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The most dangerous place in the world to be a child

The impact of war on Gaza's children

Palestinian children play in the rubble in Gaza.

Palestine 2023 © MSF

Alert is a biannual magazine published by Doctors Without Borders/Médecins Sans Frontières (MSF-USA) that features ground reporting from our work around the world. This article appears in the Summer 2024 issue (Vol. 25, no. 1), Connecting Threads: Displacement, Conflict, and the Human Stories That Link Us.

Content warning: This article includes graphic descriptions of violence.

The current war in Gaza has upended the lives of more than 1 million Palestinian children, who represent a significant percentage of the more than 36,000 killed, 80,000 injured, and 1.9 million people displaced under intense, ongoing Israeli bombardment and siege.

As Israeli forces’ operations have intensified in the south of the Strip, where the majority of the population had sought refuge, children are being uprooted yet again as families flee attacks on Rafah. But this reality is all too familiar in Gaza, where many children have never known life with sustained peace or free access to basic needs like food, water, and electricity. By the time the current war started last year, a 10-year-old in Gaza had already lived through four military assaults. 

Doctors Without Borders/Médecins Sans Frontières (MSF) has been caring for Palestinian children since 1989, and we continue to work in Gaza and the West Bank. Even before the current war started in October 2023—when the militant group Hamas launched an attack on various sites in Israel, leaving about 1,200 people dead and taking more than 200 hostage—many years of instability had already taken a toll on the physical and mental health of Gaza’s children, leaving many with life-changing injuries, amputated limbs, and the trauma of losing parents and other loved ones along with their homes and schools. Any one of these experiences on its own is traumatic. Compounded, they have resulted in a massive and spiraling crisis.

In Palestine, there’s never a “post” in post-traumatic stress syndrome. It's ongoing trauma, it's protracted trauma, it's one war after the other.

DR. AUDREY MCMAHON, MSF PSYCHIATRIST

In Gaza, MSF is providing children and their families with surgical and mental health care, physiotherapy, vaccinations, and treating wounds, burns, and malnutrition, which has become a serious threat despite having never been documented by our teams in our 36 years of medical and humanitarian work there. Among our staff who have worked in Gaza over the years are pediatrician Dr. Tanya Haj-Hasan and child psychiatrist Dr. Audrey McMahon, who have seen firsthand how the realities of life in Gaza have impacted its children and have led UNICEF to call it the most dangerous place in the world to be a child. Here, they explain the unique risks children face in Gaza and what they need from the international community.

A displaced child inside Al-Aqsa Hospital in Gaza in November.
A displaced child inside Al-Aqsa Hospital in Gaza in November. Palestine 2023 © MSF

What is the reality children are facing in Gaza right now?

TANYA: In Gaza, children’s senses are exposed repeatedly to all sorts of trauma that most adults will not experience in their lifetime. Many of the children I met in Gaza recently are expressionless, often with a vacant look on their faces. They sit in the emergency department as the scenes of horror play out in front of them, watching silently. 

I am an intensive care doctor. I am trained to receive and care for traumatic injuries, but the scenes in Gaza are on a different level. You see things that make you want to pass out. Children in Gaza are being forced to see these horrific things daily, often inflicted on the adults who protect them, on their siblings, and on their own bodies. 

Many of the children I met in Gaza recently are expressionless, often with a vacant look on their faces. They sit in the emergency department as the scenes of horror play out in front of them, watching silently.

Dr. Tanya Haj-Hasan, MSF pediatrician

Beyond the medical trauma, if you are a child in Gaza today, you have most likely been displaced multiple times, are living in a tent, don’t have food security, have lost multiple members of your close community (family, neighbors, friends), and have fallen asleep every single night for over seven months to the sound of drones and bombs falling from the sky. Many children in Gaza can distinguish the type of bombs based on the sound. Nobody should know that difference. You should not have that much experience with weaponry at any age—and certainly not as a child.

Every mechanism of child protection has been destroyed and has been targeted—homes, family structures, schools, community centers, and clinics. Every specialized pediatric hospital has essentially been put out of service. Then there are all the children with chronic diseases—with cancer, with medical needs, who now can't access care.

A child patient lies on a hospital bed in a cast and with a drawing on her lap in Gaza.
An MSF child patient who lost her whole family in a strike. Palestine 2023 © MSF

AUDREY: We are seeing something completely unprecedented ... The entire population of children and teenagers in Gaza—more than 1 million people—will need mental health support.

At the MSF clinic we see a lot of children that are not only alone, but need an amputation, sometimes without medication or sedation. Many of them will not only grieve the loss of limbs and learning how to live with a disability, but also losing their family members, their home, their toys. It's several circles of grief—to be honest, it's unbearable grief. Many children are going to be affected their whole life because they were already living in a very abnormal context. And for those who are physically disabled, now their body is, and will be, another reminder of what happened. 

In Palestine, there’s never a “post” in post-traumatic stress syndrome. It's ongoing trauma, it's protracted trauma, it's one war after the other. And when there's some sense of calm, people make the most out of it, but they never know when it's going to happen again.

