AMMAN: In May 2014, Abu Mohammad was driving an ambulance as part of his volunteer work in his rebel-held hometown just east of Damascus city.
He was responding to an artillery strike, fired by Syrian pro-regime forces, that had just torn through a crowded local market. The incident was, in Abu Mohammad’s words, a “massacre.”
As Abu Mohammad began driving the wounded away from the now-destroyed marketplace, another shell hit—this time “directly” hitting his ambulance and tearing through his left leg. Doctors at the hospital couldn’t save his leg, Abu Mohammad tells Syria Direct from his home in Kafr Batna, a bombed-out northeastern suburb of Damascus under rebel control.
His leg was amputated above the knee.
It was only after Abu Mohammad began to recover from his injury that “my tragedy began,” the 28-year-old says. Without his left leg, Abu Mohammad could no longer drive ambulances, a job that gave meaning to his life under siege. He quickly sank into a deep depression.
“I was always aggressive, and shouting at my wife,” Abu Mohammad recalls about the days following his injury. He grew addicted to painkillers. At his darkest point, he attempted suicide in his kitchen.
Then, weeks into Abu Mohammad’s recovery from both his amputation and suicide attempt, a regime airstrike hit his house while he was out visiting relatives, killing his wife and infant son. Their deaths left him in total despair, he says. “I lived many days in isolation, not wanting to see or visit anybody.”
Abu Mohammad and another depression patient interviewed asked not to be identified by their full names, due to the stigma associated with depression and other mental illnesses in East Ghouta.
“I saw everything around me and everything in my life as black—I couldn’t even bear to smile,” Abu Mohammad recalls of his own struggle with depression. “I felt that death was the only solution, to be rid of the reality I was living in.”
Douma in East Ghouta, Feb. 2016. Sameer Al-Doumy/AFP.
East Ghouta, the collection of eastern Damascus suburbs where Abu Mohammad lives, has been held under siege for four years by the Syrian government. In recent months, that encirclement has only worsened, with the closure of a key trade crossing into the enclave and the loss of a network of smuggling tunnels that once brought food and other supplies to Ghouta’s estimated 400,000 residents.
Despite East Ghouta’s formal inclusion within an international ceasefire agreement, regime airstrikes and artillery fire regularly rain down on its towns. Last month, photos began to emerge from the enclave of young children suffering—and dying—of malnutrition and secondary illnesses as the siege remains airtight.
Speaking at a press conference in Geneva late last month, UN High Commissioner for Human Rights Zeid Ra’ad Al Hussein said conditions within the besieged enclave constituted nothing less than a “humanitarian emergency.”
Years of violence and deprivation have taken a heavy psychological toll on East Ghoutans, residents and doctors tell Syria Direct. “With everything that Ghouta is suffering—bombs, siege, death and destruction—there are many cases like my own,” says Abu Mohammad, one of dozens of patients to receive therapy from a doctor living abroad.
It is difficult to pinpoint exactly how many of East Ghouta’s hundreds of thousands of residents are battling mental scars of the war and siege, including depression, anxiety and post-traumatic stress disorder (PTSD). Only one licensed psychiatrist works within the rebel-held pocket—and even then, a web of intra-rebel territorial disputes makes him inaccessible to thousands of East Ghoutans.
“We’re facing a huge problem,” says Dr. Ghazwan al-Hakeem, East Ghouta’s sole psychiatrist, who lives and practices in the city of Douma, in the encircled enclave’s north. He couldn’t provide an exact estimate of the number of Ghoutans facing depression and other psychological ailments, though he told Syria Direct he now treats around 200 cases per month in Douma alone.
The stigma surrounding depression and other psychological ailments in Ghouta’s relatively conservative society may prevent hundreds of others from seeking, or even considering, treatment, the doctor tells Syria Direct.
“Most people here who suffer from psychological issues don’t even consult with a psychologist,” al-Hakeem says.
Because psychological injuries are less apparent than the physical trauma featured in dozens of videos and photos shared weekly from East Ghouta—the victims of airstrikes, indiscriminate artillery fire, malnutrition—mental suffering is nursed silently, sometimes in secret.
