1. Background

Mental health is often neglected and stigmatized in Arab countries. People who suffer from psychological or psychiatric disorders are culturally depicted as ‘crazy,’ and their conditions are neither taken seriously nor treated seriously. This social frailty, combined with the lack of availability of mental healthcare, discourages affected persons from actively seeking professional treatment. According to the former president of the Syrian American Medical Society (SAMS), Dr. Zaher Sahloul, there were only around 100 psychiatrists for the 22 million people living in Syria before the beginning of the war. Correspondingly, there were only 815 beds for psychiatric patients in hospitals and facilities for the 24 million people in Yemen.

Recently, there has been a growing need for psychiatric healthcare in war- and conflict-torn states, such as Syria, Yemen, Iraq, and the occupied Palestinian territories (oPt). The populations in these states and communities are often exposed to extreme stress – mainly due to violence, food and energy insecurities – and inadequate healthcare. Whether they are health workers, mentally or physically ill patients, or healthy civilians, exposure to such hostilities render them more prone to developing moderate to acute mental issues. Depression, anxiety, and post-traumatic stress disorder (PTSD) are commonly found in both adults and children in war-torn communities. For example, the Gaza Community Mental Health Program (GCMHP) declared that 51% of children and 31% of adults in the Gaza Strip suffered from PTSD in 2015.

This paper discusses the recurrence of attacks on mental health facilities and their workers, severely limiting access to this particular kind of healthcare. It also discusses the impact of physical trauma on patients’ psyches. Lastly, we assess the risks posed by the jobs and duties of health workers on their own mental health.

  1. Attacks on mental healthcare facilities

In Syria, access to psychological and psychiatric help was already scarce prior to the beginning of the conflict. According to the Syria Integrated Needs Assessment (SINA), 15,000 Syrian doctors – amounting to 50 percent of the total number of doctors – had fled the country in 2013. By extrapolation, Dr. Zaher Sahloul estimates there are only 50 remaining psychiatrists in Syria to service the whole population.

In 2013, the Ibn Khaldun Psychiatric Hospital, one of the three public medical facilities dedicated to mental health in Syria, was severely damaged by shelling. The violent attack forced doctors to flee and leave patients on their own, without food or water. Some of the patients escaped and wandered around eastern Aleppo, resulting in the death of two patients by sniper attack. Patients who had remained in the destroyed facility were sheltered by a benevolent organization in the Masaken Hanano district of Aleppo, however, they were not adapted to receive and provide care for mentally ill patients. The geriatric psychiatric clinic, Dar al-Ajaza, which was abandoned by most of its staff members a year prior, was also shelled but suffered only moderate damage.

As a result, the only functioning psychiatric hospital left in Syria was the Ibn Sina Hospital in Douma, outside Damascus. However, it operated with limited capacity because of security concerns following military clashes between the Syrian government and the Islamic opposition’s armed forces. The Ibn Rushd Centre for Substance Abuse opened a psychopathology ward in order to remediate the lack of psychological and psychiatric health care in the country, but its capacity is limited to 51 beds and 30 consultations per day. But this amounts to only a fragment of the national need.

In December 2014, the World Health Organization (WHO) renovated the Ibn Rushd and Ibn Khaldun Mental Health Facilities as well as two psychiatric wards located in the Al Mowassat and Al Afia General Hospitals. Around 11,000 people suffering from moderate to severe mental disorders are estimated to benefit from these health care services each year. However, in 2016, bombings over Aleppo moderately damaged the renovated Ibn Rushd facility and its equipment.

The Ibn Sina Psychiatric Hospital in Douma was shelled three times in two years. In May 2017, it was severely attacked and five people inside the facility were killed instantly. The hospital was attacked again in early February 2018, but the shells missed and the building did not suffer any damage. The hospital was attacked once more in late February. This time it was directly hit by five mortar shells, which partially damaged some of the wards. The hospital was still functioning, but it was left without electricity.

In Yemen, there were only three psychiatric hospitals in 2014 before the beginning of the conflict. As of October 2015, the WHO reported that the Al Mudhaffar Mental Hospital in Taiz was partially damaged after an attack on the facility.

Access to mental healthcare for mentally ill patients has also been diminished in Iraq. According to the WHO’s estimates for 2014, there were around 175 psychiatrists and psychologists for a population of 35 million people. Dr. Redar Mohamed, a psychiatrist in Erbil, works at three different facilities and treats 200 cases per month to remediate to the lack of mental health staff in the country. In an interview, he stated that Iraq’s psychiatric capacity is not sustainable, and that there is a consequential demand for qualified mental health practitioners in Iraqi hospitals and clinics.

  1. Deterioration of the mental health of physically-ill patients

In conflict-torn countries, the right to health is often undermined and the access to adequate healthcare is often obstructed. Physically-ill patients are therefore deprived of access to treatment, which can have a toll on their mental health.

