Health conditions of, and assistance to, the Arab
population in the occupied Arab territories,
At the request of the Permanent Observer of Palestine to the United Nations and Other International Organizations at Geneva, the Director-General has the honour to transmit the attached report to the Fifty-sixth World Health Assembly.
Ministry of Health
HEALTH CONDITIONS OF, AND ASSISTANCE TO, THE ARAB POPULATION
IN THE OCCUPIED ARAB TERRITORIES, INCLUDING PALESTINE
Report presented to the Fifty-sixth World Health Assembly, Geneva
1. Since September 2000, the international community has been witness to a series of notoriously tragic events in occupied Palestine. These events have lead to the tragic deterioration of social and economic conditions, including the demolition of the infrastructure, with an enormous impact on the health conditions of the Palestinian citizens living under such difficult circumstances and events.
2. The Israeli occupation authorities have reoccupied numerous Palestinian towns in the West Bank during the period between March and June 2002, when Bethlehem was reoccupied for 10 days, Jenin for 40 days, Ramallah and El-Bireh for 20 days, not to mention the reoccupation of Tulkarem, and Qaliqilya for several days and the attacks launched on the Jenin and Balata refugee camps, leading to the martyrdom of 180 Palestinian refugees between 28 February and 12 March 2002. Between 29 March and 1 May 2002, the Israeli occupation forces also invaded most towns in the West Bank where 24-hour military curfews were imposed and some 260 Palestinians killed during the same period. The entire West Bank was reooccupied on 19 June 2002. Since then, these towns, as well as those in the Gaza Strip have been repeatedly reooccupied by military forces who have imposed prolonged shutdowns on them. On 66% of the total number of days, West Bank towns were subjected to strict total shutdowns, and on 94% of those days, the Gaza Strip was subject to partial shutdowns. More than 44 427 people were injured and 2995 were killed. Of these casualties 85% were civilian, the great majority of whom were between 15 and 45 years of age. Children under 18 represent 18.5% of all killings, and 179 women were also killed. A total of 260 Palestinians were assassinated or physically liquidated in violation of the law and with premeditation by use of all types of weaponry, including air-to-ground missiles fired by Apache helicopters and F- 16 aircraft at civilian buildings and cars, leaving a huge number of dead and wounded Palestinian civilians. Thirty-five people were killed by settlers. Some 2500 people, including 500 children have been permanently disabled. The number of detainees now totals 10 000, including 550 children and 60 women; 250 of the detainees were injured or suffering from chronic diseases. They are held in some 21 detention camps, most of which do not meet the minimum standards relating to prisons and detention camps, thus exposing our captives to disease, physical disability and slow death.
3. Closures of borders and international crossing points have led to declining levels of imports from Jordan and Egypt; access to Israeli ports that constitute the major transit points for Palestinian imports from outside Israel has been hampered by such measures. Such closures have also resulted in delays and postponements in the delivery of medicines, vaccines and medical services destined for the occupied Palestinian territories. Huge losses have been suffered by Palestinian traders who have had to pay storage and other charges. There has been an acute shortage of drugs, vaccines, medical care and ambulance services, as borders and crossing points were closed for 21.4% of the time at the Allenby-Karama bridge for travellers, for 36.5% of the time at the commercial crossing point at the Allenby-Karama bridge, for 38.1% of the time at the Rafah crossing point for travellers, for 61.1% of the time at the commercial Rafah crossing point and for 100% of the time at Gaza International Airport.
4. There has been large-scale destruction of property, uprooting of trees, removal of agricultural soil, forced displacement of families and strict restrictions on the movement of both citizens and goods, including the transport of medicines, medical equipment and humanitarian aid to the victims of these practices.
5. In the field of education, 123 male and female students were killed and 2500 injured on their way to and from school. Some 170 000 students and more than 6650 teachers were unable to get to school regularly, and classes were interrupted in 850 schools on account of road blocks, closures and curfews, for a total period of 1135 school days.
6. One hundred and eighty-five schools were attacked with firearms and 11 were completely destroyed, and Israeli forces broke into another 60 schools. The occupation forces turned 15 schools into military posts and detention centres, not to mention the complete interruption of higher education, the closure of institutes and universities, and the arrest and imprisonment of students. All this demonstrates the effects of the measures taken by the Israeli occupation forces on the health situation of the Palestinian people since the beginning of the intifada in September 2000. These statistics were derived from local and international sources, including the Palestinian Ministry of Health.
