I recently returned from a seven-day medical mission to the Gaza Strip from Oct. 21 through Oct. 28, 2018. I was there with six colleagues from Washington Physicians for Social Responsibility. We are a group of health care providers based in Washington state who have been providing health care teaching and resources to our host NGO, the Gaza Community Mental Health Programme (GCMHP), intermittently since 1992. This year’s delegation was smaller than usual due to the challenges involved in getting permission from Israeli authorities to enter Gaza. We ultimately obtained permission through the help of Gisha – Legal Center for Freedom of Movement, an Israeli human rights NGO that argued on our behalf in the Israeli courts, but this occurred only a short time before we were scheduled to travel, making it difficult for some of our colleagues to join us.

Our contingent consisted of an orthopedic surgeon, an adult cardiologist, a child psychiatrist, a relaxation and yoga teacher, two mental health counselors and myself, a developmental and behavioral pediatrician. This was my fifth trip to Gaza where I was asked, as a specialist in child developmental disorders and, specifically, autism, to teach about this condition which is seen with increased frequency by mental health providers in Gaza.

I don’t presume to have a complete overview of the medical issues currently in Gaza, so this report should be considered more anecdotal than comprehensive. I can say what I’ve seen, and whom I’ve talked with, but as with any such reporting, there may be much left out or even distorted. Here are some of my thoughts and observations.

On Teaching in Gaza

Each year in 2014, 2015 and 2016, I have taught in Gaza about autism, a condition I’ve studied for about 25 years. This year was no exception, I taught about 27 fourth-year medical students at the Islamic University Medical School, as well as two half-day seminars with 20-30 GCMHP staff and trainees in psychology. Over the years I’ve taught multi-day seminars with health providers and similar seminar-discussions with parents and providers. I’ve seen children and their families in clinics, public spaces and their homes. Autism is the same condition in Gaza as it is elsewhere in the world: an often severe developmental and behavioral condition whose cause is not fully understood, and for which fully effective treatment doesn’t yet exist. Each year I hear anecdotes about improved care in Gaza for children affected with autism — less use of expensive and often ineffective drugs, less use of ineffective treatments such as hyperbaric oxygen, less use of useless diagnostic tests such as EEGs and MRI scans, and more understanding of the need for early diagnosis and intervention. The Gaza Ministry of Health, in conjunction with GCMHP, issued comprehensive guidelines on diagnosis and treatment in 2014.

These guidelines seem to be having a positive effect but, frankly, the enormous lack of available professional resources impede substantial progress. Despite these barriers, what is really impressive is how the health care community continues to step up in the face of formidable obstacles.

Mental Health

Mental health issues remain a major health concern in Gaza. We met with the director of GCMHP, Dr. Yasser Jamei, as well as members of the psychiatric and psychological staff from GCMHP and Dr. Zyad Zagout, the director of mental health programs of the United Nations Relief and Works Agency for Palestine (UNRWA). Increasing numbers of children show symptoms of autism, depression, post-traumatic stress disorder (PTSD), anxiety disorders, sleep disturbance and similar mental health issues. These issues are certainly related to ongoing problems including military hostilities, high unemployment, limitations on travel outside of Gaza via Israel and Egypt, poverty, hunger and limited mental health resources.

School Mental Health Issues

To give one example, UNRWA previously employed one counselor and one facilitator at each of the 267 UNRWA schools in Gaza. The facilitator acted as a screener of problem issues referring only the most severe to the counselor. There are approximately 1,000 students in each school. It was estimated that as many as 30% of the children were displaying symptoms such as hyperactivity, aggression, sadness or withdrawal. Of these symptomatic children, the counselors had the capacity of, at best, serving 30% of those in need. With the recent cut in $360 million in U.S. funding to UNRWA, the facilitators have all been laid off and the counselors have been reduced to half-time employment. Similar issues affecting UNRWA’s operations were reiterated by Mr. Matthias Schmale, the current director of UNRWA. We were fortunate to meet directly with him when he took his evening off to meet with us. The efforts of this incredible humanitarian agency’s staff with a hugely difficult mission remain an inspiration for me.

