‘Living in a State of Perpetual Trauma’: An American Child Psychiatrist on the Impact of the 2014 Attack on Gaza

San Francisco Bay Area child psychiatrist Bahar Hashemi, MD, has been volunteering in Palestine for the past 10 years, mainly in Jerusalem and the West Bank cities of Hebron, Bethlehem and Ramallah. Following the seven-week Israeli military attack on Gaza that began on July 8th 2014, she developed a mental health initiative for an international NGO, the Palestine Children’s Relief Fund (PCRF). In September 2015, after waiting a full year for a permit to enter Gaza, she made the first of three trips there connected with the initiative.

From the U.S., Hashemi had worked remotely with the PCRF to develop screening questionnaires and trained a team of social workers in Gaza to carry out a survey (in November/December 2014) of 986 children who had been impacted by the attack.

Her most recent trip to Gaza was in mid-April 2016 to present findings from the screening and subsequent interventions at a large international mental health and human rights conference sponsored by the 26-year-old Gaza Community Mental Health Program.

The conference, which brought together 800 people from several countries, including activists from Palestinian-focused NGOs, a United Nations Relief and Works Agency (UNRWA) representative, and physicians, psychiatrists, researchers, and students, focused on the connection between mental health and human rights and the “significant impact” of the Israeli Occupation, the Gaza blockade, mass unemployment, continuing military operations, and the internal Palestinian political divide on Gazans’ mental health.

In this interview with Dr. Hashemi, conducted via phone and email nearly two years since the 2014 attack on Gaza, we talked about what she learned about the effects of perpetual trauma on the children of Gaza, how she got interested and involved in aid and advocacy work there, and why Americans should care about the work that she and others are doing there.
What did you learn from the Nov./Dec. 2014 PCRF screenings? How were the children mentally affected by the Gaza attack?

We did a screening of 986 kids. 53.6% fulfilled the full criteria for PTSD and 30.1% for both PTSD and depression. Two-thirds (66%) had at least one somatic symptom – abdominal pains or headaches or bed wetting. These symptoms reflect the overwhelming burden of trauma symptoms experienced by children in Gaza. Even if they did not fulfill full criteria, every child screened experienced some symptoms. What became clear through these screenings is that it was impossible to go through the trauma (of the 2014 Gaza attack) and not be affected.

What was the follow-up to the screenings?

Of those children we screened, we identified the most affected high-risk children and referred them for various types of treatment, including with the locally-based Gaza Community Mental Health Program (GCMHP) and the Center for Mind Body Medicine (CMBM), an American NGO with a local chapter in Gaza. Our local social workers served the function of providing the referrals, working with the families, and meeting other needs such as providing psycho-education and helping families overcome logistical barriers to treatment (i.e. transportation, child care, etc.).

Last summer, we identified 120 of the most affected children from the screening to enroll them in three mental health summer camps in North, Central and South Gaza. In addition to typical summer camp activities, the children also had daily mind-body-skills activities. This was very well received by kids and the families; getting their buy-in to continue this treatment upon completion of the summer camps. The children received weekly sessions following the camp for 10 weeks and then monthly for 10 weeks after that; we had a near 100% retention rate.

Of the children who were enrolled in the camp, more than 91% of them had positive symptom reduction following the completion of 10 weeks of follow-up treatment.

We will complete a second outcome measurement for the completion of the 10 months of monthly follow up treatment this summer. When I went to Gaza, I oversaw the logistics of the programs that were running with our local collaborators (GCMHP and CMBM), conducted field visits for challenging cases and ran seminars for the social workers and mental health professionals.

This summer we will also begin another set of summer camps for 200 additional kids identified through the screening.
Were kids also dealing with their parents’ mental trauma? I imagine that could have been an extra stressor?

Absolutely. However, it is also important to point out the protective aspect derived from the sense of community and the strength of family systems. Families are extensive and provide a large support network, which for children who were left orphans after the military incursions, this becomes very important. But there’s been such disruption to the family that I think we have to take a look into what the impact of that is in the long term, and we just don’t know at this point. Also there is not a single parent who is unaffected by the trauma, in addition to needing to provide a sense of security (false sense of security in many ways) for their children. Often times, getting treatment and promoting wellness is seen as a luxury for many people in Gaza.
Were you dealing with some kids who had lost family members?

Too many. I’ll give you an example of a visit to two of our kids from the screening. It was a brother and sister, age 5 and 6, the only two surviving members of 17 family members living in their home. Their entire immediate family was wiped out; leaving them to move in and live with their aunt. Their aunt told me a story about her children who, as children often do, would tease her nephew and niece in an argument. They teased, “You don’t even come out of our mother’s womb, you’re not even part of our family.” She said that afterwards her nephew came up to her weeping and said, “Is that true, did we not come out of your womb, auntie?” She said she responded to him by saying, “Yes it’s true you didn’t come out of my womb but you all came out of my heart.”

