Volume 22/1, June 2020, pp 179 – 186
Bram Wispelwey and Yasser Abu Jamei
The Gaza Strip is under an Israeli land, sea, and air blockade that is exacerbated by Egyptian restrictions and imposes an enormous cost in terms of human suffering. The effects of blockade, poverty, and frequent attacks suffered by the population have taken a significant toll on people’s mental health. The Great March of Return, a mass resistance movement begun in March 2018, initially provided a positive impact on community mental health via a sense of agency, hope, and unprecedented community mobilization. This improvement, however, has since been offset by the heavy burden of death, disability, and trauma suffered by protestors and family members, as well as by a failure of local and international governments to alleviate conditions for Palestinians in Gaza. Reflecting on the ephemerality of the material and political gains of this movement, this paper shows that Palestinian and international health practitioners have an opportunity to develop an understanding of the psychosocial consequences of community organizing and mass resistance while simultaneously providing holistic mental and physical health care to community members affected by the events of the Great March of Return and other efforts.
Conditions in the Gaza Strip
For 13 years, the Gaza Strip has been under a land, sea, and air blockade, imposed on top of a decades-long Israeli military occupation and with an enormous cost in terms of human suffering.1 The blockade has limited the movement of people, goods, and services in and out of Gaza and has contributed to a chronic humanitarian crisis entailing a lack of sufficient electricity, sanitation, and health services for Palestinians in the Strip.2 Israel has intentionally calibrated its occupation and blockade measures to maintain Gaza on “the brink of collapse.”3 The humanitarian stress placed on Gaza has prompted the United Nations (UN) to warn that the area will be “unlivable by 2020.”4 More than 4,400 Palestinians, including more than 1,100 children, have been killed, and tens of thousands have been injured over the course of three military assaults by Israel in the last 12 years.5 Commonly considered “the world’s largest open-air prison,” Gaza has a population of two million people, 70% of whom are refugees whose right of return to their homes in present-day Israel has been systematically refused since 1948.6 All political attempts to resolve the refugee crisis over the past seven decades have failed, leaving millions of displaced Palestinians in Gaza, the West Bank, Israel, and elsewhere in inadequate “temporary” living conditions, and—perhaps more harmfully—with an ever-waning hope for refugee return.
Exacerbating this context has been an economic crisis characterized by high levels of unemployment and poverty. For example, unemployment rose from 44% to 52% between 2017 and 2018; young adults aged 19–29 are the most affected, with a 69% unemployment rate as of early 2018.7 Over the same period, 53% of the population in the Strip was thought to be living below the poverty line (up from 39% in 2011), with deep poverty affecting more than a third of the population.8 With a dismal outlook on prospects for the future, a sense of both helplessness and hopelessness has escalated among the people.9
Mass resistance as mental health intervention
In March 2018, hope was reignited in the form of large-scale demonstrations in Gaza. Protests were triggered by collective anger surrounding Palestinians’ refused right of return, the ongoing military occupation and blockade, the dire economic situation, and US policy decisions that included the move of its embassy from Tel Aviv to Jerusalem and the defunding of the United Nations Relief and Works Agency for Palestinian Refugees (UNRWA) from US$364 million (30% of the agency’s entire budget) in 2017 to zero.10 Palestinians in the Strip began what became known as the “Great March of Return” (GMR) protest on March 30—Land Day—in solidarity with Palestinian citizens of Israel. Land Day commemorates the protests of Galilean Palestinians against the appropriation of their land by the Israeli state in 1976, an event that led to the killing of six protestors and the injury of dozens of others.11 Every Friday since, Palestinians in Gaza have massed at the border for GMR protests to assert their right to return to their homelands, as outlined in UN Resolution 194.12
The GMR demonstrations, conceptualized by a group of young Palestinians through social media, quickly developed into a grassroots community organizing effort.13 The GMR’s organizers reached out to a cross section of the Palestinian community to foster support and participation. The initial atmosphere was festival-like in its exuberance and multigenerational family inclusion.14 All the richness of Palestinian life was present: food vendors, dabke dancing, clowns, acrobats, and even wedding celebrations. The protests, which included chanting and mass movement toward the separation fence between the Gaza Strip and Israel, were faced by tear gas and live sniper fire from Israeli security forces.15
