Psychiatry and the Palestinian population

Palestinian sources estimated the population in 1992 on the West Bank as approaching 1.5 million, and that of Gaza as just under 800 000 (Abdeen & Abu-Libdeh, 1993), with an increase of about 45% anticipated over the next decade (Planning and Research Centre, 1994). Significant numbers of Palestinians also live in surrounding Arab countries, especially Jordan, where they may even be in a majority (Stendel, 1996). About 1 million Israeli Arabs also live within the borders of Israel. The majority of Palestinians are Muslim, but about 6% are Christian (Bin-Talal, 1995).

Previously under the Ottoman Turkish Empire, then subject to the British Mandate, then under Egyptian rule (Gaza) or Jordanian (the West Bank) and then, since 1967, the Palestinians became subject to Israeli military rule. But since 1993 they have undergone partial, albeit turbulent, autonomy in the framework of a potential future Palestinian state.

Aspects of the general and forensic psychiatric care of Palestinians have not been widely reported in the international medical press. This article, written jointly by a Palestinian Arab and a British Jew, seeks to describe some key issues in Palestinian psychiatry of historical and contemporary relevance.

The Arab countries may have been among the first in the world to establish mental health hospitals, at a time when European civilisation dealt with those suffering from mental illness by condemnation and punishment. Mental health hospitals were built in Baghdad in the year 705, then in Cairo in 800 and in Damascus in 1270 (Youssef & Youssef, 1996). In the Arab world, political and religious forces have always been intimately intertwined and Islam is a crucial factor in all aspects of life. In most Middle Eastern countries, until relatively recently, mental illness was thought to be due to possession by demons, failure to follow ritual, or fate — Inshallah (Alyahya, 1991). On the other hand the secular nature of western psychiatry has left it bereft of any significant spiritual focus.

Psychiatry in contemporary Arab societies is well established, though traditional and religious healers also play a major role in primary psychiatric care (Al-Subaie, 1994). Most Arab countries practise psychiatry in the context of legislation enacted during the colonial period or have none at all, although a draft Pan-Arab Mental Health Act is currently under consideration (Chaleby et al, 1996). The need for the human rights of those suffering from mental illness and learning difficulties to be legally protected is enshrined in declarations of the United Nations (Gostin, 2000). Human rights are also protected under regional systems, including those in Arab countries (Gostin, 2000). However, the extent to which such universal principles are consistent with all aspects of Islamic jurisprudence is an evolving dialogue (Chaleby, 1996). The individualism more characteristic in western societies has not been a feature of Islamic societies, which rather emphasise responsibilities and adherence to God's commands (Mayer, 1995). Notwithstanding the legal vacuum, criteria for involuntary hospitalisation in Arab countries are based on similar parameters to those in the west, namely the presence of mental illness, danger to self and others and the welfare of the patient. All Arab countries are undergoing social change towards modernisation, leading to conflicts in the role of women and increases in the level of drug and alcohol misuse (Okasha, 1993).

In the context of the national aspirations of the Palestinian population, a significant impact on its health during Israeli military rule has been recorded (El-Sarraj, 1991). According to El-Sarraj, the Intifada or Palestinian uprising that began in 1987 was a socially therapeutic process, replacing depression and hopelessness with pride and optimism. Statistics prior to and subsequent to the Intifada are unavailable, however, to test this supposition.

Since 1967, although subject to Israeli military rule, the Israel Mental Health Act has not applied, so there has been no legislative framework in which mental health has been practised. Aspects of unemployment, lack of full self-determination, refugee status in some cases and the trauma of war have all had an adverse bearing on the state of mind of Palestinians.

In May 1994, the Palestine Council of Health, formed in July 1992, began its implementation of an Israeli/Palestinian agreement on health care on the West Bank and in Gaza (Palestine Council of Health, 1994). In regard to psychiatry, its objectives included reduction of alcohol and drug misuse, reduction in disability associated with mental illness, decrease in mortality and disability associated with interpersonal and self-directed violent behaviour and the revitalisation of the psychiatric hospitals on the West Bank and Gaza, as well as of the community psychiatric health clinics in various Palestinian cities.

