“We are not Mad – We Just Need Justice”

These are two of the research findings from the Institute of Community and Public Health (ICPH) at Birzeit University.

“In 2005 we conducted a study comparing health-related quality of life (QoL) in Palestine with 23 others countries, and we came second to last,” says Professor Rita Giacaman.

“We included war-related factors in our surveys and demonstrated a link between low QoL and different aspects of political violence and Israeli military occupation. Of course it is rather obvious that political violence can impact on health, but nobody had ever proved it scientifically before.”

Outside the clinic

Rita Giacaman was the driving force behind the establishment of the ICPH in 1978 and served as its director for several years. Today she works as a programme coordinator at ICHP. She has been carrying out research on Palestinian QoL for many years.

She says that most indicators previously used to explain Palestinian health are actually disease indicators. They deal with mortality, injury and communicable diseases.’

“But health is so much more than disease. Health is mainly outside the clinic. It is about where you live, where you work, what you eat, and so on. Our own field research hit us in the face. It seemed obvious that political circumstances, poverty, land confiscation, control over water and resources and access to transport and trade all contribute to people’s health.”

Human insecurity

Adequate tools are needed in order to measure QoL. Giacaman and her colleagues started out with the WHO’s QoL measures, then added new and Palestine-specific questions as they went along.

Their own experiences suggested a need to pay attention to the bulk of the population who is not yet sick but is exposed to humiliation and violence.

Giacaman’s research group went on to develop two new measures: a distress measure and a human insecurity measure. Their studies show that individual security in Palestine is inseparably tied to national security.

“About 88 percent of the population in Gaza lives in constant fear and under constant threat. And about half of the population suffers from moderate to severe distress. The human insecurity situation is terrible. We found that the siege, not the war, is the main cause of suffering in Gaza.”

In literature it is established that stress and distress can lead to diseases such as diabetes and hypertension. In current Palestine figures show that certain chronic diseases are on the rise, notably hypertension, heart disease and breast cancer.

“If only funding existed, I would love to dig deeper into lifestyle issues such as exercise and nutrition on the one hand and political violence on the other and try to differentiate between the two by investigating possible connections to chronic diseases.”

Women are happier

The better education, the better QoL. The better socio-economic status, the better QoL. Women in general report to have better QoL than men in all domains: physical, psychological, social and environmental.

“The Palestinian patriarchy paradoxically provides protection for women in some ways. Men cross checkpoints more often than women and are significantly more exposed to violence and humiliation than women, and their level of distress is therefore much higher. On the other hand, patriarchy also restrains women in several ways in terms of decision-making and domestic violence.”

Studies from Gaza indicate an association between domestic violence and political violence.

“If you want reduce domestic violence you have to address political violence. Not only that, but you have to include it.”

According to Giacaman, women’s ill health is particularly neglected in Palestine.

“In a patriarchal society no one is interested in issues such as breast cancer,” she says.

Still, initial evidence suggests that breast cancer affects women at an extraordinarily young age in Palestine, often already in their thirties. Resources for early detection are vital, but not readily at hand.

Breast cancer is now the second biggest cause of death for Palestinian women, after cardiovascular diseases.

“Cardiovascular diseases affect men too, of course, so it has gained political attention. As for breast cancer, we do not know why it occurs at such an early age. More research is needed. Besides, we have more hypertension among women than men, which is highly unusual. Nobody cares about these issues, as they only concern women’s health. We have a lot on our agenda here at the institute, a lot of issues that we would love to develop further if only we had the funding.”

The youth wave

Patriarchy does not only discriminate against women, Giacaman warns, but also against youngsters. Current Palestine is facing a youth wave: 72.8 per cent of the population is under the age of 30.

“If you do no cater to these people’s needs, there will be problems. Today we are controlled by two armies: the Israelis and the Palestinian National Authority. Unfortunately the PNA set up a typical Arab-style state, a seniority of men controlling the young people and the women.”

Youngsters are being choked, according to Giacaman.

“Youngsters lack room for participation both politically, socially and economically. They are inevitably going to rise up, just like in Egypt.”

The victim label is typically imposed on people by international aid agencies, she says. If you want their services, you have to play the victim. Palestinians suffer, but deep down they do not regard themselves as victims, she claims. This is because their victimhood is politically framed, including the idea of taking a higher moral ground.

“Instead of playing the victim we create a counter-structure called resistance, which is basically about maintaining national dignity and identity, thinking that you are struggling for justice. To conduct research and dissemination on consequences of political violence is resistance. And it makes you feel good. Feeling good is good for your health. This is how we define health: as wellbeing.”

