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JOINT COMMITTEE ON FOREIGN AFFAIRS (Sub-Committee on Development Co-Operation) díospóireacht -
Thursday, 29 Mar 2007

Mental Health Project in Palestinian Territories: Discussion with IMHCN.

Before we commence, I advise witnesses that whereas Members of the Houses enjoy absolute privilege in respect of utterances made in committee, witnesses do not enjoy absolute privilege. Accordingly, caution should be exercised, particularly with regard to references of a personal nature.

As Chairman of the sub-committee, I welcome Ms Margaret Fleming, Mr. Damien Murray and Mr. Brian Clerkin of the International Mental Health Collaborating Network, IMHCN, who have experience in the Cavan-Monaghan mental health services. I also welcome Mr. John Jenkins who is the mental health project manager with the World Health Organisation on the West Bank and in Gaza and president of the IMHCN.

The IMHCN is a relatively young international organisation which was founded two years ago in Helsinki. It was formally launched by the Taoiseach in October 2005. We are only too aware of the detrimental impact that mental illnesses, which account for 25% of all health-related disabilities, have on society. Addressing the issue of mental illness presents significant challenges both nationally and internationally. In areas of conflict such as Palestine, the challenge is even greater.

The IMHCN, in partnership with the WHO, has put a proposal to Irish Aid for the development of a community-based health project in the Palestinian territories. The project is already well embedded in the overall Palestinian health policy and the IMHCN hopes this proposal will enable it to continue this vital work and develop its project further. I call on Mr. Jenkins to make his presentation.

Mr. John Jenkins

I thank the Chairman for the opportunity to present on the development of mental health services in the West Bank and Gaza. When the Palestinian Authority was formed, one of the first priorities of the Ministry of Health was to develop a national mental health policy in order to improve the mental health and well-being of Palestinians. Although progress was slow because of the economic, social and environmental circumstances in which Palestinian people were living, considerable efforts were made to develop a structure for the mental health system.

In 2002, the WHO and other international NGOs were asked to assist in the programme of reform of the mental health system. The WHO, together with several senior mental health professionals on the West Bank and in Gaza, undertook to conduct an analysis of the situation and found that services were fragmented, particularly in respect of services provided by the Ministry of Health and international NGOs. It could not be certain that the needs of the people were being prioritised or whether there was an overlap among service providers. At the same time, conditions in the psychiatric hospitals were deteriorating. In Bethlehem hospital, which housed 350 patients at the time, conditions had deteriorated to the extent that they were probably infringing on patients' human rights.

As the Ministry of Health had no structure to develop or implement a national policy, one of its first requests to the WHO and other partners was to develop a policy. This was done over a period of six to nine months, with widespread consultation of all stakeholders involved in mental health. A national plan was produced in 2003 to address the wide range of needs felt by people suffering mental health problems, which included not only psychiatric disorders but the psychological repercussions of conflict and trauma for people in Gaza and on the West Bank. While the research conducted on the effects of trauma and conflict has been fragmented, several studies have indicated that people living in these occupied and traumatic conditions suffer enormous stress, depression and anxiety and some have reported that 80% of children interviewed in schools express no hope for the future.

The policy and strategy were devised by the Ministry of Health, all NGOs working on mental health in Palestine and the international co-operation agencies, which at the time comprised the French and Italians, together with members of the International Mental Health Collaborating Network. The policy was approved by all the organisations and we have since tried to implement its recommendations on a number of components.

The first component is building capacity from the top down and the bottom up. With regard to building from the top down, the intention was to put in place a structure for mental health services in the Ministry of Health whereby a directorate for mental health would have responsibility for management, governance, accreditation systems and legislation because these issues had not been addressed.

The second component is training and education. The training of mental health professionals and those working in NGOs would be improved in several different ways, including in-service training, which has since been extensively provided, and postgraduate education to develop clinical psychology, social work, psychiatric nursing and occupational therapy. While undergraduate programmes are available for these professions in the universities in Gaza and on the West Bank, there were no postgraduate programmes for professionals who wish to develop further clinical experience.

