropriate, but also in facilitating the resolution of interpersonal and administrative difficulties, in which they expect us to take their side. I often do take their side privately, but should I do so formally? I have  troubles of my own. I take pains to establish that the mental health team will listen to their distress sympathetically, and in confidence, but will not make decisions that should rightfully be the work of the administrators and project leaders. This is not always possible, as we are sometimes their last resort, and I am forced to act as their proxy at the weekly project meetings. Some complaints require me to convene meetings first, specifically to gather information from the staff group as a whole, having been approached by individuals who may or may not represent the views of their co-workers. In other cases I arrange meetings with the relevant supervisors, offering the moral support of the mental health team, during and after these meetings, if required.

The non-medical Project Coordinator, Gloria, is suspicious of me initially. Who knows what she has heard? But I explain all of the above and she seems to understand. She too is frustrated with the avoidant approach of our Medical Director, Sven, and is interested to learn of my general medical concerns. I like Gloria very much, and she likes me. She is also as keen as I am to have this project work as well as possible.

I have arranged a number of group counselling sessions for staff members as well: for the outpatient nurses – who face the sight of the patients when they first arrive, black with soot and dead skin, and with burnt clothes adhering to their wounds, accompanied by their wailing relatives and friends – and for the intensive care and children’s ward nurses. Despite my dismay at their lack of interest in their patients as fellow human beings, the compassionate way they relate to one another in these groups impresses me as possibly more than their Australian equivalents would do, and I am surprised. How contradictory it all is. How families work, how groups work, and the strict divisions between whom to befriend and whom to treat as an outsider, are all slightly different here from anything I have previously encountered.

Some of the junior doctors are among those who request to speak to me privately in the late afternoons, after Alya and Baktiah have gone home. They sidle into the mental health team hut when no-one is around, and slip away an hour later without being seen. I enjoy this work particularly. The doctors are intelligent and strangely innocent, and I like talking to them one to one. They have learned from their experience of Lotte, I think, to trust the confidentiality of these meetings, and are often greatly relieved by the opportunity this provides. I benefit from their friendship too, of course.

But I have learned of further problems through the private talks with junior doctors. The consultant surgeons, who rule the roost, accept salaries not only from our expatriate organisation, but also from the Ministry of Health for the same work, and also from the medical school to which they are attached for training junior doctors. Yet they fail to fulfill on any one of these in the manner you might expect. In total they are each paid by us, I think, for thirty hours work per week on the burns unit, but spend barely two hours a day at the hospital, and half of that with their private cases on the ‘special’ ward. Most of the time they work in their own private practice elsewhere. Their overall incomes may not be lucrative by Australian standards, but compared to what other people can earn in Sulaimaniyah, they are extremely well-off.

I have also learned that the junior doctors do all the operating theatre work on burns patients without supervision or assistance, while the consultants work on their private cases using our operating theatre facilities and materials. The consultants have led the project administrators to believe they do the burns debridements and skin grafts themselves, or by closely supervising the juniors, but this is not true. Does no one in charge ever go to theatre to see? I ask myself. The inexperienced, unsupervised junior doctors do everything, they say in confidence to me, and no-one senior teaches them anything. Slightly more experienced trainees show the newest ones what to do. Do I believe this? Why would they say it if it was not true?

The arrangement is not unusual for medical consultants in Iraq, the juniors say: being paid and respected for work done by unaided juniors is the norm for senior clinicians working for the government, or in teaching hospitals, or for international organisations like ours, they say. Nor do senior clinicians provide training for their so-called junior ‘trainees’. Nor are the juniors willing to divulge this information publicly, for fear of damaging their future career prospects, dependent as they are on the good will of the consultants for whom they have worked.

Apart for being unsatisfactory for the juniors, and cheating us out of money for nothing, another effect of this charade must be the atmosphere of resentment and reluctance throughout the hospital. The deceiving consultants express a grandly authoritarian attitude to the younger doctors and have a virtually one-way relationship with the nurses, whom they treat with narrow-minded condescension. But what use are they to any of us, and why do we pay them so much? One morning no consultant turned up for the morning meeting and ward round, for example, and the junior doctors conducted these in much the same way. I remarked on this and one of them told me of an old Kurdish saying, ‘Though the cock does not crow, the sun still rises.’

The reason we have them, I learn from Sven, is that the Ministry of Health refused to allow our organisation to run the burns project at all unless we did, ‘in order to maintain standards’. Never mind that we offered to cover all costs, providing the laboratory, hospital waste disposal, sterilising and catering services, as well as all the medical equipment, materials and medications, including the most recently developed and most expensive antibiotics, and to pay all the staff salaries and to provide free catering for them too, as well as bringing expert advisors from all over the world. The high pay for the useless consultants turns out to be a kind of bribe to be allowed to offer our charity, strange as that seems, and I am an unwitting participant in this self-contempt, with much of my effort less effective than it could be. Are other well meaning Western interventions in Iraq similarly expensive while delivering so little? Or in Afghanistan? Or in corrupt countries in Africa and South America? These matters do not bear thinking about.

On the ‘special ward’ for non-burns patients, our provision of which is also part of the bribe, I now realise, the same approach to care applies as on the burns ward, of ‘everyone responsible for everything and no-one responsible for anything’ except that a particular consultant admits each patient from his private practice, and gets paid by the patient’s family for this.

‘Why should the consultant get paid when the treatment given to his patient is free, and provided by all of us?’ I ask the junior doctors pointlessly. The answers are that the consultant is able to facilitate this admission to our project because he works for us, there is no other service available and the patients’ families have no choice.

There was one incident on the ‘special’ ward during this, my first month here, that has disconcerted me in particular.  The charge-nurse came to the mental health hut late one afternoon in some agitation, wanting me to come to his ward to see one of his patients. I accompanied him and found a bed-ridden young man with an intravenous drip running, while his body was blown up with excess fluid and he cried out in pain. An old man sat by the bed wailing too. The patient’s face was like a balloon and his arms and legs like huge sausages. Everywhere was squishy to the touch, and finger pressure left indentations in his tightly swollen flesh. I was told that he also could not pass urine and that his pain was due particularly to an overfull bladder he could not empty. The patient, I was also told, was intellectually disabled and had spent so much time lying in bed at home he had developed a large pressure sore on his buttocks. He had been admitted for this to be treated. No-one knew precisely why he was receiving the intravenous fluids, however.

I advised the nurses to shut off the intravenous flow for a start, and that the patient needed a catheter to be inserted to empty his distended bladder. They could not do either, they said, without the permission of the consultant whose private patient this was. They had rung him, but he had refused to come to the phone or give them any orders. So what could they do?

I went to the junior doctors’ office elsewhere in the hospital complex, to speak to the junior doctor on duty for the night. He was similarly unwilling to do anything without the agreement of the consultant concerned. We rang the consultant together, whose secretary told us he was aware of the patient’s problems and would attend to them the following day.

Next I went upstairs to the administration department where Sven was still in his office. He was also of the opinion that we should not intervene, and criticised me, as the psychiatrist, for getting involved in physical aspects of the patients’ care. When I first met Sven I felt he was very pleased to have me here. Everyone else, even the consultant plastic surgeons, are so much younger than he and I. We walked along together, bumping shoulders and talking like boys – two old boys. This will not happen again.

I went back to the ward, turned off the intravenous drip myself and passed a urinary catheter myself. The patient passed a large amount of pale urine to his great relief, the volume of which I asked the nurses to measure and record. After some thought, I removed the intravenous cannula completely, fearing that the nurses might reinstate intravenous fluids during the night to avoid the wrath of the consultant in the morning. The urinary catheter I left in place and attached to a bag, asking the nurses to check it and empty it regularly, and to keep further records on the volume, as well as records of any fluids the patient drank, so the two could be compared.  I wrote my findings and my instructions for the nurses in the patient’s file, making it clear this was my responsibility, not theirs. Finally I cancelled further bags of intravenous fluid the consultant had ordered.

At the doctors’ meeting the next morning, I described all of this and asked for comments. My intervention was neither condemned nor condoned. There was no soul-searching and no apology. I went on the morning ward round as usual, with Alya as my interpreter. When we got to ‘special’ ward, the patient was no longer bloated with fluid and was happily eating his breakfast.  The urinary catheter had been removed, I do not know by whom, and the record of fluid input and output had not been kept, or had been discarded. On the other hand, the patient was said to be passing urine normally now, and no further intravenous fluid was to be given. The old man, the young patient’s father I suppose, kissed my hands and asked if he could pay me, rather than the designated consultant surgeon, for his son’s care.

I contribute as best I can to the morning doctors’ meetings, despite my growing private knowledge of what a farce they are. I give brief talks on myself as a psychiatrist/psychotherapist, on the doctor-patient relationship as a therapeutic tool and on the importance of a holistic approach to patient care. The first topic is the best received by the other doctors, I suspect because they see it as bizarrely beside the point, requiring nothing of them apart from an acknowledgement of how different my work is from anything they would do. I notice now how readily the consultants embark on elaborate discussions of matters that require no action, while avoiding any mention of things that do. My other two topics are greeted, accordingly, with stony silence during the formal meeting.

‘These are things one has to know for the exams,’ one of the consultants tells me later. ‘Not matters any working doctor need be concerned with in practice.’

I provide classes for the junior doctors regardless, on the uses of the doctor-patient relationships, on holistic case management, on possibly talking sometimes to the patients’ relatives and on the value of adequate pain relief. I know it is an uphill battle to make a difference with no leadership from the top. Some of the trainees are improving their history-taking and recording, at least.

At one morning meeting I present lapses I have noticed in patients’ physical care, some of them implicated in patients’ deaths. My only satisfaction is putting the smug surgeons on notice that I do know general medicine, as well as psychiatry, and am capable of informed comment on their work.

Why am I making such a nuisance of myself? I also ask. Why not accept that there are cultural differences here, and get on with providing counseling to patients in the context as I find it? As far as I know, that is what Lotte did. Why am I a troublemaker, upsetting the status quo, and proud of it? Why am I happy to be annoyed and to say so?

The junior doctors, whose private dislike of the consultants’ approach I share, enjoy this. Some of them offer verbal encouragement. The patients encourage me too. Alya and Baktiah encourage me too. I am also older, as I have said, than even the most senior of the consultant surgeons and have found that my age gives me authority in this culture beyond what I would expect at home in Australia. It is impossible for the senior surgeons to be impolite to an old man, and this forces them to listen.

One talk has been successful. I have encouraged the setting up of a system for providing pain relief to outpatients attending for burns dressings. Previously outpatient dressings were considered not to require pain relief, not even for children, even though burns are often more painful when they are half-healed than they were  initially.  I have seen patients jump about every time the nurse touches them, ineffectively cleaning and dressing their wounds. Yet I am not surprised. I am used to how mad things are. I have seen wailing children being held in an arm lock for treatment. With Alya’s help I am planning to make the outpatient environment more child-friendly overall, by having them treated in a separate area from the adults.

By comparison with everything else, training my own team is straight forward and enjoyable. Both Alya and Baktiah adored Lotte, and have quickly transferred their adoration to me. I review the excellent training she provided on psychotherapeutic interventions appropriate to the patients encountered on this unit, modifying my own practices and intentions in the interests of maintaining a consistent approach. I give them talks, day by day, on the nature of psychoses, the use of psychotropic drugs, and on drug tolerance and addiction. I introduce them to traditional and contemporary psychoanalytic thought, and conduct workshops, developed by my psychotherapist colleagues in Australia for the training of general medical practitioners in empathic listening. I am impressed, as I proceed, by Baktiah’s knowledge of Western philosophy, which he says he learned at school.

Alya is ostensibly an interpreter, and Baktiah a social worker, but both of them help me in many ways with the linguistic and cultural divide between me and the patients, and between me and other staff. They do this so adeptly I barely notice the divide and I converse readily with others. They also organise meetings for me, explain situations that perplex me, and do a great deal to support patients and other staff emotionally, independently of anything they do with me. Alya I discover to be the local ‘wise woman’, in fact. Many women, inside and outside the hospital, confide in her and seek her advice. Baktiah, only twenty-five, also does his best to explain the nature of psychological counseling to sceptical male nurses and junior doctors. Whatever they think of us, however perplexing we must seem, we find ourselves to be well liked by everyone but those in charge. Never before did I realise what a subversive profession psychiatry can be.

I also realise that there is something unfamiliar to me about the management of public and private relationships here. I hear other women criticising Alya repeatedly behind her back, for her way of dressing, and for the boldness with which she relates to me and Baktiah, or speaks her mind at meetings where women are expected to hold their peace. Yet many of them trust her with their most intimate secrets, and accept her advice on all sorts of personal matters, I am told. I hear second hand of criticisms of things I have said and done, or of my team’s behavior. I seek out the people who said these things, and they thank me for being here.

But the public space, the talking about people, is ruthless, and the need for confidential relief particularly pressing for that reason, I suppose. In every society people may express harsh opinions publicly, in support of conventional behavior, but here more than anywhere else I have been. Has this always been so in this culture? I wonder. Or is it a result of so much danger? Of so many people having grown up without a father? Of so much fear?

Towards the end of the month I write my first report on our team’s activities, to be submitted to the medical coordinator and also sent to our organisation’s head office. We assessed seventy-one new cases during the month, and provided a further one-hundred-and-eighty-five follow-up consultation. The new cases included twenty-two children less than twelve years of age, seen with their mothers, of whom there were twelve females and ten males, and whose average age was three years. All the children’s burns were the result of domestic accidents, mainly with hot water or tea. Above twelve years of age, there were forty-nine new cases – thirty-three female and sixteen male – with an average age of thirty years. Of the thirty-three females, eight were definite cases of self-immolation, eight possibly so, and seventeen appeared to be accidental burns – a similar number to the male accidental burns. Among these males, two were burnt attempting to rescue wives who had set fire to themselves, and fourteen were the result of accidents outside the home. A small number of other female patients died shortly after admission without being psychiatrically assessed, and may have represented further self-immolations.

The patients came from all over northern Iraq, including Kirkuk, Dalia, Penjuan and elsewhere, including two from small villages, with only a quarter from Salaimaniyah itself.

Most we found to be suffering initially from an acute stress reaction to a greater or lesser extent, and to benefit from immediate counseling support. Others gave a history of pre-existing anxiety or depression. I prescribed antidepressants and tranquillizers for twenty people. A few others had pre-existing physical illnesses, about which we informed the indifferent surgeons.

Of the one-hundred-and-eighty-five follow-up consultations, eighty percent were for females, and these included twenty-five who had been discharged in previous months and who saw us as outpatients.

We also provided thirteen group play sessions during the month for ambulant children, who attended with their mothers or fathers. Baktiah ran most of these, while Alya talked with the parents and I got on with my paperwork, including compiling the above statistics and writing the monthly report. For what it is worth, the report repeated all the things I had been complaining about at meetings all month. There is no getting away from me. I do play with the children too, of course. Kurdish people have remarkably beautiful children. Some have blue eyes with their olive complexions. As blue as Baktiah’s are black.

