Since the U.S. invasion of Iraq in 2003 and the ensuing civil and religious conflict in that country, more than 1 million Iraqis have fled their country, most to a precarious life in neighboring countries. Under the host country's laws, the refugees are not usually permitted to work, and often children aren't allowed to attend local schools.

The combination of dislocation, poverty, enforced idleness, and an uncertain future have taken a serious toll on these displaced individuals. FIG1

"The Iraqi refugees are not located in separate camps but live in towns and cities, often in hiding from the authorities," explained Zeinab Hijazi, the International Medical Corps' (IMC) program director for mental health in Lebanon. The IMC, based in Santa Monica, Calif., is an international nongovernmental organization providing both acute and long-term medical and psychosocial help following disasters.

It is one of several nongovernmental organizations, including the World Health Organization, the United Nations High Commissioner for Refugees, and Medicins Sans Frontieres, working with refugees in the region. The Syrian and Jordanian governments also provide some support for refugees within their boundaries.

Hijazi's work in mental health care came about because of a different war in the Middle East. Born in Los Angeles to Lebanese parents, she grew up in the United States, France, and Lebanon, where she earned a B.A. degree in architecture from the American University of Beirut.

After the 2006 war in Lebanon between Israel and Hezbollah fighters, she wanted to do something to help civilians whose homes and livelihoods were destroyed. She met Lynne Jones, M.D., an IMC-affiliated psychiatrist (Psychiatric News, March 17, 2006), who found a role for Hijazi creating "child-friendly spaces," a process helped by her interior-design training. There children could play but also could express their feelings through art.

"One child went from drawing his destroyed house to drawing his dream house," Hijazi recounted in an interview.

After the acute postwar phase passed, she helped in the transition of the children's spaces to community centers that could offer vocational training, psychosocial help, and some basic hygiene and sanitation aid. In southern Lebanon, the IMC worked to link schools and clinics to reduce the stigma of needing and seeking help for mental health problems.

Psychiatrists and psychologists from the American University of Beirut have helped train primary care clinicians to screen and refer patients with mental health needs in a program now certified by Lebanon's Ministry of Health.

In 2007 Hijazi's work expanded to include Iraqi refugees, first in five regions in Lebanon, and later in Syria and Jordan.

Many live hand-to-mouth and in fear of expulsion by local authorities, although that is less so in Syria than in Jordan or Lebanon, said Hijazi.

"In the southern suburbs of Beirut, Iraqi refugees are confined to a two-block radius of their homes," she told a group of nongovernmental organizations working on Iraqi refugee issues in Washington, D.C., in early April. "That means setting up clinics within neighborhoods or using mobile outreach units."

The IMC's work among the Iraqi refugees began in 2007, when there were 55,000 of them in Lebanon, 500,000 in Jordan, and 1.2 million in Syria; the organization is in the process of updating those figures. Besides offering basic medical care and mobile medical units for outreach and home care, the IMC sought to provide some secondary health care and follow-up services—including psychosocial interventions—to these refugees.

However, the IMC did not want to simply parachute in Western ideas and values, which could have a negative impact, said Hijazi. Any intervention had to be developed with an understanding of different cultures, whose views on behavior and on mental health and illness vary widely, both from Western norms and according to indigenous religious or ethnic groupings.

International aid agencies have poorly integrated psychosocial elements into humanitarian work in the past, but that has begun to change, said Hijazi. Basic needs—food, water, shelter, medical care—have to be addressed first in emergencies, then a variety of social, community, and personal supports must be added as time passes and other needs become apparent.

Within that framework, the IMC's goal is to prepare Iraqi refugees for return to Iraq when that becomes possible, as well as for reconciliation between factions there and reconstruction of the country, said Hijazi.

For a start, that has meant integrating mental health into primary care by training general practitioners in the tools and skills needed to identify cases, treat mental disorders of low or moderate severity, and know when to refer more complex cases for further evaluation and treatment.

Doctors participating in the 12-day theoretical training course begin by studying the social psychology of displacement, then move on to screening, diagnosis, and referral, as well as training in the use of psychotropic medications and cognitive-behavioral therapy.

Trainers then accompany the physicians back to the clinic, where they observe how the physicians put the training into action and relate to patients. The organization also recruited psychologists and social workers to go into the homes of refugees, lessening the stigma of and reducing barriers to going to a clinic for mental health care.

The IMC also implemented nonspecific activities that had psychological benefits. Because the refugees were scattered within towns, and often in hiding, there were few social focal points where they could gather. Hijazi set up spaces where the children could play. Their mothers then gathered spontaneously into what were effectively support groups to chat and interact. Cooking classes for the women served a similar function.

Outreach to men has proved more difficult, said Hijazi.

"We have tried support groups, but they didn't work, so now in Jordan we have begun using home-based services to reach them," she said." In Lebanon, we are setting up father-son sports activities."

Since refugee men are not allowed to work in the host country, many have lost their central role in their family, community, and society. Many have become depressed and anxious, and that has at times led to domestic violence against wives or children, she said. Many people have also suffered trauma and have posttraumatic stress disorder.

In each clinic serving the refugees, the IMC supports a local psychologist and psychiatrist who offer care free of charge. It also provides continuing medical education for Iraqi doctors to allow them to maintain their skills in preparation for the time when they return home.

The IMC neither encourages nor discourages Iraqi refugees to return to Iraq. Many could not do so if they wanted to. However, the group does offer information sessions to help them better assess that possibility.

Information about the IMC's mental health program is posted at<http://imcworldwide.org/section/programs/mental_health>.▪