The Occupation Causes Schizophrenia

A new article, entitled “Schizophrenia in the Context of Mental Health Services in Palestine”, reviews the literature concerning problems treating schizophrenic patients in the Palestinian Authority (PA). All authors are faculty at the An-Najah National University Faculty of Medicine and Health Sciences in Nablus. The article appears on the website of a relatively highly ranked journal.

According to the article:

Mental health conditions remain a significant cause of disability in the Arab World. Palestinians are predominantly at a higher risk for mental health problems due to their chronic exposure to political violence, prolonged displacement, and others as limited professional, educational, financial opportunities and mental health services.

What is not clear is with whom the authors are comparing the Palestinians; if Palestinians are “at a higher risk” someone else has to be a lower risk. Perhaps they should consider the mental health status of their fellow Palestinians languishing in refugee camps in Lebanon. Even Electronic Intifada made it clear that even before the Coronavirus outbreak, the 475,000+ registered refugees in Lebanon live in dire situations, legally prohibited from working in the country and with two-thirds poverty stricken. Seems to me that these Palestinians would qualify as living under chronic exposure to political violence, prolonged displacement and extremely limited professional, educational, and financial opportunities and likely also a dearth of mental health services.

Or perhaps the authors should compare them with their neighbours in Syria, whether these are the Palestinian refugees held in refugee camps or regular Syrian citizens. If residents of the PA are at risk for mental health problems during to chronic exposure to political violence, then what can one say about the Syrians, over half a million of whom who have been killed since the civil war began in 2011? What can one say about the Palestinian refugees in Syria, 91% of whom live in poverty, 2/3 of whom have been displaced since 2011 and 40% of whom are still displaced within Syria?

Do the Palestinian refugees in Lebanon and Syria receive attention in the academic literature that suggests ways to improve mental health interventions with these vulnerable populations. They do. However, unlike the article under discussion here — that blames Israel — articles about Syria and Lebanon do not complain about the regimes in these countries at all. While note is made of the fact that the refugees in Lebanon experience state-limited access to jobs and education, nowhere in this article concerned with a refugee camp in Beirut do the authors suggest that the Lebanonese government should be doing something different regarding the way they treat the Palestinian refugees living in their midst. Likewise, nowhere in this article about improving mental health interventions with Syrian refugees and internally displaced persons do they suggest that the Syrian government should stop the war.

In contrast, the authors of the article under discussion here come to the following conclusion:

Recommendations include ending the occupation as the leading cause of mental illness for Palestinians…

This difference of approach is what shows the apparent acceptability of politicizing academic articles concerning Israel and/or the PA in non-political disciplines.

The authors do concede that there are other ways to improve mental health services:

… and implementing efficient and effective mental health nursing care through the multidisciplinary work and raising awareness regarding mental illness to fight the stigma.

And the bulk of their article does review the status and training of mental health nurses and other issues that negatively impact on the treatment and care of schizophrenic patients in the PA. Important points they make on these factors get lost both because the article is politicized and because it is poorly organized and written. More on this below.

The occupation is the leading cause of mental illness for Palestinians?

First of all, they bias their results from the outset. This is supposed to be a literature review discussing problems in treating schizophrenics in the PA. Of course there are going to be inclusion and exclusion criteria regarding the studies they examine in their survey. But I wonder what the rationale is for this:

All articles that discussed schizophrenia from a genetic view were excluded.

The UK National Health Services website states that:

The exact causes of schizophrenia are unknown. Research suggests a combination of physical, genetic, psychological and environmental factors can make a person more likely to develop the condition.

and they go on to say that stress apparently does not cause the disease but it can trigger “its development in someone already vulnerable to it.” Brain development and genetic factors are implicated in causation, on the other hand.

Therefore, the fact that this paper excludes all genetic-based articles is suspect. How many of these were there? Were there more than the 11 articles on schizophrenia or 13 on general mental health that they did include? They were not reviewing hundreds, or even dozens, of articles. Surely adding another few would not be a great hardship. And how would these additional articles have affected their findings? After all, it is unclear how the stated cause of schizophrenia would affect treatment and associated problems. The only thing I can think of is that it may affect their claim that the occupation causes schizophrenia. Yet they need not be concerned with that — they could just as easily state that the occupation triggered schizophrenia in those who may not have developed it otherwise. If they really want their article to be political, that is.

Proving that it is the occupation

Let us examine one instance in which they attempt to demonstrate how this happens. They try to explain the fact that other research has shown that men and women are equally affected by the illness while most schizophrenics in the PA are male; they write:

Results also suggested that the high ratio of schizophrenia among male patients in Palestine may be due to the economic crises and political unrest especially that Israel has detained approximately 40% of men in the occupied Palestinian territory, often for indeterminate periods for no specific charges and often suffering mistreatment or outright torture while arrested [55].

The article cited [55], is the psychiatric case study of one man who was allegedly arrested and held five times without charges. The psychiatrist who wrote the study made the unsupported statement in her introduction that 40% of the men in the PA have been detained by Israel. Because the three authors of the article under discussion here wanted to make a point, they turned the otherwise undocumented story of one man into something that supposedly happens to 40% of the PA male population.

Missing the point

This poorly written paper, that jumps from one topic to another and back again, could have provided a useful basis for petitioning for improved mental health services in the PA. The bulk of their article deals with the inadequacy of mental health practitioner training and supervision, the low esteem with which mental health nurses are held and, therefore, their under-utilization, absence of multidisciplinary teamwork, lack of awareness among the population regarding mental health issues, stigmatization of the mentally ill and those working with them, and the insufficiency of resources such as medications and mental health clinics. The authors state that the budget for mental health purposes is only 2% of the PA Health Ministry budget and this can certainly be seen to be a major reason why the mental health situation is in such dire straits.

However, instead of pointing to the low budgetary allotments by their own government, as well as the fact that the PA leadership prefers to reject American financial support in order not to fall under American court jurisdiction and to give Jew-killers and/or their families lifetime salaries thus underpaying and often not paying civil servants, and heavily taxing small businesses to the point where these businesses go on strike, they argue that Israel blocks the import of medications and other essentials. However, to support their complaints against Israel, they would have to contend with this:

The authors do concede that there are other ways to improve mental health services:

… and implementing efficient and effective mental health nursing care through the multidisciplinary work and raising awareness regarding mental illness to fight the stigma.

If they could focus on the problems of their own society and stop blaming Israel for everything that goes wrong in the PA, they might actually start to build a society that would have some chance of success.

What I do not understand is why respected academic journals would play along with the ruse. While “the occupation” seems to be commonly accepted as a truism, whether or not there even is an occupation is a debate belonging in legal and diplomatic circles and I do not think mental health professionals should be taking political sides in academic journals unrelated to politics.