As regards my personal safety here in Kurdistan, I have not been worried about this now I know my way about. Since the US invasion, the region has not been affected as much by on-going violence as it once was.  Sulaimaniyah has been hit by suicide bomb attacks in October 2005 and March 2008, but the chance of my being in one of these is remote. Many soldiers stand guard in the streets, sometimes outside government buildings, and sometimes for no apparent reason. My housemate Darren avoids them at all costs, and crosses the street in order not to walk past them. Jameel, on the other hand, says the poor fellows must feel very bored and that we should at least say hullo to them. This is what I do, and many of their smiling faces have become familiar to me. I hope mine has become equally familiar to them.

Our organisation keeps a close eye on security matters, I am told, and will advise us if the situation deteriorates. Some security restrictions are in place, including a prohibition on walking in the night, or going to certain areas of the town, and we were not allowed to take taxis until recently.

It is virtually impossible for anyone in Australia to contact me in Iraq by telephone, or for me to send or receive surface mail. Some international courier services are available, should I wish to send anything home, but are considered unreliable, expensive and likely to steal your money or lose your couriered items.  I can send emails, but our internet service is somewhat intermittent. I can also ring Australia myself, and my contract offers me one free call home a month. My first call home was a great event in our household, with all my housemates gathered to watch, apparently delighted to know I really do have a wife and family in Australia.

The organisation advises me, in addition, to register my name with the Australian Embassy in Iraq, in case I ever need their help, or in case there are enquiries about me there. They do not know the address of the Australian Embassy, however, which is presumed to be in Baghdad, nor how to contact it. I find an Australian Embassy in Iraq website on the internet, myself, but this does not give an address either, nor contact information, nor opening hours, nor any opportunity to register, or seek help. Nor does it give advice, or offer assistance to Iraqis, I notice, about visas, asylum seeking, migration or citizenship. I presume all these services would be officially available, but it appears to be impossible to obtain them unless you are in Baghdad and can find out where the embassy is situated. Since moving about Baghdad is extremely dangerous, and the Embassy might not be open, or might not let me in, this is not a sensible option for me, and I remain unregistered.

In our shared house, the other guys and I watch a lot of funny films on DVD, and laugh a lot, not surprisingly. I also value enormously my relationship with Alya and Baktiah. We are going on a picnic in the mountains next weekend, with many of the hospital staff, and I am looking forward to this.

May 2009

Sulaimaniyah has roses everywhere at this time of year, as well as tall pink and red hollyhocks, foxgloves, poppies, and purple wallflowers. As I walk to work across Azardi Park, I see them there in profusion, as well as along the streets and in our own gardens at the hospital. I want the logistics team to get our fountains going again, and speak to Liberian Ken about this. There is no water shortage, but the three small fountains among the flower-beds have fallen into disrepair. Whoever once thought they were a good idea has long-since left.

One of the Kurdish logistics clerks, Soran, paints abstracts, and several of us go one day, at his invitation, to the Sulaimaniyah Artists’ Society exhibition of paintings, sculptures, and installations, in another part of town. Viewing these I find to be like having an intense conversation with forty new people at the same time. Some of the pieces are very good, I think, but I never feel very sure of my assessment of visual arts, and every conceivable European art-style is represented in a modified form. Some are very interesting, anyway, some very dignified, and there is a lot of anguish in many, for obvious reasons. Some are simply beautiful by anyone’s standards.

The exhibition takes place at Saddam Hussein’s torture prison from the mid-1980s, which has been left as a museum. I have not previously identified it, but pass it every day, I know now. It also houses a permanent display of photographs, some gruesome but many a celebration of the Pesh Merga (the Kurdish freedom fighters). One room contains a display of tiny lights, like a glow-worm cave, designed by a Kurdish woman as a memorial to the thousands of villages in Kurdistan razed by Saddam Hussein during the Anfal, one light for each village.  I know this because I visit again, another day, on my own, what must be one of the most horrifying museums on the planet.

‘They used the wood so that nobody could hear the screams,’ explains the smartly dressed Kurdish guide. He stands over a desk that once belonged to Ali Hassan Al Majid—Saddam Hussein’s right-hand man, better known as ‘Chemical’ Ali—and runs his hand over the room’s wood-paneled walls.

On the other side from the desk, a plaster male mannequin hangs on a hook from the ceiling, its hands bound behind its back and electrodes running from its head to a metal box on the desk.

‘And here,’ the guide says, walking towards the model and pointing directly at its groin, ‘is where they would attach the weights, usually twenty to thirty kilograms. Sometimes more.’

Most cities have monuments to the past, so it seems appropriate, given the bloody history of Iraqi Kurdistan, that this is Sulaimaniyah’s main tourist attraction. All Iraqi Kurds, I am told, know of this building, which is open six days a week, free of charge. In a now quiet and leafy suburb, its outside walls are riddled with bullet holes. During Saddam’s time it was known as Amna Suraka (red security) and was the headquarters of the Mukhabarat (Saddam Hussein’s intelligence agency). Until liberated by the Pesh Merga in the early 1990s, the prison held students, dissidents, and Kurdish nationalists, as well as anyone else who happened to attract the attention of Baathist authorities in northern Iraq. When freedom fighters piled into Sulaimaniyah at the start of the 90s, while Saddam was preoccupied elsewhere with the Gulf War, the last eight hundred Iraqi soldiers in the city holed up in the prison. After a week of shelling, the Kurds broke in and killed them. Tanks and artillery left by the Iraqi army still litter the courtyard, amongst rose bushes, and the building has been kept not only as a museum but as a monument to all those, on both sides of the conflict, who lost their lives inside its red, pockmarked concrete walls.

Much has been left almost as it was two decades ago. The complex is made up of three main buildings. The first, used then for administration, is now a relatively pleasant museum of Kurdish culture, with mannequins of Kurdish personalities, including Sheikh Mahmud Barzanji, as well as colourful displays of traditional clothes, tapestry, weaponry and jewellery.  The second building is dedicated to remembering the torture, and the third is a bombed-out set of corridors and cells.

‘This guy was here in this cell for a year,’ the guide explains, pointing to a mannequin, with a moustache, standing in a tiny concrete room. ‘He wrote his story on the walls.’

On the whitewashed surface I see line after line of Kurdish script, as well as pictures of butterflies, sketched in blue and green ink.

‘Pencils were smuggled in from outside and became a traded item in the prison,’ I am told. ‘It did not end well for this prisoner – he was later taken to Baghdad and executed.’

Other mannequins – pain-stricken sculptures created by artist Kamaran Omer – depict how soldiers would beat the soles of prisoners’ feet.

It is impossible to become desensitized during the guided tour, as each story is more confronting than the last. The floors of the cells are littered with dirty blankets. The toilet block still reeks of sewage. Hooks and spikes protrude from the roof and walls and, around one corner, a man stands handcuffed to a drainpipe, unable to sit down.

I am also shown the room where women were taken to be raped. ‘The soldiers used to drive around Sulaimaniyah and when they saw a girl they liked, they’d bring her here,’ the guide says. A statue of a young mother and her child is displayed in this room.

Walking across the courtyard, we come across several twisted, white statues standing on a patch of dirt. This is a monument to all the students who were brought to this wall and executed in the 1980s.

The Hall of Mirrors I have already mentioned, commemorates those who were killed during Saddam Hussein’s genocidal Anfal as their villages were destroyed. One-hundred-and-eighty-two-thousand shards of mirrored glass line the wall of the fifty-metre-long corridor. At the end of an ensuing pathway stands a replica of a traditional rural Kurdish home.

Later, Alya tells me her primary school was closed in the 1980s, in order to be also converted to a torture prison. She was ten years old, and went there one day with her friends, to peep in the window, to see if this was true. She saw the walls smeared with blood and hairs. I notice for myself that there is a scarcity of middle-aged men on the streets of Sulaimaniyah in 2009 – only old ones and young ones.

I speak again one morning at the eight-o-clock doctors’ meeting about the treatment of the dying patients under our care. I speak gently, I would say, knowing I am speaking into the different way of listening of another culture, perhaps, or at least against a long-standing habitual way of handling this issue. But I do not mince my words. The consultants, the junior surgeons, the heads of nursing from each ward, the administration staff, including the project medical officer, are all present. I invite everyone again to think how they would like to be treated, or how they would like their loved ones to be treated, if they were dying. There is total silence during my fifteen minute speech, which ends awkwardly for this reason. But as I go to sit down, saying something about a group discussion another day, everyone starts talking at once.

The meeting goes on and on. No-one will let me vacate the floor for another half hour, as if they think I have the answer to all their concerns. I like the consultant surgeons even, on this occasion, and better than I intended, and have to hide my tears. As do others. The surgeons have interesting things to say about the various dilemmas involved in taking one course of action or another, to treat the dying differently.

At the next two morning meetings after that, two junior trainees have talks to present, one on injuries to the ulna nerve, and the other on smoke-inhalation lung damage. But on the third morning, I am asked to oversee a discussion on ‘palliative care initiatives’. Considerable debate ensues with general agreement that dying patients should be treated differently from those for whom a cure is feasible. Various agreements are reached, and tasks allocated, to change things for the better.

In particular, the meeting agrees to declare certain patients on the intensive-care ward  ‘palliative care cases’ rather than ‘hopeless cases’, as has been the tradition here. Their treatment should not simply be withheld, as futile, but should be re-designed in a ‘palliative’ way, avoiding pointless interventions and encouraging comfort. This could include analgesia on request, and easy access by relatives, through relaxation of stringent medication and infection-control measures. The surgeons maintain that this designation should not be conveyed to the patients or their families, however. It is unclear to me how more visits could be allowed or infection-control measures reduced in that case, without telling people why, and without jeopardizing the care of the other patients in intensive care. I say a separate palliative care ward is needed, and that we have to be quite open about this, but there is no agreement.

On the other hand, one of the doctors talks at length about thinking of the dying patients as if we were them, or as if they were our own sister or daughter, and asks repeatedly what we would then wish to have happen. Last month I had no evidence that any of them ever considered the patients in such a way. It seems as if they had been waiting to be asked to do so.

Not a lot happens about this matter subsequently. The practical dilemmas remain unresolved, and the expatriate old-hands administering the project offer no helped. Sven continues to oppose doing anything. But something has been set in motion, and I feel I have the permission of the local staff to keep it going. This topic now comes to their minds when they see me.

One of the surgeons tells me that declaring patients to be incurable may be against the Q’ran, but the juniors say this is nonsense. Another tells me that if we provide a specific ward for palliative care, it will gain a reputation as the ‘death ward’, but the juniors tell me it is his own reputations he is worried about, as if he should be able to cure everyone. A third expresses concern that ‘palliative care’ might be more time consuming for him than the present way of doing things, as relatives may ask him to explain it. They all reveal eventually, however, that allocating a separate palliative care area in the current intensive care ward is quite doable. An unused part of the ward was once set up as an additional occupational therapy area and can be isolated from the rest, with its own plumbing and storage facilities and its own entrance from the outside through an existing side door. This could serve the purpose at little extra cost and with little difficulty. I take the fact they tell me this to represent their permission to encourage the idea further. I also argue that it would not only benefit the patients but could provide an important learning experience for all the staff.

Support for the plan is having a good effect anyway. Alya tells me that most of the intensive care ward nurses have abandoned the previously used term ‘hopeless case’ in favour of ‘palliative case’, and I hear, for myself, the word ‘palliative’ popping up from time to time as they speak to each other in Kurdish. In addition, the doctors prescribe less futile medical interventions for these cases, and close relatives are encouraged to visit the dying more readily.

The nursing staff and junior doctors must feel better too, about the clearer definition of their role this implies. Trying to give someone as good a death as possible must be more rewarding than trying to treat the untreatable. A Kurdish cultural tradition must exist anyway, I presume, for treating the dying with respect.

I am also affected and speak more frankly to the relatives of these patients than I did previously, and more frankly than any of the local doctors are willing to do. I choose generally to talk to an older, male relative, rather than to the patient’s mother, or to the patient herself. They are not shocked, these old men, or angry with the hospital as the surgeons fear, and express gratitude. They are usually not even surprised. Some say they know their daughter is not passing urine, which means her body is shutting down. Others have heard her stertorous breathing getting worse. Since these young women usually remain lucid until they die, I advise the uncle or father of this too, and let him know that all her relatives and friends are welcome to come one by one.

As regards the other patients, I have realised during this, my second month here, that I probably over-estimated the incidence of psychiatric illness in the ‘accidental’ cases previously, being unfamiliar with the culture and also perhaps expecting psychiatric illness because that is what I am employed to treat. A few have clinical depression, for which I prescribe appropriate medication, or significant post traumatic stress, but only a few. I have also diagnosed less cases of self-immolation than Lotte did – I found only four this month, out of eighty-four new patients, and judged all the other burns to be accidents. For the most part the so-called ‘mental health’ team sees normal people who are understandably distressed. We aim to see all of them, and to make them feel welcome, informed and cared for.

My psychiatric experience is needed to establish any relationship at all with one or two, whom I presume to have pre-existing difficulties relating to others. I use it too in providing family therapy for some of those who have burned themselves.  But I prescribe little of the haloperidol, chlorpromazine and risperidone available in the pharmacy, and I assign few psychiatric diagnoses. I do the work as it presents itself, knowing it is possible to make an enormous difference to people so deprived of empathy, but do still feel resentment at having to compensate for this deficiency in the service provided by others. It would be so much more useful, and far-reaching, if they changed.

There are some notable exceptions among the local staff in this regard, of course. Alya takes a brief holiday this month and another interpreter, Nazim, replaces her for one week. He is a former nurse who works in Administration, is helpful and competent as an interpreter and takes a great interest in the work. He also tells me about the continuing Zoroastrian tradition amongst the Kurds, informing me that many people’s names refer to this, including those of his own children. Their names mean ‘grace’ and ‘devotion’ in antique Persian. Nazim’s own approach to others could be described in the same way, I think. Some other nurses and physiotherapists also make a consistent effort to befriend their patients, in the absence of encouragement from their co-workers. To do so contrary to the norm seems to me to be particularly admirable, and I praise them for it.

Then, as I have said, almost all of the staff can be exceptionally nice people in other ways, capable of warm and sympathetic relationships with their friends, including me. This apparent contradiction is not new to me. When I worked in Papua New Guinea and in Nigeria in the past, the people were also remarkably friendly and sympathetic, but doctors and nurses were also surprisingly impersonal, and often callous, in their attitude towards patients’ feelings, suffering and personal concerns. It seems that this aspect of medical practice – which is largely taken for granted nowadays as part of the job in hospitals in Australia where I have worked – is not automatically present. It needs to be developed as a distinct aspect of the medical tradition, in fact, and of medical and nursing training.

But what a one-man band I am, I sometimes think, in the absence of support from anyone I can call my peers or my superiors. Then comes the visit from Dr Chandra, an eminent Indian surgeon who runs a model burns unit there, and provides training in this for others from all over India. He makes many of the same observations as I do, and in the manner of someone who has been drawing attention to these matters repeatedly, in one place after another, throughout his working life. But he only stays a week. He notes the unnecessary abundance of underemployed doctors, the lack of leadership and the duplication of services, contradicting one another. His long, written report describes his further concerns about catheters being left in place for two long, increasing the risk of infected wounds and of lifelong urinary infections, about antibiotics being prescribed for too long, or too short, a period leading to multi-drug resistant infections, about patients not being hygienically toiletted, or having their teeth cleaned, and about blood samples being taken in a contaminated way. He selects my friend Jameel for particular praise for his efforts to change all of these and more. He does say our emergency care of new admissions is good as compared to other hospitals, however, as indicated by the low mortality rate in the first forty-eight hours.

