Stepping out of a car in the West Bank town of Kafr Qaddum, I was greeted by the stench of urine, feces, and burnt tires -- a foul reminder of the near-constant confrontation between Israeli settlers and soldiers on one side, and Palestinians on the other.

The Abu Ehab family – whose two-story house is located on a slope just below the road we drove in on – is caught between these battles. They keep their chickens on the second floor and live on the first, but the walls do little to protect them from the exchange of tear gas, burning tires, and hurled rocks. The IDF frequently moves around the Abu Ehab family’s property during nighttime search operations; at times, they enter the house.

The smell comes from “skunk,” the sewage-smelling liquid that the Israeli Defense Forces (IDF) uses to soak Palestinians and foreign protestors who gather weekly on this ashen road. It is so pungent that the family’s eldest son now vomits at the sight of food. The military also uses flash-bang grenades to counter the demonstrations. After one detonated too close to their home their eldest daughter lost hearing in one ear.

"She used to not be able to finish a sentence without crying,” the Médecins Sans Frontières (MSF) psychologist who has been counseling the girl’s mother tells me. “Now, she can talk about her fears without breaking down."

This is how MSF, as a medical humanitarian organization, measures the progress of those we assist in the occupied Palestinian territories. For the past 15 years, our programs [1] in the West Bank and Gaza have focused mainly on mental health – but my colleagues at times feel like they can only give patients a thicker coat of psychological armor against the daily trauma of their lives. These patients are parents of teenagers being held in Israeli or Palestinian prisons, children with one or both parents in detention, families on the frontlines of settler-Palestinian violence or intra-Palestinian violence, and those affected by nighttime IDF search operations or other military actions.

What our staff sees, day in and day out, are the medical consequences of the occupation. But while we can treat some of our patient’s symptom, we can’t alter the underlying causes of their suffering. And as the suffering has become normalized, we have been questioning the wisdom of our presence. This is the humanitarian’s dilemma: how to alleviate the suffering of a population while not enabling the powers at the root of the pain.

As we approach the one-year anniversary of the latest (but likely not the last) war in Gaza, it should be understood that humanitarian organizations do not hold a monopoly on this dilemma. All countries, and the United States and members of the European Union in particular, that condone and help extend the occupation of the Palestinian territories -- whether by subsidizing it through humanitarian or military aid or giving political cover to its policies and practices -- must confront their responsibility for the suffering of Palestinians.

Night terrors

The Abu Ehab family's experience is painfully unexceptional. For ten years, MSF has provided psychological care for Palestinians in and around the city of Nablus – and for much longer in other parts of the West Bank. We respond to the never ending implications of an occupation by offering care for the parents of teenagers detained in Israeli or Palestinian prisons; children whose father, mother, or both parents were detained; families on the frontline of settler-Palestinian violence or intra-Palestinian violence; and those affected by nighttime IDF search operations.

In the village of Majd al-Bani Fadil in the West Bank, there is a house with six children under the age of 18—three girls and three boys—who are all living alone. When I entered the home with an MSF psychological assessment team, the children’s uncles explained how each child had deteriorated since both their parents had been arrested in separate incidents – the mother taken away in the middle of the night – over the past year.

The eldest daughter cannot focus on her studies, the middle son now regularly hits his siblings for no apparent reason, and the middle daughter is often found crying in her parents’ old room. The mother has been detained by Israeli authorities for nearly a year without sentencing. This, one of their uncles told me, is the hardest part for the children: “They don’t have hope.”

Bureaucratic violence

MSF has seen firsthand how the Israelis’ use of administrative detention – which does not require charges to be brought against those incarcerated – heightens the psychological violence inflicted on Palestinian children. The trauma of having a parent dragged off in the middle night is compounded by the uncertainty of when their mother or father might return home. 

The separation of families is on the rise with the monthly average of Palestinians held by the Israeli authorities for alleged security offences increased by 24 percent in 2014.[2] Data on Palestinian children in military detention show every month an average of 185 children were held in Israeli military custody in 2014, compared to 197 in 2013 – a mere 6 percent decrease.