With the large and united scope of these demonstrations, and broad international interest in them, Palestinians found a renewed sense of hope that active resistance in the form of large-scale protest could precipitate a fundamental change in the grim situation in Gaza. Additionally, collective organizing infused participants with a sense of dignity and self-efficacy in the face of immense political challenges to well-being. One of the GMR’s early organizers noted that “we stood against all the powers telling us to break and die in silence and decided to march for life … we are fighting back peacefully with our bodies and our love for life, appealing to the justice that remains in the world.”16 Mental health practitioners began noticing that protestors felt, for the first time, that they had agency in challenging the structures determining their conditions.17 They had refocused the global media story on their goals and actions, developing a perception that a collective Palestinian voice was being heard again. The achievement of a positive and meaningful international response felt possible, bringing hope and what mental health practitioners noted as significant improvements in mood and response to trauma.18
Mental health in the Palestinian context: Where Western models fail
While mental health has traditionally been pathologized at an individual level in Western psychological discourse, it is clear to Palestinian mental health professionals that the alarming rates of mental illness among Palestinians are driven first and foremost by the historical and ongoing political context. Mental illness rates in the occupied Palestinian territory, according to standard Western measurements, are some of the highest in the world.19 Compared to Americans, Palestinians have three to four times the rate of post-traumatic stress disorder (PTSD), and their depression rates significantly exceed those of any other people in the Eastern Mediterranean.20 But many health professionals in the occupied Palestinian territory believe that this Western mental health methodology is capturing just the tip of the iceberg, below which there exists community-wide social suffering related to occupation, blockade, violence, ethnic cleansing, land theft, daily humiliation, and a loss of faith in local and global leadership to resolve the crisis.21 In other words, health professionals are drawing a distinction between an end diagnosis of depression and underlying, justified communal misery. In order to avoid reducing community-wide experiences of political violence to individual trauma, some Palestinian investigators have abandoned Western mental health frameworks in favor of those that highlight the roles of political power and settler-colonialism in shaping an intergenerational resistance praxis.22
Some have posited that these Western mental health diagnoses, when more appropriately redefined in the Palestinian context as social suffering, require a human rights-informed and political advocacy approach to therapy.23 The false categorization of mental health illness from a Western and individualized diagnostic lens may lead to ineffective care that is not tailored to context, which poses serious ethical concerns and the possibility of harm.24 In particular, therapeutic psychosocial approaches that assume that people suffering from trauma are now post-trauma are destined to fail in a region where trauma is continuous and the triggering context is often unavoidable. For example, Palestinian children being treated for behavioral or mood disorders as a result of a wartime trauma experience delayed progress through their treatment course, with persistent anxiety and fear due to a lack of security and concern for imminent harm to themselves or family members. These patients are at high risk of relapse and further pervasive psychosomatic manifestations given their inability to escape the traumatizing context. Within such a trapped and colonized condition, Frantz Fanon’s framework connecting social subjugation to mental health distress is wholly apposite.25 The GMR is thus an example of Fanon’s Les Damnés de la Terre, for its protestors are collectively empowering themselves to become architects and agents for change.26 Acknowledging the structural oppression and systematic violence that affect all levels of society is fundamental to identifying how political advocacy, collective resilience, and mass protest should form an integral part of mental health treatment, particularly when protection from political and military violence is, as in the case of Gaza, unavailable.
