My six day experience in the Middle East
http://www.100md.com
《英国医生杂志》
1 studentBMJ
The studentBMJ editor travels to Israel and the occupied territories, trying to make sense of an impenetrable situation. This is her diary
Introduction
The team
Accompanying me is Andy Aitchison, a freelance photojournalist, and Michelle Hawkins from MDM UK. We've communicated daily on the phone, trying to arrange the complex logistics, but only manage to meet for the first time at the airport.
Before leaving I received a brief warning that I'd probably be in for harsh scrutiny on arrival at Ben Gurion airport. So I was relieved to be welcomed only with a glower, a few quickfire questions, and the request for evidence that I was from the press.
Jean Sebastién Dy, the general administrator of MDM in Jerusalem, and Sebastién Laplanche, general coordinator, meet us at the airport and take us to our accommodation in an MDM marked car with flags flying from the back. Our base is the newly refurbished MDM staff house in East Jerusalem, the predominantly Palestinian part of Jerusalem. Most of the other NGOs and UN buildings are located in the vicinity. Jean Sebastién says: "The Palestinian areas are friendlier than the Israeli parts, and we're also here to work with the Palestinian community."
Sunday
Passing the Dead Sea and Jericho, both below sea level, we travel on the smooth highway alongside the fertile banks of River Jordan, looking over to the mountains of neighbouring Jordan. The road, primarily for the use of settlers, is named Gandi Highway—the nickname of Rehavam Ze'evi, the assassinated ultranationalist Israeli tourism minister, who supported a transfer policy advocating that all Palestinians be forced into Jordan.
Mobile service for women and babies
We're on our way to Ein al-Beida, a village in the north Jordan valley, where MDM jointly runs a mobile woman and baby preventive health service with British medical relief agency Merlin and the Union of Health Work Committee (UHWC). It focuses on cancer screenings for women, developmental evaluation for children, nutritional assessments and counselling for families, and personalised health education sessions in the home.
Before we enter the road to the village, a red Israeli government sign warns that Israeli citizens are forbidden from going any further by order of the IDF commander. Entrance is allowed only after prior coordination with the responsible authorities. A multitude of similar signs is dotted around the West Bank.
The UHWC team are late. They've been held up at a checkpoint. Although there are supposed to be fewer travel restrictions for health workers, I'm told that they can't always move around freely and are often held up at checkpoints. Nevertheless, it's easier for them than for patients. The facilities may exist in towns, but, after the escalation of violence during the second intifada, the IDF tightened security and further increased the number of checkpoints, making it impossible for Palestinians in the West Bank to travel freely. I'm told that sometimes Palestinians are forbidden from travelling on many of the main roads in the West Bank.
The wall in Abu Dis makes travelling to Jerusalem's Augusta Victoria Hospital (tower is in top left of photo) and Dome on the Rock more complicated
Credit: ANDREW AITCHISON
People don't understand preventive health care
Most of those scheduled for appointments fail to turn up. As a reminder, their names are read out over the village mosque loudspeaker, which the muezzin normally uses to issue his prayer call. Suzanne Abujeradeh, outreach coordinator for the northern West Bank, explains that Palestinians generally do not understand the importance of preventive health and will try to access health care only when they are ill. We decide to trudge down the muddy dirt tracks to visit the families in their homes instead—a delegation consisting of two healthcare workers, Elham Aqab and Noujoud Shalabi, Michelle, Andy, Nadia Dibsy (our translator and advocacy officer for MDM), and me. No one seemed the slightest bit perturbed by our international ensemble and welcomed us in with sweet tea and Arabic coffee.
Looking after children
The responsibility for looking after the children falls to their mothers and grandmothers. Iron deficiency anaemia occurs in over half the young children in Ein al-Beida, as parents sell their fresh produce and feed their children tea and bread, Elham says. She explains that the trick is to convince the grandmothers to change the feeding habits—the mother in law exerts a rather large influence over parenting behaviours.
Back at the clinic, the other health workers are running a health education workshop. The children who attend are accompanied by their mothers all dressed in their smartest clothes and shoes, although the heavy rainfall has turned the paths into a mud bath. In an attempt to combat the prevalent anaemia, the health workers have brought boxes of fresh food and show how to prepare it.
