By Haim Yacobi, Michelle Pace, Ziad Abu Mustafa, Yasser Abu Jami

“The idea of continuing to search for opportunities and not finding them, then seeking and working hard to strengthen yourself to find an opportunity and then things do not work out, or to reach the interview stage in a very great institution and then not succeed? All of this takes you way back. The idea of seeking is related to finding something, so when you seek and do not find something, it causes you many problems. I cried often and experienced depression, poor appetite and anxiety. Even my face and skin have psychological problems and my hair is falling out because I keep trying in vain”.

The above quotation is taken from an interview with D, a student in Gaza, who expressed her efforts at finding a job, and how the ongoing failure, due to the current situation in Gaza, damages her mental well-being. Crucially, we argue, this is not an anecdote or a unique case. Rather, the deterioration in Gazans’ mental health conditions in general and among young people in particular, could be defined as an epidemic. According to Dr Yasser Abu-Jamei (March, 25 2023), the director general of the Gaza Community Mental Health Programme, research carried out in 2017 among university students showed that 60% felt sad, 60% felt hopeless about their future and 35% had experienced suicidal thoughts sometimes or often. The Gaza Community Mental Health Programme conducted research on this same issue once again in 2019 that confirmed (amongst another group of university students) that living under the ongoing siege compromised participants’ resilience, increased their sense of hopelessness, and exposed them to anxiety, stress and depression. Similarly, an International Committee of the Red Cross 2022 survey found that 9 out of 10 young people from Gaza believe that their lives are abnormal, suspended and their life opportunities fading.

Indeed, years of living under violence, as well as the constant fear of violence, poverty and lack of hope shape Gaza’s generations’ vision and attitude towards their uncertain future. Moreover, while the scope of mental health issues is widespread, throughout our fieldwork we have encountered interviewees who felt uncomfortable discussing this topic; this was not always directly communicated but all interviewees’ comments revolved around these issues.

Consequently, in our current research “Making the Invisible Visible: Slow Violence, Mental Health and Resilience in Gaza”, supported by The MENASP Network and the UCL Global Engagement Office, we focus on this urgent humanitarian case. In this project, we aim to make the invisible and long-term effects of violence visible, i.e., to examine how violence affects Gaza’s young generation in terms of their increasing vulnerability to mental health challenges, and how existing resilience networks could serve as a vehicle for better strategic intervention in mental health. In more detail, the main question we investigate in this project is how slow violence, implemented by Israel over Gaza, affects the mental health of Gazan young people.

A central theme at the core of our findings is the lack of possibility even to imagine a future amongst Gazan youth, which, according to Ratcliff et al (2014), is a symptom of trauma that can lead to a loss of “trust” or “confidence” in the world. This is illustrated, for instance, in an interview with M. from Khan Younis, south of Gaza city. M. did not complete his bachelor’s degree due to the tuition fees predicament. M.’s frustration was clearly voiced when he stated that:

“… because of the circumstances and conditions in Gaza and the high costs of studying, I was only able to study for one year, then I stopped. I still have one year, and a semester left. This happened because of costs and transportation, as I needed 12 shekels daily, in addition to university fees, which ranged from 250 to 300 dinars each semester. This made me stop studying”. (Interview with M, 25 years old, Khan Yunes, March, 2023)

Significantly, M. further stated:

“There is no future in this country and the situation is very difficult. If we are unable to complete our education, will we find a future in this country?… I am depressed, approaching the age of 26 and there is no life or future, not even hope for the future in four or five years’ time …”.

Indeed, as indicated by existing research, exposure to ongoing violence is associated with mental and physical health deterioration. Individuals with regular exposure to violence, such as in Gaza, are at a much higher risk of depression and lack of consideration of a positive

future. Yet, while most research focuses on individual circumstances, we argue that there are some structural foundations where violence targets a collective. As we elaborated in a previous article Israel’s ongoing settler colonialism in occupied Palestinian territory impacts Palestinians’ everyday life in all its aspects. In more detail we suggest that settler colonial violence and strategies of carceration, exploitation and elimination of the existing population is not only inherent in the production of a new reality and geography, but also at the core of the transformation of Gazans’ life into non-life.

