The Trauma Experienced in Gaza Is Beyond PTSD
By Yara M. Asi
"Ms. Asi is an assistant professor at the University of Central Florida’s School of Global Health Management and Informatics.
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“We will die. All of us. Hopefully soon enough to stop the suffering that we are living through every single second.” Those words were sent in a text last week by a physicianworking for Doctors Without Borders in the southern Gaza Strip. And it is far from an uncommon feeling shared by those struggling to survive and care for one another in Gaza these days.
What would we call this feeling from the perspective of Western medicine? Suicidal ideation? Depression? Post-traumatic stress disorder? Whatever it is, we are taught that such thoughts are abnormal and require medical intervention.
When the bombing finally stops, the rebuilding of Gaza’s homes, schools, hospitals and essential infrastructure will begin — a process Gazans are extremely familiar with at this point. They will also begin processing trauma many people on Earth cannot understand: the prospect of starving to death; waking up at the hospital and finding out you are one of the last surviving members of your family; watching a child killed by an airstrike being pulled from rubble; displacement for the second, fifth or tenth time.
How do we repair the shattered minds and emotions of these survivors? Where do we begin to bring people back from a state of mental anguish where the thought of a quick death is seen as a glimmer of mercy?
As a Palestinian from the West Bank, I am no stranger to the trauma faced by Palestinians in the occupied territories, and I have spent my career trying to answer those questions and capture and convey the various injustices faced by Palestinians, specifically as they relate to health. Most current frameworks for mental health are almost totally insufficient to describe and reckon with the war-related trauma Palestinians in Gaza have endured these last several months. And by extension, our traditional methods of providing mental health care will not be enough, either.
The aftermath of this war will undoubtedly include a harrowing period of recovery that will require extraordinary financial and political investment. But it’s also a time to rethink mental health in populations that have experienced such devastating collective trauma, as well as what genuine healing may look like to ensure that hope and justice, and not just continued trauma, is passed down to future generations. While military campaigns are being waged, the numbers of dead and physically injured tell us just one story about the entirety of the mental and emotional agony being perpetuated, funded and justified.
Some studies suggest PTSD and depression are among the most common mental health disorders observed in populations affected by war, but our understanding of how war affects mental health is fairly new. PTSD itself wasn’t a proper medical diagnosis until 1980, after over a decade of research and treatment of Vietnam veterans who returned home with what we previously called “shell shock,” “war neurosis” or “gross stress reaction.” The tools and questionnaires used to screen for PTSD were generally developed and tested in the West, but these days they are deployed extensively across populations affected by the brutality of war, including Syria, South Sudan and Ukraine.
While these tools can be valuable, a growing field of literature critiques the lack of nuance or context in some of these framings, including how people describe trauma differently across cultures and process traumatic experiences based in part on their perception of why the trauma is occurring. Too often we rely only on the relatively simple and straightforward analysis of surveys rather than the time-intensive and more subjective experience of interviews, observations and other methods that account for context.
Importantly, we also lack tools to adequately measure trauma that is ongoing and so deeply entrenched in a community. Because of its extensive history of violence, deprivation and other traumatic incidents, Gaza has been a site of many studies about the mental health burden of life in war, including many of children. A 2020 study of students in Gaza between the ages of 11 and 17 found that nearly 54 percent ofparticipants fit the diagnosis criteria for PTSD. A more recent study of Palestiniansacross the West Bank and Gaza found that 100 percent of participants had been exposed to traumas in 2021. The traumas that Palestinians face can include events as varied as land confiscation, detention, home demolition, loss of loved ones and fear of losing one’s own life.
After such persistent and endless trauma, “the effect is more profound,” Samah Jabr, a psychiatrist who works in the Palestinian Ministry of Health, told Quartz in 2019. “It changes the personality, it changes the belief system, and it doesn’t look like PTSD.”
When trauma is so normal, it can also become normalized. My own loved ones in Palestine shrug off or even laugh at experiences that would be highly distressing to most. It’s also easy to miss how poor mental health can increase the risk of physical ailments like heart disease and diabetes among the populace. The limitations of our approach to mental health become exceedingly clear in such contexts.
What does this tell us about next steps for Gaza? Like all aspects of the health system in the besieged territory, mental health care is underfunded there. Humanitarian aid distributed to Gaza must include resources devoted to providing adequate mental health services. We are already seeing small efforts to offer children art classes or puppet shows at their crowded shelters, to help them cope with the ongoing trauma, but we need to start more massively building up mental health infrastructure. That includes establishing a well-trained health care work force that can offer a wide range of culturally competent mental health treatments to those affected.
For such a wide-scale disaster like the current war, however, we cannot stop at mere medical treatments. For adequate mental health, adults need jobs, children need schools, and everyone needs shelter and regular access to food, water and medicines. Eventually, people need to return home. Robust mental health in survivors cannot be restored without stability, security and a repaired community.
Significantly, medical practitioners and researchers cannot be limited by the language of medical diagnoses or the treatment that derives from them. To call what is experienced by people in Gaza today PTSD misses that these are not people in a post-trauma situation. Treatment may help a Vietnam veteran recognize that a loud sound is not always a threat. Treatment cannot help convince a child in Gaza that the bombs they hear will not kill them, because they might. It cannot offer comfort to a mother worried her children may starve, because they could.
Rather than use the term post-traumatic stress disorder, many have called to reframe the view of such suffering. Some have called it chronic traumatic stress disorder, while others, including Palestinian scholars, have referred to it as “feeling broken or destroyed.” This is not just a matter of semantics. These alternatives show that it is not enough to offer therapeutic options that place the abnormality within the individual and not within the circumstances they are experiencing. Is it not actually quite normal and understandable to feel broken or destroyed when everything you have ever known is reduced to rubble?
The scale and scope of suffering in Gaza today remind us that people in war zones need healing, justice and a genuine feeling of physical and mental safety moving forward. Even if a temporary cease-fire is brokered, what is the good of working to recover from such trauma if one is nearly certain they will experience it again? Everyone above the age of 10 in Gaza already has, several times.
Until there is meaningful action on the social, political and economic determinants that limit people’s ability to thrive, to experience joy and safety, to merely live, we cannot expect mental health treatments to do what the world’s most powerful actors are unwilling to do.
Yara M. Asi is an assistant professor at the University of Central Florida’s School of Global Health Management and Informatics and a visiting scholar at the FXB Center for Health and Human Rights at Harvard University. She was a 2020-21 Fulbright U.S. scholar in the West Bank. She is the author of “How War Kills: The Overlooked Threats to Our Health.”
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