Palestinians Refugee: mental health
situation
Abdel Hamid Afana, Ph.D
Director of Research & Training, GCMHP
Themes
Historical Context
Mental health,Transgenerational
effects
Steps of interventions
Al Nakbah (the catastrophe)
• In 1948: 914,221 Palestinians were
displaced or become refugees
• 531 Palestinian villages and towns
were depopulated or demolished
In 1948 fully 531 Palestinian
villages and towns were
depopulated or demolished.
In 1948 more than
914,221 refugees
First uprooting (Al Nakbah)
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.
In 1967, 175,000 became
refugees for 2nd time
2nd uprooting
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)
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.
UNRWA: Reigestered Refugees
UNRWA 2005
Camps
Jordan
10
In camps
281,211
Not in camps
Total
1,477,063
1,780,701
Lebanon
12
210,952
189,630
400,582
Syria
10
112,882
311,768
424,650
West Bank
19
181,241
506,301
687,542
Gaza
8
471,555
506,301
961,645
1,259,813
2,995,307
4,252,120
Total
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.
• 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
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.
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
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.
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. (AlJazeera, 2005).
• A survey showed that about 56,000
Palestinians had to change their place of
residence (PCBS, 2001)
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)
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.
Memories of Loss
House demolitions
Triggers
the uprooting
• 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
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%).
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.
• 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
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.
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
Somatized Suffering
Most common presented symptoms in primary
care (Afana et al 2003)
• Every thing is an effort
• Nervousness
• Hopelessness
• Depressive mood
• Worrying too much
44.7%
26.8%
21.4%
17.5%
17.5%
Women endorse more somatic
symptoms than men
questions dealing with anxiety, and
somatic complaints
Headache
Crying Easily
Cont., Results
Men reported three symptoms more
frequently than women:
worries about the future
insomnia
having no interest in things
• 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.
Afana et al 2003
In General, Refugee population
constitutes around 75%;
distributed as follows:
56% in 8 refugee camps
46% outside camps
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.
Is there there a room for
optimism?
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
interpersonal oriented care
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.
In Protracted conflicts:
What does Trauma mean?
What conistitutes PTSD?
Thank you for your listening