Palestinian Chronicle: Testimony gathered by MSF medical and psychological teams working in the Palestinian Territories

Valérie Batselaere/MSF
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Contents

  1. Introduction
  2. Log Book of the Psycho-Medical MSF Team
  3. Eyewitness Account by MSF Anesthetist Philippe Trinh-Duc
  4. Gaza Strip: MSF Opens a Medical and Psychological Support Mission
  5. West Bank: MSF Observes a Worrying Health Situation with Major Obstacles to the Practice of Medicine

More than two months after the second Palestinian uprising, or intifada, the situation of the civilian population has become deeply troubling. The trap in which the Palestinian people are caught, the violence of the confrontation, the emergence of a Palestinian military resistance and the disproportionate measures being employed by the Israeli forces throughout the Palestinian Territories are all taking a heavy toll on the civilians. The military means employed against civilians are those generally used in situations of conventional war.

The economic blockade imposed by Israel on the Palestinian territories is further undermining an already precarious social structure, and underlines the state of dependence in which Palestinian families are forced to live.

The daily living conditions of these families continue to deteriorate. Palestinians live in permanent fear of reprisals by the Israeli army and the Jewish settlers. They are becoming increasingly frustrated with the Palestinian Authority. The income of Palestinian families is dwindling. Palestinians employed in Israel can no longer get to work, and the movement of people and goods is regularly blocked so that families have less and less income on which to live. Palestinian houses located close to Jewish settlements or roads used by settlers have been razed to the ground or requisitioned with full impunity, with the justification that these acts prevent terrorism. Families are forced to flee their homes because their villages regularly come under fire. Intimidation and humiliation are routine occurrences.

There are many obstacles preventing Palestinian access to health care. It has become difficult to move around freely without suffering through long and humiliating controls. This means that for some families, it is becoming impossible to reach Palestinian medical facilities or gain access to a doctor. For some people, the fear of seeing their house requisitioned or destroyed during their absence is so great that they do not dare leave to seek medical attention. People's access to health care is subject to a number of unpredictable factors. At the same time, the violence exercised against Palestinian families and the climate of terror in which they live are causing very severe feelings of stress and fear which require constant care.

In this context of violence, the international medical aid organization Doctors Without Borders/Médecins Sans Frontières (MSF) recently opened two new missions in the Palestinian Territories: one in the Gaza Strip and one in the Old Town of Hebron.

These two missions have been adapted to suit a very specific context of violence, and are structured as follows:

  1. They seek to bring together doctors and psychologists in a joint clinical practice, because current events are causing both physiological and psychological problems. Chronic or preexisting pathologies have been accentuated due to stress, anger, anxiety, fear "of having been poisoned," difficulty with sleeping, dietary problems, etc. Medical personnel detect and treat physiological problems, while the psychologist begins therapeutic treatment that enables patients to express their fear, deal with their traumas, and reduce their stress.
  2. They are structured around home visits. Fear and restrictions of movement very often prevent patients from attending consultations.
  3. They are addressed mainly to the people who are most vulnerable (both adults and children). That is, those who live close to confrontation areas, bombed districts, Jewish settlements, or Israeli army camps.

This report presents a collection of observations made by the MSF teams since November 2000, when they began making home visits among the families in the Palestinian Territories and locations under Israeli military occupation. Extracts from the daily diary of the Gaza team and the testimony from the anesthetist who worked at the Qalqylia Hospital in the West Bank both describe the daily living conditions of the Palestinian families amid acts of violence, fear, intimidation and humiliation. They also highlight the constraints imposed on the work of the medical teams.

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Log Book of the Psycho-Medical MSF Team
Gaza, November-December 2000

Sunday, November 12, 2000
Visit to the Salah'edine district in Rafah.

First family
We've come back to see a small eight-year old boy who has had problems since the floor of the house where he was sleeping with his brothers was destroyed. He is doing somewhat better since our last visit, but is still unstable. He keeps saying he is afraid and anxious. His family feels that he has changed, that he is not like he used to be, that he has lost his happiness and is worried. Firing can be heard overhead.

We speak with him and his older brother (he didn't want to be with us on his own). We help him to express his feelings and to talk about what he experienced during the attack on his home.

Second family
In this unprotected street is a house riddled with holes from gunshots. We ask the people in the street if anyone lives there. The house is lived in by a childless, but not young, couple. The husband used to be a secondary school English teacher. They invite us inside and turn out to be very willing to speak with us. They have lived in constant stress since the Intifada began, living just opposite the Israeli military post and right in the firing range. Bullets were fired past the living room several times, right where we were sitting and talking. They have to live in the back room of the house and leave by the back door to visit their neighbors. But the don't venture very far for fear of a fire breaking out in their absence.

They can no longer sleep and eat little or nothing as they "can hardly manage to swallow." The man, aged 58 complains of articulatory and muscular pain, the woman aged 37 complains mostly of incessant fear. They tell us this, however, with some sort of sense of humor, and they are grateful not to have children, as they would certainly be worse off given the fate of young people at the moment.

Under the surface, however, is a silenced anguish heard in their bitter words against the Palestinian Authority which " are filling their pockets and we cannot trust ." They feel isolated and without support, abandoned and trapped in pessimism.

