In rebel-held Idlib, Syrians battle stigma, lack of doctors to heal mental scars of war

AMMAN: Suad Naji took all the pictures of her deceased husband and daughter down from the walls of her Idlib home one year ago. Packing the photos away with the rest of her family’s belongings, Naji moved to a new house on the other side of town, hoping a fresh start could help her two surviving sons move on from the loss.

She never put the photographs back up.

Naji’s husband and six-year-old daughter died in the April 2017 sarin gas attack that killed 90 people in Khan Sheikhoun, a highway town at the southern reaches of Syria’s northwestern, largely opposition-held Idlib province.

For Naji’s oldest child, 12-year-old Abdulkareem, the loss of both his father and sister was a shock he is still struggling to cope with more than one year later.

Shortly after the attack, Abdulkareem began to suffer night terrors. He awoke nightly, screaming: “I’m choking” or “help me,” his mother says.

A doctor in town told Naji her son was likely suffering from depression, but without any psychiatric training, the medical staff in her hometown did not have the skills to treat him. 

A Khan Sheikhoun resident in a cemetery on July 12, the 100-day anniversary of the chemical attack on the city. Photo courtesy of Omar Haj Kadour/AFP/Getty Images.

At the suggestion of the same doctor, Naji and her sons moved across town to start fresh, but Abdulkareem’s symptoms did not abate, she tells Syria Direct. Instead, “he became worse.”

An elementary school teacher in Khan Sheikhoun, Naji is accustomed to children’s behavioral issues. But in the months after the deadly gas attack, Abdulkareem’s bouts of screaming, distractedness and slurred speech left her “stunned.”

Today, the only treatment Abdulkareem has received are sedatives prescribed by a local doctor. He no longer attends school, as his exasperated teachers “complain about his behavior,” his mother says.

In Syria’s largely rural Idlib province, psychiatric care was in short supply even before the war began. Today, providing adequate treatment for residents struggling with depression, anxiety and other mental illnesses after years of living under bombs and along frontlines is proving a monumental task for local health officials seeking to help those traumatized by violence.

Prior to 2011, Syria was home to just 70 psychiatrists—medical doctors who are certified to prescribe medication—and a “limited number” of psychologists to provide counseling and therapy for a population of 22 million, according to the World Health Organization (WHO).

What little treatment was available was largely limited to Damascus and Aleppo, the country’s two largest cities.

In agrarian Idlib province, only one licensed psychiatrist operating out of a private clinic served more than one million residents before the war, Dr. Monzar Khalil, head of today’s opposition-run Idlib Health Directorate, tells Syria Direct.

Government health authorities “did not provide any [public] psychological support services” in Idlib province, says Khalil.

 
The UOSSM-backed clinic for mental illness in Sarmada, Idlib in April. Photo courtesy of Bawaba Idlib.

But today, more than seven years into a violent, traumatizing civil war, Idlib province’s mental health needs are more dire than ever while psychiatric services remain scarce, health providers on the ground say.

“Severe psychological pressure, instability, constant fear—all this is driving an increase in mental illnesses,” says Dr. Mohammad Sato, a psychiatrist who runs an emergency clinic in northern Idlib province. Sato is one of an estimated 25 psychiatrists remaining in all of Syria.

‘Stigma’

Mohammad Qassem, a resident of Idlib’s provincial capital city, has been struggling with suicidal thoughts since his wife and three children were killed by an airstrike that hit their house one year ago.

“I couldn’t get up or leave my room,” the 30-year-old says. He could not sleep without waking from nightmares, shouting his children’s names. “I tried to kill myself more than once.”

“I hated the whole world.”

After the fatal airstrike, Qassem did not return to his job at a medical supply shop for more than six months. When he finally went back to work, he found he could only do so “sporadically.”

“I’d work one day then go 10 days with no work because of the stress.” Whenever an airplane happened to fly above, “I’d start crying just from the sound,” he recalls. “I would scream and shake.”

“It was hard to go back to living a normal life,” he says.

Qassem’s brother noticed something was wrong, and tried taking him to a local doctor for help several months after the deaths of his wife and children. Qassem refused to go.

“I wasn’t crazy enough to go to a psychiatrist,” he says, adding he fears the social stigma of seeking treatment for mental illness. “If I go see a doctor, that means I’m crazy.”

Mental health treatment remains a social taboo in much of conservative, rural Idlib province. In some cases, says Idlib psychiatrist Dr. Sato, patients in dire need of treatment instead seek help from religious sheikhs or traditional healers, for fear of social backlash.

“There is a stigma that is levelled at people who visit psychiatric clinics,” says Sato.

“That’s just our society,” says 12-year-old Abdulkareem’s mother Naji. “No one can accept the idea that it is a mental illness that’s affecting him.”

‘What to do’

Facing increased need, Idlib health officials and international organizations are ramping up efforts to train local doctors in psychiatry. The UN’s World Health Organization earlier this year held remote training sessions for more than two dozen Idlib doctors, who are now certified to provide psychological therapy and prescribe some medicines, provincial health director Dr. Khalil says.

In the northern Idlib town of Sarmada, roughly 10km east of the Turkish border, one international NGO is now running the province’s first public inpatient clinic for emergency mental health treatment.

The clinic’s patients include people who have attempted suicide, suffer from schizophrenia or have other “acute” mental health needs, Dr. Redwan El-Khayat, the head of mental health for the Swiss-based NGO Union of Medical Care and Relief Organizations (UOSSM), which supports the clinic. The group also funds four “mobile clinics” for outpatient care in surrounding towns, El-Khayat says.

The Sarmada clinic and more than one dozen other, smaller, UOSSM-backed mental health centers in Idlib have “benefited” nearly 3,000 patients so far, says Sato, who serves as the Sarmada unit’s director.

But not all those who could benefit from UOSSM-backed services are even aware they exist.

In Khan Sheikhoun, nearly 100km south of the Sarmada clinic, Naji was surprised to hear from a reporter this month that an inpatient clinic that could treat her 12-year-old son existed.

Even so, the Sarmada clinic is a 90km trip north of Naji’s home in Khan Sheikhoun through rebel territory—a journey, she says, that scares her as a single woman with no car. “I don’t know anybody in Sarmada,” she says. “I’d have to go there and return home all in the same day.”

In the meantime, all Naji feels she can do is continue giving Abdulkareem sedatives and hope his peers will “understand” his mental illness. Most days, she simply watches as he sits alone in his bedroom, silent.

“I no longer know what to do,” she says.