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Social Science & Medicine 74 (2012) 1163e1171

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Social Science & Medicine

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Internal displacement and health among the Palestinian minority in Israel

Nihaya Daoud a,f,*,1, Ketan Shankardass b,f,2, Patricia O’Campo c,f,1, Kim Anderson d,3, Ayman K. Agbaria e

aDepartment of Epidemiology and Health Systems Evaluation, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer Sheva 84015, IsraelbDepartment of Psychology, Wilfrid Laurier University, 75 University Avenue West, Waterloo, Ont. N2L 3C5, CanadacDalla Lana School of Public Health, University of Toronto, CanadadDepartment of Contemporary Studies, Wilfrid Laurier University, 73 George St., Brantford, ON N3T 2Y3, CanadaeDepartment of Leadership and Policy in Education, Education and Sciences Building, 5th floor, University of Haifa, Mount Carmel, Haifa 31905, Israelf The Centre for Research on Inner City Health, The Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, Ont. M5B 1T8, Canada

a r t i c l e i n f o

Article history:Available online 11 February 2012

Keywords:Internal displacementPalestiniansIsraelPolitical violence

* Corresponding author. Department of Epidemiolouation, Faculty of Health Sciences, Ben-Gurion UniversBeer Sheva 84015, Israel. Tel.: þ972 8 6477351; fax: þ

E-mail addresses: daoud@bgu.ac.il (N. Dao(K. Shankardass), o’campop@smh.ca (P. O’Campo), kuoguelph.ca (K. Anderson), aymanagbaria@yahoo.com

1 Tel.: þ416 864 6060x5403; fax: þ416 864 5485.2 Tel.: þ416 864 6060x77360.3 Tel.: þ519 756 8228x5643; fax: þ519 752 0556.

0277-9536/$ e see front matter � 2012 Elsevier Ltd.doi:10.1016/j.socscimed.2011.12.041

a b s t r a c t

Long term health impacts of internal displacement (ID) resulting from political violence are not welldocumented or understood. One such case is the ID of 300,000e420,000 Palestinian citizens of Israel andtheir descendants during the Nakba of 1948 (Palestinian Catastrophe). We aim to document the longterm health impacts of this ID. We draw on data collected in 2005 from a nationwide random sample of902 individuals aged 30e70. Research participants were interviewed in person after being selectedthrough a multistage sampling procedure. About 24% of participants reported that either they or theirfamilies had been internally displaced.

Palestinian internally displaced persons (IDPs), that is, those who were forcibly displaced anddispossessed from their homes and lands during the Nakba and its aftermath, as well as their familiesand descendants, and who reside within the current borders of Israel, had an odds ratio of 1.45 (95%CI ¼ 1.02e2.07) for poor self-rated health (SRH) compared to non-IDPs after controlling for demographic,socioeconomic and psychosocial factors. No difference was found between IDPs and non-IDPs in limitinglongstanding illness following control for confounders. Low socioeconomic position and chronic stresswere significantly related to ID and to SRH.

Our findings suggest adverse long term health impacts of the Nakba on the IDPs when compared tonon-IDPs. We propose that these disparities might stem from IDPs’ unhealed post-traumatic scars fromthe Nakba, or from becoming a marginalized minority within their own society due to their displacementand loss of collective identity. Given these long term health consequences, we conclude that displace-ment should be addressed with health and social policies for IDPs.

� 2012 Elsevier Ltd. All rights reserved.

Introduction

Many groups worldwide experience displacement due topolitical conflicts, violence and war (Internal DisplacementMonitoring Centre, 2009). Among these, some individuals crossnational borders to become refugees, while others move withinborders and become internally displaced (Toole & Waldman, 1997).Internally displaced persons (IDPs) are defined as “persons or

gy and Health Systems Eval-ity of the Negev, P.O. Box 653,972 8 6477638.ud), KShankardass@wlu.caanderson@wlu.ca, kimberle@(A.K. Agbaria).

All rights reserved.

groups of persons who have been forced to flee or to leave theirhomes or places of habitual residence as a result of, or in order toavoid, the effects of armed conflict, situations of generalizedviolence, violations of human rights or natural or human-madedisasters, and who have not crossed an internationally recognizedborder” (Deng, 1995). Estimates in 2009 indicate that there aresome 27.1 million conflict-induced IDPs in the world who areunable to return to their homes or cross an international border.Africa is the regionwith themost IDPs (11.6million), while over halfof the world’s IDPs are in five countries: Sudan, Colombia, Iraq,Democratic Republic of the Congo and Somalia. Recent estimatessuggest that there are 3.8 million IDPs in the Middle East (InternalDisplacement Monitoring Centre, 2009). Most of the latter grouphave been displaced by interstate conflicts in recent decades, suchas in Darfur, Sudan (Olsson, 2010), Iraq (Morton & Burnham, 2008),Lebanon (Choueiry & Khawaja, 2007) and Palestine (InternalDisplacement Monitoring Centre, 2009).