Third family
Opposite this home, next to the Israeli post, stands another house with a man outside. At the windows we can see women and children. The man, who lives here with his family, invites us in. To get into his house you have to go round the corner of the house, where the confrontation had just taken place. The exact place where people have been killed and wounded. When you climb the staircase you have to duck when you go in front of the openings - bullet scars and holes as big as your hand in the walls. Two floors, two families, but one has left to take refuge elsewhere. While we talk holed up in a closed room, we can hear shots nearby and our eyes start to sting from the teargas. The children are calm and quiet, they seem serious, listening to their father speak. Every night they leave with their mother and sleep somewhere else. The father returns alone to sleep in the house to look after it, there is a constant threat of fire. The 15-year-old boy has taken no part in the confrontations, at least that's what he says in front of his father. His father tries to dissuade the young ones from joining the confrontations, he now cannot bear to see them injured, everything so close to his house, but he realizes that he is powerless to stop them.

Khan Yunis
On the western edge of the town is a refugee camp that borders a colony zone. It is an enclave within an area which is completely controlled by the Israeli army, the houses on the outside are exposed to the confrontations every day; the buildings with several floors which tower over these houses are riddled with bullet holes. Nowadays they are completely empty.

We visited two families who live in the two most exposed houses located at the end of the alleyway and facing military buildings barely 20 meters away. There have been confrontations here since the beginning of the Intifada. For the past two days they have moved 100 meters away, still very close in fact, but far enough for a little peace to return to the families. Almost all the families have left this area, if only at night.

The father speaks, he is very nervous and the words tumble from his mouth. He has seven children between 2 and 14. He fears for their lives, for their health; he no longer works, he is very jumpy. He describes the history of his family before the war: his oldest daughter was killed in 1993. She was wearing a t-shirt with a picture of Saddam Hussein on it the day she was killed. Two of her brothers have been killed, one in 1976 and the other in 1991 during the confrontations. A few days ago his 7-year-old daughter wanted to knock over the television when she was watching the pictures of the Intifada. He is in a state of permanent stress, he doesn't sleep; he has seen wounded youths. He talks about his powerlessness. "We Palestinians are educated and intelligent, but we have no chances, your visit has brought us a bit of comfort."

Monday, November 13, 2000
Erez
This Bedouin village is located opposite a place where there are daily confrontations. We met people who were worn out by the situation. They live near the road: in front of them are military buildings, behind them the Beit Hanoun quarter. They are close to the shooting in front of and next to them. It is a fairly poor camp. Almost all the men work in Israel. First we sat in the courtyard of one of these houses to talk with the people there: some men, women and very young children. Most of the houses are made of sheet metal. Some of them are quite sturdy, but most are very flimsy. They have no real protection, either from bullets or tear gas. There were countless bullet holes in the 'walls' of these houses. The Israeli Defense Force buildings loom over the village - there are camouflage nets, you can't see the soldiers, but you can feel their presence and the arms permanently pointed at you - an invisible but omnipresent menace.

For the first time since the beginning of the Intifada, there have been no confrontations today, it is one o'clock in the afternoon. Yesterday at the same time we couldn't have gotten here. And tomorrow? Better to come back early in the day.

The people suffer from the effect of the tear gas. They cannot no longer protect their children or themselves from the new tear gas grenades which are much more concentrated. They protect themselves by rubbing onions on their face, but this does not work anymore.

A man tells us that there were kids injured in the confrontations who hid in the village for shelter and to find help. He saw the wounded and one dead. They had to drag them over the sand to get to the ambulance. They had been hit in the legs. There was lots of blood. This man could not stop thinking about these youth who he had seen suffering in front of him. He knew that two of them had had amputations. His mind was full of images of death. Later he told us of other problems which showed that he had serious nervous problems. He asked us to come back so he could talk to us in private, which we did.

The others pointed out another, younger, man who they said was really suffering. "Yesterday he went really crazy" they said. He told us how his father, an old man, suffocated in a gas attack about a month ago, at the beginning of the Intifada. The young man, seeing his father in difficulties, ran towards him to help him, so they were both exposed to the gas. This man told us that it had been really hard to overcome his fear. He carried his father, who was unconscious, out of the reach of the bullets. Yesterday, this man was terrified during another gas attack. He burst through his neighbours window to protect himself, his young wife who is pregnant, and his two very young children. He lost control and today his wife is in bed, ill.

We went to visit this young woman. She had problems with acute stress. We were able to speak with her and she reacted positively to our efforts. We will see her tomorrow with the doctor for a clinical examination. It is very useful in these type of cases because of the physical symptoms which she is showing. Then she will continue to be followed-up psychologically.

You hear the same worries about gas exposure from all the people: sterility, illnesses that don't show until 20 years after the exposure are in everyone's minds. The comments of one man after the doctor's visit to his wife: she's better today, but what is going to happen to the baby?

The feeling of suffocation that follows gas inhalation makes you feel as if you are dying, this is aggravated by the belief in the chemical toxicity. We have not seen this type of little cannister before. They are very concentrated and release much more gas than the ones they used to use. That type, which were made from black rubber, could be grabbed and thrown a long way; the new ones are burning metal, that whirl round and are impossible to get hold of.

Next to the Netzarim colony
There are four houses on the same patch of ground, just behind the two houses that were blown up by the IDF to clean up the place (the place where young Mohamed Dura was killed and his father wounded) in the crossroads that lead to the Netzarim colony.

Four families live here, brothers, with their many children. They are former refugees who built these houses in 1990. We sat down in the largest room. They understood the reason for our visit. Only one of the fathers is present and there are two mothers worrying about their daughters, one in particular never stops asking to leave this place. Even though the walls are thick they no longer feel safe, the story of this interminable night, buildings being blown up, is told by several voices. " We don't think we're going to come out of this alive ." A young girl who was frightened begins to talk, encouraged by her cousin. The grandmother, who joined us, told us how frightened she had been, hiding under the staircase. She wondered whether she shouldn't be taking pills to sleep. Outside we could hear the tanks coming and going - a constant reminder of the military presence that each person here could never forget. The children are only allowed to go out to go to school accompanied by their parents.