I feel slightly better about the whole dog’s breakfast we have here. He seems to come from the land of common sense. What use are the expensive medications and the expensively equipped laboratory? he asks. He puzzles me, however, by calling me ‘boss’ every time he speaks to me, and does not refer to anyone else in this way. Is this a compliment, or a joke? Is he, as a brown man, teasing me for taking on ‘the white man’s burden’ when those days are over? I like him anyway.

Not that his visit and report make any enduring practical difference. What use are expensive visits from international experts? I ask, when we employ doctors who take no notice? Our organisation simply throws good money after bad, having set up the project as it is. The visit and report is another charade, like the morning case meetings, mimicking the pursuit of excellence while supporting something worse than mediocrity.

Before he leaves, Dr Chandra offers training courses in India, in reconstructive microsurgery, to two of our junior doctors. They are greatly honoured to be selected, but what ensues is another demonstration of the grim reality of life in Iraq today. Despite our organisation offering them financial support for this, despite letters of certification from Dr Chandra offering places in his course, and despite letters from our surgeons saying how beneficial this training would be to the work, neither can obtain a passport. Ordinary people do not get passports in Iraq nowadays, not even doctors seeking advanced training, unless they are very rich or have the right political or military connections.

I diagnose major depression this month in two of the individual staff members who consult me, and prescribe them antidepressants. Not the two disappointed junior doctors who cannot go to India, but two of the intensive care ward nurses psychologically traumatised by their work. I also certify time off for one junior doctor, already seeing an outside psychiatrist and already taking medication. To some extent the hospital staff may be just as isolated as the patients. In their individual sessions with me, some junior doctors also describe their fear of secret infighting among the junior doctors, sabotaging one another’s advancement, so precarious is their situation.

On the brighter side, I go on three Kurdish picnics this month in the foothills of the mountains surrounding the Sulimaniyah plain. This being a Muslim country, most people work from Sunday to Thursday, with Friday and Saturday off, and every Friday in Spring and early Summer, large numbers of the city’s residents go on picnics. Our hospital staff and their families go together by bus, the locals dressed in traditional Kurdish clothes, singing and clapping much of the way. The roads, and favourite sites, are crowded with people enjoying themselves, and the mountain foothills are wonderfully picturesque. Red poppies, white daisies and yellow dandelions adorn vast green slopes extending up towards the rocky mountain peaks and cloudless sky. Shepherds accompany their flocks of shaggy sheep. Some have shaggy goats. Sometimes I cannot tell the sheep from the goats, which the local people find hard to believe.

The hospital picnics last all day, until well into the evening, and are wildly energetic affairs, with much dancing and football. An old guy like me has to keep stopping to catch his breath. We dance in lines holding one another, whooping and trilling. Boys and young men play makeshift football matches while others watch. Several meals, changes of clothes, naps, games of chess and backgammon, and prayings to Allah, interrupt these activities throughout the day. Baktiah insists I swap clothes with him, and I pass quite well as a Kurdish man myself in my baggy trousers, cummerbund and neat tunic. Wandering musicians pass, playing drums and reedy pipes, and boys bring donkeys for the children to ride.

Kurdish people know an endless supply of love-songs – some may be bawdy songs – and almost all are remarkably good at entertaining one another, catching one another’s eye, engaging one another in play – the men more than the women, but both – singing and clapping and physically showing-off. The women are sometimes free to hold the floor, displaying themselves in their finery, which is not what I expected in the Middle East. Their elaborate traditional clothes can be more of an asset than an impediment. Jameel enjoys himself particularly. Men are not supposed to look at women and are invited to look at them at the same time. Amongst themselves, the men behave towards one another like boys of primary school age, cuddling one another, showing off too, but to one another, as they dance or kick a football. They make me feel like a boy too. I tell them I am a bit old, but they just say ‘of course you are.’

Kurdish dancing takes various forms, involves a lot of shoulder movements and has a particular look to it for that reason. Sometimes we do an Arabian dance instead, where, by comparison, the way the chest and head are held is more important, and there are graceful bendings of the knee in unison. This looks very good when a whole crowd does it together. The Kurdish dancing, on the other hand, is wilder and less formal.

The food comprises endless lamb and beef kebabs cooked on little trays of open coals with hand-worked bellows, accompanied by salads and humus. Everyone knows how to thread meat onto kebab sticks with speed and aplomb, and everyone knows how best to cook it. No one takes alcohol or other mind-altering substances, I notice, not even tobacco. The expatriates have to sneak away to have a smoke. Yet these are the most convivial affairs you could imagine, and everyone comes home bonded, happy and physically fit.

I have become universally popular with the junior doctors and with the nurses back at the hospital since going on picnics and wearing Kurdish clothes. It has also dawned on me, as I have become more settled here, that the consultant surgeons are frightened of me – of my popularity and my knowledge. I have been frightened of the surgeons until now. I also have a new respect for Baktiah. His halting English had me underestimate how smart he is, until we play chess several times on the picnics, and he beats me every time. He is also a nifty football player and a particularly good dancer. I watch him with fatherly pride. I have one unexpected new problem, however: that many males want to kiss me when they greet me, Baktiah included, not just on the cheek but on the mouth. Meanwhile, physical contact of any kind with women is out of the question. I cannot even shake hands with Alya. Except for one old tea-lady who always gives me a morning hug as she pours my tea.

I am also taken aback by another strange incident. One afternoon I have something to report to the junior surgeon on duty and knock on the door of the little, ground-floor ‘duty doctor’s office’ where there is a desk and a bed. No one responds, so I open the door and find one of the young doctors I know well, sitting on the bed with a bag of intravenous fluid on a stand beside him, in the process of inserting an intravenous lead into his own arm. He tells me sheepishly that he has gastroenteritis today and is making sure he does not become dehydrated. I express surprise that he is on duty, in that case, but he says no one else would cover for him. I also express surprise that he thinks he needs intravenous fluids, and he says the IV line is so he can give himself intravenous antibiotics.

‘You don’t even look that sick,’ I tease.

‘You don’t know what gastroenteritis in Iraq can be like,’ he says.

We discuss the patient I came to see him about, and I leave him to go on with his treatment.

At home I re-arrange the shared common room, as I intended since I arrived. It no longer looks like a second-hand furniture store. I feel a bit of an old fusspot doing this, but it makes a big difference to me. I also sort through the jumble of DVDs. For my own room, I buy the two Persian carpets I have been wanting. Alya comes with me to help with haggling. We expatriates have been advised against going to the souk alone, anyway, not because of any danger of being attacked, but because we are so likely to get lost in the maze of streets and passageways. On the way Alya tells me that the main street of Sulaimaniyah is named after a freedom fighter from the nineteen-twenties who died opposing a British massacre of Kurds ordered by Winston Churchill. She enjoys showing me things, such as perfume shops where men can have a personalised aroma concocted, and is disappointed I choose my carpets so quickly. She was looking forward to an afternoon of carpet viewing and discussing before a decision is made. The two I select are without doubt exquisite, nevertheless. They tell of ancient things, and I feel privileged to have them.

June 2009

The brightly-coloured Spring in Sulaimaniyah dries and fades into the heat of Summer. The heat comes suddenly, like opening an oven door, and twenty to twenty-five degrees becomes thirty-five to forty degrees, unabating day and night. Some days are a little cooler because of the strong winds, but clouds of grit, and twigs, and plastic bags, make it difficult to walk outside.

I notice a few sparrows and swallows here, but other birds are strangely absent in Sulaimaniyah. Spiders, too. Insects, even, are few and far between – no beetles, no butterflies, no gnats or mosquitoes, and not even many ants. Occasionally a fly comes in through an open window with the dust, and I see a cockroach in our house on one occasion, on the stairs. I think he might be a very lonely fellow. Who would have thought you would miss insects? When I meet a ladybird in the hospital garden I feel a moment’s joy, and puzzle someone by saying so. On picnics in the fields we find scorpions under rocks and people chase them about, trying to induce them into plastic bottles. Here the joy is in the danger – not that the scorpion’s bite would kill you, but the pain is said to be excruciating.

I have been reconsidering the way the Iraqi doctors and nurses manage pain on our burns unit. They prescribe morphine 10mgm twice daily, at the most, for adults for whom we would prescribe at least this much six hourly in Australia. When additional doses are to be given by the nurses ‘on need’, the ‘need’ has to be desperate before they do so. I see them tending to someone’s intravenous fluids, or giving the antibiotics, ignoring the fact the patient is shaking, groaning and gritting his or her teeth with pain. When they mark the pain-level on the patients’ observation charts, they put zero in every case. They do not believe in the pain scales we have instituted. Even the mothers of scalded children – with red-raw back and buttocks perhaps – tell them to stop complaining. On the male ward, the all-male nurses are especially tough. Yet they accept, with good humour, my increasing the morphine doses every time I see someone in serious pain, calling me ‘grandad’.

‘You think these guys are all your little grandchildren,’ they say, and tell me younger doctors do not give men pain killers, knowing it is important to maintain their manly stamina. It is also important, I say, that their wounds be cleaned without them jerking away, and that they sleep soundly.

‘We’ll give them because we like you,’ they say, and I hear one of them refer to me as ‘Mr Morphine’.

Nevertheless, I have begun to question my usual way of thinking on this, and am becoming a slightly tougher old grandad. Physical pain is not all that bad. It makes you cry and shout, but it does not kill you. You can bear it, if you have to, and you forget about it once it is over. I am less bothered by physical pain myself nowadays, than I used once to be, and have seen this as an achievement, even before coming here, I now remember. I decline the injection of local anaesthetic when I am at the dentist, for example, preferring to put up with the few seconds when it hurts, even if it is severe, and have to reassure the dentist not to mind. Being physically attacked, or in fear of physical attack is worse. Being cheated out of a future, and frustrated in everything you do, is worse. Being alienated and alone is worse. These things destroy the soul.

In my thinking, I link the attitude to pain here to the strange phenomenon of no alcohol, or drugs, or smokes, at social occasions. All that people have is their being-together, singing and dancing. That is enough. Compare that to those people in our society who do not believe they could have a good time at a party without taking ecstasy, or getting drunk, or having sex with a stranger. Or people who think that whenever we have discomfort we should take a comforter, whenever we have a problem we should find a chemical solution, whenever we feel worried we should take a soother, whenever we feel down we should take an antidepressant. Have we been brain-washed by people wanting to sell us things? Has this eclipsed our ability to cope?

What everyone needs is love, and I love Jameel now, for example. When I get home to our shared house I tell him all the things I get annoyed about and make him upset too. He says he does not mind. We go out go-cart riding together – a silly old man and a silly young man  – and I tell him that Dr Chandra had praised him in his report. He tells me he has now instituted that doctors put the date on cannulas and catheters when they insert them, instead of leaving them unchanged for an unknown number of days. We encourage everyone else in the house to come to the fun park. We have little picnics of our own.

I also write complaining emails to my friends in Australia, and give my frank talks to the morning doctors’ meeting – this time about the discrepancy between their theoretical knowledge and the quality of the care they provide on the wards. I describe a full history I had taken from one of the patients, and a full physical examination I have done, illustrating how much useful additional information I have obtained, and how helpful it is in treating the burns more effectively. The surgeons hear this with good grace, but Sven, the project medical officer, is becoming increasingly annoyed. I tackle general medical things he has avoided, when I am supposed to be doing only psychiatry, or pseudo-psychiatry. Do I make any difference? Probably not much. Am I heading for trouble? What do I care? I am old and here for a short time.

The problem of the lack of individual case allocation may be about to be partially alleviated, at any rate. The senior surgeons propose allocating responsibility for each case to one particular senior after all, though the junior doctors will continue to have no specific case responsibilities. This means I will now be able to discuss my concerns about an individual patient with an individual senior who considers himself responsible for the case.  I am not holding my breath waiting for this to happen any time soon, however.

I also write a procedure document, in consultation with all the doctors and nurses concerned, for the assessment of new admissions, to acknowledge that some are palliative cases from the outset. This is accepted and is in use. The palliative section of intensive care ward is also open. The relatives of dying patients have access through the side entrance, as planned, without having to gown-up or wear masks and, hopefully, without jeopardising infection control for other intensive care cases. The consultants admit to some pride in this, as do I, and one tells me it is the only palliative care facility in the whole of Iraq. This is not something to get too excited about, I suppose, but is something nevertheless.

I prepare to give another talk on the normal emotional reactions of our patients to their burns and their treatment here, based on Lotte’s document, but cannot bring myself to present it. I could not bear to have something about which I feel so tenderly to be ignored, or even treated with contempt. Instead I have Alya translate the written version into Kurdish, distribute it to the junior doctors and pin copies on the notice boards in the nurses’ stations. I see one of the surgeons reading it and then quickly turn away when he sees me watching him. I wonder if he got to the bit about most people who treat me here express no interest in who I am.

Each patient in this hospital has a designated lay caretaker, or series of caretakers, generally interested close relatives, who remain with the patients throughout their hospital stay, albeit somewhat intermittently. Caretakers take care of feeding patients the food the hospital provides, and sometimes bring extras. They also bathe and toilet the patients, and assist them with other personal needs. I question how appropriately they do this, unsupervised by the nurses, with no training in the importance of avoiding contamination of the wounds. The nurses also delegate various nursing-care jobs to them, such as changing the intravenous fluid bag when one runs out, or the urine bag when one is full, or helping patients to take tablets left by the nurses on the bedside tables, again without training or supervision. On the other hand, some caretakers give some moral support to patients, and the mental health team works with them. They also act as go-betweens for the bed-ridden patients, as they are in a position to chase nurses and doctors around the wards to speak to them.

The nurses even leave it to caretakers to measure fluid intake and output, and chart this without checking. As for the observation charts of pulse rate, blood pressure and temperature, I soon realise the nurses invent a lot of their entries, without measuring them. We are traveling in a very leaky boat, I sometimes feel. Yet we remain afloat, and most patients’ burns recover sufficiently for them to leave eventually.

Jameel, as the expatriate infection control nurse, is aware of all these problems, but says they are too difficult to solve. On rare occasions the Kurdish head of nursing visits the wards, and I see her haranguing the nurses who wait sullenly for her to leave.

A former fiancé of Alya’s, one of the physiotherapists, accosts me on my own one afternoon, and accuses me of corrupting her in some way. ‘What goes on between Alya and you and Baktiah in that little hut?’ he asks. ‘I see you sometimes have the curtains drawn late in the day.’

Alya has had many proposals of marriage since her teens, which is not surprising, she is so lively and so attractive, but tells me she is lucky in that her family does not force her to marry if she does not wish to. This is unusual for a Kurdish woman. I am aware that she manages the family home, however, and provides all sorts of practical support and advice to many members of her extended family. I suspect they have a vested interest in not losing her. I would not want to lose her either. Be that as it may, she tells me that each of her suitors has told her initially he loves her just the way she is, but has soon proceeded to tell her to smile less, or talk less, or to have fewer friends, or to stop reading books, or to stop talking to expatriates, or to dress differently, and never to appear more intelligent or knowledgeable than he is. Of course she cannot marry any of them. Some of the female nurses say to me in private that Alya should know by now what men are like, and get on with it, as all women have to.