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Political violence, displacement and health

While the effects of political conflict and violence on health areof increasing interest on the public health research agenda (Panter-Brick, 2010; Spiegel, Checchi, Colombo, & Paik, 2010), there isa paucity of research on the health effects of long term internaldisplacement (ID) (Kett, 2005). IDPs are often underrecognized,unregistered and disorganized within their own countries (Spiegel,Hering, Paik, & Schilperoord, 2010). As a result, they often lackprotection and access to local resources (Salama, Spiegel, &Brennan, 2001), and they receive little or no short or long termhumanitarian aid (Internal DisplacementMonitoring Centre, 2009).Over time, as their basic needs for security, clean water, food, andshelter become non life threatening, the adversities experienced byIDPs are often overlooked or ignored. This happens in spite ofongoing health and social needs stemming from their dislocation(e.g., loss of support, economic position, education, housing andhealth care) (Anderson, 2009; Burton & John-Leader, 2009; ICRC,2009; Spiegel, Hering et al., 2010). These adverse consequencesmay also affect subsequent generations (Richmond & Ross, 2009).The current study focuses on the health of Palestinian citizens ofIsrael who became internally displaced as a result of the Nakba of1948 (Palestinian Catastrophe, described below).

The negative health impacts of ID resulting from politicalviolence can vary depending on the time since displacement.Studies of short term displacement demonstrate increases inpsychological distress and post-traumatic stress disorder (PSTD)(Barenbaum, Ruchkin, & Schwab-Stone, 2004; Carballo, Zeric, &Smajkik, 1996; Cardozo, Vergara, Agani, & Gotway, 2000; Thepa &Hauff, 2005). Studies examining the long term influences ofdisplacement on health are fewer, but the findings suggestincreased mental and physical health problems among the dis-placed. For example, using the SF-8 instrument among IDPs innorthern Uganda produced relatively low physical (PCS) andmental health (MCS) measures, indicating poor health even 20years after ID occurred (Roberts, Felix Ocaka, Browne, Oyok, &Sondorp, 2009). Negative impacts on well being and restrictedaccess to health care services were also documented in a qualitativestudy among IDPs 10 years after the war in Bosnia-Herzogovina(Kett, 2005). In Nepal, displacement of about a quarter ofa million people has increased the spread of HIV/AIDS (Nepal,2007). Large scale displacement of Aboriginal peoples in Canadaled to substantial changes in their physical environments andcultures, which has had adverse effects on health over generations(Richmond & Ross, 2009). However, past studies of long termimpacts on IDPs have had methodological weaknesses; notably,most studies on IDPs lack a comparison group. Among the fewstudies with a comparison group, one showed poorer self-ratedhealth among ID women in Lebanon compared with non-IDPs(Choueiry & Khawaja, 2007), and a study in Turkey indicatedpoorer mental health among internally resettled childrencompared to thosewho had not been resettled (Erol, Sqimsek, Öner,& Munir, 2005).

While this evidence demonstrates associations between nega-tive health impacts and ID, the mechanisms bywhich displacementinfluences long term health have yet to be revealed. Twoapproaches to examine the influence of political conflicts anddisplacement on health have been suggested (Miller & Rasmussen,2010): 1) a direct, trauma-focused approach that measures healtheffects, such as PTSD, anxiety and depression; and 2) a broader,indirect approach centered on the impacts of ID on the socialdeterminants of health. The latter examines exposure to stressfulsocial and material conditions caused or worsened by politicalviolence, including poverty, food insecurity, destruction of socialnetworks, family disruption, concentration in refugee camps, loss

of social prestige, and loss of schools and work places. It alsoincludes the ways inwhich the physical act of relocation from one’susual surroundings can disrupt identity.

Cummins, Curtis, Diez-Roux, and Macintyre (2007) recentlyproposed a “relational” approach to understanding place in healthresearch. This approach challenges us to account not only for the“processes and interactions occurring between people and placesover time,” but also for the “dynamic and changing characteristicsof places and the place-to-place mobility of populations” (p. 1828).In the case of IDPs, the notion of place attachment as a sharedaffinity between individuals and their places is particularly rele-vant. Place identity has been conceptualized as a component ofidentity, along with other aspects, like gender, social class, ethnicbackground, occupation, and religion (Cuba & Hummon, 1993). Ina similar way, collective identities have been discussed in terms ofthe ongoing reciprocal relationship between population groups andthe places they inhabit (Taylor & Whitter, 1992). Place attachmentadvances the community’s capacity to work out disputes and toimprove communal interactions, specifically in collective societies,by facilitating participation and community involvement whilecultivating a collective identity (Anheier & Kendall, 2002). There-fore, bonds to a particular place may have long lasting effects onhealth.

The case of internally displaced Palestinians

Literature on internally displaced Palestinians in Israel hasreferred to this population as “refugees in their homeland,”“internal refugees,” “refugees in Israel,” and “1948 refugees.”Whileprevious work has documented important historical implications ofthe Nakba events (Pape, 2006) and studied sociological patterns ofadjustment to these events (Al-Haj, 1986, 1988), we found nostudies that focus on how displacement has affected the health ofthese IDPs.

Before 1948, approximately 1.3 million individuals lived inhistoric Palestine (Pape, 2006). About 940,000 of this number livedin the area that became Israel. Within this group, approximately75%e80% left their homes and became refugees after the Nakba(Khalidi, 1992). The Palestinians who remained in the part ofhistorical Palestine now called Israel became a minority in theJewish state. It was recently estimated that about 25e30% (about370,000e420,000) of the current Palestinian citizens of Israel areIDPs or descendants of IDPs (BADIL Resource Center for PalestinianResidency & Refugee Rights, 2009, p. 215; Internal DisplacementMonitoring Center, 2007; Wakim, 2001). This includes peoplewhowere displaced by thewar in 1948 as well as those displaced asa result of population transfers, land expropriations and housingdemolitions after 1948.