Palestinian health professionals have long noted the links between meaningful resistance and activism efforts, on the one hand, and psychological well-being and health protection, on the other. This observation framework is in line with decades of decolonial, subaltern, antiracist, Global South, Black, and indigenous mental health praxis and literature.27 A growing radical healing movement and framework in US psychology draws on a similar legacy, seeking an activist approach to “healing and transformation that integrates elements of liberation psychology, Black psychology, ethnopolitical psychology, and intersectionality theory.”28 As activism, community organizing, and protest are gaining renewed interest in the United States and elsewhere as means of resistance, antiracism, decolonial praxis, and political change, evidence is mounting that these actions have beneficial effects, via increased agency, on people’s well-being and mental health.29 A recent US study found that political activism was a protective factor for Latinx college students against stress and depressive symptoms, and organizations such as City Life/Vida Urbana in Boston have long touted the positive connection between community organizing and mental health.30
With the social suffering thesis put forward by Palestinian health professionals such as Rita Giacaman and Samah Jabr—which links structural racism and systematic violence to all forms of well-being, including psychological—these “new” results should not surprise us.31 And this Palestinian conception offers a coherent answer to why mental health practitioners in Gaza recognized a profound positive impact on psychological well-being at the beginning of the GMR. These practitioners had already explicated the importance of including the voices of the oppressed in the healing process, and the GMR is, among other things, a bold example of the traumatized and oppressed—les damnés—taking hold of the therapeutic reins at a community level.32
Two years on: Where do we go from here?
Despite engaging in a weekly mass protest stretching for two years now, and recognition from the UN that Israel’s response to the GMR may include numerous war crimes or crimes against humanity, the situation for Palestinians in Gaza has not improved.33 In addition to the hundreds of deaths and tens of thousands of injuries since the GMR began, Palestinians have watched their political leadership and the international community fail to leverage this activism into material or political improvements.34 The broadly experienced sense of promise at the GMR’s commencement has begun to fade.
The initial positive mental health effects of mass resistance have been displaced by a significant increase in patients diagnosed with PTSD, depression, and anxiety, as well as relapsing mood and behavioral disorders in children.35 Further burden has been placed on the collective social fabric given the limited economic resources and increasing physical and mental trauma experienced by family members. A sharp uptick has occurred in Palestinians accessing mental health services across all genders and ages, especially young adult men, the group most likely to experience direct or observed trauma during the GMR.36 The Gaza Community Mental Health Program (GCMHP), a community-based organization that grounds its work in a social justice-based approach to mental health treatment, has been at the forefront of the response to addressing the downstream effects of the GMR crackdown on Gaza’s citizens. Psychological first aid, telephone counseling, and crisis-oriented community interventions strive to protect vulnerable groups in response to escalating crises. GCMHP aims to treat these acute mental health manifestations while also assisting patients in reclaiming their role as productive members of the community, but the situation has become increasingly difficult.37
Current developments on the ground—including the United States’ withdrawal of funding to UNRWA and other entities, the US Embassy’s move to Jerusalem, the fragmentation of Palestinians into disconnected populations with different rights and legal statuses, the ongoing destruction of Palestinian homes and villages, deliberate material deprivation in Gaza, and political plans for West Bank annexation—represent further entrenchments of occupation, colonization, and international abandonment of Palestinians’ rights and well-being.38 These facts, coupled with total territorial control by one the world’s most powerful militaries and systematic violence readily unleashed on protestors, make effective resistance difficult to sustain.