On the way back to Jerusalem we pass gated Israeli settlements. They have their own healthcare and urgent care centres; some have helicopter access to hospitals in Jerusalem and Beit Shalom to the north. But Kimberley says it's almost impossible for Palestinians to access the settlements. She adds that many Palestinians she meets would relish the chance to receive treatment from Israeli doctors—their training and facilities are held in high regard.
Tuesday
Nablus, in the north of the West Bank, is surrounded by steep hillsides forming a basin, containing the main town area. Bordering the town are watchtowers and a wire fence patrolled by Israeli soldiers, while the two main entrance points at either end are marshalled by checkpoints. As we passed through the Huwara checkpoint on the outer edge of Nablus, the atmosphere changed; the tension was palpable. It was the only time I was advised not to mention my surname.
A soldier climbs on board a PRCS ambulance to check a pregnant woman for explosives at the Az Za'ayyem checkpoint
Credit: ANDREW AITCHISON
Into Nablus
Ours was the only car queuing to be let through by Israeli soldiers, but we didn't move for about half an hour and watched the soldiers at work. Palestinians of different ages queued behind a fencing barrier to our right, some holding piles of textbooks, others clutching bags of food. Tightly pressed up against each other, people shout angrily as someone pushes in ahead. A few look into our car, their faces blank. By the time we've crossed the checkpoint, only three people on foot have been searched and passed through into Nablus.
The road into Nablus circuits the gaping carcasses of buildings that, I am told, have been destroyed by tanks; the road itself is cracked by the passage of heavily armoured tanks. Apparently Nablus was once an attractive town.
Our first stop is the dispensary in the old town. Established in 2002 by Nablus municipality, it's now completely funded by MDM and provides primary health care, medication, and lab tests, but facilities are basic. A lone biochemist collects the samples and operates the old fashioned centrifuge and microscope, while Dr Bashar Jaber, a general practitioner, runs the clinic. The waiting room is cold and crowded, and, judging by the coughing and sniffling sounds, there's a virus doing the rounds.
I chat to Dr Jaber for a while—he's hoping to sit his Professional and Linguistic Assessment Board (PLAB) exam in London soon. We chat about the United Kingdom for a while—his uncle coincidentally taught at one of my placements at medical school. The conversation then shifts to medicine.
Current health problems
Nowadays, Dr Jaber says he sees a lot of people with mumps and measles, whereas 15 years ago such infections were rare. He puts this increase down to incursions and curfews, which impede physical and financial access to health care.
Another explanation I'm given is that boxes of vaccines have been denatured as the army search them for explosives. The result has been outbreaks of measles—children have received ineffective injections leading to a breakdown in herd immunity.
Administrative delays
Dr Jaber also talks about his time as a doctor in East Jerusalem, practising at the Augusta Victoria hospital. For the first two months of his rotation, he didn't have a permit to enter East Jerusalem, so he took a circuitous journey to Abu Dis to jump over the wall. At other times, he says, he was turned away from Qalandiya checkpoint or had to spend weeks sleeping in the hospital to ensure he would be able to make it to work. Not only did he have a West Bank ID—worse still, it was issued in Nablus. But if there were difficulties for him, for Palestinian patients with a West Bank ID attending the hospital it was even more complex, particularly for those with chronic illnesses requiring regular treatment—each session requires a permit from the Israeli authorities, he says. For most patients, this entails a visit to the civil administration headquarters in their town, bringing with them a written report by their doctor. The hospital also needs to send an accompanying fax. Delays in this process may happen, he adds, which can influence the disease progression in people requiring interventions at specific times.
I ask him candidly what the solution is, commenting about the lack of airtime on my dictaphone. He laughs and explains diplomatically that his nostrum would start with "a change of politicians on both sides."
International intervention is needed
The community in the surrounding area is poor, and its movement is restricted by frequent curfews and incursions by the Israeli army. Sandrine Pont-Turco, MDM's field coordinator in Nablus, says that international NGO intervention is needed in Nablus because NGOs are able to set up direct links with the "IDF or IOF" (IOF is the so called Israeli occupying force—a term used to describe the IDF by some Palestinians) on a regular basis and also the District Coordination Office (DCO). This enables NGOs to liaise with the army during incursions and curfews to ensure the safe passage of staff and patients. She cites the six day curfew in the old city in August 2004 as an example. People were unable to attend the dispensary, so staff from both MDM and the Palestinian Scientific Medical Association went to collect patients from their homes, while briefing the army coordination officer about their movements.
