I am on my way leaving Northwest Syria into Turkey via the only border crossing, Bab al-Hawa, which remains open for UN humanitarian access into Syria.
We are just finishing a medical field visit organized by the Qatar Red Crescent Society (QRCS) in response to the massive Turkey-Syria earthquake on the early morning of the 6th of February 2023, with a magnitude of 7.9 on the Richter scale. The earthquake has killed more the 40.000, and injured hundreds of thousands, and made many of those homeless.
Unfortunately, there was a long delay of any aid into Syria (1), and only Qatar, Saudi Arabia, and Iraqi Kurdistan initially sent aid to northwest Syria. Instead of essential aid getting into Syria, the first few days after the main earthquake, only dead bodies of Syrian victims were transported to be buried in Syria, and a few days later, only a pre-planned UN humanitarian convoy carrying non-earthquake supplies arrived. What was available to the people are only the 2500 volunteers of the Syria Civil Defence “White Helmets” who were working on the major some 60 affected sites soon after the earthquake.(2)
This earthquake has hit the Syrians badly on the top of more than twelve years of atrocities of the Syrian regime, the Iranian and Russian forces, since the uprising 2011,with hundreds of thousands killed, and millions displaced.
There are some 4·5 million people, half of them have been forcibly displaced from other areas inside Syria(3).They live in a small area which is outside the control of the Syrian regime, and who have already endured 12 years of violence and atrocities by the Syrian regime in Damascus. The millions who live in Northwest Syrian, not only lacking essential needs, but the earthquake brought further suffering to the people who also have been under regular attacks by the Syrian, Iranian and Russian armies and militias.
The Health System:
The health system is unable to meet the increasingly complex physical and psychological needs of the population and is largely dependent on international assistance, and we should remember that the health system that has been severely weakened by almost 12 years of deliberate attacks by the Syrian regime, with very limited resources. (4, 5) and the earthquake-caused full or partial damage to 55 health facilities. (3)
That is why there should be international pressure on the Syrian regime to release the more than 3360 forcibly disappeared health workers, which are claimed mostly by the Syrian regime, some of them are specialised mental health workers, including the Syrian/American Majd Kamalmaz, a psychotherapist who has specialised in trauma related mental health, and who has been unlawfully held by the Syrian government since 15/2/2017 (6). There is no indication that the Syrian regime will stop the attacks on Northwest Syria, and this no doubt will increase the burden of disabilities and worsen the situation for both communicable and non communicable diseases to which a weakened health system cannot respond to. (7, 8)
Mental Health Services:
From my visit to several cities in Northwest Syria few days after the earthquake, like Idlib, Adana, Maree’, Iazaz and Al-Bab, we have found that there are only two psychiatrists and three psychiatric trainees who are serving the whole population of 4.5 million people! Their three trainees are due to finish their training in a couple of months, although they feel that their training was not adequate, and that they need further training with proper supervision. When I meet two of them at Idleb’s Health Authority Center, they informed me that they have stopped working in their psychiatric hospital’in patient unit in Sarmada, because the fund to run the unit was stopped early this year! I visited the psychiatric hospital in Izaz city, it has no psychiatrists on duty, but occasionally they would have a visiting psychiatrist, who is one of the only two in the province. Some medications are available in this hospital but there is a shortage of neuroleptics and antidepressants.
I have met several psychology groups in various cities, but none of them in the whole Northwest region are properly trained in Cognitive Behavioral Therapy (CBT) or Eye Movement Desensitisation and Reprocessing (EMDR), both well-known effective treatments for trauma related psychiatric complications like PTSD, depression, and others.
There is a widespread addiction problem to captagon, crystals, cannabis and others, which have been highlighted by various reports, but not a single expert in addiction treatment or proper facility for recovery(9).
Learning disability and child psychiatry disorders like Autistic Spectrum Disorders (ASD) and ADHD are other areas which are neglected. Of course these disorders aren’t regarded now as child psychiatric disorders in both DSM-5 and ICD-11. They are described as neurodevelopmental disorders, a term that would also include learning disability. Many families with affected children and teenagers have no one to turn to.
Psychiatric care of the elderly is non-existent, although families still try their best to take care of their elders. It is not surprising that the long delay in aid and the earthquake’s effects will undermine the resilience of the individual and the community.
It is too early to identify the psychological consequences of the earthquake, although it is expected that the disaster will leave a major mark on mental health. Already many survivors have anxiety, stress, and fear of further aftershocks. Many people are on the streets afraid of going back into their homes. Children in particular are terrified, restless with bedwetting.
It is expected that many survivals will suffer from psychological consequences of the earthquake. Earlier study investigated a sample of 121 survivors found that almost 80% of the victims acknowledged a strong overall impact of the earthquake on their lives even 50 years later, and almost all of them suffered intense recollection of the event at its anniversary. Young adults (17-25 years), as well as women, were the most vulnerable groups for the development of emotional problems. (10)
To minimise the suffering and build-in the resilience of the community an urgent package of help is needed to provide much needed physical and psychological support to affected survivals and injured. I call upon the WHO EMRO, Royal College of Psychiatrists and other mental health organisations to reach out their help and support to the people of Northwest Syria. This requires a lot of coordination and collaboration, and already some groups are trying to offer some assistance including the Syrian Association for Mental Health(SAMH) which is a voluntary group based in Turkey, although it has very limited resources. (11) These agencies should offer proper training in cultural safety, even in the form of online-distance learning, situational preparation, and support mental health workers with their personnel need. If it is possible to do direct face-to-face training, thenpractical matters like safe transport and housing and how safety could be protected warrant consideration.
In the face of a population burden of this magnitude it is not likely that specialist mental health services will be sufficient to meet needs. It would be helpful to acknowledge that in this context other responses will be needed, perhaps task shifting, non-health sector responses or use of online or brief psychoeducational approaches.
- The catastrophic response to the earthquake in Syria:
the need for corrective actions and accountability
- www.thelancet.com,Published online March 6,
- Syria Civil Defense. White helmets situation reports.
situation-report-9135797 (accessed Feb 20, 2023).
- UN-OCHA. Earthquakes: north
update number 12 as of Feb 19, 2023.https://reliefweb.int/report/syrian earthquakes-north-west-syria-flash-update
february-2023 (accessed Feb 20, 2023).
- Abbara A, Marzouk M, Mkhallalati H. Health system
fragmentation and the Syrian conflict. In: Bseiso J,
Hofman M, Whittall J, eds. Everybody’s war: the
politics of aid in the Syria crisis. Oxford: Oxford
University Press, 2021.
- Fouad FM, Sparrow A, Tarakji A, et al. Health
workers and the weaponisation of
Syria: a preliminary inquiry for
American University of Beirut Commission on Syria.
Lancet 2017; 390: 2516–26.
- Jabbour S, Leaning J, Nuwayhid I, et al. 10 years of
the Syrian conflict: a time to act and not merely to
remember. Lancet 2021; 397: 1245–48.
- Abbara A, Rayes D, Ekzayez A, et al.
internally displaced people in Syria: are current systems fit for purpose?
- ACAPS. Türkiye/Syria earthquake: overview of what
to watch over t
(accessed Feb 20, 2023).