Three hundred and nineteen orders for administrative detention without charge or trial have been issued by Israeli occupation military courts since the beginning of 2015, according to the Palestinian Prisoners Center for Studies. This is an increase of 500 percent over the same period in 2014, when 51 orders were issued.

The anxiety from the nightly threats is palpable. Mothers in the communities we serve often send text messages to each other at the first sign of a search operation, and many frantically wake up their children in the middle of night and get them fully clothed to avoid soldiers breaking in the front door or simply entering the home while everyone is still in their pajamas.

The body does not lie

The events most often brought up by MSF patients include a violent IDF search operation inside their home (52 percent); current incarceration of one or multiple family members (42 percent); or indirect violence such as shooting or incursion operations by IDF (35 percent). 

The presence of the Israeli army in the West Bank – and its constant use of force in most of the events they are involved in – is the main cause of the psychological trauma of our patients. Furthermore, twenty percent of our patients live close to a settlement and are therefore constantly exposed to stress. This is the psychological damage of the perpetual siege situation the population in the West Bank lives in. 

The children are the worst, most easily affected. Fifty percent of our patients are younger than 15; 25 percent are below the age of 10.  Among the most common symptoms are sleeping disorders (50 percent); anxiousness (34 percent); difficulty concentrating (28 percent); aggressiveness (23 percent) and bed wetting (21 percent). Even our most seasoned psychologists are shocked by the levels of trauma.  

Occupied minds

The mental health disorders we see in the West Bank are in many ways a reflection of the dynamics of the conflict.

In 2014, Israeli forces were implicated in the highest number of Palestinian fatalities since 2007, and the highest number of Palestinian injuries since 2005, when the UN’s Office for the Coordination of Humanitarian Assistance first started collecting data. Violence peaked in the second part of the year, following the abduction and killing of three Israeli youths and the retaliatory killing of a Palestinian youth in East Jerusalem in July.

The abduction and murder of the three Israelis and the rocket fire from Gaza was given as justification for Israel’s “Protective Edge” operation in Gaza in July and August 2014. The violence continued in the West Bank throughout the Israeli military campaign with incidents involving protests against “Protective Edge,” and in confrontations during October and November regarding the status of the Al Aqsa Mosque compound.[3]

The number of child casualties recorded in the West Bank caused by Israeli forces increased sharply: 13 were killed in 2014, compared to four in 2013, the highest number since 2006. Palestinian attacks against Israeli civilians (mostly settlers) and security forces also rose in 2014, with Israeli fatalities increasing from four to 12.

In mid-2014, Israel resumed the practice of punitive demolitions throughout the West Bank, after an almost complete halt for the previous nine years. This practice targets the family homes of perpetrators, or alleged perpetrators, of attacks against Israeli civilians and security forces. Four houses were destroyed and one was sealed in 2014, displacing at least 27 people,[4] amounting to a collective punishment.

Intimate violence

Residents of Hebron, in the south of the West Bank, endure indignities that are as relentless as they are intimate. Violence between Palestinian and Israeli communities breaks out on a daily basis. When I traveled to Hebron, it was Israeli Independence Day – otherwise known as “Nakba” day, the “catastrophe” created by the forced displacement of Palestinians. Settlers had draped the Israeli flag over the central mosque. The day after a Palestinian teenager stabbed an Israeli soldier and then was killed.[5]

On the top of a hill overlooking the old city, I met a Palestinian woman, a patient at our counseling program. Afflicted with diabetes, hypertension, and poor circulation, she has been in and out of the public hospital for several years. After having caught my breath from scaling the hill to her home, I listened as she told me how her family has lived here for more than 70 years, and how, in 1984, a settlement was built in the area just outside her front door.

Since 2003, she and her family have not been able to use their front gate. Instead, when she needs to go to the hospital – or has to leave her house at all – she has to leave through her back door and walk down a dirt path littered with trash from the settlement – a path that floods when it rains – to reach either an ambulance or her latest, beaten-up car (her five previous vehicles were destroyed by settlers).  To get to the market, a trip that used to take her five minutes, her daughter now must take a circuitous route that takes nearly half an hour.