Sandrine also explains that they are able to help fund clinics and arrange for mobile facilities to visit surrounding villages. "Nablus is a closed city," she says. "People from villages find it difficult to get in to access services."
On the edge of Nablus, close to the biblical site where Joseph was pushed down a well by his brothers, is Balata, a Palestinian refugee camp home to hundreds of people displaced during the 1948 and 1967 Israeli-Arab wars and their descendants. Houses built close together with little space between them are easing the spread of infectious diseases. Roads in the camp are in a pitiful state and every so often an earth mound restricts access.
Mental health issues
Escorted by two guides, Andy disappears between the ramshackle houses to take photos; a group of children behind him chant "Madrid." Some play with toy guns made from bits of wood, others have their hands on realistic copies. Young men hang around the "martyr's cemetery"—where people killed in the course of conflict are given the status of a legend—with little to do and looking bored. Bassam Marshoud, a Palestinian psychologist working with MDM, explains that because there's restricted movement, there are few jobs and people can't go elsewhere to work, making young people feel hopeless, worthless, useless, and humiliated. It's clearly not something that has gone unnoticed by political organisations, which flypost the area with leaflets featuring young, bearded, musclebound men toting rifles.
Working in a formal setting with children...
A group of four social workers arrives at the MDM house to receive training from Sylvie Mansour, a consultant psychologist working with the Palestinian Authority to improve mental health facilities, which are in desperate need of developing. Nablus has seen an increase in social problems both in children and in adults since the second intifada. Domestic violence has escalated as women become the brunt of men's frustration precipitated by unemployment and the perceived futility of the future. Sylvie also says it's worse for young men, who are traditionally the head of the house and are raised with the expectation they can do what they want, unlike girls, who have had relatively restricted freedom. "When they realise that going to university will have little bearing over their job prospects and that they can't do what they originally planned, it's when their mental health problems start," she says.
Children truant from school to earn money for their family or because they don't see the point in attending school when their prospects will be determined by other forces. At best, they ask why go to school when they won't be able to leave Nablus. At worst, they question the value of living. Violence between children has risen too, as they emulate what they witness both on the television and on the streets.
However, Sylvie is careful not to "psychiatrise" children or see them as potential cases. She wants to establish schemes that give children something to latch on to and works with their mothers to illustrate how they can protect their children. She is also working to change people's perception of mental health problems they encounter. Rather than believe that their disquiet is as a result of their own inadequacies, she wants to make people realise that the situation in which they live is a major factor. "Given the circumstances," she says. "Who wouldn't be crazy?"
The social workers tell me there's a shortage of psychiatrists, and for them a lack of experts and supervisors to train them and help out in crisis intervention. They want more training to know how to best deal with such complex social issues and need mental health books as a point of reference. However, they say, checkpoints, incursions, and curfews frequently impede travel, and the difficulty in attending training will remain.
That afternoon we visit a psychological theatre group at a local school, the aim of which is to help psychologists spot children with potential mental health problems. Flags feature heavily, both painted on the wall and flying from masts. In the entrance hall, a picture of Yasser Arafat looks down from the stairwell and a mural showing a child's face in the centre of a target with "Intifada" written across the top is daubed on a wall.
A team of four psychologists lead the workshop, fighting to make themselves heard over the raucous banter of schoolboys aged between 8 and 12—their task is made that bit harder when the children spot Andy's camera. The children have heard the open ended fictional story of Zania, a Palestinian schoolgirl. They then discuss the narrative in groups.
This week the children are given pieces of paper and crayons for them to convey their thoughts about the story pictorially. Palestinian flags are a centrepiece in their drawings, waving patriotically from rooftops and tanks. One child has drawn a duck swimming down a red river, saying that it represents the gunning down of his neighbours. Their houses were then bulldozed and the streets cleaned, forming torrents of bloodied water, he says.
