Twenty wounded have undergone surgical procedures in the Médecins Sans Frontières (MSF) facility in Gaza city so far this week. Half of the patients are under 15, including seven wounded children under five. The surgical team has carried out wound debridement (the removal of infected or dead tissue), skin grafts and removal of external fixators. Dressings for severe burns also need to be done by the surgical team.

Informing the wounded about secondary and specialized surgery

More patients are expected to arrive in the coming days and weeks: extensive MSF evaluations in the Gaza strip indicate significant secondary and specialized surgery needs for people injured during the first three weeks of January.

MSF identifies patients through teams going door to door in the areas most affected by the conflict, or through the medical staff in our clinics. Palestinian hospitals also refer patients to the MSF facility, and radio announcements are being broadcasted informing the population of the surgical care available.

Increased number of patients requiring post-operative care

One hundred dressings and physiotherapy sessions were carried out in the MSF Gaza city clinic for post-operative care on January 29. There has always been a large number of wounded requiring this type of medical care in the Gaza strip, and it has increased since the Israeli military operation.

The Gaza clinic, another MSF clinic located in the south of the Gaza city strip in Khan-Yunis, together with three mobile teams, used to treat an average of 240 patients per month. Now a triage for new admissions has been set up and the less severely wounded are referred to primary health care centers to make room for the recent war wounded.

A third clinic for post-operative care should open in the north of the Gaza strip to provide assistance to patients in east Jabalia, Beit hanoun and Beit Lahiya.

Psychological effects of exposure to high insecurity

Everybody has been exposed as there was no safe place and no possibility to escape.

"It is too early to evaluate the psychological impact of the latest bombings and fighting. For the moment, the psychological effects are normal given the period of intense insecurity they have endured," said Angels Mairal, coordinator of the MSF psycho-social programs set up in 2000. "Nightmares, insomnia, weight loss, irritability, poor concentration, hyper vigilance or psychosomatic signs like headaches and stomach pains often occur after periods of high stress. If these persist more than one month, they may be considered as symptoms of post traumatic stress disorder or another psychological disorder. Psychological care is needed to avoid these reactions becoming symptoms."

A psychiatrist has joined the team of two clinical psychologists in the Gaza strip. While continuing short therapies for regular patients, for two or three months length, they will focus - through discussions groups - on the needs of the emergency teams who were particularly exposed over the past few weeks.

Even in the West Bank, the MSF psychologists there have observed a deterioration in their patients. There have been no requests over recent weeks for psychological care from the 36 patients who were in the program.

"All they were thinking about was survival," said Angels. "The population was in search of practical advice, like where was the safest place in the house for the children. The next priority was to cover basic needs, like finding a new place if their house had been destroyed."

Social workers help patients in the psychosocial program to find some support through referral to different organizations providing social assistance. The MSF psychologist confirms, as always, that children are the most vulnerable.

"There is the double effect of the violence and the stress on children," said Angels. "Like everyone else, they are directly affected, but they also suffer from the incapacity of their affected parents to provide them with the support they need. They face increased difficulties, but their parents are less able than before to assume their role towards them."

Even when it not a period of intense violence, the economic and political situation makes it difficult for parents to provide their children a sense of security.