Building Treatment Systems in Palestine (w/ Rania & Dr. Fathy Flefel) – C4 Recovery Solutions Podcast Episode 7

Episode 7: Building Treatment Systems in Palestine (w/ Rania & Dr. Fathy Flefel)

In this episode, Rania Aljawi talks about a unique holistic treatment program which supports people with substance use disorders in Palestine in the face of relentless political aggression. Joined by Dr Fathy Flefel, the panel talk about how C4’s involvement propelled the effort forward, and the challenges and successes of the program today.


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Jack O’Donnell Welcome to another episode of the C4 Recovery Solutions podcast. I am your host, Jack O’Donnell. I’m the CEO of C4 Recovery Foundation. C4’s mission is to improve access to high-quality, ethical treatment services for behavioural health and social wellness. We also advocate for those who are often overlooked in drug recovery conversations. We developed service delivery systems for addiction and recovery programs throughout the United States and the world, in some of the most challenging environments.

Each time on this podcast, we tell stories of people who have benefited from C4’s programs and those who assisted C4 in the process. Today, we are talking about a unique addiction treatment program in Palestine and the impact the decades-long conflict in the region has had on the drug use habits of those living there.

The Palestinian people in the West Bank and Gaza have been a particularly vulnerable population for substance use disorders and mental health issues. Because of the harsh policies of the Israeli government, they are among the most at-risk populations in the world. The United Nations Office on Drugs and Crime has stated that “in Palestine, the unique socioeconomic context and economic tensions has created conditions that facilitate the spread of illicit drug use.” Palestinians face political persecution, house demolitions, restrictions of movement, and encroachment on their land. For many Palestinians, drug use has become a coping mechanism while living under these unfathomable conditions. The experience of violence can have long-term emotional effects and may foster harmful behaviours, including substance use.

Young people and their families are profoundly affected by the Israeli occupation and the repeated exposure of political violence. It affects all aspects of everyday life. In many respects, the Palestinian people are caught between a rock and a hard place with little hope for change.

From 2012 through 2017, the C4 Recovery Foundation led a small group of concerned organisations in an effort to educate and implement an upgraded professional approach to substance use disorder treatment. While working in the West Bank and Gaza, C4 worked with three local organisations: Al Huda, a non-profit that focused on addressing treatment needs of individuals in the West Bank; the Palestinian Red Crescent, a humanitarian organisation that is part of the International Red Cross; and various ministries of the Palestinian National Authority, which is Palestine’s national government body.

The first year of C4’s involvement was dedicated to evaluating current resources and educating on the vision and the value of a full continuum of care in a community-based model. In the next five years, C4 participated in training and technical assistance. In this phase, C4 and its partner organisations in Palestine addressed knowledge enhancement on addiction treatment, access to treatment and [essential] community issues, such as housing, food, jobs, general healthcare, and spiritual and cultural needs. C4 also addressed the need for improving professional infrastructure, which became critical to ongoing funding.

Rania Aljawi worked with C4 on developing this program. She was part of the steering committee at Al Huda, coordinated with the Palestinian authority and the local government NGOs. Here she is talking about the conception of the treatment program.

Rania Aljawi Actually, the government of Palestine and the government of Israel didn’t have, at that time, a governmental rehabilitation or treatment programs to the drug addicts. But even in Jerusalem, the type of the program by the Ministry of Social Affairs, it was even encouraging the drug addicts to continue with the substance abuse. Because, actually, if you had a blood test or urine test, and the result was that you have a high percentage of drugs in your blood, they will ask you not to go to the work and they will give you even a monthly salary. It encouraged even the addicts to continue, because they are receiving money, they are not doing anything, and they can even continue buying the drugs. So, in West Bank and in Gaza, the whole issue of the drug addicts wasn’t on the agenda of the government.

Al Huda is actually a community-based organisation. It started with efforts of individuals. And they themselves, they were drug addicts, but they recovered and they wanted to support because they know what does it mean to be a drug addict and what does it mean to be a family member of a drug addict.

When we coordinated with all the organisations working in the field of the drug rehabilitation, Al Huda was on the list. And Dr. Bob and Mr. Rick and their team, we went and we visited them. And, actually, they listened to their program and they have been impressed even with the minimal resources they have and they started to discuss how best they can support this organisation to maintain this level of comprehensive services and what type of technical support they need, capacity upgrading they need. And from this point, we started to organise all the work and the relation between C4 Recovery Solution and Al Huda to ensure that the financial contribution by the C4 Recovery Solution, it will really end up achieving the intended results.

