Beyond funding, psychosocial support in Gaza needs better strategy

The cost of conflict in Gaza is often said to be one that is disproportionately paid for by its youth. When the demographics and deaths are considered, the claim is difficult to contest. Estimates from the U.N. Population Fund point to a mostly young population in Gaza: Of Gaza’s 1.71 million people, 53 percent are aged 15 to 29. Meanwhile, according to UNICEF, more than 500 children have been killed and 3,300 children have been injured in the most recent escalation of war with Israel. But beyond the casualties lies a much less examined human toll. According to a 2014 estimate by UNICEF, at least 373,000 children in Gaza require mental health support. While a recent Overseas Development Institute report focusing on psychosocial care in Gaza notes that the lack of baseline information makes it difficult to determine the extent of the need for mental health services, a 2014 report from the Palestinian Ministry of Health shows adolescents experience post-traumatic stress disorder and other forms of anxiety and depression. Often painted as a tumultuous period of a person’s life, adolescence is tough enough for many living away from conflict zones. But being an adolescent in the middle of conflict is a different plight altogether. Combine war with a lack of economic opportunities and it’s not hard to imagine how dire the situation is for many Gazans — adults and adolescents alike. Gaza, according to the World Bank, has a 43 percent unemployment rate — the highest in the world, and one that has been exacerbated by conflict, Israeli blockades and poor governance. The World Bank itself has said that the Gaza economy is “on the verge of collapse.” One of the findings of the ODI study, which was conducted in the Shajaia neighborhood, a 120,000-resident area that was heavily affected by the 2014 conflict, is that “economic hardship has the greatest influence on adolescents’ deteriorating psychological status.” Domestic violence, low educational attainment, inadequate socialization, insufficient recreational activities and even dysfunctional relationships with their parents — adolescents can trace all these back to a low quality of life made worse by a strangled economy. The concerns of female adolescents in Shajaia range from the seemingly mundane and materialistic — lacking clothes and items that their friends have, for example — to the more serious, such as sexual harassment in the midst of seeking shelter. Aside from being all valid, they show that the psychosocial needs of girls deserve a closer look. Support vs. stigma It’s challenging to estimate the actual demand for psychosocial services in Gaza, especially when many adolescents — female adolescents, in particular — are prevented from seeking help in the first place because of the stigma attached to mental health support. Due to cultural norms, girls are made to believe that a visit to a counselor could jeopardize their reputation and chances of marrying. Parents themselves discourage their daughters from availing of psychosocial support. Gaza, of course, isn’t alone in having this taboo — and occasionally even overcoming it. The New York Times recently reported that while travel and cultural stigma prevent many Afghan women from visiting therapists, 70 percent of who do visit are women. There are no figures, let alone disaggregated ones, for those who end up looking for some form of psychosocial support in Gaza, but the ODI study shows adolescent girls have more constructive coping strategies — approaching counselors in school, for example — than their male counterparts. Still, the stigma associated with such services has an invisible, but no less important, role: The older the girl, the less likely she is to seek professional help, according to the ODI report. But unlike in Afghanistan, where mental health support is still spotty and remains a hard sell for donors and the government alike, psychosocial support services in Gaza have proliferated. The World Health Organization as well as European donors like Norway, Sweden and Switzerland have been especially active in this sector — “although not specifically in terms of catering to the particular vulnerabilities of adolescents and adolescent girls,” Nicola Jones, senior research fellow for social development at ODI and co-author of the paper, told Devex. For example, only 0.9 percent of the psychosocial programs implemented in the most recent conflict targeted those aged 15 to 29. Jones acknowledged, however, that “the [psychosocial care] situation in Gaza is more advanced in general than in Afghanistan.” “The availability and quality of services are much better, and the general level of education of government officials and the general population is considerably higher on average,” she said. A lack of coordination Gaza is teeming with organizations providing psychosocial care — more than 162 groups, according to the ODI study. The Ministry of Health, which recently integrated its psychosocial support services