“Have you ever seen a six-month old baby with exaggerated startle response?” One of my colleagues who works on our telephone counseling service was calling me for advice on how to respond to several distraught mothers asking her how to help their babies who had started showing such distressing symptoms of trauma during the recent bombing. Our telephone service was back and responding to callers on the third day of the attacks on Gaza, though of course with certain difficulties.
The question took me back 20 years to when I was a young resident in the pediatric department at Nasser hospital in Khan Younis, Gaza’s second biggest city, in the southern part of the Gaza Strip. Then, my plan was to become a pediatrician. The hospital, on the western side of the city was not far from the Israeli settlements. Often in the middle of the night I used to receive mothers arriving in the pediatric emergency department with tiny children who had started screaming with no clear reason. Physical examination mostly revealed nothing abnormal. Perhaps this was the trigger that made me train to become a psychiatrist.
During those nights, you could often hear shooting from inside the Israeli settlement’s high fortifications, with the bullets mostly ending in the walls of the Palestinian homes and other buildings that faced the settlements. That was the common experience we adults were used to, and of course something that children, even the very youngest, also had to live with.
Thinking about those mothers and babies, I then asked myself about the likely psychological consequences of this 11-day offensive on the people of the Gaza Strip, and how it is going to be different from 2014’s Gaza war which lasted for seven weeks through July and August, including a ground invasion into Gaza. There were then 2,251 Palestinians killed and 11,000 wounded.
AFTER THE 2014 WAR
In 2014, we formed in the Gaza Community Mental Health Program (GCMHP) what we called crisis response teams, that were usually composed of a man and a woman, both psychologists. Their main task was to provide Psychological First Aid: to give some psychological support and detect and refer cases in need of further interventions to our three community centers. Parents often were talking about changes that their children had begun experiencing. Children were having poor concentration, sleeping difficulties and night terrors, bed-wetting and irritability. Younger children were clinging to their parents.
During the four months that followed the attacks in 2014, 51 percent of children visiting our centers were diagnosed with post-traumatic stress disorder (PTSD), another 11 percent were diagnosed with bedwetting. For adults, 31 percent were diagnosed with PTSD while 25 percent were diagnosed with depression. During those months, almost 20 percent of the people that were visited by the crisis teams were referred to our community centers for further assessment and therapy. The U.N. Children’s Emergency Fund (UNICEF) reported then that more than 370,000 children were in need of mental health and psychosocial intervention. Would these figures predict anything for after the 2021 offensive?
We know now the physical effects: at least 242 people were killed in Gaza, including 66 children, 38 women (four pregnant) and 17 elderly people. The injured are around 1,948 people—an iconic figure for every Palestinian. It includes 610 children and 398 women and 102 elderly people. Moderate-to-severe injuries affect 25 percent of the injured. During the offensive 107,000 people were internally displaced with about two thirds of them seeking shelter at United Nations Relief and Works Agency schools.
We saw six hospitals and 11 clinics damaged, and there are some ironic stories. It was on May 17 that the Rimal primary health care center situated within the Ministry of Health (MoH) compound in Gaza city was attacked. The center included the main laboratory for COVID-19 tests and was partially affected. The MoH had to stop the testing and asked people who were supposed to get their second shot of vaccine to go to Al-Daraj primary health care center across Gaza City. However, that center, too, came under attack, as there was a house in the area that was bombed in an air strike. The Rimal clinic was also the place to get vaccinated in Gaza city. Luckily the damage to both clinics was partial and the Rimal clinic soon resumed service. However, a young physician, Dr Majed Salha was severely injured on his head, and his condition is critical.
ONGOING MENTAL HEALTH CHALLENGES
Only weeks ago, COVID was the main concern in Gaza as in any other place in the world. People calling our telephone counseling line at GCMHP or people we were meeting either in the community or at the community centers presented with two main and interlinked complaints or challenges. One was how deeply the economic conditions were affecting their lives. The unemployment rate in Gaza, even before the bombings, was 43.1 percent, and for people under 30 it was 65.5 percent. Even among those working, many are in casual employment, living from hand to mouth. Taxi drivers, or those who sell vegetables at the open markets were badly affected by the COVID-related restrictions on movement and other measures such as social distancing and closing of some of those open markets. Depression and high anxiety were rife as men were unable to provide either sanitizers or simply food for their families.
