Palestinians Refugee: mental Palestinians Refugee: mental health situationhealth situation

Abdel Hamid Afana, Ph.DDirector of Research & Training, GCMHP

ThemesThemes

Historical ContextHistorical Context

Mental Mental health,Transgenerational health,Transgenerational effectseffects

Steps of interventionsSteps of interventions

Al Nakbah (the Al Nakbah (the catastrophe)catastrophe)

• In 1948: 914,221 Palestinians were displaced or become refugees

•531 Palestinian villages and towns were depopulated or demolished

In 1948 fully 531 Palestinian villages and towns were depopulated or demolished.

In 1948 more than

914,221 refugees

First uprooting (Al Nakbah)Al Nakbah)

The Second DisplacementThe Second Displacement

In 1967: the second displacementIn 1967: the second displacement

• 325,000 Palestinians from the Gaza 325,000 Palestinians from the Gaza Strip and the West Bank were Strip and the West Bank were displaced, many of them refugees displaced, many of them refugees originally displaced in 1948, the originally displaced in 1948, the majority sought refuge in majority sought refuge in neighboring Arab states.neighboring Arab states.

In 1967, 175,000 became refugees for 2nd time

2nd uprooting

Third DisplacementThird Displacement

• 312,000 Palestinians were working 312,000 Palestinians were working and living in Kuwait in 1990, but as a and living in Kuwait in 1990, but as a result of the Iraqi invasion of Kuwait result of the Iraqi invasion of Kuwait in 1991, the vast majority of those in 1991, the vast majority of those refugees were displaced and are still refugees were displaced and are still without secure residency. without secure residency.

• Only 30,000 Palestinians were living Only 30,000 Palestinians were living in Kuwait in 2000. in Kuwait in 2000. (Shmil.com)(Shmil.com)

ScatteredScattered everywhere everywhere

• The total number of Palestinian The total number of Palestinian refugees are around refugees are around 55 million million persons, persons, of which more than of which more than 44 million million are are registered with the United Nations registered with the United Nations Relief and Works Agency for Palestine Relief and Works Agency for Palestine Refugees in the Near East (UNRWA).Refugees in the Near East (UNRWA).

• No accurate figures are available for No accurate figures are available for Europe, the United States, Canada, Europe, the United States, Canada, Scandinavian countries, Scandinavian countries, Australia, Latin Australia, Latin America, Africa and South America.America, Africa and South America.

UNRWA: Reigestered RefugeesUNRWA: Reigestered RefugeesUNRWA 2005UNRWA 2005

CampCampss

In campsIn camps Not in campsNot in camps TotalTotal

JordanJordan 1010 281,211281,211 1,477,0631,477,063 1,780,7011,780,701

LebanonLebanon 1212 210,952 210,952 189,630189,630 400,582400,582

SyriaSyria 1010 112,882112,882 311,768311,768 424,650424,650

West BankWest Bank 1919 181,241181,241 506,301506,301 687,542687,542

GazaGaza 88 471,555471,555 506,301506,301 961,645961,645

TotalTotal 1,259,8131,259,813 2,995,3072,995,307 4,252,124,252,1200

2. mental health: 2. mental health: Transgenerational effectsTransgenerational effects • Since 1948, PalestiniansSince 1948, Palestinians

- - have experienced oppression, trauma, have experienced oppression, trauma, related socioeconomic and political related socioeconomic and political problems problems

- - Al Nakbah represents the loss of the Al Nakbah represents the loss of the homeland, the disintegration of society, the homeland, the disintegration of society, the frustration of national aspiration and the frustration of national aspiration and the beginning of a rapid process of destruction beginning of a rapid process of destruction of culture and community.of culture and community.

- The psychosocial consequences of `Al The psychosocial consequences of `Al Nakbah` were very dramatic and Nakbah` were very dramatic and devastating: people lost their land, devastating: people lost their land, livelihood, and political power.livelihood, and political power.

