“I want to make them feel safe because I have never felt safe.”
Like many kids, Maram Faraj grew up wanting to be a superhero. She loved their brightly colored costumes, their grandiose capes and the way they always managed to swoop in at just the right time. Her dream didn’t fade when she shelved the bedtime stories — it just had an outfit change.
Now, at 23, Maram still envisions herself flying over her hometown and protecting civilians from harm. Trading the unitard for a tailored blazer and the superhuman flying powers for a jet plane, Maram has set her sights on becoming a flight attendant. After a particularly warm encounter with a flight attendant on a plane ride to visit family in Saudi Arabia, Maram realized the innate power the job holds: making others feel safe and protected.
Maram is a Palestinian woman living in Gaza: a 140-square mile strip of land densely populated by upwards of 2 million people. For her, safety has never been a given.
“I don’t feel safe in my country,” she says. “I always feel like I’m going to be the next victim. I always think about the way that I will die. Sometimes I ask myself, ‘Will I ever die normally?'”
Maram’s concerns mirror that of countless Gazans, especially in light of the violence this May between Israel and Hamas militants. Gazans’ life experiences underscore the unique emotional challenges they face living under constant occupation and frequent conflict. A study released this summer says 9 out of 10 children in Gaza suffer from some form of conflict-related trauma.
The 11 days of intense fighting in May killed at least 248 Palestinians, 66 of whom were children, and injured about 1,900; destroyed schools, media offices, and medical facilities; and displaced upwards of 72,000 children.
The May conflict began with protests against the planned displacement of several Palestinian families from the Sheikh Jarrah neighborhood in East Jerusalem and an Israeli raid on worshippers at al-Aqsa Mosque. Hamas and other militant groups in Gaza fired over 4,000 rockets into Israel in retaliation. While 90% of those rockets were intercepted by Israel’s Iron Dome air defense system and hundreds of unintercepted rockets misfired and fell back into Gaza, about 60 rockets still made it into population centers in Israel, killing 12 people, including two children.
As a result of the uptick in violence in May, 91% of Gazan children now suffer from some form of conflict-related trauma, according to a new report from the Euro-Mediterranean Human Rights Monitor, a Geneva-based independent, nonprofit organization that the Israeli government outlawed in 2016. The study, which surveyed 530 children across Gaza to observe behavior changes after the May siege, found that prior to the attack, about 33% of children in Gaza needed mental health support as a result of conflict-induced trauma. The violence disproportionately impacted women and children, who, the report stated, comprised 75% of the residential neighborhoods that Israeli Defense Forces targeted.
Widespread trauma is not new to Palestinians living under Israeli occupation and in the diaspora. This is especially the case for those living in Gaza, for whom the May bombings mark the latest in a series of catastrophic attacks over the years. The 2021 siege marks the fourth major escalation a 13-year-old child in Gaza would have lived through, following the wars of 2008, 2012, and 2014.
Israeli children experience the trauma that accompanies this occupation, as well. While they are exposed to less occupation-induced violence because of protection from the Iron Dome, Israel’s robust military, which ranks 14th for the highest military spending worldwide as of 2020, and Hamas’s limited resources, children in Israel are also victims of the conflict. A 2015 study from Dr. Ruth Pat-Horenczyk, the director of the child and adolescent clinical services unit at the Israel Center for the Treatment of Psychotrauma at Herzog Memorial Hospital, shows that Israeli children bordering Gaza in the town of Sderot experienced post-traumatic stress disorder symptoms at a rate of about 40%, three or four times greater than that of the rest of the country. During wartimes in the remainder of the country, child PTSD rates hovered between 7% and 10% at the time the study was conducted.
However, in terms of providing mental health care for its citizens, the situations differ drastically across borders. While Israel has an integrated health care system to treat its people for physical and mental health, the lack of an integrated health care system in Gaza compounded with restrictions on mobility, the blockade on goods and services from both Israel and Egypt, and the threat of violence with no place for shelter leaves Gaza with a traumatized population and a system ill-equipped to help, experts say.
Beyond tensions with Israel, other factors also play a role in straining mental health in Gaza. For one, Western countries’ designation of Hamas — the governing body in Gaza — as a terrorist organization prevents civilians in Gaza from receiving some of the foreign aid they need for medicine, infrastructure and mental health resources from big players such as the United States, the European Union, and the United Kingdom. Although these entities still provide humanitarian aid to Palestinians in Gaza — with the U.S. State Department pledging $150 million to U.N. Relief and Works Agency for Palestine Refugees (UNRWA) in April of this year — past reconstruction efforts have fallen flat largely because of international opposition to Hamas, according to a report from the Brookings Institution.
