World Mental Health Day 2019 - The mental health crisis in Sinjar, Iraq © Emilienne Malfatto

Surviving a genocide

More than five years after the Islamic State group killed or abducted thousands of Yazidi people in Iraq, MSF is helping survivors to heal their psychological scars

10 October 2019

World Mental Health Day 2019 - The mental health crisis in Sinjar, Iraq © Emilienne Malfatto
World Mental Health Day 2019 - The mental health crisis in Sinjar, Iraq © Emilienne Malfatto

© Emilienne Malfatto

© Emilienne Malfatto

Kate Goulding is an MSF emergency doctor from Australia.

She manages the emergency room and paediatric department at Sinuni General Hospital in Sinjar, north west Iraq.

MSF emergency doctor Kate Goulding at Sinuni General Hospital in Iraq © MSF/Gregory Kenzo Saito

When there wasn't a psychiatrist available to work in Sinuni for three months, Kate took on the task of supporting the local mental health team treating Yazidis a religious minority now struggling with widespread psychological trauma following a brutal genocide by the Islamic State group.

She shares their story...

People rarely talk about what happened to them or the things they saw on 3 August 2014… the day that the Islamic State group took control of towns and villages around Mount Sinjar in Iraq.

"Wisam had seen people killed and been forced to kill – he was having thoughts of killing himself, and often others too"
Kate Goulding | MSF doctor

Five years later, everyone here carries around with them a deep-seated grief about what the Yazidis often refer to as the “74th genocide”.

MSF emergency doctor Kate Goulding at Sinuni General Hospital in Iraq © MSF/Gregory Kenzo Saito

MSF emergency doctor Kate Goulding at Sinuni General Hospital in Iraq © MSF/Gregory Kenzo Saito

MSF emergency doctor Kate Goulding at Sinuni General Hospital in Iraq © MSF/Gregory Kenzo Saito

Background: The Yazidi genocide

In August 2014, the Islamic State group swept through the Sinjar region of north western Iraq, launching a brutal campaign of genocide against the Yazidi people – an isolated religious minority whose connection with the Sinjar mountains goes back centuries.

The militants slaughtered thousands of men and abducted an estimated 6,000 women and children, selling many into sexual slavery.

The United Nations acknowledges the atrocities as a genocide.

Those who escaped the initial attack took refuge in the Kurdish region of Iraq, nearby Syria or sought asylum in Europe.

Gule hugs her son Shahab, who recently returned to Sinuni after seeking refuge Europe © Emilienne Malfatto

Gule hugs her son Shahab, who recently returned to Sinuni after seeking refuge Europe © Emilienne Malfatto

Gule hugs her son Shahab, who recently returned to Sinuni after seeking refuge Europe © Emilienne Malfatto

In 2015, an alliance of Kurdish and Yazidi fighters recaptured Sinjar. But, many families struggled returning to a homeland that runs deep with trauma.

A damaged and deserted street in Sinjar © Emilienne Malfatto

"Do you have a gun?"

The first mental health assessment I did in Sinuni, a town on the north side of Mount Sinjar, was for a 24-year-old man I will call Wisam.

Brought to us by his brother, he showed symptoms of severe depression.

"He detailed the constellation of depressive symptoms that made his daily life so dreadfully difficult"
Kate Goulding | MSF doctor

During our first meeting, he told me about his stress, his headaches, his stomach pains, his loss of appetite, his difficulty sleeping and his nightmares. He detailed the constellation of depressive symptoms that made his daily life so dreadfully difficult.

When I do an assessment like this, I screen a patient for what is called “thoughts, plans, means and actions” using a line of questioning that goes something like:

Have you been thinking about death or hurting yourself?

What sort of things make you think about killing yourself?

How would you do it?

Do you have a gun?

Where is it kept?

Have you ever tried to hurt or kill yourself in the past?

Wisam had seen people killed and been forced to kill – he was having thoughts of killing himself, and often others too. Usually they didn’t last long, but the thoughts were becoming more frequent and were associated with angry outbursts.

Recently he had pulled out a knife during a family argument.

This would be alarming coming from any patient, anywhere in the world. But the part of Wisam’s story that disturbed my sleep for days was that he was a soldier and had access to guns every day at work – the guns he imagined using to kill himself and others.

Halo needs medication after her brother was killed and she was kidnapped along with his family - most have never returned © Emilienne Malfatto

Halo needs medication after her brother was killed and she was kidnapped along with his family - most have never returned © Emilienne Malfatto

Halo needs medication after her brother was killed and she was kidnapped along with his family - most have never returned © Emilienne Malfatto

A little girl goes through a health pamphlet while her mother waits at an MSF clinic near the Iraq-Syrian border © Emilienne Malfatto

A little girl goes through a health pamphlet while her mother waits at an MSF clinic near the Iraq-Syrian border © Emilienne Malfatto

A little girl goes through a health pamphlet while her mother waits at an MSF clinic near the Iraq-Syrian border © Emilienne Malfatto

The grey area

Mental health patients can be divided into three categories:

Those who can clearly go home and have their mental health managed as outpatients in the community; those who clearly need to stay in hospital to avoid harm to themselves and others; and those in the uncomfortable grey area in between.