The third component involves short-term skills-based training. The Ministry of Health and the NGOs do not employ many professionals, so it is not possible to remove people from work for long periods. The solution is short training periods of three months and on-the-job training with university provided education on therapies and clinical interventions for post-traumatic stress disorder and other traumas.

The final component involves improving public education and demystifying mental illness by means of anti-stigma campaigns. Our work in this area has thus far been quite successful in terms of raising awareness about mental health conditions and meeting people's needs. As members will be aware, the mystery that surrounds mental health in all cultures gives rise to a variety of beliefs. Part of our efforts in this regard involved setting up family associations and user groups, which build support for families and patients and educate the public on what it means to have a family member who suffers from a serious mental illness. These have been successful in terms of campaigns.

We have also started to change the system of developing services because it was in dire need of improvement. I refer here to outpatient clinics as well as hospitals. In community primary care centres, most people worked in one room and one or two professionals tried to meet the needs of populations of 200,000 to 500,000 without access to telephones or other infrastructure. We have developed five community mental health centres with good buildings and facilities and more staff. However, a further seven centres are needed to cover all the areas of the West Bank and Gaza. We have also tried to improve conditions in Bethlehem hospital but have a long way to go.

We have tried to establish day care services that would enable people to learn new work skills. As members can imagine, the unemployment rate is very high in Gaza and on the West Bank but there should be opportunities for people to learn new skills. There is some evidence that people with serious mental illnesses have managed to find full-time employment with the support of the mental health system.

We need to continue the implementation of this five to ten year plan if we are to transform the system, develop a good infrastructure for services, education and training and improve the governance and accreditation systems of the Ministry of Health. More funding is needed to bring together these top down and bottom up approaches. It is particularly important to develop infrastructure, such as additional community mental health centres, day care opportunities and acute units in general hospitals so that, eventually, Bethlehem psychiatric hospital can be closed. At the same time, we want to foster better co-ordination and collaboration between public services and NGOs to properly target the real needs of people and to ensure the limited resources available on the West Bank and in Gaza are utilised to best effect in treating people with a wide range of mental health problems.

I support what Mr. Jenkins said. He mentioned new centres to treat people. Given that there is such a young population in Palestine are people looked after by relatives?

I echo the comments of the Chair and wholeheartedly support this initiative. I applaud all the witnesses for having identified and highlighted an aspect of life in the occupied territories of which the Irish people might not be generally aware. The fact that the delegation has an Irish perspective, emanating from our own experience of the traumatic consequences for children of the conflict in Northern Ireland over 30 years, means it will bring a unique insight into addressing mental health issues in an area of conflict. I am sure the delegation will get a positive response from the Irish Government and I hope the Chairman will formulate an agreed resolution from this committee, which I will be very happy to support, for the attention of the Minister of State at the Department of Foreign Affairs, Deputy Conor Lenihan, so that he can solidify the approaches the delegation has already made.

Does the delegation have a costing for its proposal? Has it put any specific proposals to the Government for funding? What response has it received from Irish Aid to its initiative?

As with everybody present, I have visited the occupied territories, though it was a long time ago. This is a very brave initiative because nobody who visited the occupied territories would immediately be struck by the need for mental health services. It may sound trite but we almost forget that, in conflicts, the people involved are civilian people. The politics and violence obscure the fact that most of the people in an area of conflict are not militarily active and are victims of the violent activities of both their own and the other side. I am glad the delegation has raised this issue and it made a thoughtful and interesting presentation.

