Psychosocial support: A problematic priority in Syria

Enab Baladi’s investigation team

 

Murad Abdul Jalil/ Reham al-Assaad/ Mohamed Homs/ Haba Shehada

 

Local and international organizations working in Syria devoted specialized mental health and psychosocial support programs to Syrians. Despite the exceptional circumstances that Syrians are going through, they are placed as the main category targeted by the United Nations programs in this field. However, the health care sector in Syria has been witnessing a continuous debate regarding the categorization of citizens’ needs who are still suffering from the direct effects of war.

 

The allocation of $5.5 million fixed by the World Health Organization (WHO) to equally finance physical therapy and mental health in Syria has sparked a broad debate about the health care sector amid a split among those who believe that the culture of psychosocial support and raising awareness about it among citizens is a priority because of the war and the resulting psychological crises, in addition to providing individuals and communities with the necessary amounts of funds; and those who think that the money allocated to psychosocial support must be directed to meet basic human needs first, secure shelters and food, as well as hygiene, sanitation and clean water, especially in the refugees camps.

 

The controversy began when the Health Sector Coordinator at UOSSM, Dr. Ziauddin al-Zamil, submitted his resignation via his Facebook account on March 2, in protest against allocating the fund to mental health sector by the WHO’s  Senior Emergency Coordinator.

 

Al-Zamil considered that the amount allocated by Humanitarian Pooled Fund (HPF) should go to support hospitals and primary health care centers, noting that “thousands of wounded and sick people are not a priority for the Senior Emergency Coordinator, Jorge Castilla. Despite the attempts of some dear brothers to discourage this disaster, he seems determined to destroy a large amount of money needed by thousands of wounded and sick Syrians inside the country.”

 

Humanitarian Pooled Fund (HPF) is an international fund established by the United Nations in 2014, in response to the size and complexity of the Syrian crisis and the need for new ways to deliver humanitarian aid to Syria.

 

 

 

Al-Zamil did not only resign, but called all aid workers and journalists to support him in an open sit-in in the WHO, in addition to demanding that the financial allocations  must be directed, now and at all circumstances, to the priorities set by the organizations involved in the sector in accordance with clear and transparent mechanisms. However, the sit-in, which was designated to take place on  March 4, was postponed for the lack of permission.

 

He told Enab Baladi that it was not the first time for something similar to happen as “priorities have been always set regardless of the needs on ground and regardless of the partners’ opinion.” Al-Zamil also referred to the urgent need for “this financial aid in order to fill important gaps” for dozens of hospitals and health centers, criticizing the WHO’s decision to cancel the position of the local co-chairman, whose job was to determine the needs of national organizations and health directorates. He considered the mechanisms for the decision-making process in the health sector to be “unclear.”

 

Enab Baladi tried to communicate with the regional director of the WHO in Gaziantep and the Senior Emergency Coordinator of the health sector, but received no response.

 

However, according to the report of the Security Council’s Secretary-General on the implementation of decisions on relief assistance during December 2018 and January 2019, response teams were established in refugee camps to receive newly displaced persons and identify the most vulnerable categories in order to provide urgent assistance to them, i.e. medical support, protection and referring critical care medical cases to nearby hospitals for treatment.

 

Health-care zones have been expanded through establishing new health centers and mobile clinics, in addition to vaccination campaigns for all the newcomers and providing them with nutrition and psychosocial support.

 

According to the WHO’s 2018 annual report, 1.909 tons of medical equipment were provided for about 100 hospitals, 10 million medications were distributed throughout Syria. Additionally, 26 million infants received polio vaccine and 2.6 million received measles vaccine. Also, five medical centers have been rehabilitated and 30.865 medical staff members have been trained on a variety of fields.

 

However, the organization did not specify on its website a map of the locations of these activities or the amounts allocated to each action.

 

 

Health needs of affected Syrians

 

According to the WHO annual report for 2018, the average life expectancy in Syria has dropped from 75.5 years in 2012 to 63.8 years in 2018.

