Cover photos from the MSF report: Gaza’s Silent Killings: The destruction of the healthcare system and the struggle for survival in Rafah. Published with permission

Gaza medical staff working under ‘profound psychological strain’ as further threats loom

Marie McInerney
Alison Barrett
Thursday, May 2, 2024

Child health, Mental health, Pregnancy and childbirth, Trauma, Conflict and war, Global health, Workforce matters, Healthcare, Public health and population health, Human rights

Introduction by Croakey: Amid desperate efforts to head off an Israeli invasion of Rafah, the United Nations relief chief has warned a ground invasion would spell even more trauma and death for the hundreds of thousands of people who have fled to Gaza’s southernmost point to escape disease, famine, and fighting.

“For agencies struggling to provide humanitarian aid despite the active hostilities, impassable roads, unexploded ordnance, fuel shortages, delays at checkpoints, and Israeli restrictions, a ground invasion would strike a disastrous blow,” said Martin Griffiths, Under-Secretary-General for Humanitarian Affairs and Emergency Relief Coordinator in a statement.

“We are in a race to stave off hunger and death, and we are losing,” he said.

Meanwhile, following six months of Israeli attacks, Gaza’s healthcare workers are devastated, and the healthcare system is destroyed, according to two new publications by Médecins Sans Frontières.

Alison Barrett writes:

Gaza’s healthcare workers have had the “unprecedented challenge” of providing medical assistance to many injured and ill patients, while trying to stay alive and manage the toll of the war on themselves.

“An essential element required for psychological support and treatment is safety – and in an environment where not even the caregivers are safe, it is impossible to build resilience and coping mechanisms”, according to a recent article by Médecins Sans Frontières about the mental health impacts of the conflict in Gaza.

“No one and nowhere is safe in Gaza,” it says.

MSF psychologist Amparo Villasmil is reported as saying that healthcare workers and civilians are currently “haunted and distressed by the prospect of an impending Israeli offensive in Rafah”.

MSF psychiatrist Dr Audrey McMahon recently spent time in the Occupied Palestinian Territories.

She said medical staff in Gaza “are working under profound psychological strain”, with strong feelings of guilt at not being able to do more or for having to make decisions to leave patients behind during forced evacuations or Israeli attacks.

Healthcare workers in Gaza shared with MSF the “impacts of working in such extreme conditions”, which will “leave scars for years to come”.

Some said they live in “constant fear, stress and anxiety as they continue to treat patients”.

Over the past six months, they have tended to a large number of casualties with crushed limbs and burns, having to perform amputations with insufficient pain medication or anaesthesia.

There is an incredible shortage of medical supplies needed to save lives – largely attributed to Israel’s “complete siege of Gaza” in the first months of the conflict, according to MSF.

Healthcare workers in Gaza have been displaced from their homes, many living in tents and severely overcrowded conditions, with constant noise.

“We are alive, but we are not okay. We are tired. Everybody here is devastated,” said one of the 300 Palestinian MSF staff in Gaza, Dr Ruba Suliman. She is living in a shelter in Rafah, displaced from her home and works at Rafah Indonesian Field Hospital.

MSF is trying to provide mental healthcare to medical staff in Gaza, but says it is challenging to scale up the level of support that is required.

Medical staff require a different approach to mental health support than for patients, said MSF Mental Health Activity Manager in Gaza, Davide Musardo.

“It is mainly a psychological intervention with the possibility to express to other professionals what they are going through,” he said.

Gaza’s silent killings

Another recent MSF report, Gaza’s Silent Killings: The destruction of the healthcare system and the struggle for survival in Rafah, warns that, as the Gaza catastrophe unfolds, “the collective capacity of the humanitarian community to respond at the scale required has been hindered by… insecurity and by restrictions imposed by the Israeli authorities on vital supplies entering the Gaza Strip”.

“Healthcare workers are exhausted as they try to address people’s growing medical needs,” it says.

The emergency medical responses established in Rafah when the population was forced to evacuate northern Gaza on 13 October 2023 are nowhere near sufficient to support the 1.7 million people residing in Rafah.

“Any further military incursion into Rafah would be an unfathomable human catastrophe, jeopardising the fragile lifeline of healthcare for the people living there,” MSF write.

