Greatra Mayana

Career & Employment Opportunities

Professor Rita Giacaman on The Psychosocial Health of Palestinian Youth: Occupation and Resistance

Well it’s an absolute honour to be asked
to chair this evening’s event. Professor Rita Giacaman is really
eminent in the field of thinking about psychosocial issues for young people
living in the Occupied Territories. She’s going to talk tonight about psychosocial
health of Palestinian youth, occupation and resistance, and this is the fourth
event in the Friends of Birzeit University’s Education, Occupation &
Liberation programme and I invite you all to give her a very warm welcome for the
work she does as well as for what she’s going to say tonight. Thank you. I’m humbled by all this I must say. I’m a very simple person and I must say that I need to
thank Palestine and Birzeit University for having given meaning to my life through
work. So in fact all the credit goes to the Palestine question and also Birzeit
University for giving the space to be able to do something of meaning every
day. And I would love to say that I’m very happy to be here because I see
friends, colleagues, people in solidarity and it’s – wow – heartwarming to say the
least. Let’s go to what we would like to do
today. There are two issues that I would like to interlink to each other. The
first issue is looking at data we’re still analyzing on youth mental health and
also the relationship of youth to the broader context around them. And then I
would like to use the opportunity to raise another issue which is what we
have been developing. A conceptual framework that helps explain why the
fate or the predicament of Palestinians in ways that we
think are better than the standard ways in which we are explained. So to begin
with then. We’re doing – we did a study in 2016 it was called Power to Youth,
supported by the European Union. It was a combination of different regional
countries which made it not possible for us to add into the study questions
related to exposure to political violence. We couldn’t do that. However it
was a three year program and it was generally looking at empowering youth and
also investigating whether youth felt included or excluded from within society.
And of course we had European partners with us. Now for each country we had
three levels. One is the macro-level where it was desk work, policy work
etc. Meso-level which was largely qualitative, and micro-level which is in
the West called ‘individual’. We call ‘personal’ – there’s a big difference.
Individual level where we look at the details of persons and see how those
relate to the larger context or to their well-being. For the micro level we had a
nice sample, not too big, not too big but enough to be able to try to develop some
analysis as to why they report what they report. And it was a representative
sample of young people 18 to 29 years. And you know that youth are defined in
various ways 15 to 24, 18 to 29, 18 to 39, and not only this they are called youth
and I am critical of that because it’s as if youth is a class in itself. And it
isn’t a class in itself because the young people are divided not only by
class but also by gender. However they are called youth
worldwide so we’ll call them youth temporarily, but thinking that we should
be critical about that notion because they’re not one homogenous blob. So we
did that in the West Bank and the Gaza Strip and then we looked – this is the
sample characteristics – there’s nothing unusual there except that we had a
larger proportion of women compared to men and that’s understandable. You can find women easier when you do surveys and they are much more frequently at home.
Men are much more outside the home, especially the young people. And the
rest is basically typical of the West Bank and the Gaza Strip except that
notice that 72% were not working at the time of the survey. And I would like to
note that according to the Palestinian Central Bureau of Statistics 55%
of young people who have bachelors or higher degrees are currently unemployed.
A very high proportion of unemployment among young people. And it’s a really
very big problem, which raises the question, conceptually, about youth – what
is considered youth – as a transitional period which is biological going – and
also social – going from childhood into adulthood, where in our case the
transition has no end in sight because if you cannot work you cannot get
married, you cannot move out of your parents house, you cannot have a family,
and you cannot go on with life as an adult without working. Which – and that is
a very important issue that we have to face in Palestine – what do we do with
this category called youth which is going to be in transition for a very
long time. So that was one interesting thing that we raised during this study.
Now we also looked generally at the general demographic and now socio-economic characteristics. Nothing unusual there – 50% refugees, urban
areas, rural areas 15.5. This is confounded by Gaza because in the Gaza
Strip hardly 5% of the population live in rural areas. The rest are mostly
living in refugee camps and in urban areas. It’s heavily urban. And then we ask
them about their family economic status. In Palestine if you ask people how much
money do you make nobody will answer you. Avoiding tax, being afraid.
