DETERMINANTS OF HEALTH
1. Factors such as economic changes, including high levels of poverty, unemployment and insufficient financial support; demographical changes including high rates of fertility and population growth, and epidemiological changes such as the substantial increase in prevalence of chronic diseases are among the major challenges facing the Palestinian health system. However, the most important challenge facing the health sector in the occupied Palestinian territories is the Israeli occupation itself, its continued savage aggression against Palestinians as human beings, the construction of military barriers and of the apartheid wall which separate different parts of Palestinian lands, also separating those lands from the rest of the world through the closure of crossing points and frontiers. Israel’s blockade of the occupied Palestinian territories was reinforced following the announcement of the results of the elections which took place in January 2006, and has been intensified once more in the Gaza Strip since June 2007. On 19 September 2007, the Israeli occupation government issued a decision by which it considered the Gaza Strip a hostile entity, and on 20 June 2007, the International Committee of the Red Cross announced that the Gaza Strip was facing a critical humanitarian crisis. On 25 October 2007 the Israeli authorities issued another decision limiting fuel and electricity supplies to the Gaza Strip, a decision that was approved by the Israeli Supreme Court. On 28 November 2007, the Israeli authorities issued yet another decision reducing once more the amounts of fuel imported to the Gaza Strip. As a result, the association of owners of oil and gas, fuel and fuel derivative companies in the Gaza Strip refused to receive any fuel or gas supplies in the Gaza Strip as of 7 April 2008 in view of the continued reduction of the amounts being delivered there. Addressing the United Nations Security Council, Ms Angela Kane, Assistant Secretary-General for Political Affairs, said that the UNRWA fuel reserve would run out by 24 April 2008 and that thereafter the Agency would suspend food assistance to 650 000 Palestinian refugees in the Gaza Strip.
2. In her address to the Ministry of Foreign Affairs in The Hague, on 29 October 2007, on UNRWA and the Palestinian refugees in the current context, Ms Karen Abu Zeid, UNRWA General Commissioner, explained that the closure regime imposed on the Gaza Strip was unmatched in any part of the world, in its duration or in its serious humanitarian consequences for the people of Gaza. The seclusion of 1.5 million Palestinians within Gaza substantially lowered the quality of their lives through the reduction to the bare minimum of food, medicine, fuel and other vital supplies, while the repeated air raids, invasions, assassinations and other military operations that took the lives mostly of civilians, caused terror, extreme anger and poverty among the Palestinian people. As a result, all aspects of life became undermined and the vast majority of Palestinians were unable to leave or enter the Gaza Strip.
3. In spite of the security plan applied by the national Palestinian authorities in many parts of the West Bank, Israeli occupation forces continued their daily incursions in those areas, imposing blockades and curfews on the inhabitants and attacking civilians as well as their private and public property. In addition, the Israeli authorities continued construction of the apartheid wall, extension of settlements and creation of permanent and temporary road barriers, and have transformed parts of the West Bank into isolated cantons.
4. The importance that the Palestinian authorities attach, through the Ministry of Health, to human health as a fundamental human right, and to the provision of integrated health services to the Palestinian people in response to economic, demographic and epidemiological changes, has led to a marked improvement of health indicators, which surpass those in neighbouring countries as regards health expenditure, and demonstrate the ability of the Palestinian health sector to deal with those challenges and to make substantial progress towards achievement of the Millennium Development Goals. Notwithstanding this progress, the occupied Palestinian territories still suffer from the occupation, in addition to high morbidity rates and the dual effect of infectious and chronic diseases, obesity and malnutrition. The present report reviews the major impact of the blockade, closure and aggression on the population and the health sector in the occupied Palestinian territories.
THE ECONOMIC CONDITION
5. Economic changes such as high levels of poverty and unemployment, accompanied by insufficient financial support, resulted in many financial and administrative problems in the health sector. In 2006, the gross national product decreased by 4.8% while unemployment rose to around 22% (50% of the population of the Gaza Strip and 15% in the West Bank). The poverty level was more than 65% (49% of the population in the West Bank and 79% in the Gaza Strip, of whom 47% suffer from extreme poverty) as a result of Israeli practices, making it very difficult for individuals to pay health expenses, laying yet another burden on the Ministry of Health. During the first half of 2007, the deficit faced by the Palestinian authority amounted to US$ 100 million per month. Table 1 shows the effective and projected economic changes up to 2010.
6. The deterioration of the economic situation, high inflation, decrease in the purchasing power of the dollar and the increase in prices of consumer goods seriously affected the capacity of the individual to pay for health services; 80% of the people of Gaza Strip are now dependent on humanitarian assistance provided by UNRWA, WFP and various other institutions. There was also a sharp decrease in food supplies in general and, in particular, in animal, milk and dairy products, whose prices skyrocketed in the space of a few months. That was in addition to the accumulation of household waste in streets and floods of sewage attributed to the lack of fuel supplies, and work stoppages by municipal workers who, for many months, had not received their wages. All these factors further aggravated the health situation of the population in the occupied Palestinian territories, and the health of women and children in particular. It is expected that anaemia and malnutrition will increase in those populations. The following table shows the changing rates of effective gross domestic product growth and inflation.
