Psychiatry, ethnicity and migration : the case of Palestine, 1920-1948

DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. Psychiatry, ethnicity and migration: The case of Palestine, 1920-1948 RAKEFET ZALASHIK (*) BIBLID [0211-9536 (2005) 25; 403-422] Fecha de recepción: 15 de noviembre de 2004 Fecha de aceptación: 9 de febrero de 2005 SUMMARY 1.—Introduction. 2.—The state of psychiatry in Palestine 3.—Psychiatry and immigration in Palestine. 4.—Psychiatry and ethnicity. 5.—Epilogue. ABSTRACT The aim of the paper is to explore the development of psychiatry in Palestine from two main perspectives: ethnicity and immigration. In Palestine the subject of immigration and psychiatry were highly complicated and had unique features. Thus, both psychiatrists and patients were immigrants who belonged to the same ethnic group sharing the same ideology and objectives. The examination will uncover the social construction of mental diseases among Jewish immigrants in Palestine —patients and psychiatrists— and elucidate another layer in the development of the Zionist Jewish society in Palestine up to the establishment of the State of Israel. Palabras clave: Psiquiatría, Palestina, inmigración, etnicidad. Keywords: Psychiatry, Palestine, immigration, ethnicity. (*) School of History. Tel Aviv University. Email: [email protected] RAKEFET ZALASHIK 404 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. 1. INTRODUCTION The aim of the article is to explore the psychiatric health-care in Palestine from 1920 until the foundation of the state of Israel through prisms of ethnicity and migration. Based on archival material and psychiatric literature published at that period I analyze the cultural and medical construction of disease and mental health within the Zionist context. Palestine was a unique case with regard to psychiatry, ethnicity and immigration due to few main characteristics. All psychiatrists in Palestine during the examined period were Jews, who emigrated from Europe. They were part of a Zionist settlers community, while most of to a country mainly populated by native Arabs. This situation was further complicated by the fact that the foreign Mandate in power at the time did not share the same interests as these psychiatrists. These characteristics have widely influenced the development of psychiatry in Palestine and the activity of local psychiatrists. I claim that although Jewish psychiatrists shared some features of colonial psychiatry, such as focusing solely on settlers, demonstrating superiority upon native population and referring to it as a primitive one, the fact that there has been also a native Jewish population in Palestine, which had to be integrated into the Zionist national plan, prevailed them from conducting a typical colonial psychiatry in the country. 2. THE STATE OF PSYCHIATRY IN PALESTINE Psychiatry as a medical field did not exist in Palestine until the 1920s. The involvement of the Ottoman Regime in issues of public health in the country was minimal, and even more limited in the field of mental health. Although it passed a law for the mentally ill in 1892, the law’s implementation was poor, as the Ottomans did not found any asylum in the country (1). During that period, the only institution for mentally ill in Palestine was «Ezrat-Nashim» (Women’s (1) The law was fully published in Harefua, 1944, 27, 142-143. [Hebrew] Psychiatry, ethnicity and migration: The case of Palestine, 1920-1948 405 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. Aid) established in 1895 by Ita Yalin, Zipa Pines and Rosa Feinstein. This group of Jewish women decided to commit themselves to the problem of mentally ill people, who were wandering in the street of Jerusalem at the time without any treatment mainly for altruistic reasons (2). However, «Ezrat-Nashim» aimed at serving only the Jewish community of Jerusalem, and in its first decades lacked a basic psychiatric-therapeutic treatment offering only general medical care for its patients (3). The British Mandate Government, which ruled Palestine after the end of the first world war, established three governmental psychiatric hospitals during their time in power. The first opened in 1922 in Bethlehem was located in a building that had previously accommodated a German orphanage house. In contrast to «Ezrat-Nashim», it served both the Jewish and Arabic populations. In its first years, this asylum operated under the supervision of a British nurse and functioned mainly as a mere shelter without offering psychiatric treatment. In 1932, another governmental psychiatric ward in Bethlehem was founded, aimed at reducing to some extent the problem of mentally ill people in the country who needed hospitalization and could not find a place in the first governmental hospital, opened ten years before. In 1944, a third governmental psychiatric