I will ask a couple of questions which may sound as if I am against the proposals. However, I would like the delegation to answer frankly. Can its programme really be delivered in the context of the repression and restrictions on movement in the occupied territories? I am being realistic rather than optimistic, because it does not seem that things will change dramatically. I do not suggest not going ahead but wonder whether it will be slower and much more expensive than envisaged because of the enormous obstacles in simply getting from one place to another. I was talking to people from the occupied territories only a few weeks ago and they spoke of the difficulties for Palestinians travelling around the West Bank. The delegation may well be able to use the roads otherwise reserved for settlers but many of the people it wants to serve will not necessarily be allowed to do so.

Mr. Jenkins mentioned working with the Palestinian Ministry of Health. My understanding is that current Irish, European and international policy is not to co-operate with the Palestinian Government, particularly the Hamas section, notwithstanding the fact that it won the most free and fair election ever held in any Arab or Middle East country outside Israel. However, the wrong party won, so we decided on a certain policy. Even though the new Government is a government of national unity it does not seem to satisfy many international bodies. I do not want to divert the delegation into politics but how will it deal with the apparent constraints in dealing with a government that includes Hamas?

It is an awful analogy but the delegation is in a minefield, metaphorically as well as literally. That minefield is politically extremely sensitive and all sorts of agencies will, either accidentally or deliberately, conspire to make it very difficult to give credibility to any part of the Palestinian Government that does not conform to the demands of a misguided international consensus. How does the delegation propose to deal with the politics of the area? The Government may change at some stage and I do not know if the Minister for Health is a member of Hamas or Fatah or is a technocrat.

I welcome the delegation. Our numbers might deplete quickly so I propose we recommend to the Joint Committee on Foreign Affairs that it recommend to Irish Aid that the project be funded, possibly on an annual basis.

I second that.

I will make one or two points on the presentation. I was in the occupied territories twice in 2005. The first occasion, in January of that year, was very sanitised because of the conditions of visiting both the Knesset and Ramallah. It was useful but I returned in September, just one week after the so-called withdrawal from Gaza, with a group of six former Ministers and former ambassadors, for a more extended visit. We travelled on Palestinian roads and used our own bus and translator. I had made contact with 27 organisations on my first visit, and had more detailed meetings with them on the second.

One of the merits of this project is its potential to develop a new model for mental health. Some of the figures are very interesting, especially those relating to people treated outside as compared with those, amounting to maybe 10%, who are kept in units of one kind or another. Looking at our own figures since the legislation of 2001 we have much work to do but we will leave that for another day.

I visited the same areas during the first intifada and have visited them several times since. In the refugee camps in Gaza everything had got worse. Two generations had passed and the limitations on space had driven buildings upwards, meaning family households were multigenerational, creating interfamilial tensions. The report accurately points out the increase in poverty, dependency and unemployment and there were real problems over water. Before the withdrawal the UN purchased water from settlers for refugees. I am an admirer of UNRWA in many ways, but if efforts had been successful and the international community had not been as irresponsible, it should not have been needed in Gaza.

It is very important that this programme be contextual in its emphasis. Even during a short visit it was very clear that the trauma being suffered differs by age, gender and circumstance. I read one study of the experience of women in the southern occupied territories, which made grim reading on the relationships of these people with their children. One included interview clearly suggested the experience of a person's parents being humiliated had a more traumatic effect than the loss of a parent.

There were many examples of older women being humiliated, for example, being kept waiting outside checkpoints while their food products rot. There is also the issue of age difference where a 19 or 20 year old official takes a person's identity papers and comes back hours later during which time the person has suffered greatly in the heat of the sun.

Restrictions of movement have come up in the human rights work with which I would be much more familiar. This issue relates to people being separated from families and not being able to return because of changes in the residency permit. There is also the destruction of houses. How could a person be normal, as we would say in Ireland, if that person's house has been destroyed for the third time by bulldozers? We have witnessed this ourselves.