I invite the accusing ex-fiance into our little hut, to show him what we do in there, and to talk about his concerns in private. This enrages him further, and I realise this is not what he wants. He wants me to tell Alya to behave differently and launches into a stream of criticism of the way she conducts herself and the clothes she wears. ‘How would you like it if I dressed to show the male hairs in my armpits?’ he says.

I pride myself on my ability to defuse situations such as this, but have no success. Hell hath no fury like a man scorned, and Alya is a prize to be strongly regretted. He kicks some of the children’s toys about, and I have difficulty getting him to leave.

I have never seen Alya blush, but she does so when I broach this with her the next day. She tells me this man has been harassing her for some time, stepping on her toes on ward rounds, and slamming doors in her face whenever he gets the opportunity. She wants to marry someone like her father, she says, who has the same attitude to life as she does, and has supported her in this despite the shame the cancelled marriage arrangements bring to the family.

I ask Baktiah later what he thinks we should do, but he says he agrees to some extent with what the ex-fiance says, particularly when it comes to women exposing too much flesh, because of the difficulty this causes men. He says I should tell Alya this. I tell Baktiah he is so good looking he distracts the female nurses from doing their job properly, and that I also expect him to wear a bag over his head when he goes to the wards in future. He laughs as if this is the funniest thing he has ever heard.

‘But what is going to happen to Alya?’ the female nurses also ask. I worry about this too. Her remarkable father is not going to be around forever. Nor is our organisation going to be here forever to employ her. Even the junior doctors say to me, ‘Just wait till you are gone. Alya will find she can’t keep on pretending to be smarter than we are.’

‘Sometimes she is smarter than you are,’ I say, but know this does not help.

The all-female nurses on the female ward are a particularly lively lot. They have remarkable arguments in Kurdish, with doors being slammed, and objects being thrown across the room. I wonder if I should intervene, but Alya says there is no need. Next time I see them they have arms around each other, and all is well. I also see them helping each other to put on make-up and jewelry before leaving work, though I am not supposed to look. I ask if they are going on an outing, but they do this for their husbands before going home, they say.

I have friendly conversations with the senior surgeons from time to time, usually over lunch, despite the disagreements between us, and the associated wariness. Interestingly, in view of the above, one tells me how distressing he found his time specialising in plastic surgery in London because of the blatant behavior of English women in public. He could only cope, he says, by confining himself to his room. Even the television there he found offensive, and was so relieved, he says to get back to Iraq where women behave with decorum.

Regarding the clinical work, I am changing my mind again about the number of female patients who have burned themselves. There are many more than I thought, and they are opening up to me more as time passes, and I gain a reputation as someone to talk to confidentially. Many who told me they were involved in an accident, speak differently now. They might say, for example, ‘but the accident would not have happened, if I had not been upset…’ or ‘for some reason I had locked the bathroom door before the accident occurred…’ or even, ‘if my father had not confiscated my mobile phone, I would not be here’.

Genuinely accidental burns in women are likely to be to the hands or lower body, perhaps from their long dresses catching fire, I now see, whereas the young women who have burned themselves are distinguished by the worst burns being to their upper body and face, and by terrible inhalation injuries. They have usually poured kerosene onto their upper chest before igniting it. I do not know whether they deliberately inhale the fire, or whether they gasp involuntarily as their upper body is engulfed in flames. Either way, they lie in hospital not only with blackened and blistered faces, but also unable to breathe freely, or unable to get enough oxygen out of breathing, their lungs having been gutted by fire. That is what the worst cases die of, as much as from their external wounds.

Based on this re-appraisal, I now think twenty-two of the burned women I have seen since I have been here definitely had self-inflicted burns, thirty-five others possibly, and thirteen others probably, but died without psychiatric assessment. This includes two children under twelve years of age who died without psychiatric assessment after deliberately setting fire to themselves. The self-burned women comprise about half the adult female burns cases and eighteen percent of the total number of five hundred and seventy patients I have seen. There is also one case this month of a woman who was fatally burned when her husband set fire to her, one case of a man who burned himself and died, and another man who probably set fire to himself.

The fathers, brothers, and husbands of the self-burned women, come to look at them, and weep, and show great affection to them in their predicament. Some of the nurses, female and male, say the men want them to die quickly. To me the men seem ashamed. They also avoid talking to me initially, however, like most of the male doctors. Most horrifyingly, some of the mother’s tell me it is good, what their daughter did. ‘She was headed for trouble,’ they say.

The daily contemplation of this phenomenon begins to intrude into my off-duty life, and I have to make a concerted effort not to dwell on it at length, particularly before bed. Alya must have a similar problem, I imagine, and Baktiah tells me that he gets upset at home about the burned children he has seen during the day, and that his parents do not wish him to talk about it. One way of coping, I find, is to give a limited amount of thinking time to distressing thoughts deliberately, when they arise, then switch to something else, rather than to try in vain not to think about these matters after hours at all. I talk to my team about this, suggesting they try doing the same.

The self-immolation patients, apart from their shame at admitting to an attempted suicide, also tend to deny psychological or family problems and are difficult to help for this reason as well.  Almost all say that they did not actually wish to die, and almost all express surprise at how painful and permanently disfiguring their injuries are, as if they were oblivious, at the time, to what this would be like, or its actual consequences.  I decide to treat all of them as having a psychiatric problem, in addition to the usual emotional response of other patients, but am not sure yet how to categorise this. Only a few give a history of depression that could be appropriately treated with medication. Others describe a relationship with their family of origin, or their spouse, or both, characterised by controlling, punishing and emotionally manipulative human interactions, and an absence of empathy, or freedom to make their own choices. For some of the teenage girls there is a largely-theoretical love affair in the background, with a boy they hardly know. I think several of the women may have been deliberately burned by other family members, but only one says this. Some were told to burn themselves in the course of an argument with their mother, or father, or husband, or brother, and did as instructed.

The psychotherapy I attempt to provide for all of them, together with their families if possible, aims to share feelings and to explore behaviours in a more detached way, with a view to mutual support rather than conflict. In the case of dying patients, I provide this for the sake of those left behind, as well as it being an aspect of palliation. In the case of those who will survive, I provide it in the hope that the family will live more creatively in future.

Whether or not other family members want the dying women to die quickly, they are certainly distressed when this happens. I see them following the shrouded body as the porters wheel it out of the hospital. One young husband behaves with strange flippancy when visiting his wife in the palliative care ward, and will not talk seriously about the situation, but I will never forget, once she is dead, the way he bounds along clinging to the trolley, howling without restraint, like a child who has never before realised anything could be this painful. Another young husband, badly burned himself trying to save his wife during her immolation, will not co-operate with his own care, and does not sleep, until he has had several long talks with Alya and me, coming to terms with his guilt and grief. Later his father visits us in our hut and pours aromatic oil over my hands in gratitude for his son’s emotional recovery.

I struggle to make sense, in one case after another, of the burned women’s motivations. Expectations, based on my familiarity with young Melbourne women who attempt suicide, have misled me, I decide. This Kurdish phenomenon must be understood in terms of this Kurdish culture, with which I am still too unfamiliar. As far as I can see, there is no constant thing called ‘human nature’, or set of universal rules about how people behave, of which this is a manifestation that has previously escaped my notice. This is something new, and I do not believe that making sense of it will tell me something about all people, but only about these people. As I see it, people invent their way of being in as many ways as there are people, and cultures invent theirs in as many ways as there are cultures. This is one aspect, I believe, of the way this particular culture has invented itself in dealing with what it is to be a human being.

I gather clues from what I am learning about life in Kurdistan. Self immolation by women is also practised in Turkey, Iran, Afghanistan and northern India, but appears to be most common among the Kurds. In the Zoroastrian tradition, which once prevailed in this whole area, fire is revered as a great purifier. In modern Iraq, every home has the means to produce extremely hot flames in ovens and hot water systems. In the shops in Sulaimaniyah I see crude home-made heating devices for sale without safety regulations. On picnics I see great excitement at using bellows to make the flames as hot as possible for cooking the kebabs.  Could any of this be relevant?

In addition traditional Kurdish culture treats attractive young women as saleable commodities. I hear of men in the villages who sell their teenage daughters as brides to rich men, as part of a business arrangement, to pay off debts, or to buy a new car. The compliance of young women, in remaining virginal and amenable, is of consequent economic importance to their families. They cannot be allowed to have friendships with boys, or even draw too much attention to themselves, let alone fall in love of their own accord.

Add to this the fact that young Kurdish women are remarkably beautiful. The men too are unusually handsome. I do not think this is simply in my eye, as the beholder. Being halfway between European and Arab in facial appearance seems to be a fortunate position, and, for all their misfortune, one thing the Kurds have is good looks. On the streets of Sulaimaniyah women do not usually cover their faces, and I see beautiful, unsmiling young women who seem strangely alluring in their meek sadness. Older women tend to obesity, and Alya tells me they sit at home with little to do but eat chocolates.

More recent traditions encourage a freer female self image in conflict with this, albeit still very restricted compared to that of Western women. Older women from some influential families run the Sulaimaniyah Womens Union, with counseling services for young women which I thought might be of help to some of our patients on discharge from hospital. Alya tells me she thought so too, at one time, but has found their usual counseling is to obey and respect your father more, or your husband more, if you wish to stay out of trouble.

Another factor I consider is that large numbers of Kurdish men have died violently in recent decades, while women were spared. They speak of the deceased with reverence, and of themselves sometimes as undeserving to be alive. Many of the women who burn themselves speak about their behaviour as punishing themselves as they feel they deserve.

Central to Kurdish culture too, lies a sense, not only of allegiance, but of customary obedience to family and authority which is difficult for me, as a Westerner to imagine. Kurds, both male and female, demonstrate an attachment to doing what their families want, to an extreme degree compared with what I am used to. One of the appeals of Islam for them, too, seems to be its rules, and rules, and more rules, its ‘oughts’ and ‘shoulds’, the virtue of extreme obedience and the shame of not obeying. In family relationships there is great security in doing what the family requires, of course, and insecurity in stepping outside the family rules for the sake of self-determined aims in a very dangerous society. In many cases, for example, young people do not pursue studies, or a career, in an area that they are good at, or enjoy, but in an area their family determines. In many cases, young people do not marry the person they are attracted to, or have a friendship with, but the person their family selects. On the other hand, if a family member becomes disabled, or psychotic, the family looks after him or her, beyond what we would usually do, I think, even if other members have to make great sacrifices.

So, if their motivation is not that of distressed young Australians who make suicide attempts, what is it? Obedience to the family is a recurring theme in what they say, coupled with guilt and waywardness. Are they telling me that they are driven to set fire to themselves because they are unable to keep themselves in line in any other way? Do their mother’s approve, because they would do the same? To purify themselves?

The self-immolating women certainly seem helplessly not in charge, talking as if their behavior is scripted rather than consciously intended to achieve a planned result, or to change anything. They are generally young, many mere adolescents, often in conflict with their unapproachable and righteous fathers or husbands. Yet their apparent act of defiance does not seem strategic, or even to represent an expression of anger towards others, despite the raw ferocity of their behaviour.

I listen to their sadness, accepting that they may not be angry at their social position of subservience. They may be hopelessly confounded rather, by the dilemma of their existence in this culture, at this time.  They may be angry with themselves for not fitting in, and I see their self harm now as self-inflicted obedience – a sorrowful, painful obedience  – like a battered wife in Australia, perhaps, who not only submits to being beaten, but seems to arrange for more, as if to please her abusing husband and to mortify herself. I find this explanation more horrifying, and harder to bear. I wonder if these self-burned Kurdish women are the liveliest, or the most playful ones, the ones for whom obedience is most difficult. Or the most highly sexed. Or the most romantic. The ones who fall in love. All suppressed.

‘I did not know it would be like this,’ they cry, led astray by a system they thought they could trust. They describe the guilt, and fear of non-conformity, that they were escaping, and I listen with dismay. Mothers fail to sympathise.  Fathers, brothers and husbands are baffled that it has come to this.

They do not all die. Once healed, with their appearance spoiled, they can express relief. Younger ones say, ‘That boy will not look at me again. I am glad that’s over.’ Older ones say, ‘What freedom there is in being no longer beautiful.’

Sometimes the boy does look at the girl again, loyally coming to visit her, despite her disfigurement. I arrange for one pair to meet secretly in our mental health hut, without the knowledge of either of their families, feeling as if I am the old priest in Romeo and Juliet. But their relationship is doomed, and nothing is achieved. The girl’s older brother joins us for the second such meeting and says to his sister, ‘You know I could not marry the cousin I loved, and am married now to Noor, and am unhappy. What made you think you could have anything different?’

Here are the stories of two other young Kurdish women currently in our hospital:-

Fourteen-year-old Solon and her widowed mother live with her mother’s family as financially bereft dependents, always in fear of causing offence and having nowhere else to go. When Solon was betrothed to the son of a good family everyone was pleased. This would bring financial security as well as happiness. She was excited when she saw the handsome nineteen-year-old boy she was to marry. At the betrothal party she wore a sequined dress, and make-up for the first time, and everyone who knew her said they could not believe it was her, she looked so beautiful. She also felt the some of them looked at her with envy and disapproval, and was afraid. She felt the ‘evil eye’. Next day, getting ready to bake bread for the family, she made a terrible mistake, leaving the gas on for too long before leaning into the oven to light it. The explosion burned her hair and her beautiful face and her hands. In hospital she does worry that her face is spoiled, but her mother worries more than she does, since the betrothal has been annulled. The mother seeks comfort and reassurance from the nurses and doctors continuously. Solon has bought presents  – chocolates with pink centres, wrapped in gold paper – which  she hands out to everyone who speaks to her. She does not expect to hear from the boy or his family again.

Sixteen-year-old Payan lives in a small village with traditional parents. Her father is kind, but strict, and does not discuss his decisions with her, such as forbidding her to have a mobile phone. Her mother agrees with this arrangement. Their closest friends are members of a family of Arabs, otherwise shunned in the predominantly Kurdish village. Payan and the Arab boy, Mohammed, are in love. She wanted him to ask her father for her hand in marriage, but Mohammed said he could not do this. She wanted the mobile phone so she could speak to him in secret, and persuade him. One day, locked in the bathroom, she spilled kerosene on her clothes and caught fire. In hospital she denies inflicting this on herself, but says this shows that her father should have allowed her to have the mobile phone. Her father says he will sell the family home, if needed, to pay for plastic surgery in Iran for his beloved daughter. But her face will never be beautiful again. She has her mobile phone with his blessing now, but the relationship with Mohammed is over, despite their love.

Young men here fare better, but are also suppressed. Many remain virgins until they marry in their late twenties or early thirties. This is the case, as far as I can tell, with almost all the unmarried Kurdish men I have got to know. Nor have I seen evidence of night clubs in Sulaimaniyah, or any places where men and women socialise together. The young men’s appearance is often deceptively virile, and they dress to enhance this, but most of them pray five times a day and are amazingly ‘pure’. Handsome young Baktiah, for example, has the sweetness of a schoolboy. Most young men seem happy, nevertheless, and to enjoy each other’s company enormously despite the difficulties of these cultural constraints, as if their childhood is prolonged and they have not yet tasted adulthood.