The political topographies in Gaza are affected by Israel’s almost non-existing moral obligations over Gaza’s population, at the same time it creates the possibility of manipulating destructive power and violent practices. With a specific focus on Israel’s interventions in the field of mental health, we suggest that military power, ongoing violence and mental health are entangled in the creation of an intentional and conscious strategy that aims to instil in Gazans a sense of despair and the need to leave Gaza or, in other words, a slow form of violence as a weaponized strategy for diminishing the future of Gazan society in general and of young people, comprising one-fifth of the Gaza population (ICRC 2022), in particular. It is this Gazan youth segment – aged between 18 and 29 years old that forms the core focus of our ongoing research.

As learned from a survey we conducted among 225 students in Gaza, slow violence, indeed, increases perceived stress and impacts related future orientation. 42.8% of our respondents stated that they feel nervous, anxious, tense, or ‘about to explode’ several days over the past two weeks, 27.0% felt like this almost every day, 15.8% felt like this more than half a day, while 14.4% did not feel like this at all. This survey further indicates that 30.2% of respondents were unable to stop or control anxiety for more than half a day in the past two weeks, 29.3% had it several days, 17.7% had this inability several days, and 22.8% had no experience of feeling incapable to control these emotions at all. Indeed, symptoms of depression amongst Gazan youth – resulting from Israel’s slow violence – are clear: 35.3% of respondents answered that they had a lack of desire, interest, or pleasure in doing things several days in the past two weeks, 25.1% had it several days, 20.5% had a lack of desire for more than half a day, while 19.1% had no desire at all. These results are well echoed in the interview already mentioned above with Dr Yasser Abu Jamei who reiterates:

“Mental health is the feeling of psychological wellness and your ability to overcome circumstances, challenges and difficulties, to be productive for yourself and for society, and to feel your ability to change in your society.” Interview with Dr. Yasser Abu Jamei, March 25th, Gaza

Our survey highlights how our interviewees’ challenged state (in terms of mental health) results mainly from the dire economic and living conditions that Gazan families find themselves in. Dr B., a university lecturer, links the lack of work and economic crisis that Gaza´s youth are going through directly with stress and mental health issues. He refers to the level of stress that university students are suffering: “We find that the biggest issues are the economic pressures and basic needs that the student cannot fulfil. Of course, these issues cast a great shadow on their psyche.” Similarly, Rawia Hamam, Director of the Training and Scientific Research Department at the Gaza Community Mental Health Programme, also correlates poverty, unemployment, and Israeli aggression with Gazan youth´s deteriorating mental health condition:

“We may have said before that Palestinian youth are trapped between unemployment, poverty, lack of a horizon, frustration, and loss of hope. This applies to most young people here in Gaza. If we ask a young man how he imagines the future or what he dreams of? A young man can sometimes answer this question that he does not expect what may happen today or tomorrow, let alone the future. The continuous expectation of Israeli aggressions and continuous wars makes many young people unable to plan or form a specific picture of the future”. (March, 2024)

Importantly, despite the unpredictable future in Gaza, some voices have expressed resilience. Resilience (by which we mean the ability of Gazan youth to manage and recover from slow violence perpetuated daily by the Israeli settler colonial regime) is present among Gazan youth in the way they divulge their faith in Allah (God) and the existing social fabric (a strong sense of family and community in Gaza persists). Furthermore, some respondents indicated that, if they do not get a job after graduation, they aim to initiate some private project, continue looking for work, work with parents or neighbours, or look for online work, as well as take training courses and complete postgraduate studies:

“I was affected, but one of our advantages as Palestinians is that we make miracles out of our inhibitions, as we struggle and make something… In terms of individual salvation, I can say that I am now working on an online platform… and I am getting income” (A, North Gaza, March, 2023)