While this research offers some idea of the scope of the ID inquestion, it is difficult to track the real number of IDPs in thecontext of the Palestinian/Arab Israeli conflict for three reasons.First, the process of displacement continued in the years after the1949 Armistice Agreements (Kamen, 1988; Masalha, 2003). Forexample, as part of their efforts to colonize and “Judaize” somevillages, Israeli authorities continued to perform forced transfers ofPalestinians from one village to another within Israeli borders(Yiftachel, 2006). Second, there is no internationally recognizedborder between Israel and the 1967 “occupied Palestinian terri-tory,” and the ceasefire lines have changed frequently over time. Asthis border has changed, some individuals have moved in order tostay connected with their families (BADIL Resource Center, 2007, p.43). Third, the Israeli government does not recognize IDPs or theirright to return to their home villages.

For these and other reasons (described in depth by Sabbagh-Khoury (2011), for many Palestinians, the process of finding

N. Daoud et al. / Social Science & Medicine 74 (2012) 1163e1171 1165

permanent accommodation after the initial process of displace-ment was challenging. Military government rules remained in forceuntil 1966, and during this period, IDPs were denied the right toresettle from the villages where they initially landed followingdisplacement. Arab areas were proclaimed “closed zones” duringthis period, meaning that residents had to acquire “movementpermits” to move in and out of a given zone (Masalha, 2003).Following the termination of the military government rules in1966, IDPs were allowed to relocate their households. For a varietyof reasons, however, the process of resettling was slow and tediousfor some families. For example, Kabha and Barzilai (1996) describethe journey of one Palestinian family who passed through thirteendifferent locations before finally settling. During this period, mostIDPs built their permanent residences in segregated neighborhoodson the outskirts of sanctuary villages, close to their villages oforigin. Longer-term residents of hosting villages were themselvessuffering the effects of the 1948 events as a result of the loss of theircountry and land’s sovereignty and of becoming a minority in thenew Jewish state (Rouhana, 1997).

As with all Palestinians who remained within the new bordersof Israel after 1948, internally displaced Palestinians subsequentlybecame citizens of Israel. Those IDPs who have not been willing tocede claims to their pre-1948 property are considered “absentees”under the Israeli Absentee Property Law. Their property is trans-ferred to the care of the custodian of absentee property (Cohen,2000). Since these absentees are also “present,” in that they areIsraeli citizens who are supposedly entitled to equal rights, they arereferred to by the contradictory term “present-absentee”(Grossman, 1992).

For the purpose of this study, internally displaced Palestiniansare defined as those who were forcibly displaced and dispossessedfrom their homes and lands during the Nakba in 1948 and itsaftermath, as well as their families and descendants, who residewithin the current borders of the state of Israel. We hypothesizethat the persistent threat of losing their collective identity andplace identity as a result of being displaced (e.g., from their prop-erty or their home village) has affected the health of this pop-ulation, resulting, particularly, in chronic stress and otherassociated physical and mental health problems. This is in additionto the possible ‘material’ effects of direct experience of displace-ment on health, that were never measured, as well as otherelements of structured discrimination faced by Palestinians livingin Israel (Rouhana, 1997). In the current paper, we examine thehealth differences associated with ID and factors related to ID, thatmight help explain observed differences in health among Pales-tinian citizens of Israel.

Methods

Sample and procedure

Elsewhere, we have described our sampling procedure and datacollection (Daoud, Soskolne, & Manor, 2009a, 2009b). In theseprevious analyses, we made no distinction between the displacedand non-displaced status of Palestinians, as the focus was not onthe relationship between internal displacement and health. Briefly,data were obtained in 2005 from a nationwide study of a randomsample of Palestinian citizens of Israel, aged 30e70, who wereselected through a multistage cluster sampling procedure. First, 35statistical geographic areas (SGA) were randomly selected from 155localities according to population size and an area-level socioeco-nomic index. The SGAs had already been determined by the IsraelCentral Bureau of Statistics, which divides the country to theseareas. Each SGA forms a cluster defined by geographic borders anda socioeconomic index. The socioeconomic index includes a scale of

1e20, where 1 is the poorest and 20 is the most advantaged(Central Bureau of Statistics, 1999). Within each SGA that formsa cluster, we utilized field sampling to overcome difficulties oflocating addresses of individual households. To identify the SGAboundaries and as a starting point for where to conduct interviewswe used maps. Interviewers then progressed along the right-handside of the streets, picking out every fifth household until they hadreached 25e30 residential households. One eligible person wasinterviewed in each household. A total of 1158 households witheligible residents were approached; there were 213 refusals, and in43 households no onewas present after three visits. The refusal ratewas similar across the different SGAs of the study. The final sampleincluded 902 respondents (78% response rate) who were inter-viewed face to face using an Arabic-language structured ques-tionnaire, beforewhich they each signed an informed consent form.Distributions of demographic characteristics in the final samplewere comparable to those of the total Arab population in Israel (seeElectronic Appendix A), available only with the online version ofthis paper (Central Bureau of Statistics, 2004). The study wasapproved by the Institutional Review Board at Hadassah e HebrewUniversity Medical Center.