 

More than 13 million people need humanitarian aid, and 5.2 million of them are in urgent need. Last year, about 1.5 million people were forcibly displaced from the areas of Ghouta, Homs and Deir ez-Zor. Dozens of children died in al-Hol camp and Rukban camp due to the lack of health care. Nonetheless, several refugee camps in the north-eastern and north-western regions have suffered from torrential rains, leading to the destruction of tents and the displacement of people, who are already among the most vulnerable categories, for the second time.

 

Two-thirds of the Syrian people live below the poverty line, and 35 percent of Syrians do not have access to clean water due to recurrently vandalizing attacks targeting water pipes, which has led to outbreaks of acute bloody diarrhea, typhoid fever and hepatitis.

 

The number of people infected with measles doubled in 2018 compared to 2017, and the number of people with Tuberculosis has also increased.

 

Similarly, many Syrian regions have witnessed outbreaks of measles and leishmaniasis due to the ongoing armed conflict, the lack of access to medical care and the scarcity of health care services, in addition to the spread of dirt and rubble. Despite routine immunization campaigns, vaccination rates remain low, according to the report.

 

The organization mentioned that about 15 percent of Syrians suffered from conflict-related disabilities, and nearly half of them are likely to suffer from impairment requiring special care. Other, 12 percent had diabetes, and 20 percent had high blood pressure. The organization warns that these diseases may cause heart attacks. A number of Syrians died because of the lack of medicines they used to receive before.

 

The lack of medical equipment and the pressure health centers are suffering from, as well as the lack of specialists led to a severe shortage is terms of reconstructive surgery for burns victims, in addition to delayed necessary surgical operations. Thousands of wounded persons could not receive physical rehabilitation.

 

 

 

Programs and target groups

Defining Psychosocial support?

 

WHO has given great importance to mental health programs, including psychosocial support programs, in order to spread and put such culture into practice in poor countries, where the majority of the population was subject to disasters and atrocities of wars, thanks to the organization’s resources.

Stakeholders have sought to adopt a global definition and specific programs to set a well-defined standard addressing different target groups belonging to each program for all psychosocial support groups and individuals to stick to.

 

“Hope Revival,” the organization providing psychosocial support to the Syrians affected by war, offered Enab Baladi a special research on the global definition of psychosocial support, the  programs and target groups, based on several references, including the Guidelines on Mental Health and Psychosocial Support presented by the Inter-Agency Standing Committee “IASC” and the “Guidelines for Psychosocial Support ” offered by the International Federation of Red Cross and Red Crescent Societies.

 

 

 

The ones afflicted by wars and disasters are the neediest

 

The research offered to Enab Baladi was prepared by a group of psychologists at the Hope Revival organization, including Bahaa Jabbawi, Ayham al-Hawari and Salah Eddine Hashim. The paper defined psychosocial support as a range of activities, responses and interventions which meet the psychosocial needs of individuals, families and communities and promote for well-being.

 

The psychosocial aspect was mainly attributed to the research because it targets the individual as well as the various aspects of his health, including the social.

 

It has also highlighted that the segment characterized by the need for psychological support mainly includes the individuals who have been exposed to exceptional circumstances, such as wars, disasters or crises. The report pointed out that the situation differs depending on the degree of vulnerability and the need of the individual or group for such service.

 

Children, adolescents, disabled people, lone women supporting their families, the victims of torture and sexual violence, and individuals with previously diagnosed mental disorders, are the most vulnerable social groups in urgent need of psychosocial support at different levels.

 

According to WHO, the target groups of its mental well-being program include those exposed to extreme stress factors such as refugees, displaced persons and victims of disasters, terrorism,  war or genocide.