There may also have been psychotic behaviour on the other side from small groups of settlers. Settlers are not one homogeneous group. I am thinking specifically of the area near the caves at Hebron where the occupation has been extremely violent. We have had presentations on this issue before. This is what I mean when I suggest that the programme should be contextual in focus. One could never construct an interdisciplinary or comparative study that would hold constant parameters. It would be very important that it would have what I would term a psychoanthropological base, which would be able to capture specific narratives.

I do not intend to say much more because I am very strongly in favour of this programme. I would make a comment on the families of prisoners, whom Senator Leyden and I would have met over many visits. The Chairman may have done so himself. From my training as a sociologist I would be aware of the distinction between mind and self, which is negotiated symbolically in present time with the distortions of memory. There have certainly been heroic achievements by the prisoners' group, which has been sharing confined spaces with people who are responsible for many deaths. Last summer they arrived at a progressive conclusion for a way forward, which was unfortunately ignored.

With regard to the prison experience, it is going to be extremely difficult with transactional analysis to get people to work their way through different issues. There have been heroic examples of how people have offered to do things but they are not recognised.

There are other issues, such as the sheer despair of different generations of mothers and women. Old men, for example, will point to the destruction of 400,000 olive trees to build the wall. In the case of the first intifada, people fired stones, and the current intifada has suicide bombers, which I do not support. How can we know what to say to a son who points out that his parents and grandparents have been humiliated and nobody cared, and that everything has got worse, and yet suggest he should be in good mental health?

The legitimate rage and resentment in response to occupation, humiliation, degradation and being ignored by the international community signify a very healthy political attitude. It causes sets of actions and draws forth responses which are themselves seriously problematic and will, in turn, not be confined to the person but to families and neighbours.

I strongly support this programme. I would like to believe there would be a social anthropological dimension built into the method that would enable some fairly specific narratives that will, in turn, themselves suggest interdisciplinary therapies which might be most valuable. We should fund the programme and because of the longitudinal nature of the work, it must be funded on a multiannual basis.

I welcome the delegation and I have been reading the documentation. I am very impressed that we have a group of people from Cavan and Monaghan who are familiar with mental health services there and who have joined with the WHO and people from Italy, France, Sweden, Spain and the United Kingdom to put their expertise at the disposal of the Palestinian people. It is worthwhile for such expertise to be made available to people who are doubtlessly under enormous pressure.

I am hopeful the presentation today will be received well by the Government and the Minister of State at the Department of Foreign Affairs, Deputy Conor Lenihan. The work being done by this group in Gaza and Palestine is very important. Unfortunately, the overall scenario is very difficult, as my colleagues have expressed.

When I last visited Palestine we were not permitted to visit Gaza because of the difficulties there. Although I was anxious to go there we were not allowed, either because of a security concern or something else. I understand the situation in Gaza is extremely grave. We were in Hebron, Jerusalem and Bethlehem.

It is depressing to see the wall being built through the whole West Bank, dividing communities in Bethlehem and elsewhere. The world may not realise the problem, as there is not much coverage on television, except when there is a shooting in Gaza or a conflict involving Hamas.

I am asking our Government to recognise the new Government in the region. We were one of the first to recognise, through the late Brian Lenihan, the right of the Palestinian people to establish their own independent state. It would be very consistent with our policies. The European Union should be quite clear in putting aside the past and recognising that Hamas and Fatah are in a government together. They are not in a majority and although those groups were elected by the people of Palestine to be in government on their own, they have decided on a coalition approach, which is very reasonable.

In these circumstances, Israel is very unwise not to recognise this properly established Government under the President and negotiate with it to come up with a settlement. There were very good proposals in the past 48 hours on recognising the pre-1967 borders.

In the meantime, we can continue to support and provide aid. The withdrawal of aid by the European Union, even on a temporary basis, means that the people who will suffer will be children, mothers and families in Palestine. I am delighted to see that a group from our own country, specifically Cavan and Monaghan, is prepared to work for the people of Palestine. It is a wonderful reflection on the group and its work.