The patients who do manage to reach Dr. al-Hakeem and other, non-specialist doctors, however, are deeply scarred by life within one of Syria’s most tightly besieged pockets of territory, al-Hakeem tells Syria Direct. “They face fear, stress, confusion,” he says of his patients in Douma. “They can’t sleep.”
“They fear for the future.”
Mental health crisis under siege
The fertile, rural eastern suburbs of Damascus once fed the capital city and its outskirts with fresh produce, dairy and meat. There, farmers kept thousands of cattle, sheep and chickens.
But today, Ghouta is starving. In some parts of the enclave, almost entire neighborhoods are flattened by Syrian regime airstrikes and artillery fire. But it is not the only area to undergo such suffering over the course of the war.
Madaya, a small town 30 kilometers northwest of Damascus city outside of Ghouta, remained under airtight Syrian regime siege from July 2015 until regime forces retook the former mountain resort town this past April. Over the course of the siege, Madaya’s estimated 40,000 residents were cut off from food and basic medical supplies. Pro-regime snipers and landmines encircling the town prevented anyone from getting out. At least three residents died of kidney failure, one of the town’s only medical professionals told Syria Direct in February. They were unable to receive proper nutrients and barred from undergoing kidney dialysis outside of the encircled enclave.
Over the course of the two-year siege, Madaya saw at least 13 people attempt suicide, “compared with almost no cases” before the Syrian regime imposed an airtight siege on the community in July 2015, according to a September 2016 Save the Children report.
Among the 13 attempting suicides were six children—the youngest just 12 years old, according to the report.
One Madaya father told Syria Direct last September how his 12-year-old son Mohammad tried to kill himself by jumping off the roof of their home. The boy survived after a week-long coma, but his father remained worried that the regime’s punishing siege of their hometown had “transformed my son into another person.”
“He lost everything he loved to the siege,” his father said.
Some 160 kilometers north of Madaya, in a rural, rebel-held pocket of towns north of Homs city, an ongoing siege there reportedly led another 12-year-old boy to attempt suicide during a severe water cutoff this past January.
The boy “swallowed an entire bottle of pills,” his mother told Syria Direct at the time. “When he regained consciousness, he told me he would try to kill himself again,” she said. “He said next time we shouldn’t bother saving him.”
Only 70 formally trained, licensed psychiatrists were available for some 21 million Syrians even before the war, according to the World Health Organization. But seven years of war have driven an unknown number of them out of the country and all but shut down their practices, leaving Syrians trapped inside the country’s besieged zones ill-equipped to cope with psychological trauma.
For Dr. Manal al-Fahham, a Damascus-born neurologist living in the United Arab Emirates since before the war, the lack of psychologists inside Syria—and East Ghouta in particular—constitutes a medical crisis.
Al-Fahham, who has a secondary specialization in psychology, runs online therapy sessions for people inside Syria battling depression, PTSD and other psychological disorders. She began the sessions—which take place via Skype—in 2011, when the Syrian revolution first broke out.
Aftermath of an airstrike in Douma, Nov. 2. Hamza Al-Ajweh/Getty Images/AFP.
“I got started with Ghouta through a friend of mine, a doctor,” al-Fahham says. “He connected me with doctors and patients [on the ground].”
At the time, the now-54-year-old found that “there weren’t any civilian organizations” to properly cope with what she predicted would become a major mental health crisis in her home country.
Al-Fahham has since worked to fill that gap, she says, all while maintaining a neurology practice in the UAE. “I’ve treated everything from bipolar disorder—which is often hereditary, but can manifest itself in crisis situations—to anxiety and panic attacks,” al-Fahham tells Syria Direct. She’s had “many” patients attempt suicide, she says, even in relatively conservative East Ghouta, where suicide is viewed as a sin. After referrals from doctors on the ground in Ghouta, she reaches out to her patients for consultations via Skype.
