During wars, stressful situations and traumatic events are multiple and perceived differently by the population. As a result, psychological and psychiatric effects depend on the degree of trauma (physical or psychological), duration and repetition of the exposure, individual vulnerability – women and children being the most vulnerable -, ability to develop coping strategies, and availability of immediate psychological assistance.
Since its beginning in March 2011, the Syrian conflict has led to the biggest humanitarian crisis and exodus since World War II, with more than 220,000 killed, and over half of the population (23 million) in need of assistance.
Latest UNHCR updates regarding Syrian refugees and asylum seekers fleeing the violence (as of September 4, 2015) confirm, once again, the disastrous situation:
i) More than 11 million displaced
ii) Including 7,6 million displaced internally
iii) Four million refugees in neighboring countries: Lebanon (1,172,753), Jordan (629,245), Iraq (249,726), Turkey (1,938,999) and Egypt (132,375)
iv) A total of 16 million needing assistance inside and outside Syria
v) More than half of refugees are children under the age of 18
Add to that, the sudden rise, starting summer 2015, of the number of migrants fleeing to Europe, and to Germany in particular. Hundreds of thousands need to be relocated across the European Union.
While during wars, fighters experience traumatic events linked to injury and death, civilians go through a number of different stressful situations, including the fear of bombing, and the fear to be or to have a family member injured, killed, subject to sexual violence, torture…
Innocent Syrian civilians, not directly involved in war, are also suffering from:
i) Financial issues
ii) Restriction to the right to work and to education
iii) Restricted access to vital resources such as water, food, sanitation, shelters (or being confined to one’s home), access to health care
iv) The stress of the journey to safer places and the risks it ensues
v) The stress of moving to other areas within Syria, or other countries, with a different culture and the prospect of difficult integration.
If fighters are coping with Acute Stress Disorder and fear by consuming Captagon (amphetamine-like made in Syria), civilians, as it is the habit in developing countries, are adopting religious and coping strategies, particularly when immediate psychological assistance and physical and emotional support is lacking. Also, the prevalence of smokers among male refugees appears to be very high, a consequence of stressful situations, alcohol being religiously forbidden for Muslims, in addition to Captagon use which is becoming more frequent among refugees.
However, both fighters and civilians are at risk of developing Post-Traumatic Stress Disorder (PTSD), (including children less than six years old), a delayed consequence of exposition to traumatic events (up until three years), in addition to other psychiatric diseases such as depression, anxiety, psychosomatic (insomnia, back pain…), development of risky habits (alcohol, drug abuse, violence…), and suicide.
A study conducted by El-Khatib and al. and published in 2013 in “Conflict and Health”, has shown that 11% of diseases diagnosed among Syrian refugees in Lebanon were mental diseases.
A more recent paper, published in 2015 (International Journal of Social Psychiatry 2015, Vol. 61(1) 33–38), explored the consequences of war and their impacts on mental health, with a special attention to the Mediterranean region and stated that the frequency of PTSD among adults in two refugee camps within Syria, varied between 36,3% and 61,9% and the prevalence of PTSD among children was higher than among adults, varying between 41,3% and 76,4%. Those findings correlated with data of earlier studies among Lebanese and Palestinian populations, with psychological and psychiatric consequences lasting even 20 years after the end of the conflict.
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If the scars of war on physical health are evident, they are less so and also less predictable on psychological health, because it may not be expressed by the patient fearing stigmatization, and because it may happen long after being exposed to trauma, thus affecting the community for many years to come.
Furthermore, despite the prevalence and negative impacts of mental disorders, many affected people are not diagnosed or do not receive adequate treatment; this is particularly true for the Syrian population, and we can already anticipate the long-term consequences that the conflict and migration could have on them: we recommend close surveillance in the coming period.
Mental health consequences on individuals, family, community or country, can be disastrous:
i) Decrease in quality of life (unhygienic and inhuman living conditions…)
ii) Increased prevalence of health diseases (diabetes, coronary diseases…)
iii) Increased prevalence of risky habits (tobacco smoking, alcohol and drug abuse, gambling, sexual addiction…)
iv) Alteration of social and public life and social integration (vulnerable and often excluded group)
v) Violation of human, civil and political rights (right to work, to education, to vote; right to receive optimal health treatment, sexual abuse, prostitution…)
vi) Increased health expenses
vii) Decrease in productivity
viii) Increased poverty
ix) Increased suicide rate
x) Increased violence and criminality
If approximately 25% of people can be expected to be affected by a mental disorder at some stage in their life, 40 to 70% will be affected in case of exposure to war trauma, many of them left undiagnosed or without adequate treatment, leaving negative impacts at various levels. Furthermore, in case of asylum seekers and refugees in foreign countries with a different culture and language, the lack of communication represents a barrier to optimal psychological assistance.
This is particularly true with the Syrian conflict whose impact on health in general, will not only be felt at the national or regional levels. The globalization of Syrian migration will lead to emerging public health issues for host communities, which calls for a follow-up of the living conditions of both refugees and host communities.
The lack of attention to this public health issue will be a future barrier to a global sustainable development. This is particularly true for developing countries in the Middle East that went through decades of wars and violence. The lack of national mental health policies and resources in these countries limit the enrollment in any global strategy addressing mental health issues, and the capacity to change discriminating attitudes towards people suffering from such cases.