Every morning, afternoon and night, Bassam Hayek obsessively checks WhatsApp. He’s flicking through it as we speak, and when he speaks, images of horror, of conflict brutality and domestic abuse he’s receiving through the messaging service run across his mind, forcing him to pause while he filters what he should say aloud.
It’s been one year since the fall of east Aleppo. Slowly, some families displaced by the conflict have begun to move back to their homes. Many former opposition areas remain almost deserted, left without electricity or water, but a few shops have reopened, powering their lights with generators. Hundreds of thousands of the city’s residents are dead or displaced.
But for the estimated more than 1.5 million who are left behind there is another looming issue.
Hayek, the director of Aleppo’s psychiatric hospital Ibn Khaldoun, said the city is facing a mental health crisis – particularly among its children. In the whole of Syria, he told me, there isn’t one paediatric psychiatrist, though this sort of specialism is desperately needed.
I was in government-held Syria on a rare journalist visa. Most of the time I had a minder, assigned by their Ministry of Information, who was present during most interviews. I wasn’t stopped from speaking to anyone and met the majority of interviewees by chance, though many refused to talk explicitly about politics, including Hayek, who said his mission is a medical one. We’ve stayed in touch through Facebook since.
When I visited the hospital’s outpatient centre in central Aleppo, the corridors were lined with patients waiting to be seen. On average, some 250 patients turn up each day, Hayek said. Before the war, they saw as few as 15. The vast majority are suffering from anxiety or depression-related illnesses, including regular panic attacks and sleep disorders.
“Especially, we have the problem of the children,” Hayek said. “Small children, when they see weapons and blood and victims in front of them, they’ll be aggressive in school, at home, they’ll have attention problems.”
Syria’s revolution came to Aleppo relatively late: protests began in 2012. Within months, one of the oldest inhabited cities in the world had become a key battleground. Over the next four years, many families barely went outside for fear of snipers, harassment at checkpoints or other attacks. This was devastating for children, who – unable to run or play with friends – were particularly at risk of developing anxiety and trauma-related disorders.
Hayek said depression, anxiety and sleep disorders are all evident in young people his doctors treat: “For adults they can manage stress in many different ways, but children haven’t any way to manage it.”
Since the war began in 2011, more than half of Syria’s doctors have left a country now labelled “the most dangerous place on earth for healthcare providers.” The medical crisis has been particularly damaging to psychiatry, Hayek said, given it wasn’t a popular specialisation to begin with. There are only 60 psychiatrists left in the whole of Syria, he noted, along with around 30 psychotherapists and 1,000 psychologists.
From Ibn Khaldoun, the only psychiatric hospital in the north, 50 percent of the staff left their jobs – either to go abroad or to move to opposition areas. Despite the borders and checkpoints between them, many stay in touch by Whatsapp, regularly messaging to compare treatments and talk about diagnoses.
Aleppo’s remaining psychiatrists have now begun visiting schools and mosques to offer support, as well as training teachers to diagnose children who need treatment.
One thing Hayek says helps is walking through emergency procedures with young people, and informing them what do to when their school is hit by a bomb or mortar, because this can help them feel more in control. However, a better cure is simple childhood activities: drawing, playing, singing or football.
Children’s resilience also depends on the social network they have remaining, he said. “Our society is built on the family itself.” So many people have left that it’s fractured people’s support systems, leaving many unable to cope. “Some go to Europe, some got killed.”
Over the past few years, Hayek has treated people from across the countryside, including opposition-held Idlib and, until recently, Isis-held Raqqa. Each patient is given a document saying he’s a patient, and Hayek said militant groups, including Isis and Al Nusra, will let them pass checkpoints.
Hayek himself has been captured by Isis. They broke his nose, he laughs with some bravado, adding, “I know how to talk to them.” He said he told them he was a doctor, so they let him go.
In 2013, the building Ibn Khaldoun uses for in-patients was also captured by an Al-Qaeda-associated group, though Hayek says he rarely talks about what happened next.
Militants went through those with mental illnesses, eyeing them up and insulting them, he says. One man, who was suffering from delusions, uttered the words: “I am Allah.” It was considered blasphemous, and he was murdered on the spot.
Hayek himself was forced to move house three times to avoid fighting. He said his own children are longing to go home. “All of us have depression sometimes.”
The World Health Organisation supports the hospital, and sources them unbranded medication. It often comes from Bulgaria or Cyprus, necessary because pharmaceutical companies are worried about US sanctions on Syria. The drugs are often brought through Turkey and Lebanon to avoid detection, Hayek says.
In the longer term, Hayek predicted, there will be a PTSD crisis. “Many children in five or ten years might start suffering in the future.” He estimates that 50 percent of people in Aleppo will need psychological help.
He said there aren’t high rates of suicide, though joked “some of us say we’re still here, so this is a suicide attempt itself.”
“The good thing about the crisis was that it slowed stigma,” Hayek said. “Now people understand (mental illness). Before there was a stigma about psychiatric disease, and psychiatric hospital, and psychiatric treatment, but now it is less.” Before the war, he claimed people used to avoid the area around the hospital because they were afraid of running into patients.
Across Syria and in refugee camps outside, parents ask advice for their children’s persistent health problems. Often, they’re caused by anxiety. The children won’t sleep, refuse to leave home, or simply stop talking, withdrawing into themselves. In Zaatari camp in Jordan, a mother told me her son was developing kidney problems because he was afraid to go to the bathroom. In Lebanon’s Bekaa Valley, a father said his child felt constant pains running all over her body. In a school for children with Down’s Syndrome in Homs, one tutor told me her traumatised students were abnormally active, moving all the time like they were frightened to stop, and become aggressive when they’re asked to.
In one former opposition area in Aleppo’s east, a girl of about six wearing a leopard-print onesie spotted me taking photos. She approached me shyly to invite me to her family’s apartment on the fifth floor of a building close by. From their window, the landscape is flattened, all rubble. At night, theirs is the only light that shines in a neighbourhood that once housed hundreds of their relatives.
Upstairs, her father Huossen, 40, told me of the year they barely left home, when Syrian army attacks continued, while opposition fighters began fighting each other and it became hard to tell which group was in charge. He spoke of an epic 13-hour journey, when he and his wife finally bustled their six daughters and son through checkpoint after checkpoint, paying bribes and praying constantly on their way to escape.
After they left, the final roads to the east were cut off, and the area was bombed regularly by Syrian forces, who have been accused of deliberately targeting hospitals and using a “surrender or starve” tactic to force the rebel groups to give up. The eventual evacuations that happened were classified as a war crime by the United Nations-mandated Independent International Commission of Inquiry on Syria.
Huossen’s family have been back home again since August, but life is hard, and he can see it in his children. “My daughters have fragilities,” Huossen said. “Two of them have stomach problems.” He doesn’t know how long this will last.
Looking out at the destruction that lies in front of him, Huossen then sighed. “It is difficult,” he said. “Syrian families are supposed to live next to each other. Now they are all gone.”
Sally Hayden is an award-winning journalist and photographer currently focused on migration, conflict and humanitarian crises. Save the Children is working in northern Syria to set up safe spaces for children. You can find out more about the charity’s work here.