Not to help justice in her need would be an impiety.—Plato1
I was at the 2012 American Academy of Psychiatry and the Law meeting in Montreal last fall when Dr. Stephen Xenakis spoke on the role of psychiatry in 21st century warfare. He described torture in the military and the role of psychiatrists as leaders at times that exacted heavy costs personally and professionally. He discussed the moral dilemmas psychiatrists face in working with the military and with institutions in general. As an example, he presented the case of a military psychiatrist faced with diagnosing posttraumatic stress disorder (PTSD) in a prisoner of war and being reluctant to do so for fear of exposing torture in the military. The assessment raised the question of the role the psychiatrist played in responding to an ethics-related and humanitarian question and, in a way, upholding justice. It was eye-opening to see how many of the audience members were unaware of torture practices and the consequences of war, even when the United States, a nation with existential claims on just practices, is involved.
Having been raised in Lebanon during the civil war of 1975 through 1991, surrounded by injustice, I found my personal experience resonating with the talk. It reminded me of the men and women who were apprehended during the war. They were tortured, and some returned, but many did not. In Lebanon, individuals who stood up for justice were at risk of being assassinated. It did not matter if they were politicians, journalists, physicians, construction workers, or homemakers. I do not recall a time when I was unaware of the injustices that came with violence, crime, danger, death, corruption, and war. This is not my story though; this is the shared Lebanese experience, and I know it applies to any war-stricken community.
The Lebanese civil war was a result of a complex set of political and economic circumstances that could be traced to the fall of the Ottoman Empire after World War I. The creation of Lebanon as a French mandate included the mostly Christian inhabitants of the Lebanese mountains and the mostly Muslim inhabitants of the coastal cities. When Lebanon gained independence from France in 1943, the majority Christian population created a religion-based government in which power would be shared with the Sunni and Shiite Muslim political groups, the second and third largest religious groups in Lebanon. At the same time, representation in the new government would reflect the majority Christian population.2
By the 1970s, however, demographics had changed, and the majority group was now Shiite. When demands for political reforms were made, the Christians resisted, and all groups formed private militias as a result of a fractious government and military.1 This background, however, describes the context, but not the fuel for the war. In fact, each group would eventually be divided against itself, and personal vendettas and material gains would come to take precedence over political concerns.
Beirut became divided, with Christian East Beirut against Muslim West Beirut, by the Green Line, which was a five-minute drive from our home. This division would play a role in Beirut and other parts of the country. A person would risk his life if he crossed into an area where a different religious group dominated. In Lebanon, this danger is explicit because every ID lists one's religious affiliation.
As a child growing up in Beirut, I was not entirely surprised to find militiamen in our home one night. They had broken in while my mother, brother, and I were at my grandmother's house for dinner. My father, a physician, was on call at a distant hospital. I distinctly remember waiting, kicking a pebble on the sidewalk and thinking it was just another night, while my mother negotiated with the militia to get our home back. I was minimally concerned—a bit annoyed, but reassured that it would be resolved without incident. Looking back, I'm amazed by my reaction. They could simply have killed us.
Those who could not stay in their homes slept in bomb shelters where so-called nervous problems, referring to anxiety and depression, were a common theme. “She has nervous problems,” they would say about the mother who lost her son in the fighting. The universal survival strategy, even then, was to stay away from the windows or get out of Beirut. No wonder people got nervous.
When the fighting in the city became too dangerous even for the most steadfast, we went to South Lebanon. It was an interesting change of scenery. South Lebanon, with its picturesque beauty, lush valleys, and majestic mountains was less rife with conflict and instability. Yet, at the same time, it was the era of the 1982 Israeli invasion of the area, called a security zone by Israel. Various Lebanese and Palestinian groups fought for supremacy, and tanks and soldiers were a common sight.
My family had to pass through multiple checkpoints going in and out of the region, the road strewn with poverty and amputees. We had to travel part of the way by crowded ship rather than by land, to avoid crossing into the southern Muslim regions with our Christian IDs. You needed a permit to pass through the security zone, walk individually through a barbed wire path, and undergo a search. Sometimes people disappeared in the South or on the road between North and South. They were merely suspected of working with competing groups, faced false accusations of espionage, or were kidnapped simply for hostage negotiations. They might only be related to a politician of interest. Some returned, but with broken spirits.
