Vol 26/1, 2024, pp. 147-150 PDF
VIEWPOINT
Tania Bosqui, Sawsan Abdulrahim, Rima A. Afifi, Alastair Ager, Theresa S. Betancourt, Alan Carr, Kristin Hadfield, Ghena Ismail, Mark J. D. Jordans, Salam Jabbour, Zeena Khazendar, Bassam Marshoud, and Eve Puffer
Palestinian children today are the fifth generation to have lived under Israeli occupation, characterised by violence, restricted movement, and displacement. Children in Gaza, referred to as the world’s largest ‘open-air prison’ by Human Rights Watch, have been suffering from a decades-long land/air/sea blockade. In the first 100 days of the most recent Israeli bombardment of Gaza following the October 7 Hamas attack on Israel, over 20,000 Palestinians were killed, half of them children.[1] In direct contradiction to International Human Rights Law and the Convention for the Rights of the Child, 300,000 homes have been destroyed and over 90% of children under two have been pushed into severe food poverty.[2] Israel’s bombardment of Gaza has been called a “children’s graveyard” by the United Nations Secretary-General and the International Court of Justice has ruled that it is “plausible that Israel’s acts could amount to genocide”.[3] Healthcare and pathways for humanitarian aid have been systematically blocked, with almost 500 healthcare workers killed, 26 hospitals damaged or destroyed, and border crossings closed.[4] At the same time, Israeli violence in the West Bank has escalated, including settler attacks, night-time military raids, and detentions. Amidst this horror–and set against a background of accumulated and intergenerational trauma over decades of occupation, settler colonialism, and apartheid–the physical and mental health of the population, particularly children, will inevitably take a devastating hit. This urgent call to advocate, written by a group of mental health and public health practitioners and researchers with experience in war-affected settings, is in response to this devastation.
Epidemiological research has identified extremely high rates of anxiety and traumatic stress, as well as externalising and internalising symptoms, distress, and ‘pressure’ (known as daghet nafsi in Arabic) in Palestinian child populations. Research has directly linked these high rates to exposure to violence, poverty, and insecurity.[5] Prolonged and daily exposure has led Palestinian psychologists to push back against simplified conceptualisation of post-traumatic stress disorder. Dr.Samah Jabr, chair of the mental health unit at the Palestinian Ministry of Health said “there is no ‘post’ because the trauma is repetitive and ongoing”.[6] The mass steadfastness (somoud) of the Palestinian people, and the remarkable resilience of parents and children, is also well documented. Such resistance in the face of prolonged adversity has been sustained through mechanisms like community cohesion, nurturing families, faith, and active patience (saber).[7] However, the transgenerational cyclical patterns of violence exposure, distress, and affected parenting capacity underpin a major contributor to the continuing transmission of suffering across multiple generations.[8] This demonstrates clearly that there can be no mental health without respect for human rights.
The protracted nature of adversity suffered by Palestinian children has led to a level of collective and individual suffering that is poorly matched with existing systems of mental health support. Inter-Agency Standing Committee Mental Health and Psychosocial Support (MHPSS) international guidance for humanitarian emergencies recommends strengthening protective factors (e.g., coping skills) and addressing risk factors (e.g., exposure to violence), building on existing systems, and integrating across sectors (e.g., health, education).[9] Basic MHPSS interventions in the midst of ongoing violence–such as psychological first aid–have a growing evidence base, including evidence of previous effectiveness in Palestine.[10] However, such interventions cannot be delivered, nor are they likely to be effective, in the context of the extreme conditions of violence currently placed on Palestinian children and their families. Mental health professionals in Palestine have consistently reported the need for a mental health approach focused on human rights and social justice rather than only individual-level coping.[11]
A call to advocate
The psychological and social suffering of Palestinian children and families can never be addressed without a ceasefire and cessation of occupation, full protection of human rights, and social equity. As mental health professionals, global citizens, and parents, we must advocate for the human rights of Palestinians and an end to occupation. Anything less will continue to perpetuate generations of individual and collective pain. This is in line with the Inter-Agency Standing Committee’s statement of action to avoid worsening the catastrophe.[12] While that is the only acceptable outcome for protecting children, in the immediate term we must advocate for the protection of children under International Humanitarian Law and the Convention for the Rights of the Child. This call is an urgent request to our international community to advocate for meeting the immediate and long-term needs of children and their families. This includes advocating for the following actions, framed within the human rights-based SAFE model of child protection.[13]
- Safety and protection. At its most basic, respect for children’s human rights requires ceasing bombing of residential areas/schools/hospitals, removing restrictions on humanitarian aid, ending settler violence and freeing Palestinian children from detention. A sense of security, predictability and consistency are the most basic emotional needs for healthy child development, essential for cognitive and socio-emotional functioning, and massively impacted by violence and displacement.
