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Anthony Feinstein is a professor of psychiatry at the University of Toronto and on staff at Sunnybrook Health Sciences Centre.

Western journalists working in Syria are more psychologically distressed than their colleagues who covered conflicts elsewhere.

This new and worrying finding in the Journal of Aggression, Conflict and Peace Research begs the question why? Syria today is a charnel house, but so too was Iraq at the height of the insurgency. So what sets the Syria situation apart and what might these findings mean for journalists in the context of a long-running war with no end in sight?

In trying to answer these questions, it is both helpful and sobering to step back in time. Last year marked the centenary of the onset of the First World War, a conflict that ran for more than four years and saw the death of over seven million combatants. During this unprecedented bloodletting, two journalists were killed. To be sure, journalists were in the field covering the conflict. Philip Gibbs of The Daily Chronicle was knighted for his reporting, and his description of the Battle of the Somme remains one of the defining accounts of this calamity. Fast forward 90 years to the U.S.-led invasion of Iraq in 2003: In the first three months of the war alone, a period in which coalition military casualties were light, 16 Western journalists died.

No single factor can account for this surge in mortality, but greater derring-do in today's journalists has certainly played a role. Mr. Gibbs was not in the trenches and did not go over the top on July 1, 1916. Instead, he held back to observe the battle from a safer vantage point. In Iraq, his colleagues showed no such reticence. Not only were some embedded with the cavalry racing across the desert to Baghdad, others unattached to military units were on occasion in the vanguard of the army. It made for dramatic reportage, but such behaviour comes with increased risk.

There is, however, another key factor that has entered the equation when searching for an explanation for all these deaths. Journalists are now firmly in the cross hairs of combatants and insurgents. The kidnapping and beheading of Wall Street Journal reporter Daniel Pearl in 2002 sent this unmistakable, chilling message. Murdered because of who he was, an American and a Jew, it signalled to the Fifth Estate that their status on the frontlines of conflict had changed. They too had become targets.

The assassination of 11 journalists working for Charlie Hebdo in Paris this month represents one more step in this escalating threat. Until then, the danger from Islamic extremists had been confined largely to countries wracked by internecine violence, geographically far removed from the leafy boulevards of a great European capital. September 11 and the London and Madrid bombings had shown the far reach of terror, but these attacks were not primarily aimed at journalists. Charlie Hebdo changed that.

So what does this altered landscape mean for reporters, photographers and now, satirists? The answer is many things, some known and others still to be determined. Amongst the known is recognition that when confronted by threat, no longer abstract but now very real, psychological resilience is tested. For over 15 years, this has been the focus of my research. I have collected data on how journalists have responded to, and coped emotionally with, reporting the genocide in Rwanda, the long-running Civil Wars in the Balkans, the attacks of 9/11, the wars in Iraq and Afghanistan and the drug-fuelled violence of Mexico.

The gist of my data reveals that the majority of journalists are resilient in the face of adversity. They do not succumb to post-traumatic stress disorder, depression, anxiety or substance abuse. There is, however, a smaller number, estimated to be around 20 per cent who, over the course of a couple of decades covering war, do not fare so well. While a finding like this speaks to the cumulative effects of prolonged exposure to danger, there is another statistic, what epidemiologists refer to as point prevalence, that addresses current levels of distress. Here, the percentages are much lower, in the single digits, for they reflect the emotional state of the journalist at a brief moment in time. This statistic is particularly useful in following longitudinal trends. What the point prevalence shows is that the levels of distress in relation to Rwanda, the civil wars in Serbia, Croatia and Bosnia, and the invasions of Iraq and Afghanistan have remained fairly constant. The frequency with which journalists endorsed symptoms of PTSD and depression, to focus on the two major psychological sequelae of conflict, have fluctuated very little over time.

This chronology brings me to Syria and a Civil War which has dismembered the country, left swathes of its cities in ruins, killed over 200,000 of its citizens and according to statistics kept by the Committee to Protect Journalists (CPJ) made it the most dangerous place on earth for journalists to work in. Of the 61 journalists killed in 2014, 17 were working in Syria. Ukraine and Iraq follow on the CPJ list. Each saw five journalists killed.

