siege and mental health: walls vs. bridges. vi international conference gcmhp and who, gaza city and...

Siege and Mental Health: Walls vs. Bridges.

VI International Conference GCMHP and WHO,

Gaza City and Ramallah, Palestine, 27-29 October, 2008

The Siege of Gaza in History: Mental Health and Behavioural

Implications.

By Federico Allodi, MD. Near East Cultural and Educational Foundation Canada.

Email: < fallodi@pobox.com >

Outline of the paper

1. Quotations on history2. Some definitions, model and parameters of analysis:

(Military, material strength and suppliesPsychological preparationStrategy: attackers and defendersGroup psychology: cohesiveness and divisions. Mental health and behavioural aspectsStress disordersStress responses in defenders and attackers. Positive outcomes.)

3. Historical review of sieges: Antiquity, Modern and Police sieges

4. The siege of Gaza5. Conclusions.

History is:

• An explanation of changes in a society (Eric Hobsbaum, 1997)

• History is a teacher (Herodotus, 440 BC)

• History repeats itself (Popular)

• History is bunk (Henry Ford, 1916)

• History does not repeat itself, but it does rhyme (Mark Twain, 1835-1910)

Definitions

• Health is a state of harmony between the biological, psychological and social components of man. (WHO)

• Medicine is politics (Rudolf Virchow, 1821-1902)

• Public health is politics to the nth power (Rudolf Virchow)

Sieges in antiquity

Siege of Megiddo, 15th Century BC

Siege of Jerusalem by Sennacherib, 701 BC

• Babylonians carrying prisoners to exile, 597 BC

Nabuchadnezzar II (the Great) in his city of Babylon. He took Jerusalem in 987 and destroyed it in 597 BC.

• Nebukadnezzar, (c 630-562 BC), ruler of Babylon, by William Blake

Flavius Josephus (37-94?), Historian. The Jewish Wars

• Flavius Josephus, 70 AD, pleading before Jerusalem

The destruction of Jerusalem by the Romans, 70 AD

Siege of Jerusalem by the Romans, 70 AD. Roman triumphal arch panel showing spoils of Jerusalem temple.

• Siege of Ma’arrat by the Crusaders, 1098 AD

Siege of Ma’arrat, 12 December- 5 January,1098-9.Crusaders Throwing Heads Of Muslims Over Ramparts

Siege of Jerusalem by First Crusaders, 1099

The Siege of Jerusalem by the crusaders, 1099. Drawing by Gustav Adolf Dore

Godfrey of Bouillon takes Jerusalem, 1009

Saladin (Salah al-Din), 1138-1193

Statue to Saladin in Damascus

• Siege of Acre, 1281

Final surrender of Acre to the Muslims, 1281

Modern Sieges

Surrender of Granada, 1492

Siege of Gibraltar by the French and Spanish June 24, 1779 - February 7, 1783The Defeat of the Floating Batteries at Gibraltar,, by John Singleton Copley

Siege of El Alamo, Texas,February 23- to March 6, 1836

Siege of Madrid, T-26 republican tank,1936-1939

Savoia Bomber and Fiat fighter planes over Madrid,

1936-1939

Telephone exchange building, Madrid 1936

• Siege of Leningrad, 1942

Siege of Leningrad by the German army, 1942

Kreditbanken at Norrmalmstorg Siege, August 23-28, 1973 Stockholm, Sweden.

Swiss Bank Robbery Hostages,1974

Patricia Hearst, 1974. As Nadia in a Symbionese Liberation Army poster.

London Spaghetti House Siege, 1975

Siege of Sarajevo, 1992 to 1996. People under Serb snipers’ fire. (It claimed 12,000 lives)

Motives for the Siege(Sarajevo, 1992-996)

• Land appropriation• Property grabbing• Removal of the Other people (Ethnic Cleansing)• Elimination of the Other

(Genocide)

Damage to understructure and supplies by Serbian Army

(Siege of Sarajevo, 1992-1996)

• Five main hospitals

• Electric plants, university, transportation

• TV towers, banks

• Flour mills, bakeries, candy factories,

• Theological schools, mosque.

• Blocking off humanitarian aid

Traumas to children. (N: 65-60 000 children. Percentages)

Siege of Sarajevo, June 1992-Feb 1996.

• Saw some one shot by sniper --------- 40

• Saw someone killed ------------- 51

• Saw family member killed ----------- 39

• Saw house occupied by some else -- 48

• Had house attacked by soldiers ----- 73

Gaza, 2007. Destruction of hydroelectric plant.

Gaza Siege, 2007. Father carrying body of his dead child. Erez check point.

Health determinants Siege of Gaza, 2066-2008

• Population density: --------- 3823 /sq. km.• Pop. Child 17yrs./adult proportion --------- 50%• Income per capita: ----------- $2.00 day• Unemployment: ----------------------- 60-77%• People without sufficient food: ---------- 70• Pop. depending on UNRWA basic food ----- 80 • Pop. without access to water: (over 2/3) 70• Pop. suffering from malnutrition ----------- 48• Houses not connected to sewers ----------- 22• Houses in OT demolished by IDF(2000-2007):4170

Health care services determinantsSiege of Gaza, 2006-2008

• Pop. without medicines medicines --- 8%

• Pop. Without medical services ------ 38%

• Availability of drugs for med. trea’t --- 31%

• Availability for essential drugs ------- 0.%

• State health empl’es without reg. pay-90%

• Patients with emerg/chronic illness requiring trea’t denied exit fr. Gaza--17.5%

Children’s physical health and illness statusGaza, 200-2007

• Malnutrition ----------- 50%

• Increase diarrhoea/dysentery -- 150%

• Anaemia ----------------------- 70%

• Rate protein supplies exhausted--100%

• Change in weight at birth -----

• Infant mortality -------------

Children’s mental health statusPeriod prevalence.Gaza, 2006-2008

• Anxiety disorders and fear symptoms• Social withdrawal• Regressive and clinging behaviour• Enuresis• PTSD• Other trauma related disorders

Overall rates child population --- 68-90%

Violence turned inwards.West Bank and Gaza, 2004-2006

Women physically abused. W. Bank ----- 24% Gaza ---- 23%

Women Sexually abused. W. Bank ----- 12% Gaza ----- 23%

Increased rate since 2006 to 2007 ------- 400%

Collaborationism and Spying. (No data)

Factionalism and splitting. (No data)

Tortured becoming torturer (Clinical vignettes)

Casualties and harm to attackers

• Physical Deaths » Injuries and mutilations

• Psychological Anxiety, fears» Moral blunting, callousness» PTSD (Beware: Criterion A)» “Moral degeneration”

• Social refusenicks» Witness soldiers of the “dirty war”» Factionalism and splitting» Soldiers and veterans:

Increased suicides Increased homicides.

Family and social violence (Vignettes)

Analysis and Conclusions of Sieges

• Occur in cities which resist• Attackers and besieged suffer privation

and trauma• Starvation as siege strategy• Hunger leads to social breakdown and to

diminished resistance• Ideology and leadership enhance unity• Support network increases coping and

resistance

Analysis of Sieges (2)

• Rates and severity of ill health are related to severity/duration of siege and to

• Integrity/quality of support network

• External support breaks the siege, increases resistance materially and psychologically.

Gaza, 2008. Egyptian convoy in Rafah crossing.

Gaza,16 Agust 2008. Solidarity boats breaking the Siege.

Gaza, 2008. Ships in harbour welcoming solidarity boats

“If vicious people are united and constitute a power, then honest folk must do the

same.”

Leon Tolstoy (1829-1910). War and Peace.