Palestinians line up for food and water in Gaza during the war with Israel in October 2023.
Palestinians line up for food in Gaza. Palestine 2023 © MSF

What should people know about what's happening to children in Gaza?

AUDREY: Numbers are numbing. Seeing this on the news over and over again, there is a kind of normalization that happens because people feel helpless. But these children are human beings that have the same right to have a life lived in peace, to have access to good food, to grow healthy. They should have a right to have dreams and hope for the future. Children are born where they're born, and it doesn't make them belong to any type of group. They are just children. 

TANYA: The first thing is to humanize people in Gaza. If you even spend 10 seconds imagining that you were in their place, you would do everything in your power to make sure that this stops and to relieve the suffering. The second thing is to recognize that this is a reflection of our humanity globally. Even if it happens on the other side of the world, it has very important repercussions for similar injustices. It's not as foreign as you think it is. Whatever we accept in Gaza will one day be used as an excuse to accept it somewhere else, and it's going to set a precedent. 

A man carries a child to MSF's clinic at Rafah Indonesian Hospital in Gaza.
An injured child is carried to MSF’s clinic at Rafah Indonesian Field Hospital in late December. Palestine 2023 © MSF

What do Palestinian children need?

TANYA: There needs to be an immediate ceasefire, the immediate opening of unhindered humanitarian corridors to let in all the things that are indispensable to human life and to the protection of children—including shelter, food, water, and medicines. And the health care system needs to be rebuilt. There has to be a massive international humanitarian effort to make sure that structures and systems are put in place to provide everything that children need. 

AUDREY: You cannot heal in an unsafe environment. They'll need physical safety, a home for warmth, not being outside in the rain without food or water. The body needs to have a sense of security. And of course, they need emotional safety. If they lost their parents, they will need adults that are protective. They need to be protected, to have people who love them, who care for them, who help them grow, who help them go back to school, who support them. It will take time. 

They will teach us what they need the most, how they want to be helped, because nobody has been through what they have. It goes beyond anything that we know.

DR. AUDREY MCMAHON, MSF PSYCHIATRIST

I think that there are things that we don't even know now that we will learn from them with time, unfortunately. They will teach us what they need the most, how they want to be helped, because nobody has been through what they have. It goes beyond anything that we know.

MSF physiotherapist Mia is conducts a physiotherapy session with a 6-year-old boy in Health Post run by MSF in Al Mawasi, Gaza Strip.
MSF physiotherapist Mia conducts a physiotherapy session with a 6-year-old boy at the health post run by MSF in Al-Mawasi.
Palestine 2024 © MSF

What kinds of injuries and illnesses are we seeing in Gaza’s children?

TANYA: In addition to the thousands of children who've been killed, you have thousands of children who have been maimed. And when you have a war injury like an amputation, it's not just that your leg comes off, somebody sews up the stump, and that's it, you can walk again. On average, these complex war-related injuries will need eight to 12 surgeries in the person's lifetime. A lot of those surgeries must happen early on in recovery. If they don't, the wound could become infected and they might lose their limb—or their life, if that infection spreads to their bloodstream. 

So a lot of these children who are wounded may actually get sicker or die if they don't receive the very intense and long-term medical care that they need as soon as possible. The prosthetics will also have to be resized as the children grow. These children need physical rehabilitation, physical therapy, occupational rehabilitation, occupational therapy. These things are impossible in Gaza right now.

There are also hundreds of thousands who are starving without appropriate shelter. That will have long-lasting implications for both their physical growth potential and their cognitive or brain development potential, which will then have later effects on their ability to function in life and be productive members of society.

Starvation over time will eventually not only stunt the growth of their bodies, but also the growth of their brains and lead to developmental delays later in life and an inability to reach their full cognitive potential.

Dr. Tanya Haj-Hasan, MSF pediatrician

Children are more susceptible to malnutrition, which leads to stunting. They don’t have the kind of metabolic mechanisms that develop with age when they're very young. So what ends up happening is their blood sugar drops and they can easily die as a consequence of low blood sugar levels.

As adults, we need to eat so that we have energy, but our brains are fully developed. So if we are malnourished for some period of time, it's very unlikely to impact our cognitive ability in the long term. Whereas in children, that's not true at all. We know that starvation over time will eventually not only stunt the growth of their bodies, but also the growth of their brains and lead to developmental delays later in life and an inability to reach their full cognitive potential.

Malnourished children also have compromised immune systems. So a simple infection like a virus or a diarrheal illness that would be totally recoverable in a healthy person could actually lead to a malnourished child’s death. You end up in this vicious cycle where, as a consequence of recurrent bouts of diarrhea, disease, illness, and malnutrition, they have atrophy of the lining of their intestines, which affects their ability to absorb nutrients. So then they have malabsorption, they lose more weight, their immunity's worse, and it just keeps going until the child dies.

An MSF psychologist stands at the center of a circle of Palestinian children in a mental health session in Gaza.
“The most common things I see among children are nightmares, bed-wetting, anxiety, and fear,” said MSF psychologist Marwa Abu Al Nour. “We try as much as possible to give them support." Palestine 2023 © MSF

How are these experiences impacting children’s mental health?

