Eyad El-Sarraj, M.D.,D.P.M.
Ahmad Abu Tawahina, M.A.
Fadel Abu Hein, PH.D.

Presented at "THE FIRST INTERNATIONAL CONFERENCE ON THE MENTAL HEALTH AND PSYCHOSOCIAL WELLBEING OF REFUGEES AND DISPLACED PERSONS".

OCTOBER 6-11, 1991.
STOCKHOLM, SWEDEN,

Early History
Both the Arabs and the Jews trace their origins back to their patriarch Abraham. The Hebrew tribes, known as the Children of Israel, embarked on the conquest of Canaan (as Palestine was then known) in the 13th and 12th centuries BCE, at about the same time as the Philistines (from whom the name Palestine derives) were taking possession of the coastal area. The Hebrews established the Israelite kingdom, whihe reached its peak under King David around 1000 BC, before splitting into a northern kingdom and the southern kingdom of Judah.

After some centuries of subjection to other powers, an attempt to restore an independent kingdom ended with the Roman conquest of the area in 63 BC. The Jewish people rebelled and then over a century later, the Romans undertook the reconquest of the country, taking Jerusalem by storm and destroying its temple. After further revolts, the Emperor Adrian finally expelled all Jews from Jerusalem in AD 135.

The Arab Muslim conquest of Palestine was completed in Ad 640 ; but, it took over a century for the majority of the population to embrace the Muslim faith (10-15% of the Palestinians still adhere to Christianity). The first four Muslim caliphs (i.e. successors to the prophet Mohammed) ruled from Arabia, after which Damascus became the seat of the Arab Empire. Except for the interlude when a series of Crusader kingdoms ruled parts of the eastern Mediterranean basin in the 12th and 13th centuries, the region remained under asuccession of Muslim regimes, including 400 years of the Ottoman Turks, until the end of World War I. (El Sarraj, 1991). The Palestinians of today are the descendants of the Canaanites, the Philistines and other early tribes which inhabited the country, including Greeks, Romans, Arabs, European Crusaders and the Turks. (M. Menuhin, 1965).

Seeds of Conflict

The Palestinian modern time tragedy of today goes back to the early days of the twentieth century when the Zionist movement was created as a reaction to the anti-semitism and persecution of Jews in Europe. The declared goal of Zionism was to establish a Jewish home in Palestine. This movement coincided in time with a changing world scene and redistribution of power. While the Ottoman Empire was disintegrating, Britain and France were poised to spread their colonisation and exploitation of what we know today as the Third World. In the Sykes-Picot agreement, they decided to divide the Middle East between themselves (J.e. Hurewitz). Soon after the War, it was so arranged that Britain was "delegated" by the league of Nations to have mandate over inhabitants for independence." But already Britain had, in the name of it's foreign minister, declared it's sympathy towards the Zionist plan of establishing a home for the Jews in Palestine. The declaration, contained in a letter addressed to Lord Rothchild, came to be known as the Balfour declaration (J. Davis 1968).

The Zionists affectively used Britain's presence in Palestine to faeilitate Jewish immigration into Palestine. This immigration triggered the Palestinians to resist-sometimes violently-the obvious concerted attempt of transform their country into a Jewish state. Britain increasingly came under pressure from different directions; while the Palestinians were demanding on immediate halt to Jewish immigration and the implementation of the intent of the League of Nations Mandate, namely their Independence, the Zionist movement was exerting its powerful influence to allow for the free entry of Jewish immigrants to Palestine. Such a call held particular persuasive power in the wake of the Holocaust and the resulting European guilt over the event.

Following the second World War the United Nations debated the future of Palestine. It decided to partition the country into two states: one Jewish and one palestinian. The Jews, who formed 30% of the total population, were given 56% of the land (Fig.1). The Palestinians objected, and the confrontation between the two sides escalated.