Domestic barriers to mental health treatment access exist, as well — including both cultural stigmas against mental health care that prevent Palestinians from seeking treatment services and concerns about corruption within Hamas’s governance in Gaza that makes it difficult to create a functioning health care system.
Lack of Mobility
It is no secret that trauma is widespread in war-torn lands — and Gaza is no exception. Dr. Jess Ghannam, a Palestinian-American psychologist and researcher on the long-term health consequences of war on displaced communities, says that lack of mobility in and out of Gaza exacerbates the trauma there, as people feel powerless after not being able to get themselves to safety within or outside of Gaza.
People in Gaza are unable to move in and out of the region without approval from the Israeli government. The Gaza Strip has been cut off from the rest of the world for about 14 years now, since Israel imposed a travel ban on all individuals residing within Gaza in 2007. Exceptions are granted on a case-by-case basis, but the travel ban prevents people in Gaza from studying abroad, accessing economic opportunities, receiving certain medical services or simply visiting family and vacationing beyond Gaza in many instances.
While movement is unrestricted within Gaza, as the land is technically self-governed under Hamas, the Strip is small and densely populated — and when bombs drop, there’s nowhere to run. Residents are typically given a telephone warning before the Israeli military begins a bombardment. But media reports this year show discrepancies between how much time international media and Palestinian civilians were warned, from one hour to just five minutes.
“Families in Gaza, parents in Gaza — and this is the thing that’s so painful for me to have to bear witness to — they cannot leave, there’s nowhere to go,” says Ghannam, who has developed community-based clinics in Gaza. “So if a bomb is dropping, even if you give a five-minute warning, there’s nowhere to go. You are in a prison: you’re not able to protect your children, you’re not able to move to a place of safety. That inability to protect yourself and your children just is devastating on communities from a psychological standpoint.”
Strain on Resources and Lack of Infrastructure
The lack of an integrated health care system in Gaza is another challenge for accessing mental health treatment, a substantial barrier considering the high percentage of children and adults requiring treatment for conflict-related trauma. Even before the most recent attacks in May, 51% of children and 31% of adults visiting Gaza Community Mental Health Program centers were diagnosed with PTSD following the 2014 escalation.
A 2017 study published in the International Journal of Pediatrics and Adolescent Medicine also found that among 2,601 Gaza school children surveyed in the seventh, eighth and ninth grades, 25.9% reported suicidal ideation or planning in the 12 months preceding the survey. Suicidal thinking among Palestinian children was higher than the rates of suicidal thinking in the other countries surveyed — which included Iraq, Jordan, Kuwait, Lebanon, Morocco, Tunisia and the United Arab Emirates — “pointing toward a need for improved access to adolescent mental health services,” according to the study.
According to the World Health Organization, public health services are offered by a combination of four facilities across the occupied Palestinian territories: the Palestinian Authority, the United Nations, nongovernmental organizations, and private health care services like pharmacies and clinics. As about 56% of Gazans live in poverty, according to the U.N. Conference on Trade and Development, the main avenues available for mental health treatment are the Ministry of Health, the UNRWA and other NGO efforts.
One of the major sources of mental health relief in Gaza is the Gaza Community Mental Health Program. Dr. Yasser Abu Jamei, the director of the initiative, emphasizes that the health facilities available to Gazans are not enough to serve the mental health needs of a population so exposed to trauma.
The blockade that Israel imposed in 2007 after Hamas came to power only exacerbated an already overwhelmed mental health system by preventing essential medical equipment, medicines, supplies for clean water and other vital resources from coming into Gaza.
“This has been on a population of children who have been living under siege for almost 15 years,” says Dr. Iyad Zaqout, the head of the mental health and psychosocial support unit at UNRWA. “Many of them were born actually when the sieges were already existing so they only know Gaza when it is under siege, they have never seen Gaza without the siege and blockade and all these access restrictions […] that can be basic for any child to live an ordinary life.”
While the term PTSD has widely been used to classify the symptoms of conflict-related trauma people in Gaza experience, medical professionals in the region say that this term doesn’t paint an accurate picture of the type of trauma Palestinian children are dealing with.
