This blog is a personal account of an assignment with WHO to
Syria in February 2014. It is my personal blog and does not
reflect the views of the college or any political views of the
I am a Consultant Psychiatrist in South
London. I have been involved over many years in international
mental health and particularly in Primary care low resource
settings. Mostly I have been doing assignments in Africa.
This assignment began with an email in January
from WHO asking me if I was interested or available to do a
training in Beirut. More recent requests that I have
had include challenging environments like Iraq – which,
incidentally I loved. So Beirut sounded wonderful to
me. I know many think of Beirut from the war days but to me Beirut
is an oasis of peace with beautiful climate and beaches. I
was even more delighted to hear my old colleague from Haiti and
Sudan days would be my co trainer.
The project was to train health processionals
in how to use the WHO mhGAP manual, which is a tool to integrate
mental health into primary care in low resource settings. I am in
the position of being an expert in delivering this training.
Our task was to train 30 mental health professionals from
Damascus in Beirut in using the manual.
About 3 weeks before going we received an
email saying that, for convenience, the training would now be held
in Damascus, Syria. I had lived in Syria many years
previously so I knew it reasonably well from the days of
peace. However, the past 3 years, as everyone knows,
have been dominated in the news about the human catastrophe
occurring in Syria and amongst its refugees.
There are millions of refugees who have left
the country. When you ask a Syrian what the population is, you can
see they start at 22 million and work out the millions of refugees
that have now left.
Syria itself is scarred by frontlines of
conflict. A geopolitical map of the country doesn't actually
help much. There are hot spots of government control around
Damascus and Latakia. The rest of the country seems to be a
mishmash of competing forces dominated by the Free Syria
army. The conflict is so chronic that it is no longer front
page but atrocities continue to occur every day.
So the decision to travel or not took some
thinking – at least a minute or two - on the risks of going into an
area of active conflict.
I arrive on a pretty empty flight from London
to Beirut. The city is beautiful with a gorgeous cornice and
I meet my colleague who has been working with
Syrian refugees in Turkey. We head down town and enjoy a
beautiful meal followed by Hubble-bubble.
We go to find the old market only to find a
concrete market about 5 years old. Life is buzzing here with
lots of nightlife. This is a nice place to live - at least
this part of Beirut. There was a checkpoint to go down to South
Beirut. This is a place with some security problems.
A taxi arrives at an unearthly time of 6am for
us. We head out east for an hour or two. I was fast asleep in car
at this stage. We get to the Syrian border. This is the official
This was a place of chaos. Lots of people
hanging around and the border seeming impenetrable. There were many
cars packed inside and out, but no one seeming to be moving very
fast. But the movement was definitely west to Lebanon and not the
other way round. After a while we see our armoured Land
Cruiser to bring us to Damascus and WHO driver. This was a
regular looking vehicle. However the window was the toughest I have
ever seen and the door so heavy. This reassured, and at the same
time, alarmed us for the journey ahead.
Next was getting stamped for exit from
Lebanon. I didn’t quite know what was happening but there was a
mass of human beings, being human. It was a pitiful scene -100s of
people crammed into a shed like building. Being with WHO gave us an
advantage and we could beat the queue. This was the first
face-to-face contact with the conflict as these were clearly people
desperate to get away.
Next a few more check points, a no man’s land
and then Syria border post. This time the building was almost empty
and not many seeking Syrian entry visa. We saw a forlorn counter
for tourist groups. Empty for 3 years. After this,
pictures of President Asad just about everywhere – in buildings,
outside buildings, on walls , on streets, on cars – everywhere you
could think of. The picture is ubiquitous. We did see a few
pictures defaced on the road to Damascus but that is a dangerous
thing to do.
We then went on a journey for a couple of hours
through a green hilly and empty landscape punctuated by frequent
checkpoints. Before we know it, and relatively easily apart
from Damascus traffic, we end up in the Sheraton in Damascus.
Because of security there is clearance to stay in only 2 of
Damascus’ hotels, this being one of them.