Measures

Main outcomes included two subjective health indicators thathave been previously used among Palestinians in Israel (Daoudet al., 2009a, 2009b) and in other Arab populations (Choueiry &Khawaja, 2007; Read, Amick, & Donato, 2005): self-rated health(SRH) (Idler & Benyamini, 1997) and limiting longstanding illness(LLI) (Manor, Power, & Matthews, 2001). SRH included 5 categoriesto rate health as very good, good, fair, poor, or very poor. The firsttwo categories were combined, hereafter described as ‘goodhealth,’ and the last three combined as ‘poor health.’ LLI wasmeasured by a yes/no question asking if the participant suffers froman illness that limits his/her daily functioning compared to othersin the same age group (Manor et al., 2001).

Internal displacement was measured by a direct question:“Were you or any of your family members displaced due to theNakba of 1948?” Family refers here to the nuclear family. In theNakba and its aftermath, it was mostly whole nuclear families whowere displaced (Arneberg, 1997). Since we interviewed only oneperson in the household, displacement would be underestimated ifit was measured only for the respondent. Additionally, in Israelthere is no registration of IDP Palestinians (of 1948). We assumethat the number of people who directly experienced displacementin 1948 and are still living is very small. We would require a muchlarger sample size in order to capture ample numbers of those whowere personally displaced.

A series of variables were examined as either potentialconfounders or explanatory factors for the association between IDand health. Potential confounders included age and gender. Agewas measured by two categories, indicating two generations afterthe Nakba events. The first generation included those who haddirectly experienced the events of the Nakba and who werebetween the ages of 55 and 70 at the time of the study, and thesecond generation were those born after the Nakba and includedindividuals who were between 30 and 54 at the time of the study.

The first group of explanatory factors included four variablesdescribing socioeconomic position (SEP). This was important, asdisplaced persons lost ownership of their land and/or property,which might have affected their social standing. SEP was measuredby: (1) Number of years of education, which reflects SEP over thelife course starting from investments in early childhood, tofinancing higher education, and up to current employmentopportunities and income (Daoud et al., 2009b); (2) Assets

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ownership, which indicates current SEP by measuring the numberof specific products in the household owned by the respondent(e.g., a computer, oven, fridge, microwave, or dishwasher). Theseassets indicate the difference between the highest and lowestsocioeconomic quintiles in Israeli society (Central Bureau ofStatistics, 2004); (3) Land ownership (by the respondent or thefamily), which indicates historical wealth among Palestinians, asthey were once an agricultural society and land was a main sourceof income; And (4) loss of land or other property (e.g., a house) thatwas owned by the respondent or his/her family during the Nakba,as this may reflect a change in SEP resulting from confiscations oflands and house demolitions. These losses happened mostly butnot exclusively among IDPs, as some non-IDPs may have lost part oftheir land, or may have lost their house but not their land.

A second group of explanatory factors are psychosocial vari-ables. (1) Chronic stress: a list of yes/no questions about exposure to10 stressful situations (e.g., financial, social, family or work prob-lems) (McDonough & Walters, 2001). (2) Stressful life events: a listof yes/no questions on exposure to nine events during the previousyear (e.g., unemployment, major family problems) (McDonough &Walters, 2001). The final score for both stress variables was calcu-lated as the sum of positive responses. (3) Feelings of ethnicdiscrimination: one question examining whether participants feltdiscriminated against because of being an Arab, based on a five-item scale of categories ranging from “never” to “often”. (4) Socialsupport (an important characteristic of Palestinian collectivesociety): comprised of a six-item scale on receiving three types ofsupport: material, emotional, and informational, and five responsecategories ranging from ‘never’ to ‘always’ (Karlsson, Sjostrom, &Sullivan, 1995) (Cronbach’s Alpha ¼ 0.87). (5) Sense of nationalbelonging: respondents were asked to personally identify with oneof six identities: Palestinian, Palestinian-Arab, Arab, Arab-Israeli,Palestinian Israeli, or Israeli.

The third group of explanatory factors allowed us to examinewhether the community social context might have led to differ-ences in health across IDPs and non-IDPs. (1) Social participation:a nine-item scale on membership in formal or voluntary organi-zations (Lindstrom, Merlo, & Ostergren, 2002). The three responsecategories ranged from “always” to “never” (Cronbach’sAlpha ¼ 0.72). (2) Social capital: three yes/no questions (i.e., threevariables) about feelings of exploitation, mutual help, and trustbetween community members (Kawachi, Kennedy, Lochner, &Prothrow-Stith, 1997). (3) Civic engagement: two yes/no ques-tions (i.e., two variables) gauging whether the participant voted ineither the last Israeli national elections for parliament or the lastmunicipal elections.

