Palestinians Refugee: mental health situation

1. Palestinians Refugee: mental health situation Abdel Hamid Afana, Ph.D Director of Research & Training, GCMHP

2. ThemesHistorical ContextMental health,Transgenerational effectsSteps of interventions

3. Al Nakbah (the catastrophe) • In 1948: 914,221 Palestinians were displaced or become refugees • 531 Palestinian villages and towns were depopulated or demolished

4. In 1948 fully 531 Palestinian villages and towns were depopulated or demolished. In 1948 more than 914,221 refugees First uprooting (Al Nakbah)

5. The Second Displacement In 1967: the second displacement • 325,000 Palestinians from the Gaza Strip and the West Bank were displaced, many of them refugees originally displaced in 1948, the majority sought refuge in neighboring Arab states.

6. In 1967, 175,000 became refugees for 2nd time 2nd uprooting

7. Third Displacement • 312,000 Palestinians were working and living in Kuwait in 1990, but as a result of the Iraqi invasion of Kuwait in 1991, the vast majority of those refugees were displaced and are still without secure residency. • Only 30,000 Palestinians were living in Kuwait in 2000. (Shmil.com)

8. Scattered everywhere • The total number of Palestinian refugees are around 5 million persons, of which more than 4 million are registered with the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). • No accurate figures are available for Europe, the United States, Canada, Scandinavian countries, Australia, Latin America, Africa and South America.

9. UNRWA: Reigestered RefugeesUNRWA 2005

10. 2. mental health: Transgenerational effects • Since 1948, Palestinians - have experienced oppression, trauma, related socioeconomic and political problems - Al Nakbah represents the loss of the homeland, the disintegration of society, the frustration of national aspiration and the beginning of a rapid process of destruction of culture and community. • The psychosocial consequences of `Al Nakbah` were very dramatic and devastating: people lost their land, livelihood, and political power.

11. Al Nakbah is a moment when the majority of Palestinians become homeless and stateless: a state that is associated with a deep sense of insecurity, fear, anger, hopeless and powerless. In this situation, the house key has become the symbol of the former home and of the return to it, and the land has become the dream that transmits from one generation to another. Connecting Souls to Land

12. Culture and Identity: Struggle for Survival • First Intifada 1987 The cost of the Intifada has proved to be high and has affected all sectors of the Palestinian community. Men and women of all ages suffered general stress, frustration and hopelessness which inevitably activated new waves of violence and aggression aimed at restoring people’s dignity and self-esteem. However, thousands have been killed or left handicapped, and young adults are ready to sacrifice everything -- including their life -- for the cause of liberation of their land and for the promise of life hereafter.

13. The stalemate in the peace First recognition (Oslo agreement in limbo) • Raise the Palestinians expectations • More restrictions • Confiscation of land • No tangible results • re-opened wounds created by the loss of important family members and friends, causing more stress

14. Second Intifada 2000 • The conflict escalated further in which Israelis fight with lethal force and Palestinians resist with whatever they have. • Shelling by Israeli helicopters and tanks, and bombings from fighter jets, have become a part of Palestinian daily life: on socioeconomic, political and family structures, and resurgence of Palestinian painful memories of being uprooted, being expelled from their villages to refugee camps in the Gaza Strip etc.

15. Second Intifada 2000 • 73,105 Palestinian houses have been demolished. Feeling of collectively punished. • In the last 5 years (from Sep. 2000 to Sept.2005), over 4,000 Palestinians were killed by the Israeli Army, among them 766 children. An additional 45,486 Palestinians were injured, and 8,600 individuals put in prison, among them 288 children. (Al-Jazeera, 2005). • A survey showed that about 56,000 Palestinians had to change their place of residence (PCBS, 2001)

16. Mental illness or Disease of Living\ Mental health situation • 88.5% of teenagers in Gaza had a close family member beaten by the Israeli soldiers. • 55.7% of the sample witnessed, or knew of the arrest of their close family members, while 31.1% reported that they had close relatives in prison. • 95.0% of the teenagers said that Israeli soldiers broke into their homes on at least one occasion. Helou et al (1994)

17. Helou et al (1994) • Significant increase in fear, anxiety, anger and hatred toward Israeli soldiers. • Ways of coping with fear included prayer and reading Koran, reading books, talking with elders, meeting friends, and sleeping—although sleep was associated with nightmares. • Coping with anger involved religious rituals such as prayer, making wudu, going to mosque and directing their anger towards the IDF. The rest became agitated and cried when they were angry.