The hotel is situated in front of a large
square framed by a military camp on one side and the TV station on
This made it the safest place in some ways, as
it was heavily fortified but one could also argue vulnerable to
opposition forces. What I didn't realise is that when we
entered the hotel we would not be able to step out again.
Next we go straight into the training.
We have 30 people waiting. There are roughly 60 psychiatrists
in Syria they tell me, but almost all but one of these participants
are from the Damascus area. There were a few psychologists
and a social worker. Participants were from the ministry of
health, UNHCR, WHO and some NGOs.
We ask for cases that people have seen that we
can use for mental health training. Almost all these cases
were harrowing accounts of killings, rape and civil unrest.
Sample of cases -
Single, employed male in his 50’s, with explosion
in front of his house a few months ago. His mother was wounded and
he took her to hospital himself. Currently, he cannot go out of his
house unless his brother accompanies him. He is hesitant in
selecting the roads to go where he wants to go. He sleeps with
earplugs, hiding because he fears another explosion or mortar
attack. In addition, he has started using alcohol to control his
32 year old single
male came to the centre after stress because of random bombardment
in his area. He left to a safer place and is now an IDP. He used to
work in a shop. He now suffers from headache, difficulty breathing,
stomach cramps, racing heart, difficulty sleeping, feeling of
tension whenever there is any noise or sound even if it’s soft,
dizziness and sweating of hands.
We settle in for our night in the hotel. There
is hardly anyone present and definitely no tourists. The shops are
closed. We go to the swimming pool, which is waterless. This place
is not built for tourists now.
Syrians say they looked at Iraq and Lebanon in
the past and said that it could never happen in Syria They still
cannot believe what has happened.
What was clear is that for Syrians there is no
luxury of being able to choose to think of one side or the other.
It is a matter of survival. Damascus is a bastion of
government so this was the framework of all what we heard and saw
for our week in Damascus.
For us, we had the luxury of being able to be
neutral and step back from being partisan. What we definitely were
committed to was peace and Syrians finding a peaceful path for the
future. Then about midnight: the first sound of mortar.
First I thought it was lightening and looked out for the rain but
none present. Next bang is without any flash so I realise that this
is mortar fire. I learn later that there is a front line about 1
Breakfast and I'm the only one there for an extensive buffet of
delicious Syrian foods. My memory from when I lived here
before was the fantastic food and cakes.
The Psychiatrists, and other professionals
have a high standard of mental health knowledge and
application. We do the training through an Arabic
interpreter. It is a testament to his skills that we often forgot
he was there.
We started with Depression, as this is a key
component of the manual and most often missed at Primary
care. Feedback from the group is that currently the
most frequent cases they see are stress related. However after
going through the module there is a sense that this is missed more
than they had thought.
A long and fruitful day.
Dinner in the hotel that evening where we have
a singer singing traditional songs. Men play backgammon and every
single person smokes.
1am - I wake to hear gunfire. I remember
my rule of thumb: gunfire on one side is ok, but both sides
- not. When on both sides - then time to panic.
If the floor shakes time to
Here, gunshot and mortar fire was
sporadic and seemed far away enough not to get alarmed. At least
hearing the gunfire and mortars at a distance means they are not on
The Participants improve markedly each day in
their teaching skills in using the manual. There are some
excellent videos of International medical corps in Arabic with
subtitles. We cover more and more modules – developmental,
behavioural disorders, substance abuse, Suicide. We get a
chance to speak to the participants. It seems that life is
indeed very hard for the people of Damascus.
Our participants tell us of the difficulties
of getting to the venue across so many checkpoints. Some of
the group live in insecure areas and I can only imagine what life
is like. I know the area that I lived in before is safe which
They tell me most of the group have had to
move because of the conflict. They are crowded onto homes in safe
areas. Some have moved from rural areas. I did not go into the
politics of the group. That is not something to talk about too
loudly in Syria.
