Palestinians’ mental and physical Health

An interview with Rita Giacaman

Rita Giacaman is a professor at (and founder of) the Institute of Community and Public Health, at Birzeit University, in the Israeli occupied Palestinian territory. She has chronicled the effects of Israeli military occupation on the life and health of Palestinians under occupation focusing on the impact of chronic war-like conditions and exposure to violence on the health and wellbeing of Palestinians. Her focus lies also on the psychological and social well-being of adolescents, aiming to create methods for implementing health and welfare programmes in prolonged violent conditions.

Books and Ideas : Your research has explored mental health issues and their physical effects in contexts of war and violence. How does Palestine under Israeli occupation compare to other zones of conflict, looking at objective health indicators?

Rita Giacaman: First, I have a problem with the notion of ‘objective’ health indicators. I know this is used in the literature, but the problem is that it then, by contrast, implies that subjective indicators, such as quality of life, or self-rated health, that is, measures that rely on people’s assessment of their health status themselves, are invalid while objective ones are considered the truth. At least this is the impression which one gets using the term ‘objective’ when in fact, subjective indicators can predict death and disease and are very important because they bring in the voice of people themselves into assessments. Not that ‘objective’ measures should not be used, they should be, but combined with ‘subjective ones’ to assess people’s health from varied perspectives.

Second, I am not sure about comparing. Comparing what with what? If different so-called conflict affected zones are into different ‘stages’ of development, it would be a mistake to compare, as we only compare those which are similar in all other variables except health.

But in general, the ‘objective’ measures, such as death, disease, and disability, in the occupied Palestinian territory are better than other countries in conflict. For example, and although I have a problem comparing using infant mortality rates but perhaps needed for a bit of clarity, the infant mortality rate in Israeli-occupied Palestine, that is, the West Bank and Gaza Strip in 2021 was 13 infants under the age of one year deaths/1000 live births, compared to 21 for Iraq, 26 for South Africa, and 39 for Sudan [1]. The question is why do Palestinian fare better than other people living in conflicts and wars: this is likely because our country is not as ‘poor’ in its resources as other countries, especially human resources, as Palestinians are generally well educated, and education has an important bearing on health. And the Israeli occupied Palestinian territory has not been quite a third-world country and not quite a first-world one, somewhere in between with peaks and troughs depending on the situation. With the current war on the Gaza Strip surely measures such as infant mortality rates will be decidedly negatively affected.

While we Palestinians have lived lives in what is called conflict, and I would call warlike conditions, there were peaks and troughs over the years. Our Palestine question has been lingering for 100 years, so it is not that attacks and severe exposure to political violence begin and end, it is an ongoing situation with intensification and decline, which my grandmother, mother, myself, and our daughter have been living through all our lives. I think the main issue is the following: how does one live all one’s life in warlike conditions, and how does this affect health overall, as physical health has an important bearing on mental health and vice versa? Given such a question, it becomes essential to think long-term and in terms of objective and subjective measures to understand what happens to people in chronic war.

At the Institute of Community and Public Health at Birzeit University, on the West Bank of Israeli occupied Palestine, we have developed an understanding of health derived from our lived experiences which have led us to a research agenda that places suffering at the center of inquiries, in a continuum between ease, the state of complete health, and dis-ease, or sickness. As you know, I am a public health academic, and our Institute focuses on health research broadly defined, meaning that we understand health as primarily a social and political construction, and not only a biological predisposition. In public health, our approach to research is deductive; that is, we use theories and principles developed by others and subject them to empirical scrutiny, then rebuild from there. We deconstruct to reconstruct. Having understood the importance of the notion of suffering, which anthropologists discuss in theory or using qualitative methods, but which we experience in our daily lives, we began to develop quantitative measures that can assess the suffering people endure in chronic warlike conditions, what I call the ‘invisible wounds inside’ [2]. Such measures which we experience daily include: distress, human insecurity, uncertainty, human rights violations, deprivation, and humiliation [3]. We usually begin from the ground up, with ordinary people, with qualitative work to build measures based on their reported experiences. We then pilot these measures statistically, that is, we check their internal consistency and that the questions in the scale measure the same phenomenon and what we want them to measure, then we conduct surveys of either the entire population or groups within the population to assess these suffering items, and also their effects on health. Over time, we have developed a solid framework and measures which we use to evaluate health status, both physical and mental [4] and we continue. Right now, we are in the final stages of analyzing and writing up the results of the measure of uncertainty. Important in warlike conditions, but also important in other aspects of life as well.

