A Revised Biosocial Analysis to Social Suffering: Reframing a Paradigm on Mental Health for Palestinians Living Under Trauma
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A Revised Biosocial Analysis to Social Suffering: Reframing a Paradigm on Mental Health for
Palestinians Living Under Trauma
Enal Hindi
A Thesis in the Field of Biology
for the Degree of Master of Liberal Arts in Extension Studies
Harvard University
May 2018
Abstract
The goal of this research is to shed light on the chronic, systematic violence that the
Palestinians endure on a daily basis using a different approach from the Western model of PTSD and war trauma. The Palestinians have been under systematic oppression for more than six decades (Giacaman, 2004) and the study of mental health in the Palestinian population have become increasingly more popular by western organizations, using a western model that may not reflect all of the complex intricacies of daily oppression that includes systematic violence
(Giacaman, 2010, 2014). A biosocial approach might offer a better understanding of the trauma the Palestinians endure. Specifically, the biosocial approach uses an interdisciplinary analysis of history, ethnography, political violence, economic opportunities, and social factors all that takes into account economic duress, lack of infrastructure, daily harassments, violence, and the lack of freedom to move in one’s own country. Certain academics believe that minimizing the
Palestinian struggle to a humanitarian cause casts away the reality of political violence (Roy,
2014 and Giacaman 2011) that interferes with everyday life. Farmer suggests a ‘biosocial’ analysis that takes into account the political, biological, and social environment that affects the health and well-being of a society (Farmer, 2004) and that offers a community based approach with local knowledge of the social and political forces that contribute to the trauma.
A closer examination to better understand the trauma of the Palestinians is necessary as evidence that daily violence may have an effect on not only psychosocial symptoms, but also negative behaviors such as smoking and abuse, as well as a detrimental pattern of lifestyles including poor academic performances, poor outlook on life, and aggressive behaviors, and domestic abuse (Giacaman, 2011 and Yoke, 2014).
Acknowledgments
I want to thank Dr. James Morris for his help and encouragement throughout the process. I also want to thank the Palestinian Central Bureau of Statistics for providing such valuable data and for continuing to work on sensitive issues pertaining to the health and well-being of the
Palestinians. I also want to express sincerest gratitude to Dr. Jennifer Leaning for her guidance, kindness, support, and genuine desire for a prospect for peace, and shedding light to the vulnerable, the sick, and the oppressed. Your support was invaluable to my personal aspirations of continuing to study trauma in Palestinians as well as to my work on this thesis.
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Table of Contents
Acknowledgments…………….……………..………………………………………………… iv
List of Tables …………….…………………………………………….……………………… vii
List of Figures …………….…………………………………………………………………… ix
Chapter 1:
Introduction………………………………………………………………………………………1
Biosocial Analysis …………………………………...…………..………….……3
Limitations of Current PTSD Framework ………………...……..………….……5
Resilience ………………………………………..…...…………..………….……8
Background of the problem ……………………………………..………....……10
Injustice: Ongoing and Chronic ………...……………………………….………11
History of Health in Palestine………………………………….……...…....……14
Trauma and PTSD ……………………………………………….……...….……15
Social Suffering in Palestine …………………….……………………...….……17
Structural Violence …………………………………………….…….…….……18
Israeli Settlement are a Form of Structural Violence ….……….…………….….20
Israeli Wall is a Form of Structural Violence ……………………………...……23
Poverty is a Form of Structural Violence ……………………………….………28
Mental Health in Palestine ………………………………………………………31
Implications of Research ……………………………………………..…….……32
Chapter II:
Methods and Materials ……………………………..………………………………..…………34
Research Limitations ……………………………………………………………35
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Chapter III: Results …………………………….…………………………………...... ………41
Chapter IV: Discussion ……………………………….……………..……………...…...………70
References ……………………………….……………..……………...…………………...……78
Appendices:
Appendix 1: Definition of Terms ………………………………………..………82
Appendix 2: Map of the Middle East ……………………..………..……………84
Appendix 3: Map of Palestine ……………………..……………….……………85
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List of Tables
Table 1a Interview Results and Response Rates for Victimization Survey, 2012……..... 37
Table 1b Interview Results and Response Rates for Victimization Survey, 2012…..……37
Table 2 Interview Results and Response Rates, Victimization Survey, 2016……...……38
Table 3a Interview Results and Response Rates for Domestic Violence Survey, 2006…..38
Table 3b Response Rates for Domestic Violence Survey, 2006 ……………….…………38
Table 4a Interview Results and Response Rates, Violence Survey 2011……...……….…39
Table 4b Interview Results and Response Rates, Violence Survey 2011……...... ……39
Table 5a Interview Results and Response Rates, Palestinian Youth Survey 2015...…...…39
Table 5b Interview Results and Response Rates, Palestinian Youth Survey 2015………..39
Table 6 Crime and Violence in the Palestinian Territory, by region in 2008………...….41
Table 7 Crime and Violence in the Palestinian Territory, by region in 2012………...….42
Table 8 Distribution of type of Crime and Violence in the Palestinian Territory, by region
in 2008……………………………………………………………………...... ….42
Table 9 Crime and Violence in the Palestinian Territory, by region in 2012…………….43
Table 10 Crime and Violence in the Palestinian Territory, by region in 2016……...………43
Table 11 Location of Crime/Violence in Palestinian Territory, 2008……………...……..44
Table 12 Location of Crime/Violence in Palestinian Territory, 2012…………………….44
Table 13 Location of Crime/Violence in Palestinian Territory, 2016…………………….45
Table14 Percentage of Palestinian households exposed to violence from Israeli
Occupation Forces, 2010…………………………………………………..…….45
Table15 Married Women Exposed to Violence from Husband, 2005…………..………..48
Table16 Married Women Exposed to Violence from Husband, 2011……………………49
Table 17 Number of Injured Children reported to UNICEF from 2010-2014………..……49
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Table 18 Number of Children Martyred by Region, Year and Cause 2010-2014…….…..53
Table 19 Number of Detainees According to Type of Violence and Maltreatment,
2013, 2014 ……………...... …………..…………………………………………54
Table 20 Percentage of Children in Poverty, by region, in 2010…………….....…………54
Table 21 Distribution of Schools in Area C, 2012………………...………………………58
Table 22 Percentage of Students in Public School in Area C Experiencing Psychological or
Social Problems, 2011-2012……………………………………………………..59
Table 23 Percentage of Palestinian Children (aged 5-17 years) who suffer from
psychological attitude by type and gender, 2004……...………………………62-3
Table 24 Percentage of Children (aged 5-17 years) who suffer from behavioral issues by
type and gender, 2004………….………………………………………………64-5
Table 25 Percentage of Children (aged 5-17 years) who were exposed to certain acts of
violence, 2004 ……………………………………...…………………………..66
Table 26 Percentage of Children who have received psychological therapy in Palestine,
2004 ………………………………………………….…………………………..66
Table 27 Percentage Distribution of Children (aged 5-17 years) by ability to meet costs of
therapy services, 2004………………………………...………………………….67
Table 28 Main Reasons why therapeutic services have stopped……………………...…..68
Table 29 Issues across various aspects of Palestinian children’s’ lives (aged 5-17 years),
2004 ……………………………………………………………………………..69
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List of Figures
Figure 1 Percentage of Children (12-17 years) who were exposed to physical violence
from occupation forces 2011 by gender and region…………………………….46
Figure 2 Number of Children forcibly displaced in Area C and East Jerusalem because of
House Demolition by Israeli Occupation Forces, 2009-2012…………...……….47
Figure 3 Number of Children Forcibly Displaced because of House Demolition by Israeli
Occupation Forces, 2009 -2014 ………………………...……………………….47
Figure 4 Prevalence of Stunting/Malnutrition among Children under five years by region
2000-2010……………………………………………………………………..…50
Figure 5 Prevalence of underweight among Children under five years by region 2000-
2010………………………………………………………………………………51
Figure 6 Percentage of Children under five who had diarrhea in Palestine by region in
2006 and 2010……………………………………………………………………51
Figure 7 Percentage of Individuals (15-17 years) who smoke by region, 2015………….52
Figure 8 Number of Martyr and Wounded Children 2010-2014 …………...……………53
Figure 9 Number of Cases of Detention of Children by Age Group and year,
2008-2014………………………………………………………………………..54
Figure 10 Food Insecurity in Palestine by Region, 2009-2012 (Percentage) ………….…..55
Figure 11 Gap between Poverty Rates and Between percentage of individuals who Suffer
from a Lack of Food Security and are Dependent on Aid in 2011………………56
Figure 12 Percentage of Poor Children by Region, 2009-2011 ……………...……………56
Figure 13 Number of Poor Children by Region, 2009-2011 ……………...……………….57
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Figure 14 Drop-Out Rates in Schools in West Bank and Area C Schools, 2009/2010 and
2010/2011………………..………………………………………………………57
Figure 15 Percentage of working Children 10-17 years who were not in attendance in
school, by region and age, 2009 and 2012 ………………………………………58
Figure 16 Number of Children Charged in the West Bank and admitted to Dar Al Amal by
Age and Enrollment in Education, 2012 …………………………..…………….59
Figure 17 Number of Children Admitted to Al-Amal Rehabilitation Center for Observation
and Social Care in the West Bank 2009-2014………………..………………….60
Figure 18 Number of Children in Conflict with the Law by Type of Offense,
2009-2012………………………………………………………………………..60
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Chapter I
Introduction
“By reducing, whether in clinical terminology or in common language, the link between what happened and what was experienced to a set of symptoms, or even of predefined representations (the fact of being traumatized), it obscures the diversity and complexity of experiences. It conceals the way in which experiences take on multiple meanings in a collective history, in a personal life story, in a lived moment.”- The Empire of Trauma, Fassin D, Rechtman R. 2007
The long-term effects of war and occupation on the Palestinian children have recently gained attention in the public health global arena. Rita Giacaman and colleagues at Birzeit
University in Palestine have been researching the effects of chronic trauma on Palestinian children for over a decade. Giacaman denounces the effects of an imposed Western approach to mental health in Palestine, as she recognizes it ignores the cultural context in which Palestinians live in (Giacaman et al., 2008). The Western led discourse about mental health is centered on
PTSD and assumes the fact that the trauma that occurred was confined to a single episode, or was of limited duration. Many NGOs and global health interventions led by this Western mentality treat mental health in Palestine according to the guidelines and backdrop of a Western definition of PTSD, depression, and other mental health issues. There are many factors affecting the mental health of the Palestinians, and the current framework of addressing PTSD and mental health becomes too narrow for the unique ongoing, chronic trauma of the Palestinian people. The current model does not incorporate the context of ongoing militarization, oppression, and violence and assumes that one traumatic episode is the root cause of the PTSD symptomology.
The ongoing trauma of the Palestinian people is interwoven with poverty, oppression, chronic exposure to political violence, bombings, restriction of movements, and daily interrogation and humiliation, all from the Occupation forces. Indeed, the role of poverty, structural violence, collective punishment all contribute to the mental health of the Palestinians
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(Awad et al, 2009). But how does a society recover from an ongoing, chronic trauma? How do we address the mental health of children growing up in oppression and in warlike conditions for all of their lives? How do you help children with ongoing trauma, who will continue to live under oppression and trauma for an indefinite period, heal over time, and maybe even lead a functional life? The current framework serves too narrow a focus, and may not help in the situation of ongoing trauma, as it lacks the effects of social suffering, and structural violence that is embedded in the lives of the Palestinians. When a community itself is so fragmented, broken, and under ongoing oppression for an indefinite period of time, how can a solution apply that is inherently based on a finite number of traumatic experiences and does not take all of the environmental, cultural, and systematic oppressive restrictions into consideration?
Indeed, a revised framework, such as the biosocial approach, that can encompass the sociopolitical factors contributing to the suffering of the Palestinians is necessary, not only for the Palestinians, but for the many people around the world who live under constant oppression, violence, and systematic sets of laws that are inherently unfair and repressive. This paradigm uses a biosocial analysis combined with what economist and scholar on the Palestinian-Israeli conflict Sara Roy calls a “paradigmatic shift” of the Occupation away from the ‘humanitarian lens’ (Roy, 2012) may be necessary to address the mental health of the Palestinian youth. Roy argues, this ‘paradigmatic shift’ is one that assesses the suffering of the Palestinians in a new lens, one that is not humanitarian in nature, but actually acknowledges the political violence that is embedded in the Palestinian society (Roy, 2012). The biosocial analysis presented in the next few paragraphs intertwines the political and social suffering of the Palestinian people. Rita
Giacaman argues that the Western led discourse on therapy is not enough for the Palestinians and that this therapy approach completely ignores the political problem. Giacaman argues that the
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Western led therapy approach assumes the problem is a single episode and alludes that justice is the answer to chronic trauma. Roy argues that the problem when addressing the Palestinian suffering is that the international community has gradually turned the political conflict, a deeply unjust system of systemic violence, into a humanitarian crisis – always addressing the immediate basic needs of the Palestinians, such as food and water, rendering them almost completely dependent on international aid just to survive (World Bank, 2011) and ignoring the underlying cause of the problem – injustice (Roy, 2004, 2012).
One of the limitations of the current framework of a Western led discourse on addressing
PTSD in a humanitarian crisis is sustainability, in which many well-intended NGOs or groups intervene to help the Palestinians deal with their mental health trauma, but then leave as soon as funding ends. The Palestinian people have increasingly become dependent on international aid, which comes to the rescue of immediate basic needs for survival, but reduces their mental and emotional well-being as disposable – treatable if and when international aid and funding is available, and with a model that is typically applied to soldiers and rape survivors (Herman,
1992).
