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In Gaza, where the upheaval of war is now a tragic part of childhood and life is a matter of survival, mental health has become an afterthought, especially for doctors who find themselves traumatised by the harrowing scenes of conflict.
As Israel continues its intense bombardment and ground incursion of the Palestinian enclave, frontline healthcare workers must focus on staying alive and attending to the injured.
“When you’re in the midst of it, you just keep going – you just push through. You go from one case to another,” says Dr Ghassan Abu Sitta.
The British-Palestinian surgeon has worked in Gaza as a volunteer since Hamas launched an attack into southern Israel on October 7, leaving about 1,400 people dead and taking about 240 hostages. Israel has waged a war on Gaza in retaliation, killing more than 10,800 people, about half of them children, according to the local Health Ministry.
Despite being a veteran war surgeon who has been to Yemen, Syria, and Iraq, Dr Abu Sitta has been deeply affected by his experiences in Gaza, where the violence has taken the heaviest toll on civilians.
“There are moments when you’re caught off guard – certain things just trigger a realisation – just words said or a patient's features or age, something about them," he tells The National.
For Dr Murad Abed, a volunteer with the ministry who has a master’s degree in mental health, trauma has become a consistent struggle, but he has no time to try to heal himself.
The memories of the 2014 war between Israel and Hamas still haunt him, and the current events in Gaza have sparked flashbacks.
Just days ago, three infants lay on a bed before him, requiring urgent operations. But the lack of available rooms prevented meant the doctors were unable to act.
"We just gave them sedatives and oxygen. We watched them die," Dr Abed says.
He works 24-hour shifts at Al Aqsa Hospital, broken up by 24 hours spent at home.
“I go home and go immediately to bed after making sure my family has what it needs. Then I sleep it off. I try not to interact with anybody because I don’t know what my reaction will be," he says.
“I’m on the edge of a breakdown.”
This current war is the fifth between Israel and Hamas since 2006, but it is the deadliest of all.
In a 2022 study by the World Bank Group, carried out in association with the Palestinian Central Bureau of Statistics, 71 per cent of the 2.3 million inhabitants showed symptoms of depression.
A quarter of the 2,563 Gazans interviewed for the study said they had their homes destroyed or damaged in the Palestinian-Israeli conflict.
“One in four responders report having witnessed a war-related death before 2019, and 11 per cent reported having witnessed it in the last three years,” the study shows.
Given the infrastructure that caters to mental health needs in Gaza has broken down because of the war, which has destroyed nearly half of the enclave’s major hospitals, people are struggling to cope.
Those with existing conditions are at risk of becoming completely cut off from the treatment they need.
“There’s a big risk of relapse in people who are taking chronic medication, especially when they abruptly stop taking it, as well as due to the high-stress environment they’re in,” Dr Samah Jabr, who leads the mental health department at Ministry of Health in Ramallah, tells The National.
This can be detrimental for families trying to protect their loved ones as Israeli bombing and shelling draw closer.
“It becomes dangerous for people who have depression, for example, who begin to consider taking their own life. People with psychosis may become delusional and hallucinate,” Dr Jabr says.
Water and food are becoming scarcer, with the UN saying the average Gazan is living on “two pieces of bread” a day.
The UN's deputy special co-ordinator for the Middle East peace process, Lynn Hastings, who is also the humanitarian co-ordinator for Palestine, says only one of the three water supply lines from Israel is still operational.
“Many people are relying on brackish or saline groundwater, if at all,” she says.
Dr Jabr says such scarcity contributed to the sort of high-stress environment that can exacerbate mental health challenges.
“More people are impacted by traumatic grief when people are missing, killed or injured. There is nobody who hasn’t been touched or impacted by this war in Gaza so far," Dr Jabr says.
The issue becomes more prevalent when traumatic events pile up and are not dealt with, she says.
The Palestinian Red Crescent's spokesman in Gaza, Mohammad Abu Sabbah, speaks to The National from Al Quds Hospital, where about 14,000 civilians have sought shelter.
He says frequent strikes around the hospital and repeated warnings by the Israeli army to evacuate made him worried the site would suffer the same fate as Al Ahli Arab Hospital, where more than 500 people were killed in an Israeli air strike on October 17.
“I don’t want to even recall what we saw in that hospital strike. We try to delay these stories in our subconscious – and refrain from talking about the things we see – in order to keep our spirits high. But what we saw was harrowing,” he says.
Even so, Mr Abu Sabbah began recalling gruesome scenes of children’s burnt bodies and a mother digging at her son’s grave to say goodbye, not knowing he was buried in pieces. “We didn’t have the heart to tell her the truth," he adds.
Dr Jabr says such continuous trauma was more difficult to treat.
“People have post-traumatic stress disorder and severe bereavement but don’t have time to process what they’re going through because they’re just focused on survival. So it they dissociate," she says.
She recalls speaking to an emergency health worker who told her he often thinks of suicide, because he has had to make the harrowing decision about who is treatable and who isn't, after an air strike.
“A woman he decided isn’t treatable clung to his leg and begged him not to let her die," Dr Jabr says.
"He says he is haunted by that and thinks about it every time there is shelling.”
Yasser Abu Jamei, general director of the Gaza Mental Health Programme, warns people were unable to reach the group's three health centres for fear of being killed on the way or because the roads were too damaged.
“We’ve started a toll-free line that people can call us on," he adds.
"We can even talk to the pharmacist if they need a prescription, but a lot of people are unable to afford this medication."