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“Come and See the Blood in the Streets!”

2023; Medknow; Volume: 5; Issue: 3 Linguagem: Inglês

10.4103/wsp.wsp_68_23

2667-1085

Debasish Basu,

Migration, Health and Trauma

"You are going to ask: And where are the lilacs? And the poppy-petalled metaphysics? …I'll tell you all the news. I lived in a suburb, A suburb of Madrid, with bells, And clocks and trees. …My house was called The house of flowers, because in every cranny Geraniums burst: It was A good-looking house With its dogs and children." PABLO NERUDA, 1930S. "I'M EXPLAINING A FEW THINGS"[1] The poem by Pablo Neruda, a Nobel-winning Chilean poet-diplomat, describes the atrocities committed in the Spanish town of Guernica during the early Spanish Civil War. It is a blatantly critical response to the fascist bombing of Guernica and is one in which Neruda denounces the Nationalist forces of Spain. It talks about how a beautiful suburban home in Madrid, "with bells, and clocks and trees," "with its dogs and children," and friends such as Raul, Rafael, and Federico, with warm lovely memories, was bombed. It was blown to smithereens. And children died. "And one morning all that was burning, One morning the bonfires Leapt out of the earth Devouring human beings- And from then on fire, Gunpowder from then on, And from then on blood Bandits with planes and Moors, …Came through the sky to kill children And the blood of children ran through the streets Without fuss, like children's blood."[1] DOES IT RING A BELL? Right now, as this editorial is being composed at the dead of the night, sitting in a comfortable corner in India, houses are being destroyed elsewhere. Lives are being destroyed. Livelihoods are being destroyed. People are dying. Civilians are dying. More than 13,000 of them by some accounts – And around 5000 of them are children. Well, these are just numbers, and numbers can be disputed. Who has counted the dead and the injured? And who has counted those still trapped, or dead, under the rubbles that were once homes? And who will count the hungry, the thirsty, the soiled, the sleepless, the cold, the wet, the scared, the ones getting ready for a slow death? Do numbers do justice to them? Yet, numbers matter. Yes, this editorial is talking about the Israel-Palestine current heightened conflict, which has entered its 45th day as of this writing, and which has the potential to engulf the region. The phrase "current heightened" is important, because the conflict is not new, dating back to many decades, certainly since 1948 in a deadly form. The detailed timelines can be found at many places but the dates – and more importantly, their veracity and their interpretations – vary depending upon who is stating what; hence, a useful summary at the United Nations (UN) website is cited here.[2] FIRST THINGS FIRST This editorial strongly and unequivocally condemns, in the harshest language possible, the ghastly, dastardly and cowardly attack on Israeli territory to massacre around 1200 civilians at a music festival and in kibbutz Be'eri and to take around 240 hostages in Southern Israel to the Gaza Strip. There is no excuse, no rationalization, and no justification. Those who were killed and those who are taken hostage include men, women, and children and sick people. This is clearly one of the most gruesome terrorist attacks conducted by the militant wing of the Islamic Resistance Movement, Ḥarakat al-Muqāwamah al-Islāmiyyah, known to the world by its acronym Hamas, designated as a terrorist organization by many countries (but not all, including the UN). However, this editorial also condemns, in equally strong and unequivocal terms, and in the harshest language possible, the ghastly, dastardly and cowardly attack on the Gaza strip (an occupied Palestinian Territory along with West Bank, areas which are illegally occupied by Israel since 1967) by the Israeli military forces under the premiership of its controversy-ridden prime minister Benjamin Netanyahu. There is no excuse, no rationalization, no justification. Those who were killed and those who are injured include men, women and children and sick people. In the name of "self-defence" what Israel is doing is mass murder and ultimate desolation of a population, with the intent and the scale reminiscent of a "genocide." Numbers are anybody's guess but the reported numbers by the Hama-controlled Health Department of Gaza, as of writing this piece (November 21, 2023) include 13,000 deaths including some 5000 children, and 30,000 or so injured. Places of civilian residence, places of education, places of religion, even places of shelter (including official UN designated shelters) and most worryingly, places of medical treatment have been systematically destroyed by targeted incessant bombing and ground invasion by the Israeli army. Journalists have been killed, at least 40 of them, mostly Palestinians. Moreover, all these numbers are likely underestimates. The UN Relief and Welfare Agency (UNRWA) of the Near East reports in its latest bulletin that, as of November 18, 2023, "In total, 104 colleagues have been killed since the beginning of the war. This is the highest number of UN aid workers killed in a conflict in the history of the UN ….