The Americans, winners of the war, came into the picture in their own fashion and for their own reasons. Preoccupied with the presidential election, and concerned about the Jewish vote, the American president, Harry Truman, ordered the post war economically shattered Britain to open the doors of Palestine for the Jews. Amidst confusion , turmoil and violence, Britain decided that it was leaving Palestine.

Immediately the Zionist movement speeded its activities to control the country, mainly by waging a campaign of terror and psychological warfare. The campaign culminated in the Deir Yasseen massacar, which lead to a mass exodus of unprotected civilians. According to the eye witness account of the International Red Cross representative, 254 men, women, and children were slaughtered and many of their bodies were stuffed into a well (J. Davis, 1968 ). Sir Herbert Samuel, a Jew, himself, and the High Commissioner of Palestine, testified on the event before the House of lords : " The Jewish people have always taken pride in the good deeds and the distinction won by their members....Today these same people have given birth to a set of assassins...I feel bound to say that the Jewish population of Palestine and the Jewish Agency are blameworthy for not having extirpated this curse which has brought shame upon all members of the Jewish community."( 23/4/1947, The House of Lords debate on Palestine). The wide spread terror and fear, which was instrumental in forcing the Palestinian villagers to flee for safety, was welcomed by Menachem Begin who subsequently wrote:" The villagers were seized with limitless panic and started to flee for their lives. " (M. Begin,1951). Then the Zionist forces employed the tactics of spreading rumours among the villages that "the attachers would repaeat what they did in Deir Yasseen". Igal Allon, the head of the Jewish strike force, "The Haganah", wrote later: " I gathered all the Jewish Mukhtars, and asked them to whisper in the ears of the Arabs that a great Jewish force has arrived in the Galilee and they are going to burn the Arab villages." (W. Khalidi, 1961). The plan of emptying Palestine pf ots majority Arab population and the transformation of the country into an exclusive Jewish state was succeeding. The demographic changes in Palestine between 1918 and 1948 ( fig.2) show the extent of Jewish influx into the country: on increase of more than 400%. To consolidate their gaims and to block any attempt of the Palestinians to claim a right to return, the new Israeli government demolished and destroyed hundreds of Arab villages. (Benny Morris, 1987, Fig.3). "A country without people for a people without a country" was the slogan of the Zionist propaganda. In the absence of any effective Arab resistance, Israel embarked on the obliteration of the history of the Palestinians. Indeed, the Palestinian tragedy was blocked from the conscience of the world.

In May 1948, Israel declared its statehood in Palestine. The Arab masses in the neighbouring countries were enraged and demanded action from their regimes, all of which were unprepared and unwilling to go to war. These regimes were imposed on the people by the dominant foreign powers, who were sympathetic to the Zionist movement. But to save face seven Arab countries sent their armies into Palestine "to restore law and order." In his memoirs , the British Commander of the Arab Legion confirmed the absence of the intention to fight in the Arab side (J.b.Glubb, 1959). But the declared intention to "fight until Liberation" provided fuel for Zionist propaganda, which pleaded to the "civilised world" to protect them from the Arabs, who were out to throw the Jews into the sea.

Life in the Diaspora

Following the four-week "war", nearly one million Palestinians became refugees(annual report of the Sec. General of the United Nations 1/7/1948-30/6/1949,p.102). They found themselves dumped into refugee camps in the West Bank, the Gaza Strip, Jordan, Syria, and Lebanon. In 1950 after it had failed to implement its revalution on their repatriation (resolution, etc.) the United Nations established a special body , UNRWA , to help the Palestinian refugees. In fact, the UN General Assembly reaffirmed resolution 194 every year in its discussion of the Palestine Question. But it was to no avail since Israel remained opposed to repatriation, contrary to its declared obligation upon its admission to the UN in May 1949.