Corruption and antisocial behavior were rampant. In a country where people were so afraid that they would vow absolute allegiance to the most powerful group or never admit an allegiance out of fear of secret agents, my father gave away free medical care based solely on medical need. From him, I learned that physicians have a duty to patients, irrespective of politics and based on law, ethics, and, above all, humanitarianism. What was most admirable was that he did this in a setting where educated professionals were intimidated by illiterate militiamen. They could have no political or ethics-based opinions. Yet, he did what he thought was just. Muslims from neighboring towns would come to him for care, just as Christians would.
We continued to go back and forth between Beirut and South Lebanon, with every visit back home more and more surreal: bullet holes in my parents' bedroom walls, a balcony blown up, no electricity. Yet the sweetshop next door was still open, with its incredible fragrance of freshly baked pastries breaking through the rubble. Somehow it was always reassuring.
Our way of life was not sustainable for long, and we emigrated to the United States. During our first night in America, none of us could sleep. It was too quiet. My father, a general surgeon at the time, would eventually become a psychiatrist. I remember the psychiatric journals that started arriving in the mail with front page articles on attention deficit hyperactivity disorder (ADHD) and genetics, schizophrenia and neuroimaging, science and social welfare. I would find myself reading them before he got home from work, then talking to him about what I had read. It was easy to become interested in, and then passionate about, psychiatry.
Soon after we emigrated, Lebanon seemed to stabilize, and we began making trips back. Lebanon is a place of remarkable natural beauty, with a culture of kindness that values and pursues advanced education, but somehow regresses into utter chaos in an instant of political strife. The country has a pull so great that many who leave ultimately return in some capacity or another.
In our countless return trips, I have been able to see the postwar effects through the stories of neighbors, news headlines, and the work of colleagues: PTSD, depression, anxiety, all the supposed nervous problems. The psychotic, disorganized people who cannot find treatment wander the streets and end up involuntarily hospitalized for lack of outpatient care. The war criminals, once exiled and jailed, have returned to politics. A society where criminals can be politicians worsens the suffering of people, as the leaders work for individual financial gain. The absence of justice in a corrupt system where judges can be bribed or worse, where judges fear for their lives, worsens the plight of the vulnerable.
But the story of Lebanon is also a story of resilience—incredible, unmatched resilience. I do not intend to give the impression that I had a miserable childhood. My family was loving, and we had many days that could pass as normal. We had many special moments: picking flowers in the countryside near my grandfather's home, big family dinners, wedding parties, birthdays, school friends, afterschool activities, and material comforts. Although they were checkered with periods of intense uncertainty and danger, these moments brought us joy in the midst of the chaos in which we lived.
What stood out in my mind as I listened to Dr. Xenakis at the AAPL meeting that afternoon was the injustice that surrounded me in my birthplace and the way it motivated me to help right this wrong. Psychiatry, a field that had long captured my heart for its ability to address problems with far-reaching social consequences, offered a solution. Forensic psychiatry, at the interface of medicine and the law, offered the perfect opportunity. It is fascinating to me that Lebanon, although full of physicians, has very few psychiatrists, and even fewer forensic specialists. The university hospitals are catching up, recruiting psychiatrists earnestly, but it is still a long way from meeting the need created by war. Training in psychiatry, and forensics in particular, is a way for me to contribute, in some way, to postwar recovery and to justice.
As physicians, we advocate for our patients. Psychiatrists are in a position to advocate for justice as well. With their understanding of the law and the mental health consequences of war, forensic psychiatrists in the judicial system are in the ultimate position to act, not just as physicians, but also as humanitarians. It is the ultimate empowerment. I will continue to absorb the story of Lebanon as my trips continue and put my professional philosophy into practice.
Acknowledgments
A special thank you to Dr. Mayada Akil, Professor, Director of Outpatient Programs and Director of the Mood and Anxiety Disorders Program, Georgetown University Hospital Department of Psychiatry, for her formative feedback and support, both in writing this piece and through all aspects of residency training.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2013 American Academy of Psychiatry and the Law