Sally Hayden
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Inside a traumatised Aleppo: “Many children may suffer in the future”

“Syrian families are supposed to live next to each other. Now they are all gone.”
 

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.

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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.”

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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.

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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.

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“They are leaving at an alarming rate”: European NHS workers on the winter crisis, austerity, and Brexit’s impact

“It’s a house of cards, and we’re getting closer and closer to the point where it’s all going to collapse.”

This winter, for the first time in five years, Joan Pons Laplana, an NHS project manager and transformation nurse from Norfolk, “went back to working the front line” because his hospital “had no nurses”. As was the case in many other NHS hospitals nationwide, wards were closed, non-urgent appointments and operations cancelled, and their resources focused on A&E.

“We managed to put a plaster to stop the crisis, but now we need to catch up with the patients and operations and everything,” he says. “And that's like a catch-22.” NHS England recommends a working capacity of around 85 per cent in hospitals to absorb the winter’s patients rise, but Pons Laplana’s hospital is “constantly” working at 90 per cent, he says. “It’s a high stress environment, constantly low on resources and doctors. And now we don't have enough staff.” He sighs: “It’s getting more and more difficult to deliver safe care. At the moment, we’re playing Russian roulette.”

Originally from Barcelona, Pons Laplana has lived and worked in the UK for 17 years. He is one of around 62,000 EU citizens who currently work for the National Health Service, according to House of Commons statistics. Amid the winter crisis and severe financial pressure, the NHS’s next big problem is already unfolding: the prospect of Brexit is driving European NHS workers away. Within England’s NHS services, EU nationals make up almost 10 per cent of doctors, more than 7 per cent of nurses and 5 per cent of scientific, therapeutic and technical staff. Almost 10,000 EU workers had already left the NHS when NHS Digital released its 2017 data last autumn.

“If none of the EU citizens were [in my hospital], I can say without any exaggeration: you could absolutely close tomorrow”, Dr Peter Bauer, 47, a consultant anaesthetist in a Brighton hospital who has worked in the NHS since 1999, tells the New Statesman. In his hospital, he says, the proportion of EU staff is “phenomenal”: “Well over 50 per cent of senior staff is European, it’s about three quarters of the people. It would be disaster.” Mary, a 37-year-old British nurse from London, says her clinic, which employs many Europeans, is struggling to find a cover for her colleague on maternity leave: “Recruitment has fallen massively since Brexit.” With the British government still unclear on citizens’ rights, it is unlikely to stop there.

The ability of competent, skilled European staff to move seamlessly to the UK from the continent, thanks to the EU's freedom of movement, has been “a boom for the NHS”, Bauer says. Recruiting elsewhere (something the NHS has already started doing) will bring additional costs, visa requirements and various other complications that freedom of movement was designed to avoid. “You need these people! If you can't recruit Europeans, you then have to go out of the EU, and it's much more costly and difficult. It's a house of cards, and we're getting closer and closer to the point where it's all going to collapse.”

“If EU citizens like myself decide to go, it would take about 4,200 years to close the gap.”
Peter Bauer, consultant anaesthetist, originally from Germany

Recruitment from European countries has fallen rapidly. For instance, the number of incoming EU nurses fell by 92 per cent after the referendum, contributing to a shortfall in those able to fill the 24,000 nurse vacancies in England alone.

“For the first time, we have seen a reduction in the pool of EU citizens working for the NHS, and that is critical”, says Bauer, who teaches at medical school and has observed the “mismatch of numbers” in terms of graduates – especially a lack of British graduates. “If you want to fill the increased demand with British graduates, you would have to hugely enhance the capacity of British universities to train doctors, and then you would have to put them through specialty training, and that would take decades.”  It takes “about fifteen years” to train an anaesthetist like himself. He laughs: “If EU citizens like myself decide to go, it would take about 4,200 years to close the gap!” Mary, the British nurse, agrees: “Come 2020, we're going to be in serious, massive crap.”

Jettie Vije, a Dutch national who works as a GP practice nurse in Norfolk, meets the “occasional old patient” wanting to discuss Brexit: “They say, ‘Isn’t it great that we’re leaving the EU?’” Vije has been in the UK for four years, which is less than the five-year threshold for settled status; so “great” may not be the best word to describe her situation “I try to keep it on the medical side and not to discuss whether leaving the EU is good or not”, she says. “I am here to do my job as a nurse.”

“I try not to discuss whether leaving the EU is good or not. I am here to do my job as a nurse.”
Jettie Vije, GP practice nurse, originally from the Netherlands

Every EU citizen in the UK knows others who have left. “On a daily basis, I can see that people are leaving”, Pons Laplana says. Portuguese workers at his hospital are “leaving at an alarming rate”. An Italian colleague of Bauer’s is applying to a job in France (“He is probably going to be gone very soon” ); another one, a Czech colleague, has gone part-time, working four weeks in Czech Republic and four in the UK. “The direction isn't for people to be drawn into the UK”, Bauer says.

