Gaza's Mental Health Burden—Gaza: The Human Toll

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This transcript is from a CSIS event hosted on January 22, 2024. Watch the full video here.

Note: This transcript has been edited for clarity.

J. Stephen Morrison: Good morning, good afternoon, good evening. I’m J. Stephen Morrison, senior vice president here at the Center for Strategic and International Studies, CSIS, a Washington, D.C.-based independent think tank. Welcome to this fifth episode of “Gaza: The Human Toll,” a product of the CSIS Bipartisan Alliance for Global Health Security, in partnership with other programs here at CSIS – with the CSIS Humanitarian Agenda, the CSIS Middle East Program, and today we’re joined by the CSIS Diversity and Leadership in International Affairs Program.

The purpose of this series is to spotlight the health and humanitarian crisis in Gaza, hearing directly from experts on the ground or near to the crisis. That has proved very powerful and compelling in our previous four episodes. We post the video from today’s broadcast immediately onto the website, and soon thereafter we will post a transcript. A special thanks to my colleague, Sophia Hirshfield, who coordinates and supervises this series, and has done an exceptional job. And special thanks also to our very able CSIS production staff, in particular Qi Yu and Alex Brunner, who are with us today making this all possible.

At the top of each episode, we give a very quick summary of the major facts around the war in Gaza. Since October 7th, according to the United Nations Office for the Coordination of Humanitarian Affairs, UNOCHA, latest report, the number of Palestinians reported killed in Gaza, 24,762. Some reports put that at 25,000. Of those seriously injured, 62,108. Of those populations, two-thirds estimated to be women and children. Twelve hundred Israelis reported killed in the October 7th massacre; 5,431 Israelis reported injured. There are still 136 hostages reportedly that remain in Gaza, including soldiers and foreign nationals.

In terms of destruction of infrastructure, over 70,000 housing units destroyed in Gaza; 290,000 partially destroyed. This means 60 percent of Gaza’s housing units are reportedly destroyed or damaged. Over 1.7 million Palestinians displaced in Gaza. All 36 hospitals in Gaza are now under heavy strikes. Only 16 of them are partially functional. A hundred and fifty three U.N. staff have been killed. One hundred and fifty one from UNRWA, one from WHO, and one from UNDP. Two-point-two million Palestinians are at imminent risk of famine – severe malnutrition and famine.

Today’s focus is mental health in Gaza. We’re trying to examine three dimensions. We’re trying to examine the status of the Gazan population. How do we begin to assess the burden? What do we know about the levels of trauma and mental health disorders within this population? Second, amid the ongoing war, what’s the status of capabilities in Gaza? In terms of workforce – skilled workforce? In terms of institutions that have been created in past years to provide those services and capabilities? And how do we begin to think about the near- and medium-term priorities for serving a population that has high demand?

We all realize the environment inside Gaza is catastrophic, which make an informed discussion of these issues very difficult and sensitive. These are deeply disturbing developments for all involved, whether it is victims and patients, providers, family and friends. Whether they are Gazans, Palestinians living in the West Bank, or Israelis impacted by the October 7th massacre and violent disruption along the borders.

To lead off this conversation, we have the great honor to be joined by Rajiah Abu Sway, a prominent Palestinian expert in this area. And we’re hoping we will be joined momentarily also by Dr. Yasser Abu-Jamei. Let me introduce the two of them.

Rajiah is the mental health officer at the World Health Organization in occupied Palestinian territory. She’s had that position since 2003, based in East Jerusalem. She’s managing the mental health and psychosocial program. Technically and operationally, she has over 19 years of experience in mental health system development in Palestine, working on national strategies, professional capacity building, and supporting the implementation of rehabilitation programs. She has a lot to be very proud of, including the mental health, psychosocial systems, emergency response, and what’s called the Mental Health Gap at Heath Facilities Program. She has also supported community-based organizations in developing advocacy and awareness programs.

Let me say a few quick words about Dr. Yasser, who we are hoping will be joining us from Rafah. He’s been attempting to join, and we’re hoping he will be successful. He’s a psychiatrist. He’s the director general of the Gaza Community Mental Health Programme. He’s headed that program for the last 10 years. And for the 10 years prior to that – served that program, he’s been a resident of Gaza, Palestine since 2000. He’s been very involved in research on the impact of ongoing violence in the 15-year-long blockade of Gaza, on the physical and psychosocial health of children and their caregivers, and the connection between public health and human rights. He’s a member of the task force that developed the National Mental Health Strategy in Palestine. He suffered in July of 2014 the loss of 28 members of his extended family, including 19 children, during a strike during that period of conflict.

We’re joined also here today in our conversation by two of my dear colleagues. Michelle Strucke, director of the Humanitarian Agenda, is with us; and Hadeil Ali, director Diversity and Leadership International Affairs Project. I have the honor of serving on her advisory board.

Let me just offer a quick – five quick points. In looking – in talking to a number of experts and reading into this literature, there are five big themes that jump out, and I hope we’ll hear more about that. I’ll be turning momentarily to Rajiah to kick things off.

The first is that, pre-October 7th, the literature and discussion around the patterns of mental-health disorders in Gaza focused upon a perpetual state of trauma that spans generations. And this is a long dialogue and a long analysis that looks at how there’s transmission of trauma across generations and how a culture of war has settled in. We had the intifada, two intifada periods, ’87 to ’93 and 2000-2005, and armed clashes with Israeli forces in 2008, ’12, ’14 and ’20, ’21 and ’23. So that figures as a defining aspect of a jumping-off point in talking about mental-health disorders.

The second point is that there is a lot of study that one can look to. And Rajiah Abu Sway deserves much credit for helping engineer and support those many, many studies. And that shows a clear pattern over time of rising impacts on the majority of children, adolescents and adults. And that documentation and quantification of these different disorders is quite powerful.

There was a 2011 study by Imperial College, another by a scholar at Columbia University with Palestinian partners. Save the Children 2022 did a – which has a strong partnership program inside Gaza – did a study; 80 percent of children reporting feeling a perpetual state of fear, worry, sadness, and grief. Dr. Farajallah, a Palestinian-American scholar who’s worked in Gaza over two decades, did a similar study. We’ve had the World Bank study that came out in 2022. So there’s quite a body of analysis; much more work to be done, which we’ll hear about.

