Ahmad, a 46-year-old man from Ramallah, was doing well, until his last detention. But this time he just could not tolerate the long incarceration in a tiny cell, with complete visual and auditory deprivation. First, he lost his orientation to time. Then he became over-attentive to the movement of his gut and started thinking that he was ‘artificial inside his body’. Later, he developed paranoid thinking, started hearing voices and seeing people in his isolated cell. Today, Ahmad is out of his detention, but still imprisoned by the idea that everyone is spying on him.
Fatima spent several years doctor-shopping for a combination of severe headaches, stomach-aches, joint pain and various dermatological complaints. There was no evidence of any organic cause. Finally, Fatima showed up at our psychiatric clinic and spoke of how all her symptoms started after she saw the skull of her murdered son, open on the stairs of her house, during the Israeli invasion of her village of Beit Rima on 24 October 2001.
Such are the cases I see in my clinic. The traumatic events of war have always been a major source of psychological damage. In Palestine the kind of war being waged needs to be understood in order to appreciate the psychological impact on this long-occupied population. The war is chronic and continuous, over the lifetime of at least two generations. It pits an ethnically, religiously and culturally foreign state against a stateless civilian population. In addition to daily oppression and exploitation, it involves periodic military operations of usually moderate intensity. These provoke occasional Palestinian factional and individual responses. The vast majority of people are never consulted about such actions. While their opinion does not matter, it is they who must endure pre-emptive Israeli strikes or collective punishment in retaliation for acts of Palestinian resistance.
Demographic factors complicate the picture. Those living in the occupied territories make up just a third of Palestinians; the rest are scattered around the region in a Diaspora, many in refugee camps. Almost every Palestinian family has experiences of displacement or major painful separation. Even inside Palestine, people are refugees, expelled in 1948 to live in refugee camps. The massive displacement of 70 per cent of the people, and the destruction of over 400 of their villages, are referred to by Palestinians as the Nakba or Catastrophe. This remains a trans-generational psychological trauma, scarring Palestinian collective memory. Very often, you will encounter young Palestinians who introduce themselves as residents of towns and villages their grandparents were evacuated from. These places are frequently no longer on the map, either razed entirely, or now inhabited by Israelis.
Palestinians perceive Israel’s war against them as a national genocide, and to resist it they give birth to many children. The fertility rate among Palestinians is 5.8 – the highest in the region. This leads to a very young population (53 per cent under the age of 17) – a vulnerable majority, at a crucial stage of physical and mental development. The geographical enclosure of Palestinians in very small neighbourhoods, with the separation wall and a system of checkpoints, encourages consanguineous marriages, increasing a genetic predisposition to mental illness. Walling off friends and neighbours from each other also has a debilitating effect on the cohesion of Palestinian society.
But it is the violent environment in which they live which most undermines the mental health of Palestinians. Population density, especially in Gaza – with 3,823 persons per square kilometre – is very high. Elevated levels of poverty and unemployment – 67 per cent and 40 per cent respectively – undermine hope and deform personality. The war has left us with a huge community of prisoners and ex-prisoners, estimated at 650,000, or some 20 per cent of the population. The disabled and mutilated make up six per cent. Recent screenings found a disturbing level of anaemia and malnutrition, especially among youngsters and women. The intense emotional hostility provoked by our daily friction with the Israeli soldiers at our doorsteps is a constant stress factor. Many Palestinian kids have been living with daily violence since birth. For them, the noise of bombardment is more familiar than the singing of birds.
During my medical school training in several Palestinian hospitals and clinics, I saw men complaining of non-specific chronic pains after they lost their jobs as labourers in Israeli areas. I also saw schoolchildren brought in for secondary bed-wetting after a horrifying night of bombardment. And all too vivid is my memory of a woman, brought to the emergency room suffering from sudden blindness that started when she saw her child murdered as a bullet entered his eye and went out from the back of his head.