 

 

 

 

 

 

Five levels of psychosocial support

 

According to the guidelines set by the Inter-Agency Standing Committee (IASC), a humanitarian relief agency established in 1991 by the United Nations General Assembly, the types and levels of psychosocial support are the following:

 

 

Mental health and psychosocial support services in northern Syria

 

Absent culture

The social legacy is behind the disappearance of the culture of psychological support

 

Psychosocial support is a natural and necessary need for societies that have suffered and are still suffering from crises and wars for many years, such as the Syrian situation. It is important because of the human need for psychological well-being that enables the person to make achievements in daily life, psychologist Samah Selma told Enab Baladi. When a person is psychologically affected, he or she does not have the ability to make achievements and has a functional disability regarding his or her role in society.

 

However, the culture of psychosocial support is not widespread and is absent from Syrian society, because people believe that it is merely psychological support and that the person is suffering from a mental illness or disorder, according to Jordanian psychologist Razan Obaid.

 

Obaid, who works with Syrian civil organizations in the psychological support field, stressed to Enab Baladi that psychosocial support is integrated, tackles all aspects of an individual’s life and covers all of his needs, including the provision of assistance to the person whether physical, medical or other. She noted that following any incident, the human being is psychologically, physically and mentally affected, and the intersection of these three circles is psychosocial support.

 

She thinks that psychosocial support is a big priority and must be provided with other services because the abnormal person cannot eat, sleep or work.

 

Obaid believes that the Arab countries’ view of this culture has become a “stigma” for if a person undergoes psychosocial support sessions, he is mentally ill. “This is a result of the cultures we were raised to believe and the result of movies and media, which depicted the psychiatrist as mentally ill person. The society we live in and media have a significant impact on the spread of this term,” She clarified.

 

For her part, Selma considered that the culture of psychosocial support does not exist in our society and that its spread during wartime, crises and current circumstances has become more difficult because the priority of citizens has shifted to providing basic services of education, health, relief and services rather than psychosocial support.

 

Selma pointed out that people receive psychosocial support in their lives but unconsciously, for example from friends and during social occasions, but when placed in a scientific and professional framework, people become suspicious of and fear it. This is due to the traditional heritage that does not allow thinking out of the circle that psychosocial support is not a psychological illness but it helps the individual. She also stressed that it is necessary because of the disintegration of the social network and loss of parents’ roles and changing roles. For example, when the woman loses her husband, she is compelled to play two roles: the role of the mother and the role of the father together.

 

Awareness and information: Steps to spread the culture of psychological support

 

In order to spread the culture of this kind of support among citizens, several steps must be taken. First, it is the responsibility of the psychologists themselves. They are responsible for developing, qualifying, training themselves and adopting a professional approach to help the person, Selma said.  This is in addition to the ideas of privacy and confidentiality, which are very important, and which the psychologist must ensure to keep the person. The second step lies in the role of the media in spreading this culture among citizens, and explaining that psychosocial support is not linked to illness or mental disorder.

 

According to specialist Obaid, among the steps is to hold lectures and awareness sessions in the community, especially organizations that have an important role in this awareness, which explain to citizens the importance of psychosocial support. This is in addition to the people who provide this service and who must know the popper way to spread this culture among citizens and that it is to the benefit of the individual to know himself, his strengths and weaknesses and positive challenges in order to adapt, live a happy life and see things better.

 

 

Different points of views regarding the priority of psychosocial support

The views of the respondents in an opinion poll conducted by Enab Baladi on its online platforms have been divided between those who considered that psychosocial support is an urgent necessity in our current reality, and those who thought that providing basic services (health, education, water, electricity and food) is more important than spending huge funds on psychological support.

Enab Baladi has asked the following question via its official website and Facebook page: “Do you think that psychological support activities are a priority in Syria?” A total of 1.051 users have participated in the opinion poll.

55 percent of the respondents considered that psychological support is important, but believed that the activities need to be carried out by specialists, experts and highly qualified people.

