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Palestine needs to have a talk about suicide

If you or anyone you know is experiencing thoughts of suicide, or going through a difficult time, you can call the following hotline numbers, 24 hours a day, seven days a week. In the West Bank and Jerusalem, call ‘Sawa’ organization at 121. In Gaza, call ‘Aisha’ organization at 1800 170 171. In Israel, call ERAN organization at 1201 (also available in English).

Jerusalem24 – Every month should be September. This is the conclusion one can draw from a conversation with Mohammad Qaisi, Projects Coordinator for Médecins du Monde Suisse in the West Bank and Jerusalem, and Hector Alvarez Diaz, the Head of Mission.

In September, a rare event becomes more commonplace; a taboo, brought to the fore. And a conversation that needs to happen, happens in the open.

September is an opportunity to have a talk about one of the leading causes of death worldwide, and the second leading cause of death among 15 to 24-year-olds. Médecins du Monde Suisse estimates that worldwide, every 40 seconds, a person takes their own life. 

Launched by the International Association for Suicide Prevention in conjunction with the World Health Organization (WHO), World Suicide Prevention Day has taken place every 10 September since 2003. The campaign slogan for the years 2021-2023 is “creating hope through action”.

And that is just what Mohammad and Hector are hoping to do, by using Médecins du Monde (MDM) Suisse’s platform to not only reach out to those in need of help, but also to frontline workers, students, community and religious leaders, and journalists – sections of the population apt at triggering a conversation (and, hopefully, a change) surrounding what is literally a question of life and death for too many Palestinians.

But just why is this conversation lacking in the first place?

The situation in Palestine

Around the world, adult men and young adult men take their own lives nearly four times as often as adult women, although women attempt suicide at three times the rate.

MDM Suisse has collected anecdotal evidence that Palestine seems to fall in line with global trends. However in the absence of clear data, more work needs to be done before a clear picture can be established on the situation in Palestine, and, in turn, a strategy devised for suicide prevention tailored to the needs of Palestinians.

A recent report by Save The Children found that 80% of children in Gaza are depressed, while 96% of their caregivers also report feeling unhappy. According to a report by the World Bank, 57% of the population in the West Bank reports symptoms consistent with PTSD.

“This creates mental health problems we’re all familiar with, like depression and other mental health issues,” says Mohammad. “This sometimes also leads to suicide.”

Furthermore, each section of Palestine’s fragmented population deals with its own unique set of challenges: residents of Gaza face severe economic hardship and regular bombing campaigns; Palestinian Jerusalemites are subject to Israeli annexation without Israeli citizenship or rights; and even within the West Bank under military occupation, residents of Area A (under Palestinian Authority civil and security control) face different challenges to the residents of Area C under full Israeli control who are hit by severe poverty, lack of access to basic services like water, and a permanent risk of forcible displacement.

In addition to the general impact on mental health, these challenges put an additional burden on service providers and organizations like MDM Suisse, who may encounter difficulties at the operational level due to Israeli-imposed restrictions or a lack of access to targeted populations.

“The occupation is the main challenge in the Palestinian context”, says Mohammad. “You know, access programs, outreach services… All the escalation, the violence that Palestinian people are experiencing, it is also adding a very big burden on us.”

And, crucially, it plays a role in both preventing organizations from successfully offering their services, and Palestinians from seeking them out in the midst of a mental health crisis.

And then of course, there is the stigma.

All about the stigma

Stigma surrounding mental health in general and suicide in particular is an issue present to varying degree in most communities around the globe. The burden of stigma can prevent people from seeking help or even recognizing they may need help, and can similarly affect families and loved ones in their treatment of such issues.

The WHO aims to reduce this stigma by raising awareness among governments, organizations, and individuals, particularly on World Suicide Prevention Day.

This stigma is also very present in Palestine, and its consequences manifest themselves in different ways.

“People really, still, are not collaborative,” says Mohammad, “to reach out and to open up and to talk about mental health issues. People are not really keen to report such issues. It still falls under the taboos to talk about their feelings, about their challenges and mental health problems.”

Beyond the obvious suffering it causes both to people going through mental health issues and the loved ones who wish to support them, stigma also presents a challenge to documentation – a necessary step for suicide prevention in the first place.