Biosocial Analysis – A Concept for a Deeper Understanding of the Suffering of the
Palestinians
A biosocial approach is an interdisciplinary approach that uses history, anthropology, ethnography, the political economy, and social factors to understand the suffering – and burden of that suffering – that a group of people endure. This concept, as Dr. Paul Farmer states,
“resocializes global health with various disciplines” (Farmer et al., 2013) to not only better understand the suffering of a society, but to also help them heal using a more universal understanding of their suffering. Through a biosocial lens, the Palestinian suffering can be
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conceptualized more holistically, so that potentially, interventions can account for all the factors affecting the mental health of the Palestinians, including the role of poverty, structural violence, and social suffering, as well as to respond to the limitation of sustainability in the current framework of mental health therapy. The biosocial lens offers the opportunity to explore the impact of social barriers, political and economic factors, and patterns of violence through the study of sociology, the history of the Palestinian suffering within the political context. These layers of inequities are explored in this chapter, beginning with structural violence.
All of these factors – economic, social, political, abuse, poverty, and cultural norms - must be considered in order to fully understand and address the mental health of Palestinians.
Social suffering and structural violence are critical concepts to people living in warlike conditions indefinitely, as it affects how they live their everyday lives. A biosocial lens accounts for political conflict, injustice, and how the international community treats and responds to the crisis, main stressors in the life of the oppressed and not just temporary occurrences. A society suffering from daily harassments, collective punishments and lack of freedom requires a more holistic approach, such as the biosocial approach, to addressing their mental health, as the current approach imposes an unfairly narrow view into the reality of their lives. Current therapy focuses on a diagnosis from a traumatic event, but if that very traumatic event is ongoing, there needs to be an ‘ongoing’ approach as well. A biosocial approach intertwines the reality of biological and social factors in health, and as Paul E. Farmer suggests, biological processes and social processes affect each other and thereby influence health and disease.
Using this biosocial approach elucidates as a crucial step into understanding the suffering of the Palestinians may be more comprehensive in understanding the mental health of the
Palestinians, and possibly addressing it. A biosocial approach applies more than one lens to the
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mental health of a person, and perhaps can shed light on more than one factor that led to the mental health state of the Palestinians. Rather than relying solely on biological symptoms associated with trauma, the biosocial concept considers all the social aspects affecting the mental health of the Palestinians, including political violence. By acknowledging that such factors – as political violence – play an important role in the health and well-being of the Palestinians, this biosocial concept does not ignore the continuity of the trauma. Violence and oppression should be treated as part of the mental health problem and not a footnote, taking into account every single restrictive measure that is taken as part of the daily lives of the Palestinians. Giving
Palestinian youth tools on how to cope with ongoing violence may be more effective than a diagnosis of PTSD and the narrow treatment that accompanies it. The biosocial approach considers violence and oppression as root causes of mental health and can shed light on areas that have been previously ignored, such as the systemic violence Palestinian youth face daily. By shedding light on these previously ignored areas, the potential for addressing, or even healing, the mental health issues in Palestinian youth may be more promising than a short-term diagnosis and treatment plan based on the current model of therapy.
Limitations of the Current PTSD Framework
From 1989-2006, at least 20 research studies were published in international academic journals on the effect that the violence, including bombings, physical harassment at checkpoints, beatings, and restriction on movement from the Israeli military occupation had on Palestinian children (Yoke Rabaia et al., 2010). As the Military Occupation intensified, the international community grew more and more interested in the impacts of violence on Palestinian children.
The focus of the international interventions was on pathological symptoms, such as PTSD, depression and other mental health disorders, that Rabaia argues “creates an impression that
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young Palestinians exposed to violence had become ‘mentally ill’, and thus needed treatment1”
(Yoke Rabaia et al. 2014). Although those who are mentally ill definitely deserve the right to treatment, the Western model of mental illness and treatments is usually confined to a clinical setting and may be impractical to measure prevalence in a population (Horwitz and Wakefield,
2007). Psychiatrists who have treated Southeast Asian refugees have made clear the need for an
‘expanded concept’ of PTSD that takes into account their experiences (Herman, 1992).
Palestinian youth may display symptoms that are associated with PTSD, anxiety, depression, and other diagnoses. Rabaia et al suggest that sadness and fear are a normal reaction to the Palestinians’ experience, and may ease with time and with family and community support
(Yoke Rabaia et al. 2014). Moreover, Rabaia and colleagues argue there is a difference between patients being seen by medical professionals and diagnosed for their mental ailments and people counted in surveys, as surveys conducted in war-torn areas tend to have low reliability due to low turnout rates, and bias in self-reporting. A Gaza based study of children who lost their homes found that 54% had severe PTSD scores and 33.5% ranked as moderate (Qouta et al., 2003). In
“The Loss of Sadness” (2007), Howitz and Wakefield explain that the current model of assessing
PTSD is based on the use of the Diagnostic and Statistical Manual of Mental Disorders to help diagnose and treat mental health, but argue that use of this Western based model in war-torn countries can lead to “unrealistically high statistical rates of depressive disorders, which can do very little for an impoverished community facing continuous warlike conditions.” (Howitz and
Wakefield, 2007). Farmer’s main criticism of global health practitioners is that they mainly focus
1 Yoke Rabaia, Mahasin F. Saleh, Rita Giacaman. (2014) Sick or Sad? Supporting Palestinian Children Living in Conditions of Chronic Political Violence, Children and Society, 28:172-181.
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on immediate action and do not take into account the history and social factors that continue to affect their lives (Farmer, 2013).
Renowned psychologist Arthur Klienman is critical of using the DSM manual in populations “other than those for which they were developed, mainly European and American populations” (Farmer, 2013). Kleinman recognizes the limited use of the PTSD criteria in the
DSM across diverse cultural and social contexts. He and Farmer agree that such the DSM is shaped by the political and social structures of the time, for example, until 1973, the DSM maintained that homosexuality was a psychiatric disease (Farmer, 2013). Indeed, social norms at the time shaped this medical diagnosis. This criticism is important as it highlights how medical care and the political environment of a society are intertwined. The DSM has been revised multiple times, each time with a deeper understanding of the signs and symptoms of mental disorders. However, these were in the context of American and European populations, and not in societies disrupted by violence, war, or deep poverty. Ethan Waters, author of Crazy Like Us:
The Globalization of the American Psyche, emphasizes Kleinman’s critique of using a Western method to assess something as sensitive as mental health without full recognition of traditions, cultures, and local societal norms (Waters, 2010). He asserts that to achieve effective and
“culturally appropriate therapeutic adaptation, clinical medicine must be integrated with local knowledge and practice concerning illness and health” (Kleinman, 1998). Dr. Kleinman uses a motto to best summarize the study of mental health across cultures, as he says his objective is to
“learn from those we seek to serve.” (Farmer, 2013).
The current approach not only assumes the trauma was a single, or at least a finite episodic period, but also assumes that the treatment is just as short-lived, with a start and end. It doesn’t address the uniqueness of living under occupation for many years, as 3 generations have
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so far lived under occupation. This means that the formative years of Palestinian youth and adolescents are defined by their experiences of living in warlike conditions. In reality, the core cause of their suffering cannot be realistically solved within the normal provisions of treatments for mental disorders. Drawing on an understanding of mental health through history, ethnography, political economy, and structural forces, can offer an effective way of addressing the mental health of those in settings of violence, such as the Palestinians.
Resilience
Giacaman places emphasis on the “resilience” of the Palestinian people, invoking that this extremely important concept, both culturally and pragmatically, is often overlooked during a
Western imposed intervention for mental health. Giacaman and Arafat (2003) demonstrate that even though Palestinian youth express sadness, fear, and other symptoms, they have a general
‘optimistic view’ on their future, and thus these authors classify this as an enduring resilience. In one of her studies, conducting a quantitative survey among Palestinian students in 10th and 11th grades, Giacaman et al. highlights “small acts of resilience in simple daily activities, such as going to school in the face of checkpoints” (Rabaia et al., 2010). Although Giacaman et al recognize this current model is not as effective in a society such as Palestine, they urge that interventions should focus on ‘strengthening resilience’ in a community.
The authors Giacaman and Rabaia recognize that social suffering is not an illness that needs to be cured, but their approach on resilience does not encompass all of the biological and social dimensions that affect the Palestinian youth living under oppression. The social dimensions, including poverty, restrictions on movement from checkpoints and the Security
Wall, harassments, including physical and verbal, are explained in this chapter. Understanding the root cause of one’s suffering may better help with the coping of it and living a fulfilled life,
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and perhaps, and the ongoing suffering in the Palestinians’ lives is a multitude of complexity that requires more than psychotherapy.
Rabaia et al go on to further delineate that PTSD was initially constructed to diagnose and treat soldiers returning from war, and question whether or not this Western concept is appropriate for a society living in systematic and ongoing violence. Derek Summerfield argues that “PTSD is a Western construct that imposed a medical model on the suffering of people in war situations, thus encouraging the emergence of a trauma industry that could be exported to any culture.” (Summerfield et al., 2011) This Western construct does not capture the suffering experienced on a daily basis throughout the entire lives of the Palestinian. It is an extreme perspective, presenting mental health as a single-dimensional concept resulting from the single trauma. Palestinians live in systematic suffering throughout their entire lives, their suffering a continuum of injustices, trauma, and violence.
Cultural and social factors are often seen as secondary influences and not fundamental causes of suffering. Some acknowledgment is not enough, as the core of the problem is not inherently biological or medical, but a confluence of social suffering and structural violence.
Another limitation to the current model includes the lack of sustainability, as it is completely dependent on funding from external sources, countries or NGO’s. A biosocial lens may perhaps tap into a more sustainable approach to addressing mental health issues, since understanding suffering on a deeper level through a biosocial lens may draw upon certain local experts and resources that are more culturally appropriate for addressing mental health issues in Palestine.
There is no just or viable solution to address the mass suffering of the Palestinian people.
Nevertheless, a biosocial approach can provide a more thorough insight into the impact of
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structural violence and social suffering, to help the Palestinian youth cope with it on a real, day to day level that makes sense for a trauma that is chronic in nature.
Background of the Problem
The Israeli Occupation
Under 64 years of Israeli Occupation, the Palestinian society has found it increasingly difficult to thrive as a self-determined state. Israel has taken a political form of control to regulate all aspects of life. So much of their control strategies are embedded within the
Palestinian life-style that, that to the Palestinian society itself, it appears almost invisible. In conjunction of using excessive force to regulate the Palestinian society, Israel, the occupying power, has developed a collective form of punishment for its occupied land, Palestine.
Collective punishment is a clear violation of International Law2. The 4th Geneva Convention of
1949 requires that the “occupying power ensures respect and protects the fundamental rights of the occupied territory3”. Israel has developed this form of collective punishment to directly ensure that control over the population is strictly enforceable. In the process, it is argued by many, (Khalidi, 2006 and Halper, 2012 and Hever, 2012) that the violation of these very fundamental rights makes recovery to a self-determined state is almost implausible and extremely demanding and arduous. Some of these forms of collective punishment include the construction of the Wall, establishing checkpoints throughout the Palestinian territory, building
Jewish-only settlements, and inflicting violence on civilians (B’Tselem, 2017), including daily
2 Palestine Monitor, Health, Development, Information and Policy Institute. 2011.
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harassments at checkpoints, night raids destructing homes, and beatings, (Shehadeh, 2008). The first Intifada, or Palestinian Uprising established that the majority of the Palestinians resisted the laws of occupation through nonmilitary confrontation, thus placing them in the noncombatant category. “Most of the directives issued by the Intifada Leadership advocated civil disobedience and called for action of a nonviolent character”4. Palestinians engaged in large public demonstrations, labor strikes, commercial shutdowns, yet the Israeli Defense Forces (IDF) responded with firing rubber bullets and live ammunition. For Palestinians, the stone was the symbol of resistance and weapon against the Israeli military tanks, not guns or bombs. Israel violated the noncombatant immunity principle, as statistics reveal 20 Palestinian security personnel were killed between 1987 and 2003, and about 3400 civilians were killed during the same period5.
Injustice: Ongoing and Chronic
The problem with occupation is that a country, in this case Israel, imposes a unilateral administrative system and intervenes on the occupied population, Palestine, with its laws and policies6. These laws, and policies, as will be described in this paper, are discriminatory, unequal acts of structural violence that threaten the lives and wellbeing of the Palestinians. There exists an ethical as well as a political challenge in the arrangement of occupation. Occupations fall between interstate war and domestic civil unrest – both military and police power are necessary7.