Rafaa Rafaa commented on the opinion poll on Facebook, saying: “The most severe threat comes from support providers who are inexperienced, unqualified and who have no academic or scientific background in these activities.”

Muawiya Hariri called for the rehabilitation of specialized persons in psychological support before starting support activities, and demanded that such activities be limited to schools only.

In contrast, 45 percent of the respondents insisted that psychosocial support is not a priority.  Ahmed Ahmed commented on the Facebook post: “Psychological support is a lie,” adding that the real psychological support is “the provision of electricity, services, the reparation of people’s homes and the opening of public hospitals.”

Sulaf Bassam said that “the priority in Syria is to stop hostilities, arbitrary killing, immigration and displacement.”

 

 

Psychological support programs need development and qualification of supervisors

The programs that the specialized organizations in Syria offer for those in need of psychological support play an important role in spreading this culture. There have been different points of views on the provided programs in terms of their adequacy, method of application and working staff.

In the research presented by Hope Revival Organization for Enab Baladi, researchers asserted that psychosocial support programs in Syria are “somewhat acceptable,” as they support individuals and society and alleviate some of the suffering. However, programs of all types “are not enough” alone to reform and improve the human condition, in case they are not associated with economic, political, social, human rights and development programs that support people and improve individuals and society’s wellness.

The researchers pointed out that what reduces the effect of the results of psychosocial support programs is the lack of coordination, readiness and preparation of programs, poor management and the lack of rehabilitation and follow-up of those working in the field.

 

90 percent of psychological support staff need development

Most organizations interested in the provision of psychosocial support rely on programs developed by international organizations, such as the Red Crescent and the Red Cross.

The researchers considered that these organizations apply global standards “to a certain extent.” However, there are “some mistakes and wrong practices that affect the reputation of the services and prevent them from reaching the largest possible segment of the needy,” such as accreditation of Syrian organizations and the focus on services provided by psychologists (psychiatrist, psychotherapist), who are very few and required to serve less than 10 percent of those in need of mental health and psychosocial services. In contrast, non-specialized mental and social staffs are neglected, lack support and development, and are responsible for providing about 90 percent of the mental health services for those who need them.

The three researchers attributed the reason to the “media sparkle” and the large financial support that the project, which includes specialists and psychiatrists, brings in return for lack of attention to case managers, psychosocial support staff and facilitators of activities.

The supervisors have accumulated experience since the days of the Iraqi emigration to Syria, considering that psychological specialty have generally been uncommon in the country before that time, and that projects have been implemented in Syria to support displaced Iraqis. These projects have provided an acceptable, yet not enough, number of experts in the field.

According to the research, the international support provided for the Syrian situation after 2011 has offered those working in the field chances of rehabilitation and gaining experience. However, there are a limited number of specialists in the management of this type of psychosocial programs and services.

Programs need “continuous” development

Although the adopted psychological support programs by the organizations in Syria are “mostly” programs based on international standards that commensurate with the local need, they need to be more adequate with the current context in Syria and the overall situation in the region.

The researchers stressed that this type of adopted programs in Syria needs “continuous review and development in accordance with the context and situation of the Syrian people in the country and neighboring countries.” There is also a need to review the used means, mechanisms and techniques to prevent further “harm” to the Syrians from the standpoint of sometimes a good or bad intention.

It is the responsibility of international donors of psychosocial support projects to evaluate these programs, as they are the supporters and sponsors of such projects, by relying on the country’s people working in this type of projects.

According to the research, the evaluation and improvement of psychosocial programs is the responsibility of the Syrian organizations implementing them, through “good project management, good recruitment of resources, scientific and professional selection of staff, the development of their capabilities and their support.”

The research considers that the Syrian society, with its political, social and civil components, can play a major role in reviewing and evaluating the effect of psychosocial support programs and playing a greater role in ensuring follow-up and good coordination among organizations working in the fields, and the preservation of “the rights of the Syrian people, especially in areas liberated from the tyrannical authority.”