They tell me that there is fighting in the
suburbs. There is a front line 1 and 3 kilometre around where we
are. They tell us the mortars are from inside going out. They
also tell us they are only on the daytime because then the firing
can be visualised. However we heard mortars at all hours and so
weren’t quite convinced by the explanations.
My colleague took to phoning me whenever there
was a loud mortar –“did you hear that one “ It assumed a
crazy normality after a day or 2. This is how Damascene people
live. They told me it was much worse about 2 months
Sanctions are in place so credit cards are not
usable here. The economy has taken a hit and people are
We are progressing nicely in our training. We
cover the important chapters of psychosis, bipolar,
somatisation. But everything is prismed through the stories
of the crisis.
Evening time –the weather is beautiful.
We go for a walk around the grounds of the hotel. We ask at the
gate if we can go out to take pictures of the square. They
indicate that we could get shot so we think better of that
plan. We are going a bit stir crazy now. We are desperate to
get out of the hotel but we don't have a clear idea of how safe
that is or not. I have seen the sights before but my colleague
We are told we can go out in the evening. We
can hardly wait. Life does go on as normal in Damascus as
much as it can. In fact one of the participants asked
us if we would go to a dangerous place if asked by WHO. They
had not considered Damascus, as it is – a dangerous place.
Disappointment arrives. For whatever reason we
cannot go out today and some security problems. We stay back in our
5 star “prison”. We go to another restaurant in the hotel. They
tell us that most of the menu is not available and we need to
double the costs displayed. We can still get some falafel sandwich
and delicious with Arabic coffee
A productive training day. The
participants are skilled at teaching and can task shift (have
a mindset for primary care) to deliver mental health at a primary
care level. We emphasise the supervision that is absolutely
necessary to make the programme work of mental health in primary
care. The Psychiatrists also have the role of being expert advisors
and manage the most difficult cases. What is unclear is
how the programme will be rolled out and the supervision mechanisms
that are needed in such a volatile region.
Evening time, we are very excited to be able
to step out the door of the hotel and go on a trip into town.
We both know there are risks to this but there have been fewer
mortars. Life going on as “normal” means people can be a bit
detached from making a real assessment of risk. We go to the
old city. The market is teeming with people and life really does go
as usual. The shops are open. We go for ice cream in a packed shop.
There are no foreigners apart from us. We go to the beautiful
Following this a dinner with our colleagues from Damascus in a
packed restaurant. Beautiful food. Strange with wall-to-wall
Back to hotel and our Damascus colleagues
leave us. As soon as back in hotel we hear a loud series of
Our work colleagues say they didn't even
notice the night mortars after they left us.
Next to our training is a Polio workshop. It seems that
some of the conditions of the past are recurring like polio.
The minister of health was attending this so
he came to our training to deliver a speech. He talks about the
conflict and the opposition being terrorists and driven on by
We finish off the training by discussion of how to go onto next
stage of rolling out programme and supervision.
A surreal last night as after about 7 hours of
preparing our work report we go to the English pub downstairs – I
kid you not and play darts.
Many army people now staying in hotel.
We head off in our armoured land cruiser to
Beirut. The border takes a few hours to cross as before with a mass
of people in cars and on foot making the journey out of Syria to
Lebanon. A beautiful night in Beirut on the waterfront.
It is so strange to have this freedom of walking and of speech.
I head off to London and my colleague to
Istanbul. It has been a surreal experience being in a
dangerous city one day and back in London next.
It is hard to imagine how our programme will
roll out in such an insecure environment. Yet I wish them
well and more than anything else that there can be some peace as
this war is truly horrible, complicated. There are no winners in
Syria only losers. Fired by this experience the next thing is to
think about how we can support the people of Syria both inside and
out of the country.
We have identified about 6 UK Syrian
Consultants Psychiatrists. We invite all those with an
interest in helping Syria to contact the author of this
I would like to thank the WHO for this opportunity,
and also my Syrian hosts for their
Dr Peter Hughes
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