Re-defining collateral damage
Children's mental well-being under occupation and in conflict remains a grave problem, writes Hala Sakr
As political and social turmoil persist across the Middle East, the mental well-being of the population, particularly children, remains a major concern. Conflict, war and occupation have been the norm in countries like Palestine, Iraq and Sudan for decades.
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War, tanks and occupation have incarcerated children's dreams. Can there be any future beyond?
Although figures show that over one-third of the region's population is below 15 years old, the attention paid to their mental well-being, as opposed to adults, has not been commensurate with this demographic reality.
In response, the World Mental Health Day, 10 October, has been dedicated to children's issues for the past two years.
This year's theme, focussing on the "emotional and behavioural disorders of children and adolescents", is a continuation of last year's focus on the effects of trauma and violence on the mental and emotional well-being of the young.
"There is no doubt that mental health problems exist in every society, but surely those are compounded by this excessive exposure to traumatic events," Rita Giacaman, director of Community Health Programme at Birzeit University in Ramallah, the West Bank told Al-Ahram Weekly.
But can mental well-being be separated from other health resources, such as food, clean water, housing and security, that are all compromised by war and occupation?
Rejecting the dichotomy of physical-mental health, Soheir Morsy, professor of medical anthropology, emphasised their mutually reinforcing relationship. In her reflections on conditions in Iraq and Palestine, she noted the difficulties of accurate assessment of the human cost of war and occupation in terms of specific health indicators. "Nevertheless," she argued that "projections can be made, as was done by UN agencies before the most recent phase of the protracted US war on Iraq. Such predictions are based on scientific models which link the reduction of health resources to the status of health."
Last year, a study by Samia Halileh, also from Birzeit University, focussed on the effects of Israel's Operation Defensive Shield on Palestinian children under the age of 18 living in the West Bank. She noted that for those children the operation meant the interruption of normal life, including education, social interactions, accessibility to health care and loss of family income, in addition to psychological traumas from exposure to shelling, shootings and beatings that led to injuries, disabilities and loss of life.
"The repeated destruction of Palestinian society and history, displacement, and the continued and cumulative exposure, especially for children, to a variety of traumatic events, daily stress and the inability to lead normal daily lives can only negatively influence mental health status and well-being," Giacaman said.
This is equally valid in the case of the Sudan. According to Abdel-Basit Merghani, senior clinical psychologist, Al-Fanar Centre for Development in Khartoum, as long as war persists, people will continue to be psychologically disturbed and displaced. "Children of the last two generations in Southern Sudan are a major problem. They are severely traumatised. Unless we are able to handle the conflicts peacefully, this destructive cycle of violence is expected to continue," he pointed out.
In Palestine, prior to the Israeli incursion into the West Bank in April 2001 -- about seven months after the beginning of Al-Aqsa Intifada -- the Palestinian Central Bureau of Statistics (PCBS) documented that of 483,460 school children interviewed at the time, three per cent had been stopped at checkpoints, 1.2 per cent shot at, 1.4 per cent humiliated and 0.8 per cent beaten. Halileh wrote that the children experienced various symptoms of psychological trauma, such as crying and fears of loneliness, darkness and loud noises. About one-third showed sleep disorders, nervousness, decreased eating and decreased weight, feelings of hopelessness and frustration, as well as thoughts of death.
"Those children might not be able to ever forget what had happened to them. Any minor trigger can set off the whole mental experience again. They re-live their previous traumatic experience as though of the original magnitude," said Srinivasa Murthy, acting regional adviser for mental health at the Eastern Mediterranean regional office (EMRO) of the World Health Organisation (WHO).
"When human integrity is violated the 'bubble of immortality' bursts. One perpetually lives as if the traumatising experience will happen again at any time," he explained.
During the Israeli invasion of the West Bank, several reports indicated that the Palestinian town of Jenin witnessed by far the worst humanitarian crisis of all. Giacaman and Abdullatif Husseini wrote in their paper, "Life and health during the Israeli Invasion of the West Bank: The Town of Jenin", that this was due to the tragic events that occurred in Jenin Refugee Camp, where 47 per cent of its inhabitants were children and people older than 65. In the camp "war crimes appear to have been committed by the Israeli army, including grave breaches of the Fourth Geneva Convention and the laws of war as attested in the reports of Human Rights Watch and Amnesty International."