AUDREY: In the immediate term, when a child is injured, many go from an extreme state of dissociation to screaming in pain from amputations and dressing changes, sometimes without any sedation. Then they can go into a state of mutism, not connecting with people, not looking at people in the eyes, and struggling to speak to anyone, even their parents. Of course there are some depressive symptoms as well, and depending on the age, it'll show up differently. And it affects their capacity to learn and to focus, because the psychosocial environment was already so intense in Gaza. 

They show a lot of anxiety in different forms, like panic attacks, sleep problems—a lot of sleep problems. The level of stress on the nervous system will not go away quickly at all. It'll be very difficult to deprogram this. Even one traumatic event can take months or years to recover from. They are faced with layers and layers and layers of trauma. And they were already traumatized before October.

We are seeing something completely unprecedented ... The entire population of children and teenagers in Gaza—more than 1 million people—will need mental health support.

Dr. Audrey McMahon, MSF child psychiatrist

In fact, the situation in Gaza can impact a child’s mental health and cognitive abilities even before they are born. When a mother is pregnant, the stress hormone is secreted, which can affect the unborn child’s brain and development. It is the mother who is herself traumatized, which puts her at higher risk of symptoms of depression, of anxiety. And we know that trauma lives in the body, so it affects the child’s development as a whole. So these children are more at risk of learning disabilities like ADHD and mood disorders like depression.

The risk factors for many children in Gaza were already extremely high before the war. Rebuilding—not only practically, but physically and emotionally—is going to take years of struggling, for some of them until the end of their lives. 

Gaza – Water distribution in Rafah
Youssef Al-Khishawi, an MSF water and sanitation agent, helps children carry water to their tent in the Tal Al-Sultan area of the southern Gaza town of Rafah, on January 27, 2024.

Palestinian children fill their bottles at an MSF water truck (left); MSF water and sanitation agent Yousef Al-Khishawi with children in Rafah (right). Palestine 2024 © MSF

Many children show up at hospitals unaccompanied and are labeled “wounded child, no surviving family,” or WCNSF. How did this term come about?

TANYA: It’s a very unique thing. Normally, it's very rare for us to treat a child who's lost their entire family—occasionally you'll have a car accident, for example, where multiple members of the family die and a child survives. But WCNSF is now sadly not unusual at all in Gaza. I would often care for several children in the emergency room during mass casualties who had lost the rest of their families in the same bombardment. What we’re seeing in Gaza is actually the complete wiping out of entire families. So when we say that a child has lost their family, it's not just that they've lost a mother or a father or both, it's often that they've lost the entire extended network that would take them in.

A doctor sent a picture of a child with “unknown” written in marker on his back, covered in a hypothermia blanket—those silver blankets that are used after marathons. He's being cuddled by, I presume, a stranger. His back is also marked with the location where he was found. These children are not always marked. Sometimes you fail to resuscitate the child and you try to find their family to inform them of the child’s death, only to be told that no one in the family survived. 

You wonder who will bury the child; who will mourn their death. And then darker thoughts infiltrate: Is death a more merciful outcome for this child that lost everyone they love and who could care for them?

Dr. Tanya Haj-Hassan, MSF pedatrician

You wonder who will bury the child; who will mourn their death. And then darker thoughts infiltrate: Is death a more merciful outcome for this child that lost everyone they love and who could care for them? One young adolescent who was the only surviving member of his family told me he wished he had been killed. He said that everyone he loved in this life was in heaven now and he didn’t want to live on. 

We don't know what happens to WCNSFs after discharge. That's the really hard thing. An adult might be able to go fend for themselves under certain circumstances, but a very young child is not going to be able to do that. For unaccompanied children who don’t have a family structure anymore to protect them physically and psychologically, there are going to be long-lasting impacts and risks to their physical and psychological wellbeing.

Palestinian children fetch water in Rafah, Gaza.
Children fetch water from an MSF distribution point in Rafah, southern Gaza. Palestine 2023 © MSF

What hope remains for children in Gaza?

TANYA: I can't imagine a world in which we decide there's no hope for children. They have their whole life ahead of them. So there is absolutely hope, because anything less than that is not a world that I want to live in.

AUDREY: At the very moment they are in complete survival mode, but one thing that’s quite remarkable about people in Gaza is this amazing, collective sense of just striving, of making the best of what they have, of enjoying the sea and being so proud of sharing their amazingly good food with you. They really have this sense of who they are, of where they are from.

A colleague of mine has a 9-year-old and their house got bombed two or three weeks into the war. They had left just the day before, and their house was completely destroyed. The little boy couldn't sleep—he was waking up screaming in the middle of the night, and during the day he would build houses with Legos, trying to keep some power over the situation. We'll rebuild.

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Alert magazine: Summer 2024

Alert Summer 2024

Connecting Threads: Displacement, Conflict, and the Human Stories That Link Us

Read the issue

How we're responding to the war in Gaza