Not only can she not exit through her front gate; she also can’t prevent outsiders from using it to get into her yard. The IDF recently told her she was no longer allowed to connect to the municipality's sewage line as well.

Her daily torments are not uncommon in Hebron. Hebron's Palestinian population is estimated to be 150,000 compared with 500 Israeli settlers. Yet more than 4,000 IDF soldiers are stationed in the city to protect the settler population. There are more than 120 physical obstacles, including 18 permanently staffed checkpoints, in the over 20 percent of Hebron City, known as H2, where Israel continues to exercise full control over the freedom of movement of the Palestinian population.[6]

As I prepared to leave her home, she whispered to me through our translator, "I have been to Chicago but never to Gaza."

The misery of Gaza

She's not alone. Palestinians living in the ever-shrinking livable tracts of the West Bank are almost universally forbidden from traveling to Gaza. It’s hard to imagine they’d find it any more hospitable, though, if they traded the daily confrontation and oppression they know for the sense of deprivation and siege that pervades Gaza.

If West Bank Palestinians were able to visit Gaza, they’d see, as I did when walking through Beit Hanoun in the northern reaches of the strip, that it seems as if last summer's war just ended. They’d see that not a single totally destroyed structure has been rebuilt since the IDF launched its military operation on the Gaza strip for 50 days last July and August.

To the extent that the war is still spoken of outside the immediate region, much of the public debate—and the near weekly  UN[7] and human rights[8] reports—remains focused on the conduct of the fighters and the nature of the hostilities on both sides. These investigations are important, but they shouldn’t mask the ongoing misery in Gaza.

Numbers tell part of the story of the war’s impact. Seventy-one Israelis were killed, according to the Israeli government, including five civilians. According to the U.N. Independent Commission of Inquiry into the 2014 Gaza conflict, 2,251 Palestinians were killed,[9] including 1,462 civilians, of whom 299 were women and 551 were children. Some 11,231 Palestinians were also injured , including 3,540 women and 3,436 children.

During the war, medical facilities, transports, and personnel were repeatedly attacked. Seventeen hospitals, 56 primary healthcare centers, and 45 ambulances in Gaza were damaged or destroyed, and 16 “on duty” health workers, all Palestinians, died as a result of the conflict.[10]

MSF’s postoperative clinic remained open during the war, functioning with minimal human resources capacity, accepting around 95 new cases from July 15 – August 24, 2014 and providing follow-up care to critical patients who had already been admitted. To prevent patients from having to return to the clinic during the bombardment, a dressing kit was given to each patient for self-care.

The vast majority of the wounded were treated by Palestinian medical personnel and transported at great risk, as the casualties attest, by Palestinian Red Crescent aid workers to the network of public health facilities in Gaza.

Additional MSF surgical and emergency teams that were able to enter Gaza the first week of the conflict immediately got to work in the main surgical units, intensive care unit, and ER in al-Shifa and Nasser hospitals.  MSF teams were also able to support the burn unit in al-Shifa hospital, operating on more than 80 patients in August. Due to the massive influx of patients in July it was impossible to keep exact records of the numbers of patients treated.

A cease fire was eventually signed, but the casualties of the war are still mounting. On May 15, 2015, more than 50 people were injured when unexploded ordinance blew up in the Beit Lahia neighborhood located in the north of the strip.[11] It’s likely that this will not be the last incident of its kind: there are an estimated 7,000 unexploded bombs in Gaza.[12]

Time standing still

Teetering atop half demolished buildings, Palestinians are reduced to scavenging rebar and copper wire from piles of wreckage. Anything they can reuse is valuable given the ongoing Israeli blockade of Gaza, which was bolstered last October when Egypt closed the Rafah Crossing in southern Gaza and destroyed the smuggling tunnels that ran beneath it, which had provided a lifeline to Gazans.[13] Now many basic materials that Israel fears would be put to military use—so-called “dual-use” materials—cannot be imported into Gaza at all, from cement to rebar. Even wood for construction is now considered as dual-use material, and, therefore must be processed through the Israeli security mechanism. Sand is used to thicken what small amount of cement has gotten into Gaza.[14]

The human costs of this status quo are real. MSF clinics in Gaza City and Khan Younis are full of children who suffered severe burns in household cooking accidents in home damaged during the war. Some of our patients have been burned from explosions caused by the use of unsafe home heating products. In April, 70 percent of total cases treated at MSF facilities in Gaza were burn victims with 65 percent being children under the age of 15.

