by Hanna Kienzler, Gwyn Daniel, Weeam Hammoudeh, Rana Nashashibi, Yasser Abu-Jamei, Rita Giacaman
BMJ Global Health, E-mail: 4 October 2024. https://doi.org/10.1136/bmjgh-2023-014835 Open access
Image: SOS Children’s Villages
Summary
–The onslaught on Gaza is leading to catastrophic psychological consequences which will not be limited to the short term and to those directly affected, but will have long-term, intergenerational effects.
–This commentary argues that to understand trauma responses among Gazans, we need to go beyond individual illness and, instead, link the biomedical sphere with the political sphere through the concept of social suffering and, thereby, expose the socio-political conditions of life and the collective trauma-inducing nature of the Israeli military occupation and repression.
–Addressing these complex trauma responses requires approaches that bring together the political, social and personal-level components of mental health with a focus on three factors: safety and allyship; the right to agency and acknowledgement, accountability and reparations.
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Current media attention has mainly focused on the horrendous consequences of Israel’s onslaught on the people of the Gaza Strip, its rates of death, serious injury, on people’s struggle for physical survival and on the destruction of infrastructure. However, the integral mental health consequences of this violent onslaught also need to be highlighted, especially as decades of research have determined and verified that violent conflicts cause and gravely exacerbate overall rates of mental disorders.
The profound suffering experienced by the people of the Gaza Strip is unfolding in the context of the deadliest military assault by Israel against Palestinians since the 1948 Nakba. We are witnessing the wholescale destruction of homes, hospitals, schools, universities, mosques, churches and the vital infrastructure required to sustain peoples’ social and economic worlds. South Africa’s landmark genocide case against Israel at the International Court of Justice (backed by United Nations experts, human rights organisations and scholars) outlines that the mass killings of Palestinians, their displacement, the bodily and mental harm inflicted, the destruction of the health system, the intentional blockade of food, water and medicine and the prevention of Palestinian births constitute genocidal crimes against humanity.
Alongside the systematic destruction of Gaza’s health system with over 1,000 documented attacks on healthcare (i.e. incidents where healthcare facilities were damaged, health workers killed and health workers arrested), the mental health system has totally collapsed. All six Community Mental Health Centres ran out of medications and were forced to close, and the only existing inpatient psychiatric hospital was shelled and can no longer function. No therapeutic support is available to people with severe mental illness and those who are experiencing multiple traumas, grief, vulnerability, uncertainty and helplessness with the likelihood of catastrophic long-term psychological consequences. Children are especially vulnerable to such consequences from their exposure to extreme violence; loss of parents, family members and friends; absence of any safety; the trauma of having their limbs amputated; and the extreme hunger and thirst they experience daily. Reports reveal that children are experiencing acute trauma responses including frozenness, mutism, convulsions, confusion and loss of bladder control. Adults and children alike face extreme anxiety, fear, constant worry about their own safety and that of their loved ones. Even with a cessation of bombing, nightmares and disturbing memories, insomnia, separation anxiety and the bottling up of emotions are likely consequences. Furthermore, caregivers experience acute stress. Parents feel that their parenting capacities are diminished because the inability to protect one’s own children is such a profoundly debilitating experience. A Save the Children staff member in the Gaza Strip, himself a father, said: ‘Death is everywhere. My children look into my eyes every day, they are searching for answers. I have no answers for them’. In the case of orphaned children, caregivers and organisations are overwhelmed with extra responsibility amid minimal resources….
These horrendous experiences must be understood within the context of previous violent assaults. The psychological consequences of this chronic violence and warfare have mainly been elicited through epidemiological research focussing on individual-level responses. For instance, research carried out among Gazan women by Physicians for Human Rights and the Gaza Community Mental Health Programme found that 47.6% showed signs of severe psychological distress and 80.9% demonstrated signs of anxiety. Other research has found high prevalence of fears; aggression; poor psychological adjustment; personality and behavioural changes; neuroticism; low self-esteem; concentration, attention and memory problems; risk taking; anxiety disorders and mood disorders among others.
Without undermining the importance of such research, we need to go beyond individual illness responses. Giacaman has coined the concept of ‘the invisible wounds inside’ to link the biomedical sphere with the political sphere through the concept of suffering. She, thereby, emphasises socio-political conditions and the collective trauma-inducing nature of the Israeli military occupation and repression….
Three factors are essential if healing is ever to take place at individual and community levels in the Gaza Strip: 1. Safety and allyship; 2. Right to agency; 3. Acknowledgment, accountability and reparations.
While we do not claim to know how these factors can be activated in the current political climate, we know that for any of these to have their intended effect depends on ending the war, and a new determination from the international community to demand and promote freedom, justice, sovereignty and self-determination for Palestinians. As highlighted by Article 16 of the Sustainable Development Goals, the promotion of peace and inclusivity also requires building effective, accountable and inclusive institutions at all levels. These are, in any given society, the foundations for living dignified, meaningful and flourishing lives in which hopes, dreams and aspirations feel attainable, and people can achieve mental well-being within their communities and across generations.
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Editor’s Note: Children under the age of 16 make up 60% of the population of Gaza. 70% of those killed in Gaza since 7 October 2023 were children and women. MB