• Al Nakbah is a moment when the majority of Al Nakbah is a moment when the majority of Palestinians become homeless and stateless:Palestinians become homeless and stateless:

a state that is associated with a deep sense of a state that is associated with a deep sense of insecurity, fear, anger, hopeless and insecurity, fear, anger, hopeless and powerlesspowerless. .

In this situation, In this situation, the house key has become the the house key has become the symbolsymbol of the former home and of the return of the former home and of the return to it, to it, and the land has become the dream that and the land has become the dream that transmits from one generation to another. transmits from one generation to another.

Connecting Souls to Land

Culture and Identity: Struggle for Culture and Identity: Struggle for SurvivalSurvival

•First Intifada First Intifada 19871987

The cost of the Intifada has proved The cost of the Intifada has proved to be high and has affected all to be high and has affected all sectors of the Palestinian sectors of the Palestinian community. community. Men and women of Men and women of all ages suffered general stress, all ages suffered general stress, frustration and hopelessness frustration and hopelessness which inevitably activated new which inevitably activated new waves of violence and aggression waves of violence and aggression aimed at restoring people’s aimed at restoring people’s dignity and self-esteem.dignity and self-esteem. However, thousands have been However, thousands have been killed or left handicapped, and killed or left handicapped, and young adults are ready to young adults are ready to sacrifice everything -- including sacrifice everything -- including their life -- for the cause of their life -- for the cause of liberation of their land and for the liberation of their land and for the promise of life hereafter.promise of life hereafter.

The stalemate in the peaceThe stalemate in the peace

First recognition (Oslo First recognition (Oslo agreement in limbo)agreement in limbo)

• Raise the Palestinians expectationsRaise the Palestinians expectations• More restrictionsMore restrictions• Confiscation of landConfiscation of land• No tangible resultsNo tangible results• re-opened wounds created by the re-opened wounds created by the

loss of important family members loss of important family members and friends, causing more stressand friends, causing more stress

Second Intifada 2000Second Intifada 2000

• The conflict escalated further in which The conflict escalated further in which Israelis fight with lethal force and Israelis fight with lethal force and Palestinians resist with whatever they have.Palestinians resist with whatever they have.

• Shelling by Israeli helicopters and tanks, Shelling by Israeli helicopters and tanks, and bombings from fighter jets, have and bombings from fighter jets, have become a part of Palestinian daily life: on become a part of Palestinian daily life: on socioeconomic, political and family socioeconomic, political and family structures, and resurgence of Palestinian structures, and resurgence of Palestinian painful memories of being uprooted, being painful memories of being uprooted, being expelled from their villages to refugee expelled from their villages to refugee camps in the Gaza Strip etc.camps in the Gaza Strip etc.

Second Intifada 2000Second Intifada 2000

• 73,105 Palestinian houses have been 73,105 Palestinian houses have been demolished. Feeling of collectively demolished. Feeling of collectively punished.punished.

• In the last 5 years (from Sep. 2000 to In the last 5 years (from Sep. 2000 to

Sept.2005), over 4,000 Palestinians were Sept.2005), over 4,000 Palestinians were killed by the Israeli Army, among them killed by the Israeli Army, among them 766 children. An additional 45,486 766 children. An additional 45,486 Palestinians were injured, and 8,600 Palestinians were injured, and 8,600 individuals put in prison, among them individuals put in prison, among them 288 children. (Al-Jazeera, 2005).288 children. (Al-Jazeera, 2005).

• A survey showed that about 56,000 A survey showed that about 56,000 Palestinians had to change their place of Palestinians had to change their place of residence (PCBS, 2001)residence (PCBS, 2001)

Mental illness or Disease of Living\ Mental illness or Disease of Living\ Mental health situationMental health situation

• 88.5% of teenagers in Gaza had a close 88.5% of teenagers in Gaza had a close family member beaten by the Israeli family member beaten by the Israeli soldiers.soldiers.

• 55.7% of the sample witnessed, or knew 55.7% of the sample witnessed, or knew of the arrest of their close family of the arrest of their close family members, while 31.1% reported that members, while 31.1% reported that they had close relatives in prison. they had close relatives in prison.

