To address the consequences of the Al-Aqsa Intifada, in November 2000 Médecins Sans Frontières (MSF) initiated medical and psychological care efforts in the Palestinian territories of Hebron, in the West Bank, and the Gaza Strip. The goal of this medical intervention in a war setting is to provide care to Palestinian families regularly and frequently exposed to potentially traumatic events related to the conflict. Most of these families live in the areas most affected by violence; near confrontation sites, Israeli Army installations and Jewish settlements (1). Since the beginning of the Al-Aqsa Intifada in September 2000, the settlement policy of the Israeli Army and Jewish settlers has continued (2) and repressive measures taken against the Palestinian population has assumed the form of collective punishment. MSF doctors and psychologists work together, complementing the typical home visit with several weeks of individual or family therapy.
The isolation of Israeli and Palestinian populations is heightened daily with the harsh application of a military occupation régime in the Palestinian territories. Fearing new attacks in Israel, and given the escalation in violence since the end of 2001, the Israeli Army's strategy consists of limiting the movements of Palestinians outside the Palestinian territories. The strategy seeks to guarantee the security of the Jewish settlements and their access routes because of firing and mortar attacks of which they are the targets from different armed Palestinian groups, thus dispersing the residents of the already-segmented West Bank and Gaza Strip (3).
Living conditions continue to worsen
In Gaza and Hebron, and as well in Ramallah and Nablus, Israeli military operations have thus created enclaves in which Palestinian families are effectively confined and living in a state of permanent stress, suffering to the point of feeling completely abandoned. The sense of despair is amplified by the Israeli Army's systematic destruction of their houses and property (factories, greenhouses, orchards, olive trees) in areas adjoining Jewish settlements and near major traffic routes used by the settlers. This repeated destruction, often carried out at night, under protection of Israeli Army tanks, increases the Palestinians' feeling of humiliation and revolt. The economic blockade imposed by Israel against the Palestinian territories strengthens Palestinian families' extreme dependency. Men who usually work in Israel are deprived of jobs and thus of an income, which means that the poorest families are unable to buy enough food on a daily basis (4). Some families are even unable to reach Palestinian medical centers or to have access to a doctor. For fear of seeing their house requistioned or destroyed in their absence, some patients avoid seeking treatment. Access to health care is now uncertain, while violence against Palestinian families and climate of terror in which they live generate intense stress, fear and panic, which call for immediate medical attention. If the Palestinian Red Cross, with help from the International Committee of the Red Cross, the U.N. and various non-governmental organizations, are active in health care and provide support for caring for the wounded and for primary care facilities, there are few specialists trained in trauma care. Following an October 2000 evaluation, which confirmed the scope of the need, it seemed to us a priority to intervene immediately, even while the conflict was still underway.
When events lead to suffering or traumatic consequences of living in an occupied territory.
Nearly the entire Palestinian population suffers from the confinement, occupation, fear and an absence of hope for the future on a daily basis. However, the intensity and the number of traumas differ, as do the psychological after-effects. In this war in which civilians are on the front lines, reactions are extremely variable. Stress is a normal reaction for those subject to daily violence and humiliation, in an environment in which remaining confinement offers the only possible hope of safety and security. In the most exposed areas, leaving one's house could risk death, as could going out at night. But staying at home is sometimes hardly more secure. Often riddled by bullet holes, these houses are regular targets for Israeli soldiers. Israeli Army tanks traveling nearby all day long make terrifying noises. Children can no longer play outside or go out along. Nowhere is safe anymore. In such an environment children, like adults, develop fears and experience repeated nightmare. Children no longer want to leave their mothers or go out of the house without them. This stress may also trigger severe and deeper psychological suffering. Along with what is known as "adaptation" stress, found widely, some individuals develop more serious, severe and chronic reactive psychological syndromes, including various forms of depressive states and PTSD. Some people remain prostrate and can no longer speak or feed themselves. Others experience delirious episodes following an intense fright, like the mother who ran to find her children when firing began. She thought "We die together or we survive together." One week later, she developed a persecution mania, with auditory hallucinations, profound anxiety and sleep loss. Paralyzed by extreme fatigue, she was unable to care for her children. The considerable media attention to this conflict makes no place for individuals to tell their stories.