The third is that structural factors, along with this continuous intergenerational phenomenon of trauma, is the role, vitally important role, of structural factors – poverty, high unemployment, the impacts of a 17-year blockade, and the uncertainty around the future, the confinement of the population to a very small geography with no escape, and, in this most recent period, a sense of a lack of safe escape spaces in that; obviously, in this period, high losses in terms of personal proximity to loss in terms of family members and friends; and the dispersal – this is an important element that many have emphasized – extended families play a vitally important role in the stability of one’s emotional life. And in this period, the dispersal or dislocation of extended families takes a very, very strong role. Stigma always plays a role in the consideration of mental health. This is no exception.

A fourth point. There are significant capacities that have been created over the past decades. Many of those are now damaged and disabled. We’ll hear about them. But they’re not done by any means. There is a question of what to do into the future. The Gaza Community Mental Health Program, which we’ll hear from Rajiah in a moment, established 1990, serves a large population, including children – we’ll hear more about that – with a very strong range of services, a main center in Gaza City, a number of mental-health centers, and a strong longevity and continuity of leadership over the years. We’ll hear more about those capacities. We know that in this period, of course, that these have been closed or damaged or disrupted, including the psychiatric – the single psychiatric hospital that serves the population.

The workforce itself, the mental-health workforce itself, many have reported, is deeply traumatized and dispersed itself. And that’s a reality that we need to acknowledge, this sense of helplessness and anxiety in their ability to provide services to those that they care for under these circumstances.

Fifth point is around the future, the question around what is the future going to look like. There is obviously a very strong sense, and this comes through in many of the surveys that are being conducted now by opinion firms, a sense of abandonment and an increased distrust and alienation from the West, skepticism of external-assistance partners. What is that going to mean?

Obviously, today the lack of security and barriers are posing a – barriers to systematic investigation and examination of what the burden is and what needs to happen in the future. Nonetheless, many people are pushing forward despite the insecurity to push on this, Rajiah and Dr. Yasser among them.

I want to point out one other thing, that there was a very interesting commentary in The Lancet end of November by Samah Jabr and Elizabeth Berger which made a couple of points that are quite important in this debate. One is that they were looking at this and saying the community will need to rely on rapidly trained, community-based leaders from within Palestine to help as a new capability or an expanded capability in this emergency; that the demands will require outside expertise. Where will that come from? Will it come from the West Bank? Will it come from elsewhere? And they drew our attention to a disturbing term that has entered the parlance of this discussion of this, which is a wounded child with no surviving family – WCNSF, a term that I think cannot but leave one a bit one unsettled in thinking about what that means.

So we’ve asked Rajiah Abu Sway and Dr. Yasser to carry this conversation forward. We’re very, very grateful for the guidance and advice that they’ve both provided us in this period, and very thankful for their leadership and their contributions over many years.

When I talked about the continuity and quality of leadership in this area, I had them in mind very much, so I’m going to turn to Rajiah and ask her to kick things off. Dr. Yasser is attempting to join us, and if he is able to join us, we’ll bring him right in and hear from him after Dr. Rajiah. And after that, we’ll have a roundtable conversation and draw in Hadeil and Michelle into this conversation.

So thank you so much. Rajiah, it’s very – it’s very generous of you to be with us today. Dr. Yasser, it’s great to see you are with us.

Over to you, Rajiah.

Rajiah Abu Sway: Thank you very much, Steve, and thank you very much for CSIS to bring mental health on the table and to discuss this important topic. 

I just want to start with one thing, which U.N. secretary-general stated on the 20th of January speaking about Gaza, and saying people are dying not only from bombs and bullets, but from lack of food, poverty, clean water, hospitals without power and medicine, and this must stop. And this is, you know, the message that we want to convey: that there should be a ceasefire, humanitarian corridor, and that this must stop, of course. 

You have mentioned lots of things, actually, in your introduction, and you’ve been – point at several important topics that we need to speak about. One of the also very different datas and studies, also one of our WHO estimation, according to WHO prevalence estimates of mental disorders in conflict areas, we say 22 percent of the population will have mental health problems. And we are, like, talking about almost 485,000 of people in Gaza. But this means – that doesn’t stop there, of course. There are other studies that we did in primary care, as well, in UNRWA and Ministry of Health screening and identifying mental health problems in Gaza in the primary-care setting, and almost always the percentage is very high – 30 percent and more. 

Everybody knows in humanitarian emergencies a stress impact to the people in a very widespread emotional suffering, anxiety, fear, grief, which we are seeing all of this is Gaza – not only these emotional distress, but we’re also seeing a continuous traumatic, as well, events affecting the children, and the families, and the whole community structure. And when we speak about Gaza, we speak about extended families, and we are seeing now it is impacting these extended families, and the structure of the whole community, the solidarity as well, and the social and psychological fabric. So that we need to put in mind in our response and in the recovery afterwards, hopefully when the war will stop or the hostilities will stop.

I just want to mention as well some of the data. You have mentioned most of the data, and the displaced people, health workers being killed, how many injured. But also, there was one data that I saw today, that 20,000 babies were born since 7th of October till now. And we can imagine how the women were, I mean, delivering. There is no hospitals. There is no proper medical care, proper sanitation, proper nutrition. And how much this will impact the mental health of these women, and the babies, of course. So there’s lots of layers and different target population and groups, that when we speak about mental health we need to think of. We mainly think of also children and women, but also there are people with mental disorders that usually they are invisible and nobody think of them, and they vanish. And there’s no really services that can be provided to them in these circumstances. 

For WHO, I mean, we started – as you said, I mean, it’s an accumulation. This has not started in October 7th, 2023. This started a long time ago. And there were lots of escalation and hostilities that people have suffered in both West Bank and Gaza. And of course, there were different – more escalations started also in Gaza and the blockade in 2007. So it’s an accumulation of different – of several traumatic events that has been – occurred in Gaza as well. The WHO started in 2003, actually, with the mental health program. And it was after the Second Intifada in 2002. And we started working on developing and strengthening the mental health services in order to be – I mean, we believed that when we have a service and a system, then we can respond to all the needs for the population. 