• 95.0% of the teenagers said that Israeli 95.0% of the teenagers said that Israeli soldiers broke into their homes on at soldiers broke into their homes on at least one occasion.least one occasion.

Helou et al (1994)Helou et al (1994)

Helou et al (1994)Helou et al (1994)

• Significant increase in fear, anxiety, Significant increase in fear, anxiety, anger and hatred toward Israeli soldiers.anger and hatred toward Israeli soldiers.

• Ways of coping with fear included Ways of coping with fear included prayer and reading Koran, reading prayer and reading Koran, reading books, talking with elders, meeting books, talking with elders, meeting friends, and sleeping—although sleep friends, and sleeping—although sleep was associated with nightmares.was associated with nightmares.

• Coping with anger involved religious Coping with anger involved religious rituals such as prayer, making rituals such as prayer, making wuduwudu, , going to mosque and directing their going to mosque and directing their anger towards the IDF. The rest became anger towards the IDF. The rest became agitated and cried when they were agitated and cried when they were angry.angry.

Memories of LossMemories of Loss

House demolitions House demolitions Triggers Triggers

the uprootingthe uprooting

• Women who had their homes Women who had their homes demolished expressed more anxiety demolished expressed more anxiety and depressive symptoms than those and depressive symptoms than those who simply witnessed others’ homes who simply witnessed others’ homes being demolished.being demolished.

• Children whose homes were Children whose homes were demolished showed significantly demolished showed significantly more psychological symptoms.more psychological symptoms.

• Common symptoms were fear of the army, Common symptoms were fear of the army, diminished concentration, constant diminished concentration, constant weeping, and reexperiencing the weeping, and reexperiencing the traumatic event; the most common traumatic event; the most common symptoms in the witness group of children symptoms in the witness group of children were fear, irritability, easily provoked and were fear, irritability, easily provoked and having night terrors.having night terrors. Qouta et al 1997Qouta et al 1997

Thabet et al 1998Thabet et al 1998

• 21.5% of children in Gaza had anxiety 21.5% of children in Gaza had anxiety disorders. Girls reported higher levels disorders. Girls reported higher levels of anxiety than boys.of anxiety than boys.

• The most frequent abnormal The most frequent abnormal behaviours indicated by teachers were behaviours indicated by teachers were lying (10.5%), disobedience (10.5%) lying (10.5%), disobedience (10.5%) and bullying (11%). The most frequent and bullying (11%). The most frequent emotional symptoms were worries emotional symptoms were worries (17.3%), fears (11.8%), and feeling (17.3%), fears (11.8%), and feeling miserable (5.9%).miserable (5.9%).

Punamaki et al 1997Punamaki et al 1997

• Exposure to traumatic events increased Exposure to traumatic events increased children’s political activities regardless children’s political activities regardless of the quality of perceived parentingof the quality of perceived parenting

• Traumatic events increased the Traumatic events increased the children’s psychological adjustment children’s psychological adjustment problems regardless of the quality of problems regardless of the quality of perceived parentingperceived parenting

• Poor parenting can make children more Poor parenting can make children more vulnerable in traumatic conditions.vulnerable in traumatic conditions.

• Lifetime traumatic event was Lifetime traumatic event was reported by 36.8%. The most reported by 36.8%. The most frequent events reported were frequent events reported were imprisonment (16.1%) and torture imprisonment (16.1%) and torture 15.4%15.4%

Qouta et al 2001Qouta et al 2001

• The most recent research about The most recent research about PTSD among Palestinian children PTSD among Palestinian children between the ages of 6 to 16 found between the ages of 6 to 16 found that 58% of girls and 50% of boys that 58% of girls and 50% of boys had severe PTSD.had severe PTSD.

Qouta et al 2003Qouta et al 2003

Culture, Religion & Mental & Culture, Religion & Mental & HealthHealth• Arab society consists of Arab society consists of

complementary patterns of family complementary patterns of family structures. It emphasizes the structures. It emphasizes the collective over the individual.collective over the individual.

