Aerial view of a displacement camp. Gaza, 2023. © MSF

Enduring the unthinkable: Gaza’s healthcare workers grapple with the mental health impact of an unyielding war

After over six months of relentless war, Gaza’s healthcare workers have had to face unprecedented challenges to provide medical assistance to thousands of people, while trying to survive and manage the toll the war has taken on them personally. According to Doctors Without Borders/Médecins Sans Frontières (MSF) mental health staff, the impact of working in such extreme conditions will leave scars for years to come.

Some healthcare workers in the Gaza Strip, Occupied Palestinian Territories, say they are living in constant fear, stress and anxiety as they continue to treat patients. They have described receiving repeated large numbers of casualties with crushed limbs and burns from explosions, and having to perform amputations without sufficient pain medication or anaesthesia. They have denounced the crippling shortage of medical supplies they need to save lives, brought on by Israel’s complete siege of Gaza in the first months of the war. They have fled hospitals that were forcibly evacuated or attacked by Israeli forces, and have made the unthinkable decision of leaving patients behind to save their own lives.

Medical staff bearing the burden in times of war

MSF psychiatrist, Dr. Audrey Mc Mahon, who recently returned from Gaza, says medical staff in Gaza are working under profound psychological strain.

“Many times, because of the bombardments or because of the insecurity, medical staff had to leave patients behind. Many of them have a shared feeling of guilt for not being able to do more,” says Mc Mahon. “Other times, the guilt is about having made the choice to protect their family first and not go to the hospital to treat patients.”

Some 300 Palestinian MSF staff are in Gaza including Dr. Ruba Suliman who works at Rafah Indonesian Field Hospital. She has been displaced from her home and is living in a shelter in Rafah, southern Gaza, with her husband and two children.

“There is constant noise from the drones, which never leave us. Sometimes it’s really hard to sleep,” says Dr. Suliman. “I have this moral obligation to help people around me and I have this other obligation to save my kids.”

“We are alive, but we are not okay. We are tired. Everybody here is devastated.”

Dr. Ruba Suliman, MSF staff

Healthcare workers in Gaza face the same struggles as the other 2.2 million people living in the enclave. These doctors, nurses and emergency responders have also lost their homes; some are living in tents, and many of their friends and family members have been killed.

“It is not just about the house itself [destroyed in Gaza City], it is about losing all the small things that made you who you are,” says another Palestinian MSF doctor. “My favourite coffee cup, my mother’s pictures, the shoes I liked so much.”

The psychological toll and human cost

The intensity of and the long exposure to these traumatic events are shattering the psychological state of some Palestinian people in Gaza. This also includes healthcare workers, who say they come to work to not think about the war. But they nevertheless fear that what they see happening to their patients will happen to them or their loved ones.

“Medical workers continue to work despite their emotional state, despite their constant worries about the safety and security of their families,” says Gisela Silva Gonzàlez, MSF Mental Health Activity Manager in Gaza. “This increases the level of stress at work, which is already very high in this context. The case of every patient can be an emotional trigger for healthcare workers.”

MSF’s mental health staff in Gaza say they are seeing symptoms in medical staff linked to this level of continuous psychological stress and exhaustion. Staff experience anxiety, insomnia, depression, intrusive thoughts, emotional avoidance and nightmares, all of which can heighten the risk of mental health issues.

MSF is trying to urgently provide mental health care to medical staff, although a lot remains to be implemented to scale up this support. Davide Musardo, MSF Mental Health Activity Manager in Gaza, says the approach of mental health support for medical professionals is very different than for patients, because they possess more awareness of the impact of their work.

“For our staff, we provide a different kind of activity, more based on their own experience,” says Musardo. “It is mainly a psychological intervention with the possibility to express to other professionals what they are going through. We try to give them a more specialised service through a lot of psychoeducation.”

Looming offensive on Rafah adds to stress

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. No-one and nowhere is safe in Gaza. According to local health authorities, since Oct. 7, over 34,000 people have been killed, including 499 healthcare workers. Five of our MSF colleagues are amongst them.

“When we say that there is no safe place in Gaza today, we are not just talking about the shelling,” says Amparo Villasmil, an MSF psychologist who worked in Gaza in February and March. “There isn’t even a safe place in people’s minds. They live in a state of constant alert. They can’t sleep, they think that at any moment they are going to die; that if they fall asleep, they won’t be able to react quickly and run away, or protect their family.”

Villasmil adds that healthcare workers and civilians alike are haunted and distressed by the prospect of an impending Israeli offensive in Rafah, where an estimated 1.5 million people are crammed and living in dire conditions.

“Once, I found a colleague—a psychologist—on the stairs. He’s usually a very energetic and upbeat person but he was leaning his head on his knees. He was on the verge of tears and told me how exhausted he was,” says Villasmil, about her colleague who had just heard about the confirmation of an offensive on Rafah. “He asked me what he was supposed to do, where he should go and when this war would stop. I had no answers to give him.”

MSF reiterates its call for an immediate and sustained ceasefire to prevent more death and destruction to the lives of people in Gaza.