Overall, I am also happy, I think. I feel dreamy a lot of the time, as if distanced from my surroundings and the terrible things I am learning. But I am not completely well. My ankles swell to an uncomfortable degree this month and I become overly concerned about this. Sulaimaniyah is sufficiently elevated above sea level to affect the blood oxygen levels of newcomers like me, and my lungs are not good anyway. I have noticed how much more quickly I become short of breath here, if I hurry, or attempt to climb a mountain, or to dance. I tell Sven, our disappointing medical officer, who is pleased to take me on as his patient, and refers me to a consultant cardiologist at the nearby medical school hospital. There I have an echocardiogram, and the cardiologist physically examines me in front of his junior trainees. As he takes my blood pressure, I ask how high it is, but he refuses to say. I explain that I am also a doctor, but he says he never tells any patient their blood pressure, whoever they are, and wishes the junior doctors to respect this principle. He also tells the junior doctors, rather than me, that there is nothing much wrong with my heart, but I need to take a diuretic, which he prescribes. This solves the swollen ankle problem. Back in Amman, the supreme medical director of our project, a big Russian woman, has had a report. She rings me from Jordan and shouts odown the telephone, ‘Peter! Don’t climb any more mountains!’

July 2009

I dream one night of a young Kurdish woman in the fire. She is somehow held there, with her beautiful face confronting a bed of burning coals. They want her to breathe in the flames. She does not want to. They hold her with fire-tongs either side her pretty jaw, pulling her face forward towards the flames. Still she does not want to. At last she begins to breathe in the fire that curls and licks around her mouth and nostrils, and she cries. They tell her she is good then, as she breathes out, and breathes in more fire, and cries as she breathes the curling flames, knowing she is doing what they wanted, however painful, and crying, knowing that with each breath she is destroying her lungs forever. I wake and cannot get back to sleep. Still the dream will not leave me, days later. Each time I go to make tea at home, I see how the blue and yellow flames curl out of the gas jets and lick the base of the kettle. I remember the dream.

Does this put an end to my speculations about the self-immolating women’s motivation? I think I get it. Or am I, myself, the woman in the fire? Are the multiple challenges of this project, for which I seem unable to avoid individual responsibility, too much for me, and I need to hold back? Still I do not avoid the palliative care patients and see them every day with my interpreter. Alya, without whom I would be lost, is at least as brave as I am in this regard. I see them more and more through Alya’s eyes. Here are two of the dying patients’ stories.

Twenty-five-year-old Amina has always been a clever girl, who reads books and takes an interest in international affairs, despite having left school at ten years of age, to help at home. She lived as a child with her young mother, who was the second wife of her aged father, and with her older half-sisters and brothers, of similar age to her mother. All of them loved Amina for her lively mind. Her two brothers joined the peshmerger resistance to Saddam Hussein and died fighting. Her old father died too, soon after. The sisters did not marry, and the all-female household became poor, as time went by, and without a secure future. Five months ago a younger man fell in love with twenty-five-year-old Amina. He was a simple fellow of twenty-one, and she told him at first that he was too young for her. Then she married him anyway, only to find that, in addition to not being very bright, he resented her intelligence. He forbad her to read, listen to the radio, or see her girlfriends or family. He controlled her activities more and more firmly as time passed, requiring her to do exactly what he said. They argued incessantly. He did not treat her violently, but as a Kurdish husband he had the power to control her life. The more she argued her case the less he responded to her and the more rigidly he imposed his rules – when she rose, when she went to bed, when she ate, what she ate. She knew she was trapped with this stupid, oppressive man forever, and no-one could help her. She remembered the life she had with her sisters and mother. It had been hard but she had been loved and free. She told her husband she despised him, to no avail. One day she set fire to herself with petrol. In hospital she talks and talks – about her love of life and her regret at what she has done. Her face is black, her eyelids so swollen she cannot see and her fingers like sticks of charcoal. But her lively mind remains. She talks about wanting to live again. She refuses to see her husband who waits for news at the hospital gate, while her adoring mother and sisters sit with her continuously and cry. Her burns are too extensive for her to recover. Her gastrointestinal system and her kidneys barely function, and her voice croaks. Yet her lively mind remains. Ten days have passed since she was admitted. She has not yet died and continues to talk.

Twenty-year-old Shnoor comes from a poor family but has a naturally beautiful face, unusual and slightly oriental by chance. She married a policeman five months ago who has guarded her jealously, accusing her repeatedly of having other admirers. He soon became so obsessed with this fear that he began to berate her continuously, and then to beat her. Her family knew of her predicament but could not help. When she found she was pregnant she hoped life would improve, and looked forward to having their child. Still her husband beat her and abused her. One day, three months pregnant, she sat looking at the pictures of their wedding day and told him how happy she had been, how everyone had wished them well, and how unhappy he had made her. He threw kerosene over the photographs in her hands, and over her clothes, and set her on fire. The skin was burned from ninety percent of her body, but she put her hands over her face, and that remains. Her husband came with her to the hospital, demanding she tell people she burned herself. Her grieving family came too, accusing him in public of what he had done. They argued in the street outside the hospital. The police came and chose to believe the policeman husband’s version of events. No charges were laid. As Shnoor lay dying in hospital, her mother told the staff that the doomed baby inside her was making her pain worse, and begged us to give her an abortion. Then she died.

I already know the police to be ineffectual. Sometimes they extort money from the poor, instead of protecting them. Kidnappings are common from members of richer families, and the police are reputed to do little to investigate these either. Some say they make money out of them. One old man in our hospital tells the story of how his kidnappers bound dry straw round his legs and set fire to it while he was speaking to his relatives on the phone, begging them to pay the ransom. His family sold property and did so, as they were traditionally bound to do, and here he is on our men’s ward having his burned legs attended to.

The main work of the mental health team continues to be supportive counselling to psychiatrically normal patients in emotional distress. Kurdish women are often very different from Australian women in their expression of this distress, however. Sometimes they make me angry, they are so primitive, and so helpless in their reactions. Maybe I am feeling the anger they should feel – at their social inferiority and ignorance. I have also long known that, as a psychiatrist, I have a particular difficulty responding to helpless people. I need to take this into account and to compensate for it, if I am to be fair.

One woman this month is so inappropriately histrionic she dies of her play-acting. She refuses all treatment for several days, in response to some small slight. What is that all about?  She has her husband with her, as caretaker, running about like a headless chicken, getting things for her, constantly adjusting her pillows and her bed sheets, and repeatedly approaching staff members, me included, with trivial requests and complaints on her behalf. I cannot help but despise his silliness, and hers. In the end, having made it so difficult for the nurses to tend her wounds, and having refused her medications, while her husband and everyone else pleads with her to be reasonable, she succumbs to an overwhelming infection, despite being one of the minor cases who should have recovered. I do think: serves you right – an extreme reaction on my part too.

In my defence, I am also able to see, and sympathise with the fact, that women here have had to develop their own way of asserting some power and self-expression in the face of their oppression and their protection from responsibility or involvement in the world. But I do not like it.

We assess eighty-two new cases this month, and provide one-hundred-and-thirty-three follow-up consultations to patients.  As usual, I also treat a number of staff members, and sometimes their family members, for psychiatric problems. This involves seventeen new assessments and eighteen follow-up appointments, and includes seeing two trainee doctors stressed by the ‘assembly-line’ approach to patient care and the heavy surgical responsibilities they carry without teaching and support from senior clinicians, two female nurses with mild post traumatic stress disorder as a consequence of witnessing a large number of young women die, and two cleaners with chronic psychotic disorders requiring special consideration at work.

As I have said, when I first arrived the Mental Health team was approached daily by members of one staff group or another with requests for support in the face of the emotional challenges of the clinical work itself, which was appropriate, but also in facilitating the resolution of interpersonal and administrative difficulties. In some cases I arranged group support sessions, including several group discussions for the outpatient department staff, and for the intensive care ward and female recovery ward nurses. In rare cases I arranged meetings with the relevant supervisors, or undertook to convey group concerns to the relevant administrators myself.  Now the Mental Health team is approached less often by members of one staff group or another. This may be partly because I already have a supportive relationship with many of them, but also because I will not take sides in disputes.

As welcome distractions from the work, we have two cultural events of note this month. The Kurdish-French Cultural Association of Sulaimaniyah brings a small group of French artists, of various kinds, from Lille. In the hospital wards they sing French songs, with guitar accompaniment, to an audience of bed-ridden people swathed in bandages. In the evening, in Azardi Park, others in the group perform Isadora-Duncan-style dancing under bright spotlights. I invite all of them back to our place afterwards. They bring champagne and Camembert cheese. Jameel converses with them in French and cooks kebabs, but they have been travelling since dawn and are very sleepy.

On another occasion, our whole household attends a choral concert presented by the Women’s Union, which has its own fine concert hall in Sulaimaniyah, their patron being the wife of a member of parliament. Alya has a sister who plays the violin in the concert orchestra, and makes the arrangements at my request. The concert is spectacular. Twenty or so singers appear to be the daughters of the rich, all remarkably beautiful, dressed in lustrous red, gold and indigo. Some have trained operatic voices. They sing mediaeval Italian songs, then Mozart, then Wagner, a selection from The Sound of Music, then arrangements of Kurdish folk songs. The latter brings tears to many eyes, mine included, and the audience goes wild. I need a good cry, am much cheered up after the event, and become a fan of the Women’s Union, even if they are not very feminist.

Another source of cheer is the turkeys in our street. In March, when I first started walking to work, I met a turkey gobbler with many wives on an unfenced area of waste land not far from home. He puffed himself up, gobbling loudly and spreading his tail like a fan as I went by each morning. Now there are countless turkey chicks and the old man is still there with a future ahead of him. Well done, I think.

One weekend morning, on the other hand, I buy a live chicken for slaughter from a man who comes up our street with an ordinary sedan car full of them, ringing a bell. They are all white, with red combs, and the car is full of fluffy white feathers and brown droppings. Some look slightly mangy, and I choose the sleekest, healthiest one I can see, feeling slightly guilty that its good appearance should condemn it to death. The chicken-vendor, talking earnestly in Kurdish, hands it to me alive, with its feet tied together. I call on Jameel to help me, and we learn that most Kurdish women know how to kill chickens in the Halal way, and how to gut and pluck them, but that the vendor will do this for me if I have a sharp knife and a large bowl. We find these and leave him to it. Not long after, he rings his bell, and I go out to pay him and collect the chicken, ready to cook, plus the silver bowl full of dark blood. I manage to forget about the bowl of blood by the evening meal .

I am also the bread-buyer for our house, which I enjoy. Most households buy bread every day, and this is generally a man’s job. There are various kinds, sold by various little bakeries in our neighbourhood. I discover the small, lozenge-shaped loaves I like, best bought on my way home each afternoon, since they are delicious straight from the oven but stale and inedible next day. I line up with other men to put money on the sill of the bakery window according to how many loaves I want. The money is collected in order and the loaves provided as soon as they are pulled from the oven. Other men talk to one another in Kurdish while I watch the bread being kneaded, shaped and cooked. The bakers place raw dough lozenges on a long wooden plank, slide it into an oven, like a pizza oven, and flip off the multiple small loaves. When they are cooked, the bakers slide the plank in again to collect them. I cannot see how this is done, but it works. The bread smells so good it is hard not to eat some before I get home.

I also get my hair cut locally. I hesitated in this regard when I first arrived until my hair got ridiculously long. For one thing, haircuts cost the equivalent of fifty cents, which I found alarming . Secondly, the barbers speak no English. I discussed this very seriously with a young Australian woman in our project administration, who said, ‘At your age, what does it matter how your hair is cut?’ On a previous occasion she told me she had heard that medical services in Iraq were generally excellent, thanks to the US Invasion, and the Iraqi people were lucky for that. So maybe her opinion does not count for much.

In any event, I am now an old hand at the Kurdish barbers. Kurdish men are generally very hairy, but like to have their hair cut very short, and their necks shaved clean, so the barber shop floor is a sea of curly black hairs swirling around our feet. The barber also has a miniature electric razor for tidying wild eyebrows and cleaning up hairy nostrils and ears. When I go this month, a young man ahead of me has brought his little son for a haircut. The boy is about three years old with very black eyes, long lashes, and a mass of floppy black curls covering his head. All the men waiting delight in him. The father discusses the haircut with the barber, who then gives him a number-one buzz all over, with beautiful little-boy curls tumbling to the floor. I do not think his mother will be pleased. When it is my turn I try to indicate with gestures, ‘Not like that,’ but then worry the barber might think I am saying the opposite. As it happens, I leave in good shape and give the barber the equivalent of a whole dollar for his efforts.

Also this month, an inspiring young Muslim man from Jordan, Faris, spends a lot of time in our house over a couple of weeks. He is here to install a new hospital waste disposal system and stays with us as a change from his solitary life at his hotel. He prays five times a day when the Mullah calls, and applies the principles of tolerance, honesty, and compassion to everything he says.  He speaks graciously about the plight of the Israelis, for example, aware that Jewish people were persecuted in Europe for centuries. He explains to me that they are ‘people of the Book’ and deserve respect, and refer sympathetically to ‘the mess they have got themselves into’ in the Middle East by incurring the enmity of all their neighbours. He is also a paragon of good manners and does the washing up each evening. I could not believe what he believes, his religion is so infested with rules, as I have said, and requires such subservience, but knowing him boosts my morale. I see at work how decent he is in his actual dealings with others, and how generous his attitude to various different cultures and religions. There are many Muslims like him in Jordan, he says. I hope so. He says how disappointed they are in the rigid religiosity and hypocrisy of Arab governments of today, compared with what real Islam has previously been about. I hope this is also true, but suspect that Faris is an exceptional man.

As for what the Kurds think about Israel and its policies, my impression is that they rarely think about Israel at all, and that few people have strong opinions on this topic. They have enough else to worry about, I suppose. Faris says the Israelis tend to think everything that happens in the Middle East relates to them as a possible threat, because of their predicament, and that their politicians encourage this idea to the detriment of ordinary Israelis. Nor do many of the people I meet here hate our Western way of life. Nor do they want to convert the West to Islam on pain of death, as our politicians sometimes claim. For the most part, people concern themselves with matters closer to home, as we all do.

I have spoken to our project co-ordinator, Gloria, who has no medical training herself, about the raw deal I think we are getting from the consultant surgeons on our project. I have not wished to break the confidentiality of my conversations with the junior doctors, or to cite their testimony. I have, however, pointed out to Gloria that we have no evidence of any training of juniors, and no record of any burns patient surgery actually performed by the consultants. It is also clear to everyone that they come so little to the hospital we run, compared to the hours they are paid to work. I also tell her about complaints from patients on the ‘special’ ward that they are billed for the care we provide free, and for the operating theatre time and anaesthetists we also pay for. She was not here at the inception of the project and is as puzzled as I am that we hired these doctors without any measures of accountable for their side of the agreement. She also expresses annoyance at the current state of affairs. I wonder if she will do anything to remedy it.