I mean tax which is not used for the people but tax that goes away somewhere
else. So why should they pay tax. We all want to pay tax provided it comes back
to us, but if the tax disappears somewhere else and the question is
raised, why should we pay it. So people avoid it. We don’t ask them, but you ask
them compared to the people around you how do you define your economic status
of your family. Is it above normal, normal or below average. And what we found was
quite striking is that almost half reported that they are in a below
average situation and that’s likely the effect of the Gaza Strip. Then we are
asked about self-rated health. Now self-rated health is defined, and we’ll
talk about this a bit later, as a soft measure of health, not hard core. And they
call it subjective measure of health because you ask people simply how do you
rate your health. It includes the voice of people into the assessment, not only
the doctor, and just because of that it is no longer objective, even though in
the literature we know repeatedly that what is called these self-rated health
etc, the subjective, ones can predict death and disease
consistently. They do that. And now I’ll explain later why is it
that we focused on self-rated health and also well-being. As you can see, so we
looked at self-rated health and because health – sihha in Arabic – is seen primarily
as physical health. Then a very low proportion, less than 10%, reported that
the physical health is below good. However when we looked at well-being, and
in Arabic it’s alawfiya, and in half year in our tradition is a combination, and
Cynthia knows that very well because we’ve worked together on things like
that, it’s a combination of physical, social, psychological, in fact in the
local understanding, the local way of understanding health
this was known way before WHO defined it as the sum total of whatever. So
we’ve known that all along, and if anything, the advent of biomedicine
and the Western conception of health began to eradicate this until WHO
came back and said, oh, wait a minute, let us rethink this concept. And now it’s
beginning to come back. In any case over a third of the young people reported
that they have low well-being, i.e. they live in ill-being. And that’s an
important question – how come, what is it that alawfiya has been negatively
affected to. We’ll get to it in a bit. And then when we looked at self-rated health
by selected indicators, simple numbers not regression right now, but simple
numbers, looking at cross-tabbing, looking at other differences between
these reports among these people and selected demographic and socio-economic
factors and we found something that you would expect, some that you don’t expect.
Ill-being rises with age and of course more unemployment, more responsibility, of
course you expect that. What we did not expect is that ill-being rises with
those who are married. Now could it be financial responsibility, what are the
responsibilities. I mean we did that later I’m not going to tell you abou,t
but it, so marriage is not necessarily good for your well-being in our context.
I’m not saying that for everybody but in our context it’s not necessarily good.And
then as expected you can see that the more educated have better well-being. You
would expect that, and probably the more educated despite the unemployment
etc are more likely to rationalize or be involved in politics or something like
that. There are reasons.We will talk about that later. Now of course we expect
lower well-being among those who are poorer, and we expect crowding rate is a
proxy for poverty. The more crowded, the more ill-being. Then we said, ok, let us
look at what is called satisfaction, basic satisfaction. And some results are
typical and other results I was frankly quite shocked by. Those who are not
satisfied with their housing are at about a bit than a quarter. Those who are
not satisfied with their neighborhood 20% . Those who are not satisfied with the
government’s effective work to give them employment – the majority. Those who are
not satisfied with trade unions to find employment – very high, more than
three-quarters.And those who are not satisfied with the way in which the
country is being governed – more than two-thirds. And I was shocked by this one. I couldn’t believe it actually and we’re still
trying to understand. A third are not satisfied with life in its entirety. And
the question is why. Again with housing – the same thing. Well-being and it’s
the same exact pattern. So then we said there must be intermediate factors
between the demographic and the education and the well-being and the self-rated
health that can buffer, i.e. modify or make worse these young people’s situation.And
then we said, ok, let’s see if we can look at how much they trust
different aspects of their community etc. The results were very shocking. As you
can see the large majority reported that you need to be very careful, ok, about
people you meet, you know etc. The large majority trusts their families.But look,
suddenly you go to the extended family and the trust goes down.And then look – it’s also down for neighbours. It’s even
