Gaza City

It’s 9 am, and Mohamed Khael is standing before a room full of teenage boys in war-weary and isolated Gaza in late 2017 with a tough message: Don’t do drugs.

One message he wants the kids to take away is that they aren’t alone.

“It’s not just us,” Khael tells a sparse classroom of two dozen 15- and 16-year-old boys, who have lived more than half their lives under a repressive regime and land and sea siege. “[Drugs] are in America, too.”

These anti-drug classes, however, are something relatively new for conservative Gaza, where drug use is highly stigmatized, but widespread abuse of the synthetic opiate painkiller tramadol is now part of the coastal enclave’s many interconnected crises. Khael started giving lessons in schools (for boys only) last year to combat addiction in a police program that’s part of the Hamas-run government’s own “War on Drugs”—despite criticism that Hamas has long profited from the drug trade along the way.

Still, the highs for those connected to the tramadol business are tantalizing and tough to truly tackle. And the lows are particularly painful in a suffocating society with limited health resources and few safe outlets. In this way, the ups and downs of Gaza’s drug market trace the volatile times of people in search of a fix.

Since March 30, when weeks of protests against Israel’s siege and displacement of Palestinians began, the Israeli military has killed more than 245 Gazans and injured over 26,000, according to the World Health Organization. Of the injured, nearly 5,000 were shot by Israeli snipers in the legs; at least 93 have had to have a lower limb amputated.

The majority of those injured in the legs were young men looking for change or something to do—and they are now at a higher risk of tramadol addiction, as they seek to cope with the pain and bleak prospects ahead.

So over the next hour that day, Khael lays out different arguments: Drugs are expensive and make people poorer and sicker; they are against Islam and can lead to the worst of sins—like suicide; those in the businesses are just looking to profit off of Gaza’s troubles; and Israel lets the drugs in to make the people weak.

“Like the Israelis are trying to win in war,” he says, referencing the three wars Israel and Hamas have fought since 2009, “they are trying to win with a war of drugs.” Israel denies the charge, but no matter the argument, the people of Gaza are most definitely the ones losing.

Exact figures for tramadol abuse are difficult to determine because of the social stigma surrounding drug use in Gaza. No government body tracks rates, but a 2017 report by the UN’s Office on Drugs and Crime and the World Health Organization found that 1.8 percent of males 15 and above in the West Bank and Gaza are high-risk drug users (with tramadol Gaza’s top drug). Other news reports have said 30 percent or more of young males in Gaza as having used drugs. Anecdotally, Palestinians in Gaza frequently cite tramadol abuse as a sign of how a decade of political and humanitarian crisis has upended life, particularly for young people. Users told The Nation they could never tell their family, for fear of a violent response or social ostracism. Authorities say it’s only a male problem, but privately, women say females use tramadol, too.

Gaza, of course, has other, more immediate, ills. Hamas, a designated terrorist organization by the West, has ruled since 2007, when, a year after it won elections, it ousted the Western-backed Palestinian Authority in a power struggle. Soon after, Israel, which controls all but one of Gaza’s borders, and Egypt imposed land and sea blockades. Unemployment and population density in Gaza are now among the world’s worst, while people struggle to satisfy the most basic needs, like jobs, electricity, and medicine. The UN has warned that Gaza is fast “de-developing” and will be uninhabitable by 2020—a jarring statistic for its resilient residents.

But while America wrestles with its own opiate crisis, across much of Africa, the Middle East, and parts of Asia and Europe, tramadol pills are the drug of choice, “fueled by cut-rate Indian exports and inaction by world narcotics regulators,” a Wall Street Journal report found. Although it has prescribed medical uses, tramadol, unlike other opiates, isn’t regulated by the International Narcotics Control Board, an intergovernmental agency. So it flows freely from factories in places like India and Egypt with a direction on the box—“For Export Only”—that alludes to its unchecked use. In medicine-restricted Gaza, some have prescriptions for the painkiller to deal with ailments from war wounds and other illnesses. But that can’t account for it all.

Like much else in Gaza, the tramadol crisis started in the tunnels.

Aaed Khellah, who has a thin face and greased, spiked hair, started using tramadol in 2008, when he worked grueling 12-hour shifts in the underground tunnel network connecting Gaza to Egypt’s Sinai, which after the blockade became Gaza’s lifeline. In those days, tramadol flowed easily through the tunnels from Egypt—as did just about anything—and it was exchanged freely between the tunnel workers. Bosses handed out pills before shifts to keep people moving amid the stresses and dangers. It worked because tramadol was cheap: Sometimes hidden in chocolate boxes, water containers, and frozen fish, one pill cost just 2 shekels, according to former tunnel workers. Soon Khellah, then 17, was taking eight or so a day. Everyone was, he said.

Back then, the tunnel economy was everything. It was how Gazans procured the materials they needed, where young men found work, and how Hamas and powerful clans made their profits off the black market and taxes. It was also obvious above ground. Tunnel workers waited at certain cafes in Rafah, along the Gaza-Egypt border, to be picked up, while Rafah’s biggest families—like the Far, Shaer, and Taha clans—were noticeably showing off the profits they made running the show. Hamas and Egyptian authorities were also lining their pockets with the the bribes they received to look the other way. During the wars with Israel, Khellah kept working; the boss offered to pay extra if he did, so he self-medicated with tramadol as the bombs fell.

