Ori Nir  00:00

 Hello, everyone. Welcome to this APN webinar on the mental public health in the Gaza Strip. I'm Ori Nir and with me as my colleague Maxxe Albert-Deitch. Hi Maxxe! And, as we always do, before we start are a quick reminder of our housekeeping notes. We are recording this webinar, it will be posted. The video will be posted on our YouTube channel, the audio on our podcast, we'd like to encourage you to ask questions. So please do that using the q&a tool. It's at the bottom of your screen. And please make sure that your questions are short. We are, you know, reviewing them as we go along. And we want to make sure that there's not too much text for us to review as we do it. So children in the Gaza Strip went back to school this week, about half the population of Gaza is school age. The median age of the population is 18, and about 43% of the population is 14 years or younger. One of the Palestinian news sites which I watched yesterday, showed a video of the fifth grade classroom, in a girls school in Khan Yunis, in the southern part of Gaza. And in the first row was at a desk for two there was a girl. She was a student sitting next to a very large poster of Layan al-Shaer, the 10 year old girl who was killed earlier this month when Israel's Air Force bombed Gaza. And I examined the face of the girl who was sitting next to this large poster of her absent friend. And she was silent but but her expression really spoke volumes. About a million out of the Gaza strip's, 2 million residents are children, and recent reports by the organization Save the Children found that out of five children in Gaza four say that they live in depression, grief, fear and the burden of this distress is ever growing. Compared to the similar study in 2018, the number of children then who reported an emotional distress was 55%. So it increased from 55% to 80%. To discuss the emotional distress among Gazans, particularly children but not only were very grateful and fortunate to have with us two practitioners who are on the ground in Gaza. Dr. Suad Lubbad and Dr. Yasser Abu Jamei. Dr. Suad  is a project officer at the American Near East refugee aid (ANERA) in the Gaza Strip. The projects that she leads there mainly handle early childhood development, child health, nutrition, education, protection and hygiene. And she holds a PhD in human development and the asset of Bucha. Yassar Abu Jamei s the Director General of the Gaza Community Mental Health Program, a leading mental health service provider and the co founder of the Palestine global mail, global Mental Health Network. And his recent focus is an approach that integrates public health and human rights into mental health in the Gaza context. Suad, Yasser, thank you very much for joining us. So I would like to start by asking you what are the chief causes for the stress in the Gaza Strip, obviously, you know, war conditions are a major source of distress. But Gaza has now also been under siege for 15 years. Under blockade. How does that play? Day to day? Maybe, maybe Suad? Do you want to start?

Dr. Suad Lubbad  04:39

No, no, I will ask  Doctor Yasser to start. Yes.

Ori Nir  04:41

Yeah. Please go ahead, Doctor Yasser.