I know the junior doctors are also in excess, and do not work very hard either, but I do feel sorry for them, with no training and no support from their seniors, and no freedom to speak about this. I think what training I can give. A couple of them have been writing more history in the patients’ notes, but none of them clerks in patient as I think it should be done. I write another document for them, advising taking a full history of the burn occurrence and a quick overview of any past medical conditions as each patient is admitted, as well as a general physical examination. This could be followed later with a full history, taken at leisure, when any emergency has been dealt with. I give this to them individually, in printed form, over several days, telling them I know the consultants will take no interest but offering that they can then go through the history and physical findings with me, at any time, as a training experience. None takes me up on this. Leadership just has to come from those formally in charge.

I attempt to shame them all one morning, as diplomatically as I can, by presenting a talk on the role of the doctor versus that of a nurse, since the nurses already do much the same admission as the doctors at present. Why not leave it to them? What is the long training of a doctor for? The nurses, in fact, do more than the admitting doctor, since they also shower the patient, if possible, clean the wounds, remove debris and cut burnt hair. They also make their estimate of the extent and depth of the burns, and calculate the fluid replacement required. They insert the intravenous cannula and urinary catheter. So why have a doctor attend? Why is it so hard to get into medical school, and why is the training so long? Is it only to decide what laboratory tests to order, which the nurses could do too if given permission? And to write up the routine medication?

No-one attempts to answer my questions.

How about estimating the prognosis? How about an individual management plan taking the patient’s past medical history into account? How about establishing rapport with the patients? Or talking to the relatives and eliciting their co-operation?

None of it makes a difference. Why do I like the junior doctors at all, then? They are a bunch of lazy rascals. At least they do not avoid me, as the consultants surgeons do, or regard my ideas with contempt. ‘This is as we were taught at medical school,’ they agree. ‘You are the best practising doctor we have ever met.’

‘You have not had much chance to meet good ones,’ I tell them. ‘There are many more like me in the world.’

And why do I dislike the consultants so much? They manage to regard themselves as my superior, I suppose because they earn twice what I do here, while working a fraction of the time. They practise my profession with criminal negligence and show no concern for the junior doctors under their charge. Why should I not dislike them? Yet I should also try to understand.

‘Old men who show contempt for the young are themselves contemptible,’ I tell Jameel, thinking also of the war-mongers who wrecked Iraq, and wondering about their contribution to this Sulaimaniyah state of affairs.

August 2009

Returning to Sulaimaniyah from a meeting in Amman proves a markedly different experience from my first arrival here five months ago. Instead of seeing the snow-covered mountains and the green Sulaimaniyah basin, we descend from the clear upper air into a dense brownish-yellow dust cloud, thicker than I have seen here before. In the city people wear face masks, and you cannot see as far as the end of the street. The front steps of our house bear a deep layer of red powder. One humorous account I am given of this phenomenon is that the American army tanks, having agreed to withdraw from the Iraqi cities, are now rumbling round in the deserts stirring up this trouble instead. Another is that the Arab-dominated central government in Baghdad having, by agreement with the Americans, to send seventeen percent of State revenue to the Autonomous Region of Kurdistan, is also sending seventeen percent of Baghdad’s dust. People also say that it used not to be like this, and that the climate has changed remarkably in the past few years.

Apart from burns due to flames and scalds, some we see on our burns unit are electrical. These can be deceptively more extensive than they first appear. One young man who worked for the state electricity board was handling wires up a pole when the electricity was inadvertently turned on again. He comes to us with burns to all the fingers of his left hand, and is warned by the surgeons that he might lose his whole hand. In theatre it is found that muscles all the way up his arm are necrotic and require an amputation at the shoulder.  I see him in the ward the next day. He has a handsome, mischievous face and his eyes twinkle.

‘This is the will of Allah,’ he tells me cheerfully. ‘Allah, who loves me, wishes me to lead my life with only one arm from now on.’

I visit him daily for a while, expecting him to become depressed, or at least distressed, eventually. Weeks go by, however, and he remains as cheerful and accepting of his loss as he was initially.

A boy of eleven is found unconscious in the street, at the foot of a power pole, with burns to both hands. No-one knows exactly how this came about. He loses both arms at the shoulder and is indeed distressed. His mother cries a great deal. Over the ensuing weeks, Alya, Baktiah and I teach him, as best we can, to start using his feet and toes to write, and to play with toys. Other, smaller children visiting our hut in the afternoons, also start using their toes to play, as if this is some new game. We also play soccer with him, and he sometimes laughs and enjoys this. Sometimes he suddenly stops in the middle of trying to write, however, and says, ‘Oh I just want my arms back again,’ and Baktiah has to go outside to cry too. It is hard to imagine what this boy’s future will be.

Another, younger boy has lost his right arm at the elbow. For some time he has his bandaged arm in a sling and seems to imagine it is still complete. Perhaps it feels as if it is still there. His mother says we must not tell him otherwise, but of course he will have to know eventually. With her permission, Alya and I explain the situation to him.

‘I know,’ he says, and goes on with what he is doing.

The next day about fifty relatives of all ages come to visit him and have a huge picnic in the hospital grounds.

Large numbers of relatives and friends come to visit our patients. Alya tells me it is expected absolutely that you will visit anyone you know who is ill at least once, but this is a major problem on a burns unit where infection control is crucial. Only a small number of close relatives are usually allowed in, and the gate keepers have frequent difficult arguments with others. They offer to let the patient know the visitor came, and to relay any gifts. Most visitors do not trust the gate keepers with the gift, however, and I do not think they actually tell the patients who came. Many visitors break through, anyway. Perhaps they pay a bribe, or threaten dire consequences, or are just very forceful.

This problem is particularly hard to control when the patient is an old man of status in the family, whom no-one wishes to neglect or offend. Our big Russian medical supervisor from Amman is visiting out project this month, and I see her in the men’s ward on one occasion pleading with multiple relatives of an old man with a burned face to stop kissing him on his burns, to the amusement of the nursing staff. The burns heal well over the ensuing weeks even so, and I secretly think kisses might do more good than harm.

Our organisation is conducting an individual performance appraisal this month of all staff other than the doctors – with whom it is most needed, of course. Many staff members are afraid of losing their jobs, or that this will jeopardise their future employment prospects.

‘No,’ the administrators tell them. ‘This is so we can help you.’

How? I wonder, as does everyone else. In a discussion of this with Baktiah I amuse him by telling him the review is so that if any of us are kidnapped they can decide whether it is worth paying the ransom.

A separate, more major problem has arisen in our relationship with the doctors. Gloria has asked them to keep simple time sheets of the hours they spend at the hospital, indicating whether at meetings, or in patient care, or in training sessions. Time-sheets are already required of everyone else working on the project, and their pay reduced if they consistently arrive late, or take time off unofficially, as some do, and increased if they work later than required. The junior surgeons refuse to co-operate with the time sheet requirement for them, but go on doing their job as they have always done it. The senior consultants, on the other hand, refuse to come to the hospital at all, and the ‘special’ ward is empty.

‘No matter’ the junior doctors tell me. ‘The burns patient care goes better without them. At least we know what each other is doing.’

This may be so, but the Kurdistan Health Department soon contacts our project administration on behalf of the consultants, reminding us that they agreed to accept the services of an expatriate charity only if local specialists were employed ‘to maintain standards’. We point out that the consultants continue to be employed, and to receive their pay, but are simply not coming to work. The Health Department maintains that they should not come to work if unreasonable and insulting demands are made of them. Arguments of this kind go back and forth for a week or two. Gloria has a terrible time, being required to attend meetings at the Department of Health, then kept waiting for hours, then being told the meeting is cancelled. Sometimes she is asked into an official’s office then sits facing him while he deals with paperwork and makes multiple phone calls as if she was not there. At other meetings with multiple attendees, everyone speaks at length in Kurdish, not necessarily about the matter in hand. Eventually Gloria looks suicidal herself. Later the consultants return to working as usual without any of the doctors being required to complete time sheets. Some of the other local staff express their disappointment to me. Others say this outcome is as it should be, since the consultants are such important people.

We have trouble with another government department as well. Our organisation purchased land several months ago, some distance from the hospital, for a dangerous-waste incinerator site. We now find that the same government department sold the same land to another buyer at the same time, who is already using it for another purpose. Gloria is in the process of sorting out whether we own the land or not, or getting our money back, and what else we are to do with or dangerous waste.

She has yet another problem. She and the head of nursing try to rearrange the way all the nurses, apart from the children’s nurses and theatre nurses, are allocated to the adult wards. Everyone is to take a turn working on the emotionally taxing intensive care ward, or on admissions, for two months, followed by a less demanding stint on either the men’s ward, women’s ward, ‘special’ ward, or on the follow-up outpatients clinic. This sounds like a good idea, and very fair, but comes up against some longstanding arrangement which no-one will describe, but from which half the nurses refuse to budge. Some come to me, telling me they will become emotionally ill immediately if they have to work on intensive care, but I refuse to get involved. Long queues form outside Gloria’s office, and I hear the Kurdish head of nursing screaming at others in her office.

To top things off, we find that our outside caterers have been cheating us. Most staff members, including the administrators, eat lunch each day in the hospital canteen, where the food is appetising and varied. The intensive care and operating theatre nurses, on the other hand, have theirs served in special dining areas where they work, and have been complaining that the quality of theirs has been gradually declining to the point of being monotonous and tasteless.

‘And where is our piece of fresh fruit that everyone else gets?’ they say.

Investigation reveals that what they receive is no longer anything like what we originally contracted the caterers to provide, and for which we still pay. Further investigation reveals that the patients’ food is equally reduced, that the patients do not get their designated fresh fruit either and that the caterers sell large amounts of our food elsewhere. I then learn that the caterers paid for the buses and food for the picnics so many of the staff enjoyed in the Spring, me included, and that this was meant to have us turn a blind eye to the poor food given to the patients. Unfortunately for them, the intensive care and theatre nurses have blown the whistle on this.

‘All I can say,’ Gloria tells me, ‘is how glad I am to have somewhere else to go home to, once I have finished working here, and how sorry I am that the local people do not.’

Yet the locals do have their fun. Baktiah and his good friend Alan, head nurse on the children’s ward, invite me to join them in attending a Sorani folk festival out of town. The Kurdish people in Iraq can be divided into three main cultural groups, and Sulaimaniyah is in the large Sorani area. Baktiah comes from Halabja and is Howrami, but Alan is Sorani and considers himself to be our host on this occasion. He has a slightly misshapen face, a long neck and a squeaky voice, but wears a turban with a tassel hanging against his cheek which makes him look so suave I can hardly believe it is the Alan I know. He seems to be aware of how well this suits him, and his eyes shine. Baktiah wears the grey-green Kurdish clothes he shared with me on picnics and has brought me another suit in chocolate brown. What fine fellows we are.

We see many Kurdish horsemen wearing the same tasseled turbans as Alan’s as well as colourful jackets, with brass buttons and striped riding breeches. They have bullets wound round their bodies and carry rifles and short swords in decorated sheaths, and seem aware of how good they look too. The atmosphere is one of celebration. In my light-weight, voluminous Kurdish trousers I feel as if I have no pants on, which puts me in a slightly hilarious mood.

Alan, Baktiah and I find places in the covered stands of a large stadium, to watch a procession. We also hear a performance of ‘shouting’ singing, used traditionally by the Sorani to communicate in the mountains. This is impressive but not easy on the ears. Not easy for the singer either, who works hard, with his cheeks puffed up and his eyes bulging, and can only keep going for short bursts, each followed by enthusiastic applause from the audience. Next to us in the stand is a group of American army officers, and the one next to me is greatly surprised when I speak to him in English. It pleases me to think I am so well disguised as an old Kurdish man. He surprises me in turn my telling me how best we should make our escape should anyone in the stand becomes violent.

The crowd stirs when a large black limousine with official-looking escort cars arrives in the stadium. The dignitary who emerges is Jalal Talibani, founder of the Patriotic Union of Kurdiastan (PUK)­ and first non-Arab president of Iraq. He is greeted with luke-warm applause and mounts a platform to give a long speech in Kurdish. The election for the Autonomous Region of Kurdistan’s governing council is due the next week, and Baktiah tells me he is speaking on behalf of PUK candidates. This also ends with not much clapping.

The next week, we have the Kurdistan regional election itself, which forces our household in Sulaimaniyah to stay indoors for a few days. There are some violent clashes in the streets on this occasion, and I hear that someone is shot. In the preceding week, everyone I speak to at the hospital says they, and everyone they know, will vote for a new party called Change, because the current president and council have done little other than amass personal fortunes, and oversee human rights abuses of ordinary Kurds by the Kurdish security forces, including arresting and torturing dissidents. I do not know if this is true or not. There is little here in the way of local news reporting, only word of mouth. Whatever the case, the same president and council are re-elected, and everyone I speak to afterwards says that the elections are rigged, and that is just how things are here. When the results are announced, an elaborate fireworks display lights the dusty Sulaimaniyah night, which no one comes onto the streets to watch.

At the beginning of the month, I went to Amman for a Middle East mental health regional meeting for our organisation, which was very rewarding. A warm and lively group of psychologists and psychiatrists, both expatriate and Middle Eastern, discussed their work for internationally-funded clinical services in Jordan, Iraq, Lebanon, Gaza, and the West Bank. Most treated demoralised, war-ravaged populations, and diagnosed a lot of depression and post traumatic stress – adults with avoidance behaviours and high arousal, and children with recurring nightmares and bedwetting. Working mainly with displaced and persecuted people, they were seeing different patients from mine, but gave an impression of being better supported by colleagues than I am in Sulaimaniyah. Or maybe they were, like me, encouraged to be mixing with like-minded people at the conference.

At the end of the month another international expert visits our burns unit for a few days, this time an American infection control expert, called Richard Selby, whose aim is to strengthen the diagnosis and management of our burn-related infections. He finds no fault with our surgeons, is full of praise for their superb work, not believing the junior trainees do it all, in fact, and very dismissive of my complaints about them, as well as those of our last expert, Dr Chandra. They like him a lot and obviously better than they do me, but, after he leaves, follow none of his elaborate advice.

He emphasises the importance of detecting serious wound infections as early as possible, for example, then taking swabs and starting antibiotics immediately. Early signs might be either a sudden rise or fall in the patient’s temperature, a sudden rise or fall in the patient’s pulse rate, or breathing rate, or an alteration in the patient’s level of consciousness. Then, on the weekend after Dr Selby’s departure, an eleven-year-old boy with thirty percent burns, Aladdin, who has been making a good recovery, becomes mentally confused on the Saturday afternoon. By the evening he has a high temperature and racing heart rate. By Sunday morning his temperature has fallen below normal, his pulse rate slowed and he has lapsed into unconsciousness. Nurses on the children’s ward contact the junior doctor on call, who contacts one or other of the consultants repeatedly, but no action is taken. By the Monday morning when swabs might have been taken and antibiotics started, little Alladin is dead. I raise this case at the morning doctors’ meeting, asking why the boy was not treated urgently, as Dr Selby advised. A loud conversation in Kurdish ensues, which I cannot understand, and the matter gets no further consideration.