7. Those economic changes have led to another financing problem related to the increased volume of services provided to an increasing number of insured people. At the same time, the health sector faced several other problems such as lower incomes, irregular and delayed provision of financial advances to hospitals, high treatment costs in the private sector for services not provided by the health ministry, poor quality of public health services and low level of satisfaction among their users. In 2006, the average level of overall health expenditure per person reached US$ 120. In the same year, the overall level of the health ministry’s expenditure on the health sector reached US$ 140 million, including US$ 70 million for salaries and wages, i.e. US$ 38 per person. The following table shows the income of the Palestinian authorities, salaries, and operating expenses as a percentage of domestic product.
THE POLITICAL SITUATION: THE HEALTH CONDITION OF PALESTINIAN PRISONERS IN ISRAELI JAILS
9. The number of detainees in Israeli occupation jails reached 11 500 Palestinian and Arab detainees in more than 25 prisons, camps, detention and investigation centres in the Israeli occupation state. This number includes 13 prisoners detained for over 25 years and 81 prisoners detained for 20 or more years out of 352 prisoners arrested before the Oslo agreements. As for administrative prisoners, their number reached 920, detained in several jails for long periods on the grounds of security, on the basis of secret files. This is a flagrant violation of human rights. Israeli prison administrations practise a policy of silent killing of Palestinian prisoners through solitary confinement on a regular and systematic basis as a punitive measure aimed at degrading the prisoner’s dignity and morale by confining him in a single, narrow cell for an undefined period that may be extended to many years, during which the prisoner remains completely isolated from the outside world, deprived of all rights and needs. As indicated by the Mandela Foundation, which deals with prisoners’ files, the confinement rooms and departments in most jails are not suitable for human habitation, since they are damp, infested by insects and tightly sealed; the prisoner is allowed to go to the exercise yard only once, and usually with his hands and feet manacled. He is not allowed to meet other prisoners or to receive visits from his family. Difficult confinement conditions, especially deliberate neglect and delays in providing treatment, aggravate the prisoners’ and detainees’ health. Reports indicate that around 1300 female and male prisoners need treatment and medical care, and that they are detained in several jails where the proper care is not provided. The number of deaths among prisoners between 1967 and 2008 was 192; six of them died in 2007.
10. The Mandela Foundation noted the permanent detention of about 32 prisoners with incurable health conditions at the Ramala hospital, criticized this serious degradation of the prisoners’ health and called on both the United Nations Security Council and WHO to take their responsibility for what is happening inside Israeli prisons as regards medical negligence and delays in providing treatment, which jeopardises the lives of male and female prisoners. The Nafha institute for the defence of Palestinian prisoners in Israeli jails cited the following violations of prisoners’ rights to health:
2. Lack of effective treatment for different diseases among prisoners. The Israeli prison doctor is the only doctor in the world who treats all illnesses with a paracetamol tablet or a glass of water.
3. The lack of specialized doctors and night shift medical services to deal with emergencies in Israeli jails.
4. Lack of psychological supervision and therapy to deal with the many prisoners suffering from psychological disorders.
5. Lack of medical equipment for patients with special needs.
6. Lack of suitable and healthy diets for sick prisoners.
7. The transfer of sick detainees to hospital with hands and feet shackled, in unventilated trucks.
8. Depriving prisoners suffering from chronic diseases of their medicines as a punishment inside jails.
11. It is worthwhile mentioning that children and women prisoners suffer the most. Israeli occupation authorities have detained more than 340 children, many of whom suffered from different kinds of torture, harsh and degrading treatment. The Israeli occupation authorities, through their repressive and savage treatment of prisoners, especially children prisoners, violate all international instruments and conventions, including the fourth Geneva Convention and the 1989 Convention on the Rights of the Child. About 600 female prisoners were detained in Israeli jails, and 99 of them are still living in difficult conditions inside the Telmund “Ha Sharon” and Jelma prisons. Four of them gave birth in prison in extremely difficult conditions, where basic medical care was lacking. Pregnant prisoners are usually driven from jail to hospital in harsh conditions which further aggravate their suffering. Their transfer is usually carried out under strict military and security supervision with hands and feet shackled with metal chains. Their families are not allowed to accompany or stand by them. The prisoners are also chained to their beds until they enter delivery rooms and after giving birth they are chained once again to their beds.
12. The health conditions of female prisoners in general are extremely difficult and poor. They suffer from loss of weight and general weakness due to poor-quality food and the lack of essential nutrients. In addition, they are exposed to harsh treatment from male and female jailers with no regard for their condition or their special needs in pregnancy. All such factors contribute to their suffering, given their need for special medical care in suitable conditions, as well as a special diet. In this context, the health ministry calls on human rights organizations and international law societies to take urgent measures to put pressure on the Israeli Government to end the suffering of female detainees and to provide care and treatment for those among them who are pregnant, both prior to and after birth. It stresses the right of those women to give birth in conditions similar to all other mothers and to care for their children under humanitarian conditions. It is a shame for the world to remain silent, given the delivery conditions and practices inside Israeli occupation jails.
ISRAELI ATTACKS ON CIVILIANS
13. In 2007, some 412 Palestinians were shot dead by the Israeli occupation forces, including 53 children under the age of 18, 10 women and 70 men in targeted attacks, and 10 others were killed at military checkpoints, whereas up to 345 people were shot dead between the beginning of 2008 and 21 April 2008, 89% of them in the Gaza Strip. There were 31 women and 80 children among those killed.
