Gaza’s hidden crisis: adults, children, and generations of psychological torment to come

ABSTRACT

For more than a year, the world has been exposed to the ongoing conflict in Gaza, and the destruction, medical devastation, and the death toll of this crisis. What has been largely missing from the picture, has been an attention to the long-term mental health impact of the ongoing trauma among the Palestinian civilians and the Israeli hostages in Gaza. This article anticipates the enduring generational impact of war trauma on mental health of the civilians in Gaza, drawing from the author’s clinical and research experiences of Iraqi, Syrian, Afghan, African, and Ukrainian war-exposed civilians, refugees, and survivors of torture. Across most different studies, war exposure leads to PTSD in nearly 30–50% of adult civilians, and similar rates of depression and anxiety. Civilians in Gaza, facing daily horrors and a profound sense of helplessness, are likely experiencing even greater psychological distress. Children, significantly affected during critical developmental stages, are at risk of long-term mental and physical health issues. The psychological, cultural, and epigenetic aspects of the intergenerational transmission of trauma can lead to psychological torment across generations. Addressing the mental health needs of these populations is crucial to mitigating the profound and lasting impact of war.

HIGHLIGHTS

• War exposure leads to PTSD in up to 50% of civilians, with Gaza's population likely facing even higher psychological distress due to daily horrors and profound helplessness.

• Children in Gaza are at significant risk of long-term mental and physical health issues, including PTSD, anxiety, depression, and chronic illnesses.

• The psychological and epigenetic transmission of trauma will affect future generations, making it essential to address their mental health needs to mitigate the lasting cycle of trauma and violence.

For many months now, the world has been witnessing the harrowing stories and images of the ongoing relentless bombing and starvation of civilians in Gaza, and ongoing torment of the helpless Israeli hostages awaiting their unknown fate. While the focus of media, public, and the medical community has understandably been on the immediate casualties and those severely disabled by the war and their medical needs, another devastating aspect of this conflict is missing from conversations: the long-term psychological damage that will profoundly affect the lives of those involved and the future generations.

As a psychiatrist specializing in the research and treatment of refugees and war-exposed civilians, I have witnessed firsthand the impact of war on Iraqi, Syrian, Afghan, African, and Ukrainian refugees and survivors of torture, both adults and children.

Full-blown PTSD, a severely disabling result of trauma, that torments people for decades with daily flashbacks, nightmares, depression, and avoidance of social encounters as simple as going to a grocery store, affected one in three Syrian refugees who left their country two years before arriving in the US (Javanbakht et al., 2019) Although not passing the full diagnostic threshold, many more suffer less severe symptoms of PTSD. Depression, anxiety, substance use, and suicide, are other highly prevalent outcomes of traumatic exposure and affect almost half of refugees, internally displaced, and war-exposed populations.

The psychological torment does not cease with the end of the war. Our own research shows that, even two years after being removed from the war, many do not recover; in fact, for many, especially those exposed to death threats and war, symptoms worsen (Hinchey et al., 2023). In trauma clinics, we regularly see people still haunted by daily symptoms of PTSD and nightly terrors decades after their traumatic experience. With the current and anticipated future lack of resources in Gaza, one can only imagine how the mental health of these civilians will deteriorate over the decades.

For those with ongoing exposure, the situation is even worse. In a recent study, we found that half of the 450 adult Ukrainians living in de-occupied villages near the frontline that we surveyed, met diagnostic threshold for PTSD (Ressler et al., 2024). The situation for civilians in Gaza and the hostages, who face daily horrors, starvation, and an overwhelming sense of helplessness, defenselessness, inability to escape, and lack of control over their fate, is likely far worse.

Children are often overlooked in these discussions, yet they are as deeply affected during critical developmental stages (Abdallah Abudayya et al., 2023). Many will carry a grim and haunting view of the world throughout their lives, facing adulthood with mental health issues like PTSD, anxiety, depression, substance use, and suicide, as well as physical health problems like cardiovascular disease, metabolic disorders, obesity, and chronic pain (Strathearn et al., 2020).

The impact extends to future generations. Those not yet born will suffer through the epigenetic intergenerational transmission of trauma, and trauma-related behaviours and attitudes they will learn from their parents and grandparents (Dashorst et al., 2019).

Addressing the psychological needs of this population will be extremely challenging due to the ongoing highly unpredictable war, the destruction of the healthcare system and other infrastructure, high level of need, and cultural barriers to mainstream treatments, among other factors. In another work, I have offered practical suggestions for helping Ukrainians impacted by the Russian invasion, some of which can apply in the current situation (Javanbakht, 2022). First, the war needs to end, for which the scientific community internationally, within Israel, and in the Arab world, can only offer advocacy efforts. Humanitarian workers in Gaza can be trained in psychological first aid and culturally relevant, trauma-informed approaches to basic needs of Gazans.

Given the noted extreme limitations in Gaza, telepsychiatry services provided by an international network of Arabic-speaking clinicians is the most pragmatic and efficient approach. Group-based therapies could be more efficient given the scarcity of resources such as therapists, internet access, and devices. On the ground primary care physicians and nurses can be trained in culturally acceptable basic psychiatric screening, and to offer psychopharmacological treatments, ideally under consultation with psychiatrists abroad. Affordable medications, primarily SSRIs, should be made available as a high priority.

Screening for PTSD, anxiety, and depression should ideally become a standard part of medical evaluation in Gaza for years to come. Given the highly political nature of the conflict, efforts are needed to secure permission for research into the impact of trauma on the Gazan population, and the hostages, including prevalence studies to estimate need. Since majority of the genetic studies of trauma involve other populations of European and African ancestry, genetic and epigenetic research in Gaza will provide important insight into the biological impact, and potentially guide more effective biological treatments for this population. As this conflict appears likely to persist at varying levels of intensity, resilience based and trauma informed educational programmes in schools could have preventive effects in the future. Research into the long-term psychological impact of the prolonged siege and blockade on the civilian population in Gaza and the hostages could have significant implications for this population and those affected by similar conflicts worldwide.

Without major initiatives to tackle the mental health consequences, this will not end here. It will haunt this generation and those to come for decades, possibly a century.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

There is no data associated with this manuscript.