I'm told by one of the psychologists that the week before they had to talk about Zania and provide an ending to the story—the denouements to their stories centre on grim reality in Nablus involving politicking and warfare. One child said that he saw his family and friends gunned down and then their house knocked down by a bulldozer. He'd based it on what happened in his street. Children are clearly highly politicised. One child, no older than 10, was wearing a knitted jumper with a black and white kaffiyeh clad fighter raising a clenched fist in front of a Palestinian flag.
... and with adults in an informal one
In the evening we attend the literary cafe hosted by Bassam on behalf of MDM. The idea of the cafe is to encourage Palestinians to talk about their thoughts and feelings that are evoked by writings of eminent poets and writers. Mental health problems carry stigma in Palestine, particularly for men. While women tend to have a secure network to share their concerns, the same isn't true for men, who are supposed to be emotionally strong.
Reading today is Palestinian poet and academic Muhammad Rishah. He sits at the front of the cafe, looking on to the crowd. The audience consists of mainly men, who draw deeply on hookahs containing a flavoured tobacco. The cafe owner comments that he's relieved that crack isn't available in Nablus—he thinks people would turn to it to numb their pain.
His poems focus primarily on the conflict; they're powerful and political. They focus on struggle, destruction, resistance, identity, occupation, and bloodshed. One poem asks, "Who taught a Palestinian child to throw a stone?"
All three British people in the group become embroiled in political conversations at the literary cafe and left feeling uncomfortable. Feelings of resentment towards the United Kingdom run deep both because of the Iraq occupation and because Britain, they say, had a pivotal role in the formation of Israel. I asked why.
Britain's historical role
After the first world war, Britain became the mandatory power of Palestine. Before this, the 1917 Balfour declaration penned by then British foreign secretary, Arthur James Balfour, pledged to try to establish a national home for Jewish people in Palestine. However, with increasing clashes between Jews and Palestinians, Britain limited the number of Jewish refugees fleeing from Nazi Europe. The tension escalated further and the United Kingdom handed over responsibility for solving the Zionist-Arab problem to the newly formed United Nations in 1947. Later that year, a partition plan for Palestine was approved by the UN General Assembly, which saw the land split into Jewish areas and Palestinian areas, with Jerusalem coming under international control. Britain, however, abstained from the vote. The Arab League, Palestinian institutions, and some Jewish leaders objected to the plan and it was never realised. The land was eventually won and lost as Israeli claimed independence after the 1948 Arab-Israeli war.
So, they said, because Britain created the situation, what were they going to do to help the plight of Palestinians? "What is your country going to do to alleviate my suffering?"
Children from the Balata refugee camp in Nablus show off their toy rifles
Credit: ANDREW AITCHISON
A world apart
On the way home we hear the mortar fire signalling the first incursions of the evening. On the balcony of the MDM house, we look down into the old town, watching the flares go up and listening to the sound of bombs. That evening I received a phone call on my mobile phone from a friend wanting to meet up in Islington in a cafe on Saturday—it felt surreal even to contemplate a coffee and a chat.
Thursday
I figure that while I'm in Jerusalem, I might as well see the sites that are in part at the centre of the conflict. The old city is home to the Western Wall, Dome of the Rock, and Church of the Holy Sepulchre, which are all confined in a walled area measuring about one square kilometre.
It's raining torrentially, and rivers flow down the cobbled streets. As it's a Friday, Muslims hurry down the labyrinthine paths to pray at the al-Aqsa Mosque, which sits just above the praying Jews at the Western Wall. After a short walk along Via Dolorosa you reach the church marking the site of Jesus' crucifixion, where Christians spend time in silent contemplation. I find the religious fervour overwhelming. I've heard there's a travel psychosis called Jerusalem syndrome, affecting people hypnotised by the Holy City. They start to preach and behave as biblical characters, and the syndrome is estimated to affect up to 20 people a year.
Some light relief
Breaking the intensity are traders, desperate to flog some of their gear—nylon kaffiyehs made in China, rubber Osama bin Laden key rings, bronze Judaic memorabilia. I'm a sucker for it all. One shopkeeper tells me that trade has dried up, as tourists are too frightened to come to Jerusalem. If it's a ploy to fleece more money off me, it works. After a week of scrutinising every sentence, trying to soak up every detail, listening to political outpourings, I appreciate the mindless banter.
Competing interests: None declared.