“The concept of [PTSD] — that the traumatic event is over and that now we are living in the moment — is not applicable,” Abu Jamei says. “It’s being traumatized and traumatized and not being given the chance to start the healing processes.”
Because the trauma is ongoing, Dr. Alice Rothchild — an obstetrician and filmmaker who serves on the board of the Gaza Mental Health Foundation and as a member of the Jewish Voice for Peace Health Advisory Council — says that health care providers in Gaza have to be constantly prepared for their patients’ progress to be derailed in light of new political aggressions.
“As the children get better, as soon as either there’s another event, or there’s something that reminds them of that event, like hearing an explosion […] little triggers can often trigger sort of a re-flare of the symptoms,” she says.
Among the symptoms of conflict-related trauma in children that Rothchild refers to are bedwetting, night terrors, an inability to concentrate in school and a fear of leaving their homes.
The ongoing nature of the children’s trauma also negatively impacts their development and ability to function as adults, Rothchild adds, since kids who have a hard time concentrating in school are more prone to drop out and the trauma they have been exposed to is likely to impact their social relationships.
“The other thing is that kids that are repeatedly traumatized, it affects their cognitive abilities,” she says. “It’s hard to learn when you’re experiencing chronic trauma. Plus, you add malnutrition and lack of electricity and lack of water and all the other things that go along with living in the Strip — it really impacts the kids’ physical development, their intellectual development, and their emotional development.”
All of these factors make it difficult not only for children to access mental health services, but also for health care providers to treat children suffering from conflict-related trauma even when they are able to access counseling and psychiatric services.
In providing relief for children experiencing symptoms of trauma, Zaqout says that in his work at UNRWA, they try to provide a sense of normalcy or escape for the children they work with.
UNRWA’s child-focused mental health programs are offered through their schools and provide counseling sessions to students who display treatment needs, group activities like team sports and games, and art therapy. These programs serve to address the issues the children are dealing with while also providing them with positive, social releases that create a sense of normalcy.
Zaqout especially emphasizes the importance of strength-based approaches in addressing trauma within children in his work at UNRWA.
“The best way that the child can recover from trauma and the context in Gaza is actually to improve their self-esteem and self-confidence,” he says. “Their self-esteem and self-confidence can be a kind of a defender, or an immunity, against reactions to the major trauma and to the existing trauma.”
In doing so, counselors focus on the child’s strengths — whether it be hobbies or talents or social skills — and try to foster “post-traumatic growth” as opposed to only focusing on the areas they need to improve in.
But even amid calls for more funding and resources to mental health services in Gaza, the resounding message remains: even with enough resources, ample qualified and community-based doctors, and an integrated health care system, the only long-term solution to the mental health crisis in Gaza — and among Palestinians living under occupation — is ending the violence and threat of displacement.
Steven Sosebee, the president of the Palestinian Children’s Relief Fund, acknowledges that while there is a need for more mental health resources in Gaza, a long-term solution to the mental health crisis in the region goes deeper.
“There’s simply not enough mental health professionals or resources available on the ground to adequately address it,” he says. “And even if you could adequately address it with the number of psychiatrists, psychologists, neurologists, pediatricians, social workers, therapists — even if there were those in plenty supply — they still would not be able to adequately address this huge mental health crisis because the source of that crisis continues, which is the bombings, the siege, the poverty, the closure.”
Despite this reality and the stress it places on children, in particular, hope can still be found among the youth in Gaza.
Unfortunately, Maram’s dreams were put on hold by the occupation after she learned that the only commercial airport in Gaza was destroyed by airstrikes in 2001, when she was just 4 years old. When she applied to study abroad in the United States and had to obtain a visa from the embassy in Jerusalem, she was denied entry.
Despite the challenges she has faced in Gaza — struggling with depression and suicidal thoughts as a result of the obstacles she has faced in realizing her ambitions, seeing violence and destruction firsthand, and her own personal struggles — she still holds steadfast to her dreams for herself and for her home, hoping to study abroad before eventually returning to Gaza, where she would like to live long-term.
“My dreams are waiting for me,” she says. “If I stop here, no one will ever be able to make my dreams come true. No one will ever be able to achieve my dreams for me, but me.”
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Palestinian Children Face Constant and Unique Trauma in Gaza, Experts Say originally appeared on usnews.com