Statistical analysis

To examine the strength of the main exposure and the role ofpotential mediating variables on the associations between ID andhealth outcomes (SRH and LLI) we used the multiple pathwaysapproach (Singh-Manoux, 2005). Mediators (socioeconomic,psychosocial and community social) need to cause attenuation inthe strength of the associations between ID and the healthoutcomes. Following this approach, first, bivariate associationsbetween ID and health outcomes (i.e., SRH and LLI), as well asbetween ID and potential mediators were examined using Chi-Square or T-tests. Mediators that were associated with ID at the0.05 alpha level were subsequently examined for associations withthe health indicators. Gender and agewere considered confounderssince they were associated with health outcomes in this population(Baron-Epel et al., 2005). Multivariate logistic regression modelswere then built in three stages to examine potential confoundingand possible explanations of poorer health in IDPs compared to

non-IDPs. In the first model, effects of ID were controlled for theconfounders (age and gender), and all subsequent models includedthese potential confounders. Next, explanatory factors that hadassociations with both ID and health indicators at the 0.05 alphalevel were included in regression models by first adding relevantsocioeconomic factors and then relevant psychosocial variables(none of the community social characteristics were found to beassociated with ID). We examined age and gender as potentialeffect modifiers in the relationship between ID and healthoutcomes, but there was no evidence of statistical interaction.

Results

Table 1 indicates that 23.6% of respondents reported that they ortheir families were internally displaced, and there was a significantpositive association between ID and both indicators of poor health.The IDPs were more likely to report poor SRH (43.7% versus 34.1%)and had a higher prevalence of LLI (28.6% versus 22%), than non-IDPs (Fig. 1).

There was a significantly higher proportion of IDPs in the 55 andolder age range, compared to non-IDPs, and there were more maleIDP respondents than female. IDPs had 13þ years of education,fewer household assets, and were far more likely to have lostproperty during the Nakba. The IDPs had a higher proportion offeelings of ethnic discrimination “sometimes,” “frequently” or“often,” and a higher proportion of them reported Arab or Pales-tinian, but not Israeli identity. On average, IDPs also suffered fromhigher levels of chronic stress. Gender had a borderline associationwith ID (P ¼ 0.058). No statistically significant differences werefound between the IDPs and non-IDPs in exposure to stressful lifeevents, social support, social participation and social capital. Nordid they have different levels of civic engagement (Table 1).

In the bivariate analysis, significant associations were foundbetween most of the independent variables that were associatedwith ID and SRH and LLI (Table 2). Being older (55e70), havingfewer household assets (0e3), less education (0e8 years), andhigher levels of chronic stress were associated with poor SRH andhigher prevalence of LLI. Female gender was significantly associ-ated with poor SRH but not with LLI. Losing property in 1948,feelings of ethnic discrimination and a sense of belonging to thePalestinian national identity were not associated with any of thehealth indicators under consideration.

In a multivariate model, ID remained positively associated withSRH following control for age and gender (Table 3). IDPs were 42%more likely to report poor SRH than non-IDPs (95% confidenceinterval 2%, 98%). After controlling for socioeconomic factors, theeffect of ID remained significant and was slightly inflated(OR ¼ 1.54, 95% confidence interval ¼ 1.08, 2.19). Lower educationlevel and fewer household assets were both associated with higherrisk for poor SRH in this model; since IDPs were more likely to behigher educated than non-IDPs, the inflation of the effect of IDfollowing adjustment for these socioeconomic factors may bedriven by a strong net effect of education relative to householdassets (i.e., analogous to positive confounding).

When chronic stress was also included in the final multivariatemodel for SRH, each single unit increase in chronic stress wasassociated with a 16% increase is risk for poor SRH (95% confidenceinterval ¼ 7%e26%). In turn, the strength of the association with IDwas reduced by about 17% (OR ¼ 1.45, 95% confidenceinterval ¼ 1.02, 2.07). Odds ratios for other confounders andexplanatory factors were relatively stable across these models.

On the other hand, ID was no longer significantly associatedwith LLI after controlling for age and gender. In particular, older ageappeared to be a key confounder of this relationship, as there wasa greater risk for LLI among older participants (OR 3.37, 95%

Fig. 1. Poor self-rated health (SRH) and limiting longstanding illness (LLI) (%) amonginternallydisplaced (and theirdescendants) andnotdisplacedPalestiniancitizensof Israel.

Table 1Associations between independent variables and displacement among Palestinian citizens of Israel, 2006.

Total%

Internally displaced (N ¼ 213)%

Non-displaced (N ¼ 687)%

aP-value ¼

Demographic characteristicsAge (N ¼ 902)30e54 78.4 72.3 80.5 0.01155e70 21.6 27.2 19.5

Gender (N ¼ 902)Male 57.8 63.4 56.0 0.058Female 42.2 36.6 44.0

Socioeconomic positionEducation (N ¼ 901)0e8 39.6 37.1 40.4 0.0439e11 20.4 23.9 19.212 21.5 16.4 23.213þ 18.4 22.5 17.2

Assets in the household (N ¼ 902)0e3 assets 39.2 42.3 38.3 0.0114e5 assets 39.1 31.0 41.86 assets 21.6 26.8 19.9

Land ownership (N ¼ 902)No 67.5 72.8 65.9 0.063Yes 32.5 27.2 34.1

Lost land or house or both during Al-Nakba (N ¼ 889)Yes 27.9 86.7 9.6 �0.001No 72.1 13.3 90.4

Psychosocial factorsFeelings of ethnic discrimination (N ¼ 890)Never or seldom 59.8 52.4 62.1 0.012Sometimes, frequently or often 40.2 47.6 37.9