MSF’s observations of patients in and around medical facilities in Rafah include:

deteriorating population health, with rising rates of acute malnutrition
medical facilities that are still functioning are inundated and operating beyond their means
the current medical response is rendered ineffective by the Israeli siege.

In two of the MSF primary healthcare centres, 5,222 outpatient consultations are provided each week – 40 percent of these are for children younger than 15 years and for babies.

In addition to the thousands of people killed by the Israeli attacks, many are dying from “entirely preventable circumstances” or the disruption of usual healthcare.

Excess mortality – health-related deaths that would not have occurred in the absence of the conflict – in Gaza has been projected to result in “tens of thousands” of non-trauma-related deaths in the next six months if the current situation continues.

The report draws upon medical data from five months of medical care in Rafah, and the testimony of patients “to demonstrate that even in Rafah, conditions for survival are not in place”.

“People’s needs are skyrocketing and the healthcare system no longer has the capacity to respond.”

Jennifer Tierney, Executive Director for Médecins Sans Frontières (MSF) Australia, talked to ABC TV today about “the deaths behind the headlines”, with the conditions and collapse of medical facilities meaning that “patients are being turned away for things like diarrhoeal diseases and diabetes, and there is no patient care for people who are suffering from things like cancer”.

Tierney said the displacement and ongoing conflict was seeing MSF staff members housing 30-40 family and community members, other people living on the streets, and pregnant women giving birth in latrines.

“It’s a desperate situation, which leaves very little hope and a very high level of insecurity for the community,” she said. Rates of mental health concerns are “skyrocketing”, with MSF teams seeing children as young as five years old with suicidal ideation. Watch the interview here.

Acute malnutrition

As reported in March, the Integrated Food Security Phased Classification (IPC) warned that famine was imminent in north Gaza.

In Rafah, 25 percent of the population are experiencing “catastrophic food insecurity”.

MSF have registered moderate and severe acute malnutrition weekly in Rafah since mid-January. Between January and the end of March 2024, it registered 216 cases of moderate and severe acute malnutrition in children younger than five years old.

As these figures are based on screening of patients at the primary healthcare centres, they represent only a “small part of the larger reality”.

Mental health

Prior to this ongoing conflict, approximately 22 percent of the Gazan population lived with mental health conditions, including five percent with complex conditions, schizophrenia and bipolar disorder.

People with complex mental health conditions are often left without treatment now as the only specialised psychiatric hospital in the Gaza Strip ceased services on 6 November 2023.

According to the report, MSF mental health specialists in Gaza have observed some people caring for family members with severe mental health conditions “have resorted to excessive sedation to keep them safe and prevent them from harming themselves or others”.

The impact on children is especially devastating – MSF described to the United Nations Security Council in February, “children who survive this war will not only bear the visible wounds of trauma injuries, but the invisible ones too”.

MSF began providing group mental health sessions for children in February due to the “critical need for specialised support”.

Threat of disease and epidemics

MSF’s report also warns that the destruction of infrastructure needed for basic humanitarian needs – water, sewerage, shelter – and crowded living conditions pose a “serious threat to public health”.

More than 40 percent of MSF patients have upper respiratory tract infections, with the organisation seeing an increasing number of suspected cases of hepatitis A.

According to the report, 180 women give birth in Gaza every day. Only one hospital is providing maternity care in Rafah, attending to nearly 100 of the deliveries each day. Pregnant women experience significant challenges accessing healthcare during and after pregnancy.

People living with chronic conditions are unable to receive the healthcare they need – medical referrals are obstructed by specialist medical facilities no longer being operable, telecommunication blackouts, and no oversight over patients’ transfers.

In addition, Israeli authorities suspended referral permits for patients seeking specialised cancer treatment in West Bank and East Jerusalem.

“Without access to medical care, thousands more lives will be lost…these are Gaza’s ‘silent killings’,” MSF says.

The report recommends:

an immediate and durable ceasefire
no invasion of Rafah
rapid and unimpeded humanitarian aid to be allowed to enter Gaza
an immediate halt to rising rates of acute malnutrition
the protection and respect of people and medical facilities
the resumption of medical evacuations outside Gaza for patients who cannot be treated in Gaza.

Read the full report, Gaza’s Silent Killings: The destruction of the healthcare system and the struggle for survival in Rafah, here.