PALESTINA
- BALSAM
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Rapporti
sulla situazione sanitaria
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A Population at Risk of Risks: No One is in a Healthy
State in Palestine
April 16, 2002
Rita Giacaman,
Institute of Community and Public Health
Birzeit University
Following is a quick review of the consequences of the
continuing Israeli onslaught on the state of health of
Palestinians. This onslaught began on the evening of March
29th, 2002, and continues until today, with serious
ramifications on health status, not only in terms of mortality,
injury and disability, but also in terms of morbidity and
vulnerability to disease that affects almost all of the
population as well.
Prior to the Israeli Invasion, the country and its people were
already severely compromised at all levels, including the
domain of health. Uprising conditions, characterized by
Israeli policies of closures, serious siege, periodic re-
occupation, an unprecedented level of unemployment, all led
to substantial collective and individual economic hardship,
and a serious lack of access to health services as well. The
Palestine Central Bureau of Statistics estimated that
household income dropped by at least 48% just six months
after the policies of closures and siege took effect during this
second Palestinian Uprising. That is, other than the
thousands dead and injured, and many with permanent
disabilities, the health status of the population began to
deteriorate prior to this current onslaught, with clinical
evidence suggesting that the important indicator of health
status, malnutrition among children, was rising.
The situation today
1. Death and Injury: it should be noted that from 28
September 2000 until March 29th, on the eve of this invasion,
not less than 1300 Palestinians had died and around 27,000
were injured by Israeli army violence, adding serious burdens
on the existing medical and health care system. Since the
beginning of the current invasion , no one has been able to
ascertain the numbers of dead and injured by army violence
as Israel i continues to deny access to medical personnel,
even those of the ICRC. The numbers killed are probably in
the hundreds, and those injured, mostly civilians, in the
thousands. It is not clear how many of the injured in fact died
because of the blockade imposed on medical assistance
and harassment of ambulances and medical staff, but reports
indicate that probably many civilian deaths occurred as a
result of army violence and as a consequence of the
blockade of medical assistance, with the injured left bleeding
till they died. Reports also indicate without doubt that medical
help and humanitarian assistance were prevented on several
documented occasions and consistently, not incidentally, with
medical staff harassed, stripped naked, terrorized and even
used as human shields by the Israeli army. Reports also
indicate that some of the deaths pertain to individuals who
were shot and killed after they had first been injured, in cold
blood, and left un-evacuated in residential areas, ,
deepening the effects of this onslaught on health in every
way. Thus even by the end of the first week of the invasion,
the situation was becoming intolerable, and various
humanitarian groups, including the International Red Cross,
the EU Special Representative to the Middle East,
Ambassador Miguel Angel Moratinos, as well as many
others, began to call for immediate clear orders to respect
the safe passage of medical vehicles and staff, grant access
to the large number of unattended wounded, and allow the
evacuation of those killed. Please note the grave
consequences of death, injury and disability on families, not
only in terms of the loss of loved ones, but also in terms of the
loss of a principal means of earning income, through the
labor of predominantly breadwinning males.
With Israel 'trying to bury the evidence' of what happened in
Jenin camp, but failing to ' bury the terrible crime it had
committed', and with reports on Israel digging mass graves
to cover up its war crimes increasingly breaking news, the
Jenin camp is now becoming the symbol of this tragedy of
communal slaughter. With about 47% of its inhabitants
children under the age of 15 and people older than 65 years.
and an additional 18% women of child bearing age, the
onslaught on Jenin was bound to affect innocent civilians first
and foremost. Indeed, Jenin Camp, as well as other heavily
affected locales, such as the Old City of Nablus, Bethlehem,
Ramallah and various other locales, can only be seen as in a
condition of 'deep humanitarian crisis', with immediate
action and intervention required to ease human suffering.