Sense of national belonging (N ¼ 860)Palestinian, Palestinian-Arab, Arab 45.5 27.1 �0.001Arab-Israeli, Palestinian Israeli, Israeli 54.5 72.9

Chronic stress (mean � SD, range) (N ¼ 902) 2.91 � 1.86 (0e8) 3.19 � 2.02 (0e8) 2.83 � 1.80 (0e8) 0.013Stressful life events (mean � SD, range) (N ¼ 902) 1.48 � 1.40 (0e9) 1.61 � 1.56 (0e9) 1.43 � 1.36 (0e9) 0.123Social support (mean � SD, range) (N ¼ 900) 3.18 � 0.97 (1e5) 3.18 � 1.07 (1e5) 3.19 � 0.98 (1e5) 0.879Community social characteristicsSocial participation (mean � SD, range) (N ¼ 901) 0.62 � 0.34 (0e2) 0.62 � 0.34 (0e2) 0.62 � 0.35 (0e2) 0.999Feelings of exploitation (N ¼ 854)Yes, people take advantage 62.5 37.9 37.2 0.874No, people don’t take advantage 37.5 62.1 62.8

Trust community members (N ¼ 882)Yes, people can be trusted 11.9 12.6 11.7 0.750No, people can’t be trusted 88.1 87.4 88.3

Mutual help (N ¼ 870)Yes, people help each other 16.3 17.6 15.9 0.564No, people don’t help each other 83.7 82.4 84.1

Civic engagementVoted in the last parliament elections (N ¼ 893)Yes 82.8 82.4 82.8 0.883No 17.2 17.6 17.2

Voted in the last municipal elections (N ¼ 893)Yes 92.3 91.4 92.5 0.608No 7.7 8.6 7.5

a P-value of the differences between internally displaced and non-displaced.

N. Daoud et al. / Social Science & Medicine 74 (2012) 1163e1171 1167

confidence interval 2.37, 4.78), and older participants were muchmore prevalent among IDPs compared to non-IDPs (Table 4).

Discussion

This study is the first to examine long term, self-reported healthoutcomes among Palestinian citizens of Israel of families affectedby internal displacement during the Nakba of 1948 and its after-math, and to compare these outcomes with those seen amongPalestinians who were not moved from their homes during thisperiod. These data indicate that the IDPs are almost 50%more likelyto report poor self-rated health (SRH) than non-IDPs. Poorer SRHwas evident among the IDPs even after taking into considerationdemographic variables (age and gender), SEP (education and assetsownership) and the psychosocial factor of chronic stress. Limitinglongstanding illness (LLI) was not found to be associated with ID inthis study.

Table 2Associations between independent variables and poor self-rated health (SRH), and limiting longstanding illness (LLI) among Palestinian citizens of Israel.

Poor SRH Have LLI

% N ¼ P-value ¼ % N ¼ P-value ¼Age30e54 years 29.1 707 �0.001 18.3 698 �0.00155e70 years 62.1 195 42.2 192

GenderMale 32.6 521 0.008 21.8 518 0.166Female 41.2 381 25.8 372

Education0e8 52.9 357 �0.001 38.6 352 �0.0019e11 36.4 184 14.0 17812 22.2 194 12.4 19413þ 16.9 166 14.5 165

Assets in the household0e3 47.7 354 �0.001 32.4 349 �0.0014e5 32.3 353 19.0 3476þ 22.6 195 15.5 194

Lost land or house or both in 1948Yes 39.5 248 0.220 25.4 244 0.405No 35.1 641 22.7 633

Feelings of ethnic discriminationNever or seldom 38.0 358 0.327 23.9 351 0.849Sometimes, frequently or often 34.8 532 23.3 527

Sense of national identityPalestinian, Palestinian-Arab, Arab 39.9 271 0.200 25.9 266 0.275Arab-Israeli, Palestinian Israeli, Israeli 35.3 589 22.5 582

Chronic stress (Mean � SD) 3.14 � 1.95 902 0.007 3.32 � 2.02 890 �0.001

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Adjustment for SEP (education and assets) slightly changed theOdds Ratios in the associations between ID and SRH, but theassociation remained significant. Education, which is an importantdeterminant of SHR in the Arab population in Israel (Daoud et al.,2009a) and was higher among non-IDP than IDP women in Leb-anon (Choueiry & Khawaja, 2007), was slightly higher among theIDPs in the current study, but nonetheless, the better educated IDPssuffered from poorer SRH. It might be that after losing their land asa main source of income many of the IDPs turned to higher

Table 3Multivariate logistic regressions of poor self-rated healtha (odds ratios (OR) and 95% con

Model 1 Model 2

OR (95% CI) P-value ¼ OR (95%C

Internally displaced in 1948Yes 1.42 (1.02, 1.98) 0.038 1.54 (1.0No 1.00 1.00Age55e70 years 4.29 (3.05, 6.03) �0.001 3.30 (2.230e54 years 1.00 1.00GenderFemale 1.66 (1.24, 2.22) 0.001 1.47 (1.0Male 1.00 1.00Education0e8 3.81 (2.39e11 2.80 (1.612 1.57 (0.913þ 1.00Household assets0e3 1.96 (1.24e5 1.32 (0.86 1.00Chronic stress

Model 1 e main association between ID and SRH.Model 2 e main association þ SEP (education and assets).Model 3 e main association þ chronic stress.All models are adjusted for age and gender.

a Poor as compared with good self-rated health.

education as an alternative route to financial stability. However, anyimpacts of this change in education on income and SEP among IDPsmight need more time to emerge. Current SEP (measured byownership of household assets) was poorer among IDPs than non-IDPs. As has been seen in other marginalized groups in society,education among IDPs might lead to less social mobility than itdoes for other, non-marginalized people (Krieger, 1999).