[3] It further states: "Almost 1.7 million people (out of the total 2.3 million) have been displaced across the Gaza Strip since 7 October. As of 18 November, nearly 884,000 internally displaced persons (IDPs) are now sheltering in 154 UNRWA installations across all five governorates of the Gaza Strip, including in the North. Nearly 724,000 IDPs are sheltering in 97 facilities in the Middle, Khan Younis and Rafah areas. Nearly 160,000 IDPs were sheltering in 57 UNRWA schools in the Northern and Gaza areas as of October 12, 2023, before the evacuation order was issued by Israeli Authorities. UNRWA is not able to access these shelters to assist or protect IDPs and does not have information on their needs and conditions."[3] Sick patients and children have died, and many more people are living in unspeakable conditions, with barely any food, water, medicine, shelter or basic sewage treatment facilities, and often with no communication. Fuel is running out. Surgical operations have been done without anesthesia and without adequate medical and other support systems. Ventilators and other equipment for critically ill patients are facing crisis. Neonates have died in incubators. Surgical operations have been done with torchlight beamed from mobile phone devices. Imminent public health catastrophe is anticipated with mass displacement, overcrowding of shelters and damage to the water and sanitation infrastructure. Along with these, there have been large scale destruction of properties. Two thirds of Gaza strip is a rubble now. People have nowhere to go. They have been asked to evacuate Northern Gaza and shift Southward, only to be bombed there as well. Evacuate to where? To what condition? People – common people such as you, us, and your and our families – have been reduced to worse than animals. They – an entire population of ordinary men, women AND children AND elderly AND sick people – are being meted out "collective punishment" at an unprecedented, macabre and grossly disproportionate scale, for the heinous crimes committed by an extremist group of people. This is ethnic hounding, followed by ethnic cleansing. A much more sinister plan seems to operating behind these ruthless annihilations, much beyond the ostensible self-defense. DID IT HAPPEN IN A VACUUM? This editorial supports the statement made by António Guterres, the UN Secretary-general, who, while condemning the appalling attack by Hamas, at the same time asked to stop the "epic suffering" of the common Palestinian people and reminded us that these events "did not happen in a vacuum." Indeed, a brief look at the decades-long timeline of the Israel–Palestinian conflict would tell us that there is a long and complex history of intergenerational trauma inflicted upon, and experienced or witnessed by, millions of Palestinian people, both in the forcefully ghettoized Gaza strip and also in the unlawfully settled-colonized parts of the West Bank. Trauma of repeated inspections, restrictions, segregation, humiliation, deprivation, indeed, symbolic suffocation. Gaza strip has been called the largest open-air prison in the world. And their repercussion by violence, followed by severe retribution and the cycle continues. No true Jewish people would support the mass destruction of an entire population with merciless mercenary precision and intent, in the name of religion, nationalism, Zionism, capitalism, "this-ism that-ism," what have you. As many, many true and faithful Jewish people across the world are protesting against these desolations and massacre: "NOT IN MY NAME!" Indeed, true Jewish people would recall how – Throughout history but of course climaxing during the Nazi era – they have been hounded out of their own places, deprived of their own facilities, humiliated, segregated, deprived, maimed, tortured, and murdered. Common sense would have dictated that they would know better the pains of these experiences and would not let anyone suffer from the same. Ironically, they – Or at least some of them, certainly the politicians – are now doing the same injustice to the Palestinians that they themselves had been subjected to earlier! Why? Is it their way of taking revenge on Hitler and his team? Or is Sigmund Freud smiling quietly somewhere, recalling the "return of the repressed?" Come what may, history bears the witness that the state of Israel has repeatedly disrespected – indeed, violated – UN resolutions and even international law related to the unlawful occupation of Palestinian territory. Now, a latest UN Security Council resolution has called for immediate and prolonged humanitarian pause to allow sufficient passage of life-saving supplies to Gaza. A year ago, in September 2022, a major report prepared by Francesca Albanese, Special Rapporteur on the "Situation of human rights in the Palestinian territories occupied since 1967," was adopted by the 77th UN General Assembly.