When they started their journey fleeing the war, many Palestinians believed that they would soon return after the Arab armies had liberated the land. They were mistaken. They had gradually to comprehend what had happened, and how it all went wrong. The deep shocke and sense of helplessnes, the memory of being uprooted from their homes, and the experience of relying on charity and hand-outs had a profound impact on the

individual and collective psyche of the Palestinians. The oldes generation felt guilty and ashamed and tried to block the memories from the young. Flashbacks, dreams and nightmares haunted the people.

Some were busy occupying themselves with day to day survival, finding employment, feeding their children many of whom were forced to beg for food in the streets of Beirut or Damascus (F. Turki, 1988).

The structure of the Palestinian society was suddenly shattered; families were separated and clans were dismembered. Some lost their loved ones in fighting or during the exhausting journey to exile, and some are still unaccounted for.

The Palestinians were mainly farmers and villagers and it was these persons who were hardest hit by the abrupt and painful changes. They left every thing behind: the simple content village life, the warm neighbourhood and the close relations, and above all the land, their life-line, security, and hope. Added to this was the painful realisation that their skills were not needed in the host countries, whose own peasant population was barely surviving. They were unemployable and their skills disappeared since they could not train their children when there was no land.

Today the Palestinians number nearly five million: two million of them live in the West bank and Gaza, around one million in Jordan, one million in the other Arab countries, and one million in the rest of the world (Fig.4). Two million Palestinians are currently registered with UNRWA whose operations cover the Occupied territories,Jordan, Syria, and Lebanon. UNRWA provides shelter, basic food, primary health care, and elementary education for the registered refugees. Further education and secondary health services are dependent on the host countries.

The Palestinians appreciated the significance of education. The new generation was encouraged to pursue university and higher 10 education, and they took advantage of the free education offered to them, particularly in Egypt. From the mass of refugees some streamed to the oil rich Gulf states where they were respected as successful teachers, doctors, engineers and business men. These persons remitted some of their income to their families left behind in the refugee camps. But that relative security was not to last; in the aftermath of the Gulf War, 300,000 Palestinians were expelled from Kuwait and many hundreds were tortured, raped or killed.

From refugees to revolutionaries

Following the "Catastrophe", as their uprooting came to be known, the Palestinians began a painful soul searching. They felt guilt and helplessness in the face of the conspiracy and the superiority of the Zionist and colonial powers and they blamed the Arab regimes for failing to stand against the common enemy. Other Arab populations were also unhappy with these regimes and soon revolutions and popular disturbances broke out in Egypt, Syria, Jordan, Iraq and other countries.

The most significant development in the area following the Catastrophe was the 1952 revolution in Egypt. The leaders of the Revolutionary Command Council declared that they were determined to rid Egypt of the corrupt King, a puppet of the English, and liberate Egypt from colonial domination. They claimed that the defeat of Egypt in Palestine was determined before going to battle by the King and his regime (G.A. Nasser, 1953). The revolutionaries in Egypt became a symbol in the Arab World and a source of inspiration from Algiers to Iraq. They championed the Arab national dream of liberation , unity, and social justice. The Palestinians idolised Nasser, who became the unchallenged leader of the Arabs every where.

In the absence of a Palestinian leader Nasser became a Hero and more. He became a father.

Egypt, in effect, posed a threat to the domination of foreign Western powers in the Third World. The new revolutionaries were inspiring the masses every where to liberate their countries. Britain, France and Israel decided to wage a war against Egypt, each with a special aim in mind. They secretly concocted a plan to invade Egypt, and in October 1956, they did. But public opinion in Britain and France, and pressure from the United States and the Soviet Union, forced them to withdraw. (A. Nutting, 1967). The war has never ended.

In the wake of the Egyptian revolution and the ever repeated vows and slogans by the Arabs to "liberate the Land", and largely due to the feeling of helplessness, the Palestinians relied on the Arabs to help them regain their home and on the United Nations and the World conscious to implement UN resolutions which called for their return. Gradually the Palestinians were convinced that they could only rely on themselves. The call for organising the Palestinians and for armed struggle was rapidly gaining ground among a new generation of disillusioned youth.