All you need is hope

Palestinians are a population in danger of being eradicated, according to Giacaman. Resistance is part of life. But social consciousness is getting weaker, demoralisation is spreading, and people are tired, she warns.

“The Oslo Accord was a slap in the face. It pulled the carpet from under the feet of those who had actually fought and suffered through the first intifada (1987–1993), young people and women. There is widespread disappointment with the corruption and inefficiency of the Palestinian National Authority.”

Entertainment seems to be the name of the new Palestinian game, especially in Ramallah. She sees a development where the rich are getting richer and the poor are getting poorer.

“To have a high QoL, you need hope for the future. You need to think that what you are doing is worthwhile. People are starting to question that now,” Giacaman says.

“If you are optimistic, you will be disappointed. If you are pessimistic, it stops you from working. The best thing is not to think about it, but obsessively go on building Palestinian institutions. And that is what we are doing. Our Norwegian partners are contributing. It is called non-violent, active resistance. I never give up. I am a bulldozer.”

Beginning to help

ICPH’s research results ought to influence policy-making, Giacaman agrees. Her response is: Who is actually making policy here?

“International aid dictates most of the health policy in Palestine. Every two years a new donor appears, and then everything starts all over again. They all want quick solutions to long-lasting problems and to dictate their own priorities.”

Political despair and chronic disease are not on anyone’s agenda, she laments. And ICHP is totally depended on international funding.

“In public health we look at chronic diseases, psychology and quality of life. We try to link all that to policy-making. International aid, on the other hand, is characterised by a bureaucracy of sectorisation. This has to change. The local needs and priorities have to be heard,” she argues.

“Our health is in the no-man’s-land between different sectors. But people do not live in sectors, they live in communities.”

Speaking the truth

“We provide the research, then we push. The last ten years we have been involved in various projects, saying: ‘Palestinians are not mad. They need justice, resilience, training and community solidarity. But they do not need drugs.’ And it is working, it is beginning to change.”

Palestinian health has been highlighted through the well reputed health magazine The Lancet, which has so far devoted two special issues to Palestinian health (2009 and 2010), and a Palestinian/ Lancet health alliance has been established, partly thanks to ICPH’s long lasting cooperation with the Faculty of Medicine at the University of Oslo.

Richard Horton, editor of The Lancet, says: “The ultimate hope is that this series could contribute to a mass international social movement for peace and justice through health in, and with the people of, the occupied Palestinian land.”

Giacaman agrees: “Health research and dissemination can be a means of peace. Nobody can say that they did not know any longer.”

Lifestyle Issues

“Non-communicable diseases like diabetes are a national priority in Palestine now. We have played a very important role in raising awareness,” says Abdullatif Husseini, the director of the Institute of Community and Public Health (ICPH) at Birzeit University.

Husseini stresses that it is vital to transform research into practice and claims that ICPH has an impact on health policy. A national forum has been established for discussing how to reduce non-communicable diseases (NCDs). One main objective is to reduce obesity, which is an established risk factor for diabetes and other NCDs.

“Combating smoking and encouraging physical activity is important. We realise that it is not enough to preach or just give information. We have to provide supportive environments such as training courses in cycling and running.”

Preventing NCDs is a matter of changing lifestyle, and nutrition is crucial.

“We have to make sure we raise taxes on unhealthy foods and tobacco, which has in fact already started. An anti-smoking law was introduced in 2005 but has not been implemented yet. Palestine is still a developing country.”

Some good news from current Palestine: smoking is decreasing among adults. Still, diabetes is increasing, as is obesity.

The health research partnership between the University of Oslo (UiO) and Birzeit University started in 1995 and is still running. Husseini himself came onboard in 1996, when he started his PhD studies in Oslo on diabetes in Palestine, concentrating on risk factors such as obesity and lifestyle. He earned his PhD in epidemiology at UiO in 2002.

The long-term cooperation with the UiO, the last three years without funding, has been important for many reasons, he says.

“They have a lot of experience with statistics, for one. The main thing is that they helped us acquire the skills needed in order to do academic research and thereby grow intellectually. We have yearly meetings, presenting papers for publishing, discussions and critique to help improve our research.”

“One main challenge is to be able to plan ahead, another one is brain drain. Salaries are much higher abroad or with the domestic NGOs than at Birzeit. We are working on offering more opportunities to our candidates, creating a fruitful environment to nurture them in. Still, I do not want life to be about complaining. Nothing really prevents us from doing research.”

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