hospital was built in Bat-Yam, a Jewish settlement near Jaffa, and served Jews from Tel- Aviv and the surrounding area. The foundation of this hospital was a result of a long struggle of «The Society for the Help of the Insane», a local initiative of inhabitants from Tel-Aviv. This society opened at the beginning of the 1930’s an asylum in the town of Bnei-Brak, which was supported by the Tel-Aviv municipality and Jewish charity organizations (4). (2) About the background of this initiative see: RIVLIN, Yoel. 75 Years to Ezrat Nashim (1895-1970), Jerusalem, Agudat ezrat nashim-merkaz lebri’ut hanefesh, 1971. [Hebrew] (3) Very few mentally ill Arabs were brought to the asylum for short periods with a court order by the Ottoman police. (4) See: ZALASHIK, Rakefet. The psychiatric asylum in Bnei-Brak and «The Society for the help of the insane» 1929-1939. Korot, to be published in 2005. RAKEFET ZALASHIK 406 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. The leadership of the Zionist settlement in Palestine tended to avoid the problem of mentally ill Jews for practical, political and ideological reasons. From a practical viewpoint, the group of mentally ill Jews was hardly a subject of attention for the Zionist policy makers not only due to the common attitude of societies towards the mentally ill, but also from dynamics of the financial resources of the Zionist society in Palestine, within which mentally ill people had a low priority. The political reason for the neglect of health-care for mentally ill Jews by the Zionist local authorities at this time, was the constant debates it had with the mandatory government concerning the responsibilities towards the public health of the population in Palestine. The Zionist leadership had claimed that since the majority of the Jewish population in Palestine —in contrast to the Arab one— paid regularly taxes to mandatory government, it should enjoy a wide-scope of medical care and governmental support of Jewish medical initiatives. Therefore, it only put pressure on the British mandate to build a psychiatric institution and refused to establish an asylum under it’s own responsibility. Ideologically, from its first days, political Zionism strove to create a new society in Palestine comprised of young, healthy and productive individuals, who would become Jewish farmers that work the land and rebuilt the Jewish nation. Thus, establishing a psychiatric hospital for Jews in Palestine would contradict the fundamental line of Zionism to encourage the immigration of the physically and mentally fit and could have turned the country into a place where the sick and mentally ill were sent by their relatives in order to get «rid» of them. It is clear, then, that during the interwar period the majority of the mentally ill people in Palestine could not find any institutional health-care solution for their needs. The existing asylums suffered from a relatively small capacity of 60-80 beds per institution and created a situation where many of the mentally ill had to wait for a psychiatric bed for more than a year. Apart from the governmental and philanthropic institutes mentioned above, various private and profit-oriented asylums were opened in the country. They offered hospital care to chronically ill mental patients, usually under poor hygienic and medical conditions and without legal permission for their activities. However, since the British government could not fulfill the Psychiatry, ethnicity and migration: The case of Palestine, 1920-1948 407 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. needs of all psychiatric patients, it tended to ignore those premises, and did not close them down. The poor hospitalization possibilities for mentally ill in Palestine naturally paralleled the development of psychiatric activity in the country. Very few psychiatrists lived and worked in Palestine in the first decades of the 20th century. In 1921, the psychiatrist and psychoanalyst, Dorian Feigenbaum, emigrated to Palestine from Vienna in order to become the head of the «Ezrat Nashim» Asylum. He succeeded in the introduction of some new therapeutic conceptions within the asylum, but in March 1923, after trying to conduct a series of lectures about psychoanalysis, he was dismissed by the asylum board, which held orthodox views (5). A year later, in 1924, another two Jewish psychiatrists arrived in Palestine. Heinz Herrmann from Königsberg replaced Feigenbaum as the head of «Ezrat Nashim» and the Russian psychiatrist, Avraham Rosental, came from Berlin and was assigned to the position of manager at the Nerves Clinic in Tel-Aviv opened by Hadassah. Another Jewish psychiatrist active at that time in Tel- Aviv, was Avraham Rabinovich, who first worked as assistant in «Ezrat Nashim», from 1928 treated mentally ill people that were under the care of «The