Tuesday, November 14, 2000
Another visit to Eretz village
We are going to see the young pregnant woman. In another house they asked us to go and see a woman and child. It didn't take long for other women with very young children to arrive. The house began to resemble an improvised dispensary.

There are two children with problems connected to anxiety: a little girl of two years old who had been toilet trained had started to wet herself again and another child who was slightly older had the same symptoms. We talked to the mothers and their children to explain the links between fear and regression that can occur in young children. This is a normal reaction faced with an abnormal situation. Reassuring, consoling, protecting, cuddling; how can you do this when you have three or four children who are all asking for the same attention? The young mother expressed her feelings of being overwhelmed.

Wednesday, November 15, 2000
Khan Yunis camp
This time we visited the other part of the camp that is exposed to gun fire. The distance between it and the military post is tiny and many youths come here every day. Several of them have been killed since the beginning of the confrontations.

It is obvious that these people live under permanent stress. There is an overexcited atmosphere, everyone wants to speak at the same time, the doctor is wanted everywhere. The people are in a state that I would describe as 'hypomaniac': laughing, crying, over-excited children, little pebbles flying around. But the people are happy to have us there and to explain to us how they have managed to survive. Those who have somewhere else to go, don't sleep here. In each house there is a draught-proofed room for protection against tear gas.

During this first visit, we also saw mothers worried about their children, a baby who wasn't thriving, and a child who presented with incontinence.

Thursday, November 16, 2000
Khan Yunis camp
During our second visit we had a long interview with a mother of a baby aged seven months, during which we tried to deal with her problem, which was, to her, both shameful and worrying. Her baby had not been growing for three months now. This child presented with normal psychomotor development, however he was alert and interacted with his surroundings. It was the mother's anxiety that needed dealing with.

Another mother, who we had already met yesterday, came to speak to us about her son of 5 years who was wetting himself. We were able to give her some advice and we spoke to the little boy, who yesterday was behaving like a little 'toughie.'

The big brother of the baby is an intelligent-looking boy of 11 years. He tells us that he knew the young boy who had been killed yesterday (not long after our visit). He was in his class. He had just come back from the funeral (which we had passed). He is proud to speak and he has an almost arrogant manner when he tells us that he also goes to the confrontations, that he isn't scared, and that people who don't go there after school are cowards. Everybody goes, you can't not go. Then he adds that the dead boy, the "chahid" (martyr) was a "majnoun" (crazy), that he provoked the Israeli soldiers, (insulting them, showing his penis). According to him, the child who was killed was aimed at, he hid behind a concrete block, then he poked his head out and got a bullet in his forehead. He spoke without sorrow, wanting to impress us. He wouldn't say that he was frightened. A Palestinian psychologist who was with me was bothered by this little boy's manner.

The youth gathered in the place where the confrontations normally were and the firing of tear gas began. We could not stay. We left the camp without being able to tell the people who were waiting for the doctor and without being able to tell them when our next visit would be. A little way away we were stopped and surrounded by dozens of the youth, mostly girls who had just gone very close to the IDF posts and had been gassed; a brief moment of collective hysteria which allowed us to evaluate the overheated atmosphere of the place once again. "Why do you want to kill us?" cried one of them. The French-speaking Palestinian psychologist who was with us today told them that we were French, and that we had come to help them. The young girl wouldn't listen and said that it was the same thing. We left in confusion, which made us pensive.

Saturday, November 18, 2000
In the Al Muragah district
While cleanup efforts went on in the Netzarim, destruction of buildings, uprooting of trees and clashes broke out at the next intersection, next to a small mosque where an IDF Jeep was permanently stationed. One or more tanks patrolled the route borrowed by the settlers.

This Saturday morning is calm, and people are asking why the unaccustomed calm, which they have not seen for days, particularly since Thursday night when bulldozers continued their cleanup work. Now there is room for a four-lane highway!

We go from house to house. There is no military presence until 3:00 pm. We will leave the district around 4:00 pm, after encountering battered people in shock and visibly exhausted from sleepless nights. The anxiety is unrelenting; it is seen, heard, spoken. A young woman trained in first aid offers to take us to the homes of the most afflicted. She is very concerned by the peoples' suffering.

We identified at least 2 persons needing individual care: a 27-year-old man whose mother came to speak to us, and a housewife living in one of the houses along the route. During the night, the family saw the bulldozer come toward their house and stop only a few meters away, after smashing the palisade and well at the entrance. This woman asked for help; she could no longer cope.

Another family saw its house transformed into an base for sniper attacks two weeks ago. The Israeli military took over the empty house to set up operations and shoot. One of the little girls is visibly terrified (we would return later to see her) as the family returned only today to move back into the house.

In another house, owned by the sheik, across from the mosque, a young woman suffered a miscarriage several days ago; her baby girl of 18 months died a month ago from gas (she was hospitalized but could not be saved).

Another house where the impact of large bullets is clearly visible, the family is on permanent alert, they wait, they watch. Father and son (a pharmacist) display an air of strength. Another woman in another house suffered a miscarriage four days ago. She says she is well, she is strong, she is not afraid of the military; she and her husband will be rolled over by the bulldozers before they leave.

As we leave, we pass the youths going toward the crossing where the clashes took place: "We have not yet begun," they say!