• The family, therefore, is important to The family, therefore, is important to harmonize interrelationship between harmonize interrelationship between the individual and group. One of the the individual and group. One of the most important parts of its affiliation most important parts of its affiliation is the is the hamula,hamula, which includes a which includes a number of generations in a part number of generations in a part lineal line that have a common lineal line that have a common ancestor.ancestor.

Culture, Religion & Mental & HealthCulture, Religion & Mental & Health

• Religion as a form of self-identity, Religion as a form of self-identity, hence a threat to their culture, hence a threat to their culture, encourages people to return to their encourages people to return to their religious roots in order to protect their religious roots in order to protect their culture. culture.

• Religion imparts explanatory Religion imparts explanatory mechanisms, including meaning, mechanisms, including meaning, purpose and specific aetiologies. purpose and specific aetiologies.

• Mental disorders and PossessionMental disorders and Possession

• Physical presentation of mental Physical presentation of mental disordersdisorders

Somatized Somatized SufferingSuffering

•Every thing is an effortEvery thing is an effort 44.7% 44.7%

•NervousnessNervousness 26.8%26.8%

•HopelessnessHopelessness 21.4% 21.4%

•Depressive moodDepressive mood 17.5% 17.5%

•Worrying too much Worrying too much 17.5%17.5%

Most common presented symptoms in Most common presented symptoms in primary care (primary care (Afana et al 2003)Afana et al 2003)

Women endorse more somatic Women endorse more somatic symptoms than mensymptoms than men

questions dealing with anxiety, questions dealing with anxiety, and somatic complaintsand somatic complaints

Headache Crying Easily

Cont., ResultsCont., Results

Men reported three symptoms Men reported three symptoms more frequently than women:more frequently than women:

insomniainsomnia

worries about the futureworries about the future

having no interest in thingshaving no interest in things

• The prevalence of anxiety and The prevalence of anxiety and depression symptoms was 73% and depression symptoms was 73% and higher among femaleshigher among females

• Refugees living in refugee camps Refugees living in refugee camps demonstrated a higher prevalence of demonstrated a higher prevalence of symptoms than those who were living in symptoms than those who were living in other settings.other settings.

In General, Refugee population constitutes around 75%;

distributed as follows:56% in 8 refugee camps

46% outside campsAfana et al 2003Afana et al 2003

being a parent is one of the most being a parent is one of the most complicated taskscomplicated tasks

• a quarter of women in Gaza were exposed a quarter of women in Gaza were exposed to domestic abuse at least once in their to domestic abuse at least once in their childhoodchildhood. .

• The changing roles for women (involved in The changing roles for women (involved in the political struggle)the political struggle)

• Many of these women whose husbands Many of these women whose husbands were arrested, imprisoned or killed in the were arrested, imprisoned or killed in the struggle, had to become the head of the struggle, had to become the head of the household.household.

Is there there a room for Is there there a room for optimism?optimism?

Community Intervention ModelCommunity Intervention Model

PhilosophyPhilosophy

• Enabling families to cope with the wide Enabling families to cope with the wide range of mental health problemsrange of mental health problems,, compounded by human rights violations, compounded by human rights violations, emphasizing a social support network as an emphasizing a social support network as an effective way to face mental ill-health effective way to face mental ill-health issuesissues

• The responsibility of the health The responsibility of the health professionals is to move from intra-personal professionals is to move from intra-personal focus to interpersonalfocus to interpersonal oriented careoriented care

Ground for optimismGround for optimism

• Mobilize local services in the Mobilize local services in the community to assist individuals in community to assist individuals in feeling that they are responsible feeling that they are responsible participants, contributing to their participants, contributing to their health.health.

• Building bridges for peace through Building bridges for peace through developing developing strategic partnerships with strategic partnerships with individuals and institutions concerned individuals and institutions concerned with justice, peace and respect for with justice, peace and respect for human rights.human rights.

In Protracted conflicts:In Protracted conflicts:What does Trauma mean?What does Trauma mean?

What conistitutes PTSD?What conistitutes PTSD?

Thank you for your listeningThank you for your listening