Money speaks louder than words. The proposal should be given 100% support by our Government and the Minister of State at the Department of Foreign Affairs, Deputy Conor Lenihan. I will formally propose that the submission be accepted and submitted to the Minister.

I apologise to the delegation for coming and going but a group from my county is visiting and might not accept that this committee is more important than they are.

I support Senator Leyden's comments and believe the Government and the EU should recognise Palestine. The people of Cavan-Monaghan have probably suffered as much from the Troubles as those north of the region and they have a certain sensitivity to what is happening in the Middle East. What goes on in the Middle East is of great importance and will eventually determine world peace. The events of recent days in Ireland could provide a template for the future of the Middle East but this cannot happen as long as there is a worldwide perception that America's approach to the Middle East is unilateral. This perception may be grounded in reality. The Americans do not seem to understand that it takes two to tango and it also takes two sides to create and solve a conflict.

As a teacher of many years' experience I know that the most vulnerable people are the psychiatrically vulnerable. I have seen children suffer because psychiatric disabilities of one type or another were not at first properly diagnosed and when diagnosed there was a lack of suitable places to educate such children. There are still problems in Ireland relating to psychological support facilities for young people. I am delighted to support this call and hope it is successful. As a tribute to the agreement reached between Sinn Féin, the Democratic Unionist Party, DUP, and other parties in the North I hope the most vulnerable people in the Middle East can be helped.

As politicians, we must call for recognition of the problems facing Palestine as they are not of its own making. One man's terrorist can be another man's hero. I think the former US President Ronald Reagan referred to Nelson Mandela as a terrorist, though I am not sure what the former British Prime Minister Margaret Thatcher called him. History proved that President Reagan was somewhat off the mark in this regard. I thank the group from Cavan-Monaghan for presenting an issue that we should all pay attention to.

Would Mr. Jenkins like to respond?

Mr. Jenkins

I fully appreciate the comments relating to the overall situation in the descriptions of people who have been there and have an in-depth knowledge of the issue. In working in the area for the past three or four years I have come to recognise that the Palestinian people have a wonderful resilience in the face of all that has been thrown at them. As long as they have support and help from the international community in addition to help in building systems the Palestinians can do a great deal for themselves.

Recently a group of family members and users visited services in the UK. They managed to get out of Gaza with our assistance, though it took them three days, and are enthusiastic to return to their country to do something there, despite all their problems. Many Palestinians have not been paid for 12 months, although we are trying to help. The World Health Organisation's relationship with the people of Palestine comes before its relationship with the Ministry of Health. We collaborate with the Cavan-Monaghan mental health services and the International Mental Health Collaborating Network, IMHCN, in this regard. We provide local services because of the difficulties faced by people trying to travel between the different towns and cities in the West Bank. We try to develop more local services based in primary health care because there is a good structure of primary health care centres in Palestine.

We work, through primary health care centres, with schools, non-governmental organisations, NGOs, and the United Nations Relief and Works agency, UNRWA, with which we have a strong partnership, to try to work with families, support people at home and give hope for the future in terms of coping with the circumstances in which they live. Despite all the difficulties we and the people of Palestine are optimistic that things can improve.

I thank the delegation for its informative presentation.

Can we ensure that we communicate the motion we agreed directly to the joint committee so that it will transmit it to Irish Aid before it ends its work?

Yes, I was coming to that. There is unanimous support for that in the sub-committee and we should communicate the motion to the joint committee. I was going to suggest that we could write to the Minister of State at the Department of Foreign Affairs, Deputy Conor Lenihan, indicating our strong support for the project and requesting that he look favourably at the proposal. I understand that Irish Aid has already received the proposal, but I do not know if it has responded. Has a response from Irish Aid been received?

There was a second submission to Irish Aid last year but the organisation was committed to another project and did not feel, at the time, that it could give funding to our project.

We will certainly follow up on that and, I hope, receive a favourable response from the Minister of State.

The sub-committee adjourned at 1 p.m. sine die.
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