Therefore, we started supporting the community mental health centers within the Ministry of Health, whether in West Bank and Gaza. And then we worked on building the capacity of the professionals. And we had first national mental health strategy, 2004. That was published with all the priorities, and gaps, and challenges that we face. Of course, oPt has lots of challenges with the continuous occupation, settlements, a separation between different areas –West Bank, Gaza, East Jerusalem area, A, B, C. So there’s lots of complications and complexities when we speak about strengthening systems, because it’s a very unique, as well, system and that you can see in oPt. 

And therefore, we started working on, as well, in integrating mental health into primary care. Because one of the challenges in the mental health system in oPt is the limited human resources, especially for mental health. And this – and we’re talking about West Bank and Gaza. In Gaza, we had a – of course, and Dr. Yasser could speak later about more, of course, the NGOs and their role – the local nongovernmental organizations, and the importance they also provide.

But also there is – there used to be, actually, six community mental health centers for Ministry of Health, one psychiatric hospital, and there was a program of integrating mental health into primary care with UNRWA as well, and with primary care services, a part of Minister of Health. And also, we’ve worked with different partners on developing mental health units within the general hospital. So some of the general hospital doctors – GPs – and nurses were trained as well on mental health. 

Nevertheless, I mean, we’re now – we’re talking about what’s happening now. I mean, the psychiatric hospital was bombed twice, so it’s not functional. We know that northern Gaza is separated from the south. The mental health centers in northern Gaza is not functioning at all. We have – we don’t have any mental health centers – regarding Ministry of Health I’m talking about. They don’t have any which is functioning in the South. There are very few primary care and few general hospitals that are providing some services. 

Of course, at the beginning of the whole hostilities, the focus was more on life saving and nobody was talking about mental health. But now, we can hear lots of requests that there is a big need to support MHPSS, and the mental health services, and the people. And we are talking about also we had this, like, for example, today a meeting with UNRWA, a focal point in mental health, and they – in the shelters people are displaced, of course. There is no structure. There is no space to provide services.

Also the mental health professionals themselves are displaced and they are living the same thing like the people – insecurity, life-threatening events, also grief and loss and also, of course, this impact them as well. And today we had, like, for the first time we were informed that there was, like, an assessment in these UNRWA shelters and they have found 1,000 displaced person with mental health disorder.

So for the first time there was an assessment and there is a need, of course, to provide services for these people and psychotropics. So when we’re talking about, I mean, the emergency there’s, like, different levels. I’m not going to be able to answer all your points that you have mentioned, Steve, now in the introduction but we can come back to them.

But I wanted to be – just to show that there was – there were some services. We never said it was the best services. There was – we were in a journey to develop these mental health services in West Bank and Gaza and but, of course, now it’s a big challenge and we need to – really to be innovative and to think in which way we’re going to develop and provide support for the people in need, of course, for mental health services and this needs, of course, a multi-sectorial response.

It cannot be – we cannot think of it as, like, a horizontal approach or response. It has to be multi-sectorial. It needs to be integrated in health, education, protection, GBV – gender-based violence – child protection, shelters, wash even, in order to be able to provide also a way of dignifying people when we provide them services, even basic needs and basic services.

So, of course, now we’re talking about – I don’t want to talk about the stigma yet now because people now are just living in a mode of surviving, you know, and trying to get to the basic needs and then we need to think of – of course, we need to support the people who are really in need, people with mental disorders who were neglected totally in the last 100 day – 105 days and now we need to – really to provide them support and also to provide support when it is possible, of course, when there is a space, when there is privacy, to give it to the people. 

There are some partners who are providing, like, level one. So we have the MHPSS IASC guidelines and there’s the pyramid of the four levels of services, and I think for the time being most of the services that are provided for the people in those shelters – in the formal or informal shelters is more on level one and level two, which is fine. I mean, it has – at least there is something being provided.

But then we need to discuss how we’re going to do a structured service in different levels and referrals as well and we need to focus on how we’re going to support our local mental health professionals whether they’re working in the ministry of health, UNRWA, or local NGOs, because we believe that the services and the support that need to be provided it has to be localized and this is the way people can accept any support and any help coming from any mental health professional or organization.

So I’m going into generality now but, of course, I don’t want to take more time. Dr. Yasser is here as well. He has internet and connected to us. But I think that we can speak about lots of things as well when we discuss it together in the roundtable.

Dr. Morrison: Thank you so much, Rajiah, and, Dr. Yasser, welcome and great to have you with us. Appreciate that. And so over to you to open things up with your thoughts. 

Yasser Abu-Jamei: Hi. Good morning. Good afternoon, everyone. Thank you very much, Stephen and CSIS, for giving me the chance and giving me the floor. 

Well, I live in east Khan Younis, which is the – again, in the south of Gaza Strip. And I begin by telling you this to tell you that over the last 108 days, you know, first, I was watching what happened in Gaza and in the north. I live in a hot area, so I was placed – (inaudible). And then we moved into a – (inaudible) – in the south after the humanitarian pause took place. And we just fled during the night, so the available place was a shelter, which was a school; spent there a couple of weeks. And now I am sitting in a tent which is not far from that school. But again, it’s supposed to be the safest place. 

What’s really interesting is that during the night what I used to hear during the – (inaudible) – from displaced areas is three sounds that could, you know, happen all the time. One, a child is crying. That was happening, like – all the way night. Not just one child; children are crying. And I used to think why those children are crying now. Maybe they feel cold. Maybe they are hungry. Maybe they have some cramps, some abdomen pains. I don’t know why they were – (inaudible). 

Dr. Morrison: Dr. Yasser, you’re breaking up. You might –

Dr. Abu-Jamei: Sky.

Dr. Morrison: We’re losing you here. Maybe we can pick up again. 

While we’re – while we’re waiting, why don’t we –

Dr. Abu-Jamei: Sorry. Am I back?

Dr. Morrison: Yes, you’re back, Dr. Yasser. Yes.

Dr. Abu-Jamei: So I was saying that the second sound is based on the drones, you know. That’s what you hear in a very calm night. Of course – you hear the – sounds of bombing, bombardment – (inaudible). And – I was – are a lack of basic needs – you know, the water at schools or at shelters, the lack of power supply. You can get just luckily one hour power supply; maybe water for, like, three or four hours a day. 

And imagine, you have 2 or 3,000 people at the same school, and they have, like, 10 to 15 toilets that are operating around the clock, if I could say, you know, and the water is not there. So you can imagine what kind of life is that. I’m not only speaking of health, as a health person. I am a physician, psychiatrist. I could understand that. But I would like to speak about the pain and the agony of the people who use the toilets. The long lines are there. And the women who need to pick their young children and try, one way or the other, to help them just deal with that – you know, with that moment, just going simply to the toilet. 