Wisam was grey.

He needed to be started on antidepressants, but these can sometimes make the symptoms of depression worse and heighten the risk of suicide in the first days and weeks of the treatment, before they start helping the patient improve. So, he needed to be very closely watched.

A little girl goes through a health pamphlet while her mother waits at an MSF clinic near the Iraq-Syrian border © Emilienne Malfatto

Usually, in the hospitals where I have worked before, a patient like Wisam, so clearly in the grey, would be handled by a team of psychiatric experts. If the situation was serious enough, he might even be kept in hospital against his will in order to keep him safe.

In Iraq, however, there are no legal grounds for medical staff to keep a severely ill patient in hospital against their will to protect them from harm. With no psychiatrists in the district, the uncomfortable decision about what to do rested with me.

Letters across Sinjar

I asked Wisam if he would agree to be admitted to the emergency room for a couple of days while he started his medication.

He refused.

The best I could do was to start him on medication that would hopefully make him feel better, whilst asking his employers to let him take a week off work.

My letter to his employers read like a note from a parent to a schoolteacher, begging to keep Wisam and his angry, impulsive thoughts away from all the guns in Sinjar area.

Unfortunately, Wisam’s story is not uncommon; there are many of my politely worded schoolteacher letters floating around Sinjar – in many cases, to keep suicidal people away from weapons.

A 13-year-old Yazidi boy suffers with loneliness and poor mental health after his father joined an armed group © Emilienne Malfatto

A 13-year-old Yazidi boy suffers with loneliness and poor mental health after his father joined an armed group © Emilienne Malfatto

A 13-year-old Yazidi boy suffers with loneliness and poor mental health after his father joined an armed group © Emilienne Malfatto

Loss: A universal trigger

When we talk about the things that cause people stress, very few will speak about the genocide. In fact, it is very difficult to get anyone to talk about it at all.

However, a common theme in mental health consultations is the friends and family a patient has lost. Universally, the sudden loss or disappearance of a loved one is a clear trigger for mental health struggles, with or without the associated trauma of conflict.

"It is universal to be sad when your husband dies, when your child is sick, when you break up with your partner, when you are separated from your family"
Kate Goulding | MSF doctor

What struck me in Sinuni was that, even with all the ugliness that these people have experienced, in many ways they struggle with the same problems as any of us.

It is universal to be sad when your husband dies, when your child is sick, when you break up with your partner, when you are separated from your family. Often these are the events that trigger an exacerbation of a patient's mental illness and bring them to us.

The few things I have heard about the genocide have come from the staff I work with.

Stories of panic when Islamic State militants came to their doors at night and took their money, phones and other belongings.

The relief they felt as they managed to escape with their mothers and sisters.

The drive out of town with so many people crushed into the car that the doors wouldn’t close.

How they felt in the following days as they hid in the valleys of the Sinjar Mountains, planning their escape to Kurdistan. 

Khawla's existing depression and suicidal thoughts were made worse by the events of the genocide © Emilienne Malfatto

Khawla's existing depression and suicidal thoughts were made worse by the events of the genocide © Emilienne Malfatto

Khawla's existing depression and suicidal thoughts were made worse by the events of the genocide © Emilienne Malfatto

A storm in their minds

This community – especially the doctors, nurses and other MSF staff I work with here in Sinuni – has been the warmest and most welcoming group of people I have ever had the pleasure of knowing.

Most days, happiness and hope radiate from their faces. And yet, occasionally, clouds pass over their faces from the storms in their minds, as they grapple with the reality of their past and present circumstances.

Kate Goulding and her colleagues help a patient from an ambulance outside Sinuni General Hospital © MSF/Gregory Kenzo Saito

My colleagues return to their families in Kurdistan whenever they are not working. Most families live in camps, for now and for the foreseeable future, with no plans to return to Sinjar.

As the main breadwinners for their large families, my colleagues are under huge financial pressure.

They speak often of the sadness of being separated from family members who fled to Germany, and of the friends and relatives whom they suspect they will never see again.

They talk about balancing their families’ desires to stay in Iraq against their own dreams of escaping the instability they predict for the future here.

They speak of the complexities of their religion and culture, and of their professional responsibility to care for their community as well as those who were previously a threat to them.

They wonder whether things in Sinjar will ever return to how they were before. Whether people will ever come back.   


MSF in Sinuni

MSF has been providing emergency and maternity care at Sinuni General Hospital since December 2018.

Quickly realising the mental health crisis in the area, we have since increased our psychiatric and psychological services, including mobile mental health clinics for displace people still living in the Sinjar mountains.

Since the beginning of 2019, we have carried out 9,770 consultations in the emergency room, 6,390 in-patient consultations and helped 475 women give birth.

Kate Goulding and her colleagues help a patient from an ambulance outside Sinuni General Hospital © MSF/Gregory Kenzo Saito

Kate Goulding and her colleagues help a patient from an ambulance outside Sinuni General Hospital © MSF/Gregory Kenzo Saito

Kate Goulding and her colleagues help a patient from an ambulance outside Sinuni General Hospital © MSF/Gregory Kenzo Saito

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