- Access to basic physiological needs and health care. Access to water, nutrition, hygiene, shelter, and healthcare requires access to humanitarian aid, the protection of health care staff and facilities, as well as freedom of movement. There is no health without mental health, but equally no mental health without health. Sleep, food, and shelter are the most basic human rights and needs, essential for child survival, let alone for thriving. Poverty is strongly associated with poor child mental health and development, globally, in some cases stronger even than other major contributing factors like trauma exposure.[14]
- Family and connection to others. Protecting and restoring children’s family links is essential, particularly for children separated through detainment and military isolation. Family functioning, parent-child relationships, and attachment are strong protective factors for children during armed violence, but are also directly affected by displacement and violence.[15]
- Education and livelihoods. The interruption of livelihoods and schooling causes immeasurable harm for parents and children. Poor access to education has been associated with significantly poorer health, mental health, and livelihood outcomes all the way into adulthood.[16] Children must have access to uninterrupted education and vocational opportunity.
- Investment in developing a system that responds to the collective long-term mental health needs of children and their families. Donors must prioritise investment in mental health and psychosocial wellbeing as central to immediate and long-term responses. Following international guidance, contextually relevant mental health systems of support that address the collective needs of the population have never been more pressing.[17] Given population-wide, long-term, transgenerational suffering, it is now that we need to plan and fund a sustainable care system across sectors, integration of MHPSS into schools and healthcare, adequate referral options, and support of civil society organizations offering MHPSS.
By advocating for these urgent actions, we stand in solidarity with children and families in Palestine. We urge readers to stand with us, voice the impact of human rights violations and the urgent end to occupation and violence. The time for focusing on individual frameworks to achieve mental health is over. This means recognizing how ending violence and promoting social justice are intricately and irrevocably tied to the flourishing of mental health.
Tania Bosqui is at the American University of Beirut, Beirut, Lebanon, and the Trinity Centre for Global Health, Trinity College Dublin, Dublin, Republic of Ireland.
Sawsan Abdulrahim is at the Harvard T.H. Chan School of Public Health, Boston, US, and the American University of Beirut, Beirut, Lebanon.
Rima A. Afifi us at the University of Iowa, Iowa City, US.
Alastair Ager is at Queen Margaret University, Edinburgh, United Kingdom and the Mailman School of Public Health, Columbia University, US.
Theresa S. Betancourt is at the Boston College School of Social Work, US.
Alan Carr is at University College Dublin, Dublin, Republic of Ireland.
Kristin Hadfield, Trinity Centre for Global Health, Trinity College Dublin, Dublin, Republic of Ireland.
Ghena Ismail is at the American University of Beirut, Beirut, Lebanon.
Mark J. D. Jordans is at the War Child Alliance, Amsterdam, The Netherlands, and the University of Amsterdam, Amsterdam, The Netherlands.
Salam Jabbour is at the Trinity Centre for Global Health, Trinity College Dublin, Dublin, Republic of Ireland.
Zeena Khazendar is at Stanford University School of Medicine, Stanford, US.
Bassam Marshoud is freelance
Eve Puffer is at the Duke Global Health Institute, Durham, US.