On a daily basis, the MSF team meets Palestinian families suffering from these kinds of psychological disorganization, revived when shooting is heard and planes bomb. Another frequent situation is that of those people who were imprisoned and tortured during the first Intifada and who are now experience psychological decompensation (traumas and injuries from the first Intifada take on meaning after the event). Their disorders reappear as the result of new traumatic events. This is also the case of young adolescents who as children had terrifying experiences and who have forgotten some of what they experienced. Psychological disorders emerge during the Al-Aqsa Intifada, sometimes several years after the first traumatic event. According to the methods established by Western militaries to treat troops confronted by traumatic events on the battle field, such patients required immediate care, even in the field, and at the outset, for a limited time. Relying on this experience of psychiatric intervention in war, Médecins Sans Frontières adopted a practice in the heart of the most exposed areas where many Palestinian families still live. MSF doctors, psychologists and psychiatrists, assisted by Palestinian interpreters and drivers, come together in a joint clinical and curative practice (5). This approach is based on home visits because the obstacles to free travel as well as the fear felt by patients prevents them from leaving home for treatment. Palestinian health workers do not have access to them so MSF teams' home visits are often the only way of breaking through the isolation in which some families live. The doctor-psychologist team identifies and takes on the most vulnerable patients. If listening is important, the doctor's home visit, often conducted outside by the entrance or under olive trees, allows the targeting of untreated medical problems and psychological disorders. The doctor offers standard advice, and drugs for illnesses that the local network cannot provide. But in general, most of the chronic illnesses are aggravated or reactivated (cardiovascular illness; digestive disorders, primarily ulcers; skin problems). Family members leave home little or not at all. There is no money. Local doctors are overwhelmed, have lost motivation, are exhausted. And finally, there are very few Palestinian psychologists or psychiatrists. The MSF doctor carries out the role of home visit doctor. His or her intervention lays the groundwork and rounds out the intervention of psychiatrists and psychologists. The M.D. cares for the body before the mind are treated. The doctor refers patients suffering from psychological problems to the psychologist or psychiatrist. This can begin a therapeutic work allowing individuals and families to express their fears, to treat their traumas and reduce their stress. The reference model is that of therapeutic consults and brief therapy (individual, family or group, depending on the case); treatment lasts on a few weeks on the basis of two visits/week (close monitoring). Intervening while the conflict situation - the cause of the trauma - is still underway allows to give meaning to the event or to the reaction, to identify the trauma with the patient and thus to avoid later a more severe reaction to some new aggression (which in this context of violence is certain). The psychologist seeks to anticipate occluded emotional states, emotional pain transformed into dispairs that are difficult to reverse. Médecins Sans Frontières has already experimented with this approach in other conflicts, including in Bosnia. To ease the pain of trauma, the MSF team sought to "build connections severed by trauma" and "the working out of an account where trauma led to shutdown" (6). The MSF psychologists are assisted in their clinical work by their Palestinian interpreters. The cornerstone of the patient/therapist relationship, they are the "voice" of the doctors and psychologists and play an essential intermediary role in a complex political and cultural environment. On a regular basis, discussions of cases from the field are also organized between MSF expatriates and an Israeli psychologist based in Israel (she cannot travel to the Palestinian territories). These meetings promote clinical exchanges among trauma "professionals" outside the Palestinian territories. Finally, MSF's consulting psychiatrists and the organization's operational staff meet regularly to guarantee the supervision of MSF teams (nationals and expatriates) and, if necessary, to redirect the mission's medical goals.
The limits of our actions
The first limitation is that this kind of care cannot substitute for regular psychotherapeutic treatment. Certain kinds of problems cannot be addressed in the former context because of the conditions and techniques for maintaining the relationships. However, the presence of the MSF doctor provides, if necessary, the access to psychotropic drug prescriptions for the most serious cases until the patient can be referred elsewhere. Another limit, if it is truly such, is the number of Palestinian patients and families who seek the intervention of the MSF team. The numbers are quite high; even limitless. That is why priority is given to treating the most fragile patients who are suffering from extreme stress, multiple depressive states and PTSD. Each month, every MSF psychologist and psychiatrist conducts some forty individual or family consultations (with approximately one hundred people). The response to MSF's treatment is very positive. Palestinian families themselves often identify those individuals in greatest need and refer them to the MSF team. This medical intervention is underway today in the Gaza Strip and the Hebron district of the West Bank. The daily pain, the adjustments required to deal with material constraints and human limits still remain for the MSF teams. The fear of bombing and firing remains, too. Because one of the key limits to the work of the MSF doctors and psychologists resides in the physical risks they take daily to reach the most isolated Palestinian families. Negotiations with the Israeli authorities underway since the outset of this program do not always guarantee adequate and frequent safe access to civilian populations in the most-exposed areas. This limit imposes frequent interruptions of treatment, delaying expected visits by several hours or several days. Such interruptions are particularly difficult for the families sustained by our care.
In conclusion, we simply want to underline the intricate relationship between two sets of activities undertaken by MSF in the Palestinian territories: on the one hand, bearing witness and speaking out and, on the other, providing medical care. This involves gathering factual evidence, supported and enriched by daily contacts between MSF doctors and psychologists and Palestinian families on the Gaza Strip and in Hebron. In the face of their suffering, we are responsible for describing the war's consequences on them. It involves relating that which we witness in the Palestinian territories. This has particular therapeutic importance for the families. The considerable media attention to this conflict makes no place for individuals to tell their stories. We are trying to compensate for that lack by publishing regular descriptive reports on the consequences of violence against the civilian population.
Pierre Salignon is an attorney and program director at MSF's Paris, France operational center. Fouad Ismael is the head of MSF Jerusalem. Elena Sgorbati is program director at MSF Spain operational center.