Rita Giacaman: We normalize the abnormal

Rita Giacaman founded the Institute of Community and Public Health at Birzeit University and has spent decades building a way of measuring what happens to Palestinians that does not begin by importing a category. She was interviewed by Sélima Kebaïli for Books & Ideas on 19 December 2023, ten weeks into the war on Gaza, and the interview is unusually clear about method — which is what makes it citable rather than merely moving.

She begins by refusing the vocabulary of the field. Asked about “objective” health indicators, she answers that the term “implies that subjective indicators, such as quality of life, or self-rated health… are invalid while objective ones are considered the truth”, when in fact “subjective indicators can predict death and disease and are very important because they bring in the voice of people themselves into assessments.”

Her institute’s whole approach follows from a decision about what to place at the centre of inquiry. At the ICPH, she says, “we have developed an understanding of health derived from our lived experiences which have led us to a research agenda that places suffering at the center of inquiries, in a continuum between ease, the state of complete health, and dis-ease, or sickness.” Health, on this account, is “primarily a social and political construction, and not only a biological predisposition.” From that came the measures she is best known for: “we began to develop quantitative measures that can assess the suffering people endure in chronic warlike conditions, what I call the ‘invisible wounds inside’.” The items are named plainly — “distress, human insecurity, uncertainty, human rights violations, deprivation, and humiliation.”

On PTSD she is direct, and the objection is the same one Samah Jabr makes from the clinic: “There is a real problem with the concept and measures of PTSD. First, in the Palestinian context, there is no such thing as post. Violation and political violence are ongoing, so it is not that we have been through violation and now need to get over it. It is that we are chronically violated every day.”

But the sentence that follows is the one that most often gets cut, and it is the reason this entry exists. Having said there is no recovery period, she does not stop at damage: “although somehow, and amazingly, we seem to be resilient, and as I have written elsewhere, we normalize the abnormal. That is, we endure and resist violation by remaking daily life as normal as possible after a violent attack, especially because we are surrounded by networks of supportive relationships with families, neighbors and community who assist in accessing a range of resources to help us in resisting violation and normalizing the abnormal and getting back to daily life as quickly as possible.”

She also insists that the violence in question is not only the spectacular kind. Alongside “systematic and chronic exposure to political violence” there is “the violence of trying to obtain a permit to cross an Israeli army checkpoint with checkpoints dotting the landscape of the West Bank; the violence of trying to get to the university without being hit by tear gas or sound bombs thrown at us by the Israeli army, or walking because the Israeli army has gouged out the roads; or the violence of being denied a permit by the Israeli occupation administration to exit the country, or stay in the country no matter how old or sick you are.” Her phrase for the sum: “daily violation, even without being shot or killed or injured. Indeed, daily suffering.”

And on the war then two months old, speaking as a demographer of her own people’s deaths, she says what an archive of names has to keep in view: “Sometimes I find what is written unbearable. Numbers of dead, numbers of injured, numbers, numbers, numbers, my goodness. We are not numbers, we are people with feelings and suffering, the bulk of us are suffering as we have not been killed or injured yet.” Then the line that ought to govern how the rest of this archive is read: “It is not enough to count dead bodies; we need to tally the effects of war by finding out what happens to the living.”

Sources

• Palestinians’ mental and physical Health — an interview with Rita Giacaman by Sélima Kebaïli, Books & Ideas, 19 December 2023
• Unbearable suffering: mental health consequences of the October 2023 Israeli military assault on the Gaza Strip — BMJ Global Health, 30 September 2024 (Giacaman is a co-author; the paper glosses “the invisible wounds inside”)