THE ECONOMIC SITUATION
7. The dependency rate among Palestinians rose from 4.8% at the end of 2000 to more than 6.7%. The rate of unemployment reached a level in excess of 67% in the Gaza Strip and 48% in the West Bank. More than half of Palestinian families lost 50% of their regular income during the past two years. Estimates by the World Bank reveal that the poverty rate has doubled, reaching 84.6% in the Gaza Strip and 57.8% in the West Bank. Individual income has deteriorated on account of the increase in the rate of unemployment and the inability of the Palestine National Authority to pay civil servants’ salaries as a result of the freeze imposed by Israel on dues to the Palestinian Authority from taxes and customs duties. But for the assistance provided by sisterly and friendly countries to the Palestinian Authority, no wages whatsoever would have been paid. Measures by the Israeli occupation authorities affecting agricultural land, the felling of fruit trees and the destruction of greenhouses and wells have led to a decline in the income of agricultural workers. Some 50% of the Palestinian people depend for their livelihood on humanitarian assistance received from sisterly and friendly countries and organizations.
8. The economic situation in the Palestinian territories has had a severe effect on social conditions, on personal and family security, as well as on the psychological state of the population and has led to a sharp increase in the rates of stress, depression and fear among citizens.
HEALTH CONDITIONS OF THE PALESTINIAN PEOPLE
9. Aggression by the Israeli army and continual incursions have caused the health conditions of the Palestinian people to deteriorate sharply, causing an acute shortage of not only health resources, essential health services and other health programmes, but also the destruction of the health service infrastructure. Economic instability, the absence of security and personal safety and other current difficulties illustrate the low level to which the health conditions of the Palestinians have sunk.
Access to basic health services
10. Difficulties faced by patients and health personnel in reaching health services are caused by repeated closures, curfews and the proliferation of military road blocks, of which there are 20 in the West Bank and Gaza. This has also led to shortcomings and deficiencies in the health situation in general, and to the deterioration of public health services, such as disease prevention, environmental services and the disposal of solid waste. It has severely affected the mobility of ambulances run by the Palestinian Red Crescent Society, immunization campaigns, primary health care, school-health programmes and home visits and led to the disruption of primary and secondary health services in remote rural areas.
11. Restrictions on the movement of Palestinians, curfews and frequent shutdowns have had a devastating effect on health services in general:
(a) an increase in dangerous and high-risk pregnancies, complications and abortions;
(b) a shortage of health resources and equipment and a greater need for emergency services;
(c) a shortage of blood in hospitals, particularly of rare blood groups;
(d) a shortage of basic medicines and vaccines due to difficulty of movement of people and goods owing to repeated shutdowns;
(e) a shortage of food in a great many camps and villages;
(f) inability to administer tetanus toxoid to expectant mothers, among whom coverage has fallen to only 30% in Palestinian areas;
(g) an increase of 14% in home deliveries and childbirths;
(h) a decrease of 55% in monitoring, testing and chlorination of drinking-water in Gaza, and of 62% in the West Bank, as well as a decrease of 50% in waste disposal and sanitation services;
(i) a daily and chronic power failure, leading to difficulties in vaccine storage, which may affect the efficacy of or damage vaccines, thus exposing children to the risk of communicable diseases. Power failures have also disrupted the storage of blood in hospitals and the efficiency of diagnostic equipment;
(j) inability to obtain services has caused a human and service catastrophe in health resources, owing to closures and curfews lasting for days, weeks and months in some areas such as Jenin and Nablus, isolating them from the surrounding villages and population centres;
(k) an ever-increasing need for outpatient services in view of the intensification and expansion of Israeli violence and repression;
(l) road blocks and curfews have also led to deaths: 91 patients died at Israeli road blocks in various parts of the Gaza Strip and the West Bank. Israel has partitioned the Gaza Strip into three isolated and separate areas, and the West Bank into more than 300 isolated areas. Fifty-two childbirths occurred at Israeli check points leading to the death of 29 newborn infants.
(m) delays in transporting patients in need of specialized treatment, such as cancer, cardiovascular, and kidney dialysis patients, victims of Israeli practices needing physiotherapy and rehabilitation and chronic disease patients to local, or external specialized treatment centres led to an increase in avoidable morbidity, disabilities and fatalities.
12. Measures taken by the Israeli occupation forces such as the shutdown and isolation of cities and towns and hindrance of movement, together with repeated power failures, difficulties in transporting medicines and vaccines, are likely to have a detrimental effect on the efficacy of vaccines, thereby jeopardizing immunity among Palestinian infants and children and exposing them to the risk of communicable diseases such as poliomyelitis and measles which had been eliminated.