Unlike conventional warfare, occupation is unique because of the very fact that a foreign country is present in the country and is enforcing its laws on an occupied population. The inherent
4 Mark Tessler, A History of the Israeli–Palestinian Conflict (Bloomington: Indiana University Press, 1994), p. 691. 5 B’Tselem, ‘Total Casualties Since Dec 9, 1987’, available at: www.btselem.org/English/Statistics/ Total_Casualties.asp 6 Meron Benvenisti, The West Bank Data Project: A Survey of Israel’s Policies (Washington DC: American Enterprise Institute, 1984), p. 37. 7 Eyal Benvenisti, The International Law of Occupation (Princeton, NJ: Princeton University Press, 1993), p. 4. 11
imbalance of power of the occupier, Israel, and Occupied Palestine presents ethical issues of control and power that are inherent only to occupation. There are political challenges in occupation that need to be addressed. Israeli occupation of Palestine, it is argued here, has taken a form of aggression, a violation of the residents’ rights to live peacefully and fulfill their lives in prosperity. Occupation is a means of administrative control, where the occupier controls, through a system, the laws of the occupied. This is unique because the occupied people, the civilians, must live their lives through laws and projects imposed by a foreign institution. Examples of these projects that the Israeli occupation created are the settlements, the Separation Wall, and restrictions on movements. These projects are hostile and detrimental to the occupied
Palestinians’ lives. In conventional warfare, once the harm is rectified, the hostilities should cease, but in occupation, the very nature of it as an ongoing structure (under IHL a temporary legal structure) has embedded latent hostility. Under IHL, the aim of occupation is to help a country to return to its normal, pre-war structure and system. The Israeli Occupation of Palestine does not follow the intent or law as defined in the Fourth Geneva Convention (OCHA, 2010 and
WHO, 2011 and World Bank, 2010).
The systematic restrictions are a form of threat and violence to the occupied Palestinians.
The suffering of the Palestinians is not just endured through gun violence, but also through bureaucratic force and the administrating of unilateral laws to the occupied population. This is what makes Israeli occupation of Palestine an ongoing struggle and this is precisely what makes the Palestinian’s trauma ongoing, and chronic. The current PTSD model does not capture all of the laws and restrictions that affect the overall well-being of Palestinians.
Under occupation, the classification of the occupied people of Palestine as civilians or combatants is ambiguous. The international community perpetuates the ambiguity of their status
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– sometimes they are labeled as terrorists, other times as civilians, so this gives Israel latitude to treat the Palestinians however they want – as if they are always combatants. Israel imposes the policy of settlements as collective punishment by turning demolishing Palestinians’ homes, uprooting their trees and farms, leaving them homeless. This further intensifies their traumatic experience. Structural violence is embedded in a complex way in an occupied society. These laws become the social norms embedded in society, and administered through Israel’s occupation. Everything, every aspect of the Palestinians’ lives becomes governed by the Israeli forces.
The problem with occupation is that the occupied population is thrown into an unsustainable peace; they do not have the political power to reach their peace with Israel’s administration due to the very laws that Israel imposes on them. Occupation has a snowball effect, the more powerful the occupier gets, the more resistant the occupied get, and then the more brutal projects and laws the occupier imposes, and then the more resistant, and sometimes violent the occupied gets. Soon, the occupier hinges ongoing control through resort to increasingly illegal projects. Over time, these actions become impossible and unrealistic to reverse. It is a cyclic structure of violence that gives birth to trauma. In this way, structural violence created by the long-lasting Israeli occupation becomes a war against civilians, punishing them in laws that govern their daily lives.
This is another unique aspect of occupation – longevity. Israel has been Occupying
Palestine for half a century, with no plan for sovereignty for the Palestinian people. From the beginning, many Palestinians and many members of the international community, were operating under the belief that the occupation will end, and that Israel’s expansion into the Palestinian
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territories would stop (Roy, 2012). Roy asks if the Occupation is indefinite with no end in sight, is the humanitarian aid also projected to continue forever?
The proposed revised framework necessitates a balance of security and humanitarian provisions that allow the Palestinians to voice their trauma, and their experiences.
History of Health in Palestine:
The health care system in Palestine is that of a vulnerable one, and thus requires much international aid to all parts of the health care system, including mental health. In order to understand its structure, weaknesses, and services, one must examine the history of health care in
Palestine. This attempt, although minor in magnitude, will serve as a basis for the history of health in Palestine.
The natural and political circumstances stem from before the creation of Israel. When
Palestine was still part of the Ottoman Empire in the nineteenth century, the small area with swamps and desserts was highly conducive to several pathogens and made way for many infectious diseases8. Muslim pilgrims’ traveling to Mecca stopped in Palestine during their travel and introduced new diseases to Palestine’s inhabitants. Epidemics, in particular malaria, struck
Palestine forcefully9. As diseases flourished in this small country, political chaos from the beginning of Palestine’s history set the grounds for its vulnerable health care system today.
The fall of the Ottoman Empire by the end of World War I left Palestine in the hands of the newly founded League of Nations, granting Palestine as a mandate entity to Great Britain10.
As effectively a colony of Great Britain, Palestine was expected to pay its own way financially
8 Borowy I, Davidovitch N, Health in Palestine and the Middle Easter Context. Dynamis. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 315-327. 9 Ibid. 10 Ibid. 14
and their dues to Great Britain11. This created weak grounds to build any socio-economic system for the Palestinians, and thus, the Palestinians remained as third world under Great Britain, never encountering the appropriate economic or social means of flourishing. The rise of a dynamic
Jewish state quickly created two identities, two social classes, and two communities, juxtaposing each other in prosperity and international attention. Although traditional medicine thrived in
Palestine, the Palestinians were completely dependent on the British public health system12. The
Jewish community had access to private organizations that were willing to sponsor medical institutions13. Furthermore, the Jewish health care system catered overwhelmingly to Jewish community, leaving the Palestinians only supported by the British public health care system.
This division clearly impacted the quality of health given in each society, and clearly created a social class amongst the two and thus affected mortality and morbidity rates. The health systems of the Palestinians and the Jewish community grew in completely different directions, with
Palestine becoming more and more reliant on international aid while the Jewish community stabilized their health care system through private donors and private medical institutions14. health care system, which became the foundation for the new health care system today.
Trauma and PTSD:
Dr. Judith Herman, distinguished psychiatrist and expert on trauma, has studied PTSD symptomology in rape and incest survivors and in combat soldiers. Herman distinguishes between one traumatic episode and a victim undergoing chronic abuse, over years, offering a
‘spectrum of human adaptation’ to traumatic events. Through her years of research and talking and listening deeply to survivors of prolonged, repeated abuse, Herman proposed a new
11 Ibid. 12 Ibid. 13 Ibid. 14 Ibid. 15
diagnostic name to psychological orders that manifest from more complicated effects of prolonged abuse and tried to integrate a clinical and social perspective to understand trauma.
Studies of war and natural disasters reveal a “dose-response curve”, in which the greater the exposure to trauma, the greater the percentage of the population with symptoms of PTSD
(Herman, 1992, p. 57.) However, in the case of the Palestinians, their exposure to trauma has been ongoing, with more and more restrictive policies in place, diminishing their freedom and livelihood.
Herman emphasizes that part of the critical stages of recovery are establishing “safety, reconstructing the trauma story, and restoring the connection between survivors and their community” (Herman, 1992. p. 3-4). Palestinians are stuck between being an occupied people living under restrictive administration and finding a Palestinian state for their own – they lack the safety that is necessary for recovery, according to Herman. Giacaman echoes the importance of safety, as she recognizes that the lack of safety and human security is the biggest impediment to recovery. Giacaman further investigated human security in the Palestinian community and reveals through a cross-sectional survey that levels of high human insecurity are associated with loss, destruction, and war related factors (Giacaman, 2011). Her results reveal that displacements, poverty, and other forms of the oppressive regime yield high human insecurity
(Giacaman, 2011).
Herman argues that the study of psychological trauma depends on the support of a political movement (Herman, 1992 p. 9). She describes two examples of trauma being supported by a political movement: the study of war trauma amongst combat soldiers being met with the antiwar movement and the study of trauma by rape and incest survivors being met by the women’s movement (Herman, 1992). Thus, she argues that a political movement is necessary to
16
address such trauma, and the absence of a political movement might lead to normalizing the trauma, a concept all too familiar in the case of the Palestinians’ trauma being normalized due to a normalized presence of the occupation. In response to both of these movements, funding for research for understanding these victims’ trauma on a deeper level was created. The study of these traumas even offered a new language for understanding them – a new language that better depicted the tragedies suffered, and with that, hysteria in women was shut down as a result of the women’s movement. For centuries, the experiences of women’s trauma were devalued, but finally, after collective movement, their voices, feelings, and traumatic experiences were beginning to be heard, and a movement towards recovery has started (Herman, 1992).
Social Suffering in Palestine:
Social suffering has been part of the Palestinian narrative since around 1948, at the creation of Israel, during the Nakba, or great catastrophe. It is indeed the social structure – determined as economic, political, legal, religious, and cultural – that hinders individuals and groups of society from achieving their full potential15. Thus, structural violence is a systemic way of understanding the social suffering of the Palestinian people. Their suffering comes directly from political and economic, legal and even religious sources. Although social suffering in Palestine refers to aspects including their economy, well-being, and politics; harm to their health is at the heart of their suffering and solicits ethnographical and anthropological approaches to understand their suffering on a deeper level. Social and health problems are indeed connected, and particularly in structural violence, where social and health problems are
15 Farmer P, On Suffering and Structural Violence Partner to the Poor. Berkeley: University of California Press. 2010; Chapter 16: 40. 17
purposefully worsened16. Professor Paul Farmer emphasizes the cycle between suffering and inequality, and suffering and poverty17. The inequality that the Palestinians are treated with due to living under Military Occupation impairs any potential for growth or achieving their full potential. Galtung argues that the arrangements of social structure are “embedded in the political and economic organization of our social world”, in the case of Palestine, their social structure is built on the political organization and intensified by bureaucratic indifferences18. Galtung further argues that structural violence is an “avoidable impairment of fundamental human needs or…the impairment of human life, which lowers the actual degree to which someone is able to meet their needs below that which would otherwise be possible.19” The social suffering of the Palestinians was not limited to the refugees, but to every individual in living in the Palestinian territory, as each Palestinian was required to pass through a checkpoint or come across an earth mound or blockade systemically placed as part of the Military Occupation to get to school, work, a clinic, or even family.
Social suffering is the result of political, economic, institutional and social forces that perpetrate violence in various forms, that cause pain and suffering to individuals (Farmer, 2013).
The concept of social suffering addresses the intersection of medical and social problems, including substance abuse, depression, violence and suicide (Farmer, 2013).
Structural Violence Structural violence, a phrase devised by Johan Galtung in the 1960s as various social structures that prevent anyone from ‘reaching their full potential’ (Galtung, 1969), and that is rooted in established social structures and is pervasive amongst society, ‘normalized by stable
16 Ibid. 17 Ibid. 18 Galtung J, Violence, Peace and Peace Research. J Peace Research. 1969; 6:167-191. 19 Ibid. 18
institutions’ (Galtung, 1969). In the case of the Palestinians, the Israeli Occupation is the stable institution that is gradually encroaching into the Palestinians’ lives, both by means of military presence and land confiscation, and imposing restricting, unjust laws that affect how the
Palestinians ‘reach their full potential’ as civilians. Structural violence is normalized to the extent that these structures may seem part of life, however, Farmer links the idea of structural violence very closely to social injustice and even as part of oppression as a whole, (Farmer,
2006) – structural violence is the oppressive system that bleeds into all forms of life, including education, health, social, political, and even cultural. Roy might agree with Galtung with how the
Palestinians have and are suffering a structural, systematic form of violence, that is normalized, as she argues, by the international community through its complicity and even through continuous aid. So as long as there is aid to address the immediate concerns of the Palestinians,
Roy argues, we are ignoring the real problem: inherent, pervasive injustice (Roy, 2012).
Normalization of the occupation is a grave mistake, as Roy explains, so as long as Israel is thriving as a country, and the Palestinians are rescued with food and water, the occupation will continue to exist, and even become the norm. Although Farmer and Galtung are careful to incorporate all forms of violence, not just the physical form, in the Palestinian situation, structural violence is present ubiquitously in all forms – physical, social, economical, and cultural (Farmer, 2006) all interfering with the quality of life and wellbeing of the Palestinians.
Roy goes further to say that the economic restrictions imposed by the Israeli government on the
Palestinians are by far the single most detrimental form of structural violence, as they prevent them from thriving in any aspect of life, cultivating poverty, unemployment, a broken society largely dependent on foreign aid just to survive. Farmer admits that many clinicians are not trained to understand such forces that interfere with the wellbeing of those affected by such
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systematic oppression (Farmer, 2006). Taken all together, these are the issues that must be acknowledged and understood in order to understand how the Israeli occupation affects the mental health and well-being of the Palestinians, how their behaviors change, their psychological symptoms as a result of all of the systematic oppression. I will use data from the Palestinian
Central Bureau of Statistics to analyze trends in behavioral issues, psychological symptoms, and even domestic abuse. I will explain the various forms of structural violence the Palestinians deal with on a daily basis, including poverty, settlements, the Wall, and randomly placed restrictions on movement and freedom under occupation.
Israeli Settlements are a Form of Structural Violence:
Israel’s creation of certain projects, such as the Israeli settlements delineate not just illegitimate and immoral actions (they are illegal by international law, and inherently racist, only allowing Jewish citizens as residents), but a form of violence that affects the Palestinians well-being and potential to thrive. Although Israel has significant violations of International
Laws, and continues to perpetrate these violations by building new settlements, as of 2016, the
Israeli Human Rights Organization, B’Tselem reports that there are more than 300 Jewish
Settlements in the West Bank (B’Tselem, 2017), the Palestinians continue to suffer at the hands of these restrictive laws – uprooting them from their land, rendering them homeless refugees.
In 1967, Israel invaded and occupied the Palestinian Territories with its military power.
