Coming of Age Under Chronic Displacement: The Health and Wellbeing of Palestinian Refugee Adolescents Girls in the West Bank and Jordan The creation of the state of Israel led to the chronic displacement of Palestinians throughout the world, most notably in 1948 and then in 1967. Today many Palestinians are refugees spread throughout the world or are internally displaced both within the occupied Palestinian territory (oPt) or in what became part of the state of Israel. Presently, multiple generations of Palestinian refugees reside in Palestine refugee camps in the oPt, Jordan, Lebanon, and Syria. The continued displacement of Palestinian refugees and the manifestations of ongoing settler colonialism impact the health of Palestinians both in direct ways and through shaping the structural and social determinants of health Palestinians live under. In this study, we seek to understand the health and well-being (and their determinants) of adolescent refugee girls residing in Palestine refugee camps in the West Bank and Jordan. We draw on in-depth qualitative research consisting of 39 in-depth interviews and 24 focus group discussions with over 200 adolescent girls, in addition to about 60 interviews with various stakeholders and camp community members living and working in 29 Palestine refugee camps in the West Bank and Jordan. The findings from our study highlight the intergenerational impacts of the Nakba and ongoing settler colonialism on the health of Palestinian refugees both in the West Bank and Jordan. In both contexts, the camps are characterized by various forms of exclusion and deprivation, including socioeconomic and political exclusion that curtail opportunity and have adverse impacts on the social determinants of health. In Jordan, and particularly in more remote camps like Jarash camp, the lack of legal status for some camp residents and the stigma associated with being a refugee and camp dweller limited opportunities and shaped how girls interacted with their environments. In the West Bank, constant exposure to violence and targeting by the Israeli military had adverse impacts on health and well-being. Furthermore, the lack of infrastructure in camps and the lack of privacy linked to the overcrowding of camps were a source of suffocation and stress for girls. The findings of this study highlight the ongoing impacts of settler colonialism and chronic displacement on the health of fourth-generation refugees.

Indigenous people suffer earlier death and more frequent and severe disease than their settler counterparts, a remarkably persistent reality over time and across settler colonial geographies, and despite their ongoing resistance to elimination. Although these health inequities are well-known, they have been impervious to comprehensive and convincing explication, let alone remediation. Settler colonialism, the focus of a fast-growing multidisciplinary and interdisciplinary field, is a promising candidate to rectify this impasse. In Palestine, settler colonialism’s relationship to health inequity is at once obvious and poorly described, a paradox arising from epistemic coloniality and perceived investigatory challenges. First, in considering settler colonialism an enduring structure rather than a past event, and by wedding this fundamental insight to the ascendant paradigm understanding health inequities as structurally derived, a picture emerges in which this sociopolitical formation serves as the foundational and ongoing configuration for specific social mechanisms that impose on human health in the Israel/Palestine context through means such as ongoing land theft, dispossession, forced displacement, and ‘unchilding’, among others. Second, because modern racialization has served to solidify and maintain the hierarchies of colonial relations in Palestine, settler colonialism adds explanatory power to racism’s health impacts and potential remediation by historicizing the process of ‘racial palestinianization’ that is occurring in Israel. Finally, while not invoking settler colonialism explicitly, studies on Palestinian health have provided insight into the health impacts of various tools of settler colonialism such as displacement, urbanization and regional planning, and various means of territorial control that lead to poor health access and health outcomes for Palestinians. Furthermore, advancements in structural racism methodologies have begun to elucidate the possibilities for developing a body of literature linking settler colonialism and health, illuminating future research opportunities and pathways toward the decolonization required for health equity for Palestinians and other indigenous populations around the world.

