People in Gaza suffer crushing mental pressures due to extreme economic deprivation, the ongoing siege and over-crowded living conditions.
This is on top of having endured three brutal wars over the past decade. Dr. Mohamed Altawil, who founded the Palestine Trauma Centre (PTC) in Gaza 13 years ago, has studied the effects of extreme fear and anxiety in the population.
He acknowledges the desperate need for more medical facilities to cope with physical injuries and ailments, but stresses the generally unrecognised importance of finding more mental health support systems in Gaza to ease the trauma suffered within families.
He draws on his own experience as a child in Gaza during the 1980s and the subsequent pressures on his family today in order to trace the increasing despair and challenges that people in Gaza face each day.
"I come from a poor family who still live as second and third generation refugees in the middle area of Gaza," says Mohamed, who now lives in the UK. "As a child I was keenly aware of the need for freedom and justice in my country. With my brothers, I would run after armoured cars and soldiers, throwing stones and shouting. One day, I was shot and dragged to prison, all because I threw stones at soldiers."
After leaving his family home in the Nuseirat Refugee Camp in Gaza, Mohamed set up PTC Gaza in 2007, believed to be the first centre of its kind in Palestine and in the Arabic-speaking world.
He specialises in psychological and cultural services for the ِArab and Muslim community in Britain and overseas, with a particular emphasis on trauma, bereavement, depression and anxiety.
"We provide psychological, social and specialised medical services for Palestinians in the Gaza Strip who have suffered and continue to suffer from the blockade imposed by Israel and Egypt. Our psychological work developed emergency response methods during the bombardments in 2008-9, 2012 and the invasion of 2014. These are now being adapted to deal with the threat of the COVID-19 virus."
In the immediate aftermath of the 2014 war, WHO estimated that up to 20 per cent of the population of Gaza may have developed mental health conditions. According to UNICEF, more than 300,000 children in Gaza required some sort of psychosocial care.
Aid workers, including officials at the United Nations Palestinian refugee agency (UNRWA), warn of an unprecedented mental health crisis unfurling across Gaza, exacerbated by a surge in violence over the last year and funding cuts to vital support programmes.
Furthermore, the 13-year Israeli blockade has severely curtailed the quality of life in Gaza, where youth unemployment now stands at 60 per cent and poverty levels increased from 30 to 50 per cent.
The conflict in Palestine is something very distinct from those taking place in other countries in the region, as every child in Gaza has grown up witnessing three Israeli offensives – 2008-2009, 2012 and 2014 – that devastated the Strip. According to Mohamed, the parents have been hardest hit.
"Even though it is the elderly, children or women who are mainly the focus of charities," he says, "from my personal and professional experience, it's the parents who are most vulnerable."
"It is heartbreaking when, as a mother or father, you feel helpless after your child has been shot or injured and they're bleeding to death while you can't do anything."
During a bombing raid, you have no resources to protect the terrified child who clings to you. This profound helplessness can leave parents vulnerable to despair and uncontrolled anger.
"We believe the best therapy and treatment need to be made available to the people of Gaza who suffer not only from PTSD symptoms, but also from a form of ongoing trauma. We have found that psychosocial methods which incorporate cultural and historical elements of the Palestinian situation can aid resilience."
As a result, he developed Family and Community Therapy. "One person suffering from PTSD in a family affects all the rest," he says, "because family is the most effective central unit in the community. Intervention has to look after the family first.
"We have psychiatrists, social workers, psychologists and nurses all of whom use a multi-sensory method to deal with trauma. So it's not just all talk. Practical activities are vital during the interventions so they are physically empowered and resilient enough to feel like they can look after themselves and in turn look after their family."
A series of research studies that observed the effects of war on Palestinian children living in the Gaza Strip concluded that symptoms of depression, anxiety and PTSD were prominent amongst children who had been exposed to substantially distressing events, such as destruction of their family house, viewing their family being murdered, bombings and the arrest of family members.
The effects of these disorders are severe and can dramatically hinder a child's sleep, cause lack of concentration, panic attacks, anxiety and, perhaps even more disturbing, instill a constant sense of fear within children and babies.
Attachment to parents and family members, which Mohamed explores in his research entitled 'The Child, the Family and the Community: Overcoming Trauma in Gaza', is a crucial factor in the way a child responds to a traumatic event in war or conflict.
Parents' anticipation of the traumatic event, their reaction while it happens and the way they deal with it afterwards can increase or reduce the PTSD levels in children to a significant degree. "This is why a holistic understanding of Family Therapy can alleviate PTSD symptoms," he explains.
However, it is an on-going struggle.
Mohamed says many sufferers avoid seeking help due to a failure to recognise mental illness or because there is a stigma associated with psychiatric treatment in a conservative society.
"Not everyone can be open about needing psychological help or psychotherapy," Mohamed continues. "But the awareness has improved. Gradually, more Gazans are seeking treatment because we are careful about how we present the idea of therapy. We focus on somatic elements and use the term 'support'."
"Unfortunately," he said, "such support can only help to a limited extent, since it's not possible for psychiatrists to combat the root problem: the stifling Israeli occupation and blockade."
As he reflects on his decades-long journey dealing with this collective depression, he says the main objective of the Palestine Trauma Centre is to change the what Gaza's streets mean to its residents.
"The streets of Gaza trigger a mental impression of destruction with memories of the smell of blood, broken limbs lying about, rubble and chaos. We have street activities on a Friday which aim to transform that image into something positive."
"Every Friday, a team of performance artists along with therapists known as the 'Joy Team' go into different refugee camps to entertain children and families and bring them onto the streets for games, street theatre, clowning and dance. It is a community-building initiative developed to counter trauma and has proved to be very popular."
The results of the initiative were instantly noticeable with some parents playing with their children for the first time, he explains. "Parents end up enjoying themselves more than the kids because they say how they were not lucky enough to have anything like this in their childhood."