The Palestine Liberation Organisation (PLO) was proclaimed in Jerusalem in 1964, uniting all the under ground guerilla factions which spanned the political spectrum from left to right.

More significantly, the establishment of the PLO began a new era of Palestinian nationalism. The Palestine National Council became their Parliament in exile, and the PLO became a home in waiting and a government for every Palestinian.

 The PLO and its factions declared war on Israel on all fronts. The political scene was changing rapidly, and the Palestinians case was a dominant and central issue in the Middle East. The rise of the PLO threatened Israel, which promptly decided to act. It launched the Six Day War in June 1967 against Egypt, Syria and Jordan. Within six days it had occupied the West Bank, the Gaza Strip, the Sinai desert, the Golan heights, and East Jerusalem (Fig.5). The war resulted in the displacement of a further 350,000 Palestinians, of whom 175,000 become refugees a second time( UNRWA 1982).

In the first few years of the occupation, the Palestinians put up a stiff armed resistance in both Gaza and the West Bank. They were supported by PLO bases which had been established across the border in Jordan. Jordan, where the majority of Palestinians live, preceived the PLO as threat to its stability. In the subsequent confrontation the PLO was driven out of Jordan, leaving behind thousands of dead and injured and a legacy of deep mistrust and suspicion. One of the consequences of the violent confrontation was the further radicalisation and the birth of Black September, an under ground splinter group with the declared intention of revenge.

The PLO founded a new base in Lebanon, and it rapidly began to dominate over Palestinian affairs and later became an influential party in the complex Lebanese political situation. The multiplying military bases were used to launch attacks on the northern border of Israel, which was continuously retaliating by bombing the Palestinian refugee camps and the bases themselves. In short, the PLO presence was neithetolerated by Israel nor by Lebanon and, for that matter, by the Syrian regime, who wanted to control the politics in this area.

In 1982, Israel invaded Lebanon. After six months of heavy bombardment and intense war, Israel occupied the southern part of Lebanon and forced the PLO out. This time the PLO went to Tunisia, and its forces were dispersed between several Arab countries. The destruction of the PLO's physical presence in Lebanon crippled the Palestinian resistance movement. Finaly, however, due to the terrible blood shed and destruction the world began to take note of the Palestinian tragedy.

Life under Israeli occupation

For the last twenty five years the Palestinians in the West Bank and Gaza have been living under military occupation. The central aim of the occupation is two fold: first to gain more land and further the realisation of "Greater Israel", and second to add strategic depth and security to Israel. There is a third aim which is to use the territories in any future negotiations to obtain both Arab acceptance of Israel and American financial compensation (This third Israeli strategy proved successful in the peace treaty with Egypt, The Camp David Agreement of 1979).

The Israeli policies in the Occupied Territories have been condemned both world-wide and inside Israel itself. Criticism has focused mainly on disregard for basic human rights and on the policy of confiscating Palestinian land for Israeli settlement purposes. Many Israeli and international groups have monitered humman rights abuses by the Israeli occupation authorities, including.. Amnesty International, Physicians for Human rights, Israeli Mental Health Workers for Peace (IMUT), and Israeli Palestinian Physicians for Human Rights to name a few. Beside the denial of basic human rights, the Israelis have also implemented harsh economic measures.

Palestinians not present in the Occupied Territories when the 1967 war broke out have been denied the right to return to their homes except for visits or under limited family reunion provisions. (By contrast, under the 1950 Law of Return, Jews are allowed to come from any part of the world to live in Israel as full citizens.)

Since 1967, more than 50% of the land of West Bank and 40% of the land of Gaza has been confiscated by the Israeli occupation authorities for military and settlement purposes. (M. Benivisti, 1986). Thousands of landless Palestinians have been absorbed into the Israeli economy as cheap, unskilled and semiskilled labourers. Neverthless, unemployment- with no state benefits - is very high, especially in Gaza where two thirds of the 730,000 people live in eight refugee camps. Families of 10-15 are squeezed in two or three rooms in poor hygienic conditions which contributed to the high infant mortality rate (70 per 1000).

