Gaza’s Mental-Health Crisis and the Trauma of Permanent War

Gaza’s Mental-Health Crisis and the Trauma of Permanent War

Gaza’s Mental-Health Crisis and the Trauma of Permanent War

On the anniversary of the 2014 war, Gaza’s kids are still trying to recover from years of cascading violence.


“The Jews shot me.” I was eating breakfast with 3-year-old Ibrahim Awajah in February 2015, in the northern Gaza town of Beit Lahia, when he made this proclamation. His father, Kamal Awajah, saw the surprise on my face.

“No, no, you’re the second Ibrahim,” Kamal quickly corrected the small, sandy-haired boy. “It was your brother who was shot, not you.”

The first Ibrahim, 9 years old, had been shot and killed by an Israeli soldier during the 2009 attack on Gaza, which the Israeli military named Operation Cast Lead. His parents and siblings witnessed the killing, along with the demolition of their home. The second Ibrahim, born in 2011, was named after his martyred brother. He has already lived through two massive military campaigns. He has also lived most of his young life in tentlike structures, first while his family’s house was being rebuilt after Operation Cast Lead, and then after it was destroyed again during the summer 2014 war.

Israel launched its Operation Protective Edge on July 8 last year; its stated aim was to “restore calm to southern Israel” after an increase in rocket fire emanating from the Gaza Strip. The 50-day onslaught left 2,131 Palestinians dead, of whom roughly 70 percent were civilians, including 539 children. Hamas forces in Gaza executed at least 23 alleged collaborators with Israel. Seventy-one Israelis (66 of them soldiers) were killed during the same period, including one 4-year-old boy. Over 16,000 housing units in Gaza were demolished or severely damaged, leaving nearly 118,000 people homeless. The Awajah family is still among them. Though many of the damaged houses have been repaired a year after the war, not one totally demolished home in Gaza has been rebuilt.

I climbed with Wafaa Awajah on the mound of debris that had been her home. “Here was the girls’ room, and next to it was the boys’ room. This was the kitchen, a bathroom, and the stairs,” Wafaa said. “All my dreams are buried under this rubble. Even if the house gets rebuilt, we will always be afraid of its being demolished again.”

I asked about Sobhi, the Awajahs’ 15-year-old son. He seemed more withdrawn than on my previous visits, when I filmed the family for my documentary One Family in Gaza. Once an eager student, he was now skipping school. “Sobhi lost hope in many things,” Kamal answered. “First he lost his brother Ibrahim, and his home. We gave him mental support. ‘Life goes on,’ we told him. ‘Things can be rebuilt.’ But with the 2014 war and the destruction of the house again, Sobhi’s mental and emotional well-being were damaged. I don’t know how to deal with him.”

In a February 2015 report, UNICEF estimated that nearly 300,000 children—approximately one-third of Gaza’s youth—were still in need of psychological and social support six months after the war.

“The issue is the condition of chronic war, which doesn’t lead to speedy recovery,” said Dr. Elena Chere- panov, a mental-health specialist whose expertise is in collective and cultural trauma. She compares the psychological impact of the violence in Gaza to the public-health crises she’s seen in Chechnya, Liberia, and Abkhazia. “Ongoing war means a really severe and systemic traumatic impact on the community, which permeates all areas of life. There are generations who grow up never having the chance to live in safety or plan for the future, which is crucial for trauma recovery.”

* * *

I was sitting with Dr. Jamil Atti, Gaza’s country director for the Center for Mind-Body Medicine, in his living room in Gaza City. “When you talk about ‘post-traumatic stress disorder,’ there should be a ‘post,’” Atti said. “And in Gaza, there is no ‘post.’” His face was lit by a cellphone’s flashlight; the power had cut out minutes earlier. Six months after the cease-fire, Gaza was receiving only six hours a day of electricity, due to the damage that its only power plant sustained and the ongoing Israeli blockade, which was imposed when Hamas took charge of the coastal enclave in 2007. As of April, electricity had resumed an eight-hour-on, eight-hour-off schedule.

