A Union of Medical Care and Relief Organizations (UOSSM) employee hangs a suicide awareness poster on the wall of a health center in Idlib province, northwestern Syria, 8/6/2022 (Syria Direct)
IDLIB — Maryam, a 24-year-old woman in Idlib province, died by suicide in early June. She had recently been married to a man 20 years her senior.
At first, the family believed that Maryam’s death was due to natural causes, but it later became clear that she killed herself. However, “they still deny that, and promote a story that she died due to eating vegetables sprayed with a highly toxic insecticide,” in an effort to avoid social stigma, according to Sumayya, a relative who asked not to be identified by her real name.
Maryam’s death was one of five cases of suicide since the beginning of June in areas controlled by Hayat Tahrir al-Sham (HTS) and opposition factions in northwestern Syria. In another recent case, a young man killed himself in his tent in the Qah camps north of Idlib on June 10.
The Syrian Response Coordination Group, a local humanitarian organization, documented 33 cases of suicide and attempted suicide in northwestern Syria from the beginning of 2022 to June 5. Of those, 26 cases led to death, including 10 women and nine children. Some 75 percent of the cases took place in areas with high poverty rates, according to the organization.
Many cases of suicide in northwestern Syria involve the ingestion of aluminum phosphide, a substance used as a pesticide and grain fumigant, and “there is no monitoring from the authorities to control its use,” said Muhammad Khalil, a doctor and internal medicine specialist who also conducts periodic sessions for mentally ill patients.
In March, Odai, a 28-year-old man living in Idlib province, survived a suicide attempt after his family was able to rescue him before he died. He underwent “two surgeries to remove bullets from my body,” he said, and still suffers from “abdominal scarring and intestinal problems.”
Odai regrets attempting to kill himself, and recalls “the scene of my children crying, and how they were frightened by it. My three kids rushed into the room, and my daughter held my hand while I was bleeding.”
He had been struggling with “accumulated debts, and my inability to provide for my children.” Despite his work in decor and painting, the cost of living was beyond his ability, and he felt helpless to fulfill his duty “towards my mother, who has lost her sight and needs paid medical care.”
Speaking to the phenomenon of suicide in northwestern Syria, Ahmad al-Othman, the head of the Union of Medical Care and Relief Organizations (UOSSM)’s psychological support team, said “issues related to the cost of living and housing are among the most important reasons that could lead to psychological disorders and suicidal tendencies.”
In 2022, al-Othman’s team has worked with 12 people with suicidal tendencies in Idlib “due to severe depression and personality disorders,” he said. “People who are unable to pay the debts that have piled up on them tend towards suicide.”
Nadira al-Qasem, a psychosocial support worker with a civil society organization working in the northern Idlib Atma camps on the border with Turkey, said women may commit suicide “due to gender-based violence and family circumstances and problems, ranging from neglect and abuse to not providing [their] needs,” as well as “forced marriage,” as in the case of Maryam.
While women live “under restrictive customs and traditions,” the war has placed “new, additional responsibilities” on women, “making them in many cases the head of the family, which means responsibility for making money and managing the house, which creates additional pressures that they might not be able to bear, pushing some ultimately toward suicide,” she told Syria Direct.
More than 90 percent of Syria’s population currently lives below the poverty line. In northwestern Syria, 85 percent of people under the age of 35 are unemployed, according to a poll by the Syrian Response Coordination Group in February 2021. Some 50 percent of those over the age of 35 are also out of work.
Mohammad Hallaj, the director of the Syrian Response Coordination Group, expects unemployment rates in the region to increase, especially “with the economic crisis imposed by the Russian war on Ukraine, and the low level of individual income against high exchange rates,” he told Syria Direct.
Mental healthcare in Idlib
At the beginning of 2020, donor interest in psychological support projects noticeably increased, after previously focusing on “central projects to strengthen health sector governance in northwestern Syria,” a projects coordinator at a civil society organization in Idlib told Syria Direct. The coordinator asked not to be named due to their organizations’ unwillingness to speak to the media about psychological support projects.
Increased donor interest came “from the principle of the complementarity of services,” the coordinator said. Local organizations responded “to meet this interest, in order to increase funding opportunities.” But even so, psychological support services are still “not available to all Idlib residents.”
For organizations in northwestern Syria, “mental health services are not expensive, and are often less than three percent of the service facility’s monthly budget.” However, for services provided by specialized hospitals, “the cost is high,” he said. Only one hospital in the area—located in Sarmada, north of Idlib—specializes in mental and psychological illnesses, he added.
The mental health sector in northwestern Syria, where more than four million people live, half of whom are internally displaced, suffers from “a shortage of psychological specialists,” said al-Othman, from UOSSM.
Staff working in this sector receive “any patient who has attempted suicide or self-harm” and after a clinical evaluation “the supervisor of the active cases takes over direct and immediate supervision of those with active suicidal thoughts,” according to al-Othman. For people who are not actively suicidal, “psychological education is provided to strengthen protective factors and eliminate risk factors.”
Mental health workers in Idlib also organize “collective awareness-raising activities for the community to educate them on how to interact with individuals who have suicidal thoughts.”
In late April, a friend of Muhammad al-Idlibi, from Termanin village in the northern Idlib countryside, died by suicide. He was the fourth member of his family to do so in two years.
Al-Idlibi was present when his 30-year-old friend killed himself. He says he heard him “calling for me to save him, with his eyes closed, before he lost consciousness.” His friend died on the way to Bab al-Hawa hospital. “It was too late,” al-Idlibi said.
Two years ago, al-Idlibi’s friend’s father killed himself at a time when he was suffering “poor health and deteriorating family relationships.” His friend’s wife later died by suicide following “family disagreements and her husband’s neglect.” His brother also died by suicide “after a psychological trauma resulting from a large financial loss,” al-Idlibi said.
After the series of losses, al-Idlibi’s friend became “withdrawn,” he said. “He preferred not to leave the house, to avoid people’s hurtful words, shaming him about his wife, father and brother.”
According to Idlibi, his friend often heard comments such as “When is your turn? How many pills will you take?” His state worsened until “he seemed dead while he was alive,” al-Idlibi said.
Suicide goes against commonly held religious and social principles in Syrian society. As a result, relatives and friends of the victims may deny the reality of their loved one’s death, or refuse to mention their names in public or to the media. Some relatives seek “to escape from their [loved ones’] stories being brought up, in the hopes that time will cover them up,” as happened with Maryam’s family, which denies her suicide to this day, according to her relative Sumayya.
Some families may go as far as “refusing to hold condolence gatherings for them, or disowning the victim,” as in the case of the family of Fatima (a pseudonym), who died by suicide in the Atma camps in February “after her husband married a second wife and changed how he treated her,” her brother-in-law told Syria Direct.
UOSSM psychological support team head al-Othman said “those around the suicidal person feel shame, in addition to the feelings of sorrow and grief that overshadow them.” What frightens the relatives of suicide victims most is the “stigma,” he said, “against the background of their religious beliefs, customs, traditions and the community culture, which is what forces them not to accept the behavior, and to reject it.”
With difficult living conditions as one factor contributing to despair among northwestern Syria’s residents, al-Othman stressed that reducing the prevalence of suicide “may require some solutions at the level of the authorities, such as improving the living situation, securing job opportunities and controlling the price of basic goods.”
If you or someone you know is struggling with suicidal thoughts, the Union of Medical Care and Relief Organizations (UOSSM) operates a hotline for psychological consultations in northwestern Syria every day from 9AM-9PM, except for Thursdays: 00905468785540.
This report was originally published in Arabic and translated into English by Mateo Nelson.