On the West Bank there is one psychiatric hospital in Bethlehem, which has 320 beds, of which 178 are for males and 142 for females. Wards are gender segregated but male and female patients can, however, meet in the social club. Community psychiatric clinics are also provided in Jenin, Tulkarm, Nablus, Qalqilia, Ramallah, Hebron and Jericho. The hospital is recognised for teaching by the Jordanian Board of Psychiatry and takes medical students from Al-Quds University in Ramallah, to which the hospital is affiliated. Current staffing includes nine psychiatrists, 12 social workers, three clinical psychologists, 71 nurses, two electroencephalogram technicians and various administrative staff. Although there are no sub-speciality units as such, the hospital provides general adult psychiatry, old age psychiatry, learning disability, drug misuse and some forensic psychiatry. A new occupational therapy unit is currently being constructed from a grant from the British Consulate.

Until 1979 Gaza referred its psychiatric patients requiring admission to hospital to the Bethlehem psychiatric hospital on the West Bank. In 1979 a 20-bed unit was opened, expanded to 32 beds in 1984, based in El-Naser Psychiatric Hospital in Gaza. There is also a vigorous community mental health programme based in Gaza and an out-patient clinic in Khan Younis. The Gaza Community Mental Health Programme has held a number of conferences on psychiatry, with international participation. The provision of mental health care for children in Gaza has been recently described (Thabet & Vostanis, 1999).

According to El-Sarraj (1991), during Israeli rule levels of antisocial behaviour and aggression, including homicide, have increased within the Palestinian population. In addition, drug misuse has spread among younger Palestinians. However, as a form of culturally sanctioned homicide, the concept of family honour remains prominent for Muslims, with young women being killed by their male relatives for having brought ‘shame’ on the family by having sexual relationships that may not be culturally approved (Abu-Odeh, 1996).

The psychiatric hospitals in Bethlehem and Gaza are generally unable to take offender patients who may require security on account of serious risk to others. Three health professionals from Gaza visited Britain in 1997 for a 2-week placement in forensic psychiatry and further groups from the West Bank are scheduled to visit. A psychiatrist from Gaza is also scheduled to attend the Diploma in Forensic Psychiatry Course run by the Institute of Psychiatry, funded by a grant from an Arab organisation mediated by the British Council.

Islamic philosophy acknowledges that criminal responsibility may be affected by the presence of mental illness (Doi, 1984). The Prophet Mohammed is said to have regarded the young boy, the sleeping person, the mentally ill and the ‘insane’ as free of guilt for acts they may commit. Insanity in Islamic law is determined by the court on psychiatric advice. Involuntary hospitalisation depends on mental disorder associated with risk to self or others or the patient's ability to take reasonable care of his or her own affairs (Chaleby, 1996). Islamic law protects mentally incompetent individuals from being regarded as responsible for their crimes, but does not delineate exactly what is meant by mental incompetence, each case being left to the court to decide. Islamic Shariah law has a wider definition of criminal acts than in the West. Behaviour such as suicide, fornication and alcoholism are all regarded as criminal in Islamic religious courts (Chaleby, 1996).

Suicides in Arab societies are of low frequency, including in the Palestinian population (El-Sarraj, 1991). Cases of suicide bombing in the Middle East reflect the overriding of the prohibition against suicide by a separate factor of martyrdom (Taylor & Ryan, 1988).

All the Arab countries retain the death penalty, with a prevailing sentiment that it is integral to Islamic law and essential for the maintenance of law and order (Amnesty International, 1989). Exemption from the death penalty by Islamic law is, however, also endorsed. If a future Palestinian state was to decide against the death penalty, it would be the only Arab state to have done so. During the partial autonomy period since 1993, a few death sentences have in fact been passed by Palestinian courts and carried out.

While the improvement in psychiatric care of Palestinians does not depend solely on resolution of the military conflict, it is clear that it is a precondition for constructive efforts to prove fruitful. The authors hope that British psychiatrists will continue to play a role as part of the international medical community, fostering the facilitation of training and provision of psychiatric care to the Palestinian population.