References
Summerfield D. Palestine: the assault on health and other war crimes. BMJ 2004;329: 924.(Deborah Cohen, student editor1)
The studentBMJ editor travels to Israel and the occupied territories, trying to make sense of an impenetrable situation. This is her diary
Introduction
The team
Accompanying me is Andy Aitchison, a freelance photojournalist, and Michelle Hawkins from MDM UK. We've communicated daily on the phone, trying to arrange the complex logistics, but only manage to meet for the first time at the airport.
Before leaving I received a brief warning that I'd probably be in for harsh scrutiny on arrival at Ben Gurion airport. So I was relieved to be welcomed only with a glower, a few quickfire questions, and the request for evidence that I was from the press.
Jean Sebastién Dy, the general administrator of MDM in Jerusalem, and Sebastién Laplanche, general coordinator, meet us at the airport and take us to our accommodation in an MDM marked car with flags flying from the back. Our base is the newly refurbished MDM staff house in East Jerusalem, the predominantly Palestinian part of Jerusalem. Most of the other NGOs and UN buildings are located in the vicinity. Jean Sebastién says: "The Palestinian areas are friendlier than the Israeli parts, and we're also here to work with the Palestinian community."
Sunday
Passing the Dead Sea and Jericho, both below sea level, we travel on the smooth highway alongside the fertile banks of River Jordan, looking over to the mountains of neighbouring Jordan. The road, primarily for the use of settlers, is named Gandi Highway—the nickname of Rehavam Ze'evi, the assassinated ultranationalist Israeli tourism minister, who supported a transfer policy advocating that all Palestinians be forced into Jordan.
Mobile service for women and babies
We're on our way to Ein al-Beida, a village in the north Jordan valley, where MDM jointly runs a mobile woman and baby preventive health service with British medical relief agency Merlin and the Union of Health Work Committee (UHWC). It focuses on cancer screenings for women, developmental evaluation for children, nutritional assessments and counselling for families, and personalised health education sessions in the home.
Before we enter the road to the village, a red Israeli government sign warns that Israeli citizens are forbidden from going any further by order of the IDF commander. Entrance is allowed only after prior coordination with the responsible authorities. A multitude of similar signs is dotted around the West Bank.
The UHWC team are late. They've been held up at a checkpoint. Although there are supposed to be fewer travel restrictions for health workers, I'm told that they can't always move around freely and are often held up at checkpoints. Nevertheless, it's easier for them than for patients. The facilities may exist in towns, but, after the escalation of violence during the second intifada, the IDF tightened security and further increased the number of checkpoints, making it impossible for Palestinians in the West Bank to travel freely. I'm told that sometimes Palestinians are forbidden from travelling on many of the main roads in the West Bank.
The wall in Abu Dis makes travelling to Jerusalem's Augusta Victoria Hospital (tower is in top left of photo) and Dome on the Rock more complicated
Credit: ANDREW AITCHISON
People don't understand preventive health care
Most of those scheduled for appointments fail to turn up. As a reminder, their names are read out over the village mosque loudspeaker, which the muezzin normally uses to issue his prayer call. Suzanne Abujeradeh, outreach coordinator for the northern West Bank, explains that Palestinians generally do not understand the importance of preventive health and will try to access health care only when they are ill. We decide to trudge down the muddy dirt tracks to visit the families in their homes instead—a delegation consisting of two healthcare workers, Elham Aqab and Noujoud Shalabi, Michelle, Andy, Nadia Dibsy (our translator and advocacy officer for MDM), and me. No one seemed the slightest bit perturbed by our international ensemble and welcomed us in with sweet tea and Arabic coffee.
Looking after children
The responsibility for looking after the children falls to their mothers and grandmothers. Iron deficiency anaemia occurs in over half the young children in Ein al-Beida, as parents sell their fresh produce and feed their children tea and bread, Elham says. She explains that the trick is to convince the grandmothers to change the feeding habits—the mother in law exerts a rather large influence over parenting behaviours.
Back at the clinic, the other health workers are running a health education workshop. The children who attend are accompanied by their mothers all dressed in their smartest clothes and shoes, although the heavy rainfall has turned the paths into a mud bath. In an attempt to combat the prevalent anaemia, the health workers have brought boxes of fresh food and show how to prepare it.
