PALESTINIAN CIVIL SOCIETY UNDER SIEGE (#4): Gaza's Mental Health Crisis

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\'ON THE RECORD\': Your Electronic Link to Civil Society in Palestine
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Volume 15, Issue 4, June 12, 2001
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PALESTINIAN CIVIL SOCIETY UNDER SIEGE (4)

FEELING THE STRAIN: GAZA\'S MENTAL HEALTH CRISIS

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Contents:

EDITORIAL: COLLECTIVE TRAUMA

FEELING THE STRAIN: GAZA\'S MENTAL HEALTH CRISIS

- Memories of 1948

- The Roots of Trauma

- Crisis Intervention

- Dealing with Symptoms

\"FROM HELL WITH LOVE\" -- an open letter to European heads of state by
Dr. Eyad El Sarraj

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From the editorial desk: COLLECTIVE TRAUMA

For many years now, Israeli forces have been demolishing Palestinian
houses as a way of punishing supposed acts of terrorism, reinforcing
control over the occupied territories, and clearing Palestinians from
areas that are claimed by Israeli settlers.

The use of demolitions has escalated dramatically during the current
uprising. According to Giorgio Giacommelli, a special investigator for
the UN\'s Human Rights Commission, 773 Palestinian family homes were
destroyed between September last year and February of this year. This
was aimed not so much against the families as against the entire
population. As a result, the practice of demolitions is widely viewed
as
another form of collective punishment. Giacommelli also pointed out
that
it violates at least two articles of the Fourth Geneva Convention, as
well as the Universal Declaration of Human Rights. [1]

In recent weeks, Israeli forces have taken to entering areas that are
controlled by the Palestinian Authority, and this too has led to more
demolitions. One incursion on May 2 into Rafah (southern Gaza)
destroyed
20 homes, damaged a mosque, and killed or injured 12 Palestinians.

Demolitions are often carried out without any advance notice, often at
night, and the effect can be absolutely terrifying. This emerges
clearly
from this issue of \'On the Record,\' which profiles a family from Gaza
that was asleep when their house was torn down. Months later the entire
family is still deeply traumatized.

The task of treating this family and thousands more like them in Gaza
has fallen to the Gaza Community Mental Health Programme (GCMHP). The
project was founded in April 1990 by Dr. Eyad El Sarraj -- the only
psychiatrist working in the Gaza Strip at the time -- to provide basic
counseling for people suffering from emotional trauma.

Since 1990, the GCMHP has treated over a tenth of Gaza\'s entire
population in its clinics. Half have been children and adolescents. The
GCMHP focuses on high-risk populations: former prisoners, women victims
of domestic violence, and children. Grassroots International supports
the GCMHP\'s Jabalia clinic.

As well as providing treatment for victims of trauma and mental
illness,
the GCMHP also monitors the broad spectrum of human rights abuses in
Gaza. The second half of this issue takes the form of an open appeal
recently written by Dr. El Sarraj to European heads of state. Readers
are invited to distribute Dr. El Sarraj\'s letter as widely as possible.

FEELING THE STRAIN: GAZA\'S MENTAL HEALTH CRISIS

Early this year, an Israeli bulldozer demolished the house in Beit
Lahia, a village in northern Gaza where Khalid Abdullah Al-Hajin and
his
family had lived for years. No warning was given. The children were
asleep at the time and they woke up screaming, thinking that an
earthquake had hit. Two of them wandered groggily into the path of the
bulldozer before being rescued by their panic-stricken parents.

The family escaped with the clothes they were wearing. Everything else
was pushed into a large hole and covered over with dirt. According to
the family, 32 animals (rabbits and sheep) were buried alive along with
the house, furniture, cooking utensils, and photo albums.

It is not hard to fathom why the Al-Hajin family lost their home. An
Israeli settlement (Dugit) has been built on nearby land (some of which
belonged to the family). Like so many settlements, Dugit has acted as a
magnet for tension during the current uprising, and the exchanges of
fire grew so intense that the Israelis decided to demolish the
Palestinian houses around the settlement to create a \"security zone.\"
One of those houses belonged to the Al-Hajin family.

Demolition has become an integral, almost routine, part of Israel\'s
response to the uprising. But as the experience of the Al-Hajin family
shows, the practice creates unbearable stress for the Palestinian
families affected and adds enormously to the pressure that is building
in Gaza.