18. Memories of LossHouse demolitions Triggers the uprooting

19. Women who had their homes demolished expressed more anxiety and depressive symptoms than those who simply witnessed others’ homes being demolished. • Children whose homes were demolished showed significantly more psychological symptoms. • Common symptoms were fear of the army, diminished concentration, constant weeping, and reexperiencing the traumatic event; the most common symptoms in the witness group of children were fear, irritability, easily provoked and having night terrors. Qouta et al 1997

20. Thabet et al 1998 • 21.5% of children in Gaza had anxiety disorders. Girls reported higher levels of anxiety than boys. • The most frequent abnormal behaviours indicated by teachers were lying (10.5%), disobedience (10.5%) and bullying (11%). The most frequent emotional symptoms were worries (17.3%), fears (11.8%), and feeling miserable (5.9%).

21. Punamaki et al 1997 • Exposure to traumatic events increased children’s political activities regardless of the quality of perceived parenting • Traumatic events increased the children’s psychological adjustment problems regardless of the quality of perceived parenting • Poor parenting can make children more vulnerable in traumatic conditions.

22. Lifetime traumatic event was reported by 36.8%. The most frequent events reported were imprisonment (16.1%) and torture 15.4% Qouta et al 2001 • The most recent research about PTSD among Palestinian children between the ages of 6 to 16 found that 58% of girls and 50% of boys had severe PTSD. Qouta et al 2003

23. Culture, Religion & Mental & Health • Arab society consists of complementary patterns of family structures. It emphasizes the collective over the individual. • The family, therefore, is important to harmonize interrelationship between the individual and group. One of the most important parts of its affiliation is the hamula, which includes a number of generations in a part lineal line that have a common ancestor.

24. Culture, Religion & Mental & Health • Religion as a form of self-identity, hence a threat to their culture, encourages people to return to their religious roots in order to protect their culture. • Religion imparts explanatory mechanisms, including meaning, purpose and specific aetiologies. • Mental disorders and Possession • Physical presentation of mental disorders

25. Somatized Suffering Most common presented symptoms in primary care (Afana et al 2003) • Every thing is an effort 44.7% • Nervousness 26.8% • Hopelessness 21.4% • Depressive mood 17.5% • Worrying too much 17.5%

26. Women endorse more somatic symptoms than men questions dealing with anxiety, and somatic complaints Headache Crying Easily

27. Cont., Results Men reported three symptoms more frequently than women: worries about the future insomnia having no interest in things

28. The prevalence of anxiety and depression symptoms was 73% and higher among females • Refugees living in refugee camps demonstrated a higher prevalence of symptoms than those who were living in other settings. In General, Refugee population constitutes around 75%; distributed as follows: 56% in 8 refugee camps 46% outside camps Afana et al 2003

29. being a parent is one of the most complicated tasks • a quarter of women in Gaza were exposed to domestic abuse at least once in their childhood. • The changing roles for women (involved in the political struggle) • Many of these women whose husbands were arrested, imprisoned or killed in the struggle, had to become the head of the household.

30. Is there there a room for optimism?

31. Community Intervention Model Philosophy • Enabling families to cope with the wide range of mental health problems, compounded by human rights violations, emphasizing a social support network as an effective way to face mental ill-health issues • The responsibility of the health professionals is to move from intra-personal focus to interpersonaloriented care

32. Ground for optimism • Mobilize local services in the community to assist individuals in feeling that they are responsible participants, contributing to their health. • Building bridges for peace through developing strategic partnerships with individuals and institutions concerned with justice, peace and respect for human rights.

33. In Protracted conflicts:What does Trauma mean?

34. What conistitutes PTSD?

35. Thank you for your listening