Society for the Help of the Insane», and later became the director of the asylum, which was opened in Bnei-Brak. The field of psychiatry and the issue of mental health in Palestine went through an essential change after 1933. With the rise of Nazi regime, many Jewish psychiatrists, first from German speaking countries and later from central Europe, emigrated to Palestine (6). These refugees promoted the field of psychiatry in Palestine not only because they raised the number of psychiatrists active in Palestine. They imported modern psychiatric knowledge and therapies to Pales- (5) ROLNIK, Eran. Between ideology and identity. Psychoanalysis in Jewish Palestine (1918-1984). In: John Bunzl; Benjamin Beit-Hallahmi (eds.), Psychoanalysis identity and ideology: Critical essays on the Jewish/Israel case, Boston, Kluwer Academic Publisher, 2002, p. 153. (6) About the emigration of German Jews psychiatrists to Palestine see: NIEDERLAND, Doron. The emigration of Jewish academics and professionals from Germany in the first years of Nazi rule. Leo Baeck Institute Year Book, 1988, 33, 285-286. RAKEFET ZALASHIK 408 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. tine, opened clinics and private asylums and they founded psychiatric medical societies, such as the «Eretz-Israeli Neuro-Psychiatric Society» and the «Eretz-Israeli Psychoanalytic Society» and the Psychoanalytic Institution. These various activities, institutions and societies became the infrastructure of the mental health field after the foundation of the state of Israel. 3. PSYCHIATRY AND IMMIGRATION IN PALESTINE Migration is a well known stress factor in the field of psychiatry. Hence, immigrants tend to suffer from psychiatric diseases as a reaction to a secondary socialization process accompanied by absorption difficulties. The issue of mental disease and migration has been historically studied in the context of mass immigration at the end of the nineteenth century. Immigrants from Europe to America were subjected to psychiatric examinations, medical selection and social «engineering» (7). The debate about harsh medical inspections of potential emigrants to North-America and the demands to restrict the entrance of the mentally ill, epileptic and of persons who suffered from «bad» heredity were widely supported by psychiatrists. These psychiatrists played an active role in this debate, mainly in the framework of the «Mental Hygiene Movement». In Palestine, the restrictions on mentally ill immigrants were enforced according to the Immigration Ordinance from 1925 legislated by the British Mandate. The law prohibited entrance of «Lunatic(s), idiot(s) or mentally deficient(s)» along with individuals who suffered from epilepsy, leprosy, syphilis and active tuberculosis (8). However, in the case of Jewish immigration to Palestine, it was also the Zionist leadership, which played a crucial role in the selection mechanism of newcomers. (7) See for example: DOWBIGGIN, Ian. Keeping this young country sane: C. K. Clarke, immigration restriction and Canadian psychiatry 189?-1925. The Canadian Historical Review, 1995, 76, 598-628. (8) IMMIGRATION Ordinance, 1925, section a. Psychiatry, ethnicity and migration: The case of Palestine, 1920-1948 409 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. The Jewish Agency, the Zionist organization responsible for immigration, received the from the British Mandate the authority to choose immigrants who belonged to the category of «laborers» according to an immigration quota determined twice a year by the economic absorption capacity (9). This mandate enabled it to control and regulate immigration according to its own ideological lines and political interests, while one of the means to do so has been the apparatus of medical selection. From the beginning of the 1920s the Jewish agency conducted medical selection of potential Jewish immigrants, in order to ensure the high quality of «human material» entering the country. The inspection was carried out by medical committees in Europe that determined the candidates’ eligibility for receiving an immigration certificate. These frameworks lead to a constant tension between political and medical interests, while blotting their presumed distinctive borders. Alongside to the medical selection conducted by Zionist committees in countries of origin, an early idea of the Zionist movement to expel chronically sick immigrants, who managed to enter Palestine despite of the medical inspection, or got ill after their arrival, came into realization in the 1920s (10). The policy of Zionist organizations to restrict immigration of mentally ill Jews to Palestine and sometimes to send them back after their arrival was still common during the 1930s. At the end of November 1933, Henrietta Sald, the head of the Health department of the Jewish Agency, wrote a letter