It was a long process, but, at the end, we succeeded to come into an agreement with Al Huda on how they will invest these financial resources in the way that we will ensure quality and comprehensive services. So, here, when we started actually also to see more progress on the level of discussion with the PA government to use Al Huda as a model for any support in the future to the rehabilitation and the treatment.

And here, when also Dr. Bob and Rick offered their assistance and support to the PA government, through the Ministry of Interior, to – actually to come and three train the professionals in the country on the different approaches and modality inpatient and outpatient treatment and rehabilitation. And with all these discussions and training and capacity-building the programs, it helped a lot to change and to do a shifting in the mindset of the people in the PA, in the government.

The program is still active today. But, actually, they minimised their capacity of how much they can receive, because, actually, it is overburdening financially on them, without extra support, and also because the political situation in Jerusalem, it’s now more complicated than before, because of all the discriminatory policies, mainly because of the issues like the demolition, a high rate of detention and arrest, and other issues. Settlement expansion, confiscating more lands from the Palestinian is shrinking the space for the Palestinians to be and exist in Jerusalem. So, they started to be burdened by the political issues. And the attention, it’s now given by all the organisation on how to help people to be resilient and to help their steadfastness against the political conflict, the impact on them. So, the attention on the addicts is – is decreasing day after day. So, for the Al Huda hood to be able to sustain their programs, they needed to decrease the number of the people that they can serve.

Jack O’Donnell For today’s panel, I will be joined by Rania Aljawi and Dr. Fathy Flefel, both who were intimately involved in the development and the implementation of this program. Rania, let’s begin with you. Could you just introduce yourself?

Rania Aljawi My name is Rania Aljawi. I’m the child protection advisor working at international organisation called Save the Children and I’m living at the old city of Jerusalem.

Jack O’Donnell Tell me a little bit about, you know, how you got initially involved in this effort.

Rania Aljawi In 2008, actually, I have been selected by a welfare association to be the coordinator for the assessment on the substance abuse prevalence in West Bank, Jerusalem, and Gaza. And here, when you’ve been introduced to Mr. Rick Ohrstrom and his team, Dr. Bob, and I supported them in the coordination efforts with all the relevant line ministries and the local NGOs and international NGOs working and interesting in providing support to the youth and the protection programs, as well as to support the [families] of the drug addicts and the people with substance abuse disorder and related issues.

Jack O’Donnell You know, because the – the issue is so acute, did you really believe when you took this challenge on that you could make a difference?

Rania Aljawi Actually, after the assessment, actually, in the real world, on the ground, being exposed to the people whom they are affected by the substance abuse and how much their families are suffering—their wives, their mothers, their children—and I see actually the scale and level of impact of the substance abuse disorder on the whole family, but also the community, for me, it was very painful, heartbreaking to see all these suffer. And I felt that something should happen to support those people and to find a way also to support the addicts themselves, because, actually, they are victims. All these issues and what I experienced when I hear the people’s stories, I felt that, really, we are all responsible to protect and to support those people.

Jack O’Donnell Yeah. Well – well, thanks for that explanation. I mean, we’ve always called substance use disorders trauma addiction. We’ve always called it a family disease. Dr. Flefel, let’s, you know, let’s go to you before we move on with some of this real serious conversation. You know, why don’t you introduce yourself, if you would, and tell us how and when you first started working with C4 and on this project?

Dr. Fathy Flefel Yeah. My name is Fathy Flefel. I’m actually a therapist by professional, living in Ramallah and working as a mental health director in Palestine Red Crescent Society. And , actually, I was working in this area since ’92. I was a psychologist working with drug addicts and their rehabilitation centres in Jerusalem. More or less, in the same as Rania, as she was mentioning, I have a visit from Rick and Dr. Bob. And from there we begin talking how we can, all of us, trying to do something to help those people and their families who are really suffering from the situation that they are in.

Jack O’Donnell You know, I’m always curious when we go into a new country. You know, how receptive were the local people to having outsiders, particularly Americans in this case, come in to, you know, to your territory and evaluate what was happening in Palestine? And both of you can chime in on this one for me.

