Maram Nemer, a clinical psychologist who works with women and children from rural villages in the Hebron region of the West Bank, says that many of her patients have reported a peculiar symptom recently. “They complain about a funny taste in the mouth,” she tells TIME. “For one patient, it was a bitter taste and a dryness in the throat, which got worse every time she watched the news.”
Upon examining the patients, however, Nemer typically doesn’t find any physical abnormalities to suggest why they are experiencing such sensations. Instead, the doctor says the symptoms are more likely related to post-traumatic stress disorder, or PTSD, triggered by the war in Gaza.
“It’s a physiological manifestation of the fear and anxiety caused by the war,” explains Ronit Zimmer, the CEO of Project Rozana, an international NGO working with Nemer in an all-women, multidisciplinary team of healthcare professionals as part of a program called Women4Women.
Palestinians have long reported trauma from living in occupied Palestinian territories. But Israel’s latest military campaign in Gaza—launched following the Oct. 7 Hamas attack that killed 1,200 people—has been called a “grim milestone.” The war’s impact is largely measured by the number of physical injuries and deaths, with 29,000 Palestinians, two-thirds of whom are women and children, killed so far. Now, experts warn that the war-related trauma endured by Palestinians presents new and acute challenges that traditional mental health frameworks are not equipped to handle.
“When the bombing finally stops, Gazans will also begin processing trauma many people on Earth cannot understand,” Yara M. Asi, an assistant professor at the University of Central Florida’s School of Global Health Management and Informatics recently wrote in the New York Times. “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?”
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A breakdown in defense mechanisms
Although Women4Women doesn’t work with patients in the besieged strip of Gaza, the clinicians say the impact of the war has reverberated through the West Bank. The program, which gives free healthcare to women and children through mobile health clinics, has seen a massive surge in patients since October—from 500 to 2,000 every month—which Zimmer attributes to added security checkpoints and road closures, as well as the loss of jobs in the occupied territories, which has rendered Palestinians unable to travel or pay for healthcare. As a result, “our team has been working over[time] hours and spending a lot of time just trying to get to the community,” she says.
“When we go to the villages in Hebron, many patients say they feel guilty because they can still have food and water while people in Gaza don’t,” says the program’s coordinator Amany Abu Asabeh through her translator, director Diana Shehade Nama.
There is also a “constant state of fear” over the threat of the war reaching the West Bank. The heavy military presence, along with a lack of control, is “impeding any joy of life, as well as the most basic right to get treatment,” says Abu Asabeh. As a result, the patients report feeling constant anxiety, overthinking, and insomnia which will physically manifest through sensations like “jitters, weird smells and tastes, and a complete lack of energy.”
Mothers who have confided in Nemer report their kids constantly asking to watch the news or role-playing the war by forming gangs and fighting in schools. “In other instances, the mothers relayed that their kids have been having nightmares for a very prolonged period, where they dream of soldiers coming inside and ransacking the home,” says Nemer.
Some patients even exhibit types of behavior that would fit the characteristics of clinical obsessive-compulsive disorder, or OCD, says Abed Alkareem Asherah, another clinical psychologist working with the program. “They are paranoid about getting attacked, or before they go to bed, they will repeatedly check to make sure their doors and windows are closed shut.”
Asherah adds that such symptoms and conditions usually appear when patients experience a breakdown in their defense mechanism after being triggered by traumatic events. Eventually, a physical examination reveals that “a lot of the complaints are psychological wounds that require carefully planned and executed mental health interventions,” says Zimmer.
A long and cumulative history of trauma
Palestinians have long undergone an acute mental health crisis due to the history of violent conflict with Israel. A study conducted by the World Bank in November 2022 found that more than half of the adult Palestinian population screened positive for depression, including 71% of Palestinians in the Gaza Strip and 58% in the Israeli-occupied West Bank. A smaller number showed signs of PTSD, a mental illness that usually develops after one experiences traumatic events, first recognized in war veterans as “shell shock.”
The World Bank billed the study as a pioneering effort to determine the effects of “overlapping vulnerabilities and cumulative traumas on the Palestinian population” on mental health due to “decades of exposure to conflict, restrictions on movements, and poor living conditions,” particularly in Gaza.
Other studies have reported similar outcomes: A 2020 study found that nearly 54% of participants, made up of students in Gaza aged 11 to 17, fit the diagnosis criteria for PTSD. Another study conducted across the West Bank and Gaza found that 100 percent of participants had been exposed to traumas in 2021, including events as varied as land confiscation, detention, home demolition, loss of loved ones, and fear of losing one’s life.
But nowhere is the impact of worsening mental health more apparent than among Palestinian children. Before the war, more than 500,000 children required mental health and psychosocial support in the Gaza Strip, according to UNICEF. It is estimated that the number has risen to more than a million.
For many children, the loss of family members has exacerbated the trauma by stripping away a support mechanism that would help them cope with the conflict. Last November, medical NGOs like Doctors without Borders shared that the number of child patients in Gaza without any surviving family members was so high that a new acronym, “WCNSF” (Wounded Child No Surviving Family), was coined to identify them.
“Time and time again, we’ve warned that the toll of conflict and the blockade on children’s mental health is too great. Even before this escalation, more than half of parents we spoke to reported that their children were self-harming or experiencing suicidal thoughts,” stated Jason Lee, Save the Children’s Country Director for the occupied Palestinian territory.
“We are running out of words to raise the alarm in strong enough terms or to articulate the scale of children’s suffering,” he continued.
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Inadequate tools for treatment
As the mental health crisis worsens, some experts like Yara M. Asi say that the existing tools and frameworks used to screen for PTSD and trauma may not be adequate for what’s currently happening in Gaza—where mental health care is already underfunded, and for which current humanitarian aid lacks resources. Even the current mental health terminology and accompanying treatments may not be suitable for what they’re seeing on the ground due to the differences in the cultural experience of processing trauma.
On the ground level, interventions like the ongoing Brothers at Heart project, which provides immediate mental health care through therapy, as well as UNICEF’s space for children to engage in psychosocial support, have been lauded. “By introducing both local and foreign interventions, Gazan youth can have a clear path toward improved mental health. These endeavors are not just humanitarian imperatives but crucial investments in the future stability and prosperity of the region,” experts write in the medical journal, the Lancet.
But in the absence of any nuance in current mental healthcare as the war in Gaza continues, Nemer, the psychologist in Hebron, can only diagnose and treat patients with the limited resources at her disposal. “Usually, I’ll give them a checklist of steps they can follow to help manage their stress and anxiety,” she says. “I’ll also remind them that we don’t know when this war is going to end, so all they can do is focus on what they can control to maintain their energy, both physically and mentally.”
