October 10, 2003
In late August, Peter Orr returned from the Gaza Strip, where he served as field coordinator for MSF's medical/psychological program. The deteriorating political situation has been disastrous for civilians living in the Gaza Strip and elsewhere in the Palestinian territories. Currently, MSF has 15 international volunteers and 37 national staff working in Gaza, Hebron and Jenin.
What kind of program is MSF running in Gaza?
As in Hebron and Jenin, the mental health program in Gaza treats medical needs but focuses on the psychological effects of the occupation and the Intifada. We are working with the people most affected by the occupation: people living close to Israeli settlements, close to bypass roads, in houses occupied by the Israeli Army, in settlement enclaves, or in border areas. These people suffer the most, often hearing gunfire and tank shelling. Two psychologists treat people on a short-course program that lasts up to ten weeks and is similar to one that the US military uses to treat post-traumatic stress disorder. Each has a caseload of about 40 patients at any one time.
An MSF doctor makes at least 300 consultations a month. She refers patients for psychological treatment and the psychologists, in turn, refer patients who need medical treatment to the doctor. We also have a social worker, because it is hard for many of our patients to get much out of the psychological counseling if they're barely managing to survive.
There is one doctor and two psychologists. Isn't that unusual for an MSF program?
It is somewhat unusual. This is one of a small number of MSF "psychosocial missions." Following the outbreak of the first Intifada in the late 1980s, MSF came to the region to see how we could help. We quickly discovered that there were many competent Palestinian doctors, nurses, surgeons, hospitals, ambulances, etc. What was lacking: qualified mental health personnel to treat the trauma that so many people were suffering from. Subsequently MSF ran several mental health programs in the West Bank and the Gaza Strip. The current program nonetheless incorporates a doctor, as many of the patients in the areas in which we work are unable to get to any health care structure, or, in some cases, are unwilling to leave their homes for fear that something will happen - to their homes or their families - during their short absence.
Does MSF work on both sides of the Palestinian-Israeli conflict?
That's a good question, one that Israeli soldiers in Gaza frequently ask us. No, we don't, and for a very simple reason. In the same way that Israel has much more advanced medical facilities than exist in the Palestinian territories, it also has many qualified mental health professionals whereas there are very few in the less-developed Palestinian territories. So MSF's help in the medical and mental health fields is really not needed in Israel.
When and how does MSF intervene?
When there is an Israeli military incursion, the doctor and field coordinator go in to assess the impact on civilians in the area, paying special attention to the psychological state of the people they meet. In June, for example, there was an incursion in Beit Hanoun, a town close to Gaza City. There had been a lot of problems there in the past because it has served as a launching pad for the rockets that Palestinian militants launch towards an Israeli town just on the other side of the so-called Green Line, the de facto border between the Gaza Strip and Israel. Israeli soldiers have come in many times and shut Beit Hanoun down. These incursions often last a day, three days, but the incursion that began in mid-May extended through the month of June and the Israeli military even created a new bypass road to facilitate the movement of tanks, bulldozers and other armored vehicles.
The first time I went to Beit Hanoun following the initial incursion, the town was a scene of total devastation. Israeli soldiers had destroyed so many orchards. You had a nice little town, about 35,000 people, with very fertile soil, lush and green, and suddenly it looked like a ghost town. They knocked down all of the trees-I mean, by the acre. As far as you could see, there used to be orange trees and now, nothing. They went in with these huge specialized military bulldozers, and they just kept going. It is going take at least ten years to replant.
I went around and looked at some of the houses that were destroyed. Immediately we started meeting people who were furious with anyone they came across. Their attitude was, "Why are you here now? Where were you when my house was being destroyed? Why weren't you here then?"
Mostly we tried to just let the person talk and get out some of their anger and sorrow. And the people's stories were just incredible. Families had small fields bulldozed along with their livestock. The animals were buried alive. Why? It's impossible to see the reasoning for it.
In some cases, people were given a minute or less to leave their homes. One family had to throw their children from a balcony before the house was destroyed. The overwhelming sentiment you get from people is the injustice of it. One of the phrases I constantly heard is: "But we're human!" Because they feel that they are not being treated like human beings. And then they ask, "Who are these people attacking us? Why are they doing this?" It's not that they're unaware of the rocket attacks and everything, but the response and its impact on civilians and families seems so disproportionate, so extreme.
MSF also works with families living in the closed-off enclaves of Seafa in the north of Gaza and Mawassi in the south of the strip. Settlements have been built there with a huge fence around them. Palestinians still live in this area, but they're basically trapped. There are restrictions as to who can go in and out, and at what times. In Seafa, there used to be more than 100 families who lived inside and now there are 38. And that's counting the families who live, most of the time, outside Seafa so that their kids can go to school, so the parents can work, so they can live something close to a normal life. In Mawassi, an even bigger area, people have trouble leaving and returning, making access to health care extremely difficult.
But people manage to survive. To send one of her three daughters to school, one of our patients lives with her children in an improvised shelter outside the settlement fence in order to avoid the arbitrary controls at the checkpoint. Another family that we work with has been without electricity for over a year (because the Israelis cut it off) and point out that the adjacent Israeli guard post is getting closer and closer to their home - but they persist on holding on to what they have left. There are many cases like that - people who manage to get by despite everything. I think part of what we do when we go into these areas is to reassure them that they have outside contact, that they haven't been forgotten.
How effective is psychological counseling in this setting?