Rania Aljawi From my observations, actually, when I started to coordinate for this assessment and even also attending all these meetings, actually, because there is a huge gap, no one is thinking about those people. Actually, not the international community. What I mean, the donors who are providing the funding for programs to serve the – the affected people. Because, actually, they don’t think that this is the area that they are interested in – in funding. So, actually, they are left behind and no one is – is really putting an effort. So, when they knew that there is an assessment mission, even by externals, they will come there, because, actually, they’ve been suffering since years, since decades, and no one is showing any attention. So, actually, they will come there, because they wanted, actually, anyone to bring attention to this issue and what is happening. Because, actually, even in their communities, they are stigmatised and labelled, them and their families.

Jack O’Donnell Dr. Flefel, I – I assume you agree, but, you know, give me your impression.

Dr. Fathy Flefel Definitely. I agree totally with Rania Aljawi. And plus, I think that the Palestinians, in general, they are really used to have more and more international organisations who are working for the Palestinians. This is first of all. Secondly, that the huge need, as Rania, as she was mentioning, it means that people, especially those, you know, organisations who are working in the field of drug abuse issues, also, they are looking for any – a new, let’s say, experience of others to help themselves to be able to help those who are really in need. And the second issue, usually, you cannot really create the things from zero. What I like also in Palestinian’s organisation or the Palestine, in general, that we are more and more able to exchange the experiences with others. And when Dr. Rick and Dr. Bob, I mean, C4, actually, they are coming with their new ideas and new projects or programs, I think it was also such as good entry point with the local community and the local organisation that we were working with.

Jack O’Donnell You know, very often, we know, it’s – it’s very difficult to get people to admit they have a problem and actually seek treatment. Tell me a little bit about the obstacles you faced getting people into the program that needed the help.

Dr. Fathy Flefel Yeah. First of all, I think that one of the strength points was that we are focusing in treatment more than the prevention. Usually, the international organisation, they are coming to do some kinds of prevention. The good parts in this program that was focusing actually in how we can do, first of all, to work more and more in rehabilitation and to do some kind of methodologies, let’s say, related to rehabilitation. Secondly, to focus more in working with the existing organisation who are providing such as services. Thirdly, to build the capacity of the teams who are working in this organisation. And this is—. I think that was such a unique point to enter. It means that it facilitates a lot of missions on how to convince people to be engaged as organisations.

And the second issue, as I was mentioning before, the needs. The needs are huge. And there is a lot of organisation who are dealing with the rehabilitation part of the problem itself. But still, then this—. I think the obstacles that I can’t talk about it. First of all, let’s say a financial part, that the needs are used, means that how come that we can’t, through this project, cover the whole needs of the issue itself. Secondly, it was a little bit difficult to work with the existing organisation to reorganise their work, you know. It’s not really easy. When you’re talking about change, it’s not really easy the people to accept the change and to begin really working in a new way of reorganising their – their work. Thirdly, it was a little bit difficult also to convince people to change their ways of intervention or the methods that they are using. I think that this is the three main obstacles that we have. How we deal with these obstacles, I think, we were a little bit patient. We tried to build in what they have, not to begin from scratch. Thirdly, we try to focus in their, let’s say, strength, not in their weaknesses.

Jack O’Donnell Yeah. That’s great. Tell me a little bit about how the whole trauma piece was integrated into the program, because that, in particular, in the West Bank and in Palestine, you know, this is a huge issue. So, I am assuming that everyone basically had a dual diagnosis here.

Dr. Fathy Flefel Yeah. I can say something, that we cannot really say that if they are traumatised. But to the situation itself, it’s really so difficult that if they are rethinking trauma situation, but if they are not traumatised. This is how I see the things. We cannot really talk about trauma scientifically or clinically. Secondly, I think that even the children and the families of the people who are drug addicts, they can really deal with their own stresses. They can really try to benefit as much as they can from the – the support system that they have around them, especially the family. Because we are talking about the Palestinian family support of the whole holistic approach intervention, means that how we can really benefit from the support system coming from the family. This is also something that we can really build on that. And thirdly, that the last, let’s say, twenty years, we are focusing more how we can rebuild the hope and how we can really manage the resilience of the Palestinians more than focusing in the clinical part of it is the community work itself, it was really one of our strengths that we were focusing in.

Jack O’Donnell Great. Raina, do you have anything to add to that in terms of what you were primarily seeing and treating?

