A Tidal Wave of Trauma

From PTSD to depression, the war in Syria has spawned a massive mental health crisis -- and there are neither the doctors nor the money to stem its crushing effects.

There are as many guises of trauma as there are Syrians who have experienced the war still ravaging their country. The dead-eyed mask is common, often in children. I saw it in a refugee house in Amman, Jordan, where, seated on scratchy nylon mats that said "UNHCR," seven or so boys and girls stared at me stonily. Their mother cried until her whole face and neck turned red as she told stories of massacres and family members who had disappeared. The father sat quietly in a nearby room, praying.

There is another gaze, one full of grief, which I saw in a hospital in Kilis, a town inside Turkey near the Syrian border. A woman, 38, was bedridden with a spinal injury she incurred on the outskirts of Aleppo. Explosives had fallen on her house, crushing not only her back, but also her daughter, Ayah. A blond, 9-year-old child with plastic glasses, Ayah died that day. The pain of her death pulsed in her mother's eyes.

There is also the drawn face of exhaustion, a wounded look I witnessed on a woman I met in a park in Kilis. The park housed 4,000 Syrians in makeshift tents. The woman tried to hand me her young son. He had scabies up and down his legs. "When will all of this end?" she begged.

The question of when the fighting will end is ever present in the minds of those hurting. So, too, are memories of torture, killing, rape, and deprivation. A loss of home and country plagues refugees, as do the difficulties of trying to incorporate themselves into communities that are sometimes hostile to their presence. Many have physical problems from injuries in the war. Even more have internal, emotional damage. Suffering for Syrians has a cascade effect, one with no tangible end in sight.

The World Health Organization estimates that 3 to 4 percent of people affected by an emergency (like the war in Syria) will develop severe mental health disorders, such as psychosis or severe depression. (That's compared to 2 to 3 percent before an emergency). The organization also says that 15 to 20 percent of people in an emergency will develop mild or moderate anxiety or depression disorders or post-traumatic stress disorder (PTSD) -- as compared to 10 percent beforehand -- and that a "large percentage" of people will experience "normal distress" during an emergency.

Right now, there are about 9 million Syrians who have fled their homes, 2.7 million of whom have taken refuge in neighboring Turkey, Jordan, Lebanon, Egypt, and Iraq. And, of course, there are millions of Syrians still suffering inside their country. Do the math, and it's easy to see the enormity of the mental health crisis this war has created.

But amid a litany of humanitarian needs that aren't even remotely being met, can this crisis possibly be addressed? Can its long-term effects -- illnesses that could tear apart families and reduce quality of life -- be mitigated in a meaningful way? While there are international and local groups attempting to do just that, the need is still heartbreaking and huge.

On May 15, Physicians for Human Rights (PHR) released a map with comprehensive information on attacks on medical facilities and personnel inside Syria. It did not, however, include information about people who provide mental health care specifically. Erin Gallagher, PHR's director of emergency investigations and response, said the organization is well aware of the mental health crisis at hand, but that it lacks statistics for psychologists and other providers. This seems to be a trend: In reporting, I could not find an organization with a good sense of where or how many mental health practitioners are working inside or around Syria right now. Gallagher says what's clearly known, however, is that "so many adults and children are suffering from trauma and are not getting help."

"There is a big, big gap in accessing care for mental health for all Syrian refugees," echoes Ana Maria Tijerino, a mental health advisor for Médecins Sans Frontières (MSF) Suisse (that is, the Swiss branch of Doctors Without Borders). "We need to do more, definitely."

"We need," she adds emphatically, "to do more."


During a conversation one evening in Reyhanli, on the Turkish side of the Syrian border, a psychologist named Mohamed Suleiman from Idlib, Syria, pulled out a large tripod topped by a horizontal metal bar with little green lights running across it. He handed headphones to a colleague of mine, and we watched as the lights started blinking, one by one.

This was an EMDR (eye movement desensitization and reprocessing) machine, a method used to treat PTSD that has people recall difficult memories while receiving different kinds of sensory input; the idea is to help the brain reprocess traumatic information to make it less upsetting. Many Western specialists consider it to be cutting edge. But it is unusual to find one in a place as bereft as the Syrian border. Suleiman, who said that he and his wife are basically the only therapists in the area, described toting the machine from tent to tent in refugee camps. They can help only one person at a time.