On the other hand, reports on Iraq from different UN agencies, such as UNICEF and the WHO, predicted what would happen concerning the mental health of civilians. In early summer UNICEF warned that although the war seemed to be over, the battle to protect Iraqi children was far from won. "Iraqi children ... face grave threats to their survival, health and general well-being."
While the conflict in Iraq was relatively short, it dramatically affected every aspect of children's lives and families. The sudden collapse of the previous administration hit vital social services hard, as government buildings, water plants, schools and health facilities were severely damaged. This was further aggravated by the looting and insecurity that followed the war.
Exacerbating the problems for the young, this all occurred when Iraqi children were already weakened by two previous wars and more than a decade of sanctions.
New problems also seemed to be materialising. UNICEF reported a recent phenomenon in Iraq, namely the increasing number of street children, "Prior to the 1991 Gulf War, the problem simply did not exist." In addition, there are a number of children who have lost their parents over the last decade, although the exact figures are not yet available.
Various journalistic accounts have also documented the persistent lack of security in Iraq, detrimental as it is to the mental well-being of the population -- particularly more vulnerable groups.
"I recall the series of reports by Robert Fisk documenting 'collateral damage' -- more accurately read as war crimes -- including accounts of point blank shooting of civilians, whether children or adults. As one apparently trigger happy but no doubt frightened US soldier put it, rationalising the shooting of an Iraqi civilian, 'She was in the way and I had to take her down'," said medical anthropologist Morsy.
Similar incidents occur in Palestine. Samia Halileh's study documented the death of 14 year-old Ameen Ziad Thawabte, from the village of Beit Fajjar near Hebron, who was shot on 23 April 2002 while returning home with a group of children his age at approximately 1pm. "An Israeli Jeep passed nearby and fired a single shot that killed Ameen. There were no clashes or confrontations with Israeli soldiers in the area at the time and there was no curfew on the village. The Israeli army claimed that the children were close to a settlement. The nearest settlement however, Mijdal Oz, was located three kilometres from the place where the boy was shot."
No one can accurately assess the true extent of the effects on mental health and its ramifications for future health, especially in the case of children.
The damage to Jenin, for example, was estimated at $83 million. Eight hundred families were left homeless, and $27 million in damages to housing was inflicted. Other than estimating the physical destruction and financial damage incurred, the level of human suffering has been described as "unimaginable".
Relevant research, however, showed that 89 per cent of respondents from various groups in Jenin reported a variety of mental health problems, a rate slightly lower than Ramallah (93 per cent), but higher than Nablus (70 per cent). The authors noted that the reasons for these differences were not clear, but may be due to the severity of the experience combined with an awareness of mental health as an integral part of family health. In view of these results it was quite clear that "trauma and trauma management should become a priority action for health care providers and institutions as we are witnessing a situation where the majority of households in all three towns reported mental health problems that required immediate intervention in the hope of minimising longer- term effects on people, especially children."
Ahmed Mohit, acting director of health protection and promotion at the EMRO, explained that "There is an urgent need for the estimation of the situation in various conflict areas on the ground, assessing the help that should be provided, working for the rehabilitation of destroyed facilities and the provision for necessary human needs, particularly medical care and essential drugs."
Giacaman told the Weekly that in focus group discussions they found the young have lost the ability to dream of a better future. "Interviewing a 15 or 16 year old at a checkpoint we asked him: do you dream? He looked at us in disbelief. We asked again: do you dream of a better future? He said: Khaliha 'ala Allah (God help us). He then proceeded towards the checkpoint to throw those ridiculous stones on this phenomenally well-equipped army. The picture never left me," she recalled.
War and occupation spare no one. Reports have shown that the adverse impact of occupation can even extend to affect the occupying forces themselves. The US troops, many of whom belong to economically disadvantaged groups, are themselves reported to be traumatised. Morsy pointed to accounts of sickness and deaths, including 13 cases of suicide among these troops in Iraq, as examples of the price paid by the American people in servicing the Bush administration's strategy of Empire.
According to international humanitarian law, the well- being of the populations affected by occupation and conflict remains the legal responsibility of the occupying forces. Yet the prospect of them being able to meet the task while keeping to their present course -- now more than ever -- cannot be anything but doubted.