This article is part of the Strife Series on Women and Children’s Health in Conflict. Read the Series Introduction at this link.
In recent years, the urgent need to address the global burden of mental health disorders has grown exponentially. Huge efforts have been undertaken to investigate this in low and middle-income countries (LMIC), where many factors exist that are detrimental to mental health. These include political, economic, social and individual factors1,2. Moreover, the demographic distribution of LMICs, where on average 50% of population is under the age of 18, makes intervention all the more pressing3,4. This is supported by evidence that most mental health disorders emerge at younger ages, making it a global responsibility to cooperate and establish evidence-based strategies for Child and Adolescents Menta Health (CAMH) services in these countries5.
In this context, conflict zones have been of special interest, as it is evident that the burden of mental health in such settings is higher than in areas without conflict2,5. A well-established example is the devastating effects of the ongoing Israeli-Palestinian conflict on the Palestinian CAMH. Among Palestinian adolescents in Gaza Strip, 94.9% reported severe anxiety, 68.9% had post-traumatic stress disorder (PTSD), and 40% reported experiencing severe depression6.
Since the beginning of the second intifada, uprising, in 2000, there has been a constant increase in reported psychological and emotional symptoms among Palestinian children7. This is unsurprising as the occupied Palestinian territories (oPt), especially Gaza, have been through multiple military assaults and violent events. This has led some national and international organizations to argue that an epidemic of mental illness exists amongst Palestinians in the oPt, and that it is particularly harmful for children and young women.
Different factors need to be considered when speaking about Palestinian children’s mental health issues, which broadly fall into direct or indirect causes. Direct factors involve witnessing traumatic events experienced by people around them, such as a relative or a friend being killed, injured, targeted, or imprisoned. The effect of these factors is evident in the countless children who are lie awake at night, tormented by resistive nightmares, and mental images of mutilated bodies and buildings or houses being bombed7.
Indirect factors can be seen in the negative knock-on effects of the blockade and the subsequent lack of resources and opportunities for Palestinians. Unemployment, poverty, loss of hope and learned helplessness are major detrimental social factors that affect Palestinian families. Parents, especially fathers, experience high levels of anxiety, says Dr. Sami Oweida, a psychiatrist at Gaza Community Mental Health Program (GCMHP). Fathers in the Palestinian culture are the family leaders; therefore, they are expected to be the most resilient, and they have to complain less and show strength almost all of the time. He adds that parents take out this anxiety unwillingly on other family members, often including children. This situation aggravates the children’s already existing psychological difficulties because of the aforementioned conflict-related factors. Dr Oweida pointed to an example of one of his clients, who was already receiving treatment for PTSD related to the 2014 attacks on Gaza and was injured during the Great March of Return in 2018. ‘[H]e had not been fully treated, but he went to the border again, one of the explanations could be the release of anger in a socially proper way’.
More than 70% of Palestinian children show symptoms that qualify for the diagnosis of PTSD. These include reexperiencing traumatic events through flashbacks, nightmares, and compulsively recalling distressing images. Children also show symptoms of avoidance and withdrawal from their environment as well as hyperarousal and hyperactivity. Another endemic disorder is Separation Anxiety6. Children feel distressed, anxious and afraid when they separate from their families or parents. This has affected their academic performance, their social activities, and their self-confidence.
In the Gaza Strip, and after fourteen years of continuous blockade, it was unsurprising to hear the senior health advisor of Save the Children say, ‘A whole generation of children in Gaza is balancing on a knife edge where one more shock could have devastating life-long consequences’. But what can be done? Three major problems stand in the way of the delivery of therapy to affected children.
First, mental health professionals in Gaza agree that children do not suffer from just PTSD, where a single traumatic event results in the symptoms of PTSD. Instead, they are afflicted by ongoing traumatic stress syndrome, that it is, the continuous and multi-origin experience of trauma among Palestinians, especially the children. A leading clinical Psychologist at GCMHP said that the children do not have sufficient time to recover from previous traumatic experiences before they encounter a new one. In Gaza there were four major violent escalations between Palestinians and Israelis in less than eight years from 2006 to 2014. This has led to a near constant experience of trauma, which results in an aggravated and a cumulative effect on Palestinian children.
The second problem exacerbating the situation is that those helping are themselves not protected from the effects of traumatic life events in Gaza. Professionals who work with children are also suffering and trying to cope with their traumatic experiences. Once clinical psychologist, who is a leading professional at GCMHP and focuses on PTSD patients, lost six immediate members of his family in 2014. Mohammed Mansour, a trauma specialist at Physicians for Human Rights has said ‘mental health specialists in Gaza have no other option than to digest their emotional and traumatic difficulties before they go to treat their clients’.
Finally, mental health infrastructure, resources, and staff are extremely limited in Gaza. For the two million residents of the strip, there is only one certified child psychiatrist, despite the fact that half of the population is below the age of 18. Additionally, less than 2% of the Ministry of Health’s budget goes towards mental health services6.
In the oPt, whole generations of children have known nothing but war, blockade, poverty, and unemployment. This has resulted in unprecedentedly high levels of mental health illness and psychological afflictions for this population. A lack of resources, continuity of trauma and the helpers themselves being exposed to the situation have exacerbated the situation. However, people and children have never lost hope, and they continue to dream of a better, more peaceful, future.
- Chisholm, D., A. J. Flisher, C. Lund, V. Patel, S. Saxena, G. Thornicroft, and M. Tomlinson. 2007. “Scale up services for mental disorders: a call for action.” Lancet 370 (9594): 1241-52. https://doi.org/10.1016/s0140-6736(07)61242-2.
- Eaton, J., L. McCay, M. Semrau, S. Chatterjee, F. Baingana, R. Araya, C. Ntulo, G. Thornicroft, and S. Saxena. “Scale up of services for mental health in low-income and middle-income countries.” Lancet 378 (9802): 1592-603. https://doi.org/10.1016/s0140-6736(11)60891-x.
- de Jong, J. T., I. H. Komproe, and M. Van Ommeren. “Common mental disorders in postconflict settings.” Lancet 361 (9375): 2128-30. https://doi.org/10.1016/s0140-6736(03)13692-6.
- Steel, Z., T. Chey, D. Silove, C. Marnane, R. A. Bryant, and M. van Ommeren. 2009. “Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis.” Jama 302 (5): 537-49. https://doi.org/10.1001/jama.2009.1132.
- World Health, Organization. 2009. Mental health systems in selected low- and middle-income countries: a WHO-AIMS cross-national analysis. Geneva: World Health Organization.
- Elbedour, S., A. J. Onwuegbuzie, J. Ghannam, J. A. Whitcome, and F. Abu Hein. 2007. “Post-traumatic stress disorder, depression, and anxiety among Gaza Strip adolescents in the wake of the second Uprising (Intifada).” Child Abuse Negl 31 (7): 719-29. https://doi.org/10.1016/j.chiabu.2005.09.006.
- Vostanis, Panos. 2003. “Impact of trauma on Palestinian children’s mental health: lessons from the Gaza studies.” International Psychiatry 1: 5-6. https://doi.org/10.1192/S174936760000641X.
Dr Bahzad Z F Alakhras
Bahzad Alakhras is a medical doctor who trained in Gaza and later studied Child and Adolescents Mental Health MSc at King's College, London. He is interested in child war trauma and mental health in conflict context.