To sum up, our report concludes that the serious and permanent slow violence that Gazan youth find themselves experiencing daily is a clear reflection of the gross violations of the IHL, Geneva Conventions, the political repression, the economic strangulation, the blatant racism, apartheid and creeping genocide that the Israeli settler colonial enterprise subjects them and their fellow Gazans to on a regular, daily basis. The dire situation and status of Gazan youth mental health is what we expose here and call upon policymakers across the globe to address this situation – as an urgent, humanitarian crisis – honestly, fairly and deeply. This is a subject which involves 25% of all refugees in the world and the longest-running injustice of the 20th (-21st) century. Because Gazan youth’s every day is decided by Israel’s colonial rule it is in effect more than a humanitarian crisis: it is politically, economically, and consciously driven, the permanent occupation of Palestinian territories lead by the principal vehicle of the blockade in Gaza, continual Israeli aggressions, with Gazan youth suffering the brunt of all this slow violence, alongside domestic political divisions. In most policy circles, fear and censorship – both internal and external – are concurrent with economic imperialism, rule the discussions. Despite the routine suffering of Gazan youth’s mental health, institutionalized power enforces silence. As academics we still have an open space through which we can shed light on these important issues: But these windows are also being closed off. The ongoing brutal and inhumane reality of so many young lives in Gaza sheds light on the tools and mechanisms of slow violence that Israel’s oppression involves. In this project, we seek to give the front stage to the victims of this violence with the hope that those in power step forward and take the required ethical and moral action to bring an end to this inhumane treatment of so many young lives and to offer some rays of hope for their future.

Epilogue

While writing this blog, Israel struck Gaza once again, with 40 warplanes and helicopters hitting homes, causing fear among residents. The Gaza health ministry reports that at least

21 were killed including 6 children, 3 women, and 2 elderly people. . This current intentional Israeli aggression adds yet another layer of fear, despair and hopelessness amongst Gazan society, which is already, as we discussed above, a target of slow violence attempting to erase Gazans’ sense of the future. When will the powers take action?

This blog is the second of the health in urban development blog series. View also:
Health in secondary urban centres: Insights from Karonga, Malawi

If you are interested in DPU’s new MSc in Health in Urban Development, more information can be found on our website.

“I’m like a bird in a cage”, told Shaheen in an interview to Al Jazeera as she lay in bed at Al-Rantisi hospital. “Outside of my cage I can see water and food, but I can’t reach it. This is my condition right now.” Shaheen suffers from breast cancer, her condition has been deteriorating ever since she was denied exit from Gaza for treatment. The Gaza Strip does not have adequate resources to provide her with appropriate treatment, yet she cannot leave, as Israeli authorities rejected her permit three times in a row without explanation. But this is not an anecdote – current data indicates that 54 Palestinians, including 46 cancer patients, died in 2017 after their requests for permits were delayed or refused.

Gaza, drawings by Gazan children, Photograph: Mohammed Baroud, Screen Photograph: Yoram Kuperminz

The case of Shaheen illustrates the ways in which health, death, life and space are entangled. It is not just about the crossing of the border between the Gaza strip and Israel, but also about being in a “cage”, an urban territory where electricity, clean water, sewage system and adequate housing which are basic conditions for ensuring a health – are absent. As already noted,  in 2017 more than 96 percent of groundwater is unfit for human consumption, and the forecast is that the damage would become irreversible by 2020; Due to chronic shortage in electricity operating pumps, there is a constant threat of raw sewage flooding residential areas. The beach areas of Gaza strip are polluted by more than a hundred million litres of raw sewage flowing into the sea every day. This matter was recently defined by Zeid Ra’ad al-Hussein, the UN’s High Commissioner for Human Rights as a “TOXIC SLUM”, claiming that Gazans “…are… caged in a toxic slum from birth to death”, a ghetto of 1.9 million residents (50% under the age of 18) living in one of the most densely-populated places on earth.

The spatio-politics of health, death and life goes beyond the notion of necropolitics; it is not just about the use of social and political power to dictate how some people may live and how some must die as Achile Mbembe suggests; rather it is also about the spatial dimension of “cage politics”. Within this context I argue that spatial organisation determines the right to kill as defined by Foucault; blocking Gaza, isolating its habitants, controlling the goods that can enter the strip (such as food, construction materials etc). Yet the question is not whether the organisation of space and health are linked, but why is space organised, controlled and destructed in certain cases so as to protect the right to health; What are the ideological forces and the political processes that promote or hinder the organisation of space?