In Palestine, such cases are not registered as war injuries and are not treated properly. This realization provoked me to specialize in psychiatry. It is one of the most underdeveloped medical fields in Palestine. For a population of 3.8 million, we have 15 psychiatrists and are understaffed with nurses, psychologists and social assistants. We have an estimated three per cent of the staff we need. We have two psychiatric hospitals, in Bethlehem and Gaza, but it is difficult to get to them, due to checkpoints. There are seven outpatient community mental-health clinics. In developing countries like occupied Palestine, psychiatry is the most stigmatized and the least financially rewarding medical profession. Psychiatrists work with desperately sick patients and, in the eyes of their communities, are far removed from the glory of other medical specialties. As a result, competent and talented doctors rarely specialize in psychiatry.
I find psychiatry a humanizing and dignifying profession – not least because it helps me personally to cope with all the violence and disappointments surrounding me. I move from Ramallah to Jericho to see psychiatric patients. In one working day I see between 40 and 60 patients; 10 times the number I used to see during my training in Parisian clinics. I observe my patients’ disorganized behaviour, listen to their overwhelming stories and answer them with the few means I have: a bit of talking, to pull together their fragmented ideas; some pills that might help them to organize their thinking, stop their delusions and hallucinations, or allow them to sleep or calm down. But talks and pills can never return a killed child to his parents, an imprisoned father to his kids, or reconstruct a demolished home.
The ultimate solution for mental health in Palestine is in the hands of politicians, not psychiatrists. So, until they do their job, we in the health professions continue to offer symptomatic treatment and palliative therapy – and sensitize the world to what is taking place in Palestine.
Nowadays, Palestinians are pressured to surrender once and for all, when they are asked to ‘recognize’ Israel. We are asked to accept, reconcile ourselves with and bless the Israeli violation of our life. The fact that our homeland is occupied does not, by itself, mean that we are not free. We reject the occupation in our minds, as far as we can cope with it; and learn how to live in spite of it, rather than being adjusted to it. But, if we recognize Israel, we are mentally occupied – and that, I claim, is incompatible with our well-being as individuals and a nation. Resistance to the occupation and national solidarity are very important for our psychological health. Their practice can be a protective exercise against depression and despair.
Israel has created awful facts on the ground. What remains for us of Palestine is a thought, an idea that becomes a conviction of our right to a free life and a homeland. When Palestinians are asked to ‘recognize’ Israel, we are asked to give up that thought, and to renounce everything we have and are. This will only sink us deeper into an eternal collective depression.
After several years in Paris I returned to a tired, starved Palestinian people, torn apart by factional conflicts as well as by the separation wall. Palestinians are especially demoralized by the infighting taking place on the streets of Gaza, but orchestrated elsewhere in order to abort the results of last year’s democratic elections. Those who have stopped all money from going to Palestine are, in effect, sending us guns instead of bread. They encourage the psychologically and spiritually impoverished to kill their neighbours, cousins and ex-classmates. Even if the factions settle up, Palestinian society will be left with a serious problem of intra-family revenge.
We shall overcome
It is hard not to wonder whether Israel’s targeting of Palestinians is deliberately designed to create a traumatized generation; passive, confused and incapable of resistance. I know enough about oppression to diagnose the non-bleeding wounds and recognize the warning signs of psychological deformity. I worry about a community forced to extract life from death and peace through war. I worry about youth who live all their lives in inhumane conditions; and about babies who open their eyes to a world of blood and guns. I am concerned about the inevitable numbness chronic exposure to violence brings. I fear also the revenge mentality – the instinctive desire to perpetuate on your oppressors the wrongs committed against yourself.
There has yet to be a comprehensive epidemiological study of the psychological disorders in Palestine. And, despite all that is published on Palestinian war-related psychopathology, my impression is that mental illness is still the exception in Palestine. Resilience and coping are still the norm among our people. In spite of all the home demolitions and extreme poverty, it is not in Palestine you find people sleeping in the streets or eating from trash cans. This resilience is based on family foundations, social steadfastness and spiritual and ideological conviction.
Still, we do have a mental-health emergency. Services are urgently needed for people who have suffered and endured crises so that they can restore their recuperative powers and coping capacities. This is crucial if they are not to crack when peace finally comes, as so often occurs in a post-war period. It is not just a small number of sick individuals but an entire wounded society that needs care. Our trauma has been chronic and severe; but by recognizing our suffering and treating it with faith and compassion, we shall overcome.
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