Assignment with WHO to Syria – Dr Peter Hughes, February 2014

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 Syrian crisis.

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.

Day 1

I arrive on a pretty empty flight from London to Beirut. The city is beautiful with a gorgeous cornice and waterfront walks.

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.

Day 2

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 government crossing.

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 the other.

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.

Day 3

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 anxiety.

• 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 kilometre away.

Day 4

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 panic!

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 your doorstep.

Day 5

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 is nearby.

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 before.

Sanctions are in place so credit cards are not usable here. The economy has taken a hit and people are suffering.

Day 6

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 hasn't.

Day 7

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

Day 8

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 Umayyad mosque.

Following this a dinner with our colleagues from Damascus in a packed restaurant. Beautiful food. Strange with wall-to-wall smoking.

Back to hotel and our Damascus colleagues leave us. As soon as back in hotel we hear a loud series of mortars.

Day 9

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 outside interference.

Day 10

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.

Day 11

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.

Day 12

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 blog.

I would like to thank the WHO for this opportunity, and also my Syrian hosts for their hospitality.

Written by Dr Peter Hughes