Services Are Affected by Ongoing Hostilities

Cerebral palsy is a condition I am trained to treat, a condition that is a consequence of brain injury during very early childhood or during pregnancy and delivery. Affected children have difficulties with movement, often requiring wheelchairs or other assistive devices for mobility. They may also have cognitive problems, hearing and vision disorders and/or muscle and joint deformities. Gaza has been fortunate to have a long-standing program, the Palestine Avenir for Childhood Foundation (Pacf Cp) to provide rehabilitation, special education and occupational and physical therapy services to this population of children and adults. A new center for this NGO was recently completed which provided much needed and enhanced services. Sadly, that facility is not currently functional, as it was quite severely damaged after the bombing of the building next door. I was able to tour the new building and saw blown-out windows, destroyed ceiling tiles and damaged equipment, all due to the blast wave from the flattening of the next-door building.

We also visited the current makeshift space for continued therapy pending rebuilding of the new center. I traveled there with Mr. Ahmed Al Kashif, the longstanding director. What was immediately apparent was how beloved he is by the children he cares for. He walked in and kids ran up to him, everyone greeting him happily and enthusiastically.At the same time, however, I saw children clustered around a table with a teacher instructing them in reading and writing using a mobile phone flashlight to illuminate the workbooks as there was no electricity. A physical therapist provided therapeutic exercise with few pieces of equipment available.

War-Related Injuries

While we were in Gaza, there was a demonstration on a Friday evening that turned ugly, and intermittent bombing was heard into Saturday mid-day.

As of Oct. 18, 2018, there had been 22,897 injuries, of which 11,913 required hospitalization and 217 deaths in conjunction with the ongoing “Great March of Return” demonstrations which began on March 30, 2018 on the Gaza-Israeli border (data is assiduously collected by the United Nations Office for the Coordination of Humanitarian Affairs). One member of our delegation is an orthopedic surgeon. He operated and attended clinics at Shifa Hospital, the main public hospital in Gaza. Shifa was where most of the people with serious injuries were hospitalized following the repeated altercations between demonstrators and Israeli military.

We learned that the most serious orthopedic injuries were the result of gunshot wounds coming from an exploding kind of bullet, either a “hollow point” or a “butterfly” bullet. These bullets often destroy bone to the extent that amputation is needed. We learned that the Israel Defense Force’s policy is to shoot at the legs of demonstrators rather than elsewhere, it would seem, to avoid deaths. The consequence of using this kind of live ammunition is that there is a waiting list of about 2,000 people waiting for surgical repair. Our orthopedic colleague’s surgical team, which included surgeons from the United Kingdom, were able to complete 20 surgeries during the time we were there. That only leaves 1,980 more to do.

What Is Going On Here?

We spent much time trying to understand the current accelerated conflict at the border. The original intent of the March of Return demonstrations was to highlight the still-unsettled status of refugees from the time of Israel’s creation in 1948. Soon after the first demonstration, spontaneous demonstrations began to occur weekly, with protests primarily focused on the continued 11-year siege of Gaza. Entry into and out of Gaza is via two crossings: Erez, which is controlled by Israel in the north end of the Gaza Strip, and Rafah, which is controlled by Egypt at the south end. Entries and exits are tightly regulated; transit is very difficult, with long waiting lists for permits. Gaza is surrounded by a fence and wall to the east, north and south. Boats leaving Gaza on the Mediterranean coast are limited to between 3 and 9 nautical miles and are closely patrolled by Israeli boats. Opportunities to work, study or engage with people abroad is limited to a very small number of residents. Electricity is available only 4-8 hours per day. Food supplies for the most impoverished are decreasing. Equipment, medical supplies, pharmaceuticals — indeed all that is needed to provide health care the Gazan professionals are trained to do — is severely limited. And the ongoing political conflicts between the two major political entities, Hamas and Fateh, just add to the ongoing frustrations of Gazans, particularly young people.

We were repeatedly told that the ongoing feeling of hopelessness and fear has morphed into rage for many. There does not seem to be any obvious solution. Gaza residents continue to suffer.