August 7, 2012

"They were playing with their Atari last night." This was my young cousin's way of explaining why our street in Gaza had turned into an arrangement of chairs and tents for an outdoor funeral. He was, of course, referring to attacks by drones, which Gazans call "zennana" in an Arabic reference to the buzzing noise they make. While there is uncertainty about how many people have been killed by these drones, the Palestine Center for Human Rights estimates that at least 800 people in Gaza have died because of drones since 2006. These deaths are largely civilians, bystanders from Israeli attempts at targeted assassinations in the Gaza Strip—a narrow 41 kilometre strip of land along the Mediterranean, where more than 1·5 million Palestinians live.

Zennana, a feminine word, is also used by Gazans to refer to a whining wife or daughter, reflecting the Gazan perception of these weapons of war as a nagging nuisance of daily life, rather than a traumatic occurrence. To understand how Gazans have "normalised the abnormal", I visited Ahmed Abu-Tawahina, Director of the Gaza Community Mental Health Programme (GCMHP). He explained to me how "The idea of trauma makes no sense in the Palestinian context where people live in constant fear. Trauma makes sense in Geneva, where there is safety, stability, and routine. But in Gaza, there is no normalcy." Ahmed suggested that an alternative to "trauma" might be "mousiba", meaning tragedy. Since Gazans live in constant fear and insecurity, they are not typically shocked by violence.

The violence did startle me. Leaving the serenity of my life in the USA, where I am a resident physician at Stanford University, I arrived in Gaza in March, 2012, on the eve of an Israeli aerial campaign targeting militants from Islamic Jihad. I was greeted by my loving grandparents with offerings of tea and overly sweetened juice, but also by a near absence of electricity, a scarcity of running water, the buzz of the drones, the roar of military jets, and explosions from nearby incoming and outgoing missiles. In Gaza, I learned how the Israeli military's surveillance and attacks, international foreign aid, and the conflict between Palestinian political factions conspire to create fear, divide communities, and—above all—threaten people's dignity.

Dignity is a nebulous idea in theory and definition, but I found that Gaza is something of a laboratory for observing an absence of dignity. Jonathan Mann made the case that violations of dignity have "devastating" effects on physical, mental, and social wellbeing and he sought to create a taxonomy of dignity violations that included: not being seen or being incompletely seen; being subsumed into a group identity; invasion of personal space (including physical violence); and humiliation. Mann's persuasive ideas seem to resonate in Gaza. The constant surveillance from the sky, collective punishment through blockade and isolation, the intrusion into homes and communications, and restrictions on those trying to travel, or marry, or work make it difficult to live a dignified life in Gaza.

Riding in a United Nations car with Mahmoud Daher, head of WHO's Gaza office, he was careful to keep his distance from all other vehicles, for fear that they might be targeted by Israeli missiles. Later, Karem, a young surgeon at Al-Shifa hospital, Gaza's trauma centre, told me how "Every day, I go to work and wonder where and when I'll die. You never know when a war will start again. Just yesterday, it was calm, and now we're in war." During the 2009 Gaza war, Karem worked 19 straight days without leaving the hospital. He does not exude fragility. On his Facebook wall the day I entered Gaza, his status read, "Another tough night at Shifa hospital, then [at home] you still have the smell of smoke from grilled human bodies & that image of shattered human flesh."
Foreign aid, ostensibly provided to relieve the suffering of Palestinians, has in some ways increased social fragmentation. Since the takeover of Gaza by Hamas in 2007, after winning the 2006 election, some political actors have used foreign aid in an effort to create a prosperous and healthy West Bank, and a sick and impoverished Gaza. In fact, official development assistance has, according to the Organisation for Economic Cooperation and Development, more than doubled since 2006, from disbursements of US$1·2 billion in 2006 to disbursements of $2·7 billion in 2009 and $2·5 billion in 2010. Yet very little of this aid makes it to Gaza. As Hasan Zeyada, a psychologist with GCMHP, told me, "Aid allows foreign powers to achieve a goal they couldn't even achieve through war."

Perhaps the most devastating attack on social cohesion comes from the internal Palestinian conflict. The Palestinian power struggle has recreated many of the most threatening aspects of the Israeli occupation: barriers to movement of people and goods, fear, isolation, and torture. It takes several hours to move a few hundred metres across the Egyptian border. Medical students, eager to act on the social and political factors that affect health, report that they are unable to do so because it is dangerous to create groups and alliances. Torture techniques seem to be used by Palestinians from both political factions. Torture survivors come to clinics in secret; their charts carry false names. As one clinician observed during my visit, "It would be far more compelling to tell an optimistic story, but I cannot do that. Torture and violence destroy our hopes for Palestinian unity."

Occupation and the blockade make shortages of essential medicines and medical supplies commonplace. Yet during my visit it seemed to me that these shortages are at least partly attributable to internal Palestinian conflict. While enjoying fresh strawberry juice on Gaza's coast with Mahmoud Daher, of WHO, our conversation was not only interrupted by explosions, but also by a call from the American Consulate in East Jerusalem, asking about the health situation amid the escalation in conflict. Mahmoud informs them that of about 480 drugs on the Palestinian essential drugs list, 180 drugs are out of stock and 70 to 80 are below the 3-month threshold. The cause of the essential drugs shortage is debated in Gaza. Some blame the Palestinian Authority in Ramallah for failing to transfer medicines from their warehouses to Gaza. Others blame the Hamas Government for misallocating funds that need to be transferred to acquire the medications. Irrespective of the cause, the drug shortage is no longer simply attributable to the Israeli blockade.

Everywhere they turn, Gazans face isolation and fear: the drones and warplanes of Israeli occupation, the inequality reinforced by foreign aid, and the pervasive conflict between Hamas and Fatah. Ahmed Abu-Tawahina, of GCMHP, seemed to put it best when he likened Gazans to subjects in a Pavlovian experiment, being betrayed by political parties and donors wherever they turned. "We go to each corner of the cage and are shocked, then we stand in the middle of the cage, totally paranoid and abandoned." In an earlier era, there was stronger social solidarity. During the first Palestinian uprising of 1988—93, the divisions between cities, villages, camps, and clans had faded. But, along the way, Gazan society has become divided. Without reliable infrastructure for water, electricity, or imported goods, families hoard fuel and depend on the black market. Many people on the street now walk with their heads down—whether it is out of fear, isolation, or a loss of dignity.
The attempt to restore and protect dignity was the primary goal of many clinicians I met in Gaza. One clinician, who works with victims of torture, keeps doing his work, despite the risks to his life in doing so, because his patients remind him, "You are the window through which I can breathe". As Eyad El-Sarraj explained, the core goal of GCMPH is to make people feel like they are regaining their dignity. This is why their staff see themselves as community workers and human rights advocates, not just clinicians. Khamis Elessi, a clinician-educator at at El-Wafa Hospital and the Islamic University in Gaza, teaches his students to touch their patients. He explains, "The sick want to tell you about daily suffering, the misery of life without electricity, how he feels when his kids can't go to school." They need doctors who give them an opportunity to express these struggles. He had much more to say, but we ended our meeting so he could go to the funeral of his cousin, a 60-year-old farmer, who had recently died after an Israeli airstrike.

Further reading

<Wilson Wilson S. In Gaza, lives shaped by drones. Washington Post Dec 3, 2011