As the Gaza Strip becomes increasingly unlivable, sociopolitical stressors will mount and exacerbate the suffering that manifests, among other ways, as poor mental health outcomes. Humanitarian intervention and treatment strategies that do not embrace the political realm risk being ineffective at best and may inadvertently prolong suffering by eschewing root causes. Palestinian health practitioners and researchers continue to connect the biomedical to the political sphere, combining health work with broader efforts to support communities struggling against occupation as the most rational and effective approach.39 Palestinian health workers, at times intentionally targeted and killed by snipers, have lived out this attitude during the GMR.40
Given the dispiriting lack of material change as a result of the GMR, and its significant toll on Palestinians’ lives and well-being, we are left with difficult questions about the ephemerality of the mental health benefits that accrue from collective organizing and resistance. Despite repeated setbacks, however, Palestinians have mounted numerous and often unexpected resistance charges over the last century, leading to the development of a highly cultivated intergenerational means of coping and renewal.24 In this sense, the benefits of resistance on mental health are not purely contingent on whether demands are achieved in the short term, but are passed from generation to generation in order to keep the political struggle afloat and community hope alive. This steadfastness is in turn met with oppression designed to extinguish resistance, including, in the case of the GMR, potential war crimes or crimes against humanity committed by the Israeli army in the form of targeting and killing children, health workers, journalists, and people with disabilities.41
The extremeness of responding to mass protest with brutal violence rather than negotiation—the confirmation of an oppressor’s immovability—requires an international response. Given that many of the geopolitical factors that contribute to social suffering are within the political and advocacy realms of international health professionals, these professionals must organize on behalf of Palestinian justice and liberation in their home countries if they hope to positively affect Palestinians’ mental and physical health. Groups such as the Health Advisory Council of Jewish Voice for Peace are organizing within US communities to promote health-related avenues for activism in support of Palestinians’ health. Those of us from countries with historical responsibility and geopolitical leverage—the United States and United Kingdom, first and foremost—have a special responsibility, as we do toward citizens of our own countries, to contribute to achieving Palestinians’ rights to health and liberation. Financially, clinically, and programmatically supporting grassroots Palestinian initiatives, such as GCMHP and Health for Palestine (a community health program in West Bank refugee camps), represent tangible opportunities for Western health professionals.42 The GMR is an opportunity to recognize and add to the evidence linking mass resistance and activism to therapeutic and salutogenic effects, and to follow this exemplary Palestinian framework in both theory and practice.
Bram Wispelwey is an Associate Physician in the Division of Global Health Equity at Brigham and Women’s Hospital, Boston, USA; Instructor in Medicine at Harvard Medical School, Boston, USA; and Chief Strategist at Health for Palestine, Palestine.
Yasser Abu Jamei is a psychiatrist and Executive Director of the Gaza Community Mental Health Programme, Palestine.
Please address correspondence to Bram Wispelwey. Email: firstname.lastname@example.org.
Competing interests: Bram Wispelwey and Yasser Abu Jamei direct community health programs in Palestine (Health for Palestine and Gaza Community Mental Health Programme, respectively).
Copyright © 2020 Wispelwey and Abu Jamei. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.
- United Nations Country Team in the Occupied Palestinian Territory, Gaza ten years later: UN country team in the Occupied Palestinian Territory (2017), p. 1–33. Available at https://unsco.unmissions.org/sites/default/files/gaza_10_years_later_-_11_july_2017.pdf.
- Amnesty International, Amnesty International report 2017/18: Israel and the Occupied Palestinian Territories (2018). Available at https://www.refworld.org/cgi-bin/texis/vtx/rwmain?page=search&docid=5a9938e46&skip=0&query=amnesty 2018&coi=ISR.
- J. Norman, WikiLeaks: Israel intentionally kept Gaza on brink of economic collapse (2011). Available at https://www.cbsnews.com/news/wikileaks-israel-intentionally-kept-gaza-on-brink-of-economic-collapse/.
- United Nations, Gaza “unliveable”, UN Special Rapporteur for the situation of human rights in the OPT tells Third Committee: Press release (excerpts) (2018). Available at https://www.un.org/unispal/document/gaza-unliveable-un-special-rapporteur-for-the-situation-of-human-rights-in-the-opt-tells-third-committee-press-release-excerpts/.
- B’Tselem, Fatalities since Operation Cast Lead (2020). Available at https://www.btselem.org/statistics/fatalities/during-cast-lead/by-date-of-event; B’Tselem, Fatalities during Operation Cast Lead (2020). Available at https://www.btselem.org/statistics/fatalities/during-cast-lead/by-date-of-event.
- R. Horving, Gaza: The world’s largest open-air prison (2018). Available at https://www.nrc.no/news/2018/april/gaza-the-worlds-largest-open-air-prison/.
- PCBS, Palestinian Central Bureau of Statistics: State of Palestine (2019). Available at http://pcbs.gov.ps/site/lang__en/1/default.aspx.
- OHCA, “53 per cent of Palestinians in Gaza live in poverty, despite humanitarian assistance,” Monthly Humanitarian Bulletin (2018). Available at https://www.ochaopt.org/content/53-cent-palestinians-gaza-live-poverty-despite-humanitarian-assistance.