“When we started work in the field of suicide in collaboration with the Palestinian Ministry of Health, we tried to really figure out the numbers and the exact data that can lead us and help us to identify cases and the situation with demographics in Palestine,” explains Mohammad. “But unfortunately, we lack documentation, and we lack data.”

Instead of statistics and documentation, they had to rely on the anecdotal observations of their colleagues in MDM Suisse and Ministry of Health (MoH) centers.

These observations, says Mohammad, led MDM Suisse to realize there actually are high numbers of suicide or suicide attempts in Palestine; these cases are just not really documented.

“If you want to talk about the challenges regarding collecting data and identifying the situation, analyzing Palestine, the main thing is the stigmatization in the community,” explains Mohammad. “In many cases identified by medical staff as suicide, the family tries to deny this [is the case], and puts pressure on medical staff not to document the case as such because it affects the family’s image in the community.”

Mohammad says families can go as far as physically attacking doctors and first responders to prevent them from registering the data.

What can be – and is being done – to change the situation

As the first responders in cases of suicide or suicide attempts, medical workers (who face the added burden of facing a family’s grief, denial, or even anger) are in particular need of both institutional and individualized support.

MDM Suisse led a study in 2019 – “the first research of its kind in the Palestinian context” – that allowed the organization to identify gaps in training, care, and reach in the field of suicide prevention.

“One of the gaps was the capacity of the frontline workers who work in public health facilities,” explains Mohammad, “which MDM Suisse is trying to tackle now, step by step.”

In addition to conducting training with ER staff in how to identify and handle suspected suicide attempt cases, MDM Suisse also engages in different types of individual and group counselling to improve frontliners’ resilience, self-care, and coping mechanisms, in order to avoid situations of burn-out, depression and stress – which can lead to their own mental health issues and even thoughts of suicide.

“It’s about training them to identify people who may need support on the one hand, and giving them the tools they need to provide this support for each other,” says Hector.

But addressing the stigma and changing societal attitudes remains the single most important tool in the fight to bring suicide to the forefront of public debate.

“The main part of our work is awareness-raising among different groups,” says Mohammad. “In this campaign for instance, we’re targeting university students, police, and also journalists, training them to identify suicidal thoughts and behaviors – and also to help familiarize them with the community resources available, the location of mental health centers, and the kind of support available.”

MDM Suisse also targets community leaders, community-based organizations, and religious leaders – people who, according to Mohammad, “have the legitimacy to address suicide and suicidal behavior, in a way that can elicit support from the community rather than stigmatization.”

“Part of our effort is to create the national suicide prevention strategy that was created by the leadership of the MoH in addition to the WHO in addition to local partners and NGOs who work in Palestine,” explains Mohammad. “This national strategy, part of it is to analyze the situation in Palestine regarding the services, the capacities of the workers, the structure of the public facilities, how friendly they are to people with suicidal behaviors or mental health issues.”

“Another part of it is about the role of local partners and NGOs towards developing the sector of mental health in general and suicide prevention in particular. As a result of this national strategy, there is an action plan that was endorsed by the Ministry of Health, to identify the gaps and to work on them.”

Along with the MoH and other partner organizations, MDM Suisse also works to address specific problems such as the difficulties faced by youth and children, gender-based violence, occupation-related violence, and other stresses which lead to mental health and suicide issues in the first place.

“We are trying to follow the outcomes of these strategies and to integrate them with our programs.”

What does it mean when we talk about suicide prevention?

All of these strategies share one common goal: to understand the situation in Palestine and the drivers behind suicide, in order to implement the best prevention strategy and save lives.

So what exactly does it mean when we talk about suicide prevention?

One crucial step in suicide prevention is identifying whoever may be at risk. It may be a loved one, a coworker, a student, a friend – or anyone else. MDM Suisse aims to provide the wider community around affected individuals with the tools they need to recognize who may be in need of help.

Youth in the Palestinian community are more affected and more likely to commit suicide, according to MDM’s observations. “Also, males are the ones who approach the mental health centers the most – or at least, the most cases that we identified,” says Mohammad.