And this is just a regular calm night, a regular calm – if you look at the other very important things, water is always a problem. Food is a big problem. And – (inaudible) – your name. Now you are at the school. You can get some food. And my kid want to see – (inaudible). It was an interesting time for a family of eight. You can imagine how many people at this school – want clothing.

Dr. Morrison: Dr. Yasser, you’re breaking up. And I don’t know if it’s possible to reset the connection, because it’s very difficult – the transmission’s very difficult. I think we did hear about, you know, what you’re hearing in a calm night, in terms of children crying, drones; the absence of power/water/food, and what this means in terms of parenting for women and –

Dr. Abu-Jamei: (Inaudible) – being connected. 

Well – there are some food items that are available, but you have to buy them at plus prices, actually. Eighty percent of the population in Gaza Strip are dependent on food aid programs, you know. So imagine what will happen to you when you are, like, under these conditions.

So one thing is that the daily time is spent by the population trying to struggle to survive – to find some food, to find some water, to find maybe some better – you know, to manage somehow their life, or their kids, to try to find a health facility. In the pharmacies now in Gaza, private pharmacies, there is zero medication. Nothing is there. At all of our shelters, when I was staying, they were giving medications, like, in a couple of tablets, a couple of pills. You know, it’s – it was extremely ridiculous. 

Now, when you talk about – when you talk about what do people feel, what do they talk about, I can speak about three different, perhaps, groups or feelings that I see. 

One is that, you know, people, they just anticipate or they just expect or they just try to think, how is home? What is home going to look like when this is over? Everyone is talking about his neighborhood. Is our house up or not up? A lot of talks. A lot of questions. Can one give us an advice? Anyone came from outside? You know, thus, this person, is he still alive? Is he not there? That woman who was supposed to be in the house, is she really – was she in the house when the bombing happened? Is she now seen? Is she still alive? A lot of anticipation out of expectations, out of questions about the situation, their own situation, their own memories, their own houses. 

The second one is denial. People say that this looks just like a nightmare. Not on – we have experienced previous five or six attacks. I don’t know how to count now. I don’t know the exact count. But this is totally different. This is totally different. This is – this is just crazy. And a lot of people think that this is just a nightmare, you know, it should stop when they have to get out of here to see that, this is not happening. 

The third one is anger. People are angry. You know, people can be easily get into problems with each other. They talk bad about everything? You know, they talk bad about why this is happening, why no one is caring about us, why 100 days and there are no interventions? – why, why, why.

And then the third point that I would like to talk about is three groups of people. One is the mental health person there. I would like to highlight we have – (inaudible). People who were already on medication, they need to continue to be on medication. I meet them all the time. They ask about their medication. In our three community centers, the one in Gaza City was not reachable from day one. The one in Khan Younis city is not reachable since November, since the operations began in the south. And we can reach only the one in Deir el-Balah, and we have very limited medications. So these people really need a lot of attention. We don’t have the stocks. We don’t have – and we asked the WHO to help us with the medications. We talked to UNRWA. We will try to jointly work with UNRWA. We will send our psychiatrists to the main UNRWA primary health-care units. Together, we are going to provide the services. 

Second is, yes, I said a lot of people are just anticipating, expecting – (inaudible)– serious mental symptoms. But those who are severely affected, they have shown serious mental health symptoms, including disassociation, including mutism – including acute stress disorder. And this need a lot of attention. And they have a serious impact actually. 

The third group is helpers. I think my staff, a hundred people, maybe 95 of them are displaced. Maybe half of them are displaced more than twice. And that’s why I would just begin with – we talk about intervention. When I met them during the ceasefire, when I tried to talk to them – the humanitarian pause, or whatever they call it – I was really thrilled to know that they were – everyone was doing his best – their best at their capability. You know, whether he is in a shelter, or whether he is a neighborhood with his extended family, everyone’s trying to help one way or the other. (Inaudible) – and the rest. And they try to do whatever they can. And the only negative side of it is that this is – (inaudible) – period. And the other side and the other, let me say, difficulty, cannot really ensure privacy and confidentiality. So I’m pretty sure that the person told all the stories he or she wants to tell. But that’s what you can offer, actually. That’s what you can do. 

And finally, a ceasefire is going to take place. Maybe today, maybe tomorrow, maybe in one month, maybe in one year; I don’t know. Before talking about anything, we need two things in order to be able to operate or help the people mentally. One is we need safety. People need to feel that they are safe. Safety means an end to all kinds or forms of anything that reminds them of what happened. Safety also means, you know, removing all the debris or the wreckage being on the street, you know. Safety means that you feel that you can sleep at home. That home could be a tent. That’s not the problem. But it should be safe, at least. 

The second one is we need to have elements of hope. What do I mean by that? Well, in 2014 it took the community one full year in order to start building homes in Gaza. At this time the level of destructed houses is about 10 times, maybe 20 times the amount that it was in 2014. In 2014, they were talking about 16,000 fully destroyed residences, 60 or 70,000 partially destroyed. Now they talk about more than 200,000 fully destroyed residences. So I think it’s more than 10 times. Should we – should people wait for one year until they see bricks coming back again, holding – rebuilding their homes? Just build one house in each neighborhood, and that will bring a lot of the people, because they will expect that their turn as well will come, and that the international community is coming and helping. 

And then, third, as mental health professionals, I think the – we need the help from the outside, from the international community, yes. But that help should be mainly directed to our staff, to our people. That’s my opinion. Because the population – the people at large will be very skeptical to speak after, like, one hundred days of bombing and attacks, to someone who is from Europe, for example, or from the States, whatever place. They will not be able to show or to speak, I would say, honestly about their fears, and et cetera, et cetera. So for the one-on-one therapy and intervention, yes, we can find a lot of people locally, need to pay more people locally, and we need to offer them caregivers. So the international community can do a lot of help and caring for the givers and helping the helpers, which is very important. 