On various trips to the region in which Syrian refugees are scattered, I have met with many psychologists who similarly say they are the only ones for miles around -- in some cases, perhaps the one medical practitioner licensed to treat mental health problems in a refugee camp of thousands of people. And all of these professionals have said the number of people experiencing symptoms of depression or anxiety is staggering.

In addition to MSF, other international groups, such as the International Rescue Committee and UNICEF, offer help in various places, and so do local ones. The Kirkuk Center for Torture Victims, recently renamed the Jiyan Foundation for Human Rights, runs seven rehabilitation centers in northern Iraq, including inside the Domiz refugee camp. The number of people seeking help has been extraordinarily high. Salah Ahmad, a psychotherapist and the organization's director-general, says that in the Domiz camp, which is estimated to house more than 70,000 Syrians, the center saw more than 9,000 patients in its first 11 months. His team has had to introduce a waiting list.

"Ninety percent of families have trauma," estimates a social worker named Muna in Amman, at the Syrian American Medical Society (SAMS). The organization, which includes psychologists and social workers, carries out home visits to assess and help hundreds of new families on arrival each month. "When a plane is passing by, kids hide under chairs. 'I wish I could go back to Syria,' they say."

Another social worker in the office says, "They're scared, but they don't say why. They can't adapt to their new surroundings, and they're desperate."

The psychologists and social workers at SAMS say they do four or five visits with a family, bringing food and clothing, through which they hope to alleviate some of the isolation and ongoing need for basic items. It can take that many visits before, for example, a woman may finally open up and say she was raped. Getting to the heart of trauma, in other words, can take time and the right conditions.

"We tell them that we're here for them. We give them the safety net," says Yassar Kanawati, a psychiatrist who supervises the psychosocial team in SAMS's Amman office. (She is based in Atlanta but travels often to Jordan.)

Most caregivers I spoke to view children as a population of special concern. Many cannot attend school due to a lack of facilities, and some of those who do go cannot concentrate and learn. They absorb their parents' pain (if their parents are still alive). "Many of those who come to us cannot sleep anymore, they have nightmares, are oversensitive, many cry a lot; children are aggressive or stop talking," says Ahmad.

Kanawati describes situations in which a mother's trauma affects children, in turn potentially making them more aggressive and less able to learn. She does group therapy sessions with refugees, mainly children, who she says "are either in a daze because of the trauma or aggressive or depressed or anxious. Just thinking about their losses, thinking about their father who just died or their mother who was raped in front of them. It's very serious stuff." Kanawati explains that while medical treatment for physical issues is certainly important, giving greater support for refugees' emotional and mental health "would prevent further decline in function of the whole society."

Yet organizations like SAMS are understaffed and underfunded. Kanawati says the group has trouble finding the $100,000 a year it takes to do its work. "Resources" -- that's the word she and others repeated to me as what they need but do not always have.

Adding to the overall predicament is that individual problems usually just get worse with time. The anti-poverty organization CARE said in an April report on refugees that it "clearly identified an increase in psychosocial needs the longer the displacement lasted." Syrian families "typically identified a deterioration in their psychological state as a major change over the previous year," CARE said, "alongside and exacerbated by preoccupations about financial resources to cover basic needs and closely related to a deterioration in health."

Tijerino of MSF, who oversees the group's mental health care in the Domiz camp, agrees. "Some refugees have been inside a camp for two years, and it's not likely to change soon," she says. The lack of knowing about their future, the uncertainty, "is affecting their mental health."


Making the situation all the more difficult is a long-standing taboo surrounding mental health in the region. Kanawati knows about this issue all too well. When she got her medical degree in the 1980s in Syria and told people she was going into psychiatry, "everyone laughed."

"Thanks to Freud," she says, "they thought that therapy is about sex and sexuality. In our culture sex and sexuality is very private. You don't go to someone to talk about it."

Similarly, Ahmad in Iraq says that "psychological treatment is still widely unknown in the Middle East."

The taboo lingers, Kanawati explains, although perceptions are slowly changing. But in the midst of war, any new desire for assistance has run up against a lack of trained professionals. "We've been depending on paraprofessionals -- social workers who didn't go to school -- but we provide them with training to do this kind of work," Kanawati says.