The Incapacitation of medical and health services:
severe siege conditions, coupled with re-occupation and
curfew of the main towns that people usually seek for
secondary care have reduced the health care system into a
situation of almost total paralysis, despite the valiant efforts
of hospital staff and medical personnel to attend the
wounded. Patients are unable to reach hospitals; selected
NGO's such as UPMRC and HWC primary health care
centers as well as those of UNRWA are mostly, but not
entirely operational with activities seriously affected by the
current conditions; PRCS and UPMRC ambulances and
emergency relief heroically continue to offer vital services,
despite the great danger associated with manning
ambulances that are shot at by the army, and where health
staff are stripped, detained or used as human shields; the
large majority of the governmental primary care services
have ceased to operate, perhaps because those rely on a
town based command system; the private medical sector
has collapsed; and medications are in short supply, to name
some of the severe consequences of the current conditions
on the health care system.
The ramifications of this state of affairs has had and
continues to have far reaching impact on health. Numerous
reports document cases of severe deterioration in health
status, even death for those that were not able to reach
services because of the blockades and siege, including
mounting evidence of the injury and death of pregnant
women and newborn children because of this imposed lack
of access, or shooting by the army, or both. Indeed the tragic
case reported by a physician friend of ours, as he says, is
only one of many. In this case, Dr. Ali Sha'ar, reports that his
wife began to go into labor at 32 weeks of gestation, two
nights ago at around 4 am . They live in the occupied and
curfewed city of Nablus. He immediately called for an
ambulance to no avail. By six a.m., he managed with a doctor
friend of his to deliver the baby successfully. The baby cried,
and looked healthy, but being premature, urgently needed
incubator facilities. Dr. Sha'ar and his friend did everything
possible to maintain the baby without incubator while
awaiting for the ambulance that never came, as twice, the
ambulance personnel reported trying to reach Ali and twice
being shot at, resulting in their return to their station. By 11
am, the child began to suffer from apnea, and eventually died
at around 1 p.m.
The death of 2 year old Tabaruk Jaber Odeh, a cerebral
palsy patient from Deir al-Hatab village in the north is another
case of many. A child that survived only with great care and
life sustaining medications, siege and curfew led to her
denial of her medications for a period of ten days. By
yesterday, and after many appeals were made and
distributed, the army allowed for her transfer to hospital. This
morning, however, I found out from her father that she had
passed away.
And then of course, there are those with chronic diseases,
such as diabetes mellitus, hypertension and heart disease.
No one really knows the extent to which this curfew, blockade
of medical care, and denial of access has had a negative
impact on the health of such people, but given what is
emerging from various reports, and what happens to our
friends and neighbors, the picture seems bleak. Two nights
ago at 3 a.m, I received a phonecall frmy neighbor, who is
a physician, desperately trying to seek an ambulance to
transport his father to hospital. The father woke up with
symptoms of a heart attack. >From 3 a.m. till 8 a.m, all
attempts to get the man to hospital failed. Finally, at 8.30 in
the morning, the patient was transported successfully to
hospital, still alive. He was more fortunate than others.
Infants, school children and pregnant women's vaccination
schemes have also been either severely interrupted, or
halted altogether during the past 18 days. According to Dr.
Samia Halileh, a practicing pediatrician and faculty member
at the Institute of Community and Public Health at , Birzeit
University, one of the most dangerous diseases affecting
newborns if adequate vaccination is not available or
completed is tetanus. Usually, infants are given the vaccine
three times, at intervals of two months each and beginning at
the age of two months, in addition to a booster at 12 months.
The interruption of such a schedule during infancy, even for a
period of two weeks increases the risk of infants developing
the fully blown picture of tetanus if exposed to these deadly
spores. This is especially true of cases that have never
received the vaccine, but also includes those who have
missed taking the full three doses on schedule, as well as the
booster. Note that the fatality rate for tetanus is in the order of
90%.
While pertusis ( whooping cough) was in the controlled state
in the area up till recently, denial of any of the required
vaccinations at 2,4 and 6 months as well as the denial of the
booster increases the risk of acquiring this disease, which
can also be fatal in severe cases. The measles vaccine is
usually given in this country in one dose at 9 months, followed
by a booster at 15 months. Interrupting or delaying either one
of these doses places infants at greater risk of acquiring the
disease, which can also be fatal in severe cases. Finally, the
Hepatitis B vaccine is given at birth, followed by another
dose at one and then three months. This vaccination is vital to
newborns whose mothers have Hepatitis B. Note that a delay
of 72 hours increased the risk of the newborns acquiring this
disease, with severe long-term complications resulting in an
increase in the rate of disability and mortality.