Restrictions on humanitarian services and insecurity of health personnel
13. The Ministry of Health and numerous health institutions such as the International Red Cross and the Palestinian Red Crescent Societies, UNRWA and nongovernmental organizations have been the target of incessant aggression, in violation of international conventions and of the Geneva Conventions. Attacks by the Israeli army against Palestinian civilians and health services, as well as assassinations of individuals and army action against the movement of people and humanitarian assistance have intensified and have hampered such movement; some details of these attacks are given below:
(a) Palestinian Red Crescent Society ambulances were fired on by the Israeli army and settlers in 335 separate incidents; 240 ambulances were hit and 35 destroyed and ambulances were prevented from reaching health facilities or delayed in 660 incidents;
(b) 107 health facilities were attacked;
(c) hospitals were attacked with firearms in 285 incidents leading to the partial destruction of more than 29 hospitals and 8 primary health care clinics;
(d) 424 health workers and ambulance drivers were injured while on duty;
(e) 25 health workers and ambulance drivers were killed while on duty;
(f) 78 health workers and volunteers have been arrested since the invasion of the West Bank on 26 April 2003;
(g) more than 75% of health personnel were unable to reach their place of work, affecting the level of primary health care for patients and the immunization of children, not to mention monitoring of pregnancies, attending to childbirths and monitoring of infant nutrition.
14. Malnutrition is on the increase among Palestinian children. A recent study conducted by local and international bodies has brought to light the following facts on malnutrition and anaemia among children under five years of age, and women between 15 and 49 years of age:
(a) Malnutrition and anaemia such as:
• wasting, affecting 13.3% of the population in the Gaza Strip and 4.3% in the West Bank
• stunting, 17.5% in the Gaza Strip and 7.9% in the West Bank
• anaemia, was found in 68.2% of infants
• anaemia, in 44% of children under five
• anaemia, in 52.8% of women in the Gaza Strip and 43-49% in the West Bank.
(b) Consumption of nutrients (energy and protein). With respect to nutrient (energy and protein) deficiency, the following results were shown:
(c) Shortages of foodstuffs:
(d) Causes of food shortages. The study shows that in 57.5% of cases, the causes of food shortages in the West Bank and Gaza are border closures, road blocks and checkpoints, and in 24.5% of cases, curfews and the shutdown of Palestinian areas.
15. WHO has found that the nutritional status and anaemia among Palestinian children under five years of age, women, expectant mothers and especially mothers practising breastfeeding are tragic by any international or humanitarian standard.
16. Numerous Palestinian areas suffer from acute shortages of drinking-water and sanitation, in addition to the lack of basic foodstuffs.
17. Difficulties affecting the management and transport of solid waste, which accumulates for days on end, the inability to reach municipal waste dumps and the use of alternative temporary and unsanitary dumps have led to the appearance of a growing number of pests and insects, odours, and further contamination of groundwater by the seepage of decomposed solid waste into aquifers. Bacterial contamination of drinking-water has reached 16% of all samples analysed. The piling up of corpses and impossibility of providing proper burial have also created environmental problems. Wild polioviruses have been found in samples collected from wastewater pools in the Gaza Strip over a period of three consecutive months. This could lead to an outbreak of poliomyelitis among Palestinian children, especially on account of the uncertainty as to the viability of the vaccines administered on account of frequent power failures and of their effect on the cold chain, not to mention the difficulties in transporting such vaccines from Ministry of Health central depots to primary care posts in villages, camps and remote areas, where donkeys are sometimes used as a means of transport. Disruption of immunization campaigns on account of shutdowns and curfews imposed on towns, villages and camps, sometimes for months on end, is yet another problem in this respect.
18. In the West Bank 2883 Palestinian houses have been demolished, and 36 384 others damaged, in addition to the 661 houses demolished in the Gaza Strip, leaving some 73 600 Palestinian civilians homeless. Thirty mosques, 12 churches, and 134 water wells have been destroyed by bombardment, the use of bulldozers, or even dynamite in some cases. At least 800 other houses were destroyed when the Jenin refugee camp was invaded, as well as a large part of the old town in Nablus, in April 2002.
19. The loss of shelter through the above-mentioned measure, affecting large numbers of families and children who now live out in the open, the lack of safe drinking-water and proper sanitation will expose the entire population, and especially mothers and children to the risk of contracting communicable diseases, anaemia and to malnutrition.