Others still need more reconstructive surgery or physiotherapy for injuries from last summer’s war, including an eight-year-old girl that I met in our post-operative clinic in Gaza City, who lost most of the use of her extremities after shrapnel from an Israeli missile lodged in her back. She will likely only regain 50% percent of her orthopedic functions.

She is one of many. The backlog of reconstructive surgical cases now reaches 300. And for those amputees lucky enough to return to an undamaged home, daily life will still be incredibly precarious. Imagine trying to steer a wheelchair down a street lined with huge chunks of shattered buildings.

Nearly a year after the war both sides continue to dispute the casualty counts, but what MSF can attest to is the clear preponderance of children under 18 who make up the list of patients requiring war-related surgeries and physiotherapy. Our teams see them daily—and struggle to manage their pain given the ban by Hamas that was placed on many prescription pain killers here due to the high rates of addiction in Gaza.[15]

At our post-operative clinic in Gaza City, screams emanate from children receiving wound dressings for their burns, without the benefit of any pain killers. The scene is yet another example of how the suffering inflicted from latest war here continues to exact a toll on Palestinians. And it lays bare the visceral and excruciating limits of humanitarian action in the face of the occupation.

Why bother with hope?

A frightening, miserable sort of normalcy, bereft of hope or future prospects, has set into daily life in Gaza. War is thought to be almost as inevitable as the passing seasons. A 10-year-old child here has seen war four times in his or her lifetime. And with each war the toll escalates: 12,410 houses were totally destroyed in 2014 compared to 3,425 homes in 2009.

Gazans continue to demonstrate their resiliency in the midst of it all. In early May, groups put on a mini “Cannes” film festival amid the rubble of Gaza.[16] But there remains a foreboding inevitably to the rhythm of daily life.

Rockets are again being tested and fired from Gaza into Israel, drawing thunderous responses from the Israelis. These violent acts – called acts of resistance on one side and terrorism on the other – serve to reinforce the acceptance of a policy of separation and isolation of Israelis and Palestinians, and the further de-humanization of the "others," a dynamic that has only accelerated since the second intifada.

In recent weeks, small improvised explosive devises have been set off in the streets of Gaza at night and in the morning.[17] Thankfully there have been no casualties but many are wondering if the attacks might signal the start of a new round of intra-Palestinian conflict, should reconciliation talks between Hamas and the Palestinian Authority flounder.

Petty crimes are on the rise, too, as the noose – man-made and natural – continues to tighten around Gaza. In less than a year it is expected that the Mediterranean will penetrate Gaza's lone aquifer and make it undrinkable,[18] while its fishermen are regularly strafed by the Israeli coastguard.[19]

Things are so absurd in Gaza that the destruction of the smuggling tunnels – used for transporting weapons as well as less sinister goods needed for daily life – was often denounced by aid officials and diplomats to me during private meetings rather than the circumstances that made them necessary in the first place. [20]

All of this occurs in the absence of any meaningful progress on the political front, as the international aid community, including MSF, and states – particularly by United States and European Union – have continued to subsidize the costs of the Israeli occupation to the tune of $1.6 billion since 2010.[21]

Yet even this modest life support seems under threat. As of late April, an analysis of bilateral and multilateral aid commitments following the war revealed that donors had given only 27.5 percent of the promised $3.5 billion, or $967 million. Furthermore, only 35 percent of the aid pledged - or $1.2 billion - was actually fresh, with the majority coming from reallocated donations and emergency funding delivered as the bombs were still falling on Palestinians in Gaza. Of this new aid, just 13.5 percent - or $165 million - has come through.[22]

Meanwhile, Gaza’s unemployment rate now stands at 44 percent – the world’s highest level – 11 points higher than before the war.[23] The unemployment rate among youth has reached 60 percent, highest in the Middle East. And 40 percent of Gaza’s nearly 1.8 million Palestinians live in poverty, even though around 80 percent received some sort of aid.