[4] It was noted that. "Since 1967, the human rights situation in the occupied Palestinian territory has been steadily deteriorating, primarily as a result of gross violations of international law, including racial segregation and subjugation by the occupying power, Israel. This has taken various forms: Draconian restrictions on Palestinian movement inside and outside the occupied Palestinian territory; repression of political and civic participation; denial of residency rights, status and family unification; dispossession of Palestinian land and property; forcible transfers; unlawful killings; widespread arbitrary arrests and detention, including of children; the obstruction and denial of humanitarian aid and cooperation; the denial of ownership and access to natural resources; settler violence; and violent suppression of popular resistance against the occupation. All together, these practices constitute collective punishment of the Palestinian people."[4] In the important section called "Need for a paradigm shift," it was mentioned that. "This (paradigm shift) starts with the recognition of the current reality in the occupied Palestinian territory as that of an intentionally acquisitive, segregationist, and repressive regime, which has enabled, for 55 years, the disenfranchisement of the Palestinians, caging them into Bantustans of disrupted memories, broken ties and hopes, pursuing the ultimate goal to consolidate minority rule over a native majority on lands usurped through force, abusive and discriminatory policies and pillaging of resources. A prolonged occupation maintained for ostensible "security reasons" disguising Israeli settler-colonial intentions to extinguish Palestinian people's right of self-determination while acquiring their receding territory as its own, as explicitly indicated by Israeli political figures, is something that the international community can no longer tolerate."[4] WHAT ABOUT MENTAL HEALTH? Even before the current accentuated Israel-Palestine crisis, the prolonged and transgenerational conflicts have left their indelible marks on the Palestinian psyche. It is repeatedly documented, over the past decade, that the mental health indices are one of the lowest in the region. For example, Palestine demonstrated the maximum mental disorders burden in the Eastern Mediterranean region out of 23 countries, the difference being mostly accounted for by depressive and anxiety disorders.[5] Although a number of previous studies are available, the best, largest, and latest study was conducted as the Palestinians' Psychological Conditions Survey. The survey was conducted by the Palestinian Central Bureau of Statistics between March and April 2022 with technical assistance from the World Bank, International Security and Development Center, and Zentrum Überleben. The report focuses on mental health in the West Bank and Gaza (WB and G) based on a representative sample of 5877 individuals and statistics representative at the national, regional, and rural/urban/camp levels.[6] It is worthwhile to cite the relevant portions of the main study findings: More than half of the adult population (58%) of the WB and G screen positive for depression; in Gaza the figure was as high as 71%. These figures were much higher than in other countries using the same questionnaire About 7% of adults in WB and G screen positive for posttraumatic stress disorder (PTSD) based on their symptom score; again, the symptoms were commoner in Gaza. Further, for residents of Gaza, the highest levels of PTSD symptoms are among the youngest age brackets Adults in Gaza have higher risk of mental health problems and a lower level of life satisfaction, while aggression levels are higher in the West Bank than in Gaza The severity of depression and of PTSD symptoms among adults are strongly associated with worse economic outcomes and well-being Exposure to conflict and trauma is widespread. At least one in four respondents in WB and G reported having been exposed to conflict-related events during their lifetime, and one in ten reported experiencing a conflict-related trauma in the past 3 years For inhabitants of Gaza, PTSD symptom severity increases as the number of conflict events experienced increases Levels of psychological distress significantly worsened for those experiencing at least one traumatic event (not necessarily conflict related) compared to those who reported experiencing no traumatic events Individuals who have experienced or been exposed to trauma, violence, and conflict are more likely to exhibit mental health problems. Individuals from poorer households, whose economic situation could also be related to conflict exposure, also suffer from worse mental health outcomes. It was concluded that: "The prevalence of mental health problems in the WB and G is very high Many mental health issues vary systematically across areas and sociodemographic characteristics Poor mental health is closely linked with worse economic outcomes Poor mental health is strongly associated with exposure to violent conflict and traumatic events."