Shortly after the invasion, Israel began constructing settlements, best described as small cities, by confiscating Palestinian land, demolishing homes, and displacing Palestinian families, turning them into refugees. These settlements were enclaves that only Jewish Israeli citizens are allowed to reside in, under Israeli law. International law prohibits an occupying power from
20
transferring citizens from its own territory to the occupied territory (Fourth Geneva Convention, article 49). By building these settlements for Israeli citizens only, Palestinians are denied their rights to housing, land, and freedom. Palestinians do not share the equal property rights as Israel citizens do. Palestinians do not have the right to their land anymore because they were forcefully removed so that Israeli citizens can have to right to livelihood and property, and freedom. Since
1967, about 300 new settlements have been created, with an estimated 600,000 Jewish Israeli settlers on Occupied Palestinian land20 (Palestine Monitor, 2012), (B’Tselem, 2017). Israel would expand by creating these settlements on Palestinian territory, which is strictly prohibited by The Hague Regulations of 1907. Although created under the pretext of security and protection for its Jewish citizens, the UN stated that there is “no apparent security role or purpose for the settlements, and thus their existence is not even proportionate to the security of Israel” (UN
Security Council, 2016). The abetting complicity by the international community in which these settlements are being built at unprecedented rates (Palestine Monitor and B’Tselem, 2010) indeed normalize the unjust settlements.
The problem with Jewish settlements lies in not only with the way they are structured, but with their effects on the occupied Palestinians. Jewish Settlements are structured such that original inhabitants, the Palestinians have no access to that land, or their homes on that land at all. The discriminatory aim of this law not only leaves the Palestinians homeless and refugees, but provides no alternative or protection for the Palestinians. The settlements are unequal in design and aim at disintegrating the Palestinian population, while specifically transferring another population into the occupied territory. The occupied Palestinians’ lives are fundamentally challenged and threatened by specific Israeli projects, such as the settlements.
20 Palestine Monitor – Exposing Life Under Occupation. HDIP – The Health, Development and Information Policy Institute, HDIP 2012 21
This is unethical as the occupied populations’ existence cannot be challenged and the quality of their lives cannot be deteriorated with the creation of new projects by the occupier. Yet, according to The Hague Regulations of 1907, the occupier must serve to have humanitarian provisions and instead improve the quality of life. Perhaps, the unjust design and implications of the settlements is an aspect of the Occupation that Roy believes goes ignored by the humanitarian aid phenomena and the woven injustice that Giacaman believes is ignored by the
Western led discourse on treating PTSD in Palestinians. The Israeli settlement policy is detrimental to the Palestinians, and beneficial to the Israeli’s. This structural form of settlements that is imposed on the Palestinians disrupts their lives, leaving their homes shattered, their families broken, and displaced from their world, their homes. Violence to the Palestinians’ daily lives is not just from the Israeli tanks and bullets, but as Galtung argues, “indirect violence comes from the social structure itself” which implements “inequality, above all in the distribution of power21.” The destruction cause by building these settlements is an embedded norm in the Palestinian villages. The settlements are the most apparent form of structural violence in the Israeli occupation of Palestine.
This structural violence is embedded in their lives, impairs their ability to live, physically, and mentally in what was once their home. How do the settlements affect the Palestinians? Once uprooted from their homes and rendered homeless, with a family to provide for, how are the
Palestinians affected by these forms of violence in their lives that are addressed by humanitarian aid with tents and a check mark next to PTSD?
21 Johan Galtung, ‘Violence, Peace, and Peace Research’, Journal of Peace Research, 6, 1969, p. 175; and Johan Galtung, Peace by Peaceful Means (London: Sage, 1996), p. 2. 22
The Israeli Wall is a Form of Structural Violence
In June 2002, the Israeli government began constructing the Wall, or as they called it a temporary “Separation Barrier” as means of security measures to protect Israel from suicide bombers coming from Palestine. The Wall consists of a complex system of barriers including an 8-9-meter-high concrete cement wall that spans 800 kilometers, electrified fences, patrol roads, ditches, earth mounds, closed gates, trenches, roadblocks, electronic monitoring system and a no-go buffer zone22. 85% of the route of the concrete Wall (from here on, referred to as the Wall) does not follow the 1967 Green Line and encroaches into the West Bank23, systemically looping around 56 Jewish settlements in the West Bank conveniently keeping them contiguous with Israel24. Approximately 70,500 Palestinians currently live between the concrete
Wall and the Green Line, an area known as ‘no man’s land’, and are entirely cut off from any health care facility. The Wall, estimated to cost approximately US$4.7 million/kilometer, isolates and fragments the Palestinian communities and affects every single aspect of the Palestinians’ lives, including education, work, health, and familial relationships25.
The Wall literally cut off many Palestinians from their land, more than 123,000 dunums of land, (where 1 dunum equals 1,000 square meters, or ¼ of acres), depriving them from their agricultural lifestyle and means of income26. The Wall is the most physical and visible hardship that is placed on the lives of Palestinians every day from the Israeli occupation.
On July 9th, 2004, the International Court of Justice declared the Wall illegal, “The Court finds that the construction by Israel of a wall in the Occupied Palestinian Territory and its
22 The Humanitarian and emergency policy group (HEPG) and the Local aid coordination committee (LACC), The impact of Israel’s separation barrier on affected communities, update 3, November 30, 2003, p.7. 23 Ibid. 24 Ibid. 25 Ibid. 26 Medecins Du Monde – The Ultimate Barrier- Chapter 1: 1-30. 2009. 23
associated regime are contrary to the International law…The United Nations, and especially the
General Assembly and the Security Council, should consider what further action is required to bring to an end the illegal situation resulting from the construction of the wall.27” In addition, the
UN General Assembly emphasizes that the Wall constitutes a violation of the “prohibition on acquisition of territory by force.” The Wall is in direct violation of the International Human
Rights Law, as The International Covenant on Civil and Political Rights deems the Wall as
“restricting the freedom of movement of the Palestinians, their right to work, their right to health, an education, and their right to an adequate standard of living.28” Also under International
Humanitarian Law, Israel is prohibited from transferring any of its population into the occupied
Palestinian territories, which Israel completely violates with the numerous creations of Jewish settlements on Palestinian territory. Additionally, the 1949 4th Geneva Convention emphasizes the protection of the civilians in the occupied Palestinian territory, and since the Wall confiscates land and causes massive destruction of the Palestinian property and will create hardships, the
Wall is also in violation of the 4th Geneva Convention29. According to the 4th Geneva
Convention, as an occupying power, Israel has to ensure, respect, and protect the fundamental rights of the Palestinians, further emphasized in the International Covenant on Civil and Political
Rights (ICCPR), Israel must protect the rights of all individuals within its territory or under its jurisdiction, without any class of discrimination among its occupied territory30. The effect this took on the Palestinians is immeasurable, as unemployment sky-rocketed, illnesses prevailed, and depression, anxiety and post-traumatic stress disorder became the norm.
27 Jubran J. Health and Segregation II The Impact of the Israeli Separation Wall on Access to Health Care Services. Health, Development, Information and Policy Institute (HDIP). July 2005. 28 Ibid. 29 Ibid. 30 The Humanitarian and emergency policy group (HEPG) and the Local aid coordination committee (LACC), The impact of Israel’s separation barrier on affected communities, update 3, November 30, 2003, p.7. 24
The Wall Fragments Palestinian Land into Clusters
The Wall severely impedes any access to health care with in the Palestinian community in the West Bank and the Gaza Strip. The Wall is not only cutting off Palestinians to health care, but it is placing a multilayered burden on health care centers as well as increasing the complications of the disease. The Wall isolates and fragments 41 primary health care clinics as well as 9 hospitals within the Palestinian territory31. The Wall created 28 clusters, termed enclaves, or areas that are encircled by the Wall, in the occupied Palestine territory32. In addition to the 28 enclaves, the Wall geographically created five main parts completely separated from each other: 1) the north and the middle, which includes the districts of Jenin, Nablus, Qalqiliya,
Tulkarem, Salfit, Tubas and Ramallah, 2) villages located in the northern area in between Salfit and Qalqiliya 3) the south, which includes Bethlehem and Hebron, 4) Jericho and 5) Jerusalem33.
The 28 enclaves are located in three types of locations with the respect to the Wall: behind the
Wall, complete enclosure by the wall, and complete enclosure by the wall and other structures.
The 41 primary health care clinics are located within these enclaves34. Twelve enclaves, which include 5,000 Palestinians, will be in between the Wall and the Green Line, which will effectively break these clusters off from the rest of the West Bank. There is only one primary health care clinic within these twelve enclaves. The Wall will create eight enclaves completely surrounded by the wall, inhabited by 70,000 Palestinians and encompassing a total of 11 clinics35. Finally, seven enclaves are enclosed by Wall and other structures, which include road blocks, gates, and earth mounds. In these seven clusters, 23 clinics are dispersed within them.
31 Jubran J. Health and Segregation II The Impact of the Israeli Separation Wall on Access to Health Care Services. Health, Development, Information and Policy Institute (HDIP). July 2005. 32 Ibid. 33 Ibid. 34 Ibid. 35 Ibid. 25
Access to Medical Care
According to the Humanitarian and Emergency Policy Group (HEPG), the Wall “could effectively isolate Palestinian communities from their economic and social means of support – further exacerbating the process of economic fragmentation associated with the current internal closure.36” The Wall creates a variety of barriers impeding on access to health care to the
Palestinian community as well as access to medical staff, medical supplies and community health workers within the Palestinian enclaves. The Health, Development, Information and Policy
Institute (HDIP) of Palestine identifies five types of access difficulties throughout the West Bank and the Gaza strip due to the Wall as follows:37
1. Patient’s access for basic and specialized health care services.
2. Access of medical staff to their clinics.
3. Access of ambulances carrying patients in critical situations.
4. Access of medication, vaccinations, medical equipment, etc.
5. Access of mobile clinics to isolated villages.
Patients and medical staff all across these five categories reveal the hardships they face daily, often in humiliating, appalling, and life-threatening situations.
The Wall affects health in Palestine on two levels, first immediate care, and secondly, preventive health. Either through delays or complete denial of entry, many Palestinians suffer as their illness or health situation deteriorates in the midst of the waiting, walking back, or climbing mountains to see a doctor. The average delay for medical staff was 62 minutes and 90 minutes for
36 The Humanitarian and emergency policy group (HEPG) and the Local aid coordination committee (LACC), The impact of Israel’s separation barrier on affected communities, update 3, November 30, 2003, p.7.
37 Jubran J. Health and Segregation II The Impact of the Israeli Separation Wall on Access to Health Care Services. Health, Development, Information and Policy Institute (HDIP). July 2005. 26
patients38. Manned checkpoints with Israeli soldiers and police officers are accountable for the delays or rejections, preventing patients from being treated and medical staff from treating the patients. For example, the average travel time between the village of Aizaria and a hospital in
Jerusalem is typically 15 minutes by car and 5 minutes by ambulance before the wall was built39.
Now, the ambulance will have to travel through another gated checkpoint in Abu Dis to get to
Jerusalem the average transport, and the average time by ambulance between Aizaira and
Jerusalem is increased to 1 hour and 52 minutes, in contrast to the 5 minutes prior to the construction of the Wall40. The vital link between time and health is crucial to minimizing the time the patient is suffering, and thus avoid potential death.
Access to immediate care has not only been disrupted, but impeded the health and often lives of many Palestinians trying to get through a checkpoint. The prolonged waiting time at the checkpoint is directly associated with the wall, and Israel’s way of controlling movement across within the Palestinian territory. The vulnerable sick at the checkpoints suffer extensively and must go through extreme various measures in order to reach a health facility. By being isolated from the specialized health facilities that are only available in Jerusalem, they are required to wait at the checkpoint for hours, obtain a medical permit, which could be arbitrarily “expired” once they are at the checkpoint. The Augusta Victoria hospital is a private hospital in East
Jerusalem and is currently the only Palestinian hospital with the resources to provide dialysis treatment41. Fragmenting a society, a people into many clusters, leaving them broken, cut off from familial kinship, medical care access, other parts of their own country, and even schools, is
38 Ibid. 39 Ibid. 40 Ibid. 41 Jubran J. Health and Segregation II The Impact of the Israeli Separation Wall on Access to Health Care Services. Health, Development, Information and Policy Institute (HDIP). July 2005. 27
a form structural violence and systematic suffering. It was revealed by an Israeli economist, Shir
Hever, that Brigadier General Yair Golan, commander of the Israeli Defense Force in 2007, said in a lecture at the Van Leer Institute, that “separation and not security is the main reason or building the Wall of Separation and that security could have been achieved more effectively and more cheaply through other means (Shir Hever, 2010 and Roy, 2012). The Palestinian territories are so fragmented, that perhaps, a Palestinian State is actually no longer viable, and the
Palestinians might continue to live in this form of violence, fragmented, with imposed restrictions from another body of power.
Poverty is a Form of Structural Violence
Professor Farmer argues the vicious cycle of poverty and health status42. Poverty continues to affect large numbers in the occupied Palestinian territory. It is well established that that factors affecting health include work, education, housing and food. According to the World
Bank, the number of poor in the West Bank and Gaza has tripled to over 2 million since 2000, making two thirds of the population below the poverty line. Half a million Palestinians are completely dependent on food aid and studies reveal that the Global Acute Malnutrition (GAM) now affects 9.3% of all Palestinian children43. Moreover, this will create one of the five pitfalls in global health, as described by Dr. Arthur Kleinman, weak infrastructure44. The poverty-poor health cycle is the heart of the health care infrastructure, and the more frequent and deeply cultivated this cycle goes on, the weaker the health care infrastructure grows. The effect this took on the Palestinians is immeasurable, as unemployment sky-rocketed, illnesses prevailed, and
42 Farmer P, On Suffering and Structural Violence Partner to the Poor. Berkeley: University of California Press. 2010; Chapter 16: 40. 43 Ibid. 44 Kleinman, A. The Illness Narratives: Suffering,, Healing, and the Human Condition. New York: Basic Books. 1988. 28
depression, anxiety, anger, and sleep troubles became the norm. As Professor Farmer elucidated, this suffering is not random, but systemically distributed45. Furthermore, the most vulnerable, as
Professor Farmer predicts, are those with the greatest degree of pain and suffering46, including pregnant women, children, the elderly, and the physically disabled. Poverty led these vulnerable people compromise on their health, further exacerbating their vulnerability.