14. Most hospital admissions (66% of all injuries) were caused by shrapnel from new types of missiles and bombs, with amputation and severe burning of the injured parts of the body, which demonstrates the magnitude and gravity of the injuries. Most of the casualties also undergo surgery, limbs are amputated and charred, and burns extend to most parts of the body. The shrapnel makes small holes in the body and spreads inside, causing lacerations and burns to the intestines, spleen and most of the other internal organs; judging from the physical ruptures and internal burning it causes, the shrapnel may contain some toxic and radioactive substances, which would adversely affect the lives and future of the injured after their discharge from hospital. The shrapnel appears like powder spread on the body of the injured, with very small entry wounds and large exit wounds accompanied by severe lacerations to the bones, tissue, liver and intestines. Doctors in health ministry hospitals are faced with new kinds of injuries, since many of the dead and the wounded when examined in hospital do not seem to be affected by the shrapnel traces, which raises questions about the existence of new explosive materials that are used against unarmed Palestinian civilians. The injured need to stay for days in hospital in addition to their need for intensive and continuous rehabilitation and follow-up because of the severe infections and septicaemia resulting from direct injury.
15. The health ministry therefore calls upon the international community and human rights institutions urgently to send a medical committee to examine the wounded and check for toxic materials in the bodies of those killed or wounded by Israeli missiles. The ministry also calls upon the international institutions to apply pressure on Israel so that it stops using internationally prohibited weapons against unarmed and harmless civilians in their homes and meeting places.
16. It was also recorded and documented that 69 pregnant women were forced to give birth at Israeli military checkpoints; thirty-nine of the babies and five of the women died as a result. Furthermore, 140 patients died at military checkpoints after being denied permission by the Israeli occupation forces to be taken to hospital in ambulances, in spite of their deteriorating health condition. The dead included 28 children under the age of 18 and 14 people over the age of 70; 55 had been suffering from blood clot and heart disease and 15 others were suffering from kidney failure; other victims had suffered from cancer, chest diseases or road injury. Fifty-one women patients died: 36.4% of the total number of patients who died at military checkpoints.
17. The closure of the Rafah border crossing from June to August 2007 has also prevented more than 1000 citizens stranded on the Egyptian/Palestinian border from returning to their homes. More than 22 of those citizens died, including seven women. These were mostly patients whose health was deteriorating after completion of treatment in Egyptian and Jordanian hospitals.
18. From 28 September 2000 until the date of preparation of this report, the Israeli occupation forces have killed 78 disabled Palestinians, including 33 suffering from a mental disability, 4 from hearing impairment, 13 suffering from reduced mobility and 12 from a double disability; one suffered from a visual impairment, 12 were mentally unstable and 3 suffered from a speaking impairment.
SHORTAGE OF FOOD SUPPLIES
19. On 14 April 2008, UNRWA asserted that the population in the Gaza Strip was still facing severe shortages of essential materials, foodstuffs, power supplies and other necessities of life, as a result of the blockade the Israeli authorities had been imposing on the movement of persons and goods since June 2007. Ten in every 100 children under five are chronically or acutely undersized, with a rise of 3% during the period 2004–2006. This rate reached 7.9% in the West Bank compared with 12.4% in the Gaza Strip. Some 13 741 children are underweight: a prevalence of 2.9%. Some 38 818 children have low birth weight (7% of births).
20. A statement issued by UNRWA mentioned that the number of trucks carrying food and humanitarian supplies which entered the Gaza Strip decreased from 10 000 during March to about 2400 during April 2008; the apparent lack of animal feed took meat prices to record levels.
21. A report on the occupied Palestinian territory issued on 23 April 2008 by the United Nations Office for Coordination of Humanitarian Affairs, explained that the closure had led to a fall in economic activity and an increase in transport costs, that 8.7% of Palestinian families were now headed by women and that about 34% of the population had no secure source of food, while a further 12% of the population risked finding itself in a similar situation. In spite of the great fall in gross domestic product in the occupied Palestinian territory in 2006, the fall in the income of Palestinian families, the lack of investment and the insecurity resulting from closure and siege, there has been a rise of 31% in the proportion of households consuming iodized salt during the period 2004–2006; despite this increase, 14.3% of families (89 527) do not yet use such salt.
SHORTAGE OF FUEL AND ELECTRICITY SUPPLIES IN THE GAZA STRIP
22. A report issued by United Nations Office for Coordination of Humanitarian Affairs on 8 February 2008 indicated that most families and health institutions in the Gaza Strip suffered from power cuts for 8 to 12 hours a day or more. On 7 February 2008, on the instructions of the Israeli defence ministry, the Israeli electricity company reduced the supply of electricity to the Gaza Strip by 0.5 megawatts per week. The reduction in electricity and fuel puts immense pressure on the already crumbling electricity system of Gaza, affecting the infrastructure for drinking-water and sanitation and also hindering the provision of health care for the elderly in the Gaza Strip.
