Democracy Lab

A Country with Fourteen Psychiatrists

Libya is trying to build a new democracy. But that's a tall order for a society plagued by bad memories.

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."



Mitt's Pilgrimage

Can Romney swing American Jewish voters to the GOP ticket with his trip to Israel?

JERUSALEM – The U.S. presidential race might be deadlocked, but when Mitt Romney visits Israel on Sunday, July 29, the presumptive Republican nominee can reasonably expect the most heartfelt welcome he'll receive anywhere outside Utah.

Israeli enthusiasm for Romney is not necessarily the result of a carefully cultivated relationship -- as a former governor and business executive he had little time for foreign policy. Instead, affection for the candidate appears to be a clear case of ABO: Anyone But Obama.

The proof is in the polling. Thirty percent of Israelis surveyed think U.S.-Israel relations would improve under Romney, while a mere 8 percent said the same about a second Obama term. Among the 300,000 Americans living in Israel (half of whom are eligible to vote), support for Romney is twice as high as it is for Obama.

Romney's two-day visit -- during which he will also meet with Palestinian Prime Minister Salam Fayyad -- is his fourth ever to Israel, and it's his first foreign trip since clinching the Republican nomination. The stop is aimed at two constituencies the candidate is desperate to woo: evangelicals -- reliably Republican but leery of his Mormonism -- and Jewish Americans, heavily concentrated in swing states like Ohio and Florida and vexed, his campaign believes, by Obama's policies toward the Jewish state.

"A lot of our members moved here as registered Democrats," says Kory Bardash, co-chair of Republicans Abroad Israel, a partisan advocacy group that claims to mobilize upwards of 4,000 volunteers during election season. "A lot of people are now saying, 'I've never voted Republican, but there's no way I'm voting Obama.' That includes many who voted for him in '08."

There are now "tens of thousands" of Republican voters in Israel, according to Bardash, but the real purpose of Romney's trip is to signal his commitment to Israel to voters back home -- a cause that is aided by Obama's apparent inability to connect with Israelis. 

The problem doesn't seem to be that Israelis see Obama as openly hostile -- polls show them evenly split over whether he is "friendly" to their country. Instead, many think the president just doesn't "get" Israel and lacks the empathy of George W. Bush or even his Democratic predecessor, Bill Clinton.   

"President Obama never acquired the connection with the Israeli public that President Clinton had," says Dore Gold, the American-born president of the Jerusalem Center for Public Affairs and a former advisor to Prime Minister Benjamin Netanyahu. "Obama just hasn't managed to have the same 'click' with the man on the street."

"Many American Jews are very liberal and don't count Israel as one of the top issues in their life," says Bardash, a New Jersey native who moved to Jerusalem 16 years ago. "But among those who define themselves as pro-Israel and for whom Israel is important, we believe Obama has lost a lot of support."

Six in 10 Jewish Americans still say they support the president, roughly the same proportion that supported him a month before the 2008 election, in which Obama ultimately hauled in 75 percent of the Jewish vote. Still, Republican Jewish groups boast that Romney's 29 percent approval among American Jews is the highest for a Republican candidate in a quarter-century.

And while a solid majority of American Jews continue to vote Democratic, the Israeli left is a shadow of its old self -- discredited by the failed peace process led by slain Prime Minister Yitzhak Rabin and the bloodshed of the last decade's Second Intifada. The left's remaining holdouts (represented by just one-sixth of parliament) still generally back Obama, but there is a broad consensus in today's Israeli center that sees the U.S. president's first term as a forgettable chain of slips, snubs, and rookie mistakes.

Obama won few plaudits, even among veteran peace processors in Washington and Jerusalem, for his early insistence that Israel freeze all building in West Bank settlements. (American peace negotiator Aaron David Miller included the initiative in his "Dumb Idea Hall of Fame.") Obama's detractors argue the move emboldened Palestinians to forgo talks with Israel and unilaterally declare statehood at the United Nations. (The administration insists its threat to use its Security Council veto underscored its commitment to the peace process.)

Yet Netanyahu's government has rarely been an easy partner. In 2010, the Israeli Interior Ministry embarrassed the White House by approving new housing units in East Jerusalem during a visit by Vice President Joe Biden. The Obama administration was equally chagrined when, a year later, the Israeli premier treated the president to an impromptu history lesson in front of reporters in the Oval Office.

Still, critics accuse Obama of creating "daylight" between Washington and Jerusalem in a misguided bid to improve America's image in the Muslim world. Bardash of Republicans Abroad says that the president was clinging to the mistaken view that the Israeli-Palestinian conflict is the root cause of most of the Middle East's ills. "The Arab Spring has demonstrated that's not the case," he says. "These countries have all kinds of internal problems that have nothing to do with Israel."