Renowned Harvard economist, Sara Roy illustrates the losses faced by the Palestinian people through what she calls “critical paradigm shifts” shaped by the international community.
Roy argues that the transformation of the conflict into an outright humanitarian crisis significantly changed how the world views the conflict, which in turn shaped the losses and trauma the Palestinians have endured (Roy, 2012). Roy further argues that the traditional methods of measuring the decline of a country is inappropriate if used to measure the political and economic decline of Palestine (Roy, 2012), as it is progressively deteriorating environment directly linked to political restrictions by an occupying force, where opportunities vanish and the population, growing in numbers, continue to suffer. Roy emphasizes that the losses, poverty, and the suffering must be understood through the political framework, largely shaped by the occupying power, Israel, and conceded by the international community (Roy, 2012). The World
Bank elaborates the extremely detrimental state of Palestine:
Following the Second Intifada of 2000, the Palestinian economy began to resemble no other in the world. Limited say over economic policies and trade, the extent of dependence on Israel and international aid and a regime of internal and external closures has created an economy characterized by extreme fluctuations in growth and employment and an increasing divergence between the two territories: The West Bank a fragmented archipelago; and Gaza an increasingly isolated island (World Bank, 2011).
45 Farmer P, On Suffering and Structural Violence Partner to the Poor. Berkeley: University of California Press. 2010; Chapter 16: 40. 46 Ibid. 29
Roy argues that the shift from a political issue to a humanitarian one adversely affected the
Palestinians, leaving them dependent on aid to survive. The shift towards a humanitarian crisis is an important one, (Roy, 2012,14) because the level of international aid the Palestinian government has received sky-rocketed, increasing by 500%, with about 80% of Palestinians in both the West Bank and Gaza relying on aid for food (PCBS, 2015). Roy boldly labels this shift as a reduction in not only the human potential of the Palestinians, but also a reduction of the injustices faced by the Palestinians to a mere humanitarian issue. The lack of sustainability in humanitarian aid is echoed not just by Roy, but by global health moguls, like Drs. Arthur
Klienman, and Paul Farmer (Klienman, 2010) and political activists, Dr. Noam Chomsky
(Chomsky, 2014). At any point in time, humanitarian aid can cease due to political reasons, or sanctions by the Israeli government. For example, USAID funded activities and social projects to improve the psychosocial well-being of Palestinian children were closed down in 2012 as a punishment for Palestine’s 2011 UN membership bid (UN, 2012). Other clinics that served the poorest communities in Palestine also closed down that year, (UN, 2012) leaving thousands in need of basic health care. Roy argues that Palestinians have not only been forced to live in poverty, but also have had a cyclic, impoverished lifestyle created by a dependency on foreign aid (Roy, 2012). The World Bank confirms this dependency, “Large amounts of donor aid have produced insignificant growth and an increase in economic decency, despite the consistency improvement in the PA governance and security performance” (World Bank, 2010). By focusing on feeding the Palestinians under occupation, they have been reduced to mere beggars, when in reality, they want freedom from oppression, and conceivably, the chance to prosper. Deeming the systematic oppression of the Palestinians to a humanitarian crisis that often fades into the background as long as material aid is being delivered rings a close sentiment to Herman’s own
30
observation on trauma: that throughout history – trauma and horrible events periodically intrude into public awareness, but rarely, is it retained for a long enough time to actuate change
(Herman, 1992).
Humanitarian governance is used a framework for addressing complex emergencies, that involve chronic conflict and violence, but lacks the sustainability that is necessary in political instability. In addition, complex emergencies present an “intricate web” of various forces in violence47. The term is used to describe systems that are convolutedly woven in a very multifaceted manner and cause inconceivable violence48. Lautze et al describes this form of violence has not only being the source of poverty, but also a source of vulnerability and powerlessness49. The complexity of the Palestinian suffering and the chronic trauma deserve a multifaceted approach that includes a political, humanitarian governance as well as psychotherapy, and social approach to fully understand the intricacy of the issues and address the ongoing mental health issues. Nonetheless, humanitarian governance cannot be utilized alone, as it employs only external factors of international aid and does little to help a fragmented society.
It must be accompanied with a biological and social lens that employs internal resources, to appropriately and culturally address mental health, all a part of the biosocial approach.
Mental Health in Palestine:
Living in war-torn areas is the reality for many people around the world. For nearly seven decades, Palestinians have faced a history of loss, trauma, war and oppression under the Israeli military occupation. Exposure to such traumatic events indeed has an impact on one’s psychological, physical and emotional state. Research indicates that children living in war zones
47 Lautze S, Leaning J, Raven-Roberts A, Kent R, and Mazurana D. Assistance, Protection, and Governance Networks in Complex Emergencies. Lancet 2004; 364:2134-2141. 48 Ibid. 49 Ibid. 31
are at high risk of developing psychopathology, including, Post-Traumatic-Stress Disorder and depression. (Kinzie et al. 2001) Kinzie describes that chronic trauma as traumatic events that occur “several times over an extended period of time, and that these traumas are often multiple, severe, and recurring” (Kinzie, et al. 2003). Much research has been devoted to the effects of war on children, but it is difficult to assess the effects of chronic trauma, ongoing trauma. Research continues to reveal that child abuse may lead to developing mental health difficulties (Widom,
1999). Moreover, experiencing more than one traumatic event may lead to stronger PTSD symptoms. However, in the case of Palestine, the trauma is chronic, ongoing for decades now.
In the annual health reports published by the Palestinian Authority (PA) from 2001-2005, an upwards trend of mental disorders is seen across Palestine. Furthermore, in a 2004 study,
Palestinian adolescents reported the lowest Quality of Life scores out of 35 participating countries (Currie et al. 2004, Giacaman et al. 2004). Giacaman praises the Quality of Life reports as more revealing of the state of Palestinians’ mental health, capturing more of their experience under oppression.
Implications of Research:
The suffering related to war is not always visible, as the effects of living in chronic war conditions or oppression can have psychological effects. The main question is whether or not the restrictions, mainly the occupation by the Israeli military government affect the psychological well-being of the Palestinians to the degree of manifesting in negative behaviors that are detrimental towards health? These behaviors can include smoking, abuse, or even aggressive behaviors, in addition to being described by a lack of motivation in life. The social suffering created by the systematic oppression of the Occupation can have implications on the lives of the
32
Palestinians. How does living under oppression for manifest itself in health and well-being?
What is it like to be treated like a second-class citizen at an Israeli checkpoint, solely stopped, searched, and harassed for the sole reason of being of Palestinian nationality? What does that sort of degrading treatment due to the self, in terms of mental health? How does political violence, including restrictions on mobility, displacement, home demolition, and daily harassments, manifest itself in health and well-being, specifically, behaviors that can be detrimental to health?
The suffering related to the Occupation cannot be summarized by a PTSD diagnostic tool and must be understood within the context of the systematic, structural violence that exist and subject its society to various forms of violence, distress, and wounds. Furthermore, the social support system must be tailored to the victims’ cultural, and political reality. Understanding the wounds and damage that is due to political violence in the context of social suffering, using a biosocial analysis, can offer a deeper perspective on the health of people living in chronic war. A biomedical framework has the narrow limitations that is offered only through a medical lens of biological disease and treatment of disease. Daily exposure to such forms of violence may have long term effects on the psyche and wellbeing of a person, (Herman, 1992). Giacaman posits that the social suffering of the Palestinians needs to be placed on an ease-disease continuum that provides a richer depiction of the scars of living in war, only to be understand in the context of justice, security, and political violence. (Giacaman, 2014).
33
Chapter II
Materials and Methods
This study evaluates several sets of data on the quality of life, mental health, including psychosocial behavior, poverty, and negative behaviors among Palestinians, including domestic violence, and detrimental habits towards one’s health, from the Palestinian Central Bureau of
Statistics (PCBS) over the years in the occupied West Bank, Jerusalem, and the Gaza Strip. The study evaluated poverty rates over the years, violent behavior, school dropout rates, domestic violence, unemployment, psychosocial symptoms, and Palestinians’ opinions on the prospect of their own future. The study also includes exposure to violence over the years, including harassment at checkpoints, beatings, death in the family, and other forms of structural violence in the Palestinian society. Over the years, rates of poverty and other forms of social suffering will be analyzed in the Palestinian society, taken into context the political environment and events of that year, and if there is a correlation between these events and the rates of psychosocial symptoms, and how these events impacted these rates.
The Palestinian Central Bureau of Statistics is the official institution on statistics of the
State of Palestine, siting itself in its mission statement to “develop and enhance the Palestinian official statistical system based on legal grounds that organize the process of data collection and utilization for statistical purposes” (PCBS, n.d.). Also in their mission statement is to ‘establish a comprehensive and unified statistical system to serve Palestinian authorities…for diagnosing problems and evaluating progress made’, and inform and report to other institutions, both local and foreign, on the demographic, social, economic, and environmental developments of Palestine and operates as an independent statistical bureau (PCBS, n.d.). PCBS provides services and data
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to research institutions, universities, governmental, and nongovernmental sectors, as well as private sectors.
For each of the surveys conducted, fieldworkers were trained in basic interview intake skills, sensitivity interview skills, interpreting the questions in a clear manner and recording data appropriately (PCBS, 2004, 2006, 2010). Fieldworkers were trained in Ramallah for the West
Bank surveys, and via video conference for the Gaza Strip fieldworkers. Definitions for terms were provided as reference for interviewees. The population was divided randomly in two ways:
1. First, PCBS selected a random sample of 498 enumeration areas in Palestine
2. Second, PCBS selected a random area sample from each enumeration area selected in the first stage.
The population was divided into two groups for consistency: The West Bank, and the Gaza
Strip. Furthermore, the West Bank was divided into 17 governorates for certain surveys. Data entry and coding instructions were used across all surveys in the same manner. Data entry was entered into a computer using a template in Access and statistical analysis were conducted through SPSS. Although PCBS acknowledges that sampling errors and non-sampling are to be expected, they emphasized intensive training of fieldworkers, data entry staff, and statisticians, on professionalism of interview skills, sensitivity to cultural barriers and taboos, and data entry.
PCBS also emphasizes regular meetings and continuous contact with fieldworkers to ensure interviews are conducted in the utmost quality and sensitivity, especially in a conservative population. Nonresponse rates varied across each survey, and were mostly due to traveling or vacant households. Refusal rates remained relatively low.
Research Limitations The main limitation of this thesis will be the limited amount of documented research on mental health in the early years of the war in Palestine. Before the second intifada (Palestinian uprising in 2000), there was not a significant focus on mental health in children afflicted by the 35
atrocities of the Israeli occupation. This presents as a major limitation, as most research would be recent, while the social suffering has been going on for decades. Another limitation is that many of the surveys are self-reported, and there is a stigma associated with mental health problems in
Palestine, thus many people may misrepresent their symptoms in fear of the social stigma associated with mental health issues. There is also a stigma associated with domestic abuse in such a patriarchal society, which may affect rates reported. To attempt to overcome this limitation, all surveys are anonymous and no identifying factor will be used in this thesis.
Furthermore, the Palestinian Central Bureau of Statistics has received criticism in the past for their bias in their reporting, since they are the official statistics center for Palestine. However, they operate under a third part for ethical procedures and adopted the Declaration on Professional
Ethics for Statisticians from The General Assembly of the International Statistical Institute
(PCBS, 2018). They maintain the European Statistics Code of Practice and are audited regularly for compliance (PCBS, 2018). It is also important to note that psychosocial symptomology reporting is scarce, as mental health and the effects of the occupation on trauma came into light in recent years (Giacaman, 2010), and that in 2001, the main office of PCBS in Ramallah was raided by the Israeli military, which confiscated many files, reports, and hard drives (PCBS,
2017). The fieldworkers who conducted the surveys were trained on sensitivity, language use, translation, explanation of certain terminology, and dealing with difficult subjects, however, human error in reporting is inevitable. Surveys were conducted in clinics, schools, and homes, with fieldworkers visiting on multiple rounds to ensure high response rate. Thus, some surveys on domestic abuse were still conducted with the women in their homes. Although the surveys were conducted away from family members, (husbands, in-laws, children, etc.) to avoid potential
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bias in answers and discomfort for the subjects, this however, does not entirely eliminate bias or fear of retaliation from husbands, since they were still conducted in at home.
The sample size and nonresponse rates for the surveys used for this research are below:
Victimization Survey, 2012. Main Findings
Based on a household sample survey conducted during the period from 01/10/2012 until 12/31/2012.
Table 1a: Interview Results and Response Rates for Victimization Survey, 2012: Region Sample Size Response Rate West Bank 4,360 89.9% Gaza 2,305 94.5% Total N 7,704 91.4%
Table 1b: Interview Results and Response Rates for Victimization Survey, 2012:
PCBS defined household as “one or a group of persons living together who make common provisions for food or other essentials for living. Households members may be related, unrelated or a combination of both (PCBS, Victimization Survey, 2012).