23. Figures documented by the Palestinian Centre for Human Rights indicate that the Gaza Strip’s supplies of fuel have been reduced since the decision taken on 25 October 2007 by the Israeli authorities to reduce supplies by more than half. Hence, the supplies of petrol, diesel and gas for domestic use declined by between 60% and 73%. On 28 November 2007, the Israeli authorities issued a new decision which further reduced the quantities of fuel supplied to the Strip (to less than 10% of its needs). On 30 January 2008, the Israeli High Court of Justice rejected the appeal by human rights organizations against the Israeli authorities’ reduction of the quantities of fuel and electricity supplied to the Gaza Strip. Consequently, since Monday, 7 April 2008, the association of owners of oil and gas, fuel and fuel derivative companies in the Gaza Strip has refused to take delivery of fuel and gas supplied to the Gaza Strip, because of the continuing policy of cutting the quantities supplied to Gaza, which do not meet its basic needs.
24. The head of the UNRWA office, Mr Mathias Bergard, said that eight organizations of the United Nations had issued a joint statement that the current situation in the Gaza Strip represented a danger to the health and welfare of the Gaza population, of whom 56% were children. He added that the eight organizations which had signed the statement stressed that the current situation led to disruption of the work of the United Nations in Gaza, where it affected schools and health facilities and food distribution, pointing out that in the absence of fuel at petrol stations, the normal transport operations within the Gaza Strip had stopped. The Palestinian Centre for Human Rights stressed on the same day that the cutting of fuel supplies to the Gaza Strip by the occupation authorities had paralysed 85% of transport and communications, disrupted 50% of the educational process and closed 145 petrol stations. It was feared that all the basic services of life, such as delivery of drinking-water, sewage treatment and waste collection from the streets and neighbourhoods would be totally paralysed.
25. On 23 April 2008, Mr John Ging, director of UNRWA operations in the Gaza Strip, said in a dialogue with the United Nations radio that the humanitarian efforts in the Gaza Strip by either international organizations or the private and public sectors needed 3.8 million litres of diesel per month, but the organizations and the sectors had received no fuel since the closure of the crossing on April 2008. Mr Ging added that UNRWA had suspended all relief operations in the Gaza Strip as of 24 April 2008, since the fuel required to operate their trucks and centres had run out. He said that the fuel shortage would stop all the relief operations and distribution of the rations by UNWRA and WFP for more than one million Palestinians in the Gaza Strip. He added that fuel for mills would run out, fishermen would have no fuel to run their boats and farmers would obtain no fuel to irrigate their crops, in addition to the paralysis of industries and daily life.
The impact of the fuel and electricity shortage on the health situation in the Gaza Strip
26. The shortage of fuel and electricity obtained by the health ministry due to the blockade, closures and Israeli actions has led to the following:
· Shut-down of some oxygen generating stations, which need levels of power that cannot be supplied by small generators.
· X-Ray units running at 50% capacity.
· Increased suffering of patients with kidney failure owing to disruption and stoppage of dialysis units because of power outages.
· Disruption of the functioning of central air-conditioners in hospitals, which adversely affects the work, especially in enclosed areas such as operating theatres and intensive care units for adults, newborn babies and infants.
· Compromised validity and vitality of blood units and plasma, which can be damaged by power outages of more than two hours.
27. There are 180 water and sanitation facilities in the Gaza Strip, including 140 water wells and 37 water pumping stations and sanitation plants, and three sewage treatment plants, all of which require regular maintenance and spare parts and technical imports that are not available in local markets due to Israeli blockades and closures. In December 2007, the water authority was able to obtain only 50% of its fuel needs, leading to a chronically irregular drinking-water supply. Also, the projects of drinking-water systems funded by the World Bank and UNICEF were suspended in mid June 2007, owing to failure to introduce devices, equipment, machinery, pipes, valves, pumps and spare parts for machines needed for drinking-water and sanitation systems. The lack of spare parts has led to the stoppage of a large number of water wells and thus a shortage of drinking-water. Hence, the longer the period of the siege, the greater will be the effect of equipment and spare parts shortages on the quantity and quality of drinking-water and waste-water disposal. A UNICEF report indicates that the partial functioning of the main water-pumping station in Gaza City hinders the provision of safe water to some 60 000 Palestinians. The health officials are worried about potential contamination of drinking-water in the Gaza Strip due to lack of chlorine injection pumps and spare parts needed to clean and disinfect drinking-water. A health disaster could be caused by pollution of drinking-water, spreading diseases and epidemics among a million and a half citizens in the Gaza Strip.
28. The stoppage of sewage treatment leads also to the discharge of large quantities of untreated sewage into the sea, which causes pollution of sea water, fish and beaches. The shores of the sea at the Gaza Strip are badly polluted, because untreated sewage is pumped into the sea, thus exacerbating the crisis of the environment and public health, which is continuously deteriorating.
29. The municipal rubbish disposal vehicles have stopped working because of lack of fuel and spare parts. Rubbish is piling up in the streets, affecting public health and risking the spread of disease.
30. One third of the population suffers from lack of water supply in summer. In the Gaza Strip, more than a third of the population does not have a sanitary drainage system, and some 76 134 families, 12.2% of the total, are still unable to obtain safe drinking-water. The electricity cut in the Gaza Strip hinders the operation of water pumps and refrigerators in homes and health centres, where water is pumped for only two to three hours a day.
PREVENTION OF TREATMENT ABROAD FOR PATIENTS IN THE GAZA STRIP
31. Ms Abu-Zeid indicated in the speech mentioned above that the impact of closures on the possibility of delivering medical care outside Gaza was particularly depressing. The demand for such care was increasing at a time when the levels of medical care within Gaza were being reduced. However, the permit system imposed by the Israeli occupation authority in order to allow referral for medical operations abroad had become more stringent. For many, treatment had been delayed or even denied, which worsened health conditions and led to many deaths among the Palestinians that could have been avoided.
