Yousef’s story
================

* Tony Bruno

*This is Yousef’s story. He is an 11-year-old boy whose life has changed forever. In 2015, he was the innocent casualty of a mustard gas bomb shell attack while at home with his family in Mosul, Iraq. This narrative describes the details of his tragedy and explains how I came to know his story while working as a physician providing humanitarian aid in northern Iraq. Yousef has suffered terrible sequelae as a result of that bomb, including severe keloid scarring that has resulted in gross disfigurement. The mental anguish of such scarring at that age dominates his physical defacement, and it has pushed him to attempt to take his own life multiple times. Through the privilege of caring for Yousef, I have become aware of the all-too-prevalent use of chemical agents of war in this part of the world, which is unknown to most Westerners. The unacceptable consequences for innocent people of exposure to such chemical gases reminds us once again of the urgency to enforce the international treaties that have been signed for an effective termination of the use of chemical weapons for good. The motivation for governments to do so lies in the powerful among every nation’s people making this a global priority.*

## Sulaymaniyah, Iraqi Kurdistan, Dec. 5, 2017

I have just passed the halfway point of a six-month humanitarian mission in Kurdistan. My role here is to help supervise and instruct Iraqi physicians who care for about 25 000 internally displaced people and refugees in various camps in the region.

During mission handover, a colleague told me about Yousef: an 11-year-old boy with substantial keloid scarring — a result of the artillery shelling by ISIL, also known as ISIS or Daesh, in Mosul’s Wadi Hajar district in September 2015. Yousef’s mother brought him to the clinic in August 2017 and explained that Yousef had been sprayed with “unignited kerosene” during the shelling. She assumed that the unignited kerosene had caused her son’s burns — not the blast itself.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/190/32/E962/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/190/32/E962/F1)

A description of a shelling and the nature of Yousef’s injury led the author to suspect mustard gas was involved.

Image courtesy of Tony Bruno

I reviewed the case three weeks later and quickly began to have doubts that unignited kerosene could have burned him to any substantial extent unless there was prolonged exposure. After seeing photographs of Yousef, things did not make sense to me. I felt we were missing something.

The images of Yousef stayed with me for days — they would not leave my mind. Finally, I tracked down his mother, now back in Mosul, and set up a second interview by phone. I prepared a set of questions and the interview lasted about an hour. My hope was to be sufficiently diligent and objective to determine the most likely cause of Yousef’s burns. Needless to say, recounting the attack was extremely difficult for Yousef’s mother. Certain questions led to prolonged silences — at certain points, she began to cry. We paused, then I pressed on, as delicately as I could.

She explained that Yousef had been the only person at the far end of the room when the artillery shell struck and the wall crumbled right in front of him. Soon the entire family was gasping for air, and those more severely affected vomited. Outside, clouds of yellow smoke rose from the earth and were carried downwind. Within minutes, the family’s eyes began to burn, and they all lost their vision for hours.

This description — combined with the photographs of Yousef — led me to believe that the artillery shell was filled with mustard gas. The cutaneous manifestations that mustard gas may cause include, but are not limited to, skin burning and scarring. A moist environment tends to promote the development of these phenomena. In keeping with this theory, Yousef had keloid scarring predominantly on his neck, bilateral axilla and groin region — areas predisposed to sweating.

However, even with this new evidence, part of me still refused to accept that Yousef and his family could be victims of a mustard gas attack. I suppose denial was easier on my heart. But even a cursory Internet search will confirm that Islamic militants have used mustard gas on any number of occasions in recent years. On Nov. 21 2016, *The New York Times* reported that ISIL had “used chemical weapons, including chlorine and mustard agents, at least 52 times on the battlefield in Syria and Iraq since it had swept to power in 2014.”1 Moreover, “at least 19 of the 52 chemical attacks had taken place in and around Mosul.”

On Sept. 2, 2015, *The Guardian* reported on a mustard gas attack by ISIL in Marea, Syria.2 Before readers can scroll through the article, they find in bold type: “Warning: this article contains graphic images of injuries caused by mustard gas.” A photograph shows blistering on the back of 31-year-old Ahmed Latouf — certain patterns are uncannily similar to the scarring patterns found on Yousef. One photograph could almost be superimposed on the other. “My body was burning,” said Latouf.3 The photograph of his daughter is even more distressing — she was four days old.

