A Country with Fourteen Psychiatrists

The sun-baked streets of Misrata have a semblance of normality these days. The city’s main drag, Tripoli Street, the site of weeks of brutal urban warfare a year ago, is still broken and bullet-scarred, but below the pocked facades of the buildings are shops and fast food joints. There are carloads of families on the roads and a gentle hum of activity amid the summer heat.

But at the center of town, there’s an eerie exhibit, a makeshift museum to the days of war. Televisions bombard visitors with a continuous montage of the worst horrors of the conflict: Young men cut down by bullets on wobbly phone camera footage, the bodies of wounded children and babies shown in gruesome close-ups. The walls are papered with passport-style photos of the 1,500 people who died inside the city or fighting for it on the frontlines nearby. The man at the desk doesn’t ask for tickets; instead he shows visitors the goriest pictures he can find of the wounded and dying in last year’s war.

It’s a reminder of the ghosts that continue to haunt Libya even as it struggles to move into a new era. Earlier this month, many of the country’s citizens drew hope from their first free elections in over four decades. Yet painful memories are reverberating. Many Libyans appear to be caught between a desire to forget and an obsessive need to remember and revisit the bloodshed of the past year. For some, there is little choice.

"Imagine a ten-year-old who can tell the difference between a bullet from an AK, a tank, and a sniper," says Ali Shenaba, the founder and manager of the museum. He points to a photograph showing four small children, two boys and two girls. They were his neighbors’ children, killed by tank fire as the family tried to flee the fighting raging around their home on this street. "Every time you see the house, you remember those kids," he says.

Dr. Mustafa Al Shagmani, a clinical psychologist educated at Rennes University in France, leads a team of 24 mental health specialists in the city. In the past three months they have treated around 700 patients, ages two to eighty.

He says that a recent World Health Organization (WHO) study found that 21,000 out of the city’s population of 250,000 were suffering from psychological trauma. Misrata is believed to be one of the worst affected areas in the country.

"We have neurosis, anxiety, OCD [obsessive compulsive disorder], physical symptoms like diarrhea. Children are some of the worst affected," he said. Al Shagmani explains that young people, especially those who have lost parents, are struggling at school, fighting with classmates, or showing listlessness or an inability to concentrate.

It’s difficult to know how long the psychological effects of the conflict will last — or the extent of the population that has been affected. The country lacks the resources for diagnosing, much less treating, mental health problems.

The Deputy Minister of Health, Adel Mohamed Abushoffa, describes the lack of resources as critical. "We have a real shortage of psychiatrists. We currently have just fourteen in the whole country," he told the WHO. Libya currently has a population of around 6.4 million, according to the World Bank.

"Not a lot of time or resources were devoted to mental health under the Qaddafi regime," explains Inka Weissbecker, global mental health advisor for the International Medical Corps, who worked in Libya last year. "People couldn’t access care. It was very stigmatized. Even if they were very ill they might not go to the hospital. Mental health problems were a very private thing."

In some instances, she says, families with relatives suffering from severe mental health problems have dealt with it by locking them in their rooms.

"It’s very shameful to admit to symptoms because people believe it’s a sign of weakness," confirms Dr. Omar Reda, a Libyan-born psychiatrist practicing in Portland, Oregon, who is the temporary Mental Health Coordinator in Libya. "Maybe you don’t pray enough, maybe you are a weak Muslim, maybe you are affected by the evil eye. We try to explain that these are normal responses to an abnormal situation."

It seems likely that the collective trauma among Libyans will have an impact on their efforts to build a new, democratic, post-Qaddafi state. But it’s also impossible to predict what the effects will be.

According to Stanford University psychiatry professor Daryn Reicherter, while scientists now understand a great deal about post-traumatic stress in individual cases, they have yet to understand precisely how widespread experiences of trauma affect societies that are emerging from periods of mass violence. "This is an important social issue, and it has been ignored in the past," says Reicherter. "And I believe the reason it’s been ignored is because of the great stigma of mental illness." Still, he adds, it’s clear enough that the impact can’t be good: "It’s got to affect the functioning of the social fabric."

Majdi Al Shadeed, a 27-year-old former rebel fighter, has struggled since the war. His problems include the classic symptoms of post-traumatic stress disorder (PTSD): debilitating insomnia, nightmares, and regular flashbacks to the faces of the two men he killed during the fighting.

He struggles with his short-term memory and attention. He’s lost three phones this month and his laptop computer twice in the month before. A job working for an international company was challenging. He now works as a security guard. Nonetheless, he hasn’t sought help for his problems. "It’s easier to forget," he shrugs.

Al Shadeed faces an additional problem. As a member of a generally pro-Qaddafi tribe, he faces the opprobrium of relatives and neighbors. He was ostracized in his hometown, but was then covertly approached by relatives seeking help to recover the bodies of dead Qaddafi loyalists he had fought. It was an impossible task, but the requests left him distressed and deeply confused.

The fault line between the two sides in the conflict remains. This is a society where the war’s victors and defeated live in uneasy proximity.

"It’s important to be inclusive of all elements of society, [including] people who were Qaddafi supporters or thought to be Qaddafi supporters," says Inka Weissbecker. "A lot of them are suffering and need help."

Dr. Al Shagmani has been working with regime soldiers who are now prisoners, and he’s seen the same symptoms there. "They have the same kind of problems." He argues that many loyalists must also deal with a further problem: guilt.

But for many in the towns that supported Qaddafi, there’s little likelihood of receiving professional psychological support. There are logistical reasons for this. Facilities are concentrated in the country’s two largest cities, Tripoli and Benghazi, where the country’s two psychiatric hospitals are. There’s also little willingness to reward those who many continue to see as their enemies.

In May, aid organizations were expelled from the city of Sirte, which witnessed a brutal siege in the final days of the war when Qaddafi made his final stand there. The towns scattered across the Nafusa mountain range south of Tripoli also saw heavy fighting and continuing tribal clashes, but according to Dr. Reda, there’s just one mental health specialist to look after all 600,000 of the people living there.

With formal facilities in short supply, some people, especially veterans, are turning to their own methods of numbing the pain. "They’re self-medicating," explains Dr. Najid Assaid, a Benghazi-based psychiatrist. "People use hash, cannabis, alcohol."

Other doctors also warn of widespread abuse of illegal and prescription drugs by traumatized veterans. "We are seeing more and more people on the streets," says Dr. Reda. "They are fighting because they are intoxicated. People at the checkpoints are using lots of drugs. That’s a bad combination — and a dangerous one."

It also complicates treatment. Alcohol is illegal in Libya and its consumption a taboo topic. "Many of these young boys are dealing with a double stigma," Dr. Reda explains. "They are having to hide the symptoms of PTSD — anger, nightmares — and then hiding their alcohol problems. They find a country that does not help and families that don’t understand them."

Mental health experts say that the trauma of the war will eventually recede for the vast majority. Many are confident that Libya will improve its mental health facilities. "I think there is a real momentum right now in Libya around mental health," says Inka Weissbecker.

But for the moment, many of the fighters remain lost and angry. Some feel excluded from the new political order that they fought to bring into existence.

"We feel like strangers," said Abdul Hadi Oweinat, a 25-year-old fighter from the Tripoli brigade. "We’re the ones that started it and we feel like strangers." He thinks that many of the people who ran in the elections were close to Qaddafi. "My life used to be better than it is now. Before the revolution, I knew who my enemies were."