On the way back to Jerusalem we pass gated Israeli settlements. They have their own healthcare and urgent care centres; some have helicopter access to hospitals in Jerusalem and Beit Shalom to the north. But Kimberley says it's almost impossible for Palestinians to access the settlements. She adds that many Palestinians she meets would relish the chance to receive treatment from Israeli doctors—their training and facilities are held in high regard.
Tuesday
Nablus, in the north of the West Bank, is surrounded by steep hillsides forming a basin, containing the main town area. Bordering the town are watchtowers and a wire fence patrolled by Israeli soldiers, while the two main entrance points at either end are marshalled by checkpoints. As we passed through the Huwara checkpoint on the outer edge of Nablus, the atmosphere changed; the tension was palpable. It was the only time I was advised not to mention my surname.
A soldier climbs on board a PRCS ambulance to check a pregnant woman for explosives at the Az Za'ayyem checkpoint
Credit: ANDREW AITCHISON
Into Nablus
Ours was the only car queuing to be let through by Israeli soldiers, but we didn't move for about half an hour and watched the soldiers at work. Palestinians of different ages queued behind a fencing barrier to our right, some holding piles of textbooks, others clutching bags of food. Tightly pressed up against each other, people shout angrily as someone pushes in ahead. A few look into our car, their faces blank. By the time we've crossed the checkpoint, only three people on foot have been searched and passed through into Nablus.
The road into Nablus circuits the gaping carcasses of buildings that, I am told, have been destroyed by tanks; the road itself is cracked by the passage of heavily armoured tanks. Apparently Nablus was once an attractive town.
Our first stop is the dispensary in the old town. Established in 2002 by Nablus municipality, it's now completely funded by MDM and provides primary health care, medication, and lab tests, but facilities are basic. A lone biochemist collects the samples and operates the old fashioned centrifuge and microscope, while Dr Bashar Jaber, a general practitioner, runs the clinic. The waiting room is cold and crowded, and, judging by the coughing and sniffling sounds, there's a virus doing the rounds.
I chat to Dr Jaber for a while—he's hoping to sit his Professional and Linguistic Assessment Board (PLAB) exam in London soon. We chat about the United Kingdom for a while—his uncle coincidentally taught at one of my placements at medical school. The conversation then shifts to medicine.
Current health problems
Nowadays, Dr Jaber says he sees a lot of people with mumps and measles, whereas 15 years ago such infections were rare. He puts this increase down to incursions and curfews, which impede physical and financial access to health care.
Another explanation I'm given is that boxes of vaccines have been denatured as the army search them for explosives. The result has been outbreaks of measles—children have received ineffective injections leading to a breakdown in herd immunity.
Administrative delays
Dr Jaber also talks about his time as a doctor in East Jerusalem, practising at the Augusta Victoria hospital. For the first two months of his rotation, he didn't have a permit to enter East Jerusalem, so he took a circuitous journey to Abu Dis to jump over the wall. At other times, he says, he was turned away from Qalandiya checkpoint or had to spend weeks sleeping in the hospital to ensure he would be able to make it to work. Not only did he have a West Bank ID—worse still, it was issued in Nablus. But if there were difficulties for him, for Palestinian patients with a West Bank ID attending the hospital it was even more complex, particularly for those with chronic illnesses requiring regular treatment—each session requires a permit from the Israeli authorities, he says. For most patients, this entails a visit to the civil administration headquarters in their town, bringing with them a written report by their doctor. The hospital also needs to send an accompanying fax. Delays in this process may happen, he adds, which can influence the disease progression in people requiring interventions at specific times.
I ask him candidly what the solution is, commenting about the lack of airtime on my dictaphone. He laughs and explains diplomatically that his nostrum would start with "a change of politicians on both sides."
International intervention is needed
The community in the surrounding area is poor, and its movement is restricted by frequent curfews and incursions by the Israeli army. Sandrine Pont-Turco, MDM's field coordinator in Nablus, says that international NGO intervention is needed in Nablus because NGOs are able to set up direct links with the "IDF or IOF" (IOF is the so called Israeli occupying force—a term used to describe the IDF by some Palestinians) on a regular basis and also the District Coordination Office (DCO). This enables NGOs to liaise with the army during incursions and curfews to ensure the safe passage of staff and patients. She cites the six day curfew in the old city in August 2004 as an example. People were unable to attend the dispensary, so staff from both MDM and the Palestinian Scientific Medical Association went to collect patients from their homes, while briefing the army coordination officer about their movements.