worse for people they know personally. And it’s even worse for trusting other
religions, and again other nationalities. So the situation is one where there’s
very little trust that these young people exhibit. And so we looked at these
trust indicators and what we found is what we expected, which is that the less
trust the less well-being. As simple as that. These are the numbers here. The less
trust the less well-being. So this then led us to say, ok, let’s
look does this have to do with politics. And we had about eight questions related
to the political situation there. For example,
confidence, trust in government, trust in the law, trust in the police, trust in the
Legislative Council, trust in political parties. There were eight questions.And
usually when there are several questions actually it’s important to ask these
several questions.The reason being is that normally – we are in public health –
and in the end we measure. We crunch numbers. We don’t just do theory. We have
to crunch numbers. Although we are in multidisciplinary public health. But
basically when you want to measure a phenomenon you don’t use one variable
only because, look at this table it has different dimensions. If you look that
way it will look one way, here it will look another way and so on. And so what
you do is you put together several such questions and then you check whether
what is called the inter-rater reliability, i.e. you check whether these
groups of questions fit together or measure together what we intend, what
what we think we are measuring. So you do factor analysis, you do the alpha. If
they are together then we know that the alpha is high, for example, which is a
very good alpha, meaning that yes these questions measured something that we
think is together in itself. Whether it is what we we are measuring in fact or
not that’s another question, but at least we know that we are measuring something
that together makes a phenomenon domain. And then we looked and we said that – and
look – about almost half have no confidence at all – huh? – in any of the
governmental systems. And then 32% went to three
confidence level and then 25% four or eight of them. But almost half have no
confidence in any of the arms of government, any of the institutions of
government. So we caught on to this and we forgot a little bit about the
well-being because we’re still in that and we said goodness how do we explain
this? This is something that we need to know who are these people who have no
trust in any of the institutions of the government.So that’s what we went with
regression to, you know, say regression is a way, it’s a statistical method that
will allow us as we call it to check for confounders, i.e. to make sure that this
phenomenon is associated with that phenomenon without having something else
that would modify or change the relationship. .And so we – before doing
regression we said, ok, let’s see, let’s see about well-being.And of course those
who don’t have any confidence at all had less well-being than those who are
more confident. It’s understandable, as expected. And then with regression we got
some interesting results which is the younger you are, ok, the more
confidence you have in the institutions of government. And this is understandable
because once you graduate you cannot work, you cannot do this, you cannot marry,
and then you begin to face the problem and when you’re a student at Birzeit
University or any other university there you’re still living in the student – what do you call it – dream life. Cause once once you’re out it’s a really serious
situation. OK, we also of course expected West Bankers had
better confidence than Gazans. Would you expect? Of course. And also those who have better
income had more confidence. Expected. Also those who felt safe had more confidence. It depends on your neighborhood whether you’re safe or not depends on which
neighborhood you live. Those who thought that wasta – wasta is – what do you call it
wasta in English? Nepotism, cronyism etc. That you you don’t really need wasta
to get work felt better than those who thought wasta is needed to get work, ok?
So it directly linked to that well-being, ok? And and to that – sorry – and also
to their well-being. But also to their trust with government and also youth who
reported that young people are active in public life felt better, right, about
government than those who thought our youth are not doing well at all because
they are not active in public life and so on so forth. We looked in a post
survey to try to explain some of the results with qualitative work. One – the
participants were not surprised at all by the findings. “Oh, of course.”
So it was like endorsement, ok, they were young people thought that a main
reason for the lack of confidence in government is the split between Fatah
and Hamas. And they really discussed the political parties negatively by
stating that they their main interest is during elections. They take care of us, in
fact they give them money, they give them mobile phone cards etc to go elect and
once the elections are over bye-bye and young people are forgotten.And it
happens quite often. And also they noted that government is corrupt etc.