Palestinian farmers who have managed to keep their land have been subjected to military restrictions which control the use of water wells. Meanwhile, Israelis have dug deeper wells in order to divert the water to the Jewish settlements (M. Lowi). As a result of these and other measures, the Israeli occupation has crippled the Palestinian economy and the Occupied Territories have become Israel's second largest export market.

Palestinians are denied freedom of speech, meeting, travelling, publishing, and they are punished for expressing their national identity in any form. Even wearing a dress made of the colours of the flag or singing a national song can be considered a crime against the state. More than 67,000 Palestinians in the Gaza Strip alone have been imprisoned by the Israelis since the beginning of the occupation in 1967. This figure takes on greater importance when one considers that it does not include those imprisoned during the Intifada or that the population of the Gaza Strip dose not exceed 730,000 people. Currently, there are 5,500 Palestinians from the Gaza Strip who are imprisoned in central prisons for "Security" reasons. Another 5,700 are being detained in camps such as Ansar 2, Ansar 3, and Ansar 4. (International Red Cross, Gaza).

The Israeli policies aim to force the majority of the Palestinians out of the Occupied Terrotirres. The Israelis will then surround the remainding enclaves with settlements. In 1983, Minister without Portfolio Porat, announced that within five years, most of the refugees would be resettled in new residential areas ( Al Quds 1983). In the meantime the notorious Sharon plan for multiplying the Israeli settlements throughout Palestinian land is being carried out with vigour, determination and unashamed contempt for the Fourth Geneva Convention and UN resolutions (Fig 6). Several military "emergency" or "security" orders have been introduced in order to create the legal pretext for such policies, such as the Closed Areas Act of 1949, The Security Areas Act of 1968, and the Usage of Land Act of 1953 (Kanana 1985).

The Intifada:

On December 9th., 1987, the Palestinian Uprising, "the Intifada" erupted in the West bank and Gaza. It was a mass movement of civil disobedience and rebellion against the Occupation.

The Israeli army's response to the Intifada was to intensify and expand its brutal and oppressive measures. Shooting and killing, detention without trial, demolishing homes, torture, deportation, curfews, breaking bones, and using tear gas were among the most commonly used methods. The Israeli government has, in addition, waged a harsh economic war on the Palestinians in retaliation for their refusal to pay taxes and for their boycot of Israeli products. The Palestinian schools and universities were closed by military orders for most of the Intifada on the pretext that they were breeding grounds for rebellion. As well, the Israeli military has arrested thousands of persons.

The Israeli forces can detain any Palestinian without pressing charges for up to 12 months, and the age of criminal responsibility for the Palestinians has been reduced to twelve. Finally, in the first 33 months of the Intifada, approximately 1,100 Palestinians were shot and killed. 54% of them were children under the age of 14 years. Twenty two thousand have been physically injured, 55,000 have been detained, and hundreds of homes have been demolished (A. E. Nixon, 1990).

Mental Health :

The 1948 Catastrophe has been a central focus of fear and insecurity which deeply affects the inner layers of the Palestinian psych. The shock of uprooting and life in exile have resulted in a general state of helplessness and dependency. Some of the Palestinian new exiles were hostile.

As well, the lightening speed of Arab defeat in 1967 and the resulting occupation of the West Bank and Gaza, shocked the Arab masses but particularly the Palestinians. The dream of

libration, Arab unity, and victory was suddenly shattered. Helplessness, victimisation, and paranoia deepened. Unprepared and unprotected, the Palestinians had to face their very enemy who was now armed with a sophisticated and modern arsenal.