Sunday, 19 November 2000
Erez, along the sea
We visit this zone under IDF control, to the far north of the Gaza strip, where the Alaï Sina and Nevetz Sala settlements are located. It is an agricultural zone whose inhabitants live surrounded by two Israeli settlements. No clashes have yet occurred, but fear has taken hold and the majority no longer sleep here but return to the camp at their native seashore, and come only to work during the day. Only a few families remain there around the clock, but they do not sleep peacefully.

Also residing here are Bedouin families, who moved in during the arrival of the Palestinian Authority and are scattered throughout the zone. Their lifestyle is very traditional and clannish. Unlike the families we saw in Erez, who are more settled.

We visited one of these families, particularly exposed to fire from tanks and the advanced IDF position (stationed at the entrance to the settlement). This family feels extremely vulnerable, isolated, and helpless; nightfall brings anguish and they cannot sleep. This region, to which they came six years ago because they liked the area (they came from the south), has become a nightmare for them; they aspire to a security that is nonexistent at this time. One of the men who met us is asthmatic. His attacks have become more frequent since the start of the events. We offer to return as quickly as possible with a doctor to provide appropriate treatment to the whole family ; today we couln't see the women and children.

Monday, November 20, 2000
Third visit to the Bedouin village Erez
We will hold a personal interview with a thirty-nine-year-old man regarding problems he has had for three years but are revived by the current situation.It is a lengthy, in-depth interview revealing the man's state of post-traumatic stress regarding past events, some of which stem from his childhood, related and unrelated to the political situation. His condition is not acute, but he is prey to a continual state of anxiety that manifests itself in his somatic and psychological condition.

Monday evening, 6:00 pm: Bombing of Gaza begins and lasts until 8:45 pm.

Tuesday, November 21, 2000
We had planned to go south to the Gaza strip to meet the families previously seen on 12 November. Among them, a small boy we had already met twice. But we find ourselves stopped by the roadblock at Kusufim, which is closed to Palestinians. As our car was not outfitted so as to be adequately identifiable, we give up for today.

In view of the night's bombings, we had also planned to visit the families living near a bombed base at Deir al Balah (located before the crossing point into Kusufim). We go toward the three houses closest to the site of the bombing and are welcomed by the family living there. The mother, father and children are there. The children are not going to school this morning; the night afforded little rest. After a few moments the other members of the family arrive: three brothers and their families live together here.

A 9-year-old boy spent the entire night in a state of acute stress. The family has gone out to the garden in the early hours to protect themselves in case of renewed firing on the base. He couldn't calm down. His mother tells us he couldn't leave her for a second and constantly went to the toilet. He couldn't "sleep" in his room with his brothers, but stayed with his parents praying for daylight to arrive; only then did he begin to calm down. This morning he is here during our visit and says he feels relieved; he thinks everything will be alright now.

This is the first time something has happened in this district located by the sea. No clashes have occurred here since the start of the present events. It is far from the settlements, and even during the first Intifada there were no serious situations.

With no direct relation to the night's events, our expertise is sought for two members of the family, who are both present: a little 7-year-old boy, the youngest son of the man of the house, and a 32-year-old man, married and the father of a family, one of the four brothers living here.

While I asked the youngest his name and how he felt, his father answered for him, explaining that he stuttered as the result of a traumatic event that occurred when he was five: he was waiting alone in a car for his father when an enormous dog suddenly appeared, barking viciously. The child, terrorized, screamed until his father returned. This happened in Saudi Arabia, where his family lived at the time. Since then, the young boy has stuttered. The child has received no treatment. I turn to the child to ask him to relate his experience, and as he emotionally recounts the episode, his eyes fill with tears. He is very touching, and we are moved. He is very intelligent, a good student at school and appears open to what we can do for him; he is eager to be treated. I think of the Palestinian organizations and suggest that we contact them to arrange psychological care, the father agrees.

The second patient is a man with obvious problems; his face is contorted and he twists his fingers compulsively. His older brother explains his situation. He has severe attacks, catatonic states where his body stiffens, he pulls out his hair, he bangs his head against the wall; his throat tightens and he can eat nothing but yoghurt, and he doesn't sleep. This began 10 years ago. The problems occur intermittently, and the brothers agree that they become more severe when he confronts problems. Which is the case now, because of the events.

The young man was severely mistreated during the Intifada, when he was 22 years old: he was arrested and beaten by the IDF, and his problems began after this abuse. This description calls to mind a picture of Post Traumatic Stress Disorder (PTSD), with psychotic features. The brothers recall no prior troubles before the arrest. He is the 3rd of the four brothers, and greatly supported by them: he was treated in Jordan and in another Gulf country where he wanted to pursue his studies.

He had been seen everywhere possible, at the psychiatric hospital in Gaza, at the Gaza Community Mental Health Programme (GCMHP), where he saw a doctor who took notes and prescribed medication that helped him, but not for long. It seems that this man has not had the opportunity to pursue psychotherapy, and if there is still time, it would be to his benefit to recommend it. Rest assured that there are no underlying psychotic problems affecting this man.

Al Muragah district near Netzarim
A young man of 27 invited us to his home. His mother is there during the interview. He explains what happened two weeks ago while returning from his daily work at a Gaza restaurant (he comes home late at night). At the crossing in front of the IDF Jeep, he was arrested and roughed up by the military. They struck him in the side with the butts of their rifles, took his papers and told him to wait, then left. He was very frightened because of the wait and also because he had been detained previously (six and a half months in 1991 after taking part in a Gaza demonstration), and was afraid the military were checking his identity by computer. He believed he was in danger; the wait lasted two hours, during which he spoke with some youths a few steps away. When the Jeep returned, he was given his papers and firmly - but without physical violence - told to go home.