Sandrine also explains that they are able to help fund clinics and arrange for mobile facilities to visit surrounding villages. "Nablus is a closed city," she says. "People from villages find it difficult to get in to access services."
On the edge of Nablus, close to the biblical site where Joseph was pushed down a well by his brothers, is Balata, a Palestinian refugee camp home to hundreds of people displaced during the 1948 and 1967 Israeli-Arab wars and their descendants. Houses built close together with little space between them are easing the spread of infectious diseases. Roads in the camp are in a pitiful state and every so often an earth mound restricts access.
Mental health issues
Escorted by two guides, Andy disappears between the ramshackle houses to take photos; a group of children behind him chant "Madrid." Some play with toy guns made from bits of wood, others have their hands on realistic copies. Young men hang around the "martyr's cemetery"—where people killed in the course of conflict are given the status of a legend—with little to do and looking bored. Bassam Marshoud, a Palestinian psychologist working with MDM, explains that because there's restricted movement, there are few jobs and people can't go elsewhere to work, making young people feel hopeless, worthless, useless, and humiliated. It's clearly not something that has gone unnoticed by political organisations, which flypost the area with leaflets featuring young, bearded, musclebound men toting rifles.
Working in a formal setting with children...
A group of four social workers arrives at the MDM house to receive training from Sylvie Mansour, a consultant psychologist working with the Palestinian Authority to improve mental health facilities, which are in desperate need of developing. Nablus has seen an increase in social problems both in children and in adults since the second intifada. Domestic violence has escalated as women become the brunt of men's frustration precipitated by unemployment and the perceived futility of the future. Sylvie also says it's worse for young men, who are traditionally the head of the house and are raised with the expectation they can do what they want, unlike girls, who have had relatively restricted freedom. "When they realise that going to university will have little bearing over their job prospects and that they can't do what they originally planned, it's when their mental health problems start," she says.
Children truant from school to earn money for their family or because they don't see the point in attending school when their prospects will be determined by other forces. At best, they ask why go to school when they won't be able to leave Nablus. At worst, they question the value of living. Violence between children has risen too, as they emulate what they witness both on the television and on the streets.
However, Sylvie is careful not to "psychiatrise" children or see them as potential cases. She wants to establish schemes that give children something to latch on to and works with their mothers to illustrate how they can protect their children. She is also working to change people's perception of mental health problems they encounter. Rather than believe that their disquiet is as a result of their own inadequacies, she wants to make people realise that the situation in which they live is a major factor. "Given the circumstances," she says. "Who wouldn't be crazy?"
The social workers tell me there's a shortage of psychiatrists, and for them a lack of experts and supervisors to train them and help out in crisis intervention. They want more training to know how to best deal with such complex social issues and need mental health books as a point of reference. However, they say, checkpoints, incursions, and curfews frequently impede travel, and the difficulty in attending training will remain.
That afternoon we visit a psychological theatre group at a local school, the aim of which is to help psychologists spot children with potential mental health problems. Flags feature heavily, both painted on the wall and flying from masts. In the entrance hall, a picture of Yasser Arafat looks down from the stairwell and a mural showing a child's face in the centre of a target with "Intifada" written across the top is daubed on a wall.
A team of four psychologists lead the workshop, fighting to make themselves heard over the raucous banter of schoolboys aged between 8 and 12—their task is made that bit harder when the children spot Andy's camera. The children have heard the open ended fictional story of Zania, a Palestinian schoolgirl. They then discuss the narrative in groups.
This week the children are given pieces of paper and crayons for them to convey their thoughts about the story pictorially. Palestinian flags are a centrepiece in their drawings, waving patriotically from rooftops and tanks. One child has drawn a duck swimming down a red river, saying that it represents the gunning down of his neighbours. Their houses were then bulldozed and the streets cleaned, forming torrents of bloodied water, he says.
I'm told by one of the psychologists that the week before they had to talk about Zania and provide an ending to the story—the denouements to their stories centre on grim reality in Nablus involving politicking and warfare. One child said that he saw his family and friends gunned down and then their house knocked down by a bulldozer. He'd based it on what happened in his street. Children are clearly highly politicised. One child, no older than 10, was wearing a knitted jumper with a black and white kaffiyeh clad fighter raising a clenched fist in front of a Palestinian flag.