I discuss this with Sven and Gloria, who tell me that since our organisation took over running the burns unit three years ago, pouring money into the project to provide a high-quality laboratory service, state-of-the art antibiotics and other medications, and international expert advisers, the morbidity rate has not improved from previous levels. The money has made no difference to this.

I am more distressed than ever at how negligent our surgeons are. Another case also disturbs me, more than that of Aladdin, because I am more intricately and helplessly involved. When Ayla and I first meet Ezma, a young woman who has been subject to a gas explosion in her kitchen at home and who has sustained severe burns to forty percent of her body, we both notice her prominent eyes. This is a well-known sign of over activity of the thyroid gland. We point this out to the surgeons, who accept our comments with bad grace. I suggest that a measure of the level of thyroid hormone in Ezma’s blood would be a good idea, also accepted with grumbles of agreement.

The thyroid gland in the neck releases thyroid hormone, thyroxine, into the blood at a rate that regulates the burning of fuel by the body. It can be disordered either by being overactive, called hyperthyroidism, or underactive, called hypothyroidism. These are obviously very different problems with different symptoms, different dire consequences for the body, and different treatments needed for their correction. It is hard to imagine that trained doctors would not know this difference and would treat an underactive thyroid as if it was overactive, or vice versa, thus making the patient’s condition worse, not better. Yet this is exactly what happens subsequently, a mistake so obvious to me, and to Alya, as to be a no-brainer, while everything we say to the other doctors, junior and senior, or to the medical officer, Sven, fails to convince them of this mistake.

When we first speak to Ezma, Alya and I find her to be vague and inarticulate, and to give a poor verbal account of what has happened to her. We arrange to interview her mother, an intelligent woman who reports that a specialist physician tested Ezma’s thyroxine levels two years ago, because of changes in her eyes. He diagnosed hyperthyroidism and prescribed carbimazole, a thyroid suppressing drug available from pharmacies in Iraq without a prescription, and which Ezma has taken ever since. The admitting doctor to our burns unit arranged for this to be continued here too, at the mother’s request, she says, without asking what it is for. When Ezma was diagnosed two years ago they were not able to afford expensive further investigations to establish why her thyroid was overactive, nor further consultations with the expensive physician subsequently, and no further blood thyroxine levels were done. Ideally this should have been checked monthly, and the carbamizole dose reduced and eventually stopped when Ezma’s level was reduced to normal. Instead she remained on a dangerously long, unmonitored course of anti-thyroid drug, which probably so suppressed her thyroxine output that it became abnormally low, rather than abnormally high. This is likely to cause mental confusion, and Ezma’s mother reports that Ezma has indeed become increasingly vague in the past six months, and that this is probably why she had the accident responsible for her burns.

I check with our surgeons what level they have found, but they have not done the test. They ask a visiting physician to see Ezma. He does not order a blood level either but doubles the dose of carbimazole. I complain to our doctors that this is dangerous, since she has already been on a normal dose of this drug too long and especially without blood tests, and should not now take twice as much. They seem unfamiliar with thyroid disease, unable to follow my reasoning, and do not believe me. Ezma develops an infection of her burned abdominal wall that eats into her flesh and produces copious amounts of foul-smelling black pus. I lose sleep worrying about what we are doing to this poor young woman. I tell Jameel the problem. I tell Gloria. I plead with the surgeons to at least measure the blood level. Ezma’s  infection grows, eating deep into her abdomen, and she is in great pain. I stop the carbimazole myself, without telling the surgeons. One of the junior doctors starts it again. The blood test result comes back the day Ezma dies, showing the thyroxine level in her blood is so low it is unrecordable. So we have killed her.

I might feel sorry for the surgeons for their ignorance, and for having so little vision for their own lives, or for their profession, or their community, if I did not feel so angry. I also know this is a more general problem. Caterers are willing to deprive the patients of adequate nutrition to turn a profit. Hospital cleaners are lazy and careless. Many nurses are inactive and callous, cheating like small children, falsifying patients’ records to get out of doing things. The Kurdish head of nursing and the Kurdish hospital director constantly criticise everyone under their charge while giving little support, or instruction, or encouragement, leaving this to us volunteers from overseas, about whom they also complain. Almost everyone complains continuously, at all levels, about how unfairly they are treated, with little sense of knowing how to share difficulties or achievements.

On the surface they are bright and friendly, and most people are very kind to me. But as soon as something goes wrong they are quick to lie to cover their tracks, and to falsely blame others, even those I thought were their friends – as if everyone expects unreasonable punishment, and must act to avoid it at any cost. And I notice again how people gossip about one another in a judgemental way, so that the community seems to further oppress itself, and to oppose positive reform. Then I notice the individual Kurds who are not like this, and how much they matter, and how much they deserve support. They are saints, in fact, the good ones who keep trying under these circumstances. I keep trying, but I am only here for six months. How would it be for me, I ask myself, if I knew I was here for life, with no chance of a passport, or a visa, or a passage out?

Why this impoverished state of affairs? I also ask. Has it always been like this? The Kurdish people have no doubt suffered a lot of abuse over the past century. Is this the result? Can a whole culture suffer from burn out? They pay lip service to their religion but demonstrate a shortage of belief in anything, and a shortage of goodwill between one another. Many talk about wanting to be elsewhere, where life is different, but cannot behave differently here. Have they seen too many deaths? Have they experienced too much unfairness? Have too many young people had to take care of their own upbringing without parental love, their fathers dead and their mothers in grief? Is it easier for me to be kind to them than it is for them to be kind to their fellow Kurds?

I also remain critical of our organisation for wasting so much money and effort so foolishly on this project; and for having employed me as a liaison psychiatrist without managing the overall system in a way that cares for the patients’ physical care adequately, let alone facilitates my work. I am humiliated to be a party to our exploitation and by the negation so much of what I had to offer. I regret what I could be contributing both to the patients, and to the local doctors. So could  Gloria, and the rest of us expatriates, be contributing more, if only we had a system of accountability in place for the doctors we employ instead of paying them what amounts to bribes. If only we had a a medical director who oversaw the work responsibly and who insisted on a normal allocation of responsibility for individual patient care among the local doctors. If only we could fix the fountains in the hospital gardens and bring a bit of sparkle to the place. For me they symbolise our failure.

September 2009

Our organisation has decided to withdraw from our Sulaimaniyah project at the end of November, and to hand the running of the burns unit back to the Kurdish Department of Health. For a while another international charity considers taking over from us. On hearing of our experiences with the surgeons and the Department of Health, however, they decide against this.  I still hope some other organisation may provide a psychiatric support service, at least, and arranging this is a matter of some urgency for me.

I will leave at the end of this month, my contract ended, and will not be replaced with another psychiatrist for the remaining two months of the project. I offer to stay longer, to provide a hand over to a possible psychiatric team from elsewhere, but my offer is declined. Baktiah will leave shortly after me, leaving only Alya, who cannot be expected to do this kind of work alone. Nor is it clear who would employ her anyway. My hope is that some replacement mental health team will start in time to work with her briefly and that she can hand over to them before her contract with us is terminated.

Representatives of our project team have a forlorn meeting with the head of Sulaimaniyah Department of Health, about the end-of-November withdrawal. The man is enormously fat, and drinks a big mug of hot milk with many spoonfuls of sugar. He has a lovely smile and waves his big pudgy hands about dreamily as he talks to us about our patients’ future.

I ask him if he wants the mental health service to continue, and he says, ‘Why not?’

I ask if morphine will continue to be available for pain management under the Department of Health, and he says ‘Why not?’

Gloria signals to me not to ask anything else, and I do not mention the palliative care ward. He might well disapprove of that. Secretly I hope that the surgeons will at least appreciate the relief this had brought them and the patients, and will want this continued.

I explore independently, with Alya’s help, how to leave a continuing mental health service in place. Various international charities working in Sulaimaniyah might take over this more limited role, and we arrange to visit the most likely one. Or the Department of Health might re-appoint Alya, and other counselors, though this appears very unlikely. I recommend, whoever offers, having at least two full-time counselors, as one alone would surely find the work too difficult to continue. I also recommend that the mental health team retain its separate hut in the burns hospital, as this continues to be well-used by patients, relatives, and staff for consultations and other confidential conversations, and as a play area for children to come with their mothers. After several visits to an American charity, based in Chicago, and which trains nurse-counselors here, we make some progress.

Baktiah, meanwhile, has his own long series of efforts to make. As a social worker, he has not been employed by Department of Health, and his future employment will have to be with the Ministry of Social Affairs. He visits their Sulaimaniyah office many times, to wait for many hours, with dozens of other applicants, for an interviewer who does not turn up. Finally, on his fifth or sixth visit, he is the only one interviewed, thanks to the intervention of his influential father, he tells me. He gains their agreement to employ him and requests to work with children. They then allocate him to the Department of Education for several equally prolonged and frustrating visits to the Ministry of Education. After further intervention by his father, this ends with his being allocated to a particular school and placed on a full salary immediately, although he is not expected to start work there until December, and continues to be paid by our organisation for his full time work with us until then. This gives him two salaries simultaneously.

He is embarrassed when I express surprise at this, but says, ‘In Iraq you have to take what you can get.’ I suppose he is right. I hope he will be able to use some of what he has learned about mental health in his future work anyway.

A strange old Indian lady comes to live in our house, and I enjoy seeing what she is like. Jameel has gone back to Afghanistan, and Pavalam replaces him as the infection control nurse. She is knowledgeable, forceful and determined, and has more or less taken over the job of the head of nursing, whom she has prized out of her upstairs office and leads around from ward to ward looking a bit desperate. She has also taken over the job of the supervisor of the cleaning staff, who is being treated to a similar experience, and of the laundry supervisor, who has always done a good job anyway, I think. She has large numbers of people from each of these departments working hard, doing courses she runs on hand-washing and ward hygiene, and keeps copious records and inventories. I point out to others that she is here for three more months, so there is no relief in sight. At home she cleans, and scrubs until our place is immaculate. She also takes over the cooking, and we have very good food. When she relaxes, she watches Indian romance films, very colourful, with much singing and dancing in Indian palaces and in the mountains. They are in Hindi, and no-one else can understand the dialogue, but she has them on very loud. Sometimes I have to ask her to turn them down so I can think, or do my emails, but she gets in a huff, goes to her room and will not talk for a while. I don’t mind. I like her style. I do not know how old she is. She dyes her hair with henna, to a bright orange, and puts something on it which makes it stiff, like a helmet. She also does exercises for old people, early in the morning, while watching a DVD of old Chinese people exercising in a park in Beijing.

She gets frustrated with the nurses’ inability to employ sterile technique when doing dressings or other procedures. They cannot maintain a sterile area without contaminating it almost immediately with unsterile objects or their bare hands. They cannot even open a sterile pack without contaminating the contents as they do so. I have noticed this myself as a problem apparently unique to this place. Nurses in Australia soon learn not to do this, and when I worked in the past in Papua New Guinea even the most uneducated operating theatre assistants could keep it very clear in their minds what was sterile and what was not. I attributed this to their habitual attribution of spiritual potency or inertness in the objects in their environment.

Or maybe our nurses just will not try. Like the junior doctors, they have had so little support, or supervision, or good example from their seniors. The junior doctors tell me that the consultant surgeons do not scrub up in theatre before operating on their private patients. The consultants do not even give their hands a social wash after coming into theatre from outside, they say, before putting on sterile gowns and gloves, relying on this, and routine antibiotics, to prevent wound infections. They do get wound infections, of course, a lot more than ever used to happen in Papua New Guinea, and often with antibiotic-resistant bacteria.

One morning, at the usual doctors meeting, one of the junior doctors gives a talk on breast-augmentation surgery, which he has been asked by the seniors to do. This strikes the rest of us as odd, since we are a burns unit not concerned with cosmetic plastic surgery of this kind. Gloria, in particular, finds this offensive. Be that as it may, the talk includes much emphasis on the importance of the surgical scrub, and ultra-careful maintenance of sterility, during this particular operation. I ask the consultants present if they agree with this, which they do. I then ask if they think operations on burns patients deserve the same care, which they also say they do. This is pure mischief on my part. I know it does no good, apart from embarrassing them, as I think they ought to be embarrassed. Later one approaches me privately to tell me that scrubbing up for surgery has been largely abandoned these days, all over the world, and that this is an obsolete notion. I know this is not true.

Another morning Pavalam gives her talk on hand washing and ward hygiene at the morning meeting. This goes on at length, with many repetitions of the same points. At first the consultants agree with everything she says. Later they say they know, they know, to each thing. Later they talk amongst themselves in Kurdish. I suggest to Pavalam that she can stop now, but this is a big mistake. She is very offended, and shouts at me after the meeting. At home that evening she refuses to speak to me. I try to tell her the senior surgeons are evasive and hard to change, and to thank her for having a go. I attempt to apologise for being rude to her, but she sniffs and walks away. This silent treatment goes on for days, until everyone on the project has heard about it. She tells others that because I am a white man I look down on her as an Indian woman. Alya tells me she cannot believe I have formed a bad relationship with anyone. Gloria comes to our house to make the peace, without success.

I become suddenly very unwell, but not for this reason, as far as I can see. Nausea confines me to my bed, so severe I cannot even lie on my side, let alone sit up, without vomiting. I lie flat on my back continuously. At the same time my bowel motions are so loose and so urgent I have to rise frequently anyway, to go to the toilet, and throw up each time I do. I also have a pain in my guts as if I have been bayoneted, the sharpness of which worries me that some terrible damage is being inflicted on my gastrointestinal tract. I can think of little else. I decide I do not have dysentery, as there is no blood in my stools, but this Iraqi gastroenteritis is like no other gastroenteritis I had ever experienced. I am also utterly outraged at being so ill when I have so much to do.

For three days I lie flat, being careful not to move, sipping boiled water with a little salt and sugar, brought to me by my housemates. Early on the fourth day one of the senior surgeons visits me at home with all the equipment to set up an intravenous drip.

‘The only thing that will get you better is a large dose of antibiotics,’ he tells me. He administers this via the intravenous line without saying what it is. He looks like an angel, and I feel too desperate to have an opinion.

He then leaves me to manage the intravenous fluids myself. Within an hour my pain eases. I feel so much better I begin to believe in miracles. Alya comes at lunchtime with special soup traditionally given for my condition. It tastes wonderful. Pavalam speaks to me again, saying that giving me antibiotics for mere gastroenteritis is ridiculous, pointing out that I now have a line of inflammation running up my arm. She removes the intravenous drip and makes up a poultice which she bandages to my hot arm.

The next day, at the morning meeting, the surgeons finally detail the allocation of individual patients to the care of individual consultants, except for one consultant who will share the care of everyone else’s cases without having any of his own. I do not understand this latter part, but am pleased. After the meeting Pavalam congratulates me on this success. A cynical part of me suspects that this has been done because I am about to leave at the end of the month, and may not last long.

As regards leaving Sulaimaniyah, I do not yet know what I will feel. I know I feel lucky to have had to cope with its difficulties for only six months, while the locals are here for life, as Gloria said. Meanwhile, the weather has cooled slightly and the place is looking better. At the hospital, green vines have crept up some of the supports for the covered-ways, and made their way across ceilings, giving the place a lush, tropical look again.

