A closer look at mental health crises within conflict zones
The jfa editorial board
Content warning: Discussion of violence, trauma, and mental health disorders
Currently, access to mental health services is a privilege. Many people who need these services do not receive them due to barriers such as language and stigma, but also systemic obstacles such as accessibility, discrimination, and even the absence of mental health care providers who understand the nuances of certain crises.
For people living in conflict zones, discussions tend to focus on the physical harms of conflict rather than the toll it takes on mental health. When these discussions do happen, they focus on raising awareness of the severity of widespread mental health needs, rather than addressing the importance of cultural competence and quality of care provided.
This year, World Mental Health Day emphasises access to mental health services for all, especially in relation to the effects of Covid-19 on mental wellbeing. The jfa's Communications Assistant Anna Luo brings readers an in-depth examination of the mental health crisis in Palestine under occupation and the impact of armed conflict on the mental wellbeing of Syrian people within the country and abroad.
Palestine’s mental health crisis
Decades of conflict, including the continued Israeli occupation of Palestine, has had long-term effects on the mental health of Palestinian residents in the region. This is in part due to arbitrary detentions, home demolitions, physical attacks, as well as a militarisation of living spaces due to heavy presence of the Israeli army. Long, drawn out legal battles over housing ownership and demolitions, as well as a fear of army raids, have placed a constant anxiety on homeowners and their families.
A study of stress among Palestinian women showed that “women living under military occupation tended to appraise their environment as highly threatening and their experiences as strain-producing”. Psychosomatic symptoms such as insomnia and trembling hands have been recorded in children and teenagers. Overall, approximately one-third of Palestinians have been reported to be in need of mental health services.
Mental health providers in Palestine are scarce in comparison to both the population and the number of people in need of services. In 2016, one study noted only 13 community mental health clinics in the West Bank and one psychiatric hospital in Bethlehem, while another found that there were only 17 community mental health nurses in the West Bank to service a population of nearly three million. In 2019, there were 32 psychiatrists in Palestine for a population of 4.8 million.
The health system itself in Palestine is in a transitional stage and is heavily affected by occupation and political conflict. There is no legislation that addresses mental health, and there is no budget allocated by the Ministry of Health that presides over the clinics and hospitals.
In the West Bank, mental health resources are provided by non-governmental organisations, like Médecins Sans Frontières. While these services can connect people with care, it also means that mental health services are dependent on external humanitarian aid, which can be underfunded, revoked, or withdrawn at any point. For example, the 2006 boycott of the Palestinian government by several countries resulted in a lack of economic support and aid, particularly for health services.
Stigma surrounding mental health disorders in Palestinian culture has contributed to a lack of acknowledgement to the source of mental health stressors, as patients tend to present emotional and psychological distress in the form of physical symptoms like headaches and back pain, meaning that mental illnesses go underreported.
In the recent Israeli air attacks on Gaza, 11 of the 66 children killed had been participants of the Norwegian Refugee Council’s trauma programme. Samah Jabr, chair of the mental health unit at the Palestinian Ministry of Health has stated that talking about post-traumatic stress disorder (PTSD) does not apply to the Palestinian context because there is no ‘post’ - the occupation is ongoing, the trauma is not over.
The impact of armed violence on the mental health of Syrian people
Since 2011, conflict in Syria has become the largest refugee displacement crisis of our time. As of the end of 2020, UNHCR recorded 6.7 million displaced people from Syria under their mandate - more than half of which are children.
Human rights abuses often occur on multiple levels and come from different parties. This can include state-sponsored violence or human traffickers, and have a rippling effect on people who experience them. Children, being a vulnerable population, are at a higher risk of additional exploitation amidst the conflict, such as forced labor among adolescent boys, human trafficking, and sexual violence. These compounding human rights abuses have a significant impact on refugees seeking asylum in other countries.
It has been documented that Syrian refugees continue to face mental health issues once they arrive in their countries of asylum. This cannot be solely tied to PTSD from the conflict they experienced, but also the circumstances in which they are hosted - such as bad living conditions in refugee camps.
Forced displacement is tied to the experience of grief; for the loss of one’s homeland, one’s identity, loved ones and community members, and even material belongings. There is no promise of stability once the journey is over - the long, drawn out impact of the crisis with “no end in sight” fuels feelings of helplessness.
As children make up a significant portion of displaced people from Syria, there are a number of studies that have documented their psychosomatic symptoms of emotional disorders. These symptoms include anxiety, insomnia, grief, depression, and withdrawal from social settings, hyperactivity, temper tantrums, and speech problems or mutism.
With so many children facing disruptions in their developments, international organisations have emphasised that providing mental health and psychosocial support is “a critical part of long-term recovery for Syria’s next generation”.
The Syrian health system has been heavily impacted by the conflict, including damage to medical infrastructure and loss of medical personnel. In 2014, only 1.5 hospital beds and 1.22 physicians were available for every 1,000 people. With few mental health professionals available, mental health services for the Syrian population suffered more compared to other sectors.
Researchers have emphasised that in order to provide adequate mental health support, knowledge of the specific social and cultural realities of Syria is crucial for both the design and delivery of this support. Mental health disorders existed prior to conflict - it's crucial that mental health issues, conflict-related or not, are continuously addressed beyond rebuilding efforts.
It is detrimental to separate mental health care from other efforts to restabilise conflict zones
The lack of mental health care access is a crucial issue affecting people worldwide. This lack is even more prevalent for people living in conflict zones. However, access is not the only obstacle. Quality of care should also be present in discussions of responding to crises, as people equally deserve quality and culturally competent care that is responsive to their specific needs.
Mental health care may not seem like a priority when levelled with the physical effects of conflict, such as the lack of safety, food, shelter, and providing physical aid. However, research has consistently shown how detrimental separating mental health care is from all other efforts to restabilise conflict zones. In order for people to rebuild or improve their lives, quality mental health services must be both provided for, and made equally accessible, just like any other form of welfare or aid.