32. Although the health ministry is exerting vigorous and continuing efforts and using Arab and regional links to facilitate the movement of Palestinian patients from the Gaza Strip for treatment in hospitals in neighbouring countries, the Israeli occupation authorities continue to refuse to allow hundreds of them to travel.
33. The report of the specialist treatment department of the Ministry of Health issued on 16 February 2008 in Gaza shows that the Israeli siege has led to a significant increase in the number of medical referrals abroad; the number of those referred in the second half of 2007 increased by 63% over the same period in 2006. The report adds that the reason for this increase is the acute shortage in medicine and technical capabilities needed to treat patients, which prompted doctors to refer patients for treatment outside the hospitals of the health ministry.
34. The same report also shows a significant increase (118%) in the number of referrals for patients with tumours in the same period, due to insufficiency of doses of chemotherapy, inability to purchase the medicines and the lack of some medical tests needed for those patients.
35. Owing to the Israeli actions that hamper the movement of patients from the Gaza Strip through the crossing of Beit Hanoun (Erez), impeding or deferring their entry for additional days after the issuance of permits, the specialist treatment service has documented the death of 20 patients as a direct result of these unjust actions. With the closure of the crossings, the unjust Israeli blockade imposed on the Gaza Strip and the Israeli occupation authority’s prevention of patients from leaving the Gaza Strip to receive the necessary treatment abroad, the total number of deaths among patients had risen to 136 by 21 April 2008.
36. The continuing Israeli blockade on the Gaza Strip will complicate the medical situation of patients and worsen their health condition, in addition to raising mortality rates among them.
37. The closure of the Rafah crossing has led to the referral of patients who previously went to Egyptian hospitals for treatment, to hospitals in Israel and the West Bank and occupied Jerusalem, with delays in their arrival because of the difficulty of obtaining travel permits from the Israeli side, high treatment cost and increased pressure on hospitals in the West Bank and occupied Jerusalem.
38. The same report states that the Israeli side had only agreed to the entry of 64% of all patients who applied for permits to travel through the Beit Hanoun (Erez) crossing. Many of them are being returned and prevented from travelling through the Erez crossing, or their entry is postponed for several more days. In a flagrant violation of the fundamental rights of patients, the Israeli side remanded 71 patients for interview by Israeli intelligence in the last six months of 2007.
39. More than 70% of the population has no means of recreation or entertainment. Watching television is the main activity for children over six, leading to obesity and lack of physical exercise. The high rate of obesity in adults – about 40% – is a growing challenge to the health sector, and the greatest challenge is that most people have no access to guidance on reducing obesity and increasing physical exercise. One person in five aged 12 or over in the Palestinian territory smokes, and the rate is higher in the West Bank than in the Gaza Strip. The data indicate that the highest rate of smoking prevalence is in the 40–49 year age group, reaching 30% in 2006.
40. The demographic pyramid in Palestine is flat, and the population doubles every 23 years; 50% of the population is under 18 and about 3% is over 65. There are also the refugees who constitute about 44% of the population (69% in the Gaza Strip and 29% in the West Bank). Fertility rates remained stable in 2004 and 2006; 4.6 births per woman in the Palestinian territory in late 2006, which is the same rate as 2004, with 4.2 births in the West Bank and 5.4 births in the Gaza Strip. Table 4 shows the most important demographic indicators in the occupied Palestinian territory in 2007.
41. We note from Table 4 that rates of population growth and fertility are among the highest in the world, leading to a rise in the proportion of people under 15 and forming a flat demographic pyramid. This leads to a remarkable increase in the demand for primary health care services and public health, and burdens the workers in the health ministry.
FREEDOM OF MOVEMENT IN THE OCCUPIED WEST BANK
42. On 11 April 2008, investigations by human rights organizations and the report of the Office for the Coordination of Humanitarian Affairs of the United Nations, revealed that the declaration Israel made to the United States to remove the earthen walls in the West Bank, had not been put into effect, and that in some cases, the occupation authorities removed earthen walls in front of the cameras of the journalists, only to rebuild them again afterwards.
43. The report issued by the Betslim Organization at the end of 2007 states that the number of fixed barriers erected in the West Bank has hardly changed in the last year, at an average of 102 barriers, of which 66 are erected for controlling movement within the West Bank (including 16 barriers in Hebron), and 36 are final checkpoints before arriving in Israel. In addition to the fixed barriers, the army sets up dozens of mobile checkpoints every week. Added to that, Israel continues to use the major obstacles that restrict access to the main roads and direct traffic to the enhanced barriers. These obstacles have increased in number in recent years, reaching 459 in 2007 compared with 445 in 2006 and 410 in 2005. Israel prohibits Palestinians from travelling or imposes restrictions on more than 300 kilometres of roads in the West Bank. Restricted freedom of movement, and the geographic division stemming from this restriction, is severely affecting the performance of the basic institutions for the Palestinian population in the occupied territory, including the health system and municipal services.
44. In 2007, the population of settlements increased by 4.5% (compared with 1.5% in Israel), and the number of Palestinian homes demolished by Israel rose by 38%, to 69 homes. Palestinians are still significantly discriminated against in the distribution of water in the West Bank, leading to an acute shortage in drinking water during summer.