Also not only they look in the big government, the
local government as well with nepotism, wasta, political leadership for –
focusing on the interests rather than the people. And it’s all something that
we have lived with and we we can endorse through daily life of course. It’s not
that, it’s not a figment of their imagination. It is a general feeling from
the population at life. But the conclusion was quite remarkable.
I didn’t put in all the data but the conclusion was quite something
else. One: they report a strong sense of
exclusion and know what is called linking social capital. uou know about
social capital, but linking social capital is basically trust in governmen,t
ok, but this is as far as the Palestinian governmental system is
concerned. But they do not feel excluded when it comes to Israel, the
Israeli military. You know why? Because everybody is excluded together so as we
say in Arabic al mowt ma’ al jamea’ rahma. Death with the collective is a blessing. So they didn’t feel excluded. So we understood from this that there are
different domains for exclusion and that we cannot look at exclusion as a
homogeneous blob. There’s the Palestinian domain and the Israeli occupation. And
one wonders about what other youth in other countries think in terms of
exclusion. Do they think in terms of one domain, only country, or do they think
exclusion in multiple domains. I don’t know. It’s worth looking at and comparing
one day by doing cross, you know, studies across different countries. OK, now what
is important is that our people, our young people believe that while they are
excluded because of Israeli military occupation, ok,
the internal workings are what is most important. But this has
not stopped them from doing other things. Now. So. Intricate mix between
demographic, economic, political etc that all together make up the psyche, the
psychological state of Palestinian youth which is bound to affect even their
physical health. Not only their mental health, and I explain in a bit.
So no level of exclusion is associated with ill-being, lack of trust, lack of
space for participation actively in whatever life – social, economic etc, and
local government. However the point is that the main issue that they talked
about also is that they have no trust in the Palestinian government also because
it’s unable to do something effective about Israeli military occupation. But
although they are excluded and they endure what we call a triple captivity,
which is the captivity because of occupation, captivity because of Hamas,
and captivity because of a Palestinian Authority, but somehow they are able to
sustain a level of activism against Israeli military which is remarkable. And
you can see them on checkpoints you can see them in Gaza and they are doing that
despite the authorities in a leaderless revolt. These kids do not want to be in
political parties, do not want to be given orders by anyone and there’s a
question there – they do not want to organize. And I’m a traditionalist maybe
I think for political growth and resistance somehow in the end you need
some organization. But they don’t want organization. They don’t want leaders and
they will go to the checkpoint and come back whenever they want.
Some people believe, some researchers believe that this is an intifada. It’s
a third intifada but it has different features from the standard where it’s
not sustained like that. It comes and goes in line with what these kids decide
on the spot sometimes. On the spot sometimes. And this is how it looks like.
It’s just remarkable. I mean they are daring, these kids. Take a look. Isn’t
this cheeky? I mean in the midst of – this is Bethlehem – in the midst of such tear
gas and there he is sitting down saying hey, I mean you know, it’s, it says
something about daring. I mean you could have been shot. Women at the checkpoint.
An increasingly common phenomenon and this is our alumnus Amal. Amal was
simply holding the Palestinian flag in Jerusalem and you know what happened
they beat her up like that and this picture went viral. So it went all over
the place. Some people wrote her. It was It was really something. And A’ed from Gaza, a 22 year old. Holding the Palestinian flag. This one
went really viral because it reminded people of the Delacroix’s 1830 painting
Liberty Leading the People. There you go. Liberty Leading the People. So that’s A’ed.