20. The Primary Health Care Unit at the Ministry of Health registered an increase of 35.6% in the number of visits to its centres compared with the year 2000. This shows the enormous burden placed on the Government’s primary health care centres due to the precarious economic situation of citizens and the difficulty of providing free health coverage during the intifada, thus leading to the deterioration of health services provided and to an extreme shortage of medicines, especially those for patients with diabetes, high blood pressure, heart conditions and cancer.
21. There has been a huge increase in demand for blood transfusion services, from 25 799 units in 1999 to 67 553 in 2002, i.e. an increase of 162%. This shows the heavy burden placed on the Ministry of Health in providing care for the injured and casualties caused by the violence perpetrated by the Israeli occupation.
22. Political violence committed by the Israeli occupation forces has led to an increase in mental disorders in society, compelling health service providers to develop community mental health clinics, to improve the skills of their personnel and to step up health education programmes in addition to providing the required drugs and treatments for mental health patients. There was a huge increase (42%) in the admission of new mental health patients into community mental health centres. The measures taken by the Israeli occupation forces have led to the deterioration of the mental and social situation of Palestinian society, an increase in cases of bed-wetting anxiety and fear among small children and schoolchildren, in addition to a 6% increase in the number of cases of psychosis among the population compared with 2000.
23. The number of hospital bed-days amounted to 622 883, i.e. a 22.6% increase over the year 2000 and a ratio of 184 days per 1000 citizens. The number of hospital admissions reached 224 087 in 2002, i.e. an increase of 20% over the year 2000. A total of 82 099 operations were performed in hospitals, an increase of 27.9% compared with the year 2000. Case fatalities in hospitals amounted to 1.5% of the total number of patients discharged from hospitals, i.e. an increase of 6.8% compared with the year 2000. Hospital outpatient clinics registered 1 286 539 visits, i.e. an increase of 67.7% compared with the year 2000. Hospital emergency wards bore the brunt of the situation by admitting and treating 739 318 cases, an increase of 38.1% over the year 2000. All this confirms the heavy burden borne by the Ministry of Health’s hospitals in providing health and emergency services in order to cope with the deteriorating economic situation of the Palestinians and the increase in the number of casualties and martyrs due to Israeli violence.
24. There is a deficit of some 43% in the budget allotted by the Ministry of Health; for drugs and medical equipment, the budget amounts to only US$ 13.9 million this year, despite the steady increase in demand for drugs and medical equipment due to the huge numbers of casualties and martyrs and the deterioration of the health situation of the Palestinian people, compelling them to seek treatment at Government health facilities where health care services are free (through insurance for workers and for the intifada). The deficit in the budget allocated to specialist treatment is about 40%, amounting to US$ 4.3 million during the current year. Strategic drug stocks have been depleted. The lack of drugs and medical equipment concerned the following:
25. In most countries, the main obstacles to the achievement of health policy goals derive from insufficient funds, which are a crucial factor to the improvement of health systems and thus of the health situation of the population. The Ministry of Finance estimated the Ministry of Health budget for 2002 at US$ 109 million, of which US$ 12 million were from Ministry of Finance revenue, US$ 23.5 million from donor countries, and while salaries of staff working for the Ministry of Health amounted to US$ 57 million. As a result, the budget deficit amounted to US$ 18.2 million.
26. About 34.5% of Palestinians contribute to health insurance. Since the beginning of the intifada, the Ministry has been providing up to 189 934 poor and workers’ families deprived of income or whose income is under the poverty line with free health insurance. As a result, the Ministry’s revenue from health insurance contributions declined by 23.5% in 2002 in comparison with 1999. The major decrease was among workers (83%), while contributions from the Ministry of Social Affairs for poor families health insurance coverage has risen by about 13% compared with 1999; it should be noted that the Ministry of Health is the main provider of health services in the Gaza Strip and for more than 50% of the population of the West Bank. The following are the main reasons contributing to the decline in Ministry of Health revenue that threatens its budget:
(i) provision by the Ministry of free health insurance to 189 934 poor families since the beginning of the intifada;
(ii) increasing unemployment among workers and the consequent 83% decline in their contribution to health insurance;
(iii) increasing numbers of injuries among Palestinians and the resulting effect on the Ministry’s remaining revenue used to provide free health services for those injured;
(iv) the partial loss of income of those injured, most of whom are young, due to their inability to work;
(v) the impossibility for more than 2500 people to return to work on account of permanent disability from their injuries, the resulting reduction of their family income and the weakening of care services for the disabled.