Since then, he has been unable to return to work, feels extremely fatigued, and suffers from asthenia, anxiety and illnesses (especially sore throats). He exhibits continuous anxiety, cannot concentrate, speaks very little and is unable to relax. He must return to work because he is the only brother working at the moment (the others are out of work, since they work in Israel). He is also very worried because after his release from prison, he spent four years putting his life back together, with the help of his mother; his recent experience is reactivating his former fragility and he fears a relapse.

He is a newlywed of two months, which we surmise is also a factor in his anxiety: he is at a point in his life where he is assuming new responsibilities vis à vis his new wife, which the current stress has possibly compromised. He cannot answer her questions; she is quite aware that he is not well, but he does not tell her what is wrong.

Wednesday, November 22, 2000
We are still unable to travel to Rafah or Khan Yunis. Since the latest attacks in the Rafah region, the Israeli army has effectively cut the Gaza strip in two and strictly controls travel between north and south. It is impossible for us to return to the south of the region at this time.

We return to Al Muragah.
We meet a woman in her forties who is visibly exhausted and troubled by persistent anxiety since the first day of the events. Her house (riddled with bullet holes in various places) is located next to the road leading to the Netzarim settlement, in a 70-meter strip where buildings over one story are prohibited. The family's home is of light yet durable construction, with several rooms. Our patient is in a state of severe asthenia and stress, she no longer sleeps, eats little, her expression is sorrowful and she conveys her exhaustion. She only sleeps when they go to see the family, but this is as seldom possible since they dare not leave the house for fear it will be destroyed, even though one of the girls, the 10-year-old, often asks to leave the house.

"What will happen to the children if I die?" We listen and comfort the woman at length, and plan for another visit. Then we head for a visit to a neighboring home. The young mother came looking for us at the previous family's home.

We find the young wife alone with three very young children in a sheet metal shack: she tells us her husband has been gone since the first days of the clashes. He has said he could not stay, it was too dangerous, he was afraid. He has not returned since then.

The 18-month-old boy has a huge burn on his buttocks; he fell in a fire two days ago when tear gas was fired in the house; everyone was blinded. His mother took him to the health center for treatment and is supposed to return every day to have the bandages changed for 2 NIS which is more than she has. A social and family matter, what to do?

In speaking with the neighbors present, one thinks that the husband is traumatized, and that is why he abandoned his family. As he has been seen in the district, we offer to convey the message that we will return next Sunday, we should try to speak with him. Another mother asks our help for her nine-year-old son, who has been enuretic during the events; we offer to see him on our next visit.

Gaza city: Visit to the district where the rocket fell "by mistake"
It is in the Beach Camp, not very far from us, where the people were watching the rockets flying above them, fired from sea, when suddenly one fell in a small alley in the midst of the houses. One house was severely damaged, parts of sheet metal roofs were blown off others, a young girl received shrapnel wounds in the abdomen. A father asks us to see his 9-year-old son, who has been unable to get over the episode for two days. We speak with the child on the terrace of the neighboring house. He tells us of his fear and his feelings. He is better than yesterday but is unable to think of anything else. He is rather timid and reserved. His father reassures him as best he can despite his own state of turmoil over how he will afford to repair his house. The Palestinian police arrived just after the bombing to reassure the people.

Thursday, November 23, 2000
Visit to the Nuseirat women's center
Nuseirat is a camp where confrontations do not occur. Rather the young residents go to Netzarim and Kfar Darom to join in the confrontations. We met a number of them as they were drawing and staging a puppet show.

We had a very interesting discussion in which these fifteen-year-olds, who appeared even younger, shared their determination to go "defend their people" in spite of everything. They concealed their activities from their parents, contemptuous of the views of the coordinator (a young man of 22 who was shot in the leg during the confrontations), who advises them not to go. They are not afraid; they "hear the bullets coming and dodge them " they go to find the wounded and are unmindful of danger. The speakers display no doubts as to their determination; they are proud of what they are doing. These are sweet, charming kids. The one who has depicted the events has assembled all the elements in a single drawing: the uprooted trees, the bombings, a martyr, the tanks, the settlements, the homes destroyed, the fleeing residents. He wants his drawing to be seen by the whole world.

Saturday, November 25, 2000
We can finally set off for Rafah. Thanks to this being a Saturday and the Jewish Sabbath, we are hoping that it will be easier to get through Kussufim (no military traffic on the roads), and we have planned for every possible contingency: a white car with MSF identification and flag, driven by an expatriate, and a second, yellow car with a Palestinian driver.

The checkpoint is eventually opened at 10 o'clock in the morning. Our passage through takes some time because it is narrow and filled with pedestrians, cars, lorries, etc. Going to Rafah after a week of intense confrontation is the result of a priority which we had identified but we had been unable to do anything about until we had freedom of movement. In the Salaheddine district, we find exhausted and intimidated people. Their situation has deteriorated to such an extent that they are completely demoralised and constantly plagued by the sound of incessant gunfire.

The English teacher is unable to contain his feelings as he speaks about his anger and despair. He is extremely upset and it falls to his wife, who is more composed, to tell us about his state of exhaustion during a long conversation I have with her to calm and reassure her. She maintains that our visits are indispensable and comforting. One of her husband's cousins, a man of about fifty, was killed three days ago on his way home from prayer. He was shot in the head about 300 meters from the scene of the fighting. Their talk is totally devoid of humor and filled with anger and fear.