Not only are more journalists dying in Syria than elsewhere, their psychological health is starting to fray. Evidence for this comes from a recently published study that tells a different story from the data collected in earlier conflicts. When compared to findings from the second Gulf War (Iraq 2003), the Western journalists covering Syria include many more women and freelancers. They are also more likely to be single. Depressive symptomatology is more frequent and severe, unlike PTSD phenomena, which remain relatively constant. Of note is that depression in this context reflects not only sadness and despondency, but also emotions such as helplessness and a sense of worthlessness.

So let me return to the question posed earlier: What is it about the conflict in Syria that has produced this deterioration in mood specifically? One possible explanation is the altered demographics. For example, an often-replicated finding from the general population shows higher rates of depression in women than in men. In addition, a good marriage is known to be protective for psychological health. It could also be plausibly argued that freelance journalists, without the resources of a big news organization behind them are more vulnerable to the unpredictable vicissitudes of a war zone.

The data was therefore re-analyzed taking into account these three potential influences. The gist of the findings never changed. A different set of demographics is not the answer. Instead, we have to look at the nature of the conflict itself. For journalists wanting to work in areas not controlled by the Syrian government, there are no safe places, no pockets of relative calm and stability where they can drop their guard for a moment and relax. Even in Iraq, during the height of the insurgency, there were bureaus where journalists could take off their flack jackets, put their feet up and momentarily escape the war that surrounded them. News organizations spent large sums of money to create safe havens for their staff. In Syria, there is none of this. The telling of this war has, with some notable exceptions, been outsourced to the freelancers.

Then there is the challenge posed by kidnap. Holding a journalist for ransom can prove lucrative for insurgents. Islamic State, amongst others, has placed a bounty on the heads of journalists. The money offered is substantial, tempting some fixers to abandon often long-standing loyalties and hand over a journalist for a sum of money that could only have been dreamed about. This too is a relatively new and lethal threat for journalists, and it has taken root in the Syrian chaos.

Finally, there is the despondency that arises from bearing witness to unremitting, brutal conflict without being able to bring about change. The journalists, forced by circumstance to live amongst the local population have become the intimate chroniclers of the devastation visited upon their hosts. No matter how powerful the story or photograph the killing goes on. To a man and woman, every journalist is quick to say that their distress pales compared to the suffering of the Syrian people. Indeed, even admitting to feeling depressed can generate some painful soul searching and the self-accusatory question, what right have I as a witness to feel this way when the local population have endured infinitely worse? But thinking like this only compounds the problem. There is no equivalence. Emotional distress, like all abstract phenomena, lies along a continuum. The civilians who have lost their homes, seen their relatives tortured and killed and had their future taken away from them and their children, occupy the far end of this continuum. They are alone in this, the magnitude of their trauma beyond the experiences of others. But this cannot negate the emotional pain of others who have documented this plight for weeks going on months and now years. Their place is someway down this continuum, but it cannot be denied.

What the Syria study has shown is that a confluence of factors are at work that have the potential to uniquely undermine the emotional well-being of journalists. War has always been dangerous, but in Syria new and particularly malevolent threats, ironically exploiting mass media to draw attention to their cruel intent, have surfaced. If one views these against a backdrop of long-running, unremitting violence that renders individuals powerless to affect change, even those whose words and images can reach a worldwide audience, then it becomes easier to understand where feelings of helplessness and sadness come from. There is no ending in site to Syria's agony. Journalists who chose to work in this maelstrom know the risks. Nothing ever happens to the brave reads the title of a biography of Martha Gellhorn, herself a great frontline journalist. If only it were true. Saluting journalists' courage, while important, will not keep them safe or healthy. That responsibility falls on their own shoulders and those in news organizations who send them into harm's way.

Anthony Feinstein is the author of Journalists Under Fire: The Psychological Hazards of Covering War.

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