- Y. Hawari, “From inspiration to despair: A year of Gaza’s Great March of Return,” Middle East Eye (2019). Available at https://www.middleeasteye.net/opinion/inspiration-despair-year-gazas-great-march-return.
- “US ends aid to Palestinian refugee agency UNRWA,” BBC News (2018). Available at https://www.bbc.com/news/world-us-canada-45377336.
- Amnesty International, Six months on: Gaza’s Great March of Return (2018). Available at https://www.amnesty.org/en/latest/campaigns/2018/10/gaza-great-march-of-return/.
- UN General Assembly, 194 (III). Palestine – Progress Report of the United Nations Mediator (1948). Available at https://www.refworld.org/docid/4fe2e5672.html.
- A. Abu Artema, “I helped start the Gaza protests. I don’t regret it,” New York Times (2018). Available at https://www.nytimes.com/2018/05/14/opinion/gaza-protests-organizer-great-return-march.html; J. Abusalim, “The Great March of Return: An organizer’s perspective,” Journal of Palestine Studies 47/4 (2018), pp. 90–100.
- I. Hammad, A. Alnaouq, Z. Shaikhah, et al., “The Great March (Gaza, ep. 1),” Unsettled Podcast (2019). Available at https://www.unsettledpod.com/episodes/2019/1/14/the-great-march-gaza-ep-1.
- H. Balousha and P. Beaumont, “Defiance, then death: Gaza suffers most horrific day of violence for four years,” Guardian (2018). Available at https://www.theguardian.com/world/2018/may/14/israel-palestine-defiance-death-gaza-jerusalem-suffers-horrific-day-of-violence-for-four-years.
- A. Abu Artema, “With the Great Return March, Palestinians are demanding a life of dignity,” Nation (2018). Available at https://www.thenation.com/article/archive/with-the-great-return-march-palestinians-are-demanding-a-life-of-dignity/.
- Clinical observations of the author (Abu Jamei).
- O. Goldhill, Palestine’s head of mental health services says PTSD is a Western concept (2019). Available at https://qz.com/1521806/palestines-head-of-mental-health-services-says-ptsd-is-a-western-concept/.
- M. Marie, B. Hannigan, and A. Jones, “Mental health needs and services in the West Bank, Palestine,” International Journal of Mental Health Systems 10/1 (2016), pp. 1–8; R. Charara, M. Forouzanfar, M. Naghavi, et al., “The burden of mental disorders in the Eastern Mediterranean region, 1990–2013,” PLoS ONE 12/1 (2017).
- R. Giacaman, “Reframing public health in wartime: From the biomedical model to the ‘wounds inside,’” Journal of Palestine Studies 47/2 (2018), pp. 9–27.
- D. G. Atallah, “A community-based qualitative study of intergenerational resilience with Palestinian refugee families facing structural violence and historical trauma,” Transcultural Psychiatry 54/3 (2017), pp. 357–383.
- M. Diab, G. Veronese, Y. A. Jamei, et al., “Community work in the ongoing crisis context of Gaza: Integrating a public health and human rights approach,” Australian and New Zealand Journal of Family Therapy 39/3 (2018), pp. 320–330.
- R. Giacaman, “Reflections on the meaning of ‘resilience’ in the Palestinian context,” Journal of Public Health (2019).
- R. Greenslade, “Existential psychotherapy and the therapeutics of activism,” European Journal of Psychotherapy and Counselling 20/2 (2018), pp. 184–198.
- F. Fanon, The wretched of the Earth (New York: Grove Press, 1968), p. 324.
- Giacaman (2019, see note 24); W. Hammoudeh, A. Khatib, D. Masoud, et al., “Well-being and its determinants from the perspective of the Palestinian youth in the occupied Palestinian territory,” Lancet 393 (2019), p. S28; R. Giacaman, S. Mitwalli, and W. Hammoudeh, “Linking social capital: Political confidence among youth in occupied Palestine (the West Bank and Gaza Strip),” Power2Youth Working Paper No. 26 (2017); M. Watkins, N. Ciofalo, and S. James, “Engaging the struggle for decolonial approaches to teaching community psychology,” American Journal of Community Psychology 62/3–4 (2018), p. ajcp.12295.