I wondered the same thing before I went to Gaza. After all, if people have very little hope, if they are mostly worried about surviving, what advantage could psychiatry or psychology offer? And even in the field, there were many discussions about how useful it is to have psychological consultations when there is frequent shooting and so on, i.e., how useful is psychological care, from a clinical point of view, when the causes of the trauma are still there? But when I spoke to our patients, they gave me the impression that it was of great help to them, that it was not a waste of time to "talk trauma" when there was a good chance that they were still - or would soon be - going through traumatic events.
I remember meeting two boys being treated by our psychologists. One of them had come upon a Palestinian soldier or policeman dead on the ground following an Israeli incursion, and he'd actually seen the man's brain separated from his body. The boy couldn't stop thinking about it; he kept reliving this day, kept thinking about it over and over and over again. I saw him during one of his later consultations, and the MSF psychologist told me that he was already doing better than he had a few weeks earlier.
When I met the other boy - he was maybe 11 years old - he had already been seen by our doctor, but it was the first time that the our psychologist was visiting him. It was awkward, as most of the family was there - his parents and several of his siblings. Just a few days previously, he had been walking with one of his brothers to see what was going on during an Israeli takeover of a nearby village. As they approached the area, his brother was shot and killed right next to him. When I saw him, he was hunched over in the corner of the room, as if he were shrinking into himself, withdrawing into a corner of his mind; he could barely function, he could hardly speak. In her weekly home visits, our psychologist managed to draw him out, using toys and drawing and words, and he gradually got better.
She couldn't cure him, of course, but the aim of these psychological consultations is not to "cure" such a patient, but to make him able to face life, to become a functional human being again.
What is it like for the MSF psychologists to be working in such conditions?
I think it is both very challenging and extremely rewarding. Many of them have never worked through an interpreter before, much less lived under such high-risk conditions. But as with their patients "at home", the "psys" are rewarded by the progress that their patients make and hope that they will be better able to cope with a traumatic event in the future thanks to their treatment.
It helps our psychologists to be able to leave Gaza once a month, when we go to Jerusalem. Not only does it give them a break from Gaza, but they have a group meeting with an Israeli psychologist, where they go over their cases and their own reactions. That is of tremendous help.
There is also a local mental health NGO in Gaza that does good work. It is our main referral point for psychological patients, at least those who are able to make it to their clinics. Unlike us, they do not make home-visits, and are thus unable to reach many of the people that we see. So we refer patients to each other on an ad hoc basis.
Part of your responsibility as field coordinator was maintaining relations with the Israeli authorities. What was that part of your work like?
I had daily contact with the Israeli military, because to go to certain areas we need to give them advance notice of our movements. The Israelis have taken the process to mean that they can approve or deny our access to certain areas at will. Of course we don't see it that way. When they denied us entry, I would call to insist on gaining access to our patients. After several incidents of this kind, I would write an official letter of protest. Various reasons for these denials of access were given to us: two of our staff members were said to have "security files" (impossible to verify or dispute), another one - our best interpreter - was suddenly deemed "too young" even though he had been acceptable only a few days earlierâ€¦ But mostly they used a blanket reason: "security." Often no further explanation was given, but there were instances when we could find no apparent basis for their stopping us, except a desire to have complete control of the situation and to limit access to certain zones.
One time in June, we were given the green light to enter an area where there was ongoing Israeli military activity. We were made to wait two and a half hours to enter the area. I had to go to the roadblock where we were blocked to help negotiate our entry into the area. Once they had the passed the checkpoint, the doctor and his team stopped to see a patient. Soldiers immediately arrived on the scene and one of them told the MSF doctor to get back in the vehicle. This was the first problem: stopping the doctor from seeing a patient, even though this was an area where we had said we were going and where we had been officially allowed to enter. The doctor proceeded to another area and was stopped again. The Israeli soldiers spoke rather harshly to him, asking him who he was and what he was doing there, and telling the Palestinian staff-the driver and interpreter-to go stand behind the vehicle, as if they posed a threat. At one point the Israeli soldier told the doctor to turn off his phone, which was his only contact to me. And then he gave the doctor a time limit to see his patients-five minutes. Our doctor was really good. He said, "Five minutes?! It's going to take me five minutes just to walk to the house!" And so he managed to expand it to a half hour. But this is just to point out our problem: we're dealing with soldiers who are not trained or briefed enough about the humanitarian role that MSF and others play. And these same soldiers are often not very disciplined; indeed, they know what they can get away with.
What are some of the biggest challenges the team faces?
Other than the security risks, the big challenge is remaining neutral. It is impossible not to get upset when one sees what is being done: families' homes destroyed or occupied, the humiliation at checkpoints and so on. We are all the more receptive to the cries of injustice by women and children, in that we have seen so much of what goes on.
On an operational level, we do try to maintain good working relations with the Israeli military so as to be able to see our patients. But this was made difficult by the problems we had with individual soldiers and with the Israeli military in general. A local commander once told the MSF doctor that he had the order to kill him. This is the same doctor who had been mishandled by other Israeli soldiers in a different area. We tried to be respectful of soldiers even if they were not being respectful to us. I would protest in writing to complain of mistreatment and I would even insist on meetings at the brigade level to be able to explain what MSF does, the nature of humanitarian action, and so on. But to no avail.
As for dealing with the overall stress and dangers of the situation, it is, of course, a big advantage to be there as an international volunteer: one sees suffering but you know you're going to be there for several months and then you will leave. The Palestinian staff doesn't have that luxury. And the Palestinian interpreters working with our psychologists have it the worst, as they hear terrible stories and then repeat them in French or English, over and over, every day, at least four or five patients per day. That's why they have sessions with our psychologists as often as needed.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)