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Victimization Survey 2016, Main Findings
Based on a household sample survey conducted during the period from 10/09/2016 until 01/05/2017.
Table 2: Interview Results and Response Rates, Victimization Survey, 2016: Region Sample Size Rate West Bank 3,734 82.4% Gaza 2,124 92.2% Nonresponse Cases 1,745 14.3% Total N 7,603 85.7%
Domestic Violence Survey 2006, Main Findings
Table 3a: Interview Results and Response Rates for Domestic Violence Survey, 2006: Region Sample Size Response Rate West Bank 2,772 89.9% Gaza 1,440 94.5% Total N 4,212 91.4%
Table 3b: Response Rates for Domestic Violence Survey, 2006
Sample Palestinian Territory West Bank Gaza
Households 4,212 (1.3)* 2,772 (1.4) 1,440 (1.1)
Married women aged 3,815 (0.7) 2,488 (0.8) 1,327 (0.6) 15 and over
Unmarried women 944 (7.7) 654 (10.4) 290 (1.7) aged 18 and over
Number of Children 2,676 (0.1) 1,743 (0.1) 933 (…)** aged 5-17 whose mothers were interviewed
*(Nonresponse rates, %) **(Unavailable data)
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Violence Survey in the Palestinian Society 2011, Main Findings
Table 4a: Interview Results and Response Rates, Violence Survey 2011: Region Sample Size Response Rate West Bank 3,891 92.2% Gaza 1,920 94.9% Total N 5,811 93.5%
Table 4b: Interview Results and Response Rates, Violence Survey 2011:
Palestinian Youth Survey, 2015 Main Findings
Table 5a: Interview Results and Response Rates, Palestinian Youth Survey 2015: Region Sample Size Rate West Bank 5,124 94.9% Gaza 2,552 97.2% Nonresponse Cases 572 6.9% Total N 8,248 85.7%
Table 5b: Interview Results and Response Rates, Palestinian Youth Survey 2015
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Psychosocial Health Survey for Children, 5-17 years, 2004. Main Findings.
Total N: 1,800 households: 1,154 West Bank, 646 Gaza
The surveys were used to assess the effects of the chronic oppression the Palestinians live through on a daily basis in three different manners: economic effect, which includes unemployment and poverty rates, health and wellbeing which includes smoking and malnutrition rates, as well as psychological symptoms, and finally social effect, which includes patterns in violent behavior, domestic abuse, and dropout rates.
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Chapter III
Results
Israeli Harassment/Violence
The tables below show an increase in Israeli harassment and violence in the Palestinian territories. Tables 8, 9, and 10 reveal a striking pattern of an increase in violence. Table 8 shows the distribution of the type of crime and violence in the Palestinian Territory by region in 2008, revealing 25.6% of the crimes were by Israeli Soldiers/Settlers (including harassment or assault) in Gaza, with 30.1 in the West Bank. In 2012, this percentage more than doubled for Gaza, at
59.7%, mainly due to the 8-day intensive assault on Gaza in 2012 that killed 100 Palestinian civilians (B’Tselem, 2013). What is interesting is that in 2016, this number dropped to 0.3% in
Gaza, which could possibly be explained by the restrictions on the Gazan community and lack of access from both Israelis and Palestinians into and out of Gaza. Furthermore, in 2016, the percentage of criminal offense by Israeli Soldiers/Settlers rose again in the West Bank. This trend reveals sporadic, mostly an increase, in violence in the Palestinian territory.
Table 6: Crime and Violence in the Palestinian Territory, by region in 2008
N = 10,263 Table from Palestinian Central Bureau of Statistics, 2009. Victimization Survey - 2008: Main Findings Report. Ramallah - Palestine.
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Table 7: Crime and Violence in the Palestinian Territory, by region in 2012
N = 7,704 Table from Palestinian Central Bureau of Statistics, 2013. Victimization Survey - 2012: Main Findings Report. Ramallah - Palestine.
Table 8: Distribution of type of Crime and Violence in the Palestinian Territory, by region in 2008
N = 10,263 Table from PCBS 2009. Victimization Survey - 2008: Main Findings Report. Ramallah - Palestine.
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Table 9: Crime and Violence in the Palestinian Territory, by region in 2012
N = 7,704 Table from PCBS, 2013. Victimization Survey - 2012: Main Findings Report. Ramallah - Palestine.
Table 10: Crime and Violence in the Palestinian Territory, by region in 2016
N = 7,603 Table from PCBS, 2017. Victimization Survey - 2016: Main Findings Report. Ramallah - Palestine.
Tables 11, 12, and 13 reveal the location of crimes and violence in the Palestinian territory by type of criminal offense in 2008, 2012, and 2016, respectively. Table 11 shows that in 2008,
55.9% of crimes and or violence committed by Israeli Soldiers/Settlers occurred inside the house. This number jumped to 75% in 2012, and fell to 46.8% in 2016. This data reveals the high rates of violence inside the house – which sheds light on the harassment and structural violence the Palestinians endure. This suggests that the acts of violence done in civilian homes, are
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sporadically increasing, and render the Palestinians to a life of fear. As stated earlier, structural violence is usually embedded in a society and becomes the daily routine, where these are night bombardments, scare tactics, or physical beatings, this form of violence is not only prevalent, but also an important part of the Palestinians’ ongoing suffering. Table 14 reveals the percentage of
Palestinian governorates (cities, or villages) that were exposed to violence. Taken in 2012 by
PCBS, the lowest was 23.3% in Jericho, with the highest at 60% of residents facing violence in the town of Qalqilya (Table 14).
Table 11: Location of Crime/Violence in Palestinian Territory, 2008
N = 10,263 Table from PCBS 2009. Victimization Survey - 2008: Main Findings Report. Ramallah - Palestine.
Table 12: Location of Crime/Violence in Palestinian Territory, 2012
N = 7,704 Table from PCBS, 2013. Victimization Survey - 2012: Main Findings Report. Ramallah - Palestine.
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Table 13: Location of Crime/Violence in Palestinian Territory, 2016
N = 7,603 Table from PCBS, 2017. Victimization Survey - 2016: Main Findings Report. Ramallah - Palestine.
Table14: Percentage of Palestinian households exposed to violence from Israeli Occupation Forces, 2010
N=5,811(West Bank: 3,891, Gaza: 1,920) Table taken from PCBS, 2012. Violence Survey in the Palestinian Society, 2011: Main Findings Report. Ramallah - Palestine.
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Figure 1: Percentage of Children (12-17 years) who were exposed to physical violence from occupation forces 2011 by gender and region
Figures 2 and 3below show an increase in the number of children forcibly displaced in
Area C and East Jerusalem of Palestine. There is a marked increase in the number of children displaced, from 332 in 2009 to 651 in 2014 (PCBS, 2014) affecting their education, livelihood, and well-being. Displacement is another factor that needs to be taken into considering when assessing the mental health of the Palestinians, as displacement disrupts their daily lives, their provisions for their families, their relationships, education, and basic necessities such as food and housing. This is another form of structural violence that is embedded in the Palestinian society.
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Figure 2: Number of Children forcibly displaced in Area C and East Jerusalem because of House Demolition by Israeli Occupation Forces, 2009-2012
Figure 3: Number of Children Forcibly Displaced because of House Demolition by Israeli Occupation Forces, 2009 -2014
Domestic Violence
Domestic abuse is a form of structural violence (Galtung, 1969), and partakes in the cyclic pattern of poverty, depression, abuse (Farmer, 2005). Thus, it is no surprise to see domestic abuse rise in a society where violence, poverty, and oppression is prevalent. The tables below married women exposed to violence in 2005 and 2011, respectively (PCBS, 2006, 2012).
Psychological abuse was the highest amongst types of abuse, which includes verbal abuse. The
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numbers shown below are staggering, even for a conservative community in which such sensitive issues carry a stigma. Indeed, the rise in domestic abuse is prevalent in societies that are afflicted with poverty, war, and violence, as Farmer recognizes these trends among Haitian women as well (Farmer, 2013). Although the abuse is higher in rural areas in Palestine (Table
15), urban areas are not immune either, revealing that domestic violence and unrest is pervasive in societies where there is political violence, regardless of location.
Table15: Married Women Exposed to Violence from Husband, 2005
N=4,212 (West Bank: 2,772 Gaza: 1,440) Table taken from PCBS, 2006. Domestic Violence Survey, 2005: Main Findings Report. Ramallah - Palestine.
Kleinman also noted that after the Rwandan Genocide of 1994, the rates of domestic abuse amongst married couples sky-rocketed (Farmer, 2013) and the vulnerable women, who were homeless, poor, and sick had to deal with another layer of inequity against them – physical and psychological abuse from their partners (Farmer, 2013). A rise in domestic abuse is not uncommon in areas of unrest and violence. The numbers here may even be lower than the reality the Palestinian women deal with a daily basis. Domestic abuse is a form of structural violence – one that indeed is a result of the layers of inequities the Palestinians are forced to live with everyday (Yoke, 2010). The numbers are staggering, with 70% of Palestinian in Jericho women reporting psychological abuse in 2011 and 45% report physical abuse from Table 16, below.
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Table16: Married Women Exposed to Violence from Husband, 2011
N=5,811(West Bank: 3,891, Gaza: 1,920) Table taken from PCBS, 2012. Violence Survey in the Palestinian Society, 2011: Main Findings Report. Ramallah - Palestine.
Table 17: Number of Injured Children reported to UNICEF from 2010-2014
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Health:
Figure 4: Prevalence of Stunting/Malnutrition among Children under five years by region 2000-2010
Malnutrition is an indicator of a poverty and poor environmental resources, such as clean water and lack of sufficient food (OCHA report, 2012). Figure 5 and 6 below are also indicators of lack of food (WHO) and malnutrition indicates lack of access to adequate food. This is not only devastating to households trying to provide for their families, but also to the economy, leaving the Palestinians to count on aid for food, whether funds are there, or dried up. This devastating realization reveals that the lack of sustainability of foreign aid may have crippling effects on a society who is battling deep poverty and malnutrition.
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Figure 5: Prevalence of underweight among Children under five years by region 2000-2010
Figure 6: Percentage of Children under five who had diarrhea in Palestine by region in 2006 and 2010
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The figure below shows percentage of individuals who smoke – although this may be underreported due to the fact that there is a huge stigma associated with girls who smoke, and
PCBS repeatedly reported significantly lower numbers for girls than boys (PCBS, 2016). Peter
Glick, Salwa Massad, and colleagues analyzed in deeper details the prevalence of health risk behaviors in Palestinian Youth, including smoking, and found that not only is tobacco use among
Palestinian youth very high, but also that tobacco use and engagement in violent behavior were correlated among Palestinian males (Glick, 2016). This reveals the double-edged sword of smoking: the obvious health detriments on the body and the risk behaviors (in this case, violence) associated with smoking (Glick, 2016). Although Glick found relatively low alcohol use in the Palestinian society, he and colleagues found that “levels of interpersonal violence are quite high” (Glick, 2016). These patterns in ill behavior – smoking and violence – reveal the effects of negative behaviors in violent societies.
Figure 7: Percentage of Individuals (15-17 years) who smoke by region, 2015
Table: 18: Number of Children Martyred by Region, Year and Cause (2010-2014) 52
Figure 8: Number of Martyr and Wounded Children 2010-2014
Figure 9: Number of Cases of Detention of Children by Age Group and year, 2008-2014
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Table 19: Number of Detainees According to Type of Violence and Maltreatment, 2013-2014
Poverty:
Table 20: Percentage of Children in Poverty, by region, in 2010
Figure 10: Food Insecurity in Palestine by Region, 2009-2012 (Percentage) 54
The poverty rate among individuals in Palestine in 2011 was 25.8% and food insecurity rate was more than 27%. Those who depend on food aid totaled 34%, while this aid is unsustainable and changes constantly. Food insecurity is the result of the lack of economic power and a decrease in employment opportunities. The fact that a new measure of “deep poverty” “poverty” and “food insecurity” exists in Palestine is indicative of the dire situation of not just poverty, but of the state of dependency the Occupation has left the Palestinians in (see Figure 11 below). Furthermore, poverty rates continue to rise. This indeed is part of the structural violence that Palestinians live with every day, and the “dependent humanitarian shift” economist Roy refers to that perpetuates poverty.
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Figure 11: Gap between Poverty Rates and Between percentage of individuals who Suffer from a Lack of Food Security and are Dependent on Aid in 2011
Figure 12: Percentage of Poor Children by Region, 2009-2011
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Figure 13: Number of Poor Children by Region, 2009-2011
Education:
Figure 14: Drop-Out Rates in Schools in West Bank and Area C Schools, 2009/2010 and 2010/2011
Indeed, the measure of any society is its ability to provide quality education to its children as a means for opportunities, to learn and grow. Part of structural violence is that it affects even the most basic, every day routines, such as education. The number of schools affected by the wall
(Figure 21) and the number of students who face obstacles and barriers on their way to school is a layer of the social suffering and violence that the Palestinian children go through. Not
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surprisingly, dropout rates increased (Figure 14), leaving Palestinian youth with no future to work towards, entering them into the cycle of economic poverty and violence.