- Memories of 1948

For the first few days after their eviction, Abdullah Al-Hajin, his
wife, father, and children lived in a tent provided by the Red Cross,
unable to comprehend their loss. They then moved into a friend\'s
half-empty house in Gaza City.

This provided some respite, but the children continued to suffer from
nightmares and a loss of appetite. Their parents began to quarrel.
There
was no work for Abdullah Al-Hajin in Gaza, where unemployment is
running
at over 50%. His wife Shifa has had three operations and needed money
for medicine, but the money was not there. Everyone was on edge.

Abdullah Al-Hajin confesses that he took out his anger on his wife and
even his children. \"Yes, we had arguments and almost separated. I
became
aggressive and hit my children when they asked questions.\" On one
occasion he turned violently against his wife and broke her nose. She
left the house and lodged a complaint with a local judge.

If anything, it was worse for Abdullah\'s 72-year-old father, also named
Abdullah. The old man is still haunted by memories of 1948, when he was
expelled from his village in what is now Israel. On that occasion, the
bank refused to honor his credit. As a result, when Abdullah moved to
Beit Lahia he resolved to avoid banks altogether and kept his savings
under his bed. He did not have time to retrieve it when the Israeli
bulldozer moved in. Now the equivalent of $9,000 lies buried under the
ground.

The old man was unable to comprehend this second loss. Within days of
moving to Gaza City, he began returning to a hill that overlooked where
his house had stood. From here he watches for hours on end, eaten up by
anxiety that someone else will dig up his treasure.

That image is deeply upsetting to staff from the GCMHP who is
counseling
the family. Apart from anything else, old Abdullah\'s obsession is
highly
dangerous. One of his former neighbors was shot dead when he went back
to try and retrieve some clothes from the remains of his house.

At the same time, the case is far from unique. The years have taken a
heavy toll on the mental health of Gaza\'s population, and this is
reflected in the workload of the GCMHP. According to Eyad El Sarraj,
the
project\'s director and founder, its clinics have probably helped a
tenth
of Gaza\'s entire population in the last decade.

- The Roots of Trauma

Gaza has long been a symbol of Palestinian resistance to Israel, for
understandable reasons. Over three-fourths of the population (almost
850,000 people) are registered as refugees, and over half live in
crowded camps. It was in the largest camp -- Jabalia -- that the first
intifada began in December 1987.

In October 2000, Israel\'s response to the current uprising in Gaza
produced one of the ugliest sequences ever recorded on television, when
cameras filmed 11-year-old Mohammed Al Durra being shot to death while
he tried to shelter behind his father.

But Gaza is frightening to Israelis, too. This is the place that
produced the bus driver who ploughed his bus into a column of young
Israeli soldiers, leaving body parts strewn all over the road. The hard
men of the armed Palestinian resistance are eulogized on the walls all
over Gaza City. A recent poll by the University of Bir Zeit found
widespread support for Hamas here, as well as deep disillusionment with
the Oslo peace process.

Perhaps as a result, Israeli security forces have shown a notable lack
of restraint in responding to the current uprising in Gaza. This
delegation was told that the Israelis fired warning shots above the
cars
of the Canadian ambassador and the UN High Commissioner for Human
Rights
while they were traveling in Gaza to prevent them from going on.

The Israelis also use roadblocks to seal off areas that are deemed to
pose a security threat to Israeli settlements, or simply as a form of
punishment. The roadblocks go up without warning and when they are up
nothing is let through -- not even medicine or ambulances. For good
measure, bulldozers ripped up the tarmac at one roadblock near the
Israeli settlement of Netzarim. When this delegation passed through,
Palestinian police were struggling to repair the road with bucket loads
of dirt.

To the staff at the GCMHP, the demolitions and roadblocks are not only
vindictive but counterproductive because they fuel the pent-up anger
that is always simmering just below the surface. The Gaza Strip
comprises 360 square kilometers of land, but Israeli settlement areas
take up 42% of the land. Over a million Palestinians are squeezed into
the remaining land and three-quarters of them are refugees. According
to
the Democracy and Workers\' Rights Center (DWRC) in Ramallah, 72% of
Gaza\'s population is now living below the poverty level. They have
nowhere to go and few outlets for their stress and anxiety.