Resources. Now two of my three community centers are partially destroyed. Can we find immediate help to establish some caravans, or some tents, or whatever? Can we get immediately some stocks of medications that can help us with the population? Can we get enough resources to start training the young psychologists? Over 3,000 people in Gaza Strip provides psychological first aid and basic housing to the population. We can do a lot of – a lot of things. And we are more efficient when it comes to sustainability, for example, because people learn. They stay here. They continue to help. People who are coming from abroad, their intention is extremely nice. They help. They offer help. But then they leave, and everything continues in our lives here.

So this is what I want to say – (inaudible). Again, sorry that the connection broke several times. I am aware of the timing here – (inaudible)– discussion. Thank you very much. 

Dr. Morrison: Thank you so much, Dr. Yasser. And thank you, Rajiah, both of you. We appreciate how difficult this is for you, Dr. Yasser, in terms of the circumstances under which you’re operating and appreciate very much your persevering here. And your points did come across pretty loud and clear. 

I’m going to ask Michelle and Hadeil to offer some response to what we’ve heard as a way of getting the conversation moving into this back and forth here. So let me ask Michelle to kick things off and then Hadeil – Michelle Strucke, director of our Humanitarian Agenda program. 

Michelle, thank you for being with us. 

Michelle Strucke: Thank you. And thank you so much. I’m humbled to be on this panel to hear directly from you working in these circumstances. I know that it’s an unspeakable amount of pain you’re experiencing trying to still do your jobs. 

A couple of things I wanted to highlight. I thought that Rajiah’s statement that we need to dignify people when we provide services was really important to emphasize. You know, in humanitarian crises – this one, we’ve repeatedly heard from U.N. officials, from nongovernment organizations, from journalists witnessing what’s happening, this is unique. This is exceptional. This is not the norm, the fact that there’s nowhere safe to go, the fact that people are continually bombarded after more than a hundred days of near-constant fighting, the fact that electricity, water and basic services are cut off. This is an exceptional set of circumstances. 

And even so, I think, on the issue of mental health and humanitarian crisis, we know that the – there’s a professionalism that is really required to dignify people. And I’m hearing that in what you’re saying. And that professionalism is very difficult to achieve in these circumstances. And I think that I wanted to make that distinction, because one of the things I heard in the commentary so far is that we have the – there’s the kind of informal social extended-family structures, community structures. 

Lots of studies have been done by sociologists. And after the – in the aftermath of disasters, when people are displaced, noting that when these social bonds break down, that’s the support that people rely on, the informal supports, whether that be family, religious leaders, institutions. That support is completely broken down when someone’s displaced. 

When you add to that the lack of electricity, the fact that people, you know, as Dr. Yasser was saying, are not able to even understand the basic status of whether people they care about are safe or their own home, this is something that adds, I think, exceptionally to the mental-health situation that is happening on the ground. 

On top of that, then, I think the dimensions of the professional response for mental health are really important. We’ve seen in crises like Syria that you can’t just have a – it’s not advisable, basically, to try to provide mental-health support by people that are not professionals. There are things that can happen. If someone tries to do, for example, a group-therapy session and the people in that session are at different levels, they can actually be harmed in that setting because they are then comparing their levels of trauma. 

So I’ve heard over and over again how mental health is one area where professionalism, training, having the right people providing the services, is really essential, because they don’t want to make it worse. And, of course, the first humanitarian principle is first do no harm. So I wanted to highlight that that professional breakdown of the ability to provide dignified, safe, private social services is really important and is an element to talk about. 

Another layer that I wanted to mention that Steve brought up in the beginning is this notion of you have the individual trauma. Then you also have the family level. We’ve seen that even in the first month. It was being reported that hundreds of families had lost 10 or more people. So that means entire families being wiped out and their hope for what that family was going to mean to them in the future being wiped out. 

We’re seeing that on the individual level, the family level, but then also on the collective level. So in places like South Africa, when you look at transitional justice and healing in a society, there were studies that were done on the kind of collective memory of the population, and how people when confronted with disasters and catastrophes tend to minimize the harm that’s done to them because they think about how much worse it could have been.

So there’s this masking that happens in this kind of collective trauma that will really span generations. Obviously with Palestinians, as Steve mentioned in the beginning, you know, they’ve been dealing with a collective trauma for quite some time. But I think we can’t underestimate the impact this is going to have on these generations of people that are experiencing, you know, 60 percent of housing units being devastated, and the kinds of trauma that they’re facing. 

The last point I wanted to make is just that the civilian infrastructure I think is a really important point. The fact that these social structures – when civilian infrastructure is decimated, schools being used as shelters, all of these are meant to be temporary emergency plans. They’re not meant to continually for months upon end to be used for emergency settings. One thing we’re not talking about a lot is the fact that these children that are in tents, children that are displaced multiple times are not able to have any schooling.

Then similarly, on mental health, that there – that infrastructure of hospitals, clinics, referral centers, are, again, wiped out. So that civilian infrastructure, I think, sometimes militaries look at civilian harm and they think about it from a unit by unit – kind of a legalistic, tactical decision of whether they will, you know, commit a strike, and then – and what that means. I think that’s relevant to this conversation because the notion that civilian harm is collective, that civilian infrastructure matters, and that the loss of that civilian infrastructure affects people’s ability to access essential services like mental health, and to rely on the supports that they would have in coordination in areas like primary schools, primary care centers, is really important. 

So, again, thank you. I’m looking forward to the rest of the conversation. And this is an extremely devastating topic. 

Dr. Morrison: Thank you so much. 

Let’s pause and hear from Hadeil now. Hadeil, thank you so much for joining us today.

Hadeil Ali: Thank you so much, Steve. And thank you for organizing this important discussion. Rajiah and Dr. Yasser, it’s been truly an honor to hear from both of you.

I wanted to bring up a few points that both of you have talked about. One, this idea of community support and the lack of social cohesion that we’re seeing in family and support networks. And I think that’s important in all contexts, but I think especially in the context of Palestine or other Middle Eastern countries – the importance of that family network, and how that’s – Dr. Yasser has written about this – how critical that has been as a coping mechanism for children who have been experiencing trauma. 

Second, the point about – that Dr. Yasser made about anger. I think there’s a lot to be said about the double standards that Palestinians are feeling. Also, Arab Americans are feeling as well. The feeling of betrayal, the feeling of being left behind – both by the West, but I think there’s a sense of betrayal from Arab nations as well. And that feeling of complete abandonment is generational and perpetuates the generational trauma that we’ve been – that we’ve been talking about here. Why are we left behind? Why, when we look at other conflicts happening in the West, there isn’t the response that we deserve? And I think that point also emphasizes the level of humiliation that Dr. Yasser describes in these stories that he shared – that he shared with us.