- B. H. French, J. A. Lewis, D. V. Mosley, et al., “Toward a Psychological Framework of Radical Healing in Communities of Color,” The Counseling Psychologist 48/1 (2020), pp. 14–46.
- G. Veronese, A. Pepe, F. Cavazzoni, et al., “Agency via life satisfaction as a protective factor from cumulative trauma and emotional distress among Bedouin children in Palestine,” Frontiers in Psychology 10 (2019), p. 1674; L. Eisenstein, “To fight burnout, organize,” New England Journal of Medicine 379/6 (2018), pp. 509–511.
- E. C. Hope, G. Velez, C. Offidani-Bertrand, et al., “Political activism and mental health among black and Latinx college students,” Cultural Diversity and Ethnic Minority Psychology 24/1 (2018), pp. 26–39; M. Axel-Lute, How organizing for justice helps your mental health (2017). Available at https://shelterforce.org/2017/11/22/how-organizing-for-justice-helps-your-mental-health/.
- R. Giacaman, “Social suffering, the painful wounds inside,” American Journal of Public Health 107/3 (2017), pp. 357–357.
- Diab et al. (see note 23).
- Office of the United Nations High Commissioner for Human Rights, “No justification for Israel to shoot protestors with live ammunition.” Available at https://www.ohchr.org/EN/HRBodies/HRC/Pages/NewsDetail.aspx?NewsID=24226&LangID=E&fbclid=IwAR31gvgTvw8EEyrciD98JhH1sUPtIruuCx8QvF_eOQfLOelS02RBKuLMUL8.
- D. Mills, M. Gilbert, and B. Wispelwey, “Gaza’s Great March of Return: Humanitarian emergency and the silence of international health professionals,” BMJ Global Health 4 (2019), p. 1673.
- Gaza Community Mental Health Program, Mental health fact sheet 2018–2019 (2019), unpublished.
- Diab et al. (see note 23).
- K. DeYoung, R. Eglash, and H. Balousha, “U.S. ends aid to United Nations agency supporting Palestinian refugees,” Washington Post (2018). Available at https://www.washingtonpost.com/world/middle_east/us-aid-cuts-wont-end-the-right-of-return-palestinians-say/2018/08/31/8e3f25b4-ad0c-11e8-8a0c-70b618c98d3c_story.html?noredirect=on; I. Kershner, “Israel begins tearing down Palestinian housing on edge of East Jerusalem,” New York Times (2019). Available at https://www.nytimes.com/2019/07/22/world/middleeast/israel-demolition-palestinian-housing.html; Associated Press, “Israel used ‘calorie count’ to limit Gaza food during blockade, critics claim,” Guardian (2012). Available at https://www.theguardian.com/world/2012/oct/17/israeli-military-calorie-limit-gaza; J. McAuley, and R. Eglash, “Netanyahu vows to annex Israeli settlements in the West Bank,” Washington Post (2019). Available at https://www.washingtonpost.com/world/middle_east/on-campaign-trail-netanyahu-vows-to-annex-west-bank-settlements–again/2019/09/01/2c133f4c-cc96-11e9-87fa-8501a456c003_story.html.
- Giacaman (2018, see note 21).
- D. M. Halbfinger, “A day, a life: When a medic was killed in Gaza, was it an accident?” New York Times (2018). Available at https://www.nytimes.com/2018/12/30/world/middleeast/gaza-medic-israel-shooting.html.
- Office of the United Nations High Commissioner for Human Rights, Report of the UN Commission of Inquiry on the 2018 protests in the OPT (2019). Available at https://www.ohchr.org/EN/HRBodies/HRC/CoIOPT/Pages/Report2018OPT.aspx.
- D. Atallah, S. Kramer, L. Al Bast, et al., “Community health work under occupation: Towards the development of a new model to address social and political determinants of health in Palestinian refugee camps,” CHW Central (2019). Available at https://www.chwcentral.org/blog/community-health-work-under-occupation-towards-development-new-model-address-social-and.