But if Israel\'s policies add to the claustrophobia, the Palestinian
leadership does little to help. Eyad El Sarraj told this delegation
that
the experience of being besieged can bring out the best in people if
they have inspiring leaders. But, he said, President Yasser Arafat has
done nothing to inspire his battered people. Instead, he has left the
talking to his advisers, who project a mixed message. One moment they
preach negotiations with Israel, the next moment they advocate armed
resistance.

This, says El Sarraj, adds schizophrenia to Gaza\'s lengthening list of
mental problems. \"Gaza is one big open prison in which everyone is
exposed like guinea pigs. The Israelis can reach in and take you out.
So
can Arafat. We are traumatized to death.\"

El Sarraj cited the case of the Palestinian bus driver from Gaza who
launched his bus into a crowd of Israeli soldiers earlier this year.
According to the man\'s family, he was deeply shocked to see a dead
Palestinian dragged from a car after being bombed from a helicopter. \"I
think he just snapped,\" said El Sarraj.

Everyone feels the strain in Gaza. Husam El Nounou, who heads the GCMHP
public relations department, feels himself to be privileged. He has a
car, a responsible job, and the opportunity to help other people, which
is always good therapy. \"Imagine what it is like to live with a lot of
kids in a small house in a refugee camp without a job. The chances are
that one parent has been detained by Israelis at some stage. Imagine
the
strain in that house.\"

It is, all agree, particularly painful for the children, who see
violence coming at them from the skies, the streets, and even from
their
own parents. Bedwetting is virtually universal among children as old as
13. In the GCMHP\'s Jabalia clinic, a large sheepskin has been set aside
for children who suffer from a condition known as trichomania, which
leads them to tear their hair out. The thick sheepskin has been worn
bare by small, anxious hands.

Faced with this every day, Eyad El Sarraj and his colleagues understand
completely what the children of Abdullah and Shifa Al-Hajin are going
through following the destruction of their house. \"Most children in
Gaza
have experienced a traumatic episode. In an environment like this, the
most normal events can turn traumatic,\" said El Sarraj.

Parental stress adds to the burden on children. \"Men have to be
productive in this society, and their confidence is shattered if they
cannot protect and provide for their families. It gets worse if
children
see their parents publicly beaten and humiliated. This creates stress.
The only outlet is anger and aggression.\"

Eyad El Sarraj is sure that mental illness will surge if and when the
current violence subsides. \"We are not yet seeing mass violence against
women and children, but that will come with tranquility.\" It is, he
says, a common feature of post-traumatic stress disorder, or PTSD.

- Crisis Intervention

The Al-Hajin family is receiving help from the GCMHP\'s clinic at
Jabalia, which serves a population of 250,000 in northern Gaza. Most,
but not all, of its clients come from the Jabalia refugee camp, which
is
the biggest camp in the Gaza Strip.

Currently the clinic is treating about 3,000 patients. Many others
receive help, although such is the stigma attached to mental illness
that they do not want to be formally registered as \"cases.\"

Three of the seven workers at the Jabalia clinic also serve on a
\"crisis
intervention team\" which was established by the GCMHP at the start of
the uprising. The aim, says El Sarraj, is to respond immediately when
there is a shelling, a demolition, a helicopter attack, or a deadly
exchange of fire. Often the team arrives on the scene before doctors.
They start counseling victims before the shock has worn off.

Such work can be deeply distressing, and several foreign professionals
have come to work for the GCMHP and left suffering from PTSD
themselves.
The staff at the Jabalia clinic meets each Saturday to review the
week\'s
work and go through cases. Often, the meetings turn into joint therapy
sessions. They have to encourage each other to return to the scene of
particularly violent incidents.

The Al-Hajin family was referred to the clinic by a medical team from
Doctors Without Borders. Other cases are referred by sheikhs or
community religious leaders (imams).

Relations between the traditional healers and the GCMHP are ambivalent.
The GCMHP counselors agree that the traditional methods have their
uses,
and they would not deny that the Koran can be soothing. But they are
also skeptical about some of the methods used by the imams, who have
even been known to employ physical violence to drive out \"bad spirits.\"
In one case that was before the courts when we visited, a woman with
several children was beaten to death by a traditional healer who then
enticed her husband to take up the stick.

GCMHP treatment starts by talking through the experience and drawing
out
the patient. Then different members of the team -- psychiatrist, social
worker -- assess the facts of the case.