House demolitions, destruction and detonation: since
the beginning of this re-occupation and curfew, we have
heard detonations in Ramallah continuing practically every
single day an night, leaving homes without doors, broken
furniture and equipment, and in many instances, with
valuables stolen,
These events are dwarfed by the wanton shelling and
destruction of homes and community in Jenin Camp, the old
City of Nablus, and Bethlehem, among other locales. The
loss of home is not merely a physical loss, as it has important
consequences on health, especially the health of children,
older people and the disabled. Some of the communities that
have been most affected have been dislocated more than
once, leaving behind essentials and belongings, and have
taken refuge in villages or in homes of extended family
members and friends.
Electricity and water: are essential for health and well-
being. What seems like a deliberate cutting off of these two
services have been the subject of numerous reports. In
Ramallah alone, over 100,000 thousand people in the town
and surrounding villages remained without electricity for an
entire week. We have no idea how many remain without
electricity in the West Bank, as we are unable to accurately
ascertain the extent of the problem. However, damage to
poles, lines and other essential pieces of the network
continue until today, with what seems to be like a cat and
mouse game of finally getting approval to fix the damage,
only to have destruction the next day. According to the Chief
Engineer of the Electricity company, serious harassment, and
shooting at crews attempting to fix the different levels of
damage, from power feeders to cut off cords and broken
poles, even when approval to move around and fix the
damage was obtained from the higher echelons of the Israeli
Defense Force, has led and continues to lead to interrupted
service. With only general access to information In
Bethlehem, Nablus, Jenin and Tulkarm, available reports
indicate a major problem there as well. On 16 April, for
example Oxfam reported that specific areas of Bethlehem
(the Old town), the al-Mahed and al- Fawaghreh quarters and
al Khader, al-Doha villages and the west side of al- Dheisheh
camp -are still without water since April 4. Similarly, Oxfam
reported the unavailability of water in other locales as well,
including Qalqilia, Nablus, Tulkarm and other locales.
Destruction of the water pumps, generators, pipes as a result
of gouging out streets repeatedly, in addition to punctured
water tanks on roofs of homes as a result of the shooting all
contribute to a very unhealthy state. In Ramallah, where the
case was followed up closely, the Water Department went
through harrowing experiences attempting to fix the
damages, in the hope of bringing back the vital water supply
to the population. At least 150,000 people, for days on end,
remained without water as the cat and mouse game of
coordinating and successfully gaining approval from the
Israeli Army to fix the damage, only to result with Water
Department crews being shot at and denied entry or arrested
instead continued. A concerted campaign exposing these
activities contributed perhaps in real ways to eventually
allowing the water to run to people's homes in Ramallah
today. However, it appears that currently, the conditions are
quite severe in Jenin and Jenin camp, as well as many other
locales. The size and extent of the problem appears to be
huge, with a water on and water off situation being the norm,
but we have no way of obtaining further information.
Sanitation: since the beginning of this incursion, and curfew,
two outstanding sanitary problems remain unresolved. All that
one needs to do is roam around the streets of Ramallah
when the curfew is lifted to realize the extent of the damage,
broken glass, blown out doors, shattered poles, debris
everywhere, and above all, refuse piling up way beyond the
capacity of garbage containers, spilling out in all directions.
With the temperature now rising to up to 30 degrees
centigrade yesterday, and with flies beginning to come out of
their winter sleep, the situation can only be described as
dangerous to the health, despite initial efforts at garbage
collection when the curfew was lifted and on 16 April in
cooperation with the ICRC.. We have not been spared the
dangers of sewage either. According to the head of the
environmental committee of the Governorate of Ramallah,
around 50% of homes are linked with a public sewage
network, with the rest relying on cesspits that require
emptying regularly, usually, ever 2-4 weeks, depending on
size. The majority of villages remain without a piped sewage
system, again relying on cesspits requiring regular emptying.
Yet the state of siege and curfew have so far not allowed the
proper disposal of this sewage, setting the stage for the
spread of a variety of diseases. The story from Nablus,
Jenin, Bethlehem and their surrounding villages is similar.
