What are the general repercussions of the conflict for mental health?
I think we have to start with the original sin: the expulsion of Palestinians from Palestine in 1948. Part of the definition of being a Palestinian is being a refugee, living in exile, having your home destroyed, having your belongings destroyed, having to leave your land. I still remember - and I'm not strictly a refugee because my family originally comes from Gaza, but I was born in Be'er Sheeva - at the time of 1948, when we had to leave. I remember a very hazy vision of my mother trying to bring her sewing machine from the house. She was pulling it to the truck waiting for us. My father told her to leave it. Later, I asked my father if that had happened and he said: "Yes. Your mother was trying to bring the sewing machine, and I said it was only two weeks and we'll go back to Be'er Sheeva." It was so painful, especially in the first few years, that, though she had more sewing machines, whenever she sat at another machine she started crying. She always wanted that sewing machine. Of course, this is only a little thing, it's not about the house or the land. But, even then, there's a deep sense of grievance in every Palestinian, whether you are a refugee or not, there is something that is so unjust that you can't accept it. And I think this is basically the problem of the Palestinians. So they are defiant, they feel helpless and they feel demoralized.
Second to exile is the occupation. This has affected the Palestinians very harshly. In the last few years of the Intifada, the Palestinians have been exposed to a situation that turned their villages into prisons, but prisons without roofs, still exposed to bombings and with no escape. There is no way of telling where the next strike will be. And when the Israelis strike, usually they fill the streets with panic because nobody knows where to hide. There is nowhere to hide. Total exposure and vulnerability have resulted in intense fear that is translated to the children through the behavior of their parents. And the children perceive parents as being helpless. They perceive their father in the first Intifada as being impotent. Some of the children identified even with the Israeli soldier, the new replacement of the symbol of power. You know our children play the famous game, Arabs and Israelis? Many children prefer to play the role of the Israeli because he is powerful. With this Intifada, again the father is being seen as helpless [and] unable to protect their children. And of course the impact was due particularly to that scene of Muhammad Dura being killed in the arms of his father.
The other serious trauma that has affected people is the destruction of the home. It's as if the Israeli military government always tries to force us to relive the original trauma so psychologically we realize we have no place here. This is exactly what happens. We relive the experience every day, and every day we ask ourselves if tomorrow we will still have a home. We did a study on children and the worst kind of trauma, after losing the mother, is losing the home. Of course, there are different serious kinds of trauma, for instance the impact of torture. Israel has jailed nearly 25 percent of the adult population and some 70 percent of them were tortured. That has an impact on Palestinian society. It's like putting 20 million Americans in prison and torturing them. And the impact is far-reaching here, because violence goes from one person to another, from one generation to another, from one nation to another. And the trauma and the violence of the Palestinians who were tortured has resulted in at least some of them expressing their anger and hostility against others in their family. Some of them became security officers. So they adopted the same techniques, in a process that we call identification with the aggressor, and they became torturers themselves against other Palestinians.

What specific mental health problem do you see as the most pronounced or the most worrying?
Well, the most worrying for me is that we did a study on children of 12, and we found that 24 percent of them claim the best thing in life is to die at 18 as a martyr. This is very serious. Of course, this again is an expression of the identification with power, because power for them is to be able to fight best, and to really conquer your fears through dying. And, of course, to be glorified. This is a society that glorifies. Many of the suicide bombers of today are the children of the first Intifada, who witnessed the beating of their fathers and their humiliation. The bottom line is that this is an expression of despair. Despair is expressed in the sense of impotence, despair is expressed in depression. We see it all the time. We have children who are unable to smile, "smileless" children. It's not easy for them to enjoy life. Thirteen percent of our children up to the age of 15 have problems with bedwetting at night. Many of them have problems at school, because they can't concentrate. Some cannot go to school because they fear that there will be some bombing and when they go home their parents will have died. In the areas of the West Bank of intensive violence by the Israelis, nearly thirty percent of them [children] have developed a picture of Post Traumatic Stress Disorder (PTSD), which is a collection of symptoms.

