Anniversaries of invasions, occupations, and cease-fires are reminders that wars never end. The 10th anniversary of the U.S. led-invasion of Iraq prompted discussions about the damage that long-term occupation and violent conflict cause. Yet with few exceptions, these debates lack a willingness to engage with the psychological afterlife of wars for Iraqi civilians or recognition of international responsibility toward the psychological burden that awaits Iraqi society. When the subject of mental health is part of the debate, it is mostly from the military perspective: the mental wellbeing of veterans and soldiers has been a focus of media, academic, and governmental attention, whether noting increases in violent behavior among soldiers or rising rates of suicide (with 349 active member suicides in 2012, a 16 percent increase since 2011), depression, and Post Traumatic Stress Disorder (PTSD). But, as with estimates of more easily quantifiable physical casualties, journalists, researchers, and policymakers do not seem to have a reliable estimate of civilians' and displaced persons' psychological state.
Understanding the psychological impact of war on civilians is important because wars change a society's relationship with the future. War conditions create memories and wounds that outlive the wars themselves. Their images and sounds persist in art, economics, politics, and private lives through multiple generations. They create corrosive memories that take decades to work through. But they also resonate, belatedly, in higher rates of physical and mental illness. They create social and psychological conditions that are often obscured in the way we write history. On the 10th anniversary of the invasion of Iraq, and as we find ourselves in a perpetual discussion of future military interventions, these are the kinds of wounds that should concern us all.
The problem with psychological afterlife of wars is that they fall through cracks of more pressing wartime concerns. It is only after the dust settles and physical wounds begin to heal that psychological ones surface in their entirety. It is in part due to this delay and temporal dissonance that raising the issue of long-term psychological aftermath of sustained and perpetual military interventions has sadly been sidelined in policymaking and analysis. But they shouldn't be, precisely because of their undeniable impact on the outcomes of both endeavors. These questions are at the core of what policy is meant to address.
In psychiatric terms, war memories are often measured by incidence of mental illnesses such as PTSD and depression (and via Western diagnostic standard manuals such as the DSM-IV). Translating what wars leave behind in collective memory onto the sanitized vocabulary of psychiatric diagnostics such as these reduces history to artifacts of clinical symptoms. The question that instead needs to be at the forefront of any discussion about military interventions is what it means for a "liberated" society, as well as for the global community in their relation to them, to live in conditions of constant rupture; to be "liberated" while experiencing enduring loss and grief caused by the death of hundreds of thousands of civilians and soldiers; or to be children growing up in exploded neighborhoods and looted houses, internalizing and suppressing wartime anxieties. Similarly, in our analysis of violence (as associated with PTSD), we need to foreground its complex moral trajectories and the psychological cycle of outrage that belies it. In evaluation of successes and failures, scholars and policymakers have a responsibility to recognize these intricacies, beyond logistics and statistics, and to resist the urge to reduce a people's wellbeing to the toppling of a regime.
Causing physical displacements, broken families, physical disability, and long-term psychological repercussions, wars shape individuals' experiences in ways that cannot be easily mapped onto convenient clinical diagnostics such as PTSD. Nor can these experiences be dismissed as mere matters of individual disorder. They embody explicitly collective experiences and therefore have a historical function.
