Community mental health development in the occupied Palestinian territory: A work in progress with WHO


1 Background

1.1 Demographic

The occupied Palestinian territory includes the two geographically separate areas of the West Bank and Gaza Strip. The areas feature several historical cities including East Jerusalem, Bethlehem, Hebron, Jericho, Nablus and Gaza City.

The West Bank and the Gaza Strip have been under Israeli military occupation since 1967 and, for Palestinians, travel between the two entities is rendered impossible. Thus, the two communities remain isolated from each other and many families remain split.

The West Bank comprises an area of 5,800 sq. km. west of the River Jordan, and consists of diversified communities. The population of the West Bank is 2.3 million persons (47% urban, 47% rural and 6% in refugee camps). There are observable differences in the lifestyles and living conditions of the different socio-economic groups, religious affiliations, urban, rural and refugee communities.

The Gaza Strip is a narrow piece of land with an area of 360 sq. km, lying along the coast of the Mediterranean sea. The area has a very dense population, due to the tiny area and the lack of freedom of movement. The population of 1.3 million is mainly concentrated in cities, towns and refugee camps.

Because three quarters of the Palestinian population is under the age of 30, with a very small proportion over the age of 60 years, it can be assumed that there would be a high presentation of mental illness that is typical among younger people (such as first episode psychosis) and a low rate of presentation of mental illness more typical among older people (such as dementia and geriatric depression).

Due to the social structure of Palestinian society, and its emphasis on the extended family, even the severely mentally ill tend to remain in the family environment and are cared for by relatives. This may in part account for a relatively low (45-55%) occupancy level in the psychiatric hospitals. It also reinforces the need to strengthen community-based outpatient services, as well as to build support systems for the families of those suffering from mental health problems.

1.2 Current situation

Since the outbreak of the second intifada (Palestinian uprising against the Israeli occupation) in September 2000, the West Bank and Gaza Strip have been the focus of intensive Israeli military operations, severe restrictions on the movement of goods and people, curfews, sieges, house demolitions, land confiscation, settlement expansion and by-pass road construction.

Since the summer of 2002, the Government of Israel has also been pursuing the construction of a Separation Barrier, parts of which are being built on West Bank land east of the Green Line, and in some instances encircling whole communities in the process.

These measures have serious consequences on the day-to-day life of Palestinians. By isolating Palestinian communities from one another and fragmenting the territorial landscape of the occupied territory, they have generated dramatic economic, social and personal hardships that will leave their mark on the region for years to come.

As an illustration of the above, according to the World Bank:

- The real growth rate in the West Bank and Gaza declined from 6.3% in 2005 to 4.9% in 2006; (World Bank Quarterly Report, April 2006).

- The average Palestinian daily income is now less than 2 US dollars per day. The poverty rate was 31% in 2000 and stood at 51% in 2006; (World Bank Quarterly Report, November 2005).

- Unemployment is significantly high at more than 23% (double that of the pre- Intifada level); (Palestinian Central Bureau of Statistics Report, 2005).

- Labour access to Israel has decreased from 146,000 during the third quarter of 2000 to 67,000 in the second quarter of 2005; (World Bank - West Bank and Gaza Update Report, April 2005).

- Real GDP per capita declined by 27% in 2006 and the personal income by 30%. The main reasons are being the restriction of movement, goods, suspending the revenues and the direct handling of exports and imports by the Israeli Authority. (World Bank - West Bank and Gaza Report, April 2006).

1.3 Implications for mental health

Currently, there are very few reliable mental health data, such as incidence and prevalence, for the occupied Palestinian territory. (This should be remedied to a significant extent through the epidemiological study planned through the WHO Project in 2006 and 2007). Anecdotal evidence from many mental health sources leads to the conclusion that the high levels of acute and chronic stress in the occupied Palestinian territory, due to the socio-political situation, render the entire Palestinian population more vulnerable to mental health problems and, in particular, to a higher incidence of symptoms of anxiety and/or depression amongst the general population. Research from around the world has demonstrated that those individuals with a predisposition to severe mental illness (e.g. schizophrenia, bipolar disorder) are more likely to develop the disorders, or to see their symptoms worsen, if living in stressful conditions. In 1997, between the two Intifadas, a population-based study (n=585 adults), involving fully structured diagnostic interviews, was carried out among adults in Gaza. Data, collected by the Gaza Community Mental Health Programme, shows that in the previous 12 months before the interview the percentages of the adult population meeting the criteria for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) were:

- 10.6% post traumatic stress disorder (PTSD)

- 12.3% met the criteria for anxiety disorder

- 4.8% met the criteria for mood disorder

- 4.8% met the criteria for somatoform disorder. (Ivan Komproe, PHD, Transcultural Psychosocial Organization, written communications, 2003)

The mental health of Palestinian children and adolescents is of particular concern, as young people living in war zones are at high risk of developing emotional problems. The ongoing conflict, repeated traumas, the humiliation, and the poverty were and still are the constant environmental factors affecting individuals and communities.