This subjugation of the population to decades of international aid doesn’t have to continue.

A 2014 World Bank study projected that if the Palestinian Authority were allowed to extract minerals from the Dead Sea and farm the lands currently off limits in “Area C” of the West Bank, then this would amount to $2.2 billion per year in additional revenue, effectively neutralizing the need for additional international donor assistance.[24]

Ever-shrinking enclaves

Meanwhile, the "facts on the ground" continue to deteriorate in Gaza and the West Bank alike. Today, Palestinians can only inhabit less than 40 percent of the West Bank.[25] The rest is no-go zones controlled by the IDF or settlers, protected by check points and even land mines.  And the shrinking space and freedom of movement of Palestinians is expected to worsen.

Plans are afoot to relocate Bedouin communities to an area north of Jericho and to open an East-West corridor, inaccessible to Palestinians, stretching from East Jerusalem to the Dead Sea, essentially cutting the West Bank in half.[26] Aid agencies, MSF included, refuse to participate in any fashion – by building new shelters for the Bedouins, for instance – to the inevitable forced relocation.

There is nothing on the table internationally that would offer a political solution for the Israeli-Palestinian conflict any time soon. Speaking to Palestinians, hopelessness is as pervasive as the concrete and barbwire encasing Gaza and the West Bank. Confronted with more than 600,000 settlers in East Jerusalem and the West Bank,[27] they see few prospects for a Palestinian state, let alone the easing of travel restrictions. And in Gaza, the 1.8 million residents just try to get through the day.

Aiding & Abetting

Whether it is the nightly incursions and detentions without charges in and around Nablus, the maze of walls and checkpoints in Hebron, the partition of Jerusalem that cuts off access to medical care for Palestinian villages, or the deadly aerial bombardment and blockade in Gaza, the occupation takes many forms -- all inevitably justified through a public discourse of security for Israelis.

This is a narrative accepted, enabled, and subsidized through international aid and failed peace processes. It has reduced “progress” in the Israeli-Palestinian conflict to young women who can finish sentences without crying, the number of truckloads of cement allowed to enter Gaza, or the Palestinian medical transfers facilitated through the Erez Crossing.

Israeli fears of rocket fire from Gaza are evidenced in the trauma of air raid sirens and the necessity, now part of Israeli building codes, for homes to have bomb shelters. The ongoing threat of tunnel-enabled attacks inside Israel also precipitates anxiety amongst those in the areas bordering Gaza.

But these fears cannot justify the devastating medical and psychological consequences for Palestinians of the barriers, checkpoints, bombing campaigns, blockades, and incursions. These measures to protect Israelis must be examined today in terms of their humanitarian fallout. Israelis and supporters of Israel must question and confront the human costs of the policies used to achieve this security. And the governments and international institutions either explicitly or tacitly supporting these policies must do the same, because the devastation they have wrought is undeniable

Humanitarian complicity?

MSF teams in the Occupied Palestinian Territories and other war zones around the world are always reflecting on their actions with an eye toward ensuring aid does not do more harm than good. For now, we will continue stitching up the physical and psychological wounds of Palestinians, knowing that another war with Israel may not be far off, and that a great many people already need assistance right now.

This is our role, one constantly questioned by our medical teams on the ground, who are always struggling to see the invisible line between complicity with the occupation and a refusal not to ignore its consequences. Ultimately, though, our humanitarian action has been consistently justified as a response to the needs of Palestinians trapped by this endless war.

As has been the case for the past 15 years, our presence is our protest in the face of an occupation that has taken on a near-permanent character. While there is no shortage of suffering in Gaza and the West Bank, an international acceptance of the unacceptable is now the deadliest form of the occupation for Palestinians – with no end in sight.