Mary, the nurse from London, works with colleagues from all over Europe, from Spain and Portugal to Romania and Poland. “Just hearing the conversations they have...  They feel they're not welcome here anymore,” she says, citing one who just moved to Ireland. “Despite what we say and how much we appreciate them, it really doesn't matter” she says. “They're nervous, so a lot of them are leaving.”

The ones who stay behind aren't just losing friends and colleagues to a political decision in which they had no say. Like every Briton, they are attached to their life in the UK as they know it, and to one of its greatest pillars: their employer and health care provider, the National Health Service. As the recent winter crisis has made years of under-funding more apparent and more critical, just like Brits, they worry the NHS may not recover.

European workers have been part of the NHS and British life for years – in Bauer’s case, decades – and have witnessed different government policies. When Bauer arrived in the 1990s, Tony Blair had just taken office: “Over the first ten years, you could see how pumping money into the NHS was leading to a huge increase in the capacity”, he says. There were “more beds, more nurses and doctors”, and small things, too – like “more hand washing basins”. “As the coalition government, and then Cameron, took power, you could see how the investment was scaled back”, he adds.

The NHS is already in dire straits due to the financial pressures exacerbated by austerity. Last September, Chris Hopson, chief executive of NHS Providers, estimated in the Guardian that the Health Service needed an emergency investment of £200m to £350m to avoid a winter crisis. It didn’t come – and non-emergency procedures were cancelled across the country in January. That shortfall is only the start however, and by 2020, the NHS will face a £20 billion funding gap. The Conservative manifesto pledge of an extra £8bn is considered by leading health think tanks and experts to be inadequate. Inflation and demand, which Bauer says “keep rising”, are deepening the gap.

“At the moment, we’re playing Russian roulette.”
Joan Pons Laplana, NHS project manager, originally from Spain

“When the demand is a lot higher than the funding, then there is a gap and that gap is getting wider and wider each year. That's what provoked the crisis,” says Pons Laplana, who has seen stress in his wards go “though the roof” with the pressures. “I reckon 50 of the team have been off at some point because of the stress”, says Mary, who had to take two weeks off around Christmas because she works in a department that treats life-threatening conditions and it all became too much. “We are GPs, we are counsellors, we are social workers... We're everything at the moment.” To add to the stress, the lack of funding and the nurses’ pay cap are making situations like Mary’s more precarious: she says she had to remortgage her house to pay for a £10,000 training that may allow her to be promoted. “To be able to make ends meet, a lot of the staff do extra shifts, some are working fifty hours to have the same quality of life that they had five, six, seven years ago, and pay the mortgages”, Pons Laplana explains. “But a lot of us are getting tired. Tired people make mistakes. And mistakes cost lives.”

These problems would exist without Brexit, but the decision to leave the EU will exacerbate the health services's problems in ways beyond simply driving workers away. The famed “£350m a week for the NHS” pledge wheeled out by the Leave campaign is credited with helping to win the election, but the drop in value of the pound and economic uncertainty mean that, as Bauer points out, “in actual numbers you're seeing so far a reduction of £350m a week” – less cash in the economy is likely to mean less cash for the NHS.

Mary says she is “immensely worried” about the possibility of the British government selling NHS contracts in a future US trade deal struck to make up for lost trade with the EU: “The essence of what the NHS is, care for all, that will go and the thought of that scares me to the bone.” Brexit, Bauer says, is an “unmitigated disaster”: not just because urgent issues like the NHS’ winter crisis are being overlooked by the “completely paralysed” government’s obsession with the UK’s departure from the European Union, but also because it will exacerbate such issues further. The Home Office’s tightening of migration rules will make it harder for the Health Service to hire critically needed staff, he sighs: “It's one more dimension of self-harm on Brexit.”

“EU workers are leaving at an alarming rate”
Joan Pons Laplana

For the EU citizens who are still here, the dilemma is twofold. Leave, because Brexit has made their future and right to work in this country uncertain? Or stay to see the Health Service they have put so much work in fall into pieces? “I worked very hard for three years to be in the managerial position I have,” Pons Laplana says. “If I go back, I will not have the same job. My home is here. My heart is British.” Vije doesn’t think it will come to her leaving, but until the deal is finalized, she cannot be certain: “I'm just waiting and watching.” Although Bauer doesn’t want to leave either, he has started on his contingency plan: getting German passports for his children. “I don't see a rosy economic future for them in the UK”, he says. “Britain is so divided now, the government is divided, the Tories are divided, Labour is divided, families are divided.” 

“Nothing is agreed until everything is agreed” may work as far as the government’s negotiating strategy goes, but it also means EU workers are left in limbo. At a time when the NHS desperately needs staff, if the “really well trained, hard workers, well-educated” EU nurses and doctors to change their mind and go, they will be sorely missed, Mary says. “But then I think, what would I do?” She pauses. “Probably the same.”

Pauline Bock writes about France, the Macron presidency, Brexit and EU citizens in the UK. She also happens to be French.