[6] Not surprising, but documented results. AND WHAT ABOUT CHILDREN? THOSE WHO CAN HARDLY SPELL PALESTINE OR ISRAEL? Children are the worst sufferer of any conflict, domestic or international. They do not understand, they do not know what can be done, and they often have no escape. They are trapped. A generation grows up with a deviated trajectory of physical–mental–social–moral development. Palestinian children, especially those from Gaza, are no exception. The touching and unusual foreword of a report called "Trapped" by the organization "Save the Children," published after the May 2021 Israel–Palestine conflict, was written by young children themselves. Parts of it read like this: "We want you to know that Gaza, our home, is being destroyed. Even the nice places like schools and hospitals. There isn't much electricity for hours at a time. We all have to sleep on the floor or in hallways, and it's really dark at night. Life is scary and our roofs are falling on our heads. Every time there's an airstrike, we are terrified. Our rooms shake, and then our hearts shake too with fear for our families…. While other children dream of having video games, we dream that one day this fighting will end. We hope that one day we can open our books again, write in our notebooks and study, that we can go outside and play with friends. The first thing we wish is that the war would end. All children should be able to live in peace. We hope that all the destroyed buildings will be cleared away and something better and more beautiful will come in their place. We hope that our homes, schools and hospitals will be rebuilt. Above all, we want to live like children in other countries who can play in playgrounds instead of hiding from bombs. We want Gaza to be a safe and beautiful place where we can live in peace. We still have hope. But we want this war to be the last war."[7] Alas, that was not the last war. Where are those children today? The report found a huge increase in children who reported feeling fearful (84% compared to 50% in 2018, using similar methodology), nervous (80% compared to 55%), sad or depressed (77% compared to 62%), and grieving (78% compared to 55%). It also found that more than half (55%) of Gaza's children have contemplated suicide and three out of five (59%) are self-harming.[7] We have to realize that the deviant developmental trajectory induced by chronic, severe, and inescapable trauma of this nature can actually be a fertile breeding ground for radicalization when other conducive conditions are there. As Pablo Neruda wrote "Treacherous generals: See my dead house, Look at broken Spain: From every house burning metal flows Instead of flowers, From every socket of Spain Spain emerges And from every dead child a rifle with eyes, And from every crime bullets are born Which will one day find The bull's eye of your hearts."[1] ADDRESS THE ROOT CAUSES! Rather than counting the "radicalized rascals" (the "human animals," as the Israeli defense minister referred to the inhabitants of Gaza before cutting off all essential supplies to Gaza: "There will be no electricity, no food, no water, no fuel. Everything will be closed.")[8] It might be better to count the conditions which have changed the people. Rather than counting the symptoms from a diagnostic nosological checklist, it might be meaningful trying to understand what these symptoms mean for the person expressing them. And, rather than making a "patient" out of the sufferer (and looking exclusively for his vulnerabilities or "faults within"), it might be worthwhile to call out the social, political, economic, and ecological circumstances that create the cauldron in which the complex churning takes place before coming out with the finished "product" in the form a syndrome or a "disorder." And finally, rather than only being a psychiatrist, or even a social psychiatrist or mental health professional, it is also important to be an activist, to be able to call a spade a spade. Let this be very clear: this editorial is not supporting terrorism or armed conflict/violence in any form, whether individually motivated ("lone wolf"), organizationally orchestrated, or even state-sponsored terrorism. However, as mental health professionals dealing with human trauma and its aftermath, this editorial is asking all of us not to be scared of seeing – and speaking – the truth, and to fearlessly explore the variegated roots – the drivers and the determinants – of mental health and mental distress. That inquiry should now include, among other things, political determinants of mental health too. POLITICAL DETERMINANTS OF MENTAL HEALTH? To be fair, the mental health challenges of Israel too are daunting. The civilians of that country, the "common" people, the ordinary peace-loving people, the faithful, God-fearing, family-living people, they want peace and progress, like everywhere. With a huge hostage crisis that is yet to be resolved as of this writing (a few have released on health grounds, but the majority continue to be hostages), rockets still being launched from Gaza and occasionally from Lebanon by Hezbollah, and the general upheaval caused by a warlike situation, people on Israel are also in need of mental health support, and the system is not adequate there as well.