The second fear was always how to deal with their children under such restrictions and with schools closed. We have on average five children per household, and we live in one of the most crowded areas in the world with more than 13,000 persons in one square mile. Those children, not being allowed to leave their homes because of COVID restrictions, were badly in need of support.
Two weeks before the offensive the MoH was dealing with the second wave of COVID with about 35 to 40 percent of the people being tested showing positive. Suddenly those COVID-related concerns were overshadowed by the fears related to the airstrikes, the bombing and survival. How is that going to impact the psychological wellbeing of the population?
AN UNPRECEDENTED EXPERIENCE
In one night, it was reported, 160 warplanes attacked 450 targets in less than 40 minutes in northern areas of the Gaza Strip. The strikes happened at the same time as 500 artillery shells were fired. People from outside Gaza asked us if this experience was similar to what happened in 2008 when the first strike took place. On Saturday, December 27, 2008, at around 11:20 A.M., suddenly people in the whole Gaza strip were overwhelmed with the sounds of bombardment and the view of a huge mushroomlike smoke plume that was all over the place. It was a moment where children were either going to schools (afternoon shift) or returning from schools (morning shift) and everyone really was in a state of shock. At that moment about 60 fighter planes carried the first attack in less than one minute. People asked us whether this felt the same. Perhaps it looks the same, but there is a critical major difference.
In 2008 the bombing was a single minute or two minutes, and it was across the whole Gaza strip (140 square miles). But what happened in these 11 days is entirely different. The strikes continued for about 25 to 30 minutes, or sometimes up to 40 minutes in the same city or geographical area. You could hear continuous bombing in your own city, in your own small geographical area, that continued for about 25 to 40 minutes. In all that time neither you nor your children nor your wife nor any other family member would feel that they could take even a single breath.
The continuous bombardment and shelling that continued in different cities on different nights meant that no one really could feel any moment of safety. All of us had our nervous system at its very highest alarm level for more than 25 and up to 40 minutes. I can say that this is the most fearful experience that I have had throughout four large offensives over the years.
This type of attack caused extreme fear to the two-million population, traumatizing almost everyone.
Another key difference to keep in mind is that most of the areas that were attacked were in the heart of the cities. We witnessed the flattening of 13- or 14-story towers and many other buildings. Some families were just eliminated during those attacks. In Al-Shati camp one family had 10 people killed including eight children and two women. Fourteen families lost more than three members and some of them were killed outright.
The fear and terror that we lived with through the 11 days was something unprecedented. So, do we expect to see more people and with a similar diagnosis to 2014, or 2012, or 2008? Maybe, but definitely the lower number of people who were killed or injured does not indicate a lesser psychological impact on the population. We already see children presented with night terrors, and pains in their knees and abdomen, and parents report clinging sons and daughters. Men and women alike complain of joint pains, low back pain and difficulty in concentration. Many say that they are not sure if they are living a big dream or a reality. And the worst-affected people show severe psychological impact including dissociative symptoms. In any case, we are still in early days and we will need more time to have a better understanding of the impact.
One might think that this will be our only concern, but that is not the case. In the first few days after the ceasefire with COVID testing resumed, only a few hundred tests were made, but on average one third of the results were positive. Tens of thousands of people were displaced and stayed in school classes or at their relatives’ homes, making the whole community inevitably much more mixed and crowded. As you may imagine, COVID measures were not all carried out.
Our hospitals are already full of injured people, the health system is struggling. And it seems that we are on the verge of a third COVID wave. A wave where out of the two million people only 40,000 have been vaccinated. We have just escaped the hell of airstrikes to find the hell of COVID-19 at our doors. We are moving from living under occupation and offensive to life under occupation and blockade, with COVID.
Ours is a life that you will never understand unless you are a resident of Gaza. Outsiders love to call us resilient human beings, rather than see our reality. As the English poet T. S. Eliot wrote in 1936, “Humankind cannot bear very much reality.”