Dr. Yasser Abu Jamei  04:45

Thank you. So Adam, thank you orient, Max, the organizers and the audience. I just have noticed, one dear friend who seems to be there. Donald Millman so good. To see your name, Don, and I hope to see you in the near future, and many others. But that name just struck me immediately. Look, when we look at a place like Gaza strip, of course, it comes to the news every now and then. And unfortunately, in the last few years, it's coming more frequently into the news, and usually news for the hot stories, you know, and a hot story nowadays, unfortunately, it's about, you know, a flood or a storm or war, or let me say, something like that natural or human made disasters. You know, there are plenty of them at the moment. In Gaza, when we spoke, we speak about how things are, well, as you said, already, but I could just put it or divided into two kinds of factors, you know, something that are related to the chronic conditions of the population and Gaza Strip. And the chronicity of the conditions is not only does not only go back to let me say 15 years of blockade, no, it goes back more than that, for example, it goes back two decades of occupation. It goes back to the era that about 70% of the people who are living currently in Gaza are refugees. You know, our Israeli colleagues have proved many decades ago that there is a term that is called transgenerational trauma. And we as Palestinians also have brought so far, in some research studies, that also that happened to Palestinians. So imagine that you are born and you will carry with you the stories, even the stories that your parents talk about your grandparents talk about. So you speak about community, that's two thirds of it a little bit more than that are refugees. They grow up to know the stories, and at the same time, they are under blockade, you know, the kids. So these are a couple of chronic conditions that were exacerbated, again, by the long 15 years, blockade on Gaza Strip and with that blockade, we have more problems with electricity, we have more problems with a fuel crisis at large more problems with water supply, and all of these things that come with the fuel crisis. And it was also,let me say, complicated by the division within the Palestinian society, the de facto government that is all in Gaza at the moment, and the division between it and PA. We have two holding, let me say, but it's the government of the Palestinian people, because of chronic conditions.  And they are interesting because as it might happen, and everywhere, a lot of poverty and high unemployment rate. Now, this is something that we need all the time to keep in the background when we talk about Gaza Strip. That's the background of the picture we usually talk about. However, if you have to get to the news, again, the acute conditions that happen. Well, you know, we can speak clearly about for example, the fifth largest scale operation, if we could call it that happened in early August on the 22. It's the fifth in a series since 2008. When we speak about 17 or 18 year old boy or girl, they have certainly witnessed a lot of of things that happened during those attacks. And we say that these are large scale operations. Because you know, the Gaza Strip is a tiny place, I'm sure that you will know the geography of the area. And when we hear, for example, that just under three days attack in early August, about 150 strikes occurred by the Israeli army, you can imagine that these strikes were hard. Perhaps not perhaps not all of them, but definitely all the inhabitants of Gaza Strip have heard the bombardment. Some of them saw some bombing happened to their, let me say, neighborhoods, some of them lost their loved ones. Among the 50 people or so were killed,  17 were children. Children were killed. And most of the 50 are civilians. And this is not only the accurateness. But of course this acuteness, and within those, if I could say 12 or 13 years of attacks, we had also our own chances of COVID-19. The pandemic that exacerbated the poorness of the population made it more difficult for the social networking and social, let me say, support to help people overcome the difficulties. Those acute conditions, I think, the striking feeling that happened to adults and parents or caregivers, and then I leave the floor to Suad, I don't want to take a lot of time. But the very striking thing that happened is that certainly during the days of the attacks, you know, sometimes we count that it's 55 attacks, but sometimes we say how many days in general. The population were exposed to this extrem fear, extreme worry. Children are really terrified. They might have problems with sleep difficulties with sleeping. For parents, the feeling of being helpless, because you cannot, you know, you cannot offer your child any sense of safety during those attacks. And you have nothing in hand that you can offer that could help your family. We don't have the shelters. What what what is meant by shelter, you know, some international agencies try to prepare shelters for the Palestinian people doing those attacks. And guess what is meant by those shelters, It's just a place where you can stay far from the bombing, but it's still not a safe place. It's still a place that those people who are displaced from their areas, they will certainly just find a place that they could go to. So this chronicity and on top of it acuteness every now and then, as a summary of how people are going through. And again, the why is the wide title could be exposure, everyone during those attacks, hears the bombing, everyone exposed to the feeling of lack of safety, lack of security, in that you are helpless, you can't help your children, you cant help the people around you, you can't offer safety. And this perhaps explains the figures that came by the Save the Children report that was titled 'Trapped: 15 years of entrapment' and that is certainly a very short description of what we're going for. I want speak longer the moment so maybe Dr. Suad could explore what I am seeing.

Dr. Suad Lubbad  12:10

Thanks, Dr. Yasser. So just an addition, I want to just mention that living in Gaza is very difficult. You cannot imagine the life in Gaza unless you were there in Gaza. This is one point, people in Gaza used to face different types of problems. The occupation, I can tell you that they get used to it in the last period. But the other effect sof occupation are getting worse, like the unemployment is getting more and more and more. Poverty is getting more and more; people cannot get the basic needs for themselves. And stressors are always increasing and increasing every day. People cannot escape from their life stressor, and they cannot think of how the world can can help them. People in Gaza feel that they are ignored, even if the word is telling them that we're caring, but on the ground, nothing is done to help these people live their life. And this is the life of Gaza. In addition to what Dr. Yasser's speech about the causes.

Maxxe Albert-Deitch  13:21

So you've both sort of spoken to this a little bit already. But when you're dealing especially with children, what kinds of symptoms do you see among Gazan people in terms of stress and anxiety? Would you mind giving a few examples?