Indeed, just 18 percent of Israelis polled approve of Obama's handling of the Arab revolts, and even pundits on the center-left have found his Middle East policy perplexing. The president abstained from "meddling" in Iran's 2009 Green Revolution, but called for Egyptian President Hosni Mubarak, a three-decade ally of the United States and Israel, to resign within days of protests erupting in Tahrir Square. When an uprising broke out in Syria -- a staunch ally of Iran and the launching pad for 90 percent of foreign fighters who attacked U.S. troops in Iraq from 2003 to 2008 -- Obama waited five months before appealing to President Bashar al-Assad to resign. Democrats maintain that each case was unique and that Obama was trying to position himself ahead of events; Republicans charge the president with watching history unfold rather than employing American clout to shape it.

Obama's Iran policy has also distanced him from many Israelis. Netanyahu has pushed the White House to more seriously consider military action should diplomacy over Tehran's nuclear program fail, but Obama has remained steadfastly cautious in his rhetoric. That's not to say the two governments haven't worked together: The United States and Israel are believed to have created the Stuxnet worm discovered at Iran's Natanz enrichment facility in 2010, and that same year the White House pushed through a comprehensive fourth round of U.N. sanctions to complement the three passed under Bush. Nonetheless, roughly half of Israelis surveyed view Obama's position on Iran's nuclear drive as too soft.

Smelling blood, Romney has come out blasting, promising the credible military threat he claims Obama has failed to create: "Only if Iran understands that the United States is utterly determined when we say that their nuclear-weapons program is unacceptable is there a possibility that they will give up their nuclear aspirations peacefully," the candidate states on his website.

Broader Israeli security concerns have proved to be another stumbling block for Obama. Last week, after a terrorist attack in Bulgaria left five Israeli vacationers dead, U.S. officials privately fingered Iran and Hezbollah but declined to implicate them publicly, telling the New York Times the attack was likely a "tit-for-tat" response for Israel's alleged assassinations of Iranian nuclear scientists. Pro-Israel pundits blasted the statement -- which seemed to equate civilian holidaymakers, one of them a pregnant woman, with scientists suspected of developing an illicit weapons program -- as another instance of the administration giving the Iranians a free pass.

Moreover, Obama's popularity is hardly helped by his notoriously frosty relationship with Netanyahu. Whereas the president's interactions with Bibi have always seemed strained, Romney enjoys an amicable three-decade relationship with the prime minister dating back to their early careers at Boston Consulting Group. "We can almost speak in shorthand," Romney has said of the Israeli leader. As governor of Massachusetts, Romney sought Netanyahu's advice on limiting the size of government. And when Netanyahu wanted to help U.S. firms divest from Iran, Romney offered tips of his own.

Asked in the Dec. 10 Republican debate whether he agreed with then-contender Newt Gingrich's assessment that the Palestinians are an "invented" people, Romney spun the question to highlight his friendship with Netanyahu and, implicitly, Obama's lack thereof: "Before I made a statement of that nature, I'd get on the phone to my friend Bibi Netanyahu and say, 'Would it help if I said this? What would you like me to do?'" As Netanyahu remains broadly popular in Israel, the Republican candidate has been able to bask in his reflected glow.

The administration has insisted it has been a stalwart friend of Israel, denouncing Republican criticism as made up of so many groundless "myths." When Romney told evangelicals in June that he would do the "opposite" of the president on all things Israel, Obama's campaign promptly shot back: "[D]oes that mean he would reverse President Obama's policies of sending Israel the largest security assistance packages in history? Does it mean he would let Israel stand alone at the United Nations, or that he would stop funding the Iron Dome [rocket interception] system? Does it mean he would abandon the coalition working together to confront Iran's nuclear ambitions?"

Still, Team Romney appears convinced that along with the economy, Israel is Obama's Achilles heel -- and is gleefully preparing its poisoned darts.

Romney has accused Obama of "[throwing] Israel under the bus" and has vowed a different approach. "The best way to have peace in the Middle East is not for us to vacillate and to appease, but is to say, 'We stand with our friend Israel. We are committed to a Jewish state in Israel. We will not have an inch of difference between ourselves and our ally, Israel.'"

Dan Senor, a Romney foreign-policy advisor who co-authored a bestselling book on Israel's economic success, said his candidate believes "threats to Israel are threats to America; challenges to Israel are challenges to America.… We believe Americans of all stripes, from across the country, identify with Israel. Governor Romney believes support for Israel is an American value."

Gold, Netanyahu's former advisor, says Israel hopes to maintain constructive relations with both U.S. parties, but it's an ill-kept secret in Jerusalem that Bibi and his government would raise a Shabbat toast should America choose to vote in its first Mormon executive.

As the election looms, Israelis appear ripe for the Republicans' picking: Just 38 percent have a positive view of Obama, compared to 60 percent in 2009. Most can't vote in America, but Mitt Romney is hoping their affection helps win him just a little more love from those who can.

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