Monday, October 27, 2008

I’m sitting at the Ramallah Cultural Palace at the opening of the Gaza Community Mental Health Program’s international conference, Walls vs. Bridges. This is a modern facility with a large auditorium, in which are seated over a hundred internationals, all mental health professionals, physicians, and academics. We’re looking at a projection of the conference platform in Gaza City, with Dr Eyad El-Sarraj at the podium. Some technical problems with the audio hookup are being worked out. I write during these interruptions. So far we have seen several presentations, including video messages from Luisa Morgantini, the Italian vice-president of the European Parliament, and just now from Roselyn Carter (wife of Jimmy C.).

The absurdity of this situation is painful. It would be hard to imagine a group of individuals less threatening to the state of Israel. I was asked by a reporter for Israeli radio yesterday, by phone, if we were a security threat. I replied that, on the contrary, we were the kind of people you would want to have nearby in a crisis. Of course, the people of Gaza have suffered far worse deprivations than the absence of a group of international conference attendees, but it is heartbreaking, in its way, that our colleagues in Gaza have been planning this meeting for a year and looking forward to some direct contact with their counterparts from the outside world, and now they are deprived even of that. We had been planning on getting into Gaza and spending the better part of the week there, seeing the operation of their health facilities under conditions of siege, interviewing clinicians and patients, perhaps seeing some patients with our colleagues, and now that’s all gone. We’re making the best of it, and for sure it is a great opportunity still to meet our counterparts from around the world. Yesterday we – the international participants – held a press conference at an East Jerusalem hotel, which went well albeit the participation of the press was scant. As luck would have it, we were in direct competition with the very first soccer match of the Palestinian team on Palestinian soil, held at a newly-built stadium outside Ramallah. The president of FIFA was here and there was a press frenzy around it. Following our press conference we boarded buses and traveled to the Erez checkpoint into Gaza. I was surprised; when our group had entered Gaza in 2005, this facility was a small low building, you walked in the door, presented your credentials at a desk, sat in a small waiting room. Now it has been replaced with a monstrous stone-and-glass structure resembling the new terminal at Ben Gurion Airport, surrounded by a security fence which prevents any approach but through a locked gate. About 50 or 60 of us internationals, joined by a number of Israeli activists, young and old, and some Palestinian citizens of Israel, marched and chanted, then approached the gate and banged on it with everything we had. We kept it up with a lot of energy. The handful of uniformed, armed police and security people on the other side of the barrier looked at us impassively. No one would come and talk with us. After a while – presumably they tired of listening to our racket – some blue-uniformed police emerged from behind the fence and gently pushed us away from the gate. It also became clear that the handful of Palestinians who were sitting patiently on a bench outside the gate would not be allowed through until we moved away. So we marched some more, then gathered for some impromptu remarks from our ranks. The press was, in fact, there – perhaps a dozen or so photographers and videographers, though I don’t know for whom they were working.

We have had a very good trip so far, but it’s a trip through a landscape of despair. We are all impressed by the number of Palestinians who tell us they are tired, they are hopeless, they want to leave. This outlook seems, to our anecdotal experience, to be increasing. Prior to arriving in Ramallah for the conference, I and others from the health/mental health track of our delegation – especially Jim Deutsch and Mark Etkin, both Canadian psychiatrists – were at the Farah Center in Nablus, which is the Palestinian Medical Relief Committee’s facility for outpatient rehabilitation, mostly for children. We saw a number of patients and families with our Palestinian colleagues; Mark saw several adults disabled by IDF gunshot wounds, Jim worked with families whose children had a variety of disabilities and behavioral problems, and I saw kids with some general pediatric issues and psychosocial and developmental problems as well. This felt very natural to me – much like seeing patients at home. Fortunately, we had a good amount of time with each patient. The first child I saw had life-threatening malnutrition superimposed on developmental delay and brain atrophy. Although the Farah Center is not set up for this kind of medical care, and they have no nutritionists available to them, we developed a refeeding plan based on WHO protocols and the therapists will supervise. We saw several children with developmental disabilities and seizure disorder.

This is 8-year-old Khefaya, who lives with her parents and 3 siblings in NablusOld City. She has a seizure disorder and does poorly in school. Her mother brought her to see us because of her aggressive behavior. She often hits her siblings upon awakening, and “quarrels with everyone, everywhere.” Sometimes she refuses to take her seizure medicines. We spent at least a half hour eliciting her medical and behavioral history, and thought we had heard all the relevant background when Jim asked the therapist who was translating for us to ask her what were her fears: what was she afraid of? She answered, the Israeli (“Yehuda”) soldiers, who have broken into her bedroom at night and sent her screaming into her parents’ room. One one occasion they took her father outside, and she was terrified that they would arrest him, and she would never see him again. She reported a recurring dream: the soldiers are upstairs in their house, and the family runs outside and stands in the rain. We asked her to draw a picture of this dream:

She explained to us that she had drawn the Israeli soldiers at the top, as cats. Why cats? She didn’t say, but we know that Nablus is full of cats, many feral, and that at night they fight and scream. She drew them with no arms, and explained that that was so that they could not carry guns. Below she drew her family – though they appeared to be smiling, she explained that they were afraid, that this was something more like a grimace. Her mother told us that the last invasion of their home was about nine months ago, and that Khefaya is still afraid to go outside at night. Their home has been invaded 20 times in the past four years. Asked why, she replied that “they don’t want anything from us, they are always searching for someone else". Clinicially, this reminds us of a couple of important points. Traumatized patients do not always offer accounts of their trauma until asked - as Dr Ruchama Marton, the psychiatrist co-founder of Physicians for Human Rights-Israel pointed out to me some time ago, such painful experiences may not be held in the forefront of their consciousness, since it is too threatening; and secondly, the conditions of occupation are often inextricably linked to the health, mental health, and public health of the Palestinaian population. Sometimes this is obvious, sometimes not.

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