The nightmare for the freed Israeli hostages is far from over 

According to Rule 96 of the international Humanitarian Law Databases, hostage-taking is prohibited. The offence of hostage-taking is defined as “the seizure or detention of a person (the hostage), combined with threatening to kill, to injure or to continue to detain the hostage, to compel a third party to do or to abstain from doing any act as an explicit or implicit condition for the release of the hostage.” With the release of the first hostages in the Israel-Hamas war, dread and fear are replaced with relief and elation.  

In exchange for the release of 50 hostages, Israel agreed to honor a ceasefire for four days and release 150 individuals currently held in Israeli prisons. The seemingly good physical health of the hostages immediately after release is not a reflection of the humanity of the Hamas captors — the psychological stain to the freed hostages will be deep and prolonged.  

The strategy of hostage-taking 

From the perspective of Hamas, the strategic value of a hostage is directly related to the health and well-being of that person once set free. Hostage-taking is most effective strategically when hostages are taken from a group who values their safe return over all other tactical objectives.  

On Oct. 23, 2002, Chechen terrorists seized the crowded Dubrovka Theater and held 850 hostages. Owing to the theater building design, the prospect of a Russian rescue mission involving a frontal assault was abandoned. In addition, the Chechen attackers had multiple explosives and threatened to detonate them if a rescue mission was attempted. In reply, Russian forces pumped in a chemical agent, most likely a combination of the powerful opioids carfentanil and remifentanil, thereby incapacitating both the terrorists and many hostages.  

All 40 terrorists were subsequently shot and killed, and 132 hostages also died, likely secondary to opioid-induced apnea. Russian forces refused to disclose the nature of the incapacitating agent to first responders and other healthcare workers, likely resulting in needless death of some of the hostages. In the aftermath, Russia likely succeeded in conveying that it will not be held hostage by the taking of hostages. 

Israel, on the other hand, has demonstrated a willingness to swap Israeli hostages for prisoners even convicted of terrorism offences. This was dramatically demonstrated in the case of Gilad Shalit an Israeli soldier captured by Hamas in 2006 and held for five years. In 2011, Israel released 1,027 prisoners in exchange for Shalit. Though the swap was supported by most Israelis, others saw it as capitulation and acknowledgment that hostage-taking against Israel would be seen by enemies as an effective strategy in future conflicts.  

Right or wrong, the fact of this current hostage-for-prisoner swap redemonstrates that although the exchange rate has fallen from 1000:1 to 3:1, a market for this activity still exists.  

The health of the hostages in captivity 

The Centers for Disease Control and Prevention recognize how the inadequacies of social determinants of health result in poor health and a shortened life span. For a hostage, such concerns include inadequate access to quality healthcare, dangerous and unstable environments, threats of violence, language barriers, poor nutrition, reduced physical activity, and exposure to sunlight. In addition, poor dental care, a lack of access to prescribed medication, and mental health challenges are all, to varying degrees, the common plight of the hostage.  

The planned release of hostages in this current round included children, mothers and the elderly. Within this group, children and the elderly require special attention. The elderly have less physiologic reserve and are at greater risk of health decompensation in the setting of a health adverse environment. Some elderly hostages have died but the details of these deaths remain uncertain.  

The medical health of hostages after release 

Israel has family health clinics knows as “Tipat Halav” — a drop of milk — that will likely have previously tracked the height, weight and head circumference of the abducted children. Post-release, this information can serve as an index for growth while in captivity.  

Gaza suffered increasing food insecurity prior to the Oct. 7 attacks; Palestinian health authorities in the West Bank and Gaza had noted micronutrient dietary deficiencies and created a very successful program of micronutrient flour fortification. Under Hamas, it is unclear if this program continued. A thorough evaluation of micronutrient blood levels in the children held hostage will reveal any current deficiencies, as flour from aid organizations is unlikely to be micronutrient fortified.  

Refeeding syndrome is a severe life-threatening metabolic complication first described in World War II, when severely malnourished concentration camp survivors were refed and had sudden death. Refeeding syndrome is the consequence of fatal shifts in fluids and electrolytes that occur in malnourished individuals. The hallmark is profound hypophosphatemia — or low phosphate in the blood — but other electrolytes disturbances can occur. Starvation creates temporarily adaptive hormonal and metabolic changes to shift energy utilization from carbohydrates to protein and fat. Any person with negligible food intake for more than five days is at risk. In the two weeks prior to hostage release, food supplies ran low, and hostages may have received little more than rice and pita bread.  

The psychological health of hostages after release 

On the night of Feb. 4, 1974, 19-year-old college student Patricia Hearst, granddaughter of newspaper magnate William Randolph Hearst, was abducted from her Berkley flat by members of the Symbionese Liberation Army. In the initial weeks after her capture, Hearst had been bound, blindfolded and sexually assaulted, but was eventually given the choice to be released or join the group. She chose to remain. To survive her ordeal, she claimed, “I accommodated my thoughts to coincide with theirs.” Her long recovery after her abduction was a testament to the complex psychological trauma some hostages face.  

From the public perspective, we would hope that freed hostages display vigorous and immediate condemnation toward their captors. But this will likely not be the case universally, owing to the psychological trauma of abduction. Under enough psychological strain, people may convince themselves of anything. Objectively, the mind is designed to survive, and sympathy to a captor’s position may be a rational response to threats against survival. In the coming weeks and months after the hostages are released, what happens to that mindset as the threat dissipates? Some hostages will very likely need intense and prolonged psychological support. 

The aftermath of hostage-taking 

The taking of hostages during war is a war crime. The freeing of all hostages held by Hamas is time-sensitive and paramount; at stake for hostages are physical and mental health. Time will reveal the extent of what transpired during captivity, and in due course, with firmness and resolve, those responsible hostage-takers will be held to account.    

Joel Zivot, MD, MA, JM, is associate professor of Anesthesiology and Surgery, Emory School of Medicine; former adjunct professor at the Emory School of Law; and senior fellow in the Emory Center for Ethics.