Dr. Suad Lubbad  13:37

Yeah, some children do, and escape, but they cannot deal with, they cannot do this social life. They cannot speak. Some of them has psychosocial psycho psychosomatic symptoms. Some of them have headaches, some of them had pains in their legs. Some that children are afraid to get out of their houses. Some of them don't speak at all. Some of them have very bad nightmares. Some of them only want to stay with their mothers or parents. They just want to get their hands in the hands of their parents. They do not want to see anybody outside. They are scared to go to the pre school or the school. They are scared to go to a nearby shop. They are facing also insomnia and bedwetting, and fear- fear and fear and fear of the slight noise around people or slight noise around them. When anybody just closes the door. This fear is consistent with the children adults. Yeah, Dr. Yasser, do you want to add?

Ori Nir  14:58

it seems like we We lost him. I know that there's always problems in the Gaza strip with electricity outages. So, he may be experiencing one of those. We'll hopefully have him join us soon. Maybe we'll continue talking with you Suad and talk a little bit about how you address these things. So when you when you talk to parents, what do you what do you advise them to do? How, what kind of tools do families have to address the stress and anxiety that the children experience? And what tools do they have at their disposal? I see the Dr. Yasser  joined us again, and, you know, maybe maybe we'll wait with that and just see if... yes, Yasser wants to talk a little more about the symptoms, because that's what we just, we just had Suad talk about? You want to go ahead?

Dr. Yasser Abu Jamei  15:58

Yeah, well, we can divide them into like, you know, during the attacks, after the attacks, and in the long run. For example, during the attacks, the thing is that 3am feeling of fear, being terrified, you know, this applies to children and for adults as well. Another thing that we start to see really frequently is somatic pains, you know, pains in the knees for the children and the ankles, and for the purposes more low back pain and some pain in the big joints, mainly knees, knees, actually. And then you have the problems of sleeping, actually, it's very difficult to see because of the hearing of the bombardment. But, what happens, which is that after the, let me see if we could say, ceasefire takes place and the bombardment is not anymore there.  We start to see children who are having problems like bedwetting, and sleep paralysis, if they are very young, or have nightmares.  If they are like adolescents or older adults, immediately, they are usually preoccupied with what happened and are shaking. If I mean, if they are among the people who were, you know, affected closely, they will be really busy with gathering themselves, you know, what happened, looking after their kids, you know, trying to find the place of living, but with time, then some symptoms appear. Now, we used see, these are symptoms of either acute stress disorder, or maybe PTSD, because it's on the long, the longer term. Children start to show some, you know, poor concentration, some difficulties with, you know, studying, academic achievement. Sometimes they become disobedient, they become violent. And these are all symptoms that children show in order to attract attention. You know, even the psychological explanation, the psychoanalytic explanation for Bedwetting, sometimes when it's after trauma, is that children are weeping through their bladder as we could say, which means that they are seeking the attention of their parents when they just are looking for someone to pay attention to their needs in the morning and down, the only way that they could attract the parents perhaps is when they are, I could say punished in the morning because the they have left the bed wet. For the adults in 2014, for example, after the huge and massive 51 day attacks, we should have just made up a fact sheet and we said that we are not going to deal only with the trauma itself, you know, disorder like post traumatic stress disorder. But however, we are going to deal also the losses of the people, the loss of the safe place that was of the beloved ones, the loss of property, the loss of of jobs, you know, these are all losses that cause usually depression that are the seeds for depression among people. As Suad d said during the last few years, things exacerbated. More unemployment, more poverty, poverty is about 53% 3% of the population are under severe or the poverty which means more than 700,000 people, which means more than 350,000 children under the poverty. So, for example, when it comes to our community centers, we speak about people who will come and they have a diagnosis. I'm not talking about the general population. For example, 55 to 40% of the people who visit us are diagnosed with depression. And then 25 to 30 people are with various anxiety disorders, not necessarily PTSD. In fact, PTSD is lesser and lesser, but you have more, even something like obsessive compulsive disorder. And then the remaining is different disorders. For Kids,  It's mainly things that are related to trauma could be bedwetting could be sleeping disorders, and then it could be PTSD, if there are a little bit older. One more thing, the research studies that looked into the population at large, you know, as you said, the 'Save The Children' reports, it puts it really clearly when we're talking about the children in one hand, and the parents in other hand. We looked into the society. Last November, we looked into the symptoms of the most affected people. And the percentage of depression and anxiety among adults was really high. The third thing was anger, anger, more than 75% of the population, reported anger, but we, at that time, we looked into the most affected people, we can understand their anger, of course. But when it comes to children, again, depression and anxiety, and then problems with consulted concentration and sleep, however, the Save the Children report, first of all, the fieldwork or data collection happened in March, April, which is like four months ago, five months ago. And then,they took a sample from the whole community, the whole society. And these are really, again, very staggering. I mean, eight out of nine children have some emotional,as they put, stress. And then, and then when we talk about parents, you know, 96%, feeling unhappy, and anxious constantly. And if I really try to look into what could be the possibility of this 96%, almost every father or mother will find that two thirds of the parents caregivers feel they are not useful. What does it mean, they are not useful? Of course, if you cannot afford to give your child when he or she goes to school, one or two shekels that they can at least afford the transportation, if you can't buy them new clothes, you know, we speak about one half of the population. We speak about families of more than 500,000 children. So so how would the parents feel and then days of attacks, when the bombardment continue to happen, and you hit the loud explosives, and you know, that when you say that it will go away the children will not believe yoy, and that you will feel that you are, again, helpless, that you are really useless. But unfortunately, that feeling remains. And this is something that I'm I mean, I am really concerned about that, between May, and March, that's more than nine months. And still people feel that they are useless. Parents feel that they are not useful to their children or their life at large. It's quite a mixture, quite a combination. There are there were many academic research studies on various things. And I think anyone can look into public, for example, and they can find some, plenty of research studies that can look more into the figures, but again, the figures with time are really getting staggering. The that could be attributed to the chronicity of the conditions, that high exposure to the traumatic events, the huge impact on the psychological aspects. And then the deteriorating coping and mediating factors, you know, like, we are getting poorer, families are getting more and more scattered. Resources are less and less, we are weaker and weaker. And that's why the impact is more and more.