Please address correspondence to Tania Bosqui, email: tb33@aub.edu.lb.
References
[1] Human Rights Watch (2022). Gaza: Israel’s ‘open-air prison’ at 15. Available from https://www.hrw.org/news/2022/06/14/gaza-israels-open-air-prison-15#:~:text=For%2015%20years%2C%20Palestinians%20in,Gaza%20and%20the%20West%20Bank; Save the Children (2024). Gaza: 10,000 children killed in nearly 100 days of war. Available from: https://www.savethechildren.net/news/gaza-10000-children-killed-nearly-100-days-war.
[2] UNICEF (2024). Gaza has become a graveyard for thousands of children. Geneva: UNICEF.
[3] UNICEF (2024). Gaza has become a graveyard for thousands of children. Geneva: UNICEF; OHCHR (2024) Over one hundred days into the war, Israel destroying Gaza’s food system and weaponizing food, say UN human rights experts. Geneva: OHCHR.
[4] Médecins Sans Frontières (2024). Strikes, raids and incursions: Seven months of relentless attacks on healthcare in Palestine. https://www.msf.org/strikes-raids-and-incursions-seven-months-relentless-attacks-healthcare-palestine
[5] B. El-Khodary and M. Samara. “The relationship between multiple exposures to violence and war trauma, and mental health and behavioural problems among Palestinian children and adolescents”, European Child and Adolescent Psychiatry, 29, (2020).
[6] Z. Asad, When there is no “post-” to the trauma: Exploring continuous traumatic stress in refugee populations. Gainseville: Refuge Medical Relief, (2021).
[7] V. Nguyen-Gillham, R. Giacaman, G. Naser, and W. Boyce, “Normalising the abnormal: Palestinian youth and the contradictions of resilience in protracted conflict,” Health and Social Care Community, 16(3), (2008).
[8] K. Qamar, T. Hashmi, T, M. Sadiq, et al. “Mental health of children in Palestine: An intergenerational crisis,” Asian Journal of Psychiatry,” 75, (2022).
[9] IASC (2007). IASC guidelines on Mental Health and Psychosocial Support in emergency settings. Geneva: Inter-Agency Standing Committee.
[10] C. Barbui, M. Purgato, J. Abdulmalik, et al. “Efficacy of psychosocial interventions for mental health outcomes in low-income and middle-income countries: an umbrella review,” Lancet Psychiatry, 7, (2020).
[11] M. Diab, G. Veronese, Y. Abu Jamei, et al. “Psychosocial concerns in a context of prolonged political oppression: Gaza mental health providers’ perceptions.” Transcultural Psychiatry, 60(3), (2022).
[12] IASC Statement by Principals of the Inter-Agency Standing Committee – Civilians in Gaza in extreme peril while the world watches on: Ten requirements to avoid an even worse catastrophe. New York/Geneva/Rome: Inter-Agency Standing Committee, (2024).
[13] R. O’Connor, T. S. Betancourt, and N. V. Enelamah, “Safeguarding the lives of children affected by Boko Haram: Application of the SAFE Model of Child Protection to a rights-based situation analysis.” Health and Human Rights Journal, 23(1) (2021).
[14] A. Chen, C. Panter-Brick, K. Hadfield, et al. “Minds under siege: Cognitive signatures of poverty and trauma in refugee and non-refugee adolescents,” Child Development, 90(6), (2019).
[15] S. R. Qouta, M. Vänskä, S. Y. Diab, and R. L. Punamäki, “War trauma and infant motor, cognitive, and socioemotional development: Maternal mental health and dyadic interaction as explanatory processes”. Infant Behavior and Development, 63, (2021).
[16] H. Clark, A. M. Coll-Seck, A. Banerjee, et al. “A future for the world’s children? A WHO–UNICEF–Lancet Commission,” Lancet, 395, 605–58, (2020).
[17] T. Bosqui, “The need to shift to a contextualized and collective mental health paradigm: learning from crisis-hit Lebanon”. Global Mental Health, 7, e2, (2020).