Young Syrian refugees in Jordan’s Zaatari camp. Dusty and cramped camps like these worsen psychological trauma from the war, although it’s not always obvious.
By: Julia Jacovides
The problem with most media these days is that it favors the physical over the mental, the visible over the hidden. For the past three years, American news outlets have been saturated with images and videos of bodies and broken communities in Syria. These casualties of war are certainly relevant and poignant, but they do not tell the entire story.
Psychological illnesses as a result of the violence in Syria are an essential but overlooked part of the global health care push for the conflict’s refugees and internally displaced persons (IDPs). The World Health Organization (WHO) estimates that the number of cases involving even the most common mental health issues – depression and anxiety – can double during a conflict. And Syrians – both the 2.8 million who have left the country and the 6.5 million who have been displaced inside of it – have seen a great deal of conflict. Moreover, poor conditions at nearby refugee camps may actually exacerbate refugees’ horrific memories. Resources are scarce, privacy is rare, and aggressiveness is the main bargaining tool. Although the war’s physical effects remain the most visible, it is the hidden mental health issues which will come to have the longest influence on a post-conflict Syria.
In the United States, public discussions on mental health issues such as depression frequently wither under embarrassment: the topic is still too taboo for comfort, its sufferers too weak to help. Syrians, though, rarely discuss these issues. As the country’s civil war expands into its third year, few remain untouched, and the ramifications of remaining silent on mental health issues grows daily. The scope of the issue is overwhelming: according to the UN High Commissioner for Refugees (UNHCR), in December 2013 only 7-9 psychiatrists and 30-50 psychologists worked with nearly 850,000 Syrian refugees in Lebanon.
There is no exhaustive list of the causes of Syrian refugees’ psychological issues. However, many accounts mention torture, witnessing the death of family members, explosions, violent shelling, and rape. The normal response to such violence is hopelessness, anxiety, or outright anger. Many people recover from this over time and through the support of others. However, a select few find it difficult to get better. It grows hard for them to complete daily tasks, to seek help for physical ailments, and to work for the future. At Domeez Camp in Northern Iraq, Médecins Sans Frontières (Doctors Without Borders) has reported seeing an increasing number of patients experiencing severe psychological issues like schizophrenia or depression. In a December 2012 interview with the BBC, Syrian health professional Dr. Mohamed reported that mental health illnesses are the psychological effects of a situation in which people have no control, no voice, and no power. In adults, this frustration translates into depression, anxiety, or more serious issues. In children, the effects emerge more subtly. According to Dr. Mohamed, children undergoing mental stress get angry at their siblings, are afraid of their surroundings, cling to their parents, have nightmares, and are sometimes developmentally delayed. These all sound like the normal issues of childhood, but the longer Syria spends engulfed in war, the more likely it becomes that these children will not receive the individual assessment and care they need. And, if they do not receive it, the outlook for Syria’s next generation becomes very grim indeed.
In the same BBC interview, Syrian psychologist Dr. Omar voiced his concern that the “next generation will inherit the fear and anxiety” of the current war. He worried about domestic violence and the possibility that untreated children will resort to criminal activity. “But, we can’t deal with many of the cases that come to us, because we haven’t had the right training,” he said. (In pre-war Syria only 70 psychiatrists served the country’s 21 million inhabitants, and they worked from only two public psychiatric hospitals.) Even the medicines themselves have grown scarce and inaccessible. WHO reports that phenobarbiturates, used to treat epilepsy or bipolar disorder, are now nearly thirty times more expensive than they were before the war. While treatment and some psychosocial support may be available in the refugee camps lying outside Syria’s borders, those who remain in the country face practically no mental health assistance. The problem, then, is twofold: neither those inside nor outside the country receive sufficient care. When the war ends and each group returns to Syria, the resulting combination will present a dire health problem. The adrenaline that accompanied the start of the conflict – Dr. Mohamed calls it the “spirit of the revolution” – has started to wear off, and he predicts that there will be an overwhelming wave of need for psychological treatment only after the fighting has ended and people attempt a return to normalcy. “People will start to realize what they lost: their homes, their friends, their relatives.” Of course, there is no end in sight, which begs the question: what is being done now?
In UNHCR’s 2014 Syria Regional Response Plan, it aims to have at least one primary health center for every 10,000 people in a camp. Centers will provide a variety of services, including mental health and psychosocial support. In addition, WHO has pushed to make mental health care an integral part of medical services. However, these groups are stretched too thin and exist in a region where, as we have seen, psychiatry is not a vaulted profession. Though agencies provide refugees with housing, food, water, and health care, the primary focus of the latter is on physical ailments. The more silent (and more temperamental) illnesses are overlooked and often, unfortunately, for good reason. Physical ailments are more likely to end a life sooner than mental ones. Physical ailments are more visible and more relatable. It is obvious when a physical ailment has healed. Mental illnesses provide no such clarity. The result is a necessary but painfully shortsighted sacrifice between immediate and long-term treatment.
In an ideal world, psychological support would be just as important as physical support right from the beginning of a conflict. Mental health professionals would be on hand to see every refugee and to visit every displaced person. In reality, though, until mental health issues are viewed as equally dire as physical ailments, victims of conflict will have to deal with the ramifications of violence for decades following its conclusion. In the confusion that follows resolution, there are many reasons to blame a slow peace: public leaders, poor economies, overwhelming (or, lackluster) foreign support. The most subtle, but perhaps the truest, is the resulting collective trauma that stains a generation or more. To combat this now, NGOs and UN agencies can give refugees something over which they have control. It can be as simple as cleaning the camp facilities, or as complex as serving as research assistants in studies on mental illnesses. Give the refugees something to do that has a purpose, rhythm, and routine. The change will not be immediate, but it is a start.