Books and Ideas : What are the various ways in which violence trickles down and descends into Palestinians’ everyday lives and ordinary experiences?

Rita Giacaman: Violence here is part of our everyday life, anthropologist Veena Das discussed this in terms of the daily about all sorts of violence of living simply, in a poor place, in a strongly patriarchal context, etc. Here, we have that, but above all, we have systematic and chronic exposure to political violence, which descends to the ordinary, the daily. This means that we are subjected periodically to attacks by the army or Israeli illegal settlers on Palestinian land with bombs, bullets, etc, but there is another form of violence they subject us to in our daily life, for example, the violence of trying to obtain a permit to cross an Israeli army checkpoint with checkpoints dotting the landscape of the West Bank; the violence of trying to get to the university without being hit by tear gas or sound bombs thrown at us by the Israeli army, or walking because the Israeli army has gouged out the roads; or the violence of being denied a permit by the Israeli occupation administration to exit the country, or stay in the country no matter how old or sick you are. There is, of course, more, but these are only examples of the daily violence Palestinians are exposed to on a regular basis which makes for daily violation, even without being shot or killed or injured. Indeed, daily suffering.

Books & Ideas: The notion of trauma is most often apprehended through the definition of Post-Traumatic Stress Disorder by the Diagnostic and Statistical Manual of Mental Disorders. Do you think such an approach is appropriate to make sense of the consequences of violence on Palestinians’ health?

Rita Giacaman: There is a real problem with the concept and measures of PTSD. First, in the Palestinian context, there is no such thing as post. Violation and political violence are ongoing, so it is not that we have been through violation and now need to get over it. It is that we are chronically violated every day, as described above. No chance for recovery, that is, although somehow, and amazingly, we seem to be resilient, and as I have written elsewhere, we normalize the abnormal [5]. That is, we endure and resist violation by remaking daily life as normal as possible after a violent attack, especially because we are surrounded by networks of supportive relationships with families, neighbors and community who assist in accessing a range of resources to help us in resisting violation and normalizing the abnormal and getting back to daily life as quickly as possible.

Then, of course, the PTSD category is problematic for other reasons. It should be mentioned here that the symptomatology included in the diagnosis of PTSD was derived from US patients in clinics who were seeking help. Well, especially in mental health, culture is of the essence, and the symptoms they may have in the US can be very different from the symptoms we have here in expression of distress. We found out in one of our studies that the symptoms people have after being exposed to heightened violence in the Gaza Strip are a bit different from those on the West Bank. While we are both Palestinian, we have differing contexts and express distress differently. For example, in one of our investigations, Gazans reported having rapid heartbeats as one of the symptoms/expressions of distress, which was not reported at all by West Bankers, and so on. Likewise with depression, the symptoms of depression in one place can be very different from another. My mentor, who used to be the psychiatric director of the Bethlehem Mental Hospital in the 1950-1990 made it very clear to me that symptoms of mental health problems can change even within the same culture, given changes in context. This is why the symptoms checklist for different diseases should be updated periodically.

