A grey cloud of misfortune: The mental health crisis erupting in Syria's northwest

Dr Ahmad Boukai finally feels safe, nine weeks after a terrifying streak of earthquakes hit northwest Syria and Turkey.

They were quickly labelled the worst natural disasters that the region — which sits on the Anatolian and the Arabian tectonic plates — had seen in over 100 years, and caused widespread destruction and mass casualties.

But for Dr Ahmad, along with 4.5 million Syrians living in the northwest rebel-held territory, February’s earthquakes were just the latest psychological trauma in a long series of suffering during 12 years of conflict, in what aid agencies have described as one of the world’s most complex humanitarian and protection crises.

“[During the war] we lived to see houses collapsing on the heads of residents and people dying every day, but it was nothing compared to this disaster,” Dr Ahmad told The New Arab over the phone from Idlib where he works as a psychiatrist at Save-a-Soul hospital. “Dealing with the war on a daily basis was easier than the consequences of the earthquake.”

"People might start to heal when safety is guaranteed. But until they are provided with a safe environment, all psychological support, therapy, and medicine will not help"

For over a month after the earthquakes, Dr Ahmad, his wife and his young daughter, joined thousands of other families living in tents on the plains on the city’s outskirts, even though his house was undamaged. 

He alternated between sleeping in the tent or in the hospital during long shifts, worried for his family’s safety and finding it difficult to reassure patients that there would not be another earthquake.

“The lack of safety and the constant feeling of fear affected both the medical staff and the people,” he said.

The February 6 earthquakes of 7.7 and 7.5 magnitudes were compounded by another major earthquake two weeks later and thousands of aftershocks in between, rattling survivors. The prolonged anxiety created an unprecedented need for emergency psychological support.

“For the second earthquake on February 20, the psychological impact was greater,” Dr Ahmad explained. “To the extent that people were throwing themselves out of balconies and there were also a lot of mental breakdowns, panic attacks and some cases of heart attacks, and PTSD [post-traumatic stress disorder].”

More than 10.9 million people in the governorates of Hama, Latakia, Idlib, Aleppo and Tartus were impacted by the earthquakes, the UN Resident Coordinator for Syria told journalists in the days following the disaster. 

The earthquake centred in southern Turkey and reverberated across the Levant region — felt as far away as Egypt. Over 4,500 deaths and 10,400 injuries occurred in northwest Syria, according to the United Nations Office for the Coordination of Humanitarian Affairs.

Among those injuries are a myriad of mental health disorders. 

“After the earthquake, there were a lot of new cases, like the case of mass loss; when almost an entire family dies,” Dr Ahmad explained. “There was also something called ‘flashbacks’ due to the earthquake or the footage of people under the rubble.” 

He also treated people with phobias of noises or who were afraid to be under a roof.

Many of the men, women and children living in the region have not lived in a house for years, having been displaced multiple times.

Dr Ahmad and his family fled to Idlib from their home in the Eastern Ghouta region in 2018, when the Syrian Armed Forces carried out a chemical weapons attack there.

“I would say that people might start to heal when safety is guaranteed. But until they are provided with a safe environment, all psychological support, therapy, and medicine will not help,” he said.

"The growing hardships come against a backdrop of shortfalls in the wider health system alongside dwindling funding for Syria. The political complexities of the civil war have hindered aid access; for years, one border crossing from Turkey was the only entry point"

Ninety-seven percent of the population in northwest Syria live in extreme poverty, and the UN warned at the end of last year that the situation was expected to deteriorate further — and that was before the earthquakes struck.

The population is dependent on hand-to-mouth assistance from UN agencies and other aid groups. One such organisation is ActionAid, which has been working in the region offering psychological and social support to women and girls, a group which they say is paying the highest price from 12 years of conflict.

“The mental health of the people is deteriorating,” Racha Nasreddine, the Arab region director for ActionAid, told The New Arab. “People are traumatised, they have nervous breakdowns, especially women and young people.” 

What Racha calls “psychological first aid” was deployed by ActionAid and their local partner, Violet, following the earthquakes. “It is a response done when a disaster hits; it is more about finding safe spaces for women, stabilising the situation, [creating] safe spaces for them to interact with social workers.”

Today, women are under added strain since it has become common for them to be house custodians — contrary to Syrian custom — as husbands, sons, or brothers have died in combat. There is also a social stigma attached to divorced, widowed or single women, Racha says, which is increasing their vulnerability.

ActionAid’s concerns come in tandem with other reports from humanitarian organisations, including from the International Rescue Committee, which also sound the alarm over the dire situation for women and girls in Syria.

Repeated cases of gender-based violence, and systemic misogyny, alongside a worrying rise in child marriage, have been recorded.

A report from World Vision International in December showed a startling number of suicides and attempted suicides. Girls under 18 made up the largest group of total recorded deaths by suicide between early 2021 and mid-2022.

The report noted that “continuous instability, recurring displacements, poor living conditions and ongoing economic struggles” were seeing a rapid deterioration in mental health for a population “stuck in limbo”.

The growing hardships come against a backdrop of shortfalls in the wider health system alongside dwindling funding for Syria.

The political complexities of the civil war have hindered aid access; for years, one border crossing from Turkey was the only entry point. 

However, this changed when two further border points were reopened in February after President Bashar al-Assad agreed to allow entry for aid convoys. Although this was welcomed, the three-month time limit means aid agencies are struggling to plan beyond short-term needs of food, shelter and support, Racha explained. 

Any implementation of a long-term recovery plan which could see infrastructure rehabilitation and job creation to bring stability and independence for impacted Syrians remains far off, Racha added.

"The scale of the humanitarian need means that there is a huge need for a basic needs response, and [so] you can't really find time to think of a longer term. Already a lot of people were living in tents and camps and now there are more, already a lot of people lost lives, and now there are a lot more."

Rosabel Crean is a freelance journalist based in Beirut, Lebanon.

Follow her on Twitter: @CreanRosabel