The head of the family in the house across the street is just as deeply distressed. He looks drawn and is carried away by anger when he speaks. As he puts his exhaustion into words, he gives the impression of being about to burst into tears after every sentence. He has moved his family into a garage on the ground floor of the house. We have a conversation with his wife, who is managing to cope but is very worried about the children. We are in the house when there is a burst of violent gunfire outside (photographers have just arrived on the scene and the young men want to give them a taste of what they can do!). The IDF immediately responds with a noisy barrage of shooting: this is gunfire intended to make noise like the real thing; its purpose is therefore to frighten them and act as a sort of warning before the serious shooting begins. For those of us who aren't used to it, it is quite impressive.

Afterwards, we see the small boy once more and he is feeling better (paradoxically): we meet with him in the MSF car in order to have peace and quiet and above all because it is no longer possible to breathe in his house, which is full of tear gas from bombs that have just been thrown. This arrangement is fine with him and he is the envy of the other kids. He feels safe now that he knows he and his family will be sleeping elsewhere.

In this district, there are about 25 families at risk and another eight families who are very much at risk.

We return to Rafah and find a place where we can see our patients in peace and quiet in the MSF bus, since the houses are sitting targets where it is impossible to administer treatment and give support when we ourselves are feeling stressed!

Sunday, November 26, 2000
We have arranged to see a patient at El Muragah. He is waiting for us because he has been informed of our impending visit. We are met by an anxious man who finds it difficult to explain his situation to us: he is the one who has abandoned his house out of fear; he shows us two bullet holes in the fence around the house. He hid to protect himself and then, panic-stricken, fled to his parents' home 1.5 kilometres away, having made up his mind not to spend another minute in that hell. On that particular day, his wife and children were not in the house and so he left without them. Ever since, his wife has been alone there with the children. He has been living next door to his brother's house. The situation has been unbearable for him since the incident occurred; on top of that, he has lost his job and has no money left. Our visit brings him some comfort. He wants us to help him; he feels guilty and is in need of support. His wife left this morning with the children to attend the funeral of her father, an elderly man who died of old age yesterday. In fact, this will perhaps be a chance for her to rest; she has told us that her family live near Kerni, in a quiet area.

We will go back to see him when his wife has returned and try to help them to find a solution which is acceptable to everyone. He says that he has nightmares and is no longer able to sleep; he seems quite distraught.

Our next visit is to a patient under our care, to let her know that we will be returning the day after tomorrow with the doctor: she is very weak, almost to the point of giving cause for concern, says she is no longer able to look after her children, and seems to have no strength left at all. She tells us that in spite of conditions there, she can only rest in her own home. At her sister's home two kilometres away, where she goes from time to time, the children (who are numerous) fight because they are overexcited; the space is very cramped and it is almost worse than being at home. I suggest that we should also see her husband (he returns from work at 3 p.m.) who, in her words, "Is even more afraid in the night than I am."

In the course of our conversation, we get news of families living in houses close to the mosque: we see several people, and particularly women who have gathered together to give each other moral support. A lively and wide-ranging conversation ensues: each woman voices her feelings and shares her recipe for combating fear (massages with oils to soothe painful joints, relaxation), which makes one of them laugh at the thought of this somewhat over-the-top remedy!

An IDF tank is parked on the side of the road. From time to time gunfire can be heard in the distance but it is relatively quiet and the peace is noticeable compared to what happens each afternoon from 3 or 4 p.m., and during the night. Is it a case of harassment, or "psychological warfare"? Very much so, without a doubt.

Final visit to another family's home. Their house, which is the tallest, displays evidence of considerable gunfire (numerous, very sizeable bullet holes are visible): the children are at school; we will come back and see them another day after 1.30 p.m.

I realize that I have not included in my notes the most frequently heard phrase, particularly among old people: "They are going to kill us all, we are all going to die."

We also hear words of hope expressed by our patients, to which we will bear witness by reporting what we see and hear, because the Palestinians clearly feel abandoned and forgotten. "Do people where you live really understand what we are enduring here?"

Thursday, November 30, 2000
We are witnessing a situation in the districts closest to the settlements which is deteriorating from one day to the next; more and more families are being affected; more and more houses are occupied, riddled with bullet holes, destroyed. Families are living in tents or with relatives, with little hope of ever again seeing their requisitioned property, their farm animals savagely butchered. Fear is present on a daily basis in these isolated districts and villages. Some areaes remain inaccessible to any form of humanitarian aid, as acceptable levels of security cannot be guaranteed (Mawassi, Swidi).

Our regular visits to these families allow us to measure just how much the conflict is escalating. The Palestinians live in constant fear of Israeli army reprisals. Freedom of movement within the Gaza Strip is hampered by Israeli restrictions. The only authorised route between the north and south is the country road which passes over the Kussufim crossroads. The normal dual carriageway which connects the southern towns with those in the North has been closed off by Deir El Balah, as it runs alongside the settlement of Kfar Darom for some distance.

The settlements have become fortified towns, where the right of every man to carry a weapon is legally sanctioned by the Israeli army. The soldiers of the Israeli Defence Force (IDF), who protect the settlements, enjoy the logistical and moral support of the settlers. There is no possible comparison with the Palestinian civilian population, which for the most part is careful to avoid having anything to do with Palestinian military operations, for fear of reprisals.

Monday, December 4, 2000
At the crossroads in Kussufim, the bulldozers have continued their work, destroying any remaining vegetation. Two tanks block the road, bringing traffic to a halt. The threat of coming under fire has served to convince the drivers of any cars attempting to move forward to turn back.