45. During his visit to the West Bank on 16 February 2008, Mr John Holmes, Under-Secretary-General of the United Nations for Humanitarian Affairs and Emergency Relief Coordinator, noted the difficulties faced by the Palestinian population in accessing basic services and places of work, because of the obstacles, barriers and permit laws imposed on them by the Israeli occupation forces. He was also briefed about the major obstacles patients and health workers of the occupied West Bank face in accessing hospitals and health clinics in occupied Jerusalem in order to receive treatment or to work there because of the Israeli barriers. Although the distance the patients travel from their homes to health centres does not exceed a few kilometers, which should take 10 minutes by car, it now takes more than an hour. Patients usually go to hospital to receive basic and essential services such as radiotherapy, dialysis and pediatric oncology.
THE SEPARATION WALL IN THE WEST BANK AND OCCUPIED JERUSALEM
46. In defiance of the opinion of the International Court of Justice in 2004, the construction of the separation wall did not stop, nor did its destructive effects on the lives of Palestinians. It continues to divide and isolate communities, destroy their livelihoods and prevent hundreds of thousands of people from reaching their workplaces, families, markets, schools, hospitals and health centres.
47. In 2002, Israeli occupation forces began building the separation wall. Upon its completion, the proportion of villages unable to access health facilities in the region will be about 32.7%, rising to 80.7% if we take into account the isolated pockets, and the ”seam” zone. After completion, the wall will isolate a total of 71 clinics: 41 clinics were already fully isolated. Some 450 000 Palestinians will be directly affected, and a further 800 000 indirectly.
48. The establishment of the wall is part of an Israeli integrated policy which began with the building of settlements, then barriers, and finally the wall which dismembers the West Bank and turns it into ghettos. The aim of building 35 kilometers inside Salfit and Qalqiliya is to isolate the occupied city of Jerusalem from the West Bank, expand the settlements of “Ma’aleh Adumim”, Bethlehem and Hebron, and to create ghettos; here, we are talking about 28 ghettos containing 64 groups of Palestinians.
49. The report of the Palestinian Centre for Information in Ramallah states that the situation in the occupied city of Jerusalem is horrendous, as the wall, settlements and checkpoints cause serious health problems and fully isolate some Jerusalem communities, such as Anata village and Shufat refugee camp, from the major facilities providing them with services in occupied Jerusalem, such as Al-Uyoun, Al-Maqasid and the Red Crescent hospitals. The report also shows that more than 70 000 Palestinians with Jerusalem identity are threatened, as the next step of Israel, upon constructing the wall, is to prevent them from reaching Jerusalem, and then withdraw their health insurance and identities on the ground they no longer reside in the city.
50. Moreover, the separation wall even directly affects the villages that seem to be remote from the construction site, because of the road network the Palestinians are forbidden to use. For example, Palestinians are unable to reach Ramallah and occupied Jerusalem, because of their roads.
51. In the same visit to the West Bank, Mr Holmes states that the wall, the settlements and the Israeli permit system destroy the economic and social life of the population in the West Bank, and are responsible for exacerbating poverty and unemployment. Thus, the first step to build an economy conducive to strengthening peace talks is to stop building the wall and prevent the expansion of settlements and lift the barriers.
SHORTAGE OF DRUGS, MEDICAL SUPPLIES, LABORATORY MATERIAL AND MEDICAL DEVICES.
52. A report on health conditions during October and November 2007, issued in November 2007 by WHO’s office in the occupied Palestinian territory, stated that at the health ministry in Gaza stocks of 85 essential drugs (20% of the WHO Model List of Essential Medicines) were sufficient for less than one month, that a further 56 essential drugs (14%) were unavailable and that the strategic stock at health ministry warehouses in Gaza lacked one third of essential drugs.
53. The report stated also that the health ministry in the West Bank had less than one month’s supply of 97 essential drugs (23% of the total) and that 73 essential drugs (18%) were out of stock.
54. On January 2008, the health ministry medical warehouse service in Gaza reported that, out of 486 items listed as essential drugs, 91 were out of stock. These included drugs for tumours, intensive care, obstetrics, paediatrics and chronic disease. The remaining essential drugs were sufficient for one or two months. The strategic stock was depleted because of lack of access to drugs and lack of procurement budgets. Non-essential drugs for tumours, kidney disease and epidemic hepatitis were also out of stock. Hospitals experienced severe shortages of vitamin K. Fifteen mental health drugs remained out of stock for several months. Public sector pharmacies lacked many medicines.
55. The health ministry laboratory and blood bank service in Gaza reported on 17 February 2008 that, of 1200 items needed for blood transfusion and laboratory activities, 52 were no longer available and stocks of 150 items, mostly required for blood transfusion, measuring blood gas levels and salt assays for intensive care patients and newly born children, would be used up within two months. Much laboratory and blood transfusion equipment such as chemistry and haematology devices and blood gas measurement instruments was out of service either for lack of spare parts or because it was obsolete and unusable.
56. The same WHO office report issued in November 2007 showed that 17% of medical supplies and accessories in the Gaza Strip would not last for a month. A similar shortage had prevailed in previous months.