Gaza, Photograph: Khalil Hamra, Screen Photograph: Yoram Kuperminz

The conditions in Gaza are not the result of any natural disaster, neither the outcome of the last few months events along the border. Rather, I would suggest to see it within the context of settler colonial political history, which prioritises territorial and demographic control over basic rights. As already noted the establishment of settler colonialism is based on “the will of erasure”, or at least the “systematic containment” of the original inhabitants. First of all, the refugees: close to 70% of the Palestinians living in the Gaza Strip are refugees. Most of them ran away, or were expelled from villages, towns and cities that are part of the State of Israel today.

Since then, Israeli political discourse focuses on the idea that this problem would disappear by itself. Yet, as the last few months demonstrate this is not the case: Young Palestinians who are demonstrating at the border are the third and fourth generations of the original refugees, and they are willing to die for the right to return, reminding us that 1948 is still with us, waiting for a political (rather than military) answer. Indeed, links between health, death, life and cage politics should be understood within a wider context, where freedom of movement, access to public services and infrastructure, as well as freedom from pollution and environmental hazards, are obvious rights linked to space.

Gaza murals, Photograph: Mustafa Hassona, Screen Photograph: Yoram Kuperminz

Indeed, the case of Gaza illustrates the ways in which people who have been displaced experience “root shock” – the traumatic stress reaction to the loss of some or all of one’s emotional ecosystem. As the case of Gaza demonstrates, the very historical foundations of the root shock are the expelled of Palestinians after the 1948 war from Israel, the creation of the “refugees crisis” and the ongoing violence in the last few decades. Root shock is both personal and collective: on the individual level emotional trauma affect a person experiences when his or her environment is destroyed. It causes the risk for stress-related diseases like depression and diminishes social, emotional, and financial resources. Here, several reports point on the growing number of mental illness in Gaza, including a growing number of suicides.

Importantly this has also an effect on the community level; root shock is expressed by the loss of interpersonal ties that is vested in the collective connections and affect negatively a community resilience. A telling example is the aspect of the high rates of sexual assaults in Gaza resulted of the common addiction to Tramadol which is available in Gaza, and popularly traded as an illegal street-drug. According to Mansour, the Tramadol side-effects have an immense impact on the frequency of sexual assaults and other un-healthy sexual behaviours. In general, Mansour describes Gaza as a society in “a tremendous and accelerated disintegration” in which “people are losing their humanity”. Another aspect is gender-based violence. In 2016, more than 148,000 women were subjected to psychological and physical abuse. Studies show a link between violence against women and the worsening of living conditions. According to the UNFPA, ‘The structural, cyclical and hierarchal nature of violence… means women often become “shock-absorbers” of the crisis’ in Gaza.

To sum up, cage politics violence has two dimensions that affect health conditions in Gaza. Active violence stemming from direct military actions and explicit policy. This affects water supply, electricity, nutrition. It also causes a severe shortage of equipment, medicines (including antibiotics and morphium), and medical expertise. This, for example, means injured people with gunshot wounds to the legs are not always treated quickly, leading to amputation. But cage politics is also discursive, symbolic and implicit; this is expressed in the very de-humansing and demonising public discourse in Israel, that in turn justifies active state violence. A current example is the building of an underwater sea barrier that according to the Israelis aims to prevent Palestinian infiltrators from entering Israel by sea. The barrier will consist of three layers. The first will be below the water; the second will be made of stone; the third will be made of barbed wire. An additional fence will surround the sea fence. The effect of this project on Gaza is clear: fishing, mobility, health and economy is one side of it, but this also takes us back to the very argument presented today: cage politics of health, life and death are highly political and that access to water, electricity and services, or proximity to environmental hazards, are not neutral facts but rather the results of policy and violence.

Haim Yacobi is a Prof of Development Planning and the Programme Leader of the Health in Urban Development MSc Programme at the DPU. In his current research he focuses on the ways in which ideology, planning and health are entangled in conflict zones.