Between the need to educate people about mental health treatment and figuring out how to reach so many sufferers with so few professionals, the challenges of this crisis are extraordinary. But in addition to the dedicated people I spoke to, there are people out there mulling creative solutions. For instance, there are trauma specialists in Northern Ireland working on a web platform that would crowdsource mental health symptoms of Syrian refugees, in an attempt to assess needs and pass the information along to practitioners and NGOs, who can in turn then provide treatment. Still, such efforts are only in development -- and in the meantime, Syria's war rages on, sending more and more refugees over the border every day.

With the EMDR machine blinking away, Suleiman reflects on what lies ahead, and turns dark.

"I'm more anxious about the future," he says, "than the present."

His sentiment, it seems, unfortunately speaks for millions.

Fadi al-Halabi/AFP/Getty Images


How to Do Intervention Without Blowing Stuff Up

It’s time to relearn the good tools of the Cold War.

As the United States and its allies withdraw their forces from Afghanistan, the part of the global war on terror that involves massive military action is coming to an end. To be sure, drones and Special Forces will still engage in targeted strikes, but it may be quite some time before the Pentagon mobilizes for another large-scale invasion. Former Defense Secretary Robert Gates argued in his memoir that our foreign policy "has become too militarized" -- but in fact, the military's own long-term strategic plans would severely constrain its ability to conduct what it terms "large-scale, prolonged stability operations."

But despite the current preference for retrenchment among the American people and their president, the dangers to Western security have hardly dissipated. Russian President Vladimir Putin is stirring up serious trouble in Ukraine and throughout Russia's "near abroad," while Beijing continues to muscle about the South China Sea. From Nigeria to Yemen, large chunks of the developing world remain essentially ungoverned, giving terrorists, insurgents, and rebels of every stripe plenty of room to maneuver. American security challenges haven't gone away -- in fact, as Director of National Intelligence James Clapper noted recently, they are probably expanding.

This harsh reality raises unavoidable questions for those who shape our foreign policy. At a time when the use of military force is no longer a viable option, what actions can the United States take short of going to war? Which levers in conflict-afflicted regions should be manipulated to shape outcomes more to Washington's liking?

The answer to these questions requires a strategy of non-kinetic intervention, which brings together the instruments of national power to promote more benign behavior among governments and non-state actors that threaten the United States. But if Washington hopes to change behavior without resorting to military force, it needs two things: a deep understanding of the structures of elite power in the places it seeks to influence, and clearly articulated objectives for what it seeks to achieve. Understanding the areas of these countries' politics that are open to Washington's manipulation and setting appropriate goals for American interventions is at the heart of a non-kinetic strategy.

Non-kinetic intervention provides an essential, coercive complement to political scientist Joseph Nye's comforting notion of "soft power." To Nye, the great shortcoming of U.S. foreign policy is that it failed to capitalize on the country's unique magnetic pull on the rest of the world -- its cultural and ideological attractiveness. Nye argued that America could exploit these attributes to "get others to want" what we want in world affairs.

But soft power alone may not be up to the task of changing the behavior of certain countries and non-state actors, for the simple reason that many of those who oppose the United States find little that is attractive about its ethos. Think of such leaders as the Nigerian jihadist group Boko Haram's Abubakar Shekau, who describes his cause as "[a] war against Christians and infidels," or Iran's Ayatollah Ali Khamenei, who has labeled the United States "the devil incarnate." Nye's approach must therefore be supplemented by a "harder" form of soft power that is prepared to buy off those who are willing to negotiate with us, while sanctioning those who refuse to do so.

To promote the strategic thought that is needed, today's policymakers might delve into some Cold War history. The conflict between the United States and the Soviet Union and communist China was a nasty time, when the great powers fought doggedly for the hearts and minds of the world's citizens -- most often without putting boots on the ground.

What's most impressive about non-kinetic strategy during the Cold War was Washington's willingness to manipulate elite and popular preferences in order to advance its policy objective of containing communism. By promoting land reform and industrialization in East Asia and Latin America, for example, the United States helped to create entrepreneurs and new economic interests that sought growth and political stability over peasant and proletariat revolution. While some undesirable authoritarian leaders were undoubtedly kept in power during this period, it is a startling and under-appreciated fact that only a handful of countries around the world fell to communist insurgents. This was not simply a function of their willingness to use the tools of violent repression to curb domestic uprisings: In such countries as Chile, the government also promoted -- with Washington's support -- an economic development strategy that ultimately eroded the traditional, landed power structures.

