The 21st century has brought with it an urgent requirement to respond to the mental health needs of people, both individually and collectively, in order to move them beyond their immediate challenges. This is particularly true in areas of conflict. It is our philosophy that mental health in its wider perspective includes an inseparable bio-psychosocial link that must be emphasized in the relationship between mental health and human rights. Our hopes for peace, freedom, and democracy - hopes that all people and societies share - lie in strengthening capacity-building and in a greater involvement of people in embracing their own mental health related issues. This entails equipping mental health professionals with interdisciplinary skills to be able to advocate, from within, effective and meaningful social, economic and cultural changes that include the need for fresh perspectives about the relationship between mental health and human rights.
The training of mental health professionals in regions where there is a lack of respect for human rights is an important first step in understanding and intervening in the psychologically degenerative effects of human rights abuses and traumatic experiences. The innovative initiative of the Diploma in Community Mental Health at the Gaza Community Mental Health Program, which was started in 1997, is one such training project designed to train mental health professionals in Palestine. Our mental health training is based on linking human rights with mental health. Mental health in its wider perspective encompasses environmental, family, and community health factors, not just an inflexible medical perspective. The diploma is considered a cornerstone toward the formation of an Institute of Mental Health and Human Rights that will train mental health professionals in the Middle East to manage and intervene against the often cumulative effects of human rights abuses and traumatic experiences on individuals and their societies.

The Gazan Backdrop

According to the Palestine Monitor, in the last three years from September 2000 to October 2003, more than 2,654 Palestinians have been killed - 493, or almost one in five, were children aged 17 or younger. Another 47,000 have been injured. Of those, 2,500 will be permanently disabled, some 500 children. In October 2003, Israeli occupation forces reinvaded Rafah leaving more than eight people dead, 114 refugee shelters destroyed, 117 buildings damaged, more than 120 houses demolished, and 1,240 individuals homeless. This attack on Rafah has brought the total number made homeless in Rafah alone, since the start of the second Intifada, to 7,523. In the whole of the Gaza Strip, 11,987 have been made homeless and the number is rising every day.
There are now 482 Israeli military checkpoints across the West Bank and Gaza Strip, dividing the West Bank into 300 clusters and the Gaza Strip into four areas. These checkpoints have resulted in 82 Palestinians dying because they have not been allowed to pass through checkpoints to access medical care. Twenty-seven were children. There have been 52 cases of women giving birth at checkpoints, resulting in the death of 17 newborns. Together with closures and checkpoints, curfews have imprisoned more than two million people in their homes (The Palestine Monitor, 2003).
Such devastating environments have a great impact on the mental health status of Palestinians, and the prevalence of mental health problems is increasing. As indicated by Thabet (1998), 21 percent of children below age 12 have anxiety disorders, a figure that's higher in girls. The study found that living in refugee camps was strongly associated with anxiety problems. Qouta (1999) found that 36 percent of children reported maltreatment at least once, and 37 percent were exposed to traumatic events. The rate of occurrence of Post Traumatic Stress Disorder (PTSD) was at 19.5 percent and 63 percent of Palestinian women in Gaza were exposed to traumatic events. Punamaki et al (1997) showed that traumatic events increased children's poor perception of parenting involving punishment, control and rejection, something that is experienced by boys more than girls. In a sample of former male prisoners between the ages of 25-39, 40 percent reported PTSD symptoms. They also reported family and marriage problems, sexual problems and mal-adaptation (Sarraj, 1996).

Program Profile

The Gaza Community Mental Health Program (GCMHP) was established in 1990 as an independent, non-governmental organization. It adopts a community-based approach enabling families and communities to cope with a wide range of mental health problems compounded by human rights violations, traumatic experiences, poverty and the Israeli occupation. It serves a wide section of the community through its community mental health centers and women's centers that are geographically distributed in the Gaza Strip (North region, Gaza City, Middle region, Khan Younis and Rafah region), and its teaching institute.
The program represents a unique and comprehensive approach to the extensive problem of mental health within Gazan communities. Each center has its own multidisciplinary team that consists of nurses, a trained psychiatrist, a psychologist, and social workers. Each team collaborates with existing health and non-health organizations. GCMHP's work with adults and children, and in particular with those exposed to torture and human rights abuse and their families, emphasizes a community-based approach to tackling the overwhelming mental health problems among Palestinians in the Gaza Strip.
In many developing countries, Palestine included, mental disorders are often a source of fear, and its causes are commonly thought to be supernatural (WHO 1990). Sufferers and their families feel stigmatized to approach psychiatric services that are usually seen as custodial institutions in which troublesome and frightening people are segregated. Therefore people seek the help of primary health centers or traditional healers as the main gate of entrance, presenting their mental health sufferings in physical terms. Afana (2003) showed that 73 percent of patients at primary health care clinics have anxiety and depression symptoms, with refugees living in refugee camps demonstrating a higher prevalence than others. The ability of general practitioners (GPs) to detect mental disorders was low (11.6 percent), and 29 percent of patients assessed by GPs as having mental disorders were already well known to them (Afana, 2002). The prevalence of PTSD among primary health care patients was 29 percent and higher among women (34.4 percent) than men (21.7 percent). Of those exposed to traumatic experiences, 36.4 percent met PTSD criteria.

