Dr Michel Thieren, WHO Special Representative in Israel, spent almost 2 weeks travelling across the country to see how the health system is responding in the aftermath of the attacks led by Hamas on 7 October. This is his account of what he saw and heard. Note: Some readers may find the content of this article distressing. More than 2 weeks after the attacks in Israel that left 1400 people dead and over 4600 wounded, health-care providers there continue working around the clock to respond to the enormous needs of their patients.

Immediately after the attacks on 7 October, WHO Regional Director for Europe Dr Hans Henri P. Kluge offered WHO’s support, under the Organization’s humanitarian mandate, to the health response led by the Israeli Ministry of Health. The Ministry responded that, at the time, the health system was coping, but that it would not hesitate to ask if assistance was needed.

So far, 8 attacks on health care and medical facilities in Israel have been recorded through WHO’s surveillance system of attacks on health care, with 7 deaths attributed to these.

WHO Special Representative in Israel Dr Michel Thieren has been reviewing the health response on multiple fronts, visiting hospitals, listening to the injured, talking to displaced people, touring destroyed and deserted towns and villages, and observing the intricate, highly challenging work of forensic investigators who have yet to formally identify almost half of those who died.

Among the sites Dr Thieren visited is a hospital in the coastal city of Ashkelon that is treating many of the injured.

“What is so striking is that almost all the people I spoke to, the vast majority of them with severe injuries from gun shots, shrapnel and burns, did not want to talk about themselves at all but about the people they had seen die in front of them,” said Dr Thieren.

“Almost every one of those survivors had seen someone else die before they themselves were injured. They are absolutely haunted by this. It is dominant in their thoughts. So many need urgent mental health support.”

In addition to the dead or injured, over 200 Israeli hostages remain in captivity, including women, children and older people, with many reportedly suffering from pre-existing health conditions requiring continuity of care. WHO and United Nations partners have repeatedly called for their immediate and unconditional release.

“The fact that so many Israelis are still being held hostage by Hamas means that there is no chance for the wider public to begin the healing process,” observed Dr Thieren, who has spoken to relatives of many of the abducted Israelis.

“It is on their minds 24 hours a day. It has added to the collective psychological burden witnessed nationwide, triggering an acute need for mental health services.”

Dr Thieren said he listened to several doctors and nurses treating the injured who shared that they, too, were finding their mental health affected by the stories they were hearing from survivors and the wounds they were treating.

“From what I am seeing, mental health problems appear to be rapidly spreading among the country’s population. The human suffering is immense. People just don’t feel safe anymore, and this is a complete change in their recent history.”

Dr Thieren also visited several military bases where the bodies of many of the victims of the attacks are stored in refrigerated containers.

“Doctors and forensic experts are still working to identify the bodies. They are all wrapped in plastic bags. There are obviously adult bodies and children’s bodies, but the vast majority of bags are misshapen. Despite Israel having some of the best forensic doctors in the world, only 700 – barely half of the 1400 victims – have been positively identified so far. This, of course, is incredibly impactful on those that are doing this necessary work,” he explained.

“I have visited ghost towns in the south whose populations have been evacuated. There is still the terrible stench of death. I have listened to so many people telling their stories. Survivors, the injured, psychiatrists, doctors, first responders and soldiers – all their accounts are horrific. The shadow of national shock and grief has plunged this country into night. When mental health perishes, so does physical health.”

In his role as WHO Special Representative, Dr Thieren also met with a number of public and official figures to gauge their views on the health needs at this time, and to express WHO’s solidarity with all civilians and health workers, everywhere.

Conflict and mental health

A WHO review of 129 studies in 39 countries, published in 2022, shows that among people who experienced war or other conflict in the previous 10 years, 1 in 5 (22%) have depression, anxiety, post-traumatic stress disorder, bipolar disorder or schizophrenia.

“The sad truth is that in any conflict, it is civilians and humanitarians who end up bearing the brunt,” noted Dr Gerald Rockenschaub, WHO Regional Emergency Director for Europe.

“Amid a number of ongoing conflicts in the WHO European Region and globally, WHO stresses that civilians and health workers must never be a target, anywhere. Violence, deaths, injury, displacement – all of these contribute to significant, long-term challenges that health systems are hard-pressed to respond to adequately.”

Dr Rockenschaub added, “Only an end to the ongoing violence, including through the immediate release of all hostages, can begin to help alleviate the human suffering of those affected.”

WHO’s guidelines on mental health care amid emergencies

WHO’s guidelines for responding to urgent mental health needs in emergency situations at a number of levels, from basic services to clinical care, include the following:

Psychological first aid to people experiencing acute distress should be made available by field workers, including health staff, teachers and trained volunteers.

Basic clinical mental health care covering priority conditions, such as depression, psychotic disorders and epilepsy, should be provided at every health-care facility by trained and supervised general health staff.

Psychological interventions, such as problem-solving, group interpersonal therapy and interventions based on the principles of cognitive-behavioural therapy for people impaired by prolonged distress, should be offered by specialists in those fields.

Protecting and promoting the rights of people with severe mental health conditions and psychosocial disabilities is especially critical in humanitarian emergencies. This includes visiting, monitoring and supporting people at psychiatric facilities and residential homes.

Links and referral mechanisms should be established between mental health specialists, general health-care providers, community-based support workers, and other service providers such as schools, social services and emergency relief centres.

Community self-help and social support should be strengthened.

About WHO

The World Health Organization provides global leadership in public health within the United Nations system. Founded in 1948, WHO works with 194 Member States, across six regions and from more than 150 offices, to promote health, keep the world safe and serve the vulnerable. Our goal for 2019-2023 is to ensure that a billion more people have universal health coverage, to protect a billion more people from health emergencies, and provide a further billion people with better health and wellbeing.