Three members of the crisis intervention team from the Jabalia clinic
visited the Al-Hajin family. After diagnosing the problem -- PTSD --
the
team focused on the different needs of the family members.

The children clearly needed a lot of attention. Inshirah Zagout, a
GCMHP
social worker, had to work hard to persuade one of the boys that it was
worthwhile continuing at school. \"He could not see the point of working
hard at school in order to get a job and build a house if the house was
going to be destroyed. I persuaded him to stay.\"

Ms. Zagout took the Al-Hajin children out to see the site of their
former house. At this point, they still refused to accept what had
happened, she said. But they had to know. There was a lot of crying,
followed by some kind of calm. Their parents, meanwhile, were given
anti-depressants as they struggled with their anger and frustration.
The
GCMHP team followed up with regular visits and brought what they could
-- small offerings of soap and sweets.

- Dealing with Symptoms

Abdullah Al-Hajin veers between panic and lethargy as he contemplates
his life. He is an intelligent man with several skills. But he also
knows that his prospects for finding work in Gaza are not good, and he
wonders how he can pay his friend the $1,000 he has promised for the
rent of his house.

Abdullah\'s brother is a sheikh, and his wife takes comfort from reading
the Koran. But they both know the Koran will not restore their house.
So
for the moment, Abdullah Al-Hajin passes the time by designing posters
in his ornate, flowing handwriting.

The GCMHP team members know that at best they can only deal with the
symptoms of Abdullah\'s stress and not the root causes. This causes
frustration to Eyad El Sarraj and his colleagues, who insist on the
links among mental health, community rehabilitation, and human rights.

They have made this nexus the basis for an innovative university degree
that has been developed by the GCMHP and is taught at seven
universities
around the world, including Tel Aviv. Sixty students have graduated
with
the degree in the last four years, and many are working for the
Palestinian Authority or Palestinian NGOs in Gaza and the West Bank.

In terms of practical application, the importance of community
rehabilitation in Gaza is self-evident. However stressful every day
life
may be, and however traumatized the society, the days of treating
mental
health in institutions are long gone.

The GCMHP staff also believes that community action can be cathartic.
During the first intifada (1987-1993), says El Sarraj, project teams
cleaned up garbage from beaches and refugee camps. Everyone is too busy
coping with the current crisis to work on such schemes, but they may be
revived in due course. As for human rights, this too is clearly
relevant
in the bigger scheme of things. \"No one can enjoy sound mental health
in
a climate of repression,\" says El Sarraj.

The problem is that the GCMHP can do little to address the chronic
human
rights violations that lie at the root of much of Gaza\'s mental health
crisis. So, for the moment, El Sarraj\'s colleagues do what they can to
address the symptoms.

Their care and attention has at least brought the Al-Hajin family back
from the brink. By the time of our visit, Abdullah\'s wife had dropped
her complaint before the judge and returned to her husband, and
Abdullah
felt comfortable enough to speak to us about the tension between the
two
of them. His daughter has slipped from second place to sixth in class,
but at least she is still in school.

The main worry is the elder Abdullah, who still goes out to gaze at the
site of his former house. According to Inshirah Zagout, from the GCMHP,
Abdullah has probably given up hope of retrieving the money himself.
His
main goal now is to make sure no one else gets to it first.

The crisis intervention team has tried to meet with the old man several
times but to no avail. They are deeply troubled at the thought of the
old man with his head full of thoughts of his buried fortune. \"He needs
our help, but we can\'t get to him,\" says Ms. Zagout sadly.

FROM HELL WITH LOVE

- The following open letter was written recently by Dr. Eyad El Sarraj,
General Director of the Gaza Community Mental Health Programme. It was
addressed to all European heads of state.

When I was studying psychology, I was introduced to the laboratory of
human behavior. In one experiment, a poor guinea pig was to learn how
hard it can be to die. It was repeatedly given a piece of cheese. When
the animal tried to taste the cheese, it was given an electric shock.
The guinea pig would go then into frenzy, rocketing himself against the
cage in a desperate attempt to escape. After few episodes the miserable
animal would be frozen by terror in his cage. His earlier attempts at
rebellion were futile, and his rage could not persuade his masters to
give him a respite.