And I think about the trauma of storytellers as well. And what I mean by the trauma of storytellers, I think about – in addition, of course, to both Rajiah and Dr. Yasser, people like Wael Al-Dahdouh, who’s a prominent journalist, of course, in Gaza, who bears the responsibility of telling the story of what’s happening in Gaza because I think there’s a feeling that nobody is actually portraying what’s happening, right? That they are the only people who are going to give us the true lens of what’s happening on the ground. So, what happens to those people, right? People like Wael Al-Dahdouh, or if we think about Bisan Owda, someone else also on the ground who is reporting as well. And I think everybody right now in Gaza is a storyteller, is there to make sure that the world, and especially, I think, Western countries, understand what is happening on the ground. 

I think, Steve, there’s more to be said here. I’m cognizant of time. I think there’s more to be said about the U.S.’s credibility, both in the Middle East but across the world, and what does a localized support look like, especially because of how much U.S.’s credibility, and the West, has been impacted by why what’s been going on in the past 100 years or so. I look forward to discussing that more, if there is the time.

Ms. Abu Sway: Thank you, Steve. I mean, the first thing is, of course, what we hope is to stop – I mean, to stop all of this, and to ceasefire, and long term, hopefully not temporary, to have a solution for the Palestinian people. I think that’s the most important first, in order to get better wellbeing and mental health. 

For our response to Gaza, of course, the psychotropics is not an issue. I mean, it is on the way, and it hopefully will be there for the people. Then it has to be – as Dr. Yasser was saying, one of the most important things is when we have – people needs to feel safe and protected in order to start to work on their wellbeing. So this is one of the things that also we need to –hopefully to have, in order for us to start to build on our MHPSS response. And, of course, helping the helpers, as we mentioned before, that’s important to start to work immediately with our mental health professionals who are working in Gaza, to bring – to provide them with the support that they need, that they can be able to respond to the people’s needs. 

Of course, there will be lots of challenges because we have – talking about children, orphans, disability, amputations, that we did not mention as well who was going to respond to them, and how much we will be able to respond to all their needs. It will be a long-term response. And there is, of course, as we said, security, protection, safety, trying to build up again, the normal life, the routine life for children, which will be very – for children, the families, the parents – which will be a very big challenge for all of us, because of the huge destruction. You know, schools, teachers – I mean, all of these is challenges to think about. I mean, all these elements is – yeah, it will be a big challenge. 

But I think it will be multisectoral. It will be lots of coordination with different partners at different levels, for mental health and for all other clusters and health education, protection for parties to work together in order to start to provide the support for the people. So that’s what I think, in general. 

Dr. Morrison: Thank you, Rajiah.

Dr. Yasser, your thoughts on what we’ve just tabled?

Dr. Abu-Jamei: Well, I think Rajiah said everything that is needed. But if I could say something, it would be just only one thing. You know, keep in mind that we are humans. Think of us as humans. Treat us as humans deserve to be treated. That’s my message. 

Dr. Morrison: Thank you. Thank you. That’s a very powerful way of – and eloquent way of responding to this.

Can I come back? If we have a pause in a week’s time, what would you – what would you be urging Washington to think about with respect to mental health in terms of additional things? I hear the safety piece of this. I hear the – support the providers so that they can come back and they can resume work safely and be able to do their work effectively. What else – what else would you – would you argue in terms of elevating this – the priority of the emotional wellbeing of Gazans in this period where the stress, anxiety, and disorders are naturally going to be quite, quite prevalent?

Dr. Abu-Jamei: Look, I’ll say – I’ll use the very simple figure which the WHO uses in different areas when disasters take place. That’s about 10 percent of the population after disasters will have mild – sorry, moderate to severe mental illnesses, and that’s more than 200,000 people in Gaza Strip. 

And that – (inaudible) – a huge multi-level intervention and a huge expansion of the services in Gaza Strip, you know. I speak of mental health services at the four – the four levels, whether this is specialized care, the patients who show symptoms and they have a diagnosis, they have a disorder; or people who need some counseling, some consultation, who show some symptoms but they can still struggle and go on with their lives. 

We have also to keep in mind the vulnerable groups. We speak about children. We speak about women. We speak about elderly. The young people population in Gaza Strip is, I think, more than 60 percent of the population below the age of 30, 70 percent I think below the age of 30 – they need future help – and that 47 percent of that population is unemployed. It can’t be that 70 percent of the people below the age of 30 are unemployed. That can’t be. I mean, it’s not in any other place. 

Do we have resources, Stephen? Yes, we have resources. I am not going to move into that, you know. We have resources. The whole world knows this. And is support – your support needed? Yes, it’s needed. They’re going to do it – I speak of the international community – I hope. But start to rebuild, and at the same time ensure that this never happens again. And the international community has different mechanisms to ensure that. You need just to activate them and then, clearly, to think of us as equal human beings. That’s the key issue. 

Dr. Morrison: Thank you.

Rajiah, did you have any further thought to add?

Ms. Abu Sway: I mean, of course – I mean, building on what Dr. Yasser is – and the most important is, as we said, security, safety, and start to build up things to recover – I mean, to build up services, to build up the community again. We need to build up the community fabric again.

It was – the whole strike and the whole escalation of hostility that happened since 7th October is targeting the fabric and the social fabric of the people and the community, their resilience. Gazans are very well known for their solidarity and resilience and supporting each other.

We are facing, I mean, huge stress and grief and – yes, and it’s becoming – really affecting the community fabric and the social fabric that we need to work on and, of course, this comes when we provide support and hope and the protection and safety and starting building up homes, schools for children. 

I mean, the school children, most important when – I remember in 2014 the most important thing was to go back – after the war, to go back immediately to their routine life. And people were able because it was less destructive than this time – were able to go back to – children were able to go back to school. And just one step ahead in recovery, actually, in mental health as well, and people going to work and start – you know. And this is something that will be very challenging even when all this escalation has stopped and this hostility has stopped. 

So, yes, we need to build up all of this together, and there should be a humanitarian response being able, you know. Even the trucks and the aids are not being able. Only 80 trucks comes in, and then we – previously, it was at 500 per day. So this has to be – you know, it has to open the borders. We have to bring people to support ending military and to be able to enter Gaza and support, as well. 