According to the World Health Organization, with the medical
services not functioning, even in their limited capacity, the
risk of a disease outbreak is increasing due to a general lack
of water and sanitation as well as interrupted garbage
disposal. Furthermore, the WHO reports that the lack of
electricity has begun to destroy blood units and vaccines.
These problems combined with interrupted water supplies,
and coupled with delayed vaccinations, un-evacuated bodies
in streets, and rubble all over, creates legitimate fears of a
potential public health crisis in the country
Mental Health: it is beginning to be clear that the level of
trauma affecting the population here is much higher than
expected. No one really knows the extent of the problem
today, noits ramifications on the future health of the
population, especially children. A priority group for action
continues to be the ambulance and medical workers who
have been exposed to an almost unbearable amounts of
traumatic experiences, whether by simply dealing with the
tragic cases at hand, or by being themselves exposed to
serious harassment and army violence. Children and older
people who live alone or with an older spouse must also be
reached, not merely with physical help, but with trauma
management care as well. Of course, young people, who
have been arrested, then released, and who have witnessed
the death or injury of friends, or who have suffered terribly as
a result of all this destruction around us, feeling totally
helpless and incapacitated, with no vision or hope for a better
future, need real help in both the short and longer terms. And
as we continue listing sub-groups within the population that
needs help, a simple realization emerges: it seems as if the
entire nation needs trauma management.
At this stage, food is plentiful in Ramallah, as truckloads upon
truckloads
were allowed to enter to feed the hungry who have money, unlike the situation
in Jenin and elsewhere. The problem is the unavailability of cash. People are
either stuck without a job, or without due payments, or without cash. That is,
we are facing a problem of want, with merchandise, mostly made in Israel,
clearly available, but with a dreadful inability to buy what is essential when
the curfew is lifted.
Needs for Assistance
Overall, assistance in the sphere of public health can be divided into
immediate needs and medium/ longer term ones:
1. It is not food that is needed, except in specific circumstances, as is the
case in the Jenin Camp where drinking water is also an urgent necessity. What
is needed is a concerted effort and pressure to be placed on the Israeli
government to lift the curfew, end this re-occupation, end the 19 month long
state of siege, and allow people to pick up the pieces, get back to work,
re-start economic activity, and tally up the enormous losses. Some believe that
it will take years to re-build what has been destroyed.
2. Clearly, immediate financial emergency assistance is much needed, and must
reach the local level. Given that the state of siege has been continuous for 19
months, with no end in sight, even if the Israeli army withdraws from areas A,
and now, a few villages as well, the need in these circumstances is for
supporting decentralization and communal based health care services, especially
those of the primary health care variety. Between the ongoing state of siege
and the collapse of the private medical sector along with the economy, support
for decentralized and highly subsidized local level primary care services is
one of the few remaining options at hand that can assist the population in
surviving these trying times.
3. Replenishment of drug supplies to accommodate need is also imperative.
Perhaps the best way to assist in this area is through financial donations that
can be used to purchase medications locally.
4. There is a need to also immediately embark on setting up emergency
frameworks to assist in bringing in international volunteers to contribute to
the protection of the population.
5. There is much that will be needed in financial and technical terms in the
medium and longer terms to allow for the rehabilitation and reconstruction of a
country, a health system, an infrastructure and an economy that have been
reduced to rubbles as a result of this unilateral war.
1. PCBS 2000, Poverty in Palestine(January-December 1998),
2. MOH, UNICEF and Institute of Community and Public Health, Birzeit
University, 2001.
3. The Palestine Monitor, PNGO Information Clearinghouse appeals and
information briefs.
4. OPT: PRCS Update , 16 April, 2002
5. WHO, West Bank/Gaza Strip Health Update, 15 April 2002
6. Justin Huggler in Jenin and Phil Reeves in Jerusalem , the
Independent,13 April 2002.
7. LAW - The Palestinian Society for the Protection of Human
Rights and the Environment, Information Briefs.
8. UPMRC Appeals and Information Briefs.
9. Oxfam, April 16,2002 , Bethlehem Water Situation, 4-6
April 2002
10. Judy Dempsey and Roula Khalaf, Palestinian economy
deeply damaged, Financial Times, April 16, 2002
11. B'Tselem (The Israeli Information Center for Human
Rights in the OccupiedTerritories) Daily Briefing on Human
Rights Violations