Philosophy and Objectives

The philosophy of the GCMHP is based on the following principles:
* Enabling families and communities to cope with the wide range of mental health problems, compounded by human rights violations, emphasizing a social support network as an effective way to face mental health issues.
* The responsibility of the health professionals is to move from intra-personal focus to interpersonal-oriented care.
* Mobilizing local services in the community to assist individuals in feeling that they are responsible participants, contributing to their health.
The goal is to ensure that mental health care services in Palestine are based on the principles of justice, democracy and respect for human rights with the following objectives:
* To combat the effects of the cycle of violence and systematic violations of human rights by the Israeli military occupation that has resulted in an exceptionally high incidence of mental illness among Palestinians, particularly among women, children and adolescents.
* To overcome the lack of adequately trained mental health professionals, and to build indigenous capacity within the Palestinian state.
* To combat the stigma of mental illness in society, and to contribute to the development of appropriate and adequate public policy and practice.
The GCMHP offers four main services:
Clinical service: The GCMHP has become an internationally recognized, community-based mental health program. A major strength of the program is the clinical services offered to the Palestinian population in Gaza by skilled multidisciplinary teams of psychiatrists, psychologists, social workers and nurses. The program also has the potential to serve as a training venue for other health workers in Gaza.
Research: The research unit was established in April 1990. Its goal is to investigate and analyze the effects of violence on the Palestinian population, considered the most important psychological phenomena affecting individuals and families. Children have been one of the unit's most important target groups. The research unit has published its findings in several internationally recognized journals.
Women's empowerment services: Women in Palestinian society have had to face not only the violence and hardships of occupation, but also the lack of economic or educational opportunity. During the Intifada, in addition to being direct victims of Israeli military violence, Palestinian women faced the psychological and emotional damage of having fathers, husbands, sons and brothers killed and imprisoned. Men frequently take out their frustrations on women, children and other family members.
Training and education: When established, the primary staff recognized the absence of training institutes in Gaza that could adequately prepare mental health professionals. To overcome this difficulty, they embarked on ambitious training activities and attracted trainers from prestigious institutes around the world. The trainers provided in-house training to the GCMHP staff in order for them to offer quality services to the Palestinian population. Several members of the local staff went abroad to further their professional skills and have returned with an increased capacity to assist in the training of local staff. The capacity of the Palestinian staff to conduct their own culturally sensitive training has thus increased. Training courses are offered to health professionals - nurses, social workers, psychologists and GPs - as well as non-health professionals, including community leaders, school and kindergarten teachers, and law enforcement agencies. Religious leaders and mass media staff have also benefited from the GCMHP training activities.
In 1995, plans were developed to introduce a Postgraduate Diploma in Community Mental Health for mental health workers of health disciplines (nurses, GPs, social workers and psychologists) in an attempt to address the problem and compensate for the total lack of psychiatric training in Palestine. Training ensures that candidates have adequate knowledge of state-of-the-art theories, principles and treatment and prevention strategies used in addressing mental health concerns. It also imparts training in the influence of human rights and culture on mental health. The diploma is considered the first step toward the formation of a Palestinian Institute of Mental Health and Human Rights that will attract international students and researchers.

