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Issue 4: Feeling the Strain: Gaza's Mental Health Crisis

On the Record - Palestinian Civil Society Under Siege
Volume 15, Issue 4
Feeling the Strain: Gaza's Mental Health Crisis
June 12, 2001

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

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 percent 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 percent 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



[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@gcmhp.net. Website.


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