57. At the end of January 2008, the health ministry medical supply service in Gaza reported that 200 medical items (23% of the list) needed for hospitals and primary care centres were out of stock, while a further 150 items in stock (17%) would last only two months. Several reports by the WHO office in the occupied Palestinian territory showed that the health ministry suffered over several periods between October 2007 and April 2008 from a shortage of medical gas supplies (including nitrogen) needed for surgical operations. That shortage led to delays in terms of non-emergency operations.
58. The severe shortage of essential drugs, coupled with the lack of diagnostic and treatment equipment at all Gaza hospitals, especially equipment for neonatal feeding, kidney dialysis and computer tomography was exacerbated by lack of maintenance and spare parts due to blocked crossing points. The result was a deterioration in the quality of health services delivered by those hospitals to Palestinian patients.
59. The infrastructure of hospital and primary health care clinics is deteriorating in a dangerous, irreversible fashion, as is essential equipment. Repair and maintenance remain difficult to perform in the absence of spare parts. The health ministry engineering and maintenance service in Gaza reported on 7 February 2008 that four projects to build and extend hospital departments, including surgery and intensive care units to the value of US$ 6.15 million have been halted, as were rehabilitation and restoration work on nine buildings, including a children’s hospital, central drug warehouses and six outpatient clinics for primary health care at a cost of US$ 1 050 000. Regular maintenance of hospitals, primary care centres and several health care departments could not be continued.
60. According to the same report, 94 medical devices were no longer operational because of extended use over long periods of time without access to spare parts. Some of the devices belonged to intensive care units for general surgery, cardiology and neonatal departments. Others belonged to diagnostic and treatment units. Health ministry hospitals in Gaza needed 13 medical devices, including anaesthesiology, radiology and electrocardiography equipment to the value of US$ 500 000.
HEALTH SERVICE DELIVERY
61. Data issued by the health ministry towards the end of 2007 on health conditions in the occupied Palestinian territory during 2006 indicated that the poor economic situation and non-payment of monthly salaries had prompted West Bank Government employees to strike. Moreover, Israeli action against Palestinian citizens, including more barriers, repeated curfews and continued erection of the discriminatory separation wall, made it difficult for patients and citizens to reach primary health care centres. As a result, many health indicators were lower in 2006 than in 2005.
· The attendance rate at health facilities decreased by 15.1% for primary care centres and by 20.6% for general medical clinics.
· The attendance rate for newly pregnant women at maternal and child health care clinics decreased from 4.8 visits per pregnant woman in 2005 to 3.7 visits per pregnant woman in 2006.
· The use of community-based mental health clinics decreased by 16.6%, while registration of mental patients decreased by 44%.
63. The health ministry is working hard in cooperation with international health agencies, including UNICEF, to secure the necessary vaccines for newborn babies, children and mothers. The ministry’s vaccine section reported on 4 February 2008 that strategic stocks of most types of vaccine were secured until March 2008. Very unfortunately, measles-mumps-rubella vaccine was unavailable from October 2007 until February 2008 despite efforts to secure it.
64. Repeated power cuts and power generator fuel shortages compromised the efficiency and validity of vaccines stored in central warehouses and health care units. The immunization of a large number of children, therefore, may well have been less efficient.
65. Of 78 hospitals in Palestine, 24 are owned and managed by the health ministry (12 in the West Bank and 12 in the Gaza Strip) with a capacity of 2864 beds, representing 56% of total Palestinian hospital capacity. The rate of 13 beds for 10 000 population in Palestine is one of the lowest in the region.
66. The health ministry first aid and emergency service has 57 ambulances, 42 with petrol engines and 15 with diesel engines. The corresponding daily need is more than 600 litres of petrol and 400 litres of diesel fuel.
67. Despite endless efforts by the health ministry to secure the necessary fuel, spare parts and vehicles for delivery of health services to sick and injured persons under such difficult circumstances, the first aid and emergency service still suffers from continuous shortages in fuel supplies because of Israeli blockades. The severe shortage of spare parts for vehicle maintenance put 20 ambulances (35% of the total) out of service. The need for vehicle replacement is not urgent. Monitors of intensive care ambulances have been out of service for two years now and no replacements are available. For these reasons, the health ministry appeals to international agencies and human rights organizations, especially the International Committee of the Red Cross and WHO, to lend immediate help to first-aid and emergency crews. Action is needed to lift the blockade on the Gaza Strip and to secure fuel and spare parts for ambulances, so as to make it possible to deliver humanitarian services. The Gaza Strip is experiencing bombings, incursions and blockades. These circumstances require advanced fourwheel-drive ambulances equipped for the transportation of dead and injured persons in difficult terrain and sandy areas. They also require a telecommunications network for emergency stations.
68. The number of patients returning to health facilities for follow-up has decreased by more than 25% since 7 April 2008 because of the lack of transport. Hundreds of medical crews are unable to reach their duty stations. The Palestinian Human Rights Centre reports that most ambulances are no longer able to transport patients because of fuel shortages and that the health ministry is now using its limited fuel reserves to keep health centres and essential hospital equipment running. Soon the fuel reserve will be depleted and the entire health sector, including ambulances, will be paralyzed.
69. On 23 April 2008, Mr John Jing, Chief of Operations at UNRWA, said that doctors and patients were forced to go to hospitals on foot. He explained that 20% of ambulances were immobilized and another 60% would stop by the end of the week.
