As we have been studying the cumulative effects of environmental stressors on population health, PHS Student Zeeshan Yacoob brings our attention to an article about the effects of the Israeli-Palestinian conflict on mental health through the experience of an 11-year-old boy. Zeeshan writes:
Zeeshan writes:
This article is about an 11-year-old Palestinian boy who suffers from PTSD after witnessing his brother die. After reading this article I began to wonder how these children will grow up and what type of society they will establish in the future. Furthermore, I also began to wonder about all of the health conditions they would have to face even if their situation would change overnight (for example if they were taken in as refugees to the U.S.). I’m sure that many of these children due to their stress will suffer from conditions like hypertension, cardiovascular disease and depression. As a result, their productivity as a society will decrease and also the societies educational attainment will also undoubtedly decrease. All in all, not only do I feel frustration and anger for the situation that these children have been exposed too but I also worry what their health future will look like not only for themselves but also for the next generation after them.
Zeeshan also points us to a systematic review on the effects of conflict on mental health of children in the Middle East:
Population Health graduate, Salwa Massad, PhD has done significant work in this area. She is currently a research manager in the World Health Organization’s Palestinian National Institute of Public Health and adjunct faculty at Columbia. Here is a link to a presentation of her brave and powerful work on the health of children living in chronic war zones:
The Fantasy Equation 
Based on our lectures and readings, I agree with Zeeshan that the children involved in this study (and others involved in conflict zones) are likely to experience both physical and mental health issues throughout their life. It makes sense, to me, that the functionality and productivity of their generation will be affected because of these events. I also wonder whether any studies will be done on the children who were conceived or born during this time period, and whether followup studies will be done to see whether these children also show signs of PTSD or other health issues (or whether they show characteristics of resilience). The children and adolescents from the study may also become parents to another generation with second-hand effects from this conflict, whether through society or the health/behaviors of their parents. From what we have learned in our class so far, it seems that traumatic events do not just affect one generation, but the generations to come as well. Reaching beyond this study, there is no easy or globally accepted answer to the problem of war, conflict, or other traumatic events. However, perhaps the task should be to break the cycle of negative effects, ensuring the next generations are able to continue a healthy, functioning society. Researchers likely can provide such notions, but whether politicians, society, etc. will agree and comply is another issue we must address.
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For me, this article sparked questions about children and their health mentally and physically in America who also experience violence and conflict on a regular basis. I worked for 2 years in Milwaukee in the 53206 zipcode, which is the most highly incarcerated zipcode in the world. The students that I taught in my high school classes were exposed to violence in their neighborhoods, homes, and schools frequently. The numbers of behavioral problems and learning disabilities were high in these neighborhoods, which could be associated to a variety of different factors as we have discussed in class. However, i know it to be true that students sometimes were unable to complete work or attend school or focus if they were even able to attend school due to outside issues especially due to conflict and violence. While I was at the school, we had multiple students shot either purposefully or accidentally and one student’s death occurred from gun violence. Many of my students’ fathers and/or mothers were incarcerated and so were being raised by others, which lead to a loss in family structure and stability. To me, it would be interesting to study how the effects of conflict zones like that in Syria, Israel, Palestine, and other places in the world match up with the effects of violence in some of our neighborhoods in America. We have also discussed the concept of resilience frequently in class. Despite the experiences and their effects on some of my students, I also had many who were flourishing in similar environments. I want to know why some students were able to succeed and some were not. The concept of resilience and how to add resilience to these communities may be a way to disrupt the cycle of conflict and its health effects.
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This article is a great example of how multiple life stressors can accumulate and bear a heavy allostatic load on an individual. The single stressor of living in a high-conflict area gives rise to numerous other potential stressors that accumulate and may result in a state of distress. As we learned in class, this state of distress elicits a stress response which causes multiple adverse physiological changes in the body. As Zeeshan mentioned, a person’s productivity and societal functionality is ultimately affected. I, too, agree that these alarming trends call for action. It was interesting to read that “protective factors” decreased PTSD prevalence, and this is perhaps comparable to the concept of “social capital,” meaning that a strong social network and sense of belonging serves as a resource for people facing potential life struggles. I am surprised that the PTSD prevalence is reported at 5-8%, and wonder if this is underreported due to difficulties in being able to diagnose the children in high-conflict areas of the world?
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This was a great article for discussion, and I was fascinated to read the comments here. I have personally worked in Palestine, and I can assure you that the stress level in most health care environments is palpable. After learning about so many of the long-term impacts of stressors on health in this course, it has certainly brought about some new issues for me to consider in providing care in this setting. The health care system in Palestine certainly leaves something to be desired, and establishing long-term care for patients exposed to chronic stressors since childhood is paramount. The organization I work with, the Palestine Children’s Relief Fund, has actually begun some of this work by providing mental health services to children growing up in Gaza. It’s been fascinating to watch and learn from, and it’s something we can hopefully adapt to many other aspects of healthcare in Palestine, and worldwide. Thanks for posting this one!
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I definitely agree with Zeeshan in that this article presents a frustrating situation that not only has immediate acute affects, but likely chronic disease indicators both for this 11 year old boy and maybe even generations after his time. I think this post also adds a whole new dimension to the neighborhoods lecture we had by Dr. Robert. Although we discussed the effects of physical environment in the context of water/air quality, natural disasters, and walkability, I think we can all agree that when one’s physical environment is in a region of civil unrest it leads to so many other psychological challenges and a huge increase in allostatic load.
I wonder if these experiences also increase the social capital in neighborhoods? Although I was unable to gain access to the full article without paying, I’m happy that this kind of research is being conducted and am curious what the authors’ “specific recommendations” are that they cite in the abstract. Unfortunately, this trend of civil unrest in war zones is not new, and it would be great to have some evidence-based research on which we can constitute taking appropriate action now as well as in the future.
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Thank you for this post Zeeshan!
It made me think of the effect of adverse childhood experiences (ACEs) and the link with chronic diseases.
There is an awesome systematic review on ACEs that I would like to share.
http://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30118-4/fulltext
“To have multiple ACEs is a major risk factor for many health conditions. The outcomes most strongly associated with multiple ACEs represent ACE risks for the next generation (eg, violence, mental illness, and substance use). To sustain improvements in public health requires a shift in focus to include prevention of ACEs, resilience building, and ACE-informed service provision. The Sustainable Development Goals provide a global platform to reduce ACEs and their life-course effect on health.”
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Although I was not able to gain access to this article, reading all the comments got me thinking about intergenerational trauma and historical trauma. A lot of the times, we think about the environment, socioeconomic status, and other health disparity factors that contribute to one’s allostatic load. But being born to immigrant parents and grandparents, I have just recently learned about historical trauma that my family may still have and that contributes to how and why they/I live the way they/I do in this society. This is not often talked about when assessing a person’s history, instead just their history of their time in the United State. In some cases, there might not even be words to describe these terms in another language and therefore, can contribute to underreports of PTSD or how immigrants can even put a term to PTSD/mental health issues/trauma.
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