versión impresa ISSN 0042-9686
Bull World Health Organ vol.87 no.6 Genebra jun. 2009
Rebuilding lives, healing minds
Mental health experts and other caregivers are helping to rebuild the lives of the Gaza Strip's 1.5 million people many of whom are suffering enormous stress, injuries and grief over the loss of loved ones and homes after the recent violence this year. But the task is enormous. Dale Gavlak and Lama Jamjoum report.
It could have been a birthday party, but it was a play therapy session in one of Gaza City's schools. When a group of six-year-olds played on a huge canvas on the ground, grabbing multi-coloured balloons and popping them, not all of them were squealing with delight.
One child, Omar, clapped his hands over his ears. The blasts reminded him of recent explosions in Gaza City. Omar said he does not go to school unless his mother is with him and holds his hand. And he doesn't feel secure if his teacher isn't around.
Omar and others in Gaza are involved in play, art and music therapy in their schools as part of efforts by psychologists, teachers and community workers to help them cope with having lived through Israel's three-week offensive launched on 27 December 2008 and its aftermath.
One such programme, implemented by Gaza psychologist Fadel Abu Hein at the Zahwa Rosary Catholic School, helps children express the anxiety, anger and fear they felt over the loss of family members and the destruction of their homes. "Most of the children cry when they hear an explosion or any loud noise. Many are bedwetting. They bite their nails or have nervous twitches. They become afraid, especially at night," he said.
The World Health Organization (WHO) has worked with the Palestinian ministry of health and community-based organizations since 2002 to improve mental health services in the Gaza Strip and the West Bank. A recent WHO assessment of Gaza views children and adolescents as a "particularly at-risk group" for the psychosocial consequences they may face during and after the crisis.
Tens of thousands of people were displaced. Children's play areas became littered with crushed concrete and debris. Some children and adults were permanently disabled.
WHO estimates that between 70% and 75% of a population develop mild to moderate post-traumatic reactions after a large-scale crisis, such as the one in Gaza, while it estimates that 5% to 10% of people in Gaza may need professional mental health support to address more long-term problems, such as depression, trauma, anxiety and panic attacks.
About 1300 people died and more than 5000 were injured in Israel's military offensive in the coastal strip. Children made up about one-third of these casualties. Israel said the attacks were necessary to stop the militant Hamas, who rule Gaza, from firing rockets into southern Israel. Many in Gaza said they were deeply affected by the attack. "Nowhere in Gaza was safe," said Abu Hein, who heads the Community Training and Crisis Management Center in Gaza City.
"When you see your family killed in front of you and you're unable to save them, it's a big shock," said 12-year-old Almaza al-Sammouri, as she and her classmates drew pictures during a therapy session at the An-Jalout Islamic Girls School in Gaza City.
"I found them piled on each other. Some were dead. Others died a little later because we couldn't get an ambulance," al-Sammouri said of the airstrike that killed her mother, four siblings and several uncles. "It was a huge shock. I couldn't move or do anything."
"I want to become a first-aid nurse because if this happens again, I would be able to treat them so they wouldn't die," al-Sammouri said.
The mental health needs of such survivors of conflicts and other disasters have come under the spotlight of late. New guidelines were adopted last September by WHO along with other UN organizations and their nongovernmental organization (NGO) partners to include mental health and psychosocial support as part of their emergency response.
In a statement, these groups underscored the need to coordinate multiple agencies offering such support and, while doing so, to ensure that the affected populations are not "overwhelmed by outsiders" and local contributions to mental health and psychosocial support are not "easily marginalized or undermined". But the mental health care support provided by agencies, such as WHO and the United Nations Children's Fund (UNICEF), can also be crucial.
WHO has been working on the development of the mental health services with the Palestinian ministry of health so that in the long-term these services will be able to deal with any kind of emergency interventions. WHO and its partners are also planning consultations on assessing mental health needs in medical and paramedical staff.
Abu Hein, a UNICEF consultant, said that the start of the psychosocial programmes in Gaza was a bit like "first aid", to give people the opportunity to express their feelings about what they experienced. Further stages of the 6 to 12 month programme include techniques to address depression, anxiety and violent anger.
Dr Ahmad Abu Tawahin, who directs the Gaza Community Mental Health Programme, added that a toll-free counselling phone line operates 12 hours a day to help those through grief and trauma, which was so important in the immediate aftermath of the conflict. Khalid Mohamed Munib Abed Rabbo, aged 30, said he needed such support after Israeli planes bombed his home and a soldier then shot dead two of his children before his eyes.
"We were in utter shock. Two-year-old Amal's stomach was suddenly out of her body. She died 10 minutes later. Bullets riddled seven-year-old Suad's chest and she died immediately. Samar, aged four, sustained three shots in the chest and was seriously wounded," the grief-stricken man said, as he wandered his devastated home in Ezzbet Abed Rabbo earlier this year.
Another partner, World Vision, the biggest international humanitarian non-profit organization, is also providing mental health care services. "The emotional problems children face result not just from three weeks of severe conflict, but prior to that, a year and a half of essentially being under siege," World Vision spokesperson Ashley Clements said in Jerusalem. "They have been unable to get out and do not live what most of us would regard as a normal childhood."
"It was bad before the recent conflict, but now it's been exacerbated significantly," Clements said.
WHO officials, such as Rajiah Abu Sway, WHO's national mental health officer, said that while the situation in the West Bank is not as fragile in terms of mental health as in Gaza, still Palestinians there suffer from "panic attacks, anxiety and depression" resulting from the strains of life under occupation. "The daily humiliation in crossing checkpoints, the restriction of movement, the confiscation of lands, building the wall that is surrounding the West Bank and isolating Jerusalem, the feeling of hopelessness and no future among the young generation are affecting the mental health of the Palestinian people," Abu Sway said.
Deputy Palestinian Health Minister, Dr Anan al-Masri, said that trying to get the needed assistance to Palestinians is a challenge. He said there is a lack of health coordination between the West Bank and the Gaza Strip because of strained relations between the Palestinian Authority governed by moderate Mahmoud Abbas in Ramallah and Hamas-run Gaza.
Marixie Mercado, a UNICEF spokeswoman in Jerusalem, said: "All of Gaza's children lived through three weeks of extraordinary stress and insecurity. They will need help for a long time coming."