What are the effects of the occupation on physical health, the family structure and drug use?
Ofcourse, the physical is a complex story, because you have nutritional concerns, particularly for children. And now you see children who are really looking stunted in their growth. You ask a child, "how old are you?" and he says 12 but he looks 8. Sometimes, signs of different kinds of anemia can be diagnosed from the face, from the way they look. I know that also - I don't know what the percentage is - many women suffer from anemia when they are pregnant and that affects the children.
Generally speaking, there is a very bad environment for children in terms of hygiene, food - balanced nutrition, and so on. Poverty, of course, is the main reason and the lack of resources and care. Israel has also killed so many and injured thousands and these people will suffer, some of them for life. Mental problems are expressed in our society in physical complaints. In my clinic I have seen something like 15,000 cases. None of them said: "I am depressed." Ninety-nine percent of them were depressed. But they express it in terms of headaches, chest pains, and joint pains. It's all psychological. Stress and psychological problems here are expressed through the body. It's not denial. We have denial in other areas. We deny loss and we deny death. But the question of psychological pain is very recent in Arab societies, so we don't have the vocabulary to express ourselves. As for the family, the father... we give the children a picture and we tell them to tell us a story, and in the picture there's a father and mother and a little child. And they say the father is sitting, doing nothing, reading the paper. The mother is doing everything and the child is trying to find a game to play. Sometimes they think their father is the representation of the Palestinian Authority, even Yasser Arafat, sitting there doing nothing. Helpless. The mother has become more powerful and the women here are more radicalized than men. Religion has also affected them, in the sense that it is the last resort. It is the force of God that is protecting us and there is a kind of fatalistic resignation.
But, of course, there is a conflict. The dynamics of the family change all the time. There is an influence of the Israeli occupation causing people to come together, but there is also a process from within for individualization, liberty, women's liberation, which goes against that unity in a sense.
I expect there will be a greater use of drugs once there is some peace and tranquility, because usually this is the case when there is no outside enemy. The enemy becomes within. Tension is not resolved. [If] the anger and hostility is not resolved against the outside enemy, then it will be destructive inside. And this is what I expect, because we don't have the leadership that can lead us through a process of reconciliation, so I expect more trouble for the future.

Does Gaza exhibit unique characteristics, as opposed to the West Bank?
Gaza has been at the crossroads for centuries. If you read the history of Gaza, you know that everyone was here. You find that there is some kind of isolation that has really chronically affected Gaza. Even in the cities. In cities like Ramallah you feel like you are part of the world. Of course, Ramallah is not under siege. But in Gaza you don't have that feeling. You feel you are isolated from the rest of the world. And it is, it has been isolated for many centuries. Isolation brings a sense of paranoia, that we are let down by the rest of the world. Nobody cares about us. And the harsh reality is the poverty. The poverty, if you compare it to the West Bank, is worse here. Of course, there is also an overwhelming impression you get here of crowdedness. It's so full. When people are allowed to move out, in the streets or on the beaches, the place is full. Overcrowdedness at home, in the camp, in the village, affects people profoundly.

What are the coping mechanisms?
The tribal structure is one. It's a kind of moral duty that people come together. Money goes in circles. Somebody is employed in the family and he gives to others, and they, in turn, give to others. So the tribal structure gives you a sense of belonging and a sense of security. In the absence of a functioning state and the rule of law, there is no security except the tribe. I think the tribal structure and tribal ethics have really [enabled] the Palestinian people to survive for centuries under oppression, occupation and invaders. Mothers are very important in this also, because the mothers are at the center of the family. Although on the face of things men are the ones who are in control, the real control is in the hands of the mothers. I think the mothers have really helped in keeping society going.
Another thing that is very important for the Palestinians is the struggle. Compare the Kuwaitis and us. The Kuwaitis are now a demoralized society, where drugs are everywhere. It's a society with broken dignity. In Palestine, we don't have that. On the contrary, we have a very astute and acute sense of dignity, because we struggled against the enemy. The Kuwaitis did not resist. The resistance by the Palestinians against the Israelis has given them a sense of purpose, a sense of self-respect and a heightened self-esteem. And this self-esteem is very important for people to be able to carry on their daily lives. These are the main reasons that enabled us to cope. And that is in the absence of any form of leadership.

How popular or successful could nonviolent methods of resistance be?
I was one of the people, and I still believe, that no one has the right to kill any person for any reason. I believe nonviolent struggle is the best way of achieving justice even against, and particularly against, the overwhelming forces of the Israeli occupying forces. But it has no impact on this culture, because this culture is physical and tribal. Tribal means revenge. And revenge, if it is physical, has to be an eye for an eye. It is very difficult to influence people with ideas of nonviolence when they are subjected to this form of violence on a daily basis. So it has no basis, sadly, I think. Politically, violence by the Palestinians is counter-productive, and I don't believe people have the right to kill. I don't give this right to the Israelis, I should not give it to myself.