Interestingly, while some non-IDPs also reported having lostproperty and/or land during the Nakba, this measure was not

fidence intervals (CI)).

Model 3

I) P-value ¼ OR (95% CI) P-value ¼

8, 2.19) 0.016 1.45 (1.02, 2.07) 0.0391.00

8, 4.77) �0.001 3.56 (2.45, 5.17) �0.0011.00

8, 1.99) 0.014 1.49 (1.10, 2.03) 0.0111.00

2, 6.26) �0.001 4.02 (2.43, 6.64) �0.0014, 4.78) �0.001 2.91 (1.70, 5.00) �0.0010, 2.73) 0.114 1.59 (0.91, 2.78) 0.106

1.00

6, 3.05) 0.003 1.84 (1.18, 2.88) 0.0075, 2.05) 0.222 1.25 (0.80, 1.95) 0.326

1.001.16 (1.07, 1.26) �0.001

Table 4Multivariate logistic regressions of limiting longstanding illnessa (odds ratios (OR) and 95% confidence intervals (CI)).

Model 1 Model 2 Model 3

OR (95% CI) P-value ¼ OR (95% CI) P-value ¼ OR (95% CI) P-value ¼Internally displaced in 1948Yes 1.31 (0.91, 1.89) 0.143 1.41 (0.97, 2.07) 0.075 1.31 (0.89, 1.93) 0.175No 1.00 1.00 1.00Age55e70 years 3.37 (2.37, 4.78) �0.001 2.21 (1.51, 3.22) �0.001 2.45 (1.66, 3.61) �0.00130e54 years 1.00 1.00 1.00GenderFemale 1.38 (1.00, 1.90) 0.053 1.16 (0.83, 1.63) 0.392 1.20 (0.85, 1.69) 0.306Male 1.00 1.00 1.00Education0e8 2.70 (1.60, 4.56) �0.001 2.92 (1.71, 4.98) �0.0019e11 0.91 (0.48, 1.70) 0.757 0.93 (0.49, 1.75) 0.81112 0.88 (0.47, 1.64) 0.680 0.88 (0.47, 1.65) 0.68713þ 1.00 1.00Household assets0e3 1.69 (1.03, 2.78) 0.036 1.56 (0.95, 2.58) 0.0814e5 1.07 (0.65, 1.78) 0.790 1.00 (0.60, 1.66) 0.9926 1.00 1.00Chronic stress 1.23 (1.12, 1.35) �0.001

Model 1 e main association between ID and SRH.Model 2 e main association þ SEP (education and assets).Model 3 e main association þ chronic stress.All models are adjusted for age and gender.

a Having one limiting longstanding illness as compared with not having any.

N. Daoud et al. / Social Science & Medicine 74 (2012) 1163e1171 1169

a significant predictor of health outcomes in this cohort, whichimplies the importance of the phenomenon of ID as opposed tomere material loss. If this relationship finds support in futurestudies with larger samples, it might suggest that detachment fromplace (i.e., the village of origin) is not only important in terms ofmaterial loss, but also in terms of ruptured affective bonds with theland and place (Giuliani & Feldman, 1993). It also suggests that theNakba might be a catalyst for psychosocial sequelae rather thanaffecting health through material pathways only (i.e., exposure tounhealthy environments) (Wilkinson & Pickett, 2010).

The higher levels of chronic stress among the IDPs compared tonon-IDPs and the observation that it remained a significantpredictor of SRH in the multivariate models is further support forthe traumatic psychological impact of displacement in particular.However, adding chronic stress to the multivariate analysis did notmuch change the association between IDP and SRH, suggesting thatIDP might be a determinant of SRH through other pathways,independent of SEP, psychosocial factors, or demographic factors.Whether ID is an independent determinant and, if so, the specificpathway from ID to long term health problems should be investi-gated in future studies with both qualitative and quantitativeapproaches.

We assume that for the first generation of IDPs, theirdepopulated villages of origin are not only a tangible reminder oftheir status in Israel, as their land is subject to continuous colo-nization practices, but also a reminder of their locus of differenceand estrangement within the Arab society. In his studies on Pal-estinian IDPs in Israel, Al-Haj (1986, 1988) indicated that localArab residents of host villages often treated the IDPs as “strangers”even while the IDPs attempted to establish their own businessesand purchase land. With limited access to building lots near thevillage core, most of the IDPs have lived in distinct neighborhoodson the outskirts of the host villages, where land is more availableand affordable.