into all its 54 primary health care centers, is the largest provider, but it also acts as a supervisor and regulator of this sector. Meanwhile, the U.N. Relief and Works Agency for Palestine Refugees in the Near East, which has counselors stationed at UNRWA centers and runs a school counseling program with the Ministry of Education, is the second major provider. But recent budget cuts could threaten UNRWA’s ability to continue providing these services. With its funding coming mostly from voluntary contributions — which are largely earmarked — UNRWA is vulnerable to drastic changes in its finances. Asked by Devex on how budget slashes will affect its psychosocial support services, UNRWA spokesman Chris Gunness declined to comment and noted that the Gaza office “has yet to decide” on a transition plan. It seems the impact of the cuts can already be seen. “Not all UNRWA schools are staffed with social workers now,” Bassam Abu-Hamad, assistant professor at Gaza’s Al-Quds University and co-author of the study, told Devex. “Budget cuts are likely to result in suspending training, expansion and program development. UNRWA has already suspended hiring new employees who are needed to serve the population.” But more than a lack of much-needed financial support, psychosocial services in Gaza are weakened by poor coordination. “Services are not organized, there is no continuity of care, some people are double-served, and others totally ignored,” Jones said. “Most services rely on people self-presenting rather than proactively seeking to reach those who may be most in need. Referral services are very limited.” More worryingly, several providers have little experience in psychosocial care. “In our survey of mental health services in Shajaia area in Gaza City, of the organizations that incorporated psychosocial interventions in their emergency response, only one-third had any experience of providing such services,” Jones said. According to Abu-Hamad, enhanced regulatory function for the Ministry of Health — for example, by licensing and accrediting providers to increase professional standards — should be at the heart of efforts to improve psychosocial support in Gaza. “Because the Gazan situation is a chronic rather than a one-off emergency situation, it necessitates much better strategic management and thinking,” he said. “The Ministry of Health should work with stakeholders to agree on a framework for psychosocial service provision in Palestine. This is of course made more challenging by the political environment in which UNRWA has limited contact with the government, and many international nongovernmental organizations and donors have an official ‘no contact’ policy with Hamas.” Context-specific, not cookie-cutter For groups looking to fill the need for better psychosocial support in Gaza, Jones advised against bringing in cookie-cutter programs based on different contexts. “In terms of work with adolescent girls, it is also worth highlighting that education levels given the income levels are comparatively high, but social norms very conservative, thus arguably exacerbating the stresses that adolescent girls feel,” she said. Displacement has become a fact of life in Gaza, where 28 percent of the population had to leave their homes last year alone. In providing shelters for the displaced during and immediately after conflict periods, organizations should exercise a high degree of cultural sensitivity. For example, mixed-sex shelters are specifically stressful for adolescent girls, who fear that they will be sexually harassed or violated while staying in these shelters, constantly monitored by their parents to prevent losing “family honor,” and unable to access basic sanitary services. “Many girls argued that they would prefer to go back to bombed-out housing than risk the ‘loss of dignity’ which shelter life as currently designed entails,” Jones said. The tendency of many NGOs to adopt short-term measures lasting no more than three months, instead of what Jones said is the “internationally advocated minimum of six months to tackle psychosocial stress,” both during and after crisis episodes is also doing little to alleviate the anxieties of adolescents, especially girls. “We heard repeatedly in the interview with girls in this study, but also in other studies with adolescents, that short-term group counseling is often very inadequate in helping girls cope with the trauma and stress they face,” Jones said. “Much more tailored services are vital if meaningful support is to become a reality.” But while patchwork programs are not the way to go, groups also need to recognize that whatever solutions they come up with will be situated in what has come to be a protracted conflict. “Future solutions need therefore to work in tandem at both levels — both strengthening adolescent girls’ resilience in the face of severe psychosocial vulnerabilities, while simultaneously seeking a sustainable and peaceful political solution,” the authors wrote. 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