What can Palestinians do to change the situation?
Being tribal means we are hostage to a system in which the father figure is very important. And the father figure today is Yasser Arafat and what he represents. It's difficult for the Palestinians, and the Arabs in general, to challenge their leaders, because they take on this image of being the father figure, plus [for the Palestinians] there is an outside aggression, which makes people come together and protect each other and express solidarity. These two elements prevent the Palestinians today from changing at the grass-roots level or other levels.
The situation today is catastrophic for Palestinians, because just as the patriarchal system is working against the freedom of the individual and the freedom of the nation, the Israeli aggression only helps to strengthen the tribal system and the father figure. Every time they say they want to attack Yasser Arafat, he becomes even stronger. Every time they send bombs against us, we become more tribal. It's a vicious circle. It's impossible to remove the element of tribalism without removing the element of the Israelis' aggression. We have to remove that outside element first. If you remove that, then the Palestinian dynamics become different. I believe the Palestinians are more prepared than any Arab nation for democratization. But as long as there is an outside enemy that strengthens tribalism and the patriarchal system, there will be no change. There will be no change from within the Palestinian society, unfortunately, because Arafat and Fateh are in control, and they are in constant struggle with Hamas. Between the two forces, the majority of the people are the silent majority. They are intimidated into silence.

What can Israelis do?
The Israelis can do a lot. At least the Israeli government is very sensitive to public opinion. Each extreme group feeds the other. In order for [Ariel] Sharon to control his people, he needs Hamas to intimidate these people and to frighten them. Israel has become a culture of fear, which is dominated by the military. It has always been a military regime. And this fear is fed by suicide bombings.
As long as there are suicide bombings, Sharon will be in control. So what the Israelis need to do, from their side, is to try to pressure their government to stop this campaign of violence against the Palestinians, so at least the Palestinians will stop using suicide bombings against the Israelis. And the Israelis should respond by pressuring the Israeli government, by making the rest of the society aware that the way out of this mess, for Israel to stay as a state, particularly as a Jewish state, is for them to withdraw from the West Bank and Gaza as soon as possible. The next round will be for a one-state solution, where there will be no Jewish masters and Arab slaves. It will be a struggle for equality and a struggle against racism. If Jews want to have a Jewish state, it is now or never.

How do you rate Abu Ala's chances of getting something positive done?
I think he has the will, but I don't think he has the power. It's a very complex story. On the one hand we have Arafat, and we have [George W.] Bush and we have Sharon. These three are not really working for peace. As long as they are together - I know Arafat wants a solution - but the other two are doing everything possible not to have peace, supported by the extreme right in Israel and by the extreme right in Palestine. So Abu Ala'a will be in the middle of this. What chances will he have? Very slim chances. I think that there is a possibility, positively speaking, of him being able to do something, because Hamas is ready to stop suicide bombings inside Israel. That is very good, because that will allow him the chance to maneuver without having to confront Hamas, which would be a huge task and could lead to civil war. He can contain them and handle them in a way that would not mean confrontation.
The other major task is to give the Palestinians a sense of purpose, a sense of hope, a sense of security. But that will not happen without an Israeli government that is really interested. This Israeli government, I believe, is not interested in peace, because peace, as far as Sharon is concerned, is a danger to Israel because it means giving up the land, and land is more important than peace. Land is more important to Sharon than Jewish blood. So that is another difficulty. So I think that as long as Sharon is in power, as long as Bush is in power - with this kind of policy... maybe they will change. If they change, good. But I don't believe that Bush or Sharon will change.

If they did change their policies tomorrow, how much support will there be for a political solution?
Huge support. Everybody is waiting for a solution. The Palestinians have had enough and the Israelis have had enough. And we know what the solution is, and the question is how many people have to be killed before the solution is implemented. Although the solution is unjust for us - because Israel will take more land than was decided in the [1947 UN] partition plan - still, I think that the majority of Palestinians will accept it, if it happens today and if there are no settlements. The Geneva Declaration, for example, I think would be accepted by the majority of Palestinians because there would be no settlements, [a return to the] 1967 borders, and it will give the refugees the chance to be resettled, either in Palestine or third countries or in Israel, according to negotiations. The majority of the Palestinians and the majority of Israelis will be in support of a political solution.

Dr Sarraj was interviewed in Gaza by Omar Karmi from the PIJ.