Dr. Morrison: There has been a lot of discussion – we saw it in this Lancet piece that I referenced – about the need to draw additional – and I think Dr. Yasser, you’ve made this point yourself, that there is going to be a need to draw additional capabilities of experts from outside of Gaza. I would think that the first place people will look is to the West Bank or to other Palestinian experts in various other places. 

Can you say a bit about that? What can be done now to begin to think about that strategy of attempting to identify and enlist support among those who are embedded in the culture and understand the culture, and will be accepted but have also the expertise and skills in the area of mental health? Dr. Yasser? 

Dr. Abu-Jamei: Well, always the – my colleagues from the West Bank which are helping, I mean, they are Palestinians; they are not counted as outsiders. So simply, for example, after the May 2021 attacks that happened three years ago or – yeah – we immediately started support sessions. Some of them were one-on-one; some of them were group support. And these were our colleagues from West Bank who were helping us the helpers. And some of them managed to enter into Gaza, you know, and they managed to help and be physically in Gaza, because it’s very difficult for our colleagues in the West Bank to come to Gaza and it’s very difficult for us to go to West Bank. (Inaudible) – and this is, again, an issue – (inaudible).

Again, for people from the region, it’s a very similar culture. The language is the same. However, you know, the type of problem we talked about, you know, I wouldn’t say it’s different, you know, because now many areas – countries in the region that have somehow experienced something of what we are experiencing during the years.

So this is something that is of importance, but again, I think the international community, Western experts, we kept in SMHP since we were established in ’99 to work as a place for exchanging the expertise. So all the time some real experts were coming to Gaza, and we were helping them identify the right, I could say, trainees, and we could offer a nice sack of food within that to deliver the training. And that is something that continued, and until now it continues. At the moment, SMPH works with experts from Italy, from South America, from the United States, and they continue to come – they now – and they provide some training. 

So that needs to be a lot expanded. But again, one of the main difficulties that we are facing talking about this is a telecommunication system that is not working. Now, our toll-free line – and we have a toll-free line that operates between 8 a.m. and 8 p.m. every day. And because of the lack of communication, the lack of power supply, we were not sure that our professionals will be able to respond all the time. We manage to transfer those calls to the colleagues in the West Bank, and they were responding to them. But again, telecommunication is a big issue. The availability of the internet is a big issue. You need some means, some facilities that work and make things happen. 

And that’s – that brings me back to the nature of you know, facilities. Facilities is something very important. Immediately, once a ceasefire is happening, good internet connectivity will be needed immediately, and that is not going to be available, by the way. I know it, basically; we have experiences before. And we need to have some places that can offer some privacy, you can deliver your services – maybe not in a tent; maybe in small caravans that offer some kind of, like, your sound is not by someone else, you know, something like that. So we need really to work on this. 

Something very important, I represent a local nongovernmental organization, a national one. Our capacity to procure from the international community – I mean, from abroad – and bring things to Gaza is very limited. It’s almost none, you know. And to be able to do that, we need the help of international organizations, because they can buy things. They can transfer them to them – and bring them into Gaza. So this is something that is very important. 

And then one final thing. Sometimes construction material is an issue. Maybe we need to prioritize, you know. Our building in Gaza is partially destroyed. The one in Deir el-Balah is partially destroyed. The one – (inaudible). We need things to be prioritized. If there is no prioritizing, then this is a big problem. And we see that prioritizing things is not happening at the moment. I have seen orthopedic surgeons who should be at the hospitals standing in a line to get their flour for their children. Orthopedic surgeons were not prioritized in receiving the flour. Imagine how things are. 

So, I mean, there is a lot of things to be – to be done. There is a need for a master plan. There is a need to take all the needed people into consideration, you know, to make the lives of people who help easier so they can manage to help you, OK? So this is something very important. Caring for the caregivers is not only the psychological element but also covering the basic things, making his or her life more easy – (inaudible) – mental health-care. 

Thank you. 

Dr. Morrison: Thank you, Dr. Yasser. 

Rajiah, did you have any additional thoughts on there? I see you’ve been nodding at different points. I know you have a few additional thoughts. 

Ms. Abu Sway: No, I just want to say that, regarding the Lancet, also localization, we had this experience before – supported local NGOs to support Gaza as well in 2014, in ’21 as well, in May – and they were able to be – to access Gaza, and to go and support mental-health professionals and different partners and organizations. The issue is a bit challenging now. We don’t know to – I mean, how it will be, the access to Gaza, I mean, through where – is it through Rafah only, or will there be any other way to access Gaza? So this is one challenge. 

The second one is, like, I just want to say that we’ve been discussing this also locally. And Dr. Yasser, he is co-chairing the technical working group for mental health and psychosocial in Gaza, and WHO is co-chairing with TDH in West Bank, and we’re trying to coordinate the emergency response in West Bank. And now we are trying to also support our Gaza colleagues. 

And there was a big discussion that, you know, even the partners in West Bank, they’re very willing, you know, to support remotely, or to go there, or to have the emergency national teams that they can work with Gaza people. But of course, the access is something that – it’s a challenge that we need to think of and to see how it will convey later on when the war and hopefully the whole escalation stop. So this is something that, yes, we are taking into consideration. 

As for the response, I mean, I think we were, like, discussing it has to be – we have to think of the intervention and the response in the different levels within this MHPSS IFC pyramid for interventions and to start, you know, all the support we need. We need to take all the support and opportunities, and, of course, setting standards, of course, for interventions, and mainly the do no harm. 

And we saw it previously. I mean, we tried to coordinate as much as possible with all the sectors, with partners international and local. But always, I mean, there is an escalation with this huge destruction and chaos. Lots of times things happens without coordination. People come in – organizations come in and do short-term interventions and leave – not sustainable, not effective, no assessment, no evaluation. 

So we will try as much as we can, I mean, with all the levels of support that we are getting, for example, from the WHO local country office to our regional – to our headquarters. We are always – every week we have meetings to discuss all the needs.

But also we are in continuous contact with the MHPSS reference group that are supporting us as well if we are in need of experts, Arabic speakers, and on how to try to organize a plan of intervention.

Of course, it’s a plan. At the end, lots of challenges will occur when we implement but at least to have the framework for everybody who wants to come in and support Gaza to have this framework as a reference.