To me, this was a great example among many, from mothers and fathers being more psychologically in-tune than I had anticipated. Her instinctive response came from a place of deep love and compassion, which has helped to sustain and rebuild the children’s spirits.

Are the symptoms the kids had similar to what you would see in another post-traumatic stress situation? For example in another war, or in a shooting at a school?

In some instances, yes, there can be some overlap as far as what you would see. However, by virtue of the perpetual nature of trauma experienced by kids in Gaza, we cannot conceptualize trauma in the same way in this context. Our definition of disorders manifesting from traumatic experiences is post-traumatic stress disorder. The use of the word “post” is simply inaccurate and does not encompass what people in Gaza are facing.
So the flare-up is over, but the broader war isn’t over. Can you speak to those two levels of trauma?

There is sort of that initial impact, that’s pretty intuitive. And I think it’s similar to the way that people experience trauma in various other contexts but what’s different about what’s happening there is that there’s this perpetuity of the trauma; that it’s happening over and over again. An eight-year-old has experienced it three times and there is a constant anticipatory fear of it happening again. There is nowhere else like Gaza in this regard; that underlying fear simply does not exist anywhere else. This makes it challenging to understand and to promote healing.

One of the most important aspects of healing and moving past trauma is to be able to provide a sense of security. It is important for a parent to be able to provide that for their child, to say yes, something really terrible happened but we’re safe now things are ok now, this is behind us.

I am so impressed by parents and how they are able to keep that strength and provide that sense of security, which is, given the historical context, a false sense of security. The people of Gaza live in heightened fear of being attacked on a continuous basis. And there’s no escape. People do not have a choice to be able to move freely in and out of Gaza. It is essentially an open air prison; they have no choice but to try to redefine what normal is in this context.

Despite what they are up against, the spirit of the people of Gaza is truly remarkable. There is a pervasive and infectious resiliency, strength, compassion and love for one another and their community.

Do you think that those kids that had treatment are going to be OK or do you feel they are not OK because of the anticipation of what could happen?

I am an optimistic person who wants to believe that these children will persevere. They can have hopes and dreams like all other children. But it is hard to imagine, in this context, with the violence continuing as it does, that this will be achieved for most children in Gaza. For now, our goal is to help them reintegrate back into as normal of a life as is possible; to get back into school, to be functioning within their family systems, to eat well and sleep well. Are they at risk for developing symptoms again after another round of violence? Absolutely. Will their minds be at peace in the interim knowing this is a very real and likely occurrence? I am not sure that is realistic.
Did anything prepare you for what you saw a year after the July/August 2014 attack on Gaza?

Even as somebody who goes out of their way to see what is happening there, I don’t think there’s really much that could prepare me for what I saw. There is nothing that can prepare someone to see the destruction first hand, to speak to children who lost mothers, mothers who lost children, fathers who lost wives. But I think there’s some comfort that comes from interacting with people who embody strength and resiliency in beautiful ways. There is this warmth and generosity in Gaza that’s unlike anywhere I’ve been.
Do you have a personal connection to Palestine?

I grew up in a household where it was important to learn about social and political issues and be aware of the world outside of our lovely but rather homogeneous suburban community. So it was fitting that I went to university in an environment which was very diverse, giving me the opportunity to meet people from all around the world. It was during those years that I became more connected and interested in global issues, particularly in the Middle East. While living in Washington DC, I heard Rachel Corrie’s parents give a talk at a museum benefit and I remember feeling so moved by them. They are two American parents whose daughter was killed by a bulldozer as she was peacefully protesting Israeli home demolitions, still speaking out against injustices and advocating for peace. I knew I wanted to do more there, and it was in medical school when I took my first trip to Palestine. Spending time there, listening to stories and experiencing the infectious warmth of the people there, I knew my connection to the people there would never fade.

My positive experiences in Palestine only strengthened my commitment to address larger mental health needs there, not only to alleviate suffering but also to raise awareness and provide a voice for a people who have endured unimaginable trauma and injustice. I see this work as a responsibility and a privilege, to provide care and advocate for a people who are marginalized and often forgotten.
What impression do you think Americans who are not in your field have about your work and the suffering of the children of Gaza?

(As far as) people outside of the field and people who are not really aware of what’s happening in Palestine, they are often surprised to learn about the work I am involved in and the context in which I am working. In addition to direct patient care, I do think it is important to help raise awareness here at home where these issues are not discussed very often. I think that most people you find do want to know even if they haven’t been informed or haven’t been easily provided with this information. From my perspective I shouldn’t be there, this kind of work should not exist. The trauma is manmade. There shouldn’t be a place for it in our world. This is what surprises people, when they learn about the true impact of what’s happening. To know that the decisions we are making is perpetuating what is happening over there.
By ‘we’, you mean the U.S. government?

We all have a role to play. By not speaking up against injustices, we become complicit supporters of our government’s foreign policy. I think there are always people who have their minds and hearts closed, but for the most part people do want to understand what is happening to be more informed.

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