Now. Do I have more time? Yeah? Because Why are we sticking, why are we talking
about well-being and self-rated health? And it’s a long story and Derek Summerfield over there changed our life, and let me tell you why. You know about
Palestinians 48, 67 etc. For the longest time the West thought we needed food,
shelter etc, but that we didn’t have a psychology. That’s all they gave us. Food
and shelter etc. And then in the late 80s beginning 90s suddenly Palestinians were
discovered as having a psychology and that they are traumatized by that
experience. And then suddenly more suddenly the trauma industry was hurled
at us by the mid 90s. And you know what happened? The Palestinians caught it like
you wouldn’t believe. The reason being is that they wanted to be placed in the
category of human. And so that was fortunately. But unfortunately this led
to – this is Derek’s words and I’ve been using them ever since –
the biomedicalization of distress. Now we were working on mental health at
the time. We didn’t have access to the literature because it was too expensive. And it took us til 2002 to – through Hinari the World Health Organization’s
search engine, to be given to us free of charge. And then we began to read the
literature and we bumped on Derek. And Derek said things in his two or
three articles in the BMJ, War on Mental Health, which not only rang a bell, it
told us that why we feel uncomfortable is exactly that reason,
which is what is happening is that trauma is now
turning into a biomedical issue and the minute you pathologise
social suffering like that, then what happens is that the net result is that
they’re going to give you medications or therapies or whatever without taking
into consideration the cause of the trauma to begin with, which is justice,
injustice. So, and I will never forget that, and then we met in person, right? And
you came to Birzeit and it was quite remarkable because he said it in words,
it couldn’t have been better said. We knew it but it’s – and we realized it – but
he said it and we’ve been using it. We used you to the hilt. So. Now the other
thing that we need to note is that, so that’s one category, and we did not want
to be just seen as pathologies. There was – we were not mad, we just were suffering
trauma, and that’s a different sort of thing. The other thing that biomedicine
does is that it categorizes into dichotomies. It divides – either you’re sick
or you’re not sick. And we know from my grandmother and your grandmothers that
it doesn’t go like that. alawfiya is about a continuum between ease and disease.
And every day is another day. And not only this, that you are exposed to
insults every day, or they get better or they get worse, and it varies. It’s never
just like this or like that. And in fact my mother and my grandmother and I’m
sure your grandmothers, you will ask them, how’s your health today. She will
use a million and one words. I have about 70 words right now on the ease-disease continuum. She would say ‘mish batala’ – not bad she will say ‘unable’ – I’m unable to
function. She would say ‘mish mabsuta’ – I’m unhappy.
Unhappy means sick in our language. Unhappy it means that you might – mish mabsuta – you, it could be sick, it could be whatever.
But it’s a physical manifestation of a mental health state and so on. OK, so I
have some 70 of those. I’m sure you have from your – if you remember or if you have
a – if you, if you have tried to investigate you will know that there are
words that people use that doctors will negate. So you are not sick no matter
what you say because they cannot diagnose what the problem is. So also we
began to notice that you go back and forth between the ease-disease continuum.
It’s not like vectors, it doesn’t go in straight lines. It’s all over the place.
And if the insults are heavy enough then you might get into the disease part of
the continuum. You might, but you might not. It all
depends, it depends on the resources available to you also. The resources
available to you like community solidarity. It’s so important.
Isolation is so problematic. There are many explanations for why some people
heal within community quickly and others do not heal. And then so we said look.
