In a dimly lit room with mouldy walls, Mahmoud carefully unwraps layers of tin foil to reveal a red pill. He presses his thumbnail into the coating to split the capsule, revealing a white powder laced with crystals that shimmer in the sparse light.
In the 35-year-old Palestinian’s palm rests a powerful dose of tramadol, a synthetic opioid painkiller that has become the drug of choice in Gaza.
“It numbs the pain,” Mahmoud says of the drug’s effect.
The number 225 is impressed on to the pill in his hand, denoting its strength. At 225 milligrams, it is almost five times stronger than the lowest dose available in the coastal enclave where economic hardship and hopelessness translate into rampant substance abuse.
It is an epidemic that threatens to render a generation of Gazans dependent upon prescription pills that can be as powerful as morphine. Living in what they describe as an open-air prison, Gazans have seen their fortunes decline, with little hope of a reversal. This desperation has fuelled drug abuse.
“Drug use is much worse now,” Mahmoud says. “It's directly linked to the situation: the worse it gets, the more drug abuse there is.”
Israel and Egypt have hermetically sealed Gaza from the outside world since Hamas won elections here in 2006. The blockage has crushed the local economy, driving unemployment up to 44 per cent and pushing 53 per cent of residents below the poverty line. Crumbling infrastructure has been battered by the Israeli military, which has waged three wars with Hamas in just over a decade.
Addiction remains a taboo topic in Gaza's conservative society. The subject is so sensitive that Mahmoud declines to give his real name. This concealment makes it difficult for users to seek help. They can expect little to no assistance from the Gazan health system, which is under severe strain from the blockade.
Mahmoud lives in a decrepit apartment block on the edge of Gaza city with his wife and five children. He first started taking tramadol after he was shot in the torso during the Second Intifada, or uprising, in 2000. Doctors prescribed him the drug and he took it to combat the pain from a bullet splinter that had moved close to his spine. He laid off the drug when the pain subsided.
But he then lost his house and the family business went up in flames during the fighting between Hamas and Fatah in 2006. Around that time, tunnels were dug all along the Egyptian border to get around the blockade. Alongside goods of all kinds, drugs like tramadol were being smuggled through the tunnels. That’s when drug abuse began to spike in Gaza.
“Tunnel operators would give the kids digging the tunnels tramadol. They were the first to get addicted. Digging tunnels is hard work and dangerous,” says Mahmoud. He too began to take the drug again – this time without a doctor's prescription. It lifted his anxiety and boosted his stamina. Using the pill, he spent countless hours ferrying materials from Egypt to Gaza through the tunnels as he rebuilt his business.
“It kills any kind of exhaustion. You have the energy to do anything,” he says.
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Egypt has since cracked down on the tunnels, and Hamas has tried to rein-in the drugs trade. But the flow of tramadol across the border has not abated. Abuse rates are particularly high among the young. Two-thirds of young people are unemployed, and even a university degree is little help in finding a job.
“I have about twenty college friends who are Tramadol users,” says Abdullah, a 26-year-old unemployed university graduate who also declines to use his real name. “Every time I hang out with friends, I get offered a pill.”
Gazans looking to get high on smuggled tramadol can buy a 225mg pill for 15 shekels (about $4). The same pill costs only three shekels before being smuggled into Gaza through the few tunnels that remain. Long-time addicts take more than one pill a day. In impoverished Gaza, where the average monthly salary in 2014 was $139, tramadol is an expensive habit.
Despite the cost, many Gazans turn to the drug to escape their dismal reality.
“When you are addicted you stop thinking about your future,” says Dr Ibrahim Rabie, who works at a psychiatric clinic run by the Palestinian Ministry of Health. “[Drugs are the] only thing that can make you stop thinking about the situation you are in, and the only drug you can get is tramadol.”
Dr Rabie's workplace is the only government institution that caters for drug abusers. The rundown cluster of buildings in Gaza City hosts 12 beds for addicts, who spend three weeks to a month in the facility to wean themselves off of the drug and its addictive effects. There are no funds for specialised equipment or for follow-up treatment, and relapse rates are high. Given the scale of drug use in Gaza, the impact of the government response is minimal.
“The clinic is not big enough to deal with the problem,” Dr Rabie admits.
Most of the patients are between 22 and 28 years old, the doctor says.
Apart from the clinic, a few private institutions offer treatment and counselling. But many addicts are afraid to seek help, afraid of the social stigma attached to drug use and psychological issues.
"Because of the culture here, it's difficult to present your suffering as a psychological problem," says Hassan Zeyada, a psychologist at the Gaza Community Mental Health Programme, an NGO that runs a hotline for drug users.
The persistent threat of violence heightens the existential fears of Gaza’s 1.8 million inhabitants who live in economic deprivation, producing high levels of trauma. The last war in 2014 cost the lives of more than 2,100 Palestinians and wounded tens of thousands more.
“The correlation between trauma and addiction is very high. People use drugs to alleviate their suffering, and gradually they become dependent,” Dr Zeyada says.
According to Unicef, the UN agency responsible for children, 250,000 Gazan minors are in need of treatment from trauma inflicted during the seven-week war. Adults are also affected but, rather than seeking therapy, they visit regular doctors to deal with side effects like headaches. They are then prescribed painkillers such as tramadol, setting off a spiral of addiction.
Constant worry and constraints have also found their way into the bedroom, Mahmoud says. Weighed down by their grievances, many Gazan men are struggling to perform in bed. They are instead turning to tramadol to boost their sex drive. Mahmoud claims to have stopped taking the pill regularly, but admits that he uses it before intercourse.
“The hardships that you go through, it affects your wellbeing. In our traditional society, you are expected to satisfy your wife,” he says. “But if your cousin is being killed or your shop is being bombed, how can you perform? In our situation, unless you have something to help you, you can't do that.”
Looking at the pill that rests in his hand, Mahmoud illustrates the power of the drug taking a hold of Gaza’s anguished youth.
“I don't have a single shekel in my home,” he says. “But I have this.”