Ori Nir  23:58

Before we before we talk about treatment, which which we'd like to do soon. Just a quick question since you you mentioned adults, you know, two things that we see among adults who are depressed and suffering from anxiety is substance abuse and, and suicide. So I wanted to ask you if you've experienced that among adults in the Gaza strip

Dr. Yasser Abu Jamei  24:26

Look, first suicide. The figures that are reported for suicide rate in Gaza are not that many. I mean, they are below the, if I could say, the international prevalence rates when it comes to suicide. But the whole idea of suicide in a place like Gaza Strip, it's a big taboo first of all, and then we have not heard about suicide for example. But before the years 2003 or 2004. So the issue is...

Ori Nir  25:04

Thats because of religious reasons, right?

Dr. Yasser Abu Jamei  25:07

Well, it could be because of religious reasons, but then we have never had so much lack of hope, you know? This is, I think, a very important, you know, we are mostly Muslim inhabitants in Gaza Strip. But I wouldn't contribute the that among 2 million people. Only 30 of 35 have committed suicide only for religious reasons. No, religion could be an important factor. But it's not the main, it's not only that, it's many other things, you know, why you give hope in life? And what's going to hit you in the afterlife? I mean, why you need to end your life one way or the other. So, but again, the prevalence is not high. But it's happening more frequently than ever, which is a big question why. Suicide attempts are like 20 to 25 times the number of success, the succeeded events, which is like the international community. So if we have 30 to 35, people who committed suicide, succeeded in ending their lives, we have 600 to 800 people who have tried. Which is in line with the international community, which is fine, you know, I understand that. But half of the people who attempt suicide are women don't have women. Globally, it's like one to four. One woman, to four men. So why we have so many women who are trying to commit suicide? You know, it's a big question. And that highlights the, perhaps the severe impact that is caused by the economic and living conditions and occupation and the  division, on the family, and on the mothers and on the girls. And one other thing, you know, many of the cases, the Ministry of Health did some look into the reasons I think about six years ago, in 2016, or 17, about 75% of those who commit internationally or globally, about 80% of people who commit suicide are people with mental disorders. In Gaza, that was only 50% were people with the disorders. So it's more like out of anger, out of frustration, out of a family dispute, for example, a problem within the family, you don't find the solution you are like on the edge, so why not to commit suicide at any moment. The other thing is with substance abuse, we had a big problem with substance abuse about 15 years ago, but the main cause was not the economic conditions then, or bad coping mechanism, then.  The main reason was, because of the tunnels with Egypt, they allowed a lot of Tramadol to come. And the tunnels were mainly digged by the young people, and they were given Tramadol to be able to feel the energy and continue doing it. And fortunately, then, I think it was 2000 miles, something like that tunnels were the only thing even to bring shoes for your children. The only way that you can bring clothes to yourself, you know, I remember very anecdotal things, you know, when you visit houses, and you go to drink tea or or juice and they bring you they usually bring five different cups, you know, you cannot find the house with the same five cups collection. Why? Because of the extensive blockade at that time, you know,  it's a lot with goods, it's a lot better. So that brought a lot of problem. The problem of addiction is limited because of the financial issues, I think. And then the other thing because of the way the society deals with people who are in substance abuse are facing response, a big taboo, again, it's like a suicide. But if I if you allow me to add a third part, which is, we spoke about or we speak or what we hear a lot of community engagement. Organizations talk about more violence, more domestic violence, violence against women, gender based violence. And we thought that, you know, it's so much frustration in the families that they try to how to say, get rid of that ventilation, and they do it in the wrong manner, you know, to be to be more aggressive. Perhaps the study that we conducted in November explains it better. When we find that 75% of being adults, if you're really angry. The question is always how can you overcome your anger? You know, how can you get around that?