Objective measures of health – the so-called objective – are all good. But
they’re necessary, but they’re not sufficient. That’s the first thing to say –
necessary but not sufficient. That’s an age-old epidemiological principle that
we’re using also here. And we’re saying that death, injury, disability, disease are not
sufficient to explain the Palestinian predicament. We’re sick and tired of
being seen either as mad or crazy and requiring medication, when actually what
we need is world level solidarity to remove the injustice we live in daily. And this is when between Derek, and
Duncan Pederson, and Veena Das, and Arthur Kleinman, so we began to go into the
anthropological part. We – and that’s all because WHO gave us the chance to
read the literature. So, and our publications rose quite a bit since that
time because we began to see the literature. What’s interesting is that together what happened is that we began – in public
health we are – public health is a field of inquiry. It’s
not a discipline for us. Multidisciplinary public health especially. So what you do is that you
take concepts and ideas from different disciplines – anthropology, sociology,
medicine whatever – and you yank them, squeeze them etc and then you come up with an idea and
you develop metrics and you check whether the metrics do what they want
you to d, or what you think you want them to do. And so from anthropology,
economics, social science etc we began to develop a domain which we call the suffering domain. Suffering – the anthropologists called it
social suffering, we call it political suffering, and maybe social too, so we kept
it as a suffering. And the suffering domain is what we call the invisible
wounds inside. The trauma of war that you cannot see but over the life course can
lead to disease and all of us are living with this trauma of war daily. And we
might all look normal but there’s something, there’s a wound there that makes
us slightly different. The wound of having experienced whatever it is. Not
only death, injury, imprisonment, how homes destroyed or bombs nearby. In my view something that really affects Palestinians quite
negatively is how at some point they’re unable to protect their children.
I think it’s a most difficult. I’ve been through it too it’s a most difficult. It’s a most difficult feeling of when you know that you can’t protect your
children from trauma. And if you talk to Palestinians, mmm, my goodness. I mean
almost everybody has had that experience. So anyway the suffering domain is about
exposure to political violence and we have scales now developed for exposure
to political violence and it’s about being directly exposed and about
witnessing. And directly exposed is not not only what is called individual, it
is also, it’s also collective, so there’s for example crossing the
checkpoint to Birzeit University from 2000 to 2004 on gouged out road, that was
collective exposure. They didn’t know you from Adam. They threw teargas at
everybody. Collective exposure, negative health outcomes. Even if you witnessed,
even if you witness you would have have negative health outcomes. OK.
Human insecurity – and people talking left and right about the human
insecurity so we developed a scale from the bottom upward. We would start
with qualitative methods and then we’d go up and we built a scale and now it’s
being used in somewhere in Himalaya, Kashmir etc and then somebody else is
using it in in Lebanon. And I want to tell you, yes,
Palestinians can produce and do produce knowledge. There is no reason to think
that we always have to swallow knowledge which comes from somewhere else. Of
course we have difficulty publishing as a result but that’s ok. And with
time we’re getting to publish, for example we developed a humiliation
measure and it was published and we give it – and by the way we give our measures
free of charge. I was shocked in the United States you
have to buy the measures that people, academics produced. It was really –
wow, ok – so we developed these measures, human insecurity, ambiguity not yet,
uncertainty we’re working with Alessandra on that now. Humiliation we
did deprivation, we’re in the process of analyzing the data. Silencing is very
important and I think whoever is crushed as a people will know that silencing is
very bad for your health. And silencing means many wounds inside. And so many
times as Palestinians we were silenced and then violations of human rights, all
sorts of violations. So that’s the suffering domain and then there are of
course the subjective measures of health, well-being, quality of life, self-rated
health, different types of somatization and so on. We have a scale for that
because also somatization and behavioral change it’s culturally specific. You
can’t use somebody else’s. We tested – it didn’t work. So we did from the bottom up
etc and then we said all of this is into something we call the political
determinants of health, or the political domain and we we maintain that WHO did
not go far enough. WHO stopped at the social
determinants of health and we’re saying, oh no, we know from experience and from
reading it is the political determinants of health.
Wars, conflicts, biopower, biopolitics, Foucault, yeah,
necropolitics, Imbembe, who can live who can die, racism, distribution of
power and money, class, patriarchy, global market forces, global and country
specific policies, internal conflict, all are the political determinants of health
which determine the social determinants of health and of course there is
biological predisposition. So this is how we now conceptualize health in war. And
by the way, quite often in in the local tradition we don’t divide mental health
from physical health. This is about health, and you might have mental health
symptoms but they can become physical. So this is how we see it. We see
that this is ultimately determinant and it can determine directly subjective
measures, social suffering and two words – the objective measures or you can have
social suffering affecting subjective measures and to objective measures. And
that’s it.

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