In Khan Yunis, the situation appears to have stabilised. In spite of the lull, the inhabitants are still in a state of shock. As soon as the fasting is over and they have eaten (in their own houses so as not to be an extra burden to the host family), everyone leaves the district to take refuge in the centre of town. It must be said that the walls of every house are scarred by bullets holes and breaches. Parents describe distressing scenes of panic to us: shooting begins, they have to leave their homes and their children are crying and shouting. Everyone rushes into the narrow streets to find shelter elsewhere. Some parents appear very demoralised and resigned to the situation; they have no hope of things ever improving. Others declare that they cannot go and fight because of the children. All are suffering from a feeling of insecurity.

It is our understanding that the Israeli army seemingly wants to move a number of families out in order to occupy their houses.

I was hailed by a woman with her children in tow. She showed us one of the children and told us that he had problems that needed to be dealt with. I went with the woman and talked to the child. He was ten years old and explained that having suffered the trauma of gunfire and shelling at home, he was now prone to panic attacks at the same time every day. Every day at the same time, he relives the fear he experienced at that moment in time; he cries, shakes and shouts to be taken to his grandfather's house.

His father, who joins us later, confirms the fact that his son is unable to recover from this fear. Not knowing what else to do for the best, he gives him tranquilisers, makes him stay at home and forces him to eat. I advise him to be patient and understanding of his son's fear; his son must decide for himself whether or not he wants to stay at home. I have promised the child that I will return to see him.

We have also met the headmistress and teachers from the primary school in Netzarim, who are very much in need of someone to listen to them and offer advice. While we are talking to them, a burst of gunfire rings out; I almost dropped dead with fright. For the children, as well as for the female teachers, this is what life is like every day. I just don't know how they cope. Judging from the teachers' reactions, I do not believe they have become used to it yet!

Wednesday, December 6, 2000
Rafah
The street is reminiscent of Beirut or Kabul. Families, living in terror, still cling to the ruins of their homes. Where else can they go? And so they stay. Sick with fear. Praying that a bulldozer won't come to knock down their house.

We cross into the Israeli-controlled zone to visit a shantytown populated by Bedouin refugees who haven't seen a doctor for months. We are still in the "Independent Palestinian Territory" but due to the proximity of the Israeli settlements, the camp is cut off from the rest of the world. The settlements resemble small islands of prosperity entrenched behind electrified fences or huge concrete walls, with watchtowers and security cameras, protected by tanks, airships attached to the ground providing surveillance, and, at sea, by military patrol boats. The concrete walls are built from movable blocks.

In the Gaza Strip, some five thousand Israeli settlers, protected by thousands of soldiers, control forty per cent of a territory with a total population of one million people. We are shown the Qfariom settlement: it is made up of one couple with their two children, around twenty soldiers and some dogs. Occasionally, the dogs manage to get out and then bite Palestinian children. All around this fortified camp, a whole population is living is terror and misery. The Palestinians provide cheap labour for Israeli plantations. The roads used by the Israelis are out of bounds to the Palestinians. The zone's main highway is made up of two parallel roads. In this way, each of the two communities has its own buses, taxis and schools. Two communities kept completely apart.

We went into the district of Rafah called al Brasil. There, we observed that the Palestinian families have been fired on by the IDF. Situated right beside the border, this district has found itself caught in the crossfire between two positions: one located along the border and supported by a tank; the other level with Salah Ad Din, where an Israeli Army watchtower is situated. The flat belonging to the family we are visiting has been shot right through by the gunfire coming from both sides at once. The kitchen is the only room to have escaped. When I meet this family, none of them dare admit to feeling frightened. They show me the youngest child, explaining that he has become fearful and that they can no longer understand him. It takes more time in conversation before each admits to being frightened, even the older brother who says that he could no longer feel his legs during the shooting. The youngest child narrowly escaped death when a bullet passed between him and his brother. Since then, he can't stand the noise of tanks any more and wants to take refuge in his uncle's house in order to sleep. He says that he doesn't feel safe there either, but he is able to sleep. Three of the four brothers talk about their fear. The fourth claims not to feel frightened. I explain to the family that everyone has his own threshold of resistance and that each person's fear should be respected. I think that for the first time, the members of this family were able, in front of the others, to exteriorise feelings which had, up until then, remained too shameful to be mentioned.

It seems to me that each member of the family is trying to conquer his or her fear and resist the temptation to run away, which would be seen as evidence of cowardice; the family's duty is to stay in their home. One person suppresses all emotion, another wants to join the army, and a third wants to go to America. All are obliged to remain in this house, transferring their fear, as it were, to the youngest, whose own fear, to which none can then relate, becomes incomprehensible. This is the first time that I have been able to identify this family phenomenon so clearly.

Another phenomenon appears to present itself here. In spite of the lull in fighting, many people seem to find it difficult to relax and return to normal life. Perhaps what we have here are the circumstances for the onset of trauma. If this is the case, we should soon be able to observe the symptoms. I am reserving judgement until I have collected more evidence to give me a better idea about this subject. But it can be said right here and now that the mood remains gloomy despite the rapidly changing situation. Fear is still uppermost in people's minds, and even dominates their physical state.

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Eyewitness Account by MSF Anesthetist Philippe Trinh-Duc
Qalqilia, November 15, 2000

The Palestinian Red Crescent brought a 15-year-old "chebab" into the Emergency ward. He was dying of a gunshot wound to the abdomen. For him, the Intifada was the only way of building a future. It turned him into a martyr.