Dr. Suad Lubbad  30:02

Just a little, little thing to add about the Tramadol, it was the oly marketed will among people. People didn't know at that time that they are going to be addicted to just taking it as a happiness pills. And after that they discovered that they were addicted and, it was put in there, and everybody was taking it at the ceremonies or gatherings or weddings parties.  So it was scattered among people, even women, They are not the people who get addicted quickly. But because it was the easily handled between people, it was the substance abuse that gets higher. Okay, are you going to ask the other question, or should I add about my own experience with my kid? As a parent?

Ori Nir  31:01

Yes. I mean, what we wanted to ask you is to talk about that. And specifically, you know, Dr. Yasser referred to the stresses, women specifically. So if you could talk about that, that'd be great. Please. Yeah.

Dr. Suad Lubbad  31:16

You know, in Gaza, when we talk about parents as caregivers for their children, we mainly mean women. They are the in charge of everything. In the past, when there was good employment and good work chances. Men used to go to their work. And women the wife, the wife, the keeper, they are the caregivers for the children. And that's it. Now, both are at home. But parents, men ,are like depressed. Like the feeling that are they are unqualified parents or unqualified fathers, they cannot give any, they don't have anything to give for their children, because they are young, trying to find ways to get money to feed their children, okay. And this, this will put more on the mother, she has to take care of their children, she has to find places or ways to get food for her families. Maybe she will go to  her neighbors or ask her that will people give their money or food. And she's supposed to be a person of honor  to get support and good for her family. If you imagine yourself in this position, you will feel that you are overwhelmed and stressed. And you cannot ask a person who is in need of care to provide care, am I right? In addition, these women are facing a lot of violence from their husbands, because the feeling of helplessness I mean the fathers or husbands, they turn it into violence against women who do whatever she can. Like aggression or progression of their inability to do other things for them to do. So everything is put on the burden of the woman, when we want to tell her please take care of your child, I think we are putting more pressure on her. But we have to do it because she's the adult and the child will pay the price for all his life. So what we do, do we try to give her awareness about how to take care of for herself before, so that she can care for others. In addition, we hold for social support, we give them chances to talk to get this pressure out, we tell we give them a chance to let them feel that we did hear you. Please get your feelings out. We can hear you and we want to help. And we try to help them as much as we can. Now, for what to do for the children also we give them awareness about their normal growth and development for children. We give them also awareness about the signs and symptoms of PTSD. We give them assurance, how to give, how to protect their children as much as they can. For example, their daily routine is a very good example for protection for children. We don't have it and Gaza, the adults and the children. We work every day just,  we don't know what we'll do tomorrow,there are no plans, anything can happen. Bad things are expected more than the good ones. So the feeling of insecurity is there in the household for the mother for the Father for the children. So we try to teach the women some skills to do any daily routines for her children to give him the feeling of security. We will also teach her some art, art exercises or art and play materials that she can play with their children. We asked her if she can get her children with her to, to go out walk around your home.  I want to add something else about Gaza in the past when I was a child, I have plenty of places to play around my home. Now, people are living in apartments, no front yards, no backyards, they have to be just get in this small prison, that represents the prison of Gaza. You know, growth and development for children, they need to move and play and just lack their their motor skills to improve their motor skills. This is inhibited in this such and such life of Gaza. So this is, I want to give you an example about me, I consider myself strong woman. And the last war on Gaza on May 21. We heard that a building near to us will be bombed soon. So I, me and my children, and I just moved to live safest place at our apartments. Now my daughter was so stressed, she was crying, she was seeking the feeling of security in my eyes. I try to give her as much as I can. But you know, then my adrenaline was high. So she couldn't get the security that she she wants, because she feels the stress in me. However, my voice was coming. My touches were calming. But they just felt this is it from you?