Recent studies in the occupied Palestinian territory have shown that the stressors present in every-day Palestinian life due to the Israeli occupation (severe restrictions on freedom of movement, unemployment, lack of access to education and healthcare, etc.) seriously impact on personal, familial and community functioning.

A Quality of Life survey - recently conducted by WHO (WHO, Community & Public Health Institute "Birzeit University" and Palestinian Central Bureau of Statistics - "Quality of life survey in WB and Gaza", 2006) revealed that: About 1 in 4 Palestinians (25.6%) feels their quality of life is poor or very poor; 1 in 5 (21.2%) suffers a lot or extremely from physical health problems that negatively influences their ability to function and affect their life quality; about 4 in 10 feel frustrated (38.3%), anxious (38.2%), fed up with life (37.9%), and, in greater proportion, bored (46.7%).

Almost 1 in 2 Palestinians is dissatisfied a lot or extremely with their living environment, while 1 in 3 Palestinians suffers a lot or extremely from financial problems. In particular, almost 1 in 2 Palestinians (49.7%) would not be able to bear sudden medical expenses. Nearly half of the respondents seriously fear losing their home (45.5%), losing their land (46.1%), to be displaced or uprooted (44.5%).

Preliminary research has shown a significant increase in emotional, physical and behavioural symptoms in the population affected by the 'Wall' that is currently being constructed. For example, research carried out by the Palestinian Counselling Centre in Qalqiliya area, showed that:

- 52% of those surveyed had thoughts of ending their life

- 92% feel no hope for the future

- 100% reported feeling stressed

- 84% expressed feelings of constant anger because of circumstances beyond their control. (The impact of Israel's Separation Wall on Palestinian Mental Health: A Study in the Qalqilia District, Palestinian Counseling Center, 2005)

Feelings of insecurity have also increased in the areas directly affected by the Separation Barrier (90% compared to 75% in other areas of the West Bank).

1.4 Situation analysis

According to WHO's Global Burden of Disease (2001), 33% of the years lived with disability are due to psychiatric disorders. This growing burden amounts to a huge cost in terms of human misery, disability and economic loss. The widening recognition of mental health as a significant international public health issue has led to the growing need to demonstrate that investment of resources in service development is not only required, but also worthwhile. There is growing economic evidence to support the argument that interventions for schizophrenia, depression and other mental disorders are not only available and effective, but are also affordable and cost effective. (WHO Report, " in Mental Health", 2003).

In 2002, the first situation analysis undertaken by WHO in West Bank and Gaza revealed no mental health policy and a lack of public mental health services.

The mental health system was still more hospital-based than community-based. Psychiatric hospitals in Bethlehem and Gaza were still the main assets to mental health care, while community mental health provision was extremely patchy and rooted in a traditional and biomedical-oriented approach.

Services were fragmented, under-developed, poorly resourced and, in many areas, no services were available. Mental health human resources were extremely scarce, and existing staff were over-worked, burnt out, poorly trained and demotivated.

The public were unaware of the nature of mental illness, had misconceived views and held very stigmatising and fixed beliefs surrounding mental illness.

There was a lack of knowledge of mental health at primary health care level, no referral system or cooperation between different parts of the public health sectors or between the public health sector and the private sector or NGO sectors.

Some non-governmental organizations were, indeed, providing good mental health services but in an uncoordinated way; therefore these fragmented good practices were not able to influence the general mental health system and actually were leaving untouched the culture of public sector services.

In this situation a traditional and sometimes archaic, biomedical model was prevailing and actually preventing innovative approaches taking place. This led to a lack of an integrated service system and waste of resources in some situations, as the real needs of people with mental health problems were not addressed.

In addition, the 2002 situation analysis revealed no concept of holistic mental health care, high levels of stigma and no consumer support or advocacy groups. Last but not least, the general situation of West Bank and Gaza was obviously not conducive to good mental health for the population, including mental health workers.