Broad Aims

The postgraduate diploma is a two-year full-time course that is jointly run by the GCMHP and the Islamic University in Gaza. Seven other local, regional and international universities contribute to the teaching and supervision of students. It combines both theory and the clinical aspects of community mental health and human rights and provides candidates with a broad knowledge base. The curriculum is culturally sensitive and community oriented and critically analyzes the concepts of human rights and mental health. At the commencement of their first year, students are assigned to one of the GCMHP teams and are gradually exposed to clinical and community practice. The diploma is designed to:
* Encourage candidates to explore theoretical concepts in community mental health and human rights in addition to their practical applications. Wide exposure to clinical experience enables them to discover their particular interest in mental health, while learning about widely different fields and how to integrate them in clinical practice and research.
* Widen the scope of the medical model and its tendency to focus on microscopic aspects of mental health. The diploma places the study of mental health within a wider social, political, environmental and biological context. Further, it seeks ways to shift psychiatric therapy away from traditional Freudian concentration on the individual and unconscious motivational conflicts to move closer to an emphasis on the social interpersonal care and the role of a person's environment.
* Place mental health care firmly within the philosophy of the community-based approach and emphasize the shift from segregated and self-contained mental health care systems in institutions to community-based therapy and involvement. It also emphasizes the change in the role of mental health care professionals from being providers of mental health care to facilitators of care, thus enabling individuals to solve their problems using the resources of the family and community institutions such as schools, mosques, etc.
* Enable candidates to analyze the applications of health and human rights and the role they play within the community. It, therefore, tries to expose students to notions of human rights and to highlight the links between these concepts.

The Main Lessons

The GCMHP's experience has led us to a number of conclusions. First and foremost, the planning of a community-based approach to mental health care must come from within the community, through professionals who have contact with the community, and not by way of a political program. Since the approach is multidisciplinary, it is important to avoid conflict between different disciplines in the mental health team. Everyone needs to work together. A clear mandate and job descriptions have to be in place. Professionals working in community mental health centers have to be trained in the philosophy of community mental health. It would be a great weakness to move health professionals from institutional settings to community settings without the proper training.
One can look at the process of choosing a specific human right to focus on at the exclusion of others as a selective approach to human rights. Such a process concentrates on improving the conditions of one aspect of human rights in a community. Where a comprehensive approach to human rights focuses on the process of empowerment and increasing control over all influences that impact basic rights, a selective approach assumes that political rights create and ensure control over human rights promotion by politicians.
This does not mean that selective human rights are not crucial in addressing certain sufferings such as torture. However, by only addressing those abuses, the fear is that we constantly risk addressing only the end result of the problem instead of the root causes and/or the social conditions underlying these abuses.
Cultivating a comprehensive approach to human rights is a developmental process. Such a process is established through the presence of social justice, equity, community development and social change, the right to health and education, and the right to live in peace and with dignity. It is a process that requires people's involvement in decisions related to their lives, as well as examining the positive and negative conditions that promote human rights and human rights abuses.

Afana Abdel-hamid; Dalgard, Odd Steffen; Bjertness, Espen; and Grunfeld, Berthol. 2002. The ability of general practitioners to identify mental health problems among primary care patients in the Gaza Strip. Journal of Public Health and Medicine 24(4): 326-331.
Afana Abdel-hamid; Dalgard, Odd Steffen; Bjertness, Espen; and Grunfeld, Berthol. 2002. The prevalence and associated socio-demographic variables of Post Traumatic Stress Disorder among patients attending primary health care centers in the Gaza Strip. Journal of Refugee Studies 15(3): 284-295.
Afana Abdel-hamid; Dalgard, Odd Steffen; Bjertness, Espen; and Grunfeld, Berthol. 2003. The assessment of mental disorders in primary health care clinics in the Gaza Strip. Journal of Public Health and Medicine 4: 267-274.
El Sarraj E., Punamaki RL, Suhaile S. and Summerfield D. 1996. Experiences of torture and ill treatment and Post Traumatic Stress Disorder: Symptoms among Palestinian political prisoners. Journal of Traumatic Stress 9(3): 595-605.
Punamaki Raijia-Leena, Qouta S., and El Sarraj E. 1997. Models of traumatic experiences and children's psychological adjustment: The role of perceived parenting and the children's own resources and activity. Child Development 66(4): 718-728
Qouta S., El Massri M., Termraz. 1999. The prevalence of mental disorders in the Palestinian community in Gaza. GCMHP Newsletter, Gaza, Palestine
Palestine Monitor. 2003. Press Conference with Dr. Mustafa Barghothi.
Thabet A. and Vostanis P. 1998. Social adversities and anxiety disorders in the Gaza Strip. Arch Di Child 78: 439-442
WHO. 1990. The Scope of Mental Health into Primary Health Care. WHO. Geneva