One cannot pursue “the right to a standard of living adequate for the health and well-being of himself and of his family,” Article 25 of the Universal Declaration of Human Rights, without free movement. Yet evidence suggests that restrictions of freedom of movement are a consistently deployed tool by oppressive and violent state regimes, often based on some characteristic of the oppressed that is relevant to the conflict: religion or sect, race, geographic location, or political affiliation. When an individual’s freedom of movement is restricted, their ability to achieve the highest standard of health is restricted as well. This has been evident throughout the 75 years since the establishment of the Israeli state, exacerbated by the military control and restriction of the occupation of the West Bank and Gaza Strip and, later, the blockade of the Gaza Strip. This has resulted in a fragmented Palestinian health system and stunted health outcomes, issues that are too often approached as unfortunate humanitarian outcomes of war, rather than as purposeful tactics of a settler colonial regime. Further, the tangible outcomes on individual patients and providers are missed when considering only population-level outcomes. In this study, my primary research question is the following: how do movement restrictions impact the health services experience of patients, providers, and other health system stakeholders in the West Bank? Additionally, how do movement restrictions impact the experience of health services for different patient populations (e.g., based on sex, income) and types of healthcare (e.g., primary, emergency)? Using a qualitative research approach, I conducted 7 focus groups and 40 individual interviews with patients, providers, and other health stakeholder in the occupied West Bank. Building on previous research and reports from NGOs, I describe how restricting movement is a mechanism of structural violence in occupied Palestine that significantly reduces health access, quality, and outcomes, punctuated by the real-life experiences and accounts of the respondents in this study. I found that the negative health outcomes from such restrictions are vast, including delays or denials in accessing care, burnout among health providers, and an avoidance in attempting to access care altogether in some patients. Although further research is needed, this study shows that Israeli movement restrictions have significantly impacted Palestinian health negatively—and many respondents found these challenges to be purposeful mechanisms of oppression, not merely outcomes of an overly securitized state.

Because the roots of Palestinian health inequity reside in their historic and ongoing dispossession, achieving full health and wellbeing requires remediation of the power dynamics and domination that impede Palestinian rights to freedom, sovereignty, and, for refugees, return home. With the current absence of such a geopolitical solution, strategies to mitigate the chronic health impacts of settler colonialism and apartheid are of interest, particularly those that might heighten community health agency rather than contribute to passive dependence. This research analyzes the feasibility and outcomes of a specific community-run health initiative, Health for Palestine (H4P), that was designed to mitigate the fragmentation of care resulting from settler colonialism and the complexities of a massive, prolonged refugee crisis. H4P was established in 2018 by the Lajee Center, a grassroots community center in Aida refugee camp in Bethlehem, occupied Palestinian territory (oPt), that focuses on health, education, and the cultural arts. Partnering with 1for3, a Palestinian-led and US-based NGO, Lajee has recently expanded its H4P program to Nablus’ Balata refugee camp. In consultation with the Aida and Al-Azza camp inhabitants, H4P began with targeting chronic diseases like diabetes and hypertension that fuel the most common causes of morbidity and mortality in the oPt. H4P’s model consists of professionally trained, paid community health workers, all refugees themselves, who provide social accompaniment consisting of medication supervision and delivery, transportation facilitation to clinics and hospitals, adherence support, motivational interviewing, and monitoring of vital signs and glucose. Despite the ongoing medical professional emphasis on behavior and biology, diabetes is now increasingly recognized to be overdetermined by structural and social factors, exemplified by the stark settler-Indigenous disparities seen in every settler colonial context. In mitigating the impacts of some of these factors, H4P’s work, run by and for Palestinian refugees with support from grassroots fundraising, has resulted in significant improvements in diabetes and blood pressure control, while also providing sociopsychological support, near-complete patient retention, and health data ownership to many of the camps’ inhabitants living with chronic disease. Given that traditional health models are unlikely to succeed on their own in settings like the oPt that are afflicted by chronic violence, dispossession, and occupation, intensive community-run health initiatives like H4P may represent a feasible supplement that can provide multimodal organizing and health benefits while eschewing humanitarian depoliticization and demobilization.