The long-term casualty of conflict: mental health

Magen David Adom (MDA) National Dispatch Headquarters, Kiryat Ono, District of Tel Aviv.

To collaborate on the provision of mental health and psychosocial support in Israel (a Member State of the WHO European Region), WHO/Europe spoke to health-care workers, families of hostages and members of community resilience centres about the support they need and how they are coping with their grief.

Many said they still feel as if they are dreaming, that they need to keep working or they will not be able to deal with the emotions they are suppressing, and that they cannot afford to grieve right now.

Confronting horror, danger and human misery – regardless of the circumstances – is emotionally demanding and potentially affects people’s mental health and well-being. This is no less true for first responders.

Jonathan Jaledenco and Aviv Shneor, from Sderot, are both paramedics at Magen David Adom (MDA), Israel’s national rescue organization and a member of the Red Cross and Red Crescent movement.

Both are still reliving the day of the attack. Like other frontline workers, they struggle to come to terms with the fact that many ambulances were shot at and their drivers killed while on their way to treat the injured.

To date, WHO has verified 33 attacks against health care in Israel since 7 October, leading to 21 patient or health-care worker deaths.

Aviv Shneor, an MDA paramedic.

Shneor explains, “A vehicle designed to save lives is damaged and the staff inside hurt. It's a difficult feeling when ambulance staff, whose purpose is to save lives, and not to distinguish between religion, race or nationality, suddenly becomes a target. We were required to treat the injured after the events and are still dealing with the consequences.”

Jaledenco was at home when Hamas attackers entered his compound. “It was unreal, I didn’t understand what was going on. I discovered there were several shooters. But I am medical staff and, as such, I thought we weren’t a target. That’s when I was told that one of my friends had been killed in the ambulance he was driving.”

He continues, “October 7 feels like one long day that hasn’t ended. I work on autopilot, I do what I need to do. I don’t ask questions. I need to keep myself stable mentally in order to do my job. When the war ends, then I’ll start to process everything that happened.”

The process of opening up and confronting their trauma and fear is a daunting task.

Jonathan Jaledenco, an MDA paramedic.

“If I ask for help, I’ll get it. But that means I need to open up and talk about everything I’ve seen, and I am afraid that if I do that, I won’t be able to keep saving lives and treating people because I’ll be depressed. I am not thinking about it now. I’ll think about this later,” says Jaledenco.

Although a reluctance to seek support in the immediate aftermath of distressing events is understandable, prolonged exposure to such events is associated with a higher likelihood of poorer mental health outcomes, including post-traumatic stress disorder. That likelihood increases as a conflict continues and if support is absent or not accessed. With the right help, the majority of people can overcome their difficult experiences over time.

Gilad Bodenheimer, Head of Mental Health Services at Israel‘s Ministry of Health.

When Gilad Bodenheimer, Head of Mental Health Services at the Ministry of Health, is asked how many in Israel could be in need of mental health and psychosocial support, he shares his assessment that the entire population is experiencing some kind of anxiety or other trauma-related symptoms, because their sense of security has been shattered.

He believes that mental health services should target the whole population while focusing in particular on reaching specific population groups at this time. “These include people whose families have been massacred, and families whose loved ones are still missing or were taken hostage.”

He adds, “We believe that going through a terror attack is not necessarily a mental health issue, it is a community issue. Coping with it is about resilience and the forces inside of us – but some people will also need mental health assistance.”

Bodenheimer explains that, going forward, community resilience centres – a model being scaled up rapidly – are vital. Their staff have the skills to psychologically guide groups to deal with their experiences and can help build resilience in times of crisis.

“If we, for instance, have people who are provided with these resilience factors and they know how to deal with each other, conflict inside the community will be handled differently, and other emergency and crisis issues may be handled differently.”

Bodenheimer offers 3 important things to remember for those suffering distress: what people are feeling is a normal reaction to something abnormal; most people already possess the tools needed to move on; and helping others is mutually beneficial.

Medical students in Soroka Medical Centre’s emergency room.

Soroka Medical Centre, 40 kilometres from Gaza, is the hospital that took in most of the wounded on 7 October. In the first 16 hours, the emergency department treated about 680 patients, of whom 120 were critically wounded.

Tzachi Slutsky, Soroka Medical Centre’s Deputy Director, talks at length about how proud he is of his multicultural workforce, with health workers of all backgrounds working side by side to treat casualties. He also acknowledges their growing need for psychological support.

“Since 7 October, we have been trying to find the staff members that are in need of more help. And as the days go by, we understand that our staff need a lot of help. What they saw, what they suffered, is beginning to come out.”

Slutsky explains, “Because most of them have been at work, they didn’t think about their mental health. Now, while the days are quieter, those who saw and treated casualties are speaking out and starting to feel afraid. They are beginning to understand that their mental health is not the same. Many are seeking someone to talk to.”

Tzachi Slutsky, Soroka Medical Centre’s Deputy Director.

When asked about their common symptoms, Slutsky responds, “Many are less talkative, they work longer hours and spend less time at home to avoid situations that make them think about what happened. Many staff are afraid to go home after it is dark. A lot of staff members have problems sleeping.”

Many of Soroka Medical Centre’s staff lost close relatives or live in the areas that were attacked, and among the victims were 2 physicians and 2 retired nurses. A Soroka nurse is believed to be among the hostages still held by Hamas.

“Work is therapy. Because when you are at work you're together, you’re speaking together. This is the short-term measure. But we understand and we know that as soon as staff get some psychological support it will be better for them,” Slutsky says.

Tal Hayun, Head Nurse of the Operation and Recovery Rooms at Soroka Medical Centre.

As hospitals and their staff strive to return to some sense of normalcy, many health professionals are reflecting on the importance of what they call health for peace. One of them is Tal Hayun, Head Nurse of the Operating and Recovery Rooms at Soroka Medical Centre.

“Health for peace is one of the main goals. We've been working together for many years, and there are no differences when it comes to religion, sex or beliefs. All the staff were here working together on that Saturday, and every day since then we have worked together. We’re here to save lives, that’s the main goal. It doesn’t matter what the problem is or what type of injury it is, we are here for everyone. We work together shoulder by shoulder.”

Since the attacks on 7 October, WHO and the wider United Nations family, citing international humanitarian law, have been calling for the immediate and unconditional release of all hostages, along with urgent medical access to these individuals, some of whom have serious chronic conditions.

Additionally, WHO has been working with other humanitarian partners to gain access to civilians and health facilities in Gaza, where the vast majority of the civilian population has been impacted by the conflict that has claimed well over 11 000 lives and damaged or destroyed scores of health and other facilities.

WHO and United Nations partners have repeatedly called for a ceasefire and unimpeded, safe and sustained access to health and humanitarian assistance for civilians in Gaza. WHO also strongly condemns attacks on health facilities and health workers under any circumstances, emphasizing that health cannot be a target.

“Health for all, regardless of who or where, or under what circumstances – that is WHO’s vision and guiding principle, underpinned by health as a human right,” says Hans Henri P. Kluge, WHO Regional Director for Europe.

“WHO is applying this principle at this tragic time, doing all we can to support people who are suffering on all sides, and the heroic health workers who press ahead with their selfless mission, often paying the ultimate price.”