I asked Atti about the change I saw in the Awajah family. When I first met them, six months after the end of the 2009 assault, the family had been in shock. Now, six months after the 2014 war, they seemed numb. “One of the traumatic symptoms is numbness, of feelings and the body,” Atti explained. “When people have this kind of ongoing trauma, they create a new kind of reality.”

Kifah Kahaman, the principal of Ibrahim Awajah’s nursery school, described that new reality as she led me into its ruins. “The kids are still crying and scared,” she said. “We spent a full month providing them with psychological support and releasing their fear from the war.” Though the cinder-block ceiling was intact, supported by cement pillars, most of the walls had been blown out. With her youthful, pear-shaped face framed by a light-blue head scarf, Kahaman pointed to a six-inch object lying in the chunks of cement, mangled metal, and rebar. “This is one of the missiles which destroyed the place.”

The Israeli military demolished 20 schools in Gaza during the war, including 11 kindergartens, and 450 other educational facilities were damaged. Among them were three United Nations schools turned shelters; 44 displaced Palestinians were killed in the attacks. A United Nations inquiry found that three empty UN schools had been used by Palestinian militants to store and fire weapons—but not the ones sheltering the displaced families.

Kahaman’s young charges, ages 3 to 5, huddled together on a plastic mat and stared at me. Nearly every pupil had been directly affected by the war: either a family member had been killed or injured, or they had been forced to flee their home. The children’s colorful Dora the Explorer and Hello Kitty backpacks contrasted sharply with their eyes, which looked dulled, as if covered by a thin veil. The missile lay near their feet.

“Some of the children are aggressive, hitting their classmates, smashing things in the classroom,” Kahaman said. One previously joyful little boy now cries for his parents all day.

The courtyard beyond the preschool’s missing back wall was filled with debris. One boy stepped through the nonexistent wall and picked up a small chunk of concrete. He carried it back, nestled it firmly in the sand, and returned to select another. A classmate leaned outside and grabbed her own jagged concrete block. Within minutes, all the children were silently building towers from the rubble of their demolished nursery school.

“I saw and heard about similar scenes in Kosovo and Ukraine,” said Cherepanov. “The children built structures and then destroyed them, and were [play-acting] funerals. In most cases, it’s a normal way for children who have been exposed to severe trauma to process their experiences.” Though the attention paid to children’s mental and emotional health in war zones has increased, much work remains to be done, Cherepanov said, especially on supporting the existing community infrastructures, “such as families, community organizations, and teachers, who could provide ‘trickle-down’ support to children and other vulnerable community members.”

* * *

Yousef Ahmed is a stocky, blond primary-school teacher in the eastern Gaza City neighborhood of Shejaiya. “The most brutal of the three wars was last summer’s. The kids suffered a lot,” Ahmed told me.

I had already seen the appalling aftermath of the four-day Israeli campaign in Shejaiya. Whole areas were devastated; not a building in sight was habitable. F-16 fighter jets had flattened some buildings, multiple stories stacked like pancakes. Tank and mortar fire had blown out the walls of others, leaving their frames intact. A twisted staircase hung from the ceiling of a three-story apartment building, connecting to nothing. Family killed by F16 USA was spray-painted on one shell-pocked wall. Young men loaded donkey carts with rubble, slowly clearing the mounds of war debris.

When Ahmed’s students returned to Shejaiya primary school, two and a half weeks after the cease-fire, “their talk was all about the war, the shelling and destruction that they witnessed: Who got bombarded? How were his legs amputated? How did his family member get killed? How and where they got displaced, the nonstop sound of airplanes.” One of Ahmed’s pupils had been a star first-grader. “When he came to second grade, I noticed a change in his behavior. He was withdrawn, not talking to people. His family told me that he saw his brother get killed, swimming in his blood.”

Ahmed enumerated the behavioral disorders he now sees in his classroom: “There is withdrawal, nail-biting, fear, night terrors. Bed-wetting—not only nocturnal wetting, but sometimes I notice children wetting their pants while in class. There are also speech problems, stuttering. Their behavior has also become more aggressive, more violent, and those who are not withdrawn are hyperactive.”