Maxxe Albert-Deitch  37:00

Thank you for sharing that, first of all. Suad, you've talked a little bit about this. So I'm going to direct the next one to Yasser. When you're speaking with parents and working with families, I mean, what do you advise them to do? What are the tools that they have on hand to address the stress anxiety, the sort of constant mode of dealing with all of this, what are the tools that you and they have at your disposal?

Dr. Yasser Abu Jamei  37:29

Well, it's not that many tools, and unfortunately, this is because of the harsh economic conditions, you know, most of the patients who come to our community centers and our clients, you know, they can't even afford to, not only buy medication, but even the transportation, you know, sometimes is a problem for them to come to community centers.  Sometimes we just visit them, sometimes we go and work in their community and their neighborhoods, you know, the most affected areas. So, but, you know, we try to find hope in people's lives one way or the other, sometimes hope is because the child is healthy, that no one was really hurt. You know, sometimes you see people who have lost their homes, wellness, everything, and the only thing that they are happy about and you can talk about is that everyone is alive, that their house was like, you know,we are going to have to call, we can call it by mistake was ok or whatever we can call it. But anyway, that everyone is alive, that everyone is safe, that children can go back to schools and our children in a very different way, they give us a lot of strength. You know, as you said, a few days ago, it was actually Monday, just three, four days ago when when the new academic year began. And almost you can see all the children just walking in the streets going back to their schools, you know, and 2014 after the 51 day, lengthy attacks, that ended something like in late August, I was wondering how children are going to go back to schools. And I think almost everyone went back to schools, you know, so we you try to identify areas. And then you need to really work on the social network around that family. You need to strengthen the ties. You need to make them understand and you know family education is a big important tool. That what happens is really not your mistake. You know what happened is not your mistake, that you need to stick together. The mother when she just ran away from the room, because she heard the loud bombardment she left her baby in the room. That is something that is human. She's not a bad mother. The father when he jumped from the stairs and ran away. He is not a bad father. It's just very nature. very primitive response to a life threatening event. And then you tell the parents that the way they react to the things is felt with their children, they really can feel you immediately. And then you give very small tools about how to encourage, how to find feeling of safety within the place you live in. And finally, you try to restore the routine, the normal life routine. The one of the major issues that we struggled during COVID-19 was not only that tasks that happened during our them was not only the Blockade, but was the problem that children are not going back to school. It's you know, so that issue was making out problems for the parents. What can we do in hand, you know, you need to at least allow the children to go out, to go to school, the only place that children can have fun, or can change the mood that they live in, like in a small house with on average six people in their house, is just to go to the school, you know, to go out to see the friends, spend four or five hours and then go back to sleep, sorry, go back to home. So restoring normal life process is very important. Again, educating the population is very important making sometimes parents understand that their children misbehavior doesn't mean that the child is bad, doesn't mean that the parents are bad. It means perhaps that the child is looking for something else. So clarifying these things does a lot of magic. And they can give you another very strange example, you know, you know, in that was after May 2021. In the last few weeks, we have teams who that will visit homes, a man and a woman, both psychologists, they go in teams and visit the most affected areas. And the interesting thing is that they were talking about. Imeet them and ask them, how was your day, et cetera, et cetera. So they said that, you know, we visit that place. The family of five or six, including a boy and the girl, you know, the girl was 12. And she was referred to our community centers, I mean, the parents asked to bring her to our community centers. So after what what's the problem? They said she had bed wetting. So that cause of referral was bed wetting. So I asked about the living condition. They said, You know, they live in a small home not far from the fence separation fence. So the, during the attacks, the Israeli army fire, I think, a tank or something like that, that destroyed the one of the walls on the upper floor. It's not even on the floor, but in the same building, you know. So the children jump below the beds, and then they escaped the home. And since then, the girl is having bedwetting the daughter is having. So as to what about I mean, do they have some other children? This is a severe traumatic condition, I mean, exposure. Do they have another children, they said, Yes, they have more children. But it was two or three, including a boy who was seven, and the both, they said that we asked them to also refer the seven year old boy, to our community center, because their initial assessment is that the child this child needs also care. He looked scary, terrified, he was not that much communicating, you know, etc, etc. And the father refused. And when they asked him why you are not happy with bringing the child said, Look, my daughter having bed wetting , it's a big problem. She is 12 cannot allow that to continue. We all agree that she needs therapy, and thank you for your help. But about my son, you know, all the children in the neighborhood, they show the same thing that my child, my child, show, they all look scary, they  all went through the attack. So this was something really crazy to hear that, you know, parents think that despite all the children are having some problems. So this is again, something everyone has, you know, why to take them to treatment.