Of course, this doesn’t exclude any other category of population from harboring thoughts of ending their own lives. Depression in older people in Palestine is particularly widespread, with just over one in two over the age of 60 affected.

It’s also important, says Hector, to distinguish two different groups: people who start to have suicide ideations, and people presenting actual suicidal behaviors. “Both are highly stigmatized, and I would say 95% of the time, this kind of stigmatization forces most people to isolation, and it has a devastating impact on their mental health.”

In both groups, identifying patterns of suicide ideation and suicidal behavior and acting rapidly is key.

But how can we identify someone in need of help?

Mohammad says there are many signs to look out for. “Many times we’ve heard how miserable their life is, and how they’re trying to think of solutions – but they feel incapable of continuing in this way.”

According to the Suicide Prevention Resource Center, suicidal behavior may be overt, with someone talking about wanting to end their life or looking for a way to do so, or expressing hopelessness or a difficulty finding a reason to live; while someone who may have or is developing suicide ideations may talk about being trapped or feeling unbearable pain, or being a burden to others, and may withdraw or display rage or extreme mood swings, or begin taking (or increase) their usage of alcohol or drugs.

“We’re trying to spread the information for the people who are taking responsibility,” says Mohammad, “to tell these people, the first time that they identify anyone with suicidal thoughts, to take it seriously in the first instance.”

In the mental health community, adds Hector, “it’s a rule: when you hear someone talking about a plan or talking about suicide or ending their life, you should immediately talk to their parents or to their relatives to provide the needed support.”

That is, of course, in the immediate absence of professional support – a problem the national suicide prevention strategy is working to remedy.

Where can people turn to for help?

This absence of professional support can put an undue burden on loved ones and people affected by suicidal thoughts seeking help and not knowing where to find it, or even that it is available.

For anyone not knowing where to start, the hotline numbers offer a first port of call.

And they’re not only for anyone struggling with thoughts of suicide, or whose loved one may be struggling: “They’re also for people who seek any kind of mental health support, and for anyone to report any kind of abuse,” underlines Mohammad.

The MoH also has a large number of community health centers around the West Bank that people can easily reach.

MDM Suisse also aims to reach out directly to the people in need through its programs. Its 2019 study issued “a lot of recommendations that were shared by the frontliners, by the families of the people who committed suicide or a suicide attempt.”

“So usually we tell teachers, doctors, and friends sometimes, how to deal with such situations,” says Mohammad. “Always, we invite people to talk and to open up and to provide support. And sometimes – I don’t want to call it counseling – rather, information about where to get help. As part of our campaign we highlight the service providers’ resources in Palestine, where these places are located and how to reach them.”

And what about those people for whom the worst has happened and who actually have lost a loved one, and who feel they can’t talk about it?

“It’s important to consider that you should never feel alone,” emphasizes Mohammad. “In case you are feeling that something is not okay, people should be free to request support.”

“It’s often considered that suicide affects only one individual – but there is much more: family members, friends, as well as the whole community can be impacted by suicidal behavior.”

“Ideally there should be no stigma, there should be not be any kind of fear. People need to feel free, to be able to openly discuss mental health. And this is one of the first gaps that we are facing here: the stigmatization, the problems for people to have an open discussion relating to mental health.”

“But in any case there are several sources. We have public mental health facilities where people can go and ask for support. They can also request support from their primary healthcare center: they will receive all the information that will support them. There is also support provided by other actors like international or local NGOs.”

“I believe the first step is to tell people that there is hope, there is support,” concludes Mohammad. “Sometimes people end their lives because really, they feel alone. They don’t have someone to trust or to talk to or to discuss their feelings with. Here, we are saying that there should be some space for these people to be heard.”

Hector adds: “For anyone in need of support, remember you are not alone, there is always someone to support you.”

“So don’t be afraid to ask if you feel that you are in a critical situation.”

Listen to the full interview on Wake Up Palestine.

If you or anyone you know is experiencing thoughts of suicide, or going through a difficult time, you can call the following hotline numbers, 24 hours a day, seven days a week:

  • If you are in the West Bank and Jerusalem: call ‘Sawa’ organization – 121
  • In Gaza: call ‘Aisha’ organization – 1800 170 171
  • In Israel: call ERAN organization –1201 (also available in English)

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