The Child Protection Rapid Assessment Report (CPRA), published in October 2014 by the Child Protection Working Group in Gaza, supports Ahmed’s observations. Without exception, everyone surveyed for the CPRA noticed significant changes in behavior. Boys were more likely to demonstrate aggression, while girls were more likely to exhibit general sadness, crying, nightmares, and bed-wetting.

Ahmed also observed an impact on his students’ ability to learn. “They have weakness in memory, scattered attention, and decreased concentration. They absorb less material. They lack a desire to learn.” They also lack proper conditions to study. “I can’t tell a student to do his homework when I know that the electricity is out,” Ahmed said, “or the student can’t buy notebooks and pencils, because his father doesn’t work.” According to the World Bank, Gaza’s unemployment rate—43 percent overall and more than 60 percent for youth—is one of the highest in the world.

Teachers, of course, have lived through the same trauma as their students. The blockade and related economic crisis, as well as the chronic power outages, make day-to-day life here grueling still. Salaries have been withheld due to a standoff between Hamas and Fatah, the dominant Palestinian parties, which have been negotiating a unity deal. The lack of fuel makes transportation to and from school extremely difficult. “Teachers are also human,” Ahmed observed. “Their mental states deteriorated; their thinking has become scattered, and they can’t focus. Teachers’ behavior with students and with colleagues also became violent and aggressive.”

Ahmed’s school, though still functioning, was among those shelled. The school next door to his was demolished completely. “The kids there were distributed to other schools,” he said.

The CPRA found that traveling far from home to attend school is a significant post-hostility stressor for children. According to Dr. Yasser Abu Jamei, executive director of the Gaza Community Mental Health Program, so is living among the constant reminders of war. “When children live in partially destroyed houses, or in tents or caravans near the debris of the war, when they attend schools in which classrooms are destroyed, or sit next to empty seats because classmates were injured or killed…this delays the natural healing process and prolongs the trauma.”

Mental-health workers are trying to fix this. According to the Child Protection Working Group, nearly 50,000 children and more than 20,000 adults in Gaza have been offered support. The United Nations Relief and Works Agency’s Community Mental Health Program has trained 8,000 teachers how to cope with their own—and their students’—traumatic experiences. The work with community structures is crucial, Cherepanov said, since “the child’s success in recovery is largely [dependent on] family support. But when the family is traumatized and overwhelmed, this support may be compromised.”

* * *

Leila Al-Hilu showed me a cellphone video of her twin 6-month- old grandsons, Karam and Kareem. Dressed in matching green outfits and propped in an overstuffed armchair, the babies babbled to each other, grabbing hold of each other’s fingers. Aside from the crop of curls atop Karam’s head, they looked identical. “The video was taken one day before they were killed,” Leila told me.

Leila sifted through a stack of photographs of her deceased loved ones, muttering “God’s mercy on them” as her husband, Talal, recounted what had occurred at approximately 3 am on July 21, 2014, in Shejaiya. Seven Israeli soldiers had been killed, and a night of intense shelling had followed, in revenge, many in Shejaiya believe. Leila was preparing the predawn Ramadan meal when Talal’s brother Jihad, who lived just across the road, phoned to check on the family. Minutes later, F-16 fighter jets shot two missiles into Jihad’s house.

Talal, a trim man with glasses and a neatly groomed mustache, led me to the pile of rubble under which 11 members of his family had been crushed. His 11-year-old daughter Hadeel and 13-year-old son Ahmed scampered behind him as Talal quietly recited the names of the dead: “My brother Jihad and his wife Siham; their children Mohammad, Ahmed, Tahrir, Asmaa, and 15-year-old Najiya; and my daughter Hidaya”—married to Jihad’s son Ahmed—“and their children: 2-year-old Maram and the twins, Kareem and Karam.”

Talal pointed to a cement pillar in the wreckage. “Asmaa was alive, and this pillar was on her chest.” Talal lowered his face, which suddenly looked 10 years older. “She was burned and calling for help.” For two hours, Talal said, they tried to extricate her. Shelling began again over their heads, and they were forced to run for cover, with Asmaa calling after them. A late-afternoon cease-fire finally enabled firefighters to arrive and remove the pillar. “Asmaa was still alive, but she fainted and remained unconscious in the hospital. She died the next day.”