Ori Nir  44:46

Thank you. I'm looking at the clock here. And you know, we don't have much time left. So maybe I'll bench two questions, and you can address them as you wish, one that we have from the an attendee here, from the audience has to do with the impact of time, the impact of the, you know, the duration of stress. So the idea is do the symptoms that show themselves among children get worse, when those children become adolescents, when they become teens? Maybe I'll just say a couple of words from my own experience from a conversation that I had recently with a Gazan. Not teen, he's in his 20s. Now, but I asked him that question, and one of the things he said was, even when you try, as a teenager to get over the stress to use, you know, maybe the Internet to go to the beach to do activities that could help you overcome the stress, you're always reminded of it because there's always the hum, of the, you know, unmanned planes that fly above. There's always the drones, there's always the balloon that you can see up there, you know, the, the Israeli intelligence balloon. You know, that your phone calls are being, you know, listened to by the Israeli authorities. And you see the impact of wars that have punctuated your life, in terms of, you know, disabled people who've suffered injuries, Rubble, as in things of that sort. So that's one what questions that I thought you may want to to address;the cumulative impact. And then the other thing has to do with a question that has been asked here, and that is the the resources, or in other words, government resources versus nonprofit. I think both of you work for nonprofits. The question is whether the government has the means to invest in in mental public health.

Dr. Suad Lubbad  47:00

Okay, I want to talk about the first question, and the impact of these accumulated stress on the adolescents. The early childhood development, we know that the first 1000 days of children life is the most important period for their good growth and development. I mean, this starts from the conception side, until the year three, and we normally say the five years of age are the most important years in the human beings life. Now imagine that the mother when she's pregnant with a child, she's facing accumulated stress, in essence, there is what we call, we call that toxic stress, and the fetus will be facing distress, and we when he comes out, he will continue facing the same stress, in addition to the mother fearing of security, the mother nutrition is not good. And so the child will have these things over time. And when he gets out, he will start facing the life the bombing the problems, the family problems, the mother, the mother, which she is exposed to violence from her husband, or so on. So these children will never reach their full potential when they are adults, or when they are even adolescents. Now something else for the adolescents in the Gaza Strip, when they start the academic life in the university. You can hear it anywhere in the streets of Gaza, they just go to the university just to spend time, they don't believe that a certificate that they will take it one day will give them a chance to work and to be a productive people. So the despair is there. And the impact is very clear that they won't be living a good life in the future and will affect their resilience that affect their skills for problem solving. They will affect their living in a family like a husband and the wife, they would affect their social relations. It will affect also the mental health and I'm sorry to say most of it will be deteriorated.

Dr. Yasser Abu Jamei  49:32

For the second question, if I could say, you know we live in an area generally speaking that does not prioritize mental health. Okay. So, this is such a pity that place that is exposed to so many socio economic problems and traumas still, to find Methodists prioritize is not there that's one thing they Other thing is that the Ministry of Health itself is having big problems that are reported, by the way for WHO reports. So reports, for example, show on average, 45% of the drug stocks are not there on the Ministry of Health, do not speak about drugs that are likely psychotropic drugs like for mental health clinics, but also for  non communicable diseases like diabetes, you know, like hypertension, even medications for this kind of, of diseases is sometimes out of stock. So, unfortunately, on the when it comes to mental health, and what we call the MHP assessment that we can psychosocial interventions, the non governmental sector of the civil society sector is doing a huge work on that.

Ori Nir  51:04

Yeah, Maxxe do you want to go?