27. The Ministry has succeeded in controlling many communicable diseases and no new cases of diphtheria or poliomyelitis have been registered since 1982. The incidence rate of measles also declined (1 per 100 000). Tuberculosis is also continually decreasing (1 per 100 000) while no cases of hepatitis B were registered among children under the age of 10, indicating the success of vaccination programmes and epidemiological monitoring of those diseases.
28. It is regrettable however that the measures taken by the Israeli occupation forces have affected epidemiological monitoring in Palestine, undermining supervision, registration and information about diseases. This was clearly shown by the failure to achieve one of the most important health indicators used to measure the efficiency of epidemiological monitoring, the reduction of the incidence of rickets among children under the age of 15 to less than 1 per 100 000 per year. There has also been a gradual increase in the number of cases of viral and bacterial meningitis, with prevalence rates of 9.5 and 22.1 per 100 000 successively. An outbreak of shigellosis was registered in one refugee camp in Nablus Governorate due to the contamination of drinking-water by sewage leaking because of destruction caused by the passage of Israeli tanks. About 600 cases were registered among residents of the camp while a large number of other cases were not registered due to the curfew imposed there by the military for several successive days.
29. In spite of the broad success of the Ministry of Health in controlling and limiting the spread of diseases affecting both human beings and animals, especially after the implementation of human and animal brucellosis control in cooperation with the Ministry of Agriculture and international institutions, which led to a 3.11% decrease in prevalence rates in Palestine in 2001, the interruption of the veterinary vaccination programme resulted in new cases of the disease being observed in one Salfite village in the West Bank in 2002. Forty cases were registered among the population there, an incidence rate of 69 per 100 000 people. Leishmaniasis rates have also been rising in the West Bank governorates of Jenin, Nablus and Jericho due to the interruption of insect vector control. Rabies on the other hand, has been under control for decades among the population of the occupied territories. Unfortunately one case was registered among the citizens of Hebron as a result of a weak epidemiological supervision and monitoring system, in combination with the interruption of veterinary vaccination against rabies.
30. Since communicable diseases know neither boundaries nor checkpoints, the continuation of the current situation threatens once more to lead to the outbreak of common and new communicable diseases among Palestinian children in the region as a whole.
31. The Palestinian community is going through an epidemiological transition whereby communicable diseases continue to spread while noncommunicable diseases represent a heavy burden and high costs for society. The diabetes prevalence rate among the population has reached 9%, causing 5.7% of total deaths in 2001. Appropriations for diabetic drugs in primary health care centres have fallen from US$ 1 503 833 to US$ 1 100 473, i.e. by 26.8%, leading to the deterioration in the health of people with chronic illness in general and diabetes in particular.
32. The continuous intentional killing of Palestinian civilians by the Israeli military will lead to the breakdown of the demographic structure, especially among youth. The male mortality rate is 26.7% higher than that of females, having risen from its previous level of 5.6%. This increase is attributed to the intensification of Israeli practices since the beginning of the intifada. The imbalance in the demographic structure will no doubt have a negative impact on the Palestinian social and economic situation.
33. There was also a slight increase in infant mortality rates. The rates rose from 22 per 1000 live births in 2001 to 23.4 per 1000 in 2002 in the Gaza Strip, while in the West Bank there was a sharp fall in all vital statistics concerning infants and mortality rates. This was due to the continuous closure of the area, curfews and the widespread military checkpoints all around the West Bank.
34. The Health Ministry condemns the ongoing Israeli military aggression in the occupied Palestinian land. These unacceptable acts have clear harmful consequences on human health and safety, reflected in high numbers of injuries, deaths and disabilities, as well as in a continued weakening of basic infrastructures throughout the occupied territories. We, in the Ministry of Health, call on the international community to bring pressure to bear on Israel to compel it to respect and fully implement the universally accepted rules of international law and in particular its humanitarian provisions and to apply the rules of the Fourth Geneva Convention relative to the Protection of Civilian Persons in Time of War. It is also essential to undertake every effort to ensure the delivery of humanitarian assistance to the occupied Palestinian territories in order to relieve the serious humanitarian crisis affecting the Palestinian people. Accordingly, we request the international community once more to put pressure on the Israeli Government to compel it to cease obstructing the movement of medical emergency teams and ambulances and preventing the transport and treatment of the injured.
35. There is no doubt that continued disruption of electricity and water supplies will cause further deterioration of the Palestinian social and economic structure. The achievement of equity of access to health and all other social services is an essential component of human security and a fundamental human right for all peoples to ensure their dignity and respect for them as human beings.
= = =