Table 21: Distribution of Schools in Area C, 2012
Figure 15: Percentage of working Children 10-17 years who were not in attendance in school, by region and age, 2009 and 2012
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Psychological Symptoms:
Table 22: Percentage of Students in Public School in Area C Experiencing Psychological or Social Problems, 2011-2012
Behavioral Problems
Figure 16: Number of Children Charged in the West Bank and admitted to Dar Al Amal by Age and Enrollment in Education, 2012
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Figure 17: Number of Children Admitted to Al-Amal Rehabilitation Center for Observation and Social Care in the West Bank 2009-2014
Figure 18: Number of Children in Conflict with the Law by Type of Offense, 2009-2012
In a 2003 study, Vikrem Patel and Arthur Kleinman conclude that the experience of insecurity and hopelessness and the risks of violence may explain the greater vulnerability of the poor to common mental disorders (Patel, 2003). Tables 22, 23, and 24 reveal symptoms of depression,
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behavioral issues and anxiety to name a few among Palestinian youth. In other words, structural violence predisposes the poor and the vulnerable to mental distress (Patel, 2003). These problems, such as poverty, unemployment, violence and crimes, restriction of movement, can take a toll on mental health, even to the extent, Kleinman argues, of a major life crisis such as bereavement (Patel, 2003). It would be difficult to understand these staggering numbers of mental health distress and try to address them without acknowledging the political and social factors that contribute to them.
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Table 23: Percentage of Palestinian Children (aged 5-17 years) who suffer from psychological attitude by type and gender, 2004
Source: Table taken from PCBS, 2005. Psychosocial Report, 2005: Main Findings Report. Ramallah - Palestine.
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Table 23 continued…:
Source: Table taken from PCBS, 2005. Psychosocial Report, 2005: Main Findings Report. Ramallah - Palestine.
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Table 24: Percentage of Children (aged 5-17 years) who suffer from behavioral issues by type and gender, 2004.
Source: Table taken from PCBS, 2005. Psychosocial Report, 2005: Main Findings Report. Ramallah - Palestine.
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Table 24: Continued…:
Source: Table taken from PCBS, 2005. Psychosocial Report, 2005: Main Findings Report. Ramallah - Palestine.
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Table 25: Percentage of Children (aged 5-17 years) who were exposed to certain acts of violence, 2004
Source: Table taken from PCBS, 2005. Psychosocial Report, 2005: Main Findings Report. Ramallah - Palestine.
Table 26: Percentage of Children who have received psychological therapy in Palestine, 2004
Source: Table taken from PCBS, 2005. Psychosocial Report, 2005: Main Findings Report. Ramallah - Palestine.
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Table 27: Percentage Distribution of Children (aged 5-17 years) by ability to meet costs of therapy services, 2004.
Source: Table taken from PCBS, 2005. Psychosocial Report, 2005: Main Findings Report. Ramallah - Palestine.
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The main criticism of the Western led model into offering therapeutic services is the lack of sustainability. As Giacaman echoes, when funds dry up, NGO’s pack their bags and leave
(Giacaman, 2010). This leaves a vulnerable Palestinian society to pick up the pieces and either look for other institutions, or cease services all together. Farmer argues that a deep local knowledge of the barriers to care is necessary – citing the example of when the organization
Partners in Health (PIH) provided donkey rental fees to rural Haitians to ensure they had enough means to make it to their appointments in the city (Farmer, 2013). This deeper knowledge of the structural barriers can offer insight on strengthening social support, such as covering transportation and food costs, so that vulnerable populations can go to their appointments.
Table 28: Main Reasons why therapeutic services have stopped
Source: Table taken from PCBS, 2005. Psychosocial Report, 2005: Main Findings Report. Ramallah - Palestine.
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Table 29: Issues across various aspects of Palestinian children’s’ lives (aged 5-17 years), 2004
Source: Table taken from PCBS, 2005. Psychosocial Report, 2005: Main Findings Report. Ramallah - Palestine.
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Chapter IV
Discussion
Traumatic events produce profound and lasting changes in psychological arousal
(Herman, 1992). Palestinians have long suffered various forms of trauma, living under oppression for most, if not all, of their lives. Their everyday routines have been greatly impacted by many of the restrictions imposed on the Palestinians. How have these measures changed the behaviors or mental well-being of the behaviors? The results shown above from the many surveys reveal chronic domestic abuse, increasing over the years, a deeply impoverished people, trying to make ends meet, all facing insurmountable loss.
Herman urges that victims cannot resume a normal life as long as the trauma continues to stimulate the sympathetic nervous system. How can they live a normal life? Traumatic experiences can recondition the human nervous system, interfering with sleep patterns, shattering the flight or fight response to danger, and creating a continuous hyperarousal state of anxiety
(Herman, 1992). The profound impact of a death or trauma can remain with one forever, as
Robery Jay Lifton, who studied survivors of Hiroshima, described the traumatic memory of the survivors as an “indelible image” or “death imprint” that has crystallized in their minds forever
(Lifton,1968). When a person is powerless, any form of resistance manifests, even when that resistance comes in abusing others. Traumatic events have profound effects not only on psychological well-being, but also on “systems of attachment”, whether through personal relationships or ones bound by community (Herman, 1992). The increase in domestic abuse is telling sign of a deeply oppressed people. A sense of disconnection is often the case of people who faced trauma. Herman even elaborates on the trauma faced as an ‘injustice’, – leaving the victims mistrusting of any authority and lacking hope for any type of other protection (Herman,
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1992). The natural order of community and personal protection is shattered, and when that is shattered, relationships at home are also at risk of falling apart. Herman explains the victims’ sense of justice and fairness is shattered, perhaps, explaining the rise in domestic abuse amongst
Palestinians. One can argue that Palestinians are held in captivity, and Herman argues that in captivity the psychology of the victim is shaped by the actions and beliefs of the perpetrator
(Herman, 1992), in this case, the Palestinian men and women are victims of the Israeli occupation, and the men’s psychology and actions towards their wives can be shaped by their perpetrator’s actions. They may even use similar techniques, subconsciously, of abuse, oppression, and tyranny against their wives, attempting to create power and control in an extremely powerless environment. Through verbal abuse, or as the results reveal, psychological abuse, they may instill terror or anger to regain any power or control they lost as a provider for their families by the occupation. The men’s behavior’s might even mirror those of their oppressor, petty rules on leaving the house, abusive language, degrading acts (see Tables 15 and
16), capricious approvals of small indulgences (Herman, 1992) – for Israeli – that is visa granting to get to another city via a check point, or access to prayer on the Islamic holy day,
Friday and for the Palestinian men, it can range anywhere from ‘letting’ their wives go to school or work, or spend leisure time with family and friends.
Layers of vulnerability, such as poverty, insecurity, and lack of freedom all add to the trauma of the Palestinians, making the current model of PTSD symptomology a little too narrow.
Some clinicians agree that there is a need for a new diagnosis on personality changes that follow prolonged, repeated trauma (Herman, 1998), and in the case of the Palestinians, trauma that occurs from layers upon layers of injustices.
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The longevity of the occupation has another effect – it robs the Palestinians their right to mourn, as they are constantly facing the possibility of death, random detentions, and oppression.
Herman emphasizes the necessity of mourning, “incomplete mourning results in stasis and entrapment in the traumatic process” (Herman, 1992, p. 69). The ultimate form of resistance – hunger strikes, boycott, etc. – are nearly impossible, since their very existence is dependent on the laws created by Israel. What are the psychological effects of not even being able to resist the oppression you’re in, but complying in order to live and to let your family live? Compliance is rewarded with small improvements in their conditions, such as allowing foreign aid in – food, water, etc. These rewards bind the victim – ‘you will not eat or have food to feed your family, or be allowed to cross a checkpoint to go back to your family if you in any way resist’. As Eli
Wiesel explains his family’s experience at the hands of the Nazi’s, “you are bent to the will of your enemy” (Wagner, 2007). Living in any other way is insubordination to your oppressor, which has far greater consequences than complying to your oppressor. Critics of the Palestinians fault them for their compliance, their willingness to cooperate to the random rules of movement, but as Herman points out, this is an inherent flaw in treating victims of trauma – blaming them for their compliance, or for staying. In the immediate aftermath of the Holocaust, critics blamed the Jews for their ‘passivity’ and ‘complicity’ in their fate (Herman, 1992), just as Palestinian lawyer and activist Raja Shehadeh points out critics blame the Palestinians for their complicity in waiting in long lines at checkpoints or purchasing goods from the Israeli markets (Shehadeh,
2012). However, historian Lucy Dawidowicz points out that this complicity and cooperation “are terms that apply to situations of free choice. They don’t have the same meaning in captivity”
(Dawidowicz, 1981).
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Furthermore, the oscillation between eruption of violence and quietude further adds normalcy, as structural violence becomes part of daily life, and even the coveted norm under moments of bombings, shellings, and shootings. The Palestinians have been reduced to a goal of simple survival, psychologically changing the way they adapt to trauma (Herman, 1992).
Through the practice of suppression and minimization of their daily forms of structural violence, they learn to adapt to an unbearable reality of oppression.
Herman discussed normalization in other victims as well, as prisoners do not think about how to escape any more, but how to survive, a concentration camp inmate doesn’t think about leaving anymore, but when and how to obtain the next meal or a blanket, or air, a prostitute doesn’t think of leaving, but how to hide money from her pimp, (Herman, 1992) a battered women doesn’t think about escaping the abuse, but how to cover up bruises and survive the next beating, and in the case of the Palestinians, life now is not about how to end the occupation, but how to grow a few vegetables to feed the entire family when foreign aid is cut off. The unpredictable nature of violence of living under oppression is another layer of insecurity and structural violence – which village will have stricter laws today? Which village will be invaded by Israeli tanks ‘for security measures’?
Those trained in the current medical model have difficulty with giving power to the patient (Herman, 1992), and those trained in a public health model have difficulty giving power to the vulnerable, the poor (Farmer, 2009). Restoring control to the traumatized person is essential in recovery, both in recovering from trauma, and in giving them the power to gain their own opportunities to earn for their families instead of, as Roy puts it, rescuing them with food.
By giving a victim food and water, one is not giving them power, but the basic necessities of survival, rendering them, dependent. How can one grow, thrive, and rise above their trauma if
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they are locked in a cycle of poverty and dependency that won’t allow for them to heal from or escape their trauma? Diminishing helplessness is critical in the healing process of trauma, but how can one feel but helpless when he or she has no say on when food, movement, or freedom is possible?
Herman and Farmer emphasize, one cannot assume the role of a rescuer, but rather, giving power back to the victims of oppression, rather through a political movement, or a model of resistance that enables them to both resist and be free of the occupation. “No intervention that takes power away from the survivor can possibly foster her recovery, no matter how much it appears to be in her immediate best interest” (Herman, 1992). Furthermore, safety is essential to recovery from trauma. Herman explains that recovery occurs in three stages, the central task of the first stage is establishment of safety, while the second stage is remembrance and mourning and the third stage is reconnection with ordinary life (Herman, 1992), although emphasizes that they are not linear or even straightforward. Without safety, no other task for recovery can resume
– and the victims are just looking for a new way to survive. The first is comprised of the basic materials needed for survival such as shelter, food, water and safety, which the second is the psychological and social component, which includes three main categories, sense of home, a link to community and a positive and hopeful sense of the future (Giacaman et al, 2007). Here we see
Roy’s argument that only one of these components is being met in Palestine – through humanitarian aid, food (not always) is secured, but the Palestinians still lack the security of freedom, movement, and psychological security having hope for a better future.
As for the second stage of recovery, the Palestinians might never reach it without first establishing a sense of security. One of the many tragedies of the Holocaust is the lack of mourning, the lack of closure when thousands upon thousands of Jewish people were mass
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murdered. Herman vehemently emphasizes the importance of mourning, recounting the tragedy and acknowledging what has happened, the loss, the pain and the identifying the symptomology.
The problem in Palestine, is that we may never reach the mourning level because safety cannot even be established for the survivors – rendering their lives at risk every single day, whether in front of a tank, at a checkpoint, or waiting for food.
Without a safe environment, therapeutic work towards healing is impossible. A safe environment must take precedence over anything else – the ability to feel safe to live a full life is essential to healing from the trauma. This is precisely what is robbed of the Palestinians – the luxury of safety, living a life free of violence, and healing from their trauma. Being robbed of this important part of healing puts the Palestinians back in a cycle of trauma – dependency – normalization – trauma, and their behaviors may continue to be impacted negatively by this vicious cycle. Structural violence defies the ordinary conventions of bereavement – the tragedy is ongoing. Remembering Roy’s warning into a descent to a humanitarian issue closes the door on justice and even a political movement, further normalizing the occupation. Normalizing the occupation, normalizes the traumatic experience – as it indeed becomes the norm of their lives, and not worthy enough of improving, treating, or saving.
Although Herman’s groundbreaking studies on trauma and recovery challenge established diagnostic concepts, it doesn’t push further enough to cover the challenges and symptoms that are faced by Palestinians’ chronic trauma and social suffering under political oppression. Both Herman and Giacaman talk about a certain type of resilience that victims of trauma possess and use for opportunity, but what is not clear is what happens to this resilience when the chance for any opportunity to escape is gone? Does this resilience manifest in other
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symptoms, acts of aggression against one’s loved ones, or diminish into a hallow hole of depression, or does it simply go away?
Conclusion:
According to Herman, what made these responses successful was that they were organized outside of the traditional framework of medicine and mental health – a new framework was established to better understand their trauma. Without the context of a political movement, it was never possible to study the effects of psychological trauma in warfare or rape/incest victims
(Herman, 1992).