A few days later it would die, and the dissection of the body revealed
severe internal hemorrhage of the suprarenal, which had been producing
serious amounts of adrenaline. The experiment was about the effects of
stress, we were told. You can apply it to the world we live in: human
relations, power, and powerlessness.

This letter of course is not about guinea pigs, but it is about us,
Palestinians. It is about human life, about the politics of arrogance
and the \"violence\" of the oppressed. I feel the duty of writing to you,
with the hope that you may see and act.

I am aware, like all of us, of the sad fact of today that only America
can decide on issues of the world, even stubbornly and unilaterally
insist on polluting it. As for matters of the Middle East, you know
very well that Israel is reassured of the American support, the
impotence of the Arabs, and the silence of the world. So we enter the
cage.

The Palestinians are caged on their own land, while the Israeli
military
marches towards the complete and final \"victory.\" What you are
observing
from a distance is a Palestinian \"violent\" reaction to a vigorous
Israeli attempt at domination and imposing submission, with or without
cheese.

The Israeli plan to achieve \"victory\" is not very difficult to
understand, especially if you belong the club of Israeli generals. The
plan is based on the following:

a) Present the Palestinians with offers that they have to refuse, and
let them be seen as the obstacle to peace.

b) Incite the Palestinians; make them react violently, so Israel is
seen as the victim. The tragedy is that the Palestinians have reacted
always as Israel demands as they could not see other non-violent
alternatives.

c) Talk about peace and the future, and let the Palestinians talk
about
history and liberation.

d) Let the world know that you seek security, while Palestinians are
painted as terrorists.

e) Make the world believe that Israel is eager to solve the problem by
negotiation while Palestinians are trying to impose solutions under
fire.

From that logic Israeli soldiers are projected as defending themselves,
and Palestinian children are killed because they are asking to be
killed
and their families are inhuman. The same logic means that Israel has no
hesitation in demolishing Palestinian homes, while talking about its
desire to improve their life. And Israel has the nerve to seize land on
the West Bank and Gaza and tell the world that Palestinians have 22
Arab
countries while Jews have only one Israel.

If the Israeli military is allowed to pursue its final victory it must
produce a new exodus that may reach Europe. The Palestinians in Gaza
will have to leave, and those who would remain in the West Bank would
have to accept Jordan as their state.

To achieve its goal the Israeli military will have only to commit a
savage war, and massacres \"by mistake!\" As at Deir Yassin 53 years ago,
Israeli defense forces will kill a few hundreds or thousands. They will
open the border to Egypt, and Palestinians will flee.

Victory in the eyes of Israeli military establishment is said to be
peace and security. But it is not. Clearly and increasingly it is about
eating up the rest of Palestine.

As you know, peace and security for Israel can only be achieved if it
abides by the International law and ends its occupation of Palestinian
Land. In America the remnants of the \"red Indians\" have been reduced to
misery on reservations and die at an early age -- of stress, of
poverty,
of powerlessness and defeat. The U.S. administration is prepared to let
Israel treat the Palestinians in a similar way.

Will Europe simply stand by and watch? Or how can you explain your
abstention on the UN human rights commission ruling for the protection
of the Palestinians against the brutal Israeli policies of occupation,
which are already condemned by your government?

Sincerely yours,

Dr. Eyad El Sarraj

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[1] \"Question of the Violation of Human Rights in the Occupied Arab
Territories, Including Palestine,\" (C/CN.4/2001/20. March 21, 2001), p.
3.

Gaza Community Mental Health Programme (GCMHP) P.O. Box 1049, Gaza
City,
Palestine. Tel: 972-8-2824073; fax: 972-8-2824072. E-mail:
rana [at] gcmhp.net. Web site: http://www.gcmhp.net.

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In the next issue: Empowering Women

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- Grassroots International provides financial and material support for
community-led development in Brazil, East Timor, Eritrea, Haiti,
Mexico,
and Palestine. GRI began its work in the occupied West Bank and Gaza
Strip in 1983 following Israel\'s invasion of Lebanon. GRI\'s Palestine
work was renamed the Palestine Democratic Development Program after the
Oslo process began. To learn more about GRI visit:
http://www.grassrootsonline.org, or contact: Sona Bari, Communications
Coordinator, sbari [at] grassrootsonline.org. tel: 617-524-1400, fax
617-524-5525

- The Advocacy Project was established in 1998 to support advocates
working for human rights and peace. Visit the web site at
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