to Dr. George Landauer from the German Department of the Jewish Agency in Berlin where she demanded the conduction of a more severe medical inspection of immigration candidates who applied to the office in the city. Sald mentioned in her letter the case of family M. that managed (9) MOSSEK, Moshe. Palestine immigration policy under Sir Herbert Samuel: British Zionist and Arab attitudes, London, Frank Cass, 1978. (10) MARGALIT, Meir. Issues of newcomer selection at the beginning of mandatory period. Ideology, policy and execution. Judaism of our time. Zionism, the state of Israel and the diaspora, 1999, 13, 243-246. [Hebrew] RAKEFET ZALASHIK 410 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. to pass the medical inspection in the Berlin office and arrived in Palestine. The mentally ill mother was hospitalized in a psychiatric asylum straight after her arrival, while the father was classified as a «psychopath» by all local authorities, who had had contact with him. This ill family became a burden on the German newcomer organization in Palestine, which financed the treatment of the ill mother and took responsibility for the children’s family. Sald urged Landauer «to take back this family to Germany since the office (…) was not allowed to send over such a family, especially as the members of the family were known also in Germany as ill and not normal» (11). Despite of the double selection mechanism conducted on Jewish immigrants by the Jewish Agency in the countries of origin and by British Mandate in the ports of Palestine, it seems that compared to other immigration countries, Jewish psychiatrists in the land played only a very limited role in the restriction, medical selection and expulsion of mentally ill immigrants. They merely acted in cooperation with the Zionist leadership, warning repeatedly against the arrival of chronic mentally ill patients in Palestine that would make exacerbate the already acute problem of the unavailability of psychiatric beds. In cases of expulsion of chronic mentally ill from Palestine, local psychiatrists were often requested to examine the mental state of the individual and to determine whether he was fit to take the long trip back to Europe —either escorted by medical staff, by a relative or unaccompanied. Jewish psychiatrists were de facto the only psychiatrists in the country, and while their involvement in the medical inspection of immigrants was limited, they were certainly preoccupied with the mental and emotional state of Jewish immigrants. From a scientific point of view, the psychiatrists regarded the immigration of Jewish Zionists as a «mass experiment» that offered an opportunity to investigate the connections between the individual’s adjustment to the new life and (11) Zionist Archive, J1-6203. There is no further information about the fate of Family M., so it is not clear whether Sald succeeded in sending the family back to Germany. Psychiatry, ethnicity and migration: The case of Palestine, 1920-1948 411 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. his mental state (12). Psychiatrists in Palestine conceived the act of immigration as a fertile ground for the development of psychoses and neuroses, which break out as a result of adjustment to bad conditions in the new land. This view was supported by indications proving that the highest number of mentally ill cases among immigrants occurred especially in the first years after their arrival in Palestine. But it was not only a scientific interest, which drove local psychiatrists to concentrate on Jewish immigrants. From a practical point of view, since Jewish immigrants needed a psychiatric treatment more than any other group in Palestine at that time, they became the focal point of psychiatric interest. It is impossible to determine whether the high frequency of Jewish immigrants who were in need for a psychiatric care was indeed a result of an absolute high rate of mentally disturbances among them. It might be that the fact these individuals lacked financial resources and relatives in the country turned them quicker than other groups to psychiatric patients. It is also possible that the native communities strove to avoid, when possible, the hospitalization of mentally ill members because of the social and financial costs. However, it seems that also Jewish psychiatrists in this period could not determine whether Jewish immigrants indeed suffered more than any other group in Palestine from psychic morbidity (13). In 1924, Feigenbaum reported about few hundreds of Jewish newcomers from Russia and Poland he treated during his stay in Palestine between 1921-1923. This wave of immigration, termed in the Zionist historiography as the «Third Aliya» was an ideological wave comprised of many youngsters triggered by the anti-Semitism, which had broken out in Eastern Europe during