Then, of course, with PTSD, there is the problem of researchers using a checklist of symptoms derived from patients attending health centers in the US, then using these symptoms for surveys of the general population elsewhere, in another context and culture. That is, extrapolating from the health center in one place to a population survey in another place is quite problematic and raises questions about the validity and relevance of using such instruments everywhere. We do not swallow whole what is relevant and applied in the US, or elsewhere, without validating and ensuring the reliability of such instruments in our setting. Of course, we do not throw the baby with the bathwater either, so we do not reject all instruments developed elsewhere. Instead, we test international measures and assess their validity and utility in the Palestinian context, reject some [6], and use others that we have validated and know work in the Palestinian context, such as the WHO 5 wellbeing index; we then develop measures which are derived from the Palestinian people’s daily lives and as people express them. Our work focuses on examining how Palestinians react and survive chronic exposure to violence and the violence of the daily.

I suppose you can call this decolonization of knowledge production as well. This entails conducting qualitative interviews to understand people’s experiences with daily political and other forms of structural violence, and how they express such experiences and what they do to their health broadly defined; then use such interviews to develop a local instrument related to one of the aspects of suffering , then validate such an instrument quantitatively, then conduct studies to assess the suffering item, such as humiliation, insecurity, human rights violation etc., and their effects on health.

What is interesting is that now the literature does indicate that stress through distress can lead to disease. But our conceptualization preceded this understanding and relied on the local conceptions of health and disease, which do not differentiate between physical and mental health. To give you an example, if you ask someone how is your health today, one might say: I am unhappy (mish mabsout), but it means ill, so combining physical and mental. If you continue to ask, you discover that there is a range of feelings/symptoms that people express denoting health status, which run on a continuum from: not bad (mish battaleh), to tabaneh (tired), to mjaalakeh (wrinkled) etc, to marida (sick), all noting general physical and mental health. Is this not interesting that the local/and Arab notions of health and disease are, in fact, going along with something that took the West a long time to understand: the inseparability of physical and mental health?

That is, our conceptualization of health is therefore not dichotomous (either healthy or sick). Instead, we conceptualize health as in a continuum between ease and disease as manifested in the example above, as opposed to dichotomies of either sickness or health. And within this continuum, suffering operates in various ways affecting both physical and mental health, and includes aspects such as human insecurity, uncertainty, human rights violations, humiliation, all of which can, over the life course, lead to disease, depending on the type, severity and extent of insult and resources available to people. We have suffering as a domain and an important domain that can affect physical health in different ways.

We particularly appreciate what anthropologists have been writing all along, including Veena Das and others about the notion of suffering [7]. They posit that social suffering is the result of political, economic and institution power and their consequences on people and their health, and as part of the daily. Some suggest that such suffering can derive meaning from an understanding that suffering is human, but that not all suffering is equal. Furthermore, it is thought that one can experience suffering while also being part of a ‘moral’ community which gives meaning to this suffering. Indeed, in the Palestinian context, meaning making is derived from the fact that we are all exposed to Israeli political violence as a community, albeit to different degrees; we believe that the moral imperative is ours as we are the occupied and Israel is the occupier; and we are supported by strong communal and national social solidarity which peaks during times of intensification of political violence [8].

Our framework explaining the trauma of war, but not only, allows for an understanding that goes beyond this dichotomy by expanding the concept of health to be a continuum rather than yes or no, with a range of feelings, symptoms, and responses to trauma which over the life course, can lead to illness. We know now from the international literature that stress is associated with diabetes mellitus, hypertension, even cancer, and suffering can lead to stress which in turn can lead to disease.

Books & Ideas: Do you believe this reframing of public health has become even more critical today?

Rita Giacaman: Yes, I do, especially now with the war on the Gaza Strip. Sometimes I find what is written unbearable. Numbers of dead, numbers of injured, numbers, numbers, numbers, my goodness. We are not numbers, we are people with feelings and suffering, the bulk of us are suffering as we have not been killed or injured yet. In the Gaza Strip, about 18 000 have been killed as of the time of saying this, but there are more than two million Gaza Palestinians, so what are they enduring? What type of suffering comes as a result of the destruction of infrastructure, home, services, social worlds, the killing of family members, and the lack of food or water? What does this mean to life and health? It is not enough to count dead bodies; we need to tally the effects of war by finding out what happens to the living.