Dr. Morrison: Thank you so much. We’re getting – we’ve run over time. I’m very grateful that you’re willing to give us some additional time.

I want to ask Hadeil and Michelle to offer some closing thoughts so we can hear from both of you, and then we’ll come back to our – to Yasser – Dr. Yasser and Rajiah for some closing thoughts from them. 

Over to Hadeil. 

Ms. Ali: Thank you, Steve.

A couple points for me. I think both Dr. Yasser and Rajiah mentioned the importance of a localized response and I think there are three elements to make sure that are kept in mind.

One is the cultural – understanding that cultural context; second, making sure that these programs are sustainable; and then, lastly, thinking about how are we tailoring these programs based on age groups – children, adolescents, young men as well – I think a group that we haven’t talked about as much that have experienced a lot of humiliation – and then women, too.

I think Dr. Yasser mentioned the importance of bringing in experts to work with mental health professionals but not directly with the Palestinian population. I think that point is crucial because of the damage that has been done in terms of the perceptions of the West on the ground. 

Rajiah talked about the multi-sectoral response and I think there’s a lot there in terms of the education system as well and thinking about schools and higher – the higher education system.

And then, lastly, I want to bring up the point about hope. I know Dr. Yasser mentioned, you know, Palestinians need to feel that there’s some kind of hope. But right now it’s just survival, right? It’s just a mode of survival.

How can we create a sense of hope for Palestinians that there is a day after, that they will be able to go back to schools, that they will be reunited with their families?

Dr. Yasser talked about what is home. We’ve talked a lot about the resilience of the Palestinian people but I think we need to go beyond that, recognizing that they are being resilient but there needs to be a certain response from international organizations to make sure that we’re not just address – talking about their resilience but, rather, creating structures that allow them to feel that there’s some hope and not stay in this perpetual cycle of survival.

Dr. Morrison: Thank you, Hadeil. 


Ms. Strucke: Thank you so much, Steven. Thank you to everyone for the participation on this panel.

For me the mental health situation in Gaza, using, like, kind of the iceberg metaphor is really the huge, enormous under-the-surface elements that, again, will I think pervade for a very long time and cannot be addressed without really addressing these basic needs.

I wanted to bring it back to that element, that things that have been successful in other crises – telemedicine, remote kind of doctors helping other doctors – none of these things can be possible if the electricity is not working, if people are not able to use emergency communications, and if they’re not even able to know where their families are.

The idea of helping the helpers I think is essential and the shocking lack of aid that is actually getting into Gaza is absolutely affecting the ability of the caregivers – the many types of caregivers to provide services. So in my view more aid is needed, not less. 

Electricity, water – these are the basic things. Food that people need to be able to be a caregiver. And while Palestinians have an incredible resilience I think the point about humiliation is really important. I was struck by Dr. Yasser saying just think of us as human. When you think of that kind of humiliation of what parents have to experience who are devoted to taking care of their children, what a doctor – the duty that they and the oath that they have given to be impartial and to give care to people – when you think of those elements that are completely degraded in this situation, it’s horrific. So, to me, bringing in more aid, allowing for basic services so that people are able to provide care, and helping the helpers, is essential.

And I don’t think there’s enough conversation in Washington about what will be needed tactically to make sure that more border crossings are open and that aid can get inside. Because the amount right now is, frankly, I think, inexcusable. When all of us have had so many years of experience in humanitarian crises and disasters, so much research, so much knowledge, so much expertise. And clearly, the issues here are political and military that need to be solved, or at least paused, in order to get people the aid they need, so that this iceberg doesn’t continue to grow and grow in a way that people are not able to bounce back from. 

Dr. Morrison: Thank you, Michelle. I’d like to come back to Rajiah and have Dr. Yasser close. Any final thoughts you wish to share with us? I think this exhortation about, help us get to a point where in the midst of what is a catastrophic and harrowing situation, how to begin to restore hope. I know Dr. Yasser has at many times been referred to as a very durable optimist. (Laughter.) And, in fact, has referred to himself in those terms at different times. This is a prerequisite for, I think, being in this profession. But over to you, Rajiah. Thank you so much for your leadership, your guidance, your generosity to us today, but also all of the work you’ve done over the last decade and a half in building up these capabilities that now need to be revitalized. Closing thoughts from you. 

Ms. Abu Sway: So, I mean, most – I think the most important step is the ceasefire. That this has to stop. And everything then starts to build up and we can respond. Humanitarian aid, of course, to enter Gaza. And I think for mental health, the most important is to ask what the Gazans want. I mean, according to their needs we need to set out plans, and not according to theories. And there is lots of things that has occurred and done in Gaza, so we need to build up on what available – what kind of available services, professionals, and build up from there our response and support them. That’s my final. Thank you very much. 

Dr. Morrison: Thank you, Rajiah. 

Dr. Yasser, your closing thoughts, please. Thank you so much for, under very difficult circumstances, making the time to be with us today. 

Dr. Abu-Jamei Thank you. I would say – (inaudible) – to happen – (inaudible) – and health is – (inaudible). So we need to keep in mind that mental health services are important. We need all the services – (inaudible) – health services – (inaudible) –

Dr. Morrison: Dr. Yasser, you’re breaking up, I’m afraid. I think we’ve – I think we’re losing you here. 

So I think at this point we’re going to go ahead and close for today. I want to, again, thank Rajiah and Dr. Yasser for the time they’ve given us, and the candor, and open and honest thoughts shared with us. I want to thank my colleagues, Hadeil and Michelle, for their leadership and contributions here today. This is a cooperative effort within CSIS to bring our different perspectives and different programs into this forum around “Gaza: The Human Toll.” That’s quite important for us. Most importantly is hearing directly from those who are on the ground, living and working these realities. And that’s where I think the power comes from in this kind of conversation. 

Again, thank you to our audience for joining, and your patience as we got off to a slightly late start. We’ve gone over time. We will post the video immediately and we will post the transcript soon. And so at, you can find both of those. And we will continue in this endeavor. This is the fifth episode of Gaza: The Human Toll. And we will – we will continue with regular broadcasts. So keep an eye out for the sixth episode in the coming weeks. So thank you so much. We wish you all the best. And we will stay in touch, I promise, Rajiah and Dr. Yasser.

Ms. Abu Sway: Thank you very much.