To better understand the historical impact of these experiences, we need to remember lessons from past conflicts in the region. In neighboring Iran, over 20 years after the end of the Iran-Iraq War, different generations of civilians and veterans are suffering from internalized anxieties, nightmares, and memories that go beyond individual DSM-IV listed diagnoses. As with all wars, anxiety prevails during the struggle and contributes to both resilience and problems with demobilization and reintegration. Yet, wartime anxieties are often replaced with postwar dysphoria once there is time to reflect, and when lost promises of wars come to surface. In Iran, there are over 60,000 civilian victims of chemical warfare who continue to suffer from physical and psychological disorders. Moreover, a generation of children who grew up during war struggle with psychological and physical issues from birth defects to rising rates of suicide, drug abuse, and depression. This is not to depict a society devoid of hope, nor is it to attribute health issues to a single cause. The point is that these complexities integrate into collective memory, and weave into everyday relationships, generational identification, cultural forms, and expressions of nationalism. The speed with which the rest of the society -- and the world -- has moved on is not lost on the war-inflicted. Iranians collectively feel that the world turned a blind eye to the suffering of hundreds of thousands of people and the deaths of over a million people in both countries. They call for recognition of their struggles, and accountability for those responsible for them. To medicalize all of that (i.e., treating individuals for alleged depression or PTSD) is a double-edged act: providing individual relief (if it works), at once depoliticizes war memories that are, in their essence, socio-political phenomena. No pill can remedy inherited resentment.
We could expect similar yet distinct trends in Iraq once new generations of war children become adults. The Iraq War, in its experience of suffering, represents less deviation than continuity. Prior to 2003, Iraqi society had already been in a state of intense infliction for decades due to the 1980 to 1988 Iran-Iraq War, the 1991 Gulf War, and the decade-plus sanctions. Since 2003, several studies have reported alarming mortality, disability, and displacement rates. A 2011 estimate reported that there were 4.5 millions Iraqi orphans, 70 percent of whom lost their parents after the 2003 invasion. That scenario alone constitutes a public health emergency, demanding provisions for long term physical and psychological care. A generational shift in the future of these children is possible, where wartime experiences will be worked into their future understandings of community, kinship, nationalism, and resilience. There will be distinct truth claims and demands for recognition of suffering. Attempting to normalize and medicalize the collective Iraqi experience of war leaves no room for a society's long-term struggle with memories of the war and emotions that they invoke.
At the most basic level, there is a pressing need to integrate psychiatric care into post-war plans, particularly now that Iraq's healthcare infrastructure is severely damaged and half of Iraqi doctors have left the country. Yet the question of mental health is not solely a question of individual treatment; the clinical apparatus of psychiatry cannot single-handedly respond to social discord brought on by war. To reduce the Iraqi experience to the convenient diagnosis of PTSD would not only be to erase the war and occupation's social and political afterlife, but it will also fail policymakers and health practitioners in their therapeutic aspirations.
Even if health policy insists on operating within a so-called PTSD framework, there is need for a broader understanding of its collective and generational manifestations. The PTSD paradigm in its clinical and therapeutic sense aspires to forget, to rid of excess and painful memory. Yet, we know from the many wars of the 20th century that collective post-war-psychologies are less concerned with forgetting and more reliant, even insistent, upon remembering. There needs to be room in post-war mental healthcare policymaking for remembering, as part of social and collective processes of healing. Health policymaking should invest in community building inside Iraq as well as in emigrant destination countries such as Jordan and Lebanon. Policy should also prioritize the reintegration and rehabilitation of displaced individuals, particularly women and children, who will be the carriers of the future burden of this war. Building on the capacities of an already powerful oral culture, scholars and policymakers need to facilitate alternative and bottom-up narratives of history, in part for their healing capacities, rather than erasing them. Instead of trivializing acts of witnessing (e.g., in art and literature), policymakers and practitioners should recognize and harness the relevance of these acts to mental healthcare policy. So too, historical accountability is a crucial element in collective conciliation and healing. In other words, post-war health policymaking cannot and should not operate without engaging in processes of remembrance, recognition, and accountability. Above all, international policymakers ought to make sure that they sustain their attention to the Iraqi people's psychological wellbeing beyond this moment.
The internalized, normalized, and assimilated memories of war will come back, belatedly, in pieces and bursts. Not only will they affect individual lives, but they will also shape how a society feels toward, holds accountable, and relates to the world around it. They write an alternative history of loss or neglect; they shape a society's sense of well-being, and can then translate to medical, political, and economic consequences. If the international policy community is concerned with the wellbeing of people, they must attend to internalized anxieties and memories of individuals in post-war societies, not just now, but for decades to come.
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