One of the male nurses, Rasa, takes me to a concert one evening by a group of twenty-year-old Kurdish youths, who are amazingly talented and entertaining. Just when I am thinking Kurdish culture is bankrupt, I find something surprising. The music is something like that of an Irish folk-band, as best I can describe it, but also sounds Middle Eastern, played on many clarinets, a saxophone, a keyboard, violins, cellos, guitars, and three sets of drums, one traditional Kurdish. The drumming, especially, is breathtaking in its intricacy. So is the variety in the style of playing from one piece to the next.

Afterwards Rasa, and his friends and I, go to an ice cream parlor and eat Italian ice cream with groups of other guys. You do not go for a drink here, and you do not go where the girls are. You eat ice cream with the boys. They take me, wearing tight pants and leather jackets, and with close cropped hair, to a pink and yellow ice cream shop where they earnestly discuss whether to choose chocolate, vanilla or strawberry.

At work, Baktiah gives me a list of ‘world-famous’ Middle Eastern singers to listen to when I get home, none of whom I have heard of. This he finds hard to believe, since they go regularly to Europe for sell-out concerts, he says. On the other hand, he has never heard of Elvis Presley, or Abba.

Rasa, who took me to the concert, is in trouble at the hospital for having a violent argument with the relatives of a girl who has just died. He says the argument was the fault of the relatives who made rude comments about the nursing care provided. I say, ‘but their daughter had just died …’ to no avail. Rasa is not contrite, and is angry with me for daring to criticise his behavior. I am sorry.

Meanwhile, my friend Faris, the devout Moslem and patriotic Jordanian, is in trouble of a different kind back in Jordan. He went to attend a concert one evening in Amman, and got into an argument with the security police over the roughness of their approach to searching him before he could enter. During the course of the search, to which he had to submit anyway, some coins fell from his pocket, and he put his foot on one to stop it rolling down the stairs. He was then charged with treason for stepping on an image of the face of the King of Jordan, and went to prison for a week. Nor is the matter over. He has a trial pending, not with a civil court but with a military court, and if the charge is not dropped he has been advised he faces a further one to three years in prison for this offence.

Then I have further problems in my relationship with Pavalam. She forbids all children to leave the ward, for reasons of infection control, even to sit in the garden, let alone come to playgroups in our mental health hut. My argument to Gloria is that sitting outside in the sun and the breeze provides better infection control than staying in the ward where little air circulates and hygiene is poor. I also argue for the benefits to the children of playing with others, including in our hut, particularly since we have no soft toys, only pencils and paper and plastic objects. Baktiah obtains spray antiseptic from the pharmacy and nobly sprays and wipes every pencil and every toy after every play session, to facilitate this, as well as disposing of all paper the children touch. I purr with pride in him as I watch him. Our arguments win, of course, and Pavalam stops speaking to me again.

Alya has a further proposal of marriage, this time from a man she knew as a child at primary school, but has not seen for many years. He has permanent residence in the United Kingdom and is able to offer that she live with him there if she becomes his wife. He cannot return to Iraq but pays for Alya to meet him in Syria. This she does and comes back very excited about having seen the sea for the first time, but not very excited about the man. He is not handsome, she says, but is considerate and not controlling, and other people have advised her that he is extremely kind. In addition, having seen her and spoken to her again, he is even more keen to marry her. She will surely learn to love him in due course, he says. This may be so. Out of concern for Alya’s bleak future in Iraq, I urge her to accept his proposal, probably more forcefully than I should. Having known her for only six months, and never having met the man, who am I to tell her what to do? She is smart enough, and independently minded enough, not to take too much notice of me, however. She does decide to marry him, and I am reasonably sure this is her own decision. She will leave Iraq shortly after I do.

Other members of our team hold a farewell party for me. Alya cannot attend without a family escort, but Baktiah does so with a full Kurdish traditional outfit for me, as a gift, including a turban and prayer beads. He puts the turban on me in a way I will never be able to do myself. He also kisses me, as he has always threatened to do. In fact, he clings to me and cries and kisses me many times. Other expatriates tease me about it later. ‘He’s very fond of you, isn’t he?’ they say. ‘Do you deserve it?’

In my final written report, I do not only give an account of what I have done here, as required, but include my unsolicited opinion on lessons our organisation could learn from the set-up of this project, now being abandoned, and advice on what we should do in establishing future projects. In brief, I say the obvious things, supported with documented examples and illustrations, that it is a mistake to employ anyone without a job description clearly outlining his or her individual responsibilities; that it is a mistake to employ anyone without agreeing on a mechanism to account for what they are doing; and that it is a mistake to give anyone an incentive payment without saying what it is for – i.e. under what circumstances it will be paid, and under what circumstances it will not be paid. I also say that it is a mistake to employ a group of doctors, in particular, if they are not personally committed to the patients’ best interests, either individually or as members of a group. My main lesson from Sulaimaniyah, in fact, is that the capacity to give good medical care cannot be imposed on doctors from outside, or induced by persuasion, or financial incentives, or the provision of excellent resources, if they lack this essential devotion to duty in themselves. It is possible for them to appear to assess cases thoughtfully, to appear to be following their progress, and to appear to be providing treatment in a safe and thoughtful manner, but it takes personal commitment and self-monitoring to actually do these things. I dare, in fact, to refer to the consultants here as criminally negligent by Australian standards. I dare, in fact, to call what we pay them a bribe, the purpose of which is left unstated for this reason. They are aware that they are extorting money, I am sure, and to regard us with contempt.  We do not deserve contempt by anyone’s standards, and should not be paying anyone to allow us to help them for free. We waste effort and money which would be effective elsewhere, and we risk doing more harm than good.

With reference to this final assertion, I dare to say that some of the drugs supplied so generously are positively dangerous in the hands of people who do not take the trouble to use them safely. Some, used badly, give patients unnecessary side effects. Others help poison people. Others induce high levels of multi-drug-resistant infectious organisms, which remain an intractable problem after our departure. Similarly, expertly thought out infection-control measures, appropriate to a high-functioning burns unit, are rendered ineffectual by low-functioning doctors. They merely represent a hardship to the patients, contributing to their distress. They should not be imposed in the absence of basic hygiene and good doctoring.

I do not mention the psychological toll this takes on us, having the people we work alongside disdaining our best efforts. You would think we would value ourselves for our acts of kindness to strangers, and take pride in them. I felt this throughout my time at the Sulaimaniyah Burns Unit, I now realise – that I had been placed in a position of reduced self-respect – expected to be grateful for being allowed to help, and to feel apologetic that doing my job well might make the local doctors look bad.

Was this culturally sensitive, anyway, as some might claim? It could be seen as patronising to act as though members of another culture are incapable of honest financial arrangements and that doctors in another culture are incapable of treating their patients with respect for their welfare, as if these were somehow uniquely ‘Western’ values.

On my last day, my least favorite among the consultant surgeons hugs me and kisses me goodbye, as do many other people. I run my hands up and down his smooth, bony back, aware of how short of physical contact with other human beings I have become. You poor man, I think, hugging my least favorite consultant. You must be very pleased to be rid of me, but not very pleased with yourself for the failure of our relationship. I regret how little respect I have for you as a medical colleague, and you for me, as a thorn in your flesh.

Epilogue

After my time in Sulaimaniyah I participated in several further humanitarian projects, not all with the same organisation. These took me to Sri Lanka, Israel, Papua New Guinea, Armenia and Jordan. I resumed work as a psychotherapist in Melbourne in 2013.

Despite many emails from me, I never heard again from Jameel, the person with whom I most shared my experiences in Iraq. Others of less importance to me kept in touch and said that is how Jameel usually behaves – he moves from place to place and does not keep up friendships. I remain fond of him, nevertheless, and heard two years later that he has married and has a child. I heard from Alya by email regularly for a time, mainly to say how lonely and unhappy she found it, living in a bleak northern English town, struggling to overcome many barriers to her doing anything interesting or useful there. She gradually became more cheerful and we lost touch. Baktiah had no email address, and I have no news of him.

As regards the possibility of a continuing mental health service on the Sulaimaniyah burns unit, this did not happen. The charity I wooed in my final weeks sent a single young woman to provide this for a time, who then gave up. I can imagine how difficult this would have been for her to provide alone, unsupported by colleagues and discouraged by the doctors there. It was difficult enough for Alya, Baktiah and me.

My final report, with its unsolicited opinions and advice, caused great annoyance initially back at the headquarters of our organisation. Two years later someone was good enough to thank me for it, saying how useful it had been in their final review of the project. Not that this gave me much satisfaction. I wish the whole thing had gone better.

I also heard that later attempts to establish a reconstructive hand surgery service in Baghdad, with Gloria involved in the negotiations, were abandoned. No agreement could be reached with the local surgeons there either, on accountability for the services they would be paid to provide. This also gave no-one much satisfaction . The only answer might be for our organisation to provide its own volunteer surgeons for such projects, but, as far as I know, few such Western surgeons make themselves available to go to Iraq.

As for the country itself, circumstances there have deteriorated further since 2009. The Shia-dominated government in Baghdad , supported by the West, does not govern for all and appears to benefit in its hold on power from sectarian violence continuing.  Sunni Arabs, the former governors, administrators and teachers, who have suffered most since the US invasion and occupation and who make up 20% of the population of Iraq, continue to be persecuted and presumably unhappy with their treatment. ISIS arose among them and has now been contained militarily, at the cost of further suffering by large numbers of noncombatants and the destruction of cities, leaving the Sunnis in a worse position and presumably more frustrated than ever. In addition the failed state of Iraq threatens to break apart. If the result of a recent referendum is to be believed, ninety percent of the Kurds, also Sunni and making up 17% of the population of Iraq, now want to secede. It is unclear how many voted, and how fair the polling was, but, even so, the military response to this by the government in Baghdad, supported by the West, cannot have helped heal the rifts in Iraqi society.

Other parts of the world, including Australia, face a growing threat of terrorism from some Iraqi citizens, as well as from some of their extremist supporters in our own countries. This threat appears to worsen with each military intervention, rather than to improve. Although ISIS has been contained militarily, inter-sectarian grievances, for which the West is partly to blame, and which the West does not make effective efforts to address, have become worse. So too has the threat of continued terrorism against the West.

In Sulaimaniyah I had the opportunity to observe a society in which an every-man-for-himself approach is commonplace, in which government officials, doctors, nurses and caterers lied and cheated and often displayed horrifying lack of concern for the patients we treated. I also became familiar with the terrible suffering of the whole society. I also met many indivduals with little hope of being treated fairly by their own people and wishing in vain to be elsewhere. I also found, as usual, that all people are a mixture of good and bad qualities. I left Iraq with much affection for people I had met. Some were extraordinary in their efforts to behave decently under the circumstances there, and I will never forget them.

In my attempts to make sense of that experience, I have taken into account that the population of Iraq is made up of disparate groups who did not originally choose to form a single country together and lack a whole of country allegiance. It also includes a large proportion of uneducated and illiterate people, who think in tribal ways, a large proportion of young and inexperienced people and a large number of mistrustful people who grew up in decimated families.

I have also been tallying the costs to Iraq of the invasion, occupation and counter-insurgency measures by the United States and its ‘coalition of the willing’. We now know that up to one million Iraqis died, as direct and indirect results of the invasion, occupation, inflaming of sectarian conflicts and eventual civil war. An unknown number, presumably greater than the number killed, were left with major physical disabilities, or gross disfigurement, as a result of being blown up or burned, the majority by Western forces and others as a result of sectarian violence. An unknown, probably greater, number have been left psychologically traumatised.

The society itself was also severely damaged. Several million Iraqi citizens left the country for residence elsewhere, including many doctors, paramedics, university teachers and experienced administrators. Several million more were internally displaced from their homes. Three quarters of a million were outlawed by the US invaders soon after the invasion, and dismissed from their posts with no prospects of re-employment, for being members of the Baath Party or the Iraqi army. Virtually the whole civil service was disbanded as well as the whole army. Countless others lost their jobs, or courses of study – as did Alya, for example – or career prospects or businesses. A thriving business sector has now gone, and a developing middle class of professionals and administrators has also now gone.

In addition, large numbers of people were imprisoned and tortured for their opposition to the invasion and occupation of their country, chiefly Sunni Arabs. Some were doctors or medical academics. Some were killed, imprisoned or tortured simply for providing medical care to others. An effective medical education system and health service, once considered the best in the Middle East, has now been lost. An effective general educational system has now gone, including the loss of centres of excellence in Baghdad in various fields. A once lively recreational and social life is also now gone. Museums, art galleries, public parks and sports amenities have been destroyed. An effective system of law and order is now gone, to be replaced with a police and judiciary that often prey on the people they are meant to serve, and the rule of sectarian vigilante groups encouraged by central government. High rates of extra-judicial killings occur, including many beheadings, as well as kidnappings for ransom and criminal violence of all kinds. The invasion also destroyed much of the country’s infrastructure. Reliable supplies of water and electricity are now gone. Roads and bridges have been destroyed and not rebuilt. Humanitarian and reconstructive efforts by the invaders have often been political shams rather than of genuine assistance.

We removed a despotic government which imprisoned and tortured its opponents, but we removed one which was non-religious, anti-Al Qaeda, had no weapons of mass destruction, was not a military threat to the West and which maintained sufficient stability, in a disparate society, for all sorts of enterprises to thrive. We replaced it with an unstable, religiously-extremist government and administration, including large numbers of corrupt or incompetent people, which treats its sectarian enemies no better, and possibly worse than Saddam Hussein did, persecuting those they have displaced and continuing to imprison and torture their opponents. And we continue with bombs and guns to take sides with one group of brutal leaders against another, finding fault with the brutality of those we attack, while ignoring that of those we wish to support for our own reasons.

Iraq has a population about twice that of Australia. Even halving the figures, imagine what Australia would be like if all of the above happened to us. As far as I can see, any society, after suffering so much, would include some who now hated us and wished us harm. Our governments, mass media and social commentators often try to explain the terrorist attacks in terms of Islam, or traditional Middle Eastern culture, or ‘hatred of our way of life’, or as if the ruthless ideologies of extremist groups was the cause of their anger, rather than an expression of it. We avoid acknowledging what we have done to them, and that we have been the enemy of many of the citizens of Iraq and remain the enemy for many. We do not think what it would be like if this happened to us, because it suits us to pretend we did nothing, and that their hostility towards us is something foreign and incomprehensible. Is that why we keep doing the same thing that does not help and makes matters worse? Is that why we do not acknowledge grievances and do little to help heal Iraq’s wounds? Now we have razed much of Mosul to the ground, wrecking Iraq just that much more.

There must be a combination of causes for terrorism, but the chief cause must surely be the suffering we inflict.  It is retaliatory. It represents an angry, irrational attempt to pay us back. Whether they hate our way of life or not, many Iraqis surely hate what we have done.

As for our willingness to help individuals there, the website of the Australian Embassy does now give an address in Baghdad with opening hours, as well as telephone and email contact information, and does now offer assistance to Australian citizens in Iraq, like me. For Iraqis, however, for whose plight we bear some responsibility, it gives only general information about visas, migrating to Australia, or obtaining Australian citizenship. It does not offer individual advice or supply or accept application forms of any kind. Applications can only be made in Jordan, where Iraqis without a passport cannot go.