Maxxe Albert-Deitch  51:07

Yes, thanks. So I think a lot of the stories and reports that we see coming out of Gaza, there's this very strong central theme across all of them about resilience and about hope in the face of just so much. From your experiences and your work on the ground. I mean, what is your experience with that?

Dr. Suad Lubbad  51:37

Yeah, we are, we are living in Gaza, we are still living, because we have still hope. But it's decreasing. It's decreasing by time. Yeah. And we need we need the people of Gaza. They want to tell the whole world that we are good people. We want to live in peace like any other ones. We want to live in dignity. Dignity means that we don't want this bunch of donations, we want to work and get money in return and provide our basic needs. And maybe the complementary needs. We want to live a good life, because we are human beings. We don't want to be built like, you know, evil people in a movie. Our life is not a movie. We are human beings. So we want to be young, we want our issue to be solved out. And we want to live like others. We want to get out of this big prison. Maybe they will not want to travel from from to and from Gaza, but the feeling that our you are kept there in a prison is very bad. It's very bad.

Ori Nir  52:48

Yeah, look, Dr. Yasser. So do you want to add to it? I mean, one would expect the population that lives under such stress to show maybe even more symptoms of you know, stress and anxiety and depression and so on. And yet it seems like the Gazan population is pretty, you know, rough and tough, I would say and resilient. Do you agree?

Dr. Yasser Abu Jamei  53:14

Thank you for saying the word rough and tough. Look, In one hand, we had an example of how the stress or when they were a kid, you know, when we had the right of return campaigns, and demonstrations, many people are thinking, well, those people who are just demonstrating, you know, in peace, and they were shot at. But despite that being shot at that they were coming back to the Friday demonstrations, some people will even shot when they were in a wheelchair. A person with twoamputated legs was shot and killed, you know, an ambulance health worker was was killed, you know. So I mean, despite those, let me say disastrous results,  people continue to go there because they want to change. They wanted a change. And they felt for a certain moment that now they can say something and that the world is listening to them because they were they're demonstrating. So this is one aspect of it. People are perhaps resilient, but they have all the time emotions, they have the right to speak up for their rights and to ask the international community to stand up for humanity, you know, for justice. So this is one aspect. The other very unfortunate aspect is that sometimes it's present as both people are really tough. You know, the next time you can hit harder because they were tough. We couldn't do anything. They are still a threat. Palestinians we are a threat, you know, to a state like Israel, which is one of the biggest armies in the world. We are considered a threat so they can hit the heart on and on. third issue, I think the word resilience make people somehow make their emotions. I mean, you might sleep well, if you hear that Palestinians are resilient, you know? Well, please, we are resilient. Yes, but we are human beings. Yes. And we have the right to have the same rights as everyone else. If we are more resilient, yes, we are happy for that. And we are doing our best, we will continue to be resilient. But this does not, let me say, excuse the international community from helping the ones who are under occupation from helping people get their justice and achieve their freedom.

Dr. Suad Lubbad  55:43

Maybe I want to add something that please, it's not my words, the people's words. Please don't compare us with the Israelis  who face psycho somatic problems or fear or anxiety. There is no way to compare, their life is better, their situation is better, their country is well developed, their mental health agencies are working well, their medical agencies are very advanced. So they have everything. But in Gaza, the situation is very much far. And the boom is big;its  over our heads. We don't have something on the ground to be hidden under. So there is no comparison. Please don't compare us with Israel.

Ori Nir  56:36

Fair enough. We have reached the end of this of this conversation. I always say that, you know, these webinars that we have show you how fast an hour can pass. I think at this this time around, it was particularly poignant. It was a really interesting and good conversation which I think should be should serve as a as a trigger, or as an invitation, perhaps as a word better word here for people to read more about this. And I would like to encourage all of the people who are listening to us or viewing us now to share the link to our podcast and to our YouTube video once it's posted with other people so that they can also listen to this and learn about the situation in Gaza. I want to thank you, Dr. Suad Lubbad and Dr. Yasser Abu Jamei very much too, for joining us on this on this podcast. And well, I hope that we'll have a chance to invite you, you know, again in the future to share some more of your of your experience. So thank you.

Dr. Yasser Abu Jamei  57:56

Thank you. Thank you very much. Thank you,

Ori Nir  57:58

and this brings our webinar to an end. Thank you everyone.

Dr. Suad Lubbad  58:03

Thank you- Bye.