Hamish de Bretton-Gordon, a chemical weapons adviser to nongovernmental organizations working in Syria and Iraq, wrote:

> The fear of chemical weapons is the real terror of war. Less than 0.5 percent of casualties during World War I were attributed to chemical weapons, yet the Great War has become synonymous with their use. The current conflict in Syria and Iraq depicts a similar picture. ISIL employs a morbidly brilliant psychological warfare, and chemical weapons are the ultimate psychological weapon against all their enemies.4

Groups such as the Organization for the Prohibition of Chemical Weapons, a United Nations chemical weapons watchdog, look on helplessly as these attacks continue. Public or political pressure is not going to work on ISIL. And if we consider the horrific chemical weapons attacks by Syrian president Bashar al-Assad on his own citizens — all with the support of larger, well-known political entities — we find that the Western countries, including Canada, are doing little to stop these atrocities. We seem to have “a willingness to tolerate the morally intolerable.”5

I admit, before my arrival, I had only a vague notion about what was going on in this part of the world. I do not think I am alone in admitting that. If I had come across these images of Yousef while in Canada, I would have been horrified, of course, but for how long? Probably a few minutes. Then right back to my day. It is a defence mechanism. It is easier.

Even being here now, I find myself trying to keep my emotional distance. Once again: self-preservation. Of course, it is a balance. A friend of mine recommended that I listen to a TED Talk by Joan Halifax, who is a Buddhist nun.6 She points out that the way to deal with life’s horrors is not by turning away but by acquiring great strength to leave behind mere pity (which is more about yourself) and aspire to true compassion. She continues:

> In Buddhism, we say, “It takes a strong back and a soft front.” It takes tremendous strength of the back to uphold yourself in the midst of [trying] conditions. And that is the quality of mental equanimity. But it also takes a soft front — the capacity to really be open to the world as it is, to have an undefended heart.6

This is not easy and I am not a Buddhist, but I do think this perspective has helped me cope here. It has allowed me to see things from different perspectives and to become connected to the suffering of the people around me. Their loss is my loss. I have realized that their love for their children is no less than ours and that they are no different from us. This is a corrupt land with as many powers trying to profit from it as it is littered with landmines. There is gain for those in power to keep the population poor, ignorant and dependent. And, despite suffering beyond what most of us can even fathom, these people still hope for prosperity and peace one day. Yousef’s story was simply my awakening. It privileged me with spiritual growth. I have been unshackled from the emotional apathy that I previously possessed, and from my prejudices. I observe with an altered eye and listen with an unfamiliar ear these days. This is the magic of missionary work. The transformation comes within the journey, whether it is felt or not.

The heartbreaking twist to Yousef’s story is that the extensive scarring on his neck has made him the target of teasing by other children. The anguish this has caused him cannot be overstated — Yousef has attempted suicide three times. The question remains: Will he try again before we can get him the help he needs?

## Acknowledgement

The author wishes to thank C.T. for his review of this manuscript.

## Footnotes

*   *CMAJ* Podcasts: audio reading at [https://soundcloud.com/cmajpodcasts/180131-enc](https://soundcloud.com/cmajpodcasts/180131-enc)

*   This article has been peer reviewed.

*   This is a true story. Yousef’s mother has given her consent for this story to be told.

## References

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2.  Chulove M. “My body was burning”: survivors recall horror of Isis mustard gas attack. The Guardian [London (UK)]. Available: [www.theguardian.com/world/2015/sep/02/syria-mustard-gas-attack-my-body-was-burning](http://www.theguardian.com/world/2015/sep/02/syria-mustard-gas-attack-my-body-was-burning) (accessed 2015 Sept. 2).
    
    

3.  Van Bergen L. Before My Helpless sight: suffering, dying and military medicine on the Western front, 1914–1918. Farnham (UK): Ashgate Publishing: 2009;184.
    
    

4.  de Bretton-Gordon H. Remembering Halabja chemical attack. Al Jazeera [Doha (Qatar)]. Available: [www.aljazeera.com/indepth/opinion/2016/03/remembering-halabja-chemical-attack-160316061221074.html](http://www.aljazeera.com/indepth/opinion/2016/03/remembering-halabja-chemical-attack-160316061221074.html) (accessed 2016 Mar. 16).
    
    

5.  Geras N. The contract of mutual indifference: political philosophy after the Holocaust. Brooklyn (NY): Verso Books; 1998:170.
    
    

6.  Halifax J. Compassion and the true meaning of empathy [TED Talk]. Ted.com; 2010. Available: [http://tedtalkspsychology.com/compassion-and-the-true-meaning-of-empathy-with-joan-halifax](http://tedtalkspsychology.com/compassion-and-the-true-meaning-of-empathy-with-joan-halifax) (accessed 2011 Sept. 2)