The tunnel heyday was 2012 to 2013, when the Muslim Brotherhood and Mohamed Morsi were in power in Egypt—where tramadol is also widely abused—and Hamas and Egyptian relations were strong. But then Abdel Fatah El-Sisi ousted Morsi and escalated a crackdown on an already simmering insurgency in the Sinai. Soon, Egypt and Israel were flooding and bombing the tunnels as security cooperation between the two grew. By 2014, Khellah, then 23, decided he couldn’t do tunnel work anymore. It was too dangerous now with all of the attacks. And his family was always worried.

So, like many of his generation, Khellah suddenly found himself unemployed and addicted to tramadol. But the tramadol wasn’t the same quality as when he had started, he said, so he felt he needed more. His family fretted about how skinny and angry he had become. And on top of it all, Khellah’s wife, a cousin whom he had married when she was 15, was having trouble conceiving. So his family sent him to a doctor, who said that one of the causes of the infertility could be tramadol use. That hit him hard.

He self-detoxed on a regimen of orange juice and exercise and dreams of making his family right. “It was a long, hard way to quit,” he says. After seven months, it worked. Soon after, his wife conceived. “After God saw how much I wanted to quit, he gave me a new baby girl,” he says.

Most of the cases Doctor Khaled al-Safadi sees don’t end like Khellah’s. Al-Safadi has worked for 15 years in Gaza’s Psychiatric Hospital and for six years privately consulting in his own clinic specializing in addiction and dependency. He estimates that only 15 percent of his clients will actually kick the addiction, because the rest lack the will and support.

“The percent [of tramadol users] is rising because of the severe situation, the siege that we are in, the generation that has no income,” he says. “It’s an escape from the world they are living in.… In this current situation, people want to put their head down and not move.”

Al-Safadi has a stoic expression, and with a weary cadence describes his biggest success: Gaza’s first in-patient ward for treating drug addiction opened last year in the psychiatric hospital. There are 12 beds and round-the-clock care for 200 Israeli shekels (about $57). On a visit last year, just two of the beds were filled. Before this ward opened, the few drug addicts who sought or were sent to treatment received it in the adjacent psych ward; now they have their own section, where the main treatment includes anti-pain and anti-seizure medication to ease withdrawal, as well as therapy and exercise.

Still, the basic problem remains: Drug abusers are afraid to seek help because of social stigma and lack of trust in dealing with government institutions—combined with the government’s own inattention to these pressing issues, said Al-Safadi.

Things have been changing, though, as Hamas has stepped up its drug busts. In January of 2017, Hamas proudly announced that in that one month it had confiscated more drugs than in all of 2016 and arrested eight smugglers in one of the biggest recent stings, Reuters reported. In March of 2017, after toughening its narcotics law, Hamas for the first time sentenced two drug smugglers to death. “Such actions represented a threat to Palestinian national security, with its economic and political dimensions,” the court said in its ruling. Two more have been sentenced to death since then.

“There’s more fear now from the smugglers,” says Ahmed Alqidra, who heads Gaza’s anti-narcotics unit, where there’s a glass-covered display of drugs, alcohol, and sex products confiscated over the years. “The government is trying,” he says, but money is tight, and they need to do more to raise awareness and treatments for addiction.

That’s because the tramadol keeps coming. With the tunnel economy crushed, it now enters in bulk shipments through one of the few remaining tunnels, or smuggled in smaller quantities in washing machines and gas canisters, or in exchanges from boats along the coast with Egypt, according to current smugglers. One smuggler said he did regular shifts on fishing boats that exchanged goods (80 percent drugs and 20 percent weapons) with Egyptians, all while perilously avoiding Israeli authorities who monitor the waters for anything suspicious. Ecstasy, or sa’ada [happiness] in Arabic, is used less but is said to come unmarked from Israeli dealers hidden in food and clothes through the Kerem Hashalom crossing with Israel.

The collapse of the tunnel trade combined with continued high use has also pushed prices up and up. A decade ago, 20 shekels paid for 10 tramadol pills; today that buys just one. Hashish has doubled, from 25 shekels a gram a few years ago to 50 now. That has increased the pressure on already heavy users in what several describe as an apt metaphor for Gaza’s deteriorating quality of life: Even the one escape left to them, getting high, is now increasingly unattainable.

On top of that, big political unknowns face Gaza: Hamas and its arch-rival, Fatah, have tried and failed to reconcile after their bitter split, while Israel and Hamas continue to dance around another war. In January 2018 the Trump administration cut funding to the United Nations Relief and Works Agency, which 1.3 million of Gaza’s 1.9 million people depend on for food. As regional dynamics shift, Hamas’s relations with its Arab patrons have suffered, increasing the group’s economic and political isolation and the feeling among Gazans that they’ve been forgotten.

That all leaves Gaza’s drug users largely stuck in the same cycles. One small-time dealer and hashish user, who requested anonymity because he works for the government and his family doesn’t know, often gets high every day to detox from his pressures and traumas—and to just do something. He’s smart and motivated, but bitter because the siege has kept him locked in and he’s been denied better work for not supporting Hamas.

Death haunts him. Not just from war, when he drove an ambulance during Israeli bombardments and witnessed a massacre that he still can’t shake or talk about. But also from the punitive electricity cuts by the PA and Israel, which endangers the lives of the babies under his care at the hospital where he works. “What is their guilt?” he asks.

He takes a long drag from a makeshift bong fashioned from a plastic water bottle. “Every day I see these things,” he says.