In the Gaza strip, a ten-year-old girl named Maha suffers from upper body paralysis, also known as quadriplegia. Shrapnel from the bombs that hit her home in July 2014 severely damaged her neck and spinal cord. Maha started her treatment at Al-Shifa hospital, but the lack of adequate therapy prompted her transfer to another hospital in Turkey. However, traveling and being alone in a hospital abroad at such a young age is very harsh. Soon after her relocation, Maha’s mental health started deteriorating and she returned to her family in Gaza.

Persons suffering from corporal disabilities are also affected by mental disorders directly linked to their physical condition.

An article entitled “Life after conflict-related amputation trauma: a clinical study from the Gaza Strip” assesses the high risks of depression, anxiety, and sleep disturbances amongst civilians who had lost limbs because of Israeli fire and shelling. Abdul Rahman Nofal, Abdullah Elanqar, and Muhammad Abu Hussain are Palestinian boys aged between 11 and 13. They were all shot by Israeli soldiers next to the border, and they had to have limbs amputated following their injuries. It is difficult for Gazan amputees to get access to prosthetic limbs, as they are costly and often necessitate further surgery to adapt residual stumps to the prosthetics. Abdul Rahman, Abdullah, and Muhammad are most likely to be confined to their crutches and wheelchairs for the rest of their lives. All three of them now suffer from psychological complications and are in severe need of rehabilitation.

In Yemen, a twelve-year-old child named Khaled is wheelchair-bound following an airstrike which hit his school bus. He is the only survivor among his friends. Ever since the attack, Khaled suffers from depression and PTSD.

Refugees are also at high risk of developing anxiety-related mental disorders. Syrian refugees who suffer from chronic renal failure are not always able to afford their costly dialysis sessions in Lebanon and Jordan, seeing as the high costs are not completely covered by organizations such as the United Nations Office of the High Commissioner for Human Rights (OHCHR) and the Syrian Expatriate Medical Association (SEMA). Consequently, these persons live in fear and have very high levels of anxiety. Stopping dialysis also induces depression and insomnia.

  1. Mental health of health care workers

The jobs of doctors, nurses, and relief crews put them under a lot of pressure and stress, especially in times of conflicts when emergencies are frequent. They face the same amount of distress as other citizens, yet, they continue to provide help to others.

The International Committee of the Red Cross (ICRC) launched a program entitled “Helping the Helpers” in 2015, which aims to provide adequate physical and mental health care to health workers. According to the ICRC, the protection of healthcare also encompasses the provision of adequate mental healthcare to frontline health workers. The Gazan Ministry of Health implemented the program locally to benefit its emergency workers, whom are repeatedly exposed to emergencies and witness traumatic injuries and deaths. The Gazan health workers have declared feeling less anxious about their jobs after the trainings.

In Yemen, the intensification of the conflict is driving the remaining health workers out of the country. Dr. Mohammad Al-Kholaidi, a Yemeni psychiatrist and neurologist, suffers from vicarious trauma directly tied to his profession. Vicarious trauma happens when a counsellor is often exposed to the fear, pain, and terror of victims of traumatising events. The symptoms are the same as those of PTSD.

Syrian doctors and nurses have suffered from psychological traumas due to the numerous attacks on the health care facilities in which they work. Many of them now suffer from PTSD and are extremely anxious in their work place. Dr. Tennari, the director of the Sarmin field hospital in Idleb, has declared: “When I am in the hospital, I feel like I am sitting on a bomb.” Other Syrian health staffers have declared feeling depressed because of the traumatic experiences of the patients whom they treat.

Most of the aid and relief workers in Syria are often national citizens and are generally internally displaced themselves. They already suffer from a significant amount of stress due to their situation and plunge themselves into work as a result. As they only allocate time for patients and victims, they tend to isolate themselves and limit contact with their friends and families.

  1. Recommendations

Mental health has a severe impact on a country’s population. It is therefore important to seriously assess the mental health needs of civilians and health workers. Mentally and physically healthy doctors, nurses, and emergency workers will provide better care to those in need.

Defenders for Medical Impartiality (DMI) acknowledges the value of ICRC’s “Helping the Helpers” campaign, and calls for its implementation in all conflict and war-torn countries. Psychological care aimed at health workers will contribute to reducing their anxiety levels and will help minimize the traumatic impact of their job on their own mental health.

DMI calls for the establishment of psychological units in all hospitals. Immediate psychological care reduces the traumatism linked to severe injuries and will therefore decrease a patient’s need for intense rehabilitation.

DMI urges the health ministries in Iraq, Yemen, Syria, and the occupied Palestinian territories to clearly define national mental health strategies and to allocate larger budgets to put the strategies in place. We also encourage the ministries to conduct sensitization campaigns about mental health on a national-level, to raise awareness about the severity of the topic.