Every day, adolescents and young adults like him arrive at the hospital after being wounded during confrontations with the Israeli army at the military checkpoints. The number of victims is rising (as many dead and injured over the last fortnight as during the whole of the month of October); but above all, Tsahal's use of live ammunition instead of rubber bullets is on the increase: of the Intifada victims hospitalized, 40% are suffering from wounds caused by live rounds.

Given the young age of the participants, their lack of organization and their scant equipment, these confrontations are more like riots than urban guerrilla warfare, so how is the use of live ammunition justified? The Israeli government invokes legitimate defense. The definition of this term clearly states that the intensity of the response must be commensurate with the gravity of the attack. How can this be legitimate defense, when high-caliber weapons respond to slingshots? How can this be legitimate defense, when a number of the wounded received in the hospital have entry wounds in their backs, showing that they were shot while running away from the fighting? How can this be legitimate defense, when two people were shot in their apartment, near the conflict zone?

The figures recorded during my stay (total of 10 days) in the Qalqilia hospital, show a rise in the number of wounded during the Intifada confrontations during the first half of November as compared to the previous month (51 in October, 49 in the first half of November). Of these patients admitted to the Emergency wards, 39% suffered from live ammunition wounds (55% had secondary injuries due to the use of rubber bullets).

The Palestinians we met in Qalqilia, rather than asking for personnel or material help, asked me to tell my family, friends and colleagues what I had seen. My mission therefore continues here.

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Gaza Strip: MSF Opens a Medical and Psychological Support Mission
Paris, November 13, 2000

To combat the trauma suffered by the populations most exposed to the violence, MSF opened a medical and psychological support mission in Gaza in November 2000.

On Sunday November 13, MSF opened a mobile medical and psychological support unit intended for the most exposed persons living close to the confrontation areas, the settlements and the military camps and suffering from disorders related to the violence, in particular children under twelve.

The blockading of the territories and the constant checks, the problems with moving about and the constantly visible confrontations and violence, as well as daily exposure to shelling and bombing, have seriously degraded daily living conditions for the families inhabiting the Gaza Strip.

"This situation generates acute psychological stress requiring rapid and specific treatment. The situation here for everyone is far more serious and traumatizing than the first Intifada," explained Dr Christian Lachal, psychiatrist.

"We went to see a young woman who was three months pregnant," said Dr Pierre-Pascal Vandini. "Tear gas grenades had been thrown into the house. The family panicked as they couldn't breathe and left through the window: she, her husband and their two children. At the first consultation, she was unable to get up. She was afraid of being paralyzed and was worried for the baby she was carrying."

Events such as these cause physiological troubles (partial and temporary paralysis) and psychological disorders: anger, anxiety, fear of poisoning, nutritional disorders, etc. A medical consultation enables the physiological troubles to be detected and treated. At the same time, the psychologist can begin therapeutic treatment enabling the patients to express their fears, to treat their traumas and reduce their stress levels. This young woman who could not leave her house for fear of finding it destroyed when she came home, will be regularly monitored and supported by a mobile team consisting of a psychologist and a doctor.

The MSF teams have been working in the West Bank since 1994. Since the confrontations began last October they have been reinforced. The programs were first of all oriented towards support for the Palestinian surgical teams (donation of surgical kits) to help them handle the massive influx of wounded and injured as the medical needs were being well taken care of. Given the gravity of the trauma suffered by the population in the zones subject to the violence, psychological treatment of the families was identified as an urgent need. At present 10 volunteers from the association are present on the West Bank and in the Gaza Strip.

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West Bank, Hebron: MSF Observes a Worrying Health Situation with Major Obstacles to the Practice of Medicine
Paris, December 7, 2000

Faced with the growing obstacles to health care access in the old town of Hebron, on the West Bank, MSF set up mobile teams consisting of doctors and psychologists. This work is based on home visits and highlighted a deterioration of the health of the Palestinian population over the last two months.

Since 28 September, the old town of Hebron has been under permanent curfew, lifted for only a few hours each day. Most of the residents are reticent about leaving their homes, either because of the curfew, or through fear of military inspections, or fear of requisitioning or destruction of their property. It is only with extreme difficulty that they can get to a hospital or a doctor.

Medical assistance, whether public or private, is officially authorized, but in fact there are so many obstacles (inspections, check-points, intimidation) that there are not always doctors in the old town.

In this zone under Israeli control, comprising some 40,000 inhabitants, there are 400 settlers protected by 1500 soldiers: "The streets are almost deserted, it's like a ghost town" explains Dr Etcheverry. "On 28 November, we went through five military check-points before reaching a quarter near Abraham's tomb. We had come to give medication to someone suffering from asthma and who had no drugs. When we knocked at the door, the people inside were afraid to open up to us."

"In one family," added Dr Vandini, "we found a young man who had his wrists broken during a police check, a 15-year old adolescent girl who complained of recent paralysis in one arm and a 5 year old epileptic child, completely without medical care. In another, we met a 60-year-old diabetic today suffering from rare and extremely serious complications. These examples show that the families have virtually nowhere to turn for help whenever someone else falls sick. This population is showing signs of a chronic lack of health care."

Medical and psychological home visits are designed to meet the general medical needs but also to deal with acute stress and prevent the occurrence of post-traumatic stress disorder (PTSD). They also take in the villages in the surrounding area, which are often isolated by military checkpoints. A similar program was opened on 20 November last in the Gaza Strip.

The MSF teams have been working in the West Bank since 1994. Since the confrontations began last October they have been reinforced. At present 13 volunteers from the association are present in the West Bank and in the Gaza strip.