[9] The point is that, earlier there was talk primarily only of biological determinants, then slowly followed by the importance of social determinants, of health including mental health. It is time to realize, and emphasize, that political determinants of mental health are equally important, especially in strife and conflict-ridden areas, of which the present conflict in Palestine is a strong case. Social psychiatry should focus on this neglected aspect too.[10] We will stop with two eminent exemplars to elucidate this point, both mental health professionals from Palestine. Samah Jabr is the Head of Mental Health Unit, Palestinian Ministry of Health, Palestine, based in the West Bank. She has been writing on the social, political, and contextual underpinnings of psychiatric diagnosis and treatment. In a recent acclaimed movie featuring her, and also a book by the same name, she has talked about resistance and resilience but from different vantage point.[11] She has also questioned the Western concept of PTSD. Because the trauma in the conflict-ridden areas is often not a singular trauma but a continuous process, the term "post" is problematic. Furthermore, the trauma is very genuine rather than imaginary – The bombing is real and can recur any time soon, rather than the Iraq-returned war veteran who was indeed exposed to war trauma but is now back home safe though with nightmares. In a critical analysis of PTSD, her colleague Maria Helbich and she "advocate for a shift from a decontextualized and individualistic approach to mental health to acknowledging the structural, social, and political oppression that are the underlying factors for suffering in the occupied Palestinian Territory. In order to alleviate the social suffering of Palestinians and to prevent their victimization, interventions that acknowledge the political nature of mental health ill-being and promote a human rights approach are needed."[12] Finally, when you read this editorial, remember that 10 years ago around this time, on December 17, 2013, Eyad Rajab El-Sarraj died of multiple myeloma. He was a psychiatrist but also a human rights activist. Born in Beersheva in 1943, then a British mandate Palestinian territory called Bir Seb'a in Arabic but later annexed by the state of Israel, Eyad El-Sarraj fled with his family to Gaza in 1948, and never again lived in his original home. He witnessed extremist views on both the Israeli and Palestinian sides and spoke against both, and was arrested by both on multiple occasions. However, he retained his conviction to speak for oppressed humanity. Realizing that violence and oppression, structural inequities, or various types are major drivers of mental health issues, he moved from an exclusively clinic-based practice and founded the Gaza Community Mental Health Programme. It aims to combat the stigma still associated with mental illnesses and also seeks international publicity for the dire conditions under which so many Palestinians live.[13] BLOOD IN THE STREETS Thus, this editorial is different from the usual, predominantly academic ones. It makes a plea for coming out of our cushy and secure homes, and rather than talk of "lilacs and poppy-petalled metaphysics", which is fine otherwise but not during these deeply disturbing times; it asks for coming out on the street instead – And see the blood there. It calls for us being true, context-driven psychiatrists, then goes beyond psychiatry and become advocates for determinants of mental health, including its political determinants. Tough times demand tough calls. As Samah Jabr and Elizabeth Berger have written in a latest correspondence in the Lancet Psychiatry (worth reading in full, to fathom the destruction of mental health services in Gaza caused by the war): "we must emphasise that the overwhelming need now is not mental health but ceasefire. In comparison to ending the immediate assault, the meeting of mental health needs—important as they are—cannot claim the highest priority."[14] To conclude with the immortal lines of Neruda: "And you will ask: Why doesn't his poetry Speak of dreams and leaves And the great volcanoes of his native land? Come and see the blood in the streets Come and see The blood in the streets Come and see the blood In the streets!"[1] Disclaimer This editorial expresses the opinion exclusively of the author, and not necessarily of the Journal.