For over 40 years the Palestinian community has been terrorized, haunted by insecurity, an increasing sense of helplessness, and frustration. This has translated clinically into varied pictures of psychopathology, particularly depression and anxiety. Drug addiction has also spread rapidly among the young. Another form of psychopathology has been the increase of physical and verbal forms of violence and anti-social behaviour. Families, clans, and political factions have been plagued by infighting. Finally, men have abused their women and children, the most helpless and vulnerable members of society. This phenomenon indicates that Palestinans directed aggression inwardly in a self-destructive reaction (El Sarraj, 1988).

Initially, the Intifada transformed the Palestinian psychology; it restored a positive self-image, high self- esteem and national pride. Helplessness was replaced over- night by a positive assertiveness. The individual felt responsible and identified strongly with the national struggle. Social cohesion replaced the infighting. Depression gave way to hope, Joy, andmass euphoria. The Intifada was an outlet for the simmering bottled up anger. The individual and the communal psychic tension found a legitimate target: The Israeli soldiers.

 Four years on, the picture has changed. The stagnated political process, and the aggressive Israeli response have both contributed to the re-emergence of the feelings of frustration, and calls for radical and violent tactics, particularly in the Gaza Strip, which in many ways fits the model of a prison. The youth, are prepared to sacrifice every thing and themselves for the cause of liberation of the Holy Land. Death is conquered by glorifying the life hereafter. In this environment, everyone is affected by the overwhelming stress, which is bound to reactivate new waves of violence. In a pilot study we recently carried out in Gaza to assess the level of anxiety among adults, we found that 22% of the adult males and 37% of adult females are suffering from high to severe anxiety. In the clinical room 45% of the clients have stress-related disorders (Fig.7).

According to a study in the West Bank on adult Palestinians , 64% of the participants were subjected to humiliation , harassment, and/or beating (E. Awwad, 1989). The resulting anxiety of the parents themselves is obviously transmitted to their children.

Children, experience a variety of stressful events like being beaten, injured, or witnessing their parents beaten or killed. Others are terrified by the night raids of the soldiers, and not a small number had been separated forcibly from their families. These experiences have left severe marks on the children. In our latest survey of 1500 children (average age 11 years), we found that 95% of them were tear gassed, 52% had been beaten, 11.2% detained, 97% had their house raided, 3% had suffered death in the family, and 1.1% had had their house demolished.

Baker concluded a study in 1989 with results showing a high incidence of behavioral problems among Palestinian children (A. Baker, 1988). Abu Heine concluded his PHD thesis by stating that 28% of the children expressed profound anxiety in the first six months of the Intifada. This percentage dropped to 13 % in the following 6 months, possibly due to adaptation (F. Abu Heine,1988). In a recent study on children from the Gaza Strip, We found that 60% of them are continuously hyperactive, 22% querulous, 38% easily provoked, 62% are fearful of the soldiers, and 30% wet their beds. (GCMHP, 1990).

In an apparent contrast, some researchers have observed that Palestinian children express a high self-esteem in identifying strongly with their national struggle, and they express a willingness to participate actively in the struggle ( Punamaki R.L. 1987). What is obvious from all these studies and observations is that Palestinian children are suffering from the effects of victimisation while at the same time keeping a heroic profile at the expense of healthy assimilation of the trauma.

Conclusion:

Nations are like individuals, each tries to be the master of his own destiny. Palestinians and Jews are victims of history, discrimination, and persecution. In their attempt to conquer their history of victimisation and to change the image of the helpless Jew into a master, the Jews , victims of yesterday, have turned into the oppressors of today. What is happening in Palestine today is a desperate battle of wills. The Palestinian nation is struggling to assert its identity and to heal its injured dignity. Jacobo Timerman, an Argentinian-born Israeli writes "Nothing can replace the need of a people to organize into a state in the territory in whihc they live and which belongs to them. The alternative our government offers, no matter how it masks it, is to continue repressing the Palestinian people until we destroy their will to live and liquidate their national identity. It's incredible that such a policy is being considered by the very people who demonstrated that this is impossible, that it is immoral, that it is criminal." (El-Farra 1987)

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