When the United States deviated from the emphasis on non-kinetic instruments, as in Vietnam, it proved a serious mistake. Among the many tragedies of Vietnam is that its historical shadow continues to obscure the many successful episodes of intervention that both preceded and succeeded it. Take, for example, the Huk Rebellion in the Philippines during the early 1950s, which was a communist-led movement aimed against that country's landed elite. The policies advanced by the United States to counter this insurgency included legal services to tenant farmers, the ability of poor people to send cheap telegrams to government officials to report abuses by the military, and the creation of an Economic Development Corps (EDCOR) that worked with former Huk rebels to resolve their economic-based grievances. In fact, the Philippines may be the country where the link between counterinsurgency and economic development has been most self-consciously forged.

American diplomats in Manila proved adept at spotting cleavages within the Philippine government and the country's elite. The U.S. government conducted economic missions that pointed out the need for land reform among other structural changes in the economy, and these findings were widely publicized in the local press. Similarly, import-substituting industrial policies won the allegiance of growing numbers of urban business leaders. To be sure, the American military also provided supported to the Philippine armed forces, but that was largely aimed at stopping its use of violence towards its own citizens while creating a program of "civic action." In short, American aid was used to divide elites and to promote a set of reform measures that undermined the Huks' political and economic appeal.

Similarly, President John Kennedy played an active role in America's involvement in Venezuela during the early 1960s, when that country was threatened by a communist-backed insurgency. The United States provided financial support to the regime of Rómulo Betancourt for a wide range of social programs, while it backed negotiations with other elite groups -- including the military, Catholic Church, and petroleum interests -- who opposed the government's reform measures. Again, military assistance was provided to the government, but mainly in the form of technical support and training.

Today's policy community can draw powerful lessons from this forgotten history. First, non-kinetic instruments can and do work in many instances. This is because, to put it bluntly, the allegiances of most people can be bought. This is even true with fundamentalists: At least some terrorist and jihadist activity in Somalia and northern Nigeria, for example, is bolstered by poor economic conditions. To be sure, non-kinetic programs can be expensive: It takes real money to increase economic activity, even in poor countries -- this is not foreign policy "on the cheap."

Second, successful strategies require a careful matching of means with ends. It is unlikely, for example, that a military invasion can be stopped by the use of non-kinetic instruments. For example, Russian troops are massed on the Ukrainian border, and no amount of non-kinetic tools can stop them if Putin gives the order for them to pour into eastern Ukraine. Still, it is plausible that the sanctions that have been adopted have played some role in causing Putin to rethink his aggressive strategy, even without the threat of military involvement.

Third, policies for conflict zones cannot simply mimic those used in more highly developed markets -- the same rules do not apply. In these troubled regions, Western states must be willing to work with some unsavory characters, quite possibly in ways that do not meet the contracting standards written up by teams of lawyers in the comfort of their offices on K Street or the Strand.

In an important sense, Russia and Ukraine exemplify both the opportunities and limits of a strategy of non-kinetic intervention. Even with the limited tools at our disposal, however, the West's response can go well beyond what it has done so far: Sanctions imposed on Russia should be greatly expanded and buttressed by an effort to undermine Putin's instruments of power, which are primarily in the military and natural-resource realms. On the military front, Western countries should actively counter any Russian effort to export its weaponry to countries like India or Malaysia, offering better equipment and more attractive terms to potential buyers. This would undermine Russia's ability to raise the cash needed for investment in its domestic defense industry, especially at a time when its own economic resources are dwindling. 

On the natural resource front, Europe should immediately begin to take the steps needed to diversify away from dependence on Russian oil and gas. Yes, this will take some time -- but the very threat of diversification will make Russia's oil oligarchs reconsider the costs of supporting the Putin regime. Obama can contribute to this effort by promoting exports of American fuel to Europe for reasons of national security, while continuing to impose economic sanctions on Russia and those elites who are Putin's greatest supporters.

The crucial starting point for any strategy of non-kinetic intervention is to recognize the world for what it is: a violent place where both state and non-state actors will continue to act ruthlessly to secure their own interests. In such a world, our ambition must often be limited to the neutralization of contested environments so that they no longer threaten us. Getting from here to there will undoubtedly require some treasure, but that is always less costly than spilling blood.

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