Talal pointed to different areas of the shattered cement and twisted rebar. “From here we pulled Jihad out, and his wife. That was eight days later. For eight days they were under the rubble—no one could reach them. Ahmed, we pulled him out from here. Mohammad was beside his father.” Talal exhaled through pursed lips. “By the time we pulled them out, the bodies were bloated and decaying.” He appeared vacant for a moment, then repeated the detail that seemed to haunt him most. “Eight days under the debris.”

This was not the al-Hilu family’s first tragedy. Talal and Leila’s 14-year-old son Izzeldin was killed by the Israeli army in 2002. Then, in 2011, shrapnel from an Israeli tank shell penetrated the stomach of their then-9-year-old son Ahmed. At his parents’ prompting, Ahmed pulled up his T-shirt and lowered his jeans to show me the entrance and exit wounds. Chunks of flesh were missing from his abdomen, with bulbous scarring on his left hip. But his parents were more worried about Ahmed’s behavior since the summer than about his previous injuries. “Ahmed and Hadeel are afraid at night,” Leila said. “They both wet themselves. They refuse to sleep in their bedrooms; they sleep in ours.”

Ahmed refuses to go outside after dark, Talal told me. He’s easily angered at home, often shouting at his mother or breaking dishes in the kitchen. “We don’t discipline him,” Talal said. “We know very well what he’s feeling.”

When I asked him what does he feel as a father, Talal replied: “What can I do, as a father? There’s nothing I can do.” This is a common emotion among Gaza’s adults. “Parents cannot protect their children,” Dr. Atti said. “And the children understand and feel that. The parents themselves are constantly afraid.” This fear is compounded by a pervasive uncertainty—whether there will be another war, when rebuilding materials will arrive, how many hours of electricity or water will they have, whether their cooking gas will last the month. “The prolonged siege and consecutive assaults deplete people of their natural protective resources, their stress mediators, and their ability to cope with difficulties,” Dr. Abu Jamei explained.

* * *

I first met Ahmed Abu Hatab, from the Khan Younis refugee camp in southern Gaza, in 2001, when he was an 11-year-old boy with a love of magic tricks and an irrepressible grin. There was no flicker of that grin when Ahmed met my taxi. He graduated from university with a degree in information technology five years ago, but he cannot find a job. “No work. No electricity. No hope. No future,” Ahmed said.

The Abu Hatabs’ desperation began with the 2007 blockade and intensified acutely after the 2014 war, they told me. Ahmed’s friend tried to escape by boat to Italy, but the boat capsized and his friend drowned. Ahmed’s 30-year-old sister Abeer, a 12th-grade teacher with three daughters, elaborated: “The war not only destroyed homes, hospitals, mosques—it also destroyed all feelings. Where is there hope to live?”

When I asked the family what could bring hope, the answers came piling on: Open the gates. End the siege. Build an airport. Be permitted to visit Al Aqsa in Jerusalem. Have rights like other people.

But Cherepanov pointed to another, unlikely source of hope. “When the future is uncertain, strength can come from past survival experiences,” she said. “Humanity has been plagued by war since the beginning of time, and has developed culturally engraved skills of how they coped in the past and managed to preserve the values of kindness, forgiveness, and compassion. This is how the experience of trauma can become a strength.”

Leila al-Hilu is an example of this. Immediately after the war, she began sewing dresses free of charge for the little girls in the neighborhood. “It helps me compensate for my loss and my lack of emotions after my daughter, granddaughter, and the twins were killed,” Leila said. And as precarious as the future is, the eldest Awajah child is planning for hers. Omsiyat, 17, completed her final high-school exam on June 17 of this year. She plans to enter university in the fall to study journalism.

Still, Abu Jamei had a warning to impart: “When these children, who lived through three assaults, grow up and lead society…how will their experiences, memories, stress, and trauma impact them? Growing up in a hostile environment with no window for the future…what is left for that child? Nothing but despair and anger—which will lead to aggression, which will also backfire on the Israelis. This situation needs to end, for the sake of Palestinian and Israeli children.”

Kifah Kahaman, surrounded by children building towers from rubble, said her dreams for herself and for those children were simple: “To have bread to eat, to receive an education, and to live in dignity.”

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