the first world war and the October revolution in Russia. Feigenbaum described cases of Jewish youngsters, who suffered from a traumatic past in their countries of origin: (12) The concept of «mass experiment» is present in most of contemporary psychiatric literature. See for example: BLUMENTAL, Kurt. Mental diseases among newcomers. Harefua, 1937, 13, 251-258. [Hebrew] (13) BLUMENTAL, note 12, p. 257; HALPREN, Liphman. Mental diseases among the Jews in Erez-Israel. Harefua, 1937, 12, 6. [Hebrew] RAKEFET ZALASHIK 418 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. Hence, British officials in Palestine conducted a hierarchical separation between indigenous Muslims and Christians, while romanticizing the rural life of Muslim peasantry in the country, which in reality has been the opposite of tranquil and peaceful. As mentioned before, psychiatrists in Palestine did not only distinguish between the mental morbidity of Jews and Arabs, but also constructed an internal distinction. From the end of the 19th century, the Jewish population in the country consisted of several sub-groups: Jewish immigrants, native Jews, Ashkenazim and Sephardim. In general, most of the psychiatric literature in Palestine concentrated on immigrants from Europe, whereas native Jews, especially the Oriental one, were almost fully ignored. When native oriental Jewish population was mentioned, it was often presented in a negative light as primitives that either hardly suffered from mental diseases or as a community that treated its mentally ill people with ignorance and cruelty. In 1929 the psychiatrist Rabinovich wrote a summary article about the type of patients, who were hospitalized in «Ezrat Nashim» asylum between 1921-1928 relating to their diagnosis, duration of treatment etc. In this article Rabinovich distinguished between what he called «primitive races» and the rest of the patient explaining: «One cannot ignore our primitive races (Bacharian, Persian, Georgians). Their consciousness, has poor content, it has no special demands from life, it is submissive in a slavery way to external conditions and therefore, it suffers no conflict and is very little inclined towards functional diseases in the nerves system and especially within mental illnesses» (27). And indeed during seven years only 21 patients treated in «Ezrat Nashim» belonged to the «primitive races». However, Rabinovich was less optimistic about the future: (27) RABINOVICH, Avraham. The Eretz Israeli reality and the help for mentally and nerves ill people. Harefua, 1929, 3, 10. [Hebrew] Psychiatry, ethnicity and migration: The case of Palestine, 1920-1948 419 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. «The development of culture and its invasion of these races, will no doubt influence them, and in the future they will also produce a significant percentage of neuroses, psychoses etc, as it happened to many primitive races. Among the Negroes in the United-States, which used to show a negligible rate of mental diseases, the situation changed substantially with the entrance of European culture to their tents, on their advantage and disadvantage. The rate of the mentally ill people among them increased and has become equal to those of whites» (28). From Rabinoch’s article it is clear that not only has he seen insanity as a disease of civilization whereas it can only exist among individuals or ethnic groups who have a developed consciousness and a cultivated personality, but also that he conceived himself as white superior man in comparison to other sub-groups within the Jewish community. In another article, Herrmann, who treated native Jews in «Ezrat Nashim» and Arabs in his private clinic, determined that the available European reports about manic-depressive patients were not very different from the material Herrmann gathered in Palestine after ten years of psychiatric activity: «I have found that paranoid patients have significant hallucinations only quite rarely. The fact that the fantasies of insanity among the natives with an oriental origin are sometimes of another nuance, and have in a familiar way a certain local feature, is insignificant in comparison to general common picture. Our catatonics also hide under the blanket, our hepephrenics tend to become manic as well, our irritated patients also tend towards violent acts (…) etc.» (29). However, Herrmann’s material about 126 Arab schizophrenics he treated, suggested different conclusions. Herrmann reported about his difficulty in diagnosing Arab and Oriental Jews in his clinic especially in manic cases: (28) RABINOVICH, note 27, pp. 10-11. [Hebrew] (29) HERRMANN, Heinz. Ten years of experience in psychiatric work in Jerusalem. Harefua, 1935, 10, 387. [Hebrew] RAKEFET ZALASHIK 420 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. «Signs of general neurasthenia