A new language must be created for the powerless – we must listen to them, in their own words, in their own experiences, however painful or tragic, to gain a deeper understanding of their lives under oppression, the value of their lives being chipped away day by day, law after law, with every restriction imposed. Whether it’s through a personal encounter with death, or living in an open-air prison with no freedom – their traumas matter, and they must be understood on a level that is closest to their experience – not on one we define in another context.
For centuries, the trauma women faced was being studied by men – people who didn’t understand the nature of the trauma on the most intrinsic level – being violated by a more powerful, dominant, and aggressive offender, and subsequently diminished as hysterical. It took years of research, listening, community engagement, and a political movement to give voice to those afflicted by this trauma. An entirely new diagnostic tool was setup to understand their traumatic experiences inflicted by their powerful aggressors. Perhaps, as in the case of understanding trauma in women, we have been doing the Palestinians an injustice – giving the voice to the powerful, the key international players that deem the Palestinians as unfit for their
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own state, rather than giving the voice back to the Palestinians, the people facing the trauma.
Holding a perpetrator accountable for the crimes committed is not just necessary for justice, but for the well-being and healing of the victims.
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References Abu Zayd, Karen “Palestine Refugees: Exile, Isolation and Prospects” (Edward Said Lecture, Princeton University, Princeton, NJ, 6 May 2008).
Altawil, M., Nel, P.W., Asker, A., Samara, M., &Harrold, D. (2008). The effects of chronic war trauma among Palestinian children. In M. Parsons (ed.) Children: The invisible victims of war – An interdisciplinary study. Peterborough-England: DSM Technical Publications Ltd.
Awad Mataria et al., “The Quality of Life of Palestinians Living in Chronic Conflict: Assessment and Determinants,” European Journal of Health Economics 10, no. 1 (2009): pp. 93–101, https://doi.org/ 10.1007/s10198-008-0106-5.
Bearing the Brunt Again. Child Rights Violations During Operation Cast Lead. Al Mezan Centre for Human Rights. September 2009.
Bridget H, Kleinman A, (2011). Chapter Two, Unpacking Global Health. Case Studies in Global Health: Biosocial Perspectives. Vol 1.
Borowy I, Davidovitch N, (2005). Health in Palestine and the Middle Easter Context. Dynamis. Acta Hisp. Med. Sci. Hist. Illus. 25, 315-327.
B’Tselem: Statistics on Settlements and Settler population, May 2011, updated 2017. https://www.btselem.org/settlements/statistics
Clea McNeely, Brian K. Barber, Carolyn Spellings, Rita Giacaman, Cario Arafat, Mahmoud Daher, Eyad El Sarraj & Mohammed Abu Mallouh (2014): Human insecurity, chronic economic constraints and health in the occupied Palestinian territory, Global Public Health: An International Journal for Research, Policy and Practice.
Dawidowicz, Lucy S 1981. The Holocaust and the Historians. Harvard University Press
Farmer PE, 2005. Pathologies of power: Health, human rights, and the new war on the poor. 2nd edition. Berkeley: University of California Press. 402 p.
Farmer P, (2010). On Suffering and Structural Violence Partner to the Poor. Berkeley: University of California Press. Chapter 16: 40.
Farmer P, Jim Yong Kim, Arthur Kleinman, Matthew Basilico. Reimagining Global Health. An introduction. University of California Press. 2013
Farsakh Laila, Palestinian Labour Migration to Israel, p. 55. Also, see pp. 53–54 and pp. 58–60. London: Routledge 2005.
Galtung J, Violence, (1969). Peace and Peace Research. J Peace Research. 6:167-191.
Galtung J, 1997. Violence: Reflections on a national epidemic. New York: Vintage Books. p.306
78
Giacaman, R. Khatib, R., Shabaneh L., Ramlawi, A., (2009) Health Status and health services in the occupied Palestinian territory. The Lancet. 373:837-849.
GISHA, Restrictions on the Transfer of Goods to Gaza: Obstruction and Obfuscation (Tel Aviv: January 2010) and GISHA, Brie ng: Israeli High Court Decision Authorizing Fuel and Electricity Cuts to Gaza (HCJ 9132/07, issued January 30, 2008) (Tel Aviv: 31 January 2008).
Glick, Peter. Kammash Umaiyeh, Mohammed Shaheen, Ryan Andrew Brown, Prodyumna Goutam, Rita Karam, Sebestian Linnemayr, and Salwa Massad. Prevalence and Patterns of Health Risk Behaviors of Palestinian Youth. Rand Corporations – Working Paper. 2016
Halper, Jeff “The Obfuscation of the Two-State Solution: You Can’t Get There From Here,” Counterpunch, 21 February 2012, www.counterpunch.org/2012/02/12/ you-cant-get there-from-here.
Herman, Judith 1992, 1997. Trauma and Recovery. Basic Books
Hever, Shir The Political Economy of Israel’s Occupation: Beyond Mere Exploitation (London: Pluto Press, 2010).
Khalidi, Rashid. The Iron Cage: The Story of the Palestinian Struggle for Statehood. Beacon Press, Boston. 2006.
Kleinman, A. (1988). The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books.
Leaning J. (2008). Disasters and Humanitarian Crises: A Joint Future for Responders? Prehospital and Disaster Medicine 23(4): 291-294.
Lautze S, Leaning J, Raven-Roberts A, Kent R, and Mazurana D. (2004). Assistance, Protection, and Governance Networks in Complex Emergencies. Lancet 364:2134-2141.
Li, Darryl From Prison to Zoo; Darryl Li, “Disengagement and the Frontiers of Zionism,” Middle East Report, 16 February 2008, www.merip.org/mero/ mero021608.
Li, Darryl “From Prison to Zoo: Israel’s ‘Humanitarian’ Control of Gaza,” Adalah’s Newsletter, Volume 44, January 2008, www.adalah.org. Also see “HCJ 9132/07, Jaber al-Basyouni Ahmed v. The Prime Minister,” www. adalah.org.
Lifton Jay, Robert, 1968. Death in Life: Survivors of Hiroshima. Random House.
Makdisi, Saree “The Strangulation of Gaza,” Nation, 1 February 2008.
OCHA Humanitarian Monitor September 2008 and occupied Palestinian territory cap 2009
OCHA, “Humanitarian Fact Sheet on the Jordan Valley and Dead Sea Area,” February 2012, http://www. ochaopt.org/documents/ocha_opt_ jordan_valley_factSheet_february_2012_ english.pdf.
79
Palestinian Central Bureau of Statistics, 2009. Victimization Survey - 2008: Main Findings Report. Ramallah - Palestine. Palestinian Central Bureau of Statistics, 2013. Victimization Survey 2012. Main Findings. Ramallah Palestine.
Palestinian Central Bureau of Statistics, 2017. Victimization Survey 2016. Main Findings. Ramallah Palestine.
Palestinian Central Bureau of Statistics, 2006. Domestic Violence Survey (December, 2005-January, 2006): Main Findings Report. Ramallah - Palestine. Palestinian Central Bureau of Statistics, 2012. Violence Survey in the Palestinian Society, 2011 Main Findings. Ramallah - Palestine.
Palestinian Central Bureau of Statistics, 2012. Annual Report. Palestine Children–Issues and Statistics. Child Statistics Series (No. 15). Ramallah–Palestine.
Palestinian Central Bureau of Statistics, 2016. Annual Report. Palestine Children–Issues and Statistics. Child Statistics Series. Ramallah–Palestine.
Palestinian Central Bureau of Statistics, 2005. Psychosocial Report, 2005: Main Findings Report. Ramallah - Palestine
Palestine Red Crescent Society, (PRCS) Annual Report, 2010.
Patel, Vikram, and Arthur Kleinman; Poverty and Common Mental Disorders in Developing Countries; Bulletin of the World Health Organization 81, no. 8 (2003); 615.
Rita Giacaman, Yoke Rabaia, Viet Nguyen-Gillham, Rajaie Batniji, Raija-Leena Punamaki & Derek Summerfield (2011). Mental health, social distress and political oppression: The case of the occupied Palestinian territory, Global Public Health, 6:5, 547-559, DOI: 10.1080/17441692.2010.528443
Roy, Sara 2012. Reconceptualizing the Israeli-Palestinian Conflict: Key Paradigm Shifts. Journal of Palestine Studies, 41:3; p. 71-91.
Salama P, Speigel P, Talley L, Waldman R. (2004). Lessons Learned From Complex Emergencies Over Past Decade. Lancet 364: 1801-13.
Shehadeh, Raja 2012. Occupation Diaries. OR Books, New York and London
Shehadeh, Raja 2008. Palestinian Walks: Notes on a Vanishing Landscape. Profile Books Ltd.
Sphere Handbook. Humanitarian Charter and Minimal Standards 2004; Chapter 1 – The Humanitarian Charter. Vick, Karl “Why Israel Doesn’t Care About Peace,” Time Online, 2 September 2010, http://www.time.com/ time/magazine/article/0,9171,2015789,00. html.
Wagner, Heather Lehr. 2007. Elie Wiesel, Messenger for Peace. Chelsea House Publishers
80
Waters, Ethan. Crazy Like Us: The Globalization of the American Psyche. Free Press, New York, NY; 2011.
World Bank, Coping with Con ict: Poverty and Inclusion in the West Bank and Gaza (Gaza and Washington: The World Bank Group, 2011), p. 1.
World Bank, Palestinian Economic Prospects: Aid, Access and Reform (Washington, D.C.: 22 September 2008), p. 22; Sara Roy, “Gaza: Treading on Shards,” Nation, 17 February 2010.
World Bank, Palestinian Economic Prospects: Gaza Recovery and West Bank Revival, p. 6.
World Bank, Towards a Palestinian State: Reforms for Fiscal Strengthening— Economic Monitoring Report to the Ad Hoc Liaison Committee (Washington, DC: 13 April 2010), pp. 1–12
World Bank, The Underpinnings of the Future Palestinian State: Sustainable Growth and Institutions Economic Monitoring Report to the Ad Hoc Liaison Committee (Washington, DC: 21 September 2010)
World Bank–West Bank and Gaza, “Restrictions Continue to Undermine Palestinian Economic Viability, Say World Bank,” news release, 16 September 2010 also see: and International Monetary Fund, Macroeconomic and Fiscal Framework for the West Bank and Gaza: Sixth Review of Progress Staff Report for the Meeting of the Ad Hoc Liaison Committee (New York: 21 September 2010).
World Bank, Stagnation or Revival? Palestinian Economic Prospects—Economic Monitoring Report to the Ad Hoc Liaison Committee (Washington, DC: 21 March 2012).
World Health Organization: Health and Human Rights. Update 2011.
World Health Organization: Health Conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan. A62/INF.DOC./2 May, 2009.
Yoke Rabaia, Mahasin F. Saleh, Rita Giacaman. (2014). Sick or Sad? Supporting Palestinian Children Living in Conditions of Chronic Political Violence, Children and Society, 28:172-181.
Yoke Rabaia, Rita Giacaman and Viet Nguyen-Gillham (2010). Violence and Adolescent Mental Health in the Occupied Palestinian Territory: A Contextual Approach, Asia Pac J Public Health, 22:216S
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Appendices
Appendix 1: Definition of Terms
1. oPt – Occupied Palestinian Territory 2. West Bank – Refers to the Palestinian Territory under Israeli Control, also Occupied Palestinian Territory. 3. Nakba – Arabic term refers to the “Great Catastrophe” of 1948, when more than 700,000 Palestinians, or about two thirds of the population, were forcibly expelled from their homes, creating refugees, displaced Palestinians, and war. 4. Checkpoints – A network of manned gates, usually with Israeli police or soldiers, throughout the Palestinian territory, as a way to control the movement of the Palestinians both within Palestine and outside of Palestine (to Israel, Jordan, Egypt, etc.) by checking identification documents and performing body searches. 5. The Wall – In June 2002, the Israeli government began constructing the Wall, or as they called it a temporary “Separation Barrier” as means of security measures to protect Israel from suicide bombers coming from Palestine. The Wall consists of a complex system of barriers including a 8-9 meter high concrete cement wall that spans 800 kilometers, electrified fences, patrol roads, ditches, earth mounds, closed gates, trenches, roadblocks, electronic monitoring system and a no-go buffer zone50. 6. Intifada – Arabic term for “Uprising” refers to the Palestinian uprising against the Israeli military occupation, as a way to resist the oppressive regime. First intifada was in 1987, second intifada was in 2000. 7. WHO – World Health Organization 8. PCBS – Palestinian Central Bureau of Statistics 9. UNRWA - United Nations Relief and Works Agency for Palestine Refugees in the Near East 10. Settlements- Residential enclaves created by the Israeli government throughout the Palestinian territory for Jewish residents only and that have restricted networks to connect
50 The Humanitarian and emergency policy group (HEPG) and the Local aid coordination committee (LACC), The impact of Israel’s separation barrier on affected communities, update 3, November 30, 2003, p.7. 82
its residents to Israel. Under international law, these settlements are illegal, as they have turned its native Palestinians into refugees. (Palestine Monitor, 2012). 11. Area C: Area C covers 60% of the West Bank, where about 300,000 Palestinians live, and 325,000 Jewish settlers live in 125 settlements and 100 outposts (settlements not legally recognized) distributed across the area. With heavy military presence, Israel maintains control of security and land, imposing restrictions on movement, between villages, agricultural and economic development (B’Tselem, 2017). 12. Dar Al Amal: Rehabilitation center in the West Bank for youth in trouble with the law or who have behavioral issues reported by their schools or families (PCBS, 2012 and OCHA, 2012)
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Appendix 2: Map of Middle East
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Appendix 3: Map of Palestine
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