Among al-Fahham’s patients in East Ghouta is 47-year-old Umm Mohammad, a mother of five who lives in the town of Saqba. That town, located in the southwestern reaches of East Ghouta, is currently undergoing heavy regime airstrikes and artillery fire.
Umm Mohammad’s troubles began in 2012 when her oldest son, a regime conscript, defected from the army—a move that put his life in danger. He later joined rebel forces in the besieged pocket of East Aleppo before the city was recaptured by government forces in a devastating final battle in December 2016.
Umm Mohammad’s son survived and now lives more than 200 kilometers north of her, in rebel-held Idlib province. “I haven’t seen him since the beginning of the revolution,” she tells Syria Direct from her home in Saqba, where she lives with her two youngest children.
The mother lives in constant fear for her son in Idlib and for another son—her eldest—who is living in Turkey after being injured while fighting for the Free Syrian Army (FSA).
Her “suffering,” Umm Mohammad says, reached a climax this past May, when she went through what she describes as a “stroke.” During treatment at a local charity-run hospital, she was diagnosed with depression. The feelings of loss, poverty under siege, and living “scattered” from her sons “invaded me,” Umm Mohammad recalls.
Dr. Ahmad al-Baqaai, director of the East Ghouta hospital where Umm Mohammad received treatment, confirms the diagnosis. The 47-year-old mother “couldn’t sleep or focus on what people [around her] were saying,” al-Baqaai says. “She was constantly hallucinating, always thinking about the siege, and the difficulty of obtaining daily necessities.”
So al-Baqaai referred Umm Mohammad to al-Fahham in the UAE. The two women talked over Skype, al-Fahham asked about her symptoms and prescribed antidepressants, Umm Mohammad says. She continues to receive treatment via Skype.
Still, says Umm Mohammad, depending on a doctor some 2,000 kilometers away has its difficulties. Her medicine is nearly impossible to find amid the siege over East Ghouta, and internet access often shuts down completely, cutting off their Skype sessions.
“Personally, I feel a lot of pressure,” says al-Fahham, “because I am unable to work on the ground inside [Ghouta] to observe and treat people, despite knowing what is happening to them there.”
‘There are things worth staying alive for’
For Abu Mohammad, who also underwent daily therapy sessions with al-Fahham for two months, treatment came at a particularly dark period in the months following the loss of his wife and child three years ago.
“Depression—it’s a feeling that makes you despise life,” he recalls. “The thing I would think about most when I was depressed was death. I longed for it incessantly.”
When he did attempt suicide several weeks after his injury, in his kitchen, he came dangerously close to death. “I was passed out,” he says of the incident.
Fortunately, Abu Mohammad’s wife later found him and took him to the hospital, where he regained consciousness. Just weeks later, she and their infant son were killed in the airstrike on their house. Doctors later referred Abu Mohammad to al-Fahham.
So how does al-Fahham, speaking via Skype across international borders and thousands of kilometers, convince patients like Abu Mohammad, trapped with the psychological wounds of one of Syria’s worst sieges, to keep going?
For some, al-Fahham says, the goal is simply to relax. “We try to talk about topics that don’t have any connection to anything the patient is going through—about nice things, so they know that there are things still worth staying alive for.”
“I often suggest the idea to them of going somewhere away from where they are,” al-Fahham says. “ I tell the patient to go to an empty room and stand by the window. Contemplate the beauty of nature.”
Abu Mohammad says his mental health has improved since his suicide attempt and the loss of his wife and son two years ago, that through therapy sessions he found some renewed hope in the small, tangible joys he can still find under the siege. He finds solace in nature, he says, and in playing with children and spending time with his second wife, whom he married after recovering from depression.
And yet, though he says he has “emerged” from his depression and recovered from his painkiller addiction, the reality of the worsening siege on his hometown simply has not disappeared.
“I lost every glimmer of hope,” Abu Mohammad says, “of getting out of the general situation I’m living in, of having a normal life.”
“I’ve realized that everyone in Ghouta who's suffered through years of siege, hunger, killing and destruction needs mental health treatment as soon as this war ends.”
With additional reporting by Ammar Hamou.