The Middle East's mental health crisis

While my focus has been more on recent research findings in neuroscience, after my harrowing recent conversations with colleagues providing medical assistance in the Middle East, I have felt it necessary to write a piece delving into mental health in that region. 

Amidst the COVID-19 pandemic and ongoing reckoning with racial injustice, one thing has not changed: the fact that armed conflict and instability continue to hang like an unrelenting cloud over the Middle East. This has had an impact not only on infrastructure, physical health, and survival, but also on the mental health of those who are fortunate enough to survive (or unfortunate to have to live through) the unending war and conflict, and resulting devastation. 

Armed conflicts have a devastating impact on the mental health of affected populations. Post‐traumatic stress disorder (PTSD) and depression are the most common mental disorders in the aftermath of war for both adults and children, occurring in at least one-third of people directly exposed to traumatic war experiences. 

PTSD among Syrian refugee children has been so severe and unprecedented in magnitude, that it has escalated to the point where some mental health professionals have coined a new term for these particular cases of trauma: “human devastation syndrome." Dr. M.K. Hamza, a Syrian neuropsychologist, uses this term as it aptly reflects the fact that the children’s devastation “is above and beyond what even soldiers are able to see in the war," including “seeing dismantled human beings that used to be their parents, or their siblings”. 

A 2018 Save the Children survey in Iraq found that “43 percent of children in the city of Mosul reported feeling grief always or a lot of the time”. In the Gaza Strip, 91% of children have now been found to suffer from PTSD. Moreover, nearly 97.5% of similar adolescents who experienced war have displayed severe anxiety levels. 

A 2007 survey of Palestinian schoolchildren found that 80% of children witnessed shootings firsthand, with 10% exhibiting a depressive-like state, and 14.1% exhibiting emotional difficulties. Psychiatric patient admittances in Gaza have increased by 69% within the last few years, with increases in reported anxiety, depression, and suicidal thoughts and behaviors. Independent journalist Harry Fear delves into the situation there in a recent documentary after visiting the enclave. 

Despite the widespread nature of anxiety, depression, and PTSD, much of the responsibility for remedying these emotional and psychological impacts have fallen to non-governmental organisations such as Médecins Sans Frontières (MSF — Doctors Without Borders), which has provided welfare and support to many Iraqis with mental health ailments. MSF advises that there are currently only 4 psychiatrists for every 1 million residents in Iraq, and even fewer professionals are trained in related mental health professions such as psychological counseling. As things stand, there are only four professionals currently looking after Syrian refugees in Iraq who must grapple with carrying out 70 to 100 counseling sessions per week with these individuals. 

Similarly, in Jordan, a country now hosting nearly 700,000 refugees, there are a total of 31 psychiatrists for the whole country, which is largely composed of refugees from Palestine, Iraq, and Syria. Lebanon and Turkey also have inordinate numbers of Syrian refugees who have fled the devastation within their own country. Unfortunately, most psychiatric professionals are strictly hospital-based and provide mainly biological care leaving no mental health professionals to address PTSD in these populations. 

Add to that the situation in Yemen, home to the worst humanitarian crisis on earth, where hundreds of thousands have been killed, with millions suffering from malnutrition and preventable diseases such as cholera. It has been difficult to quantify and evaluate mental health there, but it is clear that the situation is especially dire. When you have children witnessing the deaths of their family members, or witnessing their loved ones withering away from starvation in front of their own eyes, it takes a massive psychological toll. 

Moreover, there has been a shortage of psychiatric specialists in Yemen since the start of the Saudi-led intervention. In January 2016, the WHO estimated that there were 40 psychiatric specialists in Yemen, most of whom were based in the capital, Sana’a. In December 2016, the director of the mental health program at the Ministry of Health suggested there were just 36 psychiatric specialists. Mental health is not integrated into the primary health care system, and many Yemenis are unable to access treatment when they first make contact with the healthcare system. 

Mental health in the COVID-19 era 

On top of the devastation and mental health crisis, these populations have had to contend with the COVID-19 pandemic as well. In their dire state, to have to grapple with this condition only adds to the mental health catastrophe that they face. 

Since the pandemic and national lockdowns, the United Nations High Commissioner for Refugees (UNHCR) has documented alarming reports of increasing mental health issues among the many refugees in the Middle East and Northern Africa. In Lebanon, Libya, Yemen, and other countries in the Middle East, there have been spikes in suicide, domestic violence, insomnia, and depression. 

To the credit of the UNHCR, they have been implementing a number of approaches to address these mental health issues. They are utilizing and training personnel in Psychological First Aid (PFA), an evidence-based approach to intervene for individuals in the immediate aftermath of disaster and terrorism to prevent the development of PTSD. 

For instance, in Iraqi refugee camps, trained community workers have provided PFA to primary healthcare staff, NGO workers, and community outreach volunteers. Furthermore, the UNHCR has created hotlines to receive and respond to psychological issues. This is helping the situation, but more needs to be done to address the dearth of mental health professionals, as well as the root cause of the dire circumstances that have led to the resultant mental health catastrophe in the first place. 

Another endeavor that has made great strides in addressing the mental health of migrants and refugees from that region is The Humanity Crew. This organization, founded by psychiatrist, Dr. Essam Daod, a Palestinian resident of Israel, and his partner Maria Jammal, have been around since November 2015 and has been working to address the mental health concerns of a traumatized population fleeing destruction and persecution. Dr. Daod gave a brilliant TED talk that really shows how crucial and beneficial mental health intervention can be, particularly for a juvenile population marred by psychological trauma. 

Why this matters, and what we can do 

The cruel fact of the matter is that U.S. and Western foreign policy and military intervention have contributed greatly to, as well as exacerbated further, the current situation in that region of the world. To quote the late, award-winning former Beirut-based journalist, Robert Fisk of The Independent, “We always arrive with our tanks and our helicopters and our [armored] personnel carriers, and our soldiers, instead of arriving with our teachers, our educators, our doctors, and our social carers.” 

From my position, I would like to emphasize doctors, and add on professionals from all spheres of health care, including mental health. As a physician-in-training, a contributor to this website, and as an everyday citizen in touch with close friends living in that region who also serve in health care, my role here is to really present the numbers, some (but, by no means, all) of the details, and put the story across of how that region in the world is faring from a mental health perspective. 

Numbers do not tell the whole story, but they do not lie either. It is easy to slight the human impact of war when it does not immediately impact you. Before you finish reading this, ask yourself: of all the hundreds of thousands to millions of fatalities and casualties in that region, can you name one of them? What I have mentioned here barely scratches the surface of how dire the situation really is. 

While citizen advocacy against detrimental military intervention should always be at the forefront, what we can do from a mental health perspective, in particular, is the following: I implore mental health professionals who contribute to this website, as well as everyday readers, to, at the very least, donate to these organizations, or even better, donate your time and efforts to volunteer and provide your assistance to those who need it. 

It is the very least we can do for a people who have had to contend with historical and present-day injustice, endless bloodshed, and instability, in no small feat because of our own leaders' policies towards the region, which is why we, as citizens, should bear some responsibility for allowing this situation to escalate to this point. 

There are certainly other humanitarian organizations helping with such efforts that I have not mentioned. They are out there; it's just for us to seek them out. It may be slightly more difficult in the era of COVID-19, but please, any form of contribution to such organizations like MSF, Humanity Crew, or the UNHCR will go a long way. It won’t necessarily address all of the mental health concerns in all locations, but it will certainly make a considerable difference for many. Millions of lives may benefit now and in the future. 

by Racheed M Mani

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