... and with adults in an informal one
In the evening we attend the literary cafe hosted by Bassam on behalf of MDM. The idea of the cafe is to encourage Palestinians to talk about their thoughts and feelings that are evoked by writings of eminent poets and writers. Mental health problems carry stigma in Palestine, particularly for men. While women tend to have a secure network to share their concerns, the same isn't true for men, who are supposed to be emotionally strong.
Reading today is Palestinian poet and academic Muhammad Rishah. He sits at the front of the cafe, looking on to the crowd. The audience consists of mainly men, who draw deeply on hookahs containing a flavoured tobacco. The cafe owner comments that he's relieved that crack isn't available in Nablus—he thinks people would turn to it to numb their pain.
His poems focus primarily on the conflict; they're powerful and political. They focus on struggle, destruction, resistance, identity, occupation, and bloodshed. One poem asks, "Who taught a Palestinian child to throw a stone?"
All three British people in the group become embroiled in political conversations at the literary cafe and left feeling uncomfortable. Feelings of resentment towards the United Kingdom run deep both because of the Iraq occupation and because Britain, they say, had a pivotal role in the formation of Israel. I asked why.
Britain's historical role
After the first world war, Britain became the mandatory power of Palestine. Before this, the 1917 Balfour declaration penned by then British foreign secretary, Arthur James Balfour, pledged to try to establish a national home for Jewish people in Palestine. However, with increasing clashes between Jews and Palestinians, Britain limited the number of Jewish refugees fleeing from Nazi Europe. The tension escalated further and the United Kingdom handed over responsibility for solving the Zionist-Arab problem to the newly formed United Nations in 1947. Later that year, a partition plan for Palestine was approved by the UN General Assembly, which saw the land split into Jewish areas and Palestinian areas, with Jerusalem coming under international control. Britain, however, abstained from the vote. The Arab League, Palestinian institutions, and some Jewish leaders objected to the plan and it was never realised. The land was eventually won and lost as Israeli claimed independence after the 1948 Arab-Israeli war.
So, they said, because Britain created the situation, what were they going to do to help the plight of Palestinians? "What is your country going to do to alleviate my suffering?"
Children from the Balata refugee camp in Nablus show off their toy rifles
Credit: ANDREW AITCHISON
A world apart
On the way home we hear the mortar fire signalling the first incursions of the evening. On the balcony of the MDM house, we look down into the old town, watching the flares go up and listening to the sound of bombs. That evening I received a phone call on my mobile phone from a friend wanting to meet up in Islington in a cafe on Saturday—it felt surreal even to contemplate a coffee and a chat.
Thursday
I figure that while I'm in Jerusalem, I might as well see the sites that are in part at the centre of the conflict. The old city is home to the Western Wall, Dome of the Rock, and Church of the Holy Sepulchre, which are all confined in a walled area measuring about one square kilometre.
It's raining torrentially, and rivers flow down the cobbled streets. As it's a Friday, Muslims hurry down the labyrinthine paths to pray at the al-Aqsa Mosque, which sits just above the praying Jews at the Western Wall. After a short walk along Via Dolorosa you reach the church marking the site of Jesus' crucifixion, where Christians spend time in silent contemplation. I find the religious fervour overwhelming. I've heard there's a travel psychosis called Jerusalem syndrome, affecting people hypnotised by the Holy City. They start to preach and behave as biblical characters, and the syndrome is estimated to affect up to 20 people a year.
Some light relief
Breaking the intensity are traders, desperate to flog some of their gear—nylon kaffiyehs made in China, rubber Osama bin Laden key rings, bronze Judaic memorabilia. I'm a sucker for it all. One shopkeeper tells me that trade has dried up, as tourists are too frightened to come to Jerusalem. If it's a ploy to fleece more money off me, it works. After a week of scrutinising every sentence, trying to soak up every detail, listening to political outpourings, I appreciate the mindless banter.
Competing interests: None declared.
References
Summerfield D. Palestine: the assault on health and other war crimes. BMJ 2004;329: 924.(Deborah Cohen, student editor1)