Rania Aljawi My answer to your question is that, because I’m not a practitioner in the field of clinical therapy treatments or rehabilitation, because, actually, I’m providing the technical support to the child protection programs, but I can say that I’m dealing with the overall child protection issues. One of these issues and risks is that having a family with an addict family member, mainly one of the parents. As Dr. Fathy mentioned, they are actually exposed to more than a traumatic incident in their life and events, starting from the political conflict violence, ending up with the internal environment on a domestic level, when the family, at the same time, having a problem in providing sufficient and proper care for the children. It is traumatising. But maybe because no much researches studied the trauma among the Palestinians, we don’t have much of statistics and scientific correlation between the substance abuse and trauma in a clinical definition of the trauma.

Jack O’Donnell You know, doctor, if we fast forward to today, what is your funding stream today? How – how have you been able to maintain, you know, the programs over the years?

Dr. Fathy Flefel I think, thanks to C4 Recovery, that they were putting their effort and support, now I can say that one of the organisation that they were benefiting from this program, now they have their own system, they have their own income that they are trying to benefit as much as the. They doubled up own relationship with the community. And now, part of the fund it’s coming from the community itself. The second issue that the Palestine authority also, they create the National Centre for Treatment funded by the Palestine Authority. People, they start talking about what we did that time and they appreciate what we are doing and they were trying to maintain their work as much as they can.

But definitely, as Rania, as she was saying from the beginning, that the drug issues or, let’s say, the treatment, let’s say, because it’s a little bit costly, needs always more and more fundraising. It needs more and more [inaudible] building and it needs more and more developing the methods of intervention. Because, you know, if you tell me that, every single day, there is a new treatment methods that definitely we are in need to be able to understand it and to be able to maintain it to be acceptable by the Palestinian culture itself.

Jack O’Donnell Yeah. Thank you. You know, this last question that I have for both of you, arguably, it’s probably an emotional one. But, you know, even the most recent escalations that we’ve seen this year in the regions have, once again, seen a disproportionate amount of damage to both the infrastructure and to the Palestinian people. I know it’s heartbreaking. But if you are comfortable, could you tell me what gives you hope?

Dr. Fathy Flefel I believe in [inaudible]. I believe that people, they will continue trying and trying and trying to save their selves and to help each other. I believe that the Palestinians also, they are able to rebuild their resilience and to be able to deal with any new, let’s say, situations that they are facing. I also believe in those who are trying and continue trying to help people in need.

In a daily basis, you can see more and more youth who are became volunteers working for local and the international organisations. And I think seeing those youth who are able to give time and to give to help those were really need, it give us more and more hope that we will reach our, let’s say, dreams someday.

Jack O’Donnell Great. Thank you. Rania?

Rania Aljawi Actually, it’s—. The people there are—. I visited Gaza after the recent escalation. The resilience of the people there is phenomenal. When I visited Gaza recently, actually, and I saw the people, that they are going out, they are trying to – to bring joy and happiness and to forget about all the pain that they are living in, it wasn’t easy for me. I went there with a huge burden of emotional situation and I felt that I will see a collapsed people emotionally and mentally. But when I reached there and they started to ask me, “Would you like to go for – for a coffee and to see the seaside of the city?”, I felt, “Oh, my God, those people really are fighting for life. They want to live.” So, actually, this gives me a strength to continue for another ten days in Gaza. When I arrived there, I felt that I might, at some point, feel that I can’t continue, that hearing the people’s stories and narrating how they – they are impacted by this situation and these miserable life conditions, that will make me actually feel helpless and unable to help them. But after that and after seeing all those people walking beside the sea, trying actually to continue their life and to see that there is something in the horizon, maybe not now, but in the future, it completely inspired me.

Jack O’Donnell Well, that really is inspiring. And I have to say, to wrap this up today, that you’re both an inspiration. And I can tell you, on behalf of C4 Recovery Foundation, we’re very proud that we were able to work with you both and we’re very, you know, just inspired that your work continues today. And we wish you the best. And thank you, thank you so much for participating in this podcast today. We are all deeply appreciative at C4. So, thank you very much.

Rania Aljawi Thank you.

Jack O’Donnell Thank you for listening to this episode of the C4 Recovery Solutions podcast, brought to you by C4 Recovery Foundation. For more information, please visit our website at or email us at Thanks and goodbye.