resulting from degeneracy make it hard for the normal psychiatrist to treat non-Jewish patients in particular, and sometimes they can lead wrong diagnosis. There is no doubt that also in depressive cases of Jews and Arabs, one can often find a demonstrative theatrical line, and more explicitly: an oriental motor line in the formation of melancholy» (30). The problems that cultural differences posed for diagnoses expressed by Herrmann, is familiar from the reports of other psychiatrists, who were active in an ethno-psychiatric milieu in the colonies from the end of the 19th century onwards. These psychiatrists complained about the difficulties they face in distinguishing between «normal» and «abnormal» behaviour of the «natives» they treated (31). Megan Vaughan claimed that while in Europe the mentally ill was defined as the «other», in colonial African the «other» has already existed in the form of the colonial subject. Hence, the category of the mentally ill included already the colonial subject who was insufficiently «other» (32). The cultural tensions manifested in interactions between immigrant psychiatrists and native patients was more present with the arrival of many Jewish psychiatrists from German speaking countries during the 1930’ies. Already in the first meeting of the «Eretz Israeli Neuro-Psychiatric Society» in Jerusalem, which took place in 1934, the psychiatrist Hirsch, a newcomer from Germany, gave a lecture entitled «The affinity of the patient to the physician with attention to special condition in Eretz-Israel». In this lecture, Hirsch complained that he had difficulties in treating patients in the country which belonged to the old Jewish settlement. He found among them a strange mental attribute, which reminded him the primitives (33). However, his (30) HERRMANN, note 29, p. 388. (31) See for example: CAROTHERS, John Colin. The African mind in health and disease: A study in ethnopsychiatry, Geneva, World Health Organization, 1953; SACHS, Wulf. The insane native: an introduction to a psychological study. South African Journal of Science, 1933, 30. (32) VAUGHAN, note 21, p. 101. (33) SOCIETY for mental and nerves diseases in Jerusalem (The). Harefua, 1934, 7, 94. [Hebrew] Psychiatry, ethnicity and migration: The case of Palestine, 1920-1948 421 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. attempt to make a full uniformity between the native Jews and the primitives met an objection. It the discussion following his lecture it was said that: «The attempt to find proves between the characteristics of patients from the old generation and the characteristics of the primitives is not successful. (…) The primitives relate to their physician with full trust and admiration. In contradiction to the primitives, the Jews of the old type, have a developed mental culture, which is, indeed, hard to understand if the physician lacks the knowledge. If he does not know the milestones of this culture, he cannot gain the trust of the patient, especially, when it comes to questions of drive and personal issues» (34). 5. EPILOGUE As shown, the case of psychiatry, ethnicity and immigration in Palestine until the foundation of the state of Israel is not a typical case of ethnicity and immigration. The psychiatrists who were active in the country played a limited role in issues of immigration restriction, however they were preoccupied with the Jewish immigrants who suffered from mental diseases. Although they rejected a racial hierarchy between the native population and the Zionist newcomers, they adopted other common explanations concerning the difference in manifestations and frequency of mental illnesses between the immigrants and the natives pointing at the primitivism of the latter. Since the native population in Palestine included Jews, the opinion about local primitivism was ambivalent. On the one hand, they wished to distinguish between the Zionist Jews and the Jews of the old Jewish settlement in Palestine in order to give validation to the Zionist project of national motivated settlement. On the other hand, since one of the justifications of political Zionism was the historical connection between the Jews and the land of Israel along with the blood relation between all Jews around the world, unifying between the Arab (34) SOCIETY, note 33. RAKEFET ZALASHIK 422 DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 2005, 25, 403-422. natives and Jews in relation to mental disturbances, created a certain uneasiness. Therefore, although the Jewish psychiatrists conceived themselves as representatives of the white European culture, one can trace in their writings and activities during the examined period a constant tension between definitions of mental illness as disease of civilization, primitivism and the ethnical groups and sub-groups who were put into these definitions.