This residential pattern has helped the first generation of IDPs tonurture traditions and to preserve an affinity based on the village oforigin within the Arab society, but it has also contributed to theirdisadvantaged status as “strangers” within this society. This statusbecomes especially evident when issues relating to mixed

marriages, local politics, and land acquisition are considered(Al-Haj, 1988). Therefore, the problem of IDPs within the hostvillages has been not only dealing with the question of whether orhow to integrate into Israeli society as members of a Palestinianminority, but also integration with respect to host villages as IDPs.This position, which Al-Haj has termed “minority within minority,”has resulted in a strong sense of estrangement that has beentransferred from the generation of the Nakba to the second andthird generations, since these generations also recognize theirdistinction within host villages (Al-Haj, 1988). In fact, many IDPscontinue to view their status as temporary in host towns andvillages and await their return to their villages of origin (Al-Haj,1988; Kabha & Barzilai, 1996).

As for the second and third generations of IDP families whomight have become more integrated in the host villages, a sense ofidentification with the original home place is still evident at manylevels. At one level, it is worth noting that IDP families were oftenrenamed according to their village of origin. For example, the nameof Damouni was given to all families of IDPs from the depopulatedvillage of Al-Damoun. At another level, the place identity is evidentin the way that IDPs often reside in separate neighborhoods namedafter their village of origin. For example, in the host village of Kabul,IDPs from the vacated village of Miar live in the Miari neighbor-hood. Similarly, in Nazareth, the Safari neighborhood is named afterthe destroyed village of Saffuriyya.

We assume that at least for those who personally experiencedID, a root cause of poor SRH is their detachment from their villagesof origin. Not only do these IDPs have personal memories related tothe villages that theywere forced to vacate and remain cut off from,these lands are also national symbols from which internally dis-placed Palestinians mould their collective identity and maintaina distinctive place identity (‘Imhajar’ in Arabic e meaning ‘dis-placed’) (Al-Haj, 1988). However, the fact that identity variables(sense of national identity and feelings of discrimination) wereassociated with ID but not with SRH might be affected by the wayID was measured. Our question on displacement might havecaptured three generations of IDPs: those who experienced IDdirectly, their children and grandchildren. But this might mask theassociation between sense of identity and SRH for those with direct

N. Daoud et al. / Social Science & Medicine 74 (2012) 1163e11711170

experience of displacement. In order to clarify the health impacts ofdisplacement we suggest that future research separately examinethose who experience displacement themselves and those whosefamilies have experienced it.

Lack of association between ID and community social factors isnot consistent with findings from a Lebanese study indicating thatlower social support due to family disruption among ID women isa main explanatory factor for the associations between ID and SRH(Choueiry & Khawaja, 2007). We suggest that this difference mightbe because the Palestinian participants in the Lebanese study werenot IDPs, they were refugees who crossed the border intoa different country. The current study population were internallydisplaced Palestinians, not refugees, and most of them were dis-placed together with their families and not as individuals. Weassume they did not lose their family support.

In summary, our findings suggest that even though the Nakba of1948 had important implications for the entire Palestinian society(Sabbagh-Khoury, 2009), its long term effects on SRH are moreevident among ID Palestinians. There are several broad pathwaysrelated to the unique situation of these IDPs that may havecontributed to their relatively poor subjective health and that areworth further investigation. First, their status as IDPs is notrecognized by the government, which prevents efforts to redresshistorical displacement or to address current conditions underlyingpoor health status though targeted interventions. In terms of theformer, IDPs in Israel are denied the right to return to their ownvillages and homes, which might have contributed to psychosocialsequelae. Second, ID Palestinians have been socially and economi-cally marginalized within their own society of Arabs in Israel (Al-Haj, 1988), which may indicate both materialist and psychosocialexplanations for poor SRH. Third, although we did not find asso-ciations between ethnic discrimination and health outcomes in thecurrent study, IDPs reported stronger feelings of ethnic discrimi-nation than non-IDPs. We think this needs future study, as struc-tural discrimination within the Arab minority in Israel, and thestruggle for collective civic rights and equality have already beenreported (Rouhana, 1997).

This study has limitations. First, it is important to note that sincedata on explanatory factors and health outcomes were collectedcross sectionally, inferences of causality cannot bemade. Second, IDwas measured here by the question; “Were you or any of yourfamily members displaced due to the Nakba of 1948?”. While thisquestion might be inclusive in that it asks about participants andfamily members who were displaced, it limited our ability tounderstand the effects of the Nakba on each generation separately.We do not think that assignment to IDPwas impacted by recall bias,as it is a major life event and we do not expect any measurementerror that may be observed to be differential with respect to healthstatus. Third, our outcomemeasures were self-reported only. Whilethese measures were highly correlated with physical healthconditions (Idler & Benyamini, 1997), future studies need to address(1) the associationwith objective measures of the health of IDPs fora wide variety of health outcomes, and (2) the subjective andobjective effects of the Nakba on the second and third generationsof all Palestinians.

Conclusions

This study has shown that internal displacement as a form ofhistorical violence needs to be considered as a determinant ofhealth of internally displaced Palestinians citizens of Israel, evenlong after displacement. Social and health policies to properlyaddress the negative effects of the Nakba on IDPs should bedeveloped with consideration of the long term impacts of internaldisplacement, particularly on psychosocial dimensions of health.

Funding

No funding was provided for this secondary analysis.

Acknowledgment

We would like to thank Prof. Sarah Curtis and three anonymousreviewers for their valuable comments on previous versions of thepaper.

Appendix. Supplementary data

Supplementary data related to this article can be found online atdoi:10.1016/j.socscimed.2011.12.041.

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