70. In 2007, the Palestinian Red Crescent reported a total of 520 attacks against ambulances, medical crews and health facilities. The occupation forces committed acts of aggression which prevented 20 ambulances from reaching patients and saving their lives by taking them to health centres and hospitals. The occupation forces severely damaged 16 ambulances and completely destroyed another, attacked 36 emergency crew members, seriously injuring 13 of them in the line of duty, arrested another two crew members, and bombed and raided a number of hospitals and government centres. These acts resulted in damage to medical premises. In the occupied West Bank, for example, the hospitals in Nablus and Rafidia were raided on 3 and 4 January; patients and staff were searched. On 16 April 2008, Israeli tanks shelled the Wafa Medical Rehabilitation Hospital in eastern Gaza, thereby stopping medical activities in several departments.
Primary health care and maternal and child health
71. There are 654 health centres in the Palestinian territory (525 in the West Bank and 129 in the Gaza Strip). The health ministry owns and manages 63.6% of primary care centres (360 in the West Bank and 56 in the Gaza Strip). There are 1.8 centres per 10 000 population. The maternal mortality in women of childbearing age is 33 per 100 000 births. However, this does not reflect the Palestinian reality, since much of the population is unregistered because of the fragmentation of Palestinian areas into several isolated cantons by the Israeli army and to low registration of neonatal deaths. The health ministry continues to give priority to child immunization. However, Israeli actions have reduced coverage to under 90%. The nutrition status of children under three years of age features 54.7% anaemia and 4.1% ricketts. The maternal care rate was five visits per pregnant woman. 20% of all births were by caesarean section and the Gaza Strip had the highest proportion of high risk pregnancies. In 2006, 62 347 children under five years of age (11.7%) were affected by diarrhoea; the highest diarrhoea incidence for the West Bank was registered in Qalqilia Governorate (15.8%), while Gaza Governorate registered the highest incidence in the Gaza Strip (13.2%) in 2006. Some 79 890 children under five (14.1%) suffered from respiratory inflammation. Anaemia incidence increased among pregnant women and the poor. This was a natural result of the increased fertility rate and shorter intervals between births. The use of contraceptives reached 47%. This is to be considered an acceptable rate when compared with surrounding countries. However, access to reproductive health services should be made easier.
Infectious and chronic diseases
72. The ministry supports the epidemiological monitoring programme, which succeeded in eliminating or stopping the spread of several diseases, thus reducing infectious diseases mortality rates to 27.8 per 100 000 population. The prevalence of mumps, epidemic hepatitis A and B and, brucellosis has been reduced. The microbiology unit of the public health laboratory in Gaza and Ramallah now has enhanced capacity to diagnose avian influenza. Meningitis, brucellosis, hepatitis and tuberculosis are the main endemic diseases in Palestine. Cardiovascular diseases are the main cause of mortality in the population, at 60 per 100 000 population, while mortality rates from stroke and basic hypertension amounted to 30 and 15 per 100 000 respectively. The prevalence of diabetes (9%) is not among the first ten causes of mortality. In 2004–2006 the prevalence of chronic disease increased by 31.1%; hypertension and diabetes accounted for the highest morbidity among the elderly. Diabetes prevalence rates among people aged 60 years or more reached 24.8%, and hypertension 35.2%. In 2007, cardiovascular diseases, stroke and tumours were the main causes of mortality. The most important causes of death in infants were respiratory diseases, accidents, congenital malformations, and basic hypertension.
73. In 2007, 100 000 patients were admitted to mental clinics, with more than 2500 new cases in the Palestinian territory (62.2 per 100 000 population) as compared to 956 cases in 2000 (30.3 per 100 000 population). 13% of them suffered from schizophrenia, 15% from psychosis, and 27% from emotional disorders. These rates have doubled since 2000 with the deterioration of the political and economic situation of the Palestinian people. Due to the use of various banned weapons, and the policy of destruction and annihilation followed by the Israeli occupation authorities, the killing, assassination, destruction and shelling tactics adopted by those authorities have given rise to an entire generation of physically and mentally handicapped people, especially children, who are traumatized every day by the sight of maimed bodies. Mental health services should be bolstered in order to cope with the hardships generated by the prevailing situation. Priority should be given to the promotion of psychological support and counselling for various segments of society. The ministry should be provided with psychiatrists and furnished with efficacious medicines for such diseases.
74. The report of the Department for Community Mental Health, published on 6 February 2008, shows that Gaza has increasing numbers of people, particularly children, seeking treatment at the community mental health clinics. In 2007, 16 725 children under 18 attended those clinics, including 414 new cases. In some parts of the Gaza Strip the rates of bed-wetting have increased to 63% and the rates of nail-biting have increased to 8.8% among children in the 6–12 age group. This large increase in the numbers of mental patients is due to intense frustration, fear and panic resulting from the conditions they live in, as well as the increase in stress resulting from darkness, especially among children. Mental health clinics are experiencing breakdowns in the electroencephalography devices due to the daily disruption of electricity, and many medicines used in mental health care are lacking. The Gaza centre for mental health confirmed that the tight blockage on the Gaza Strip is leading to catastrophic physical and mental health conditions. It added that the blockade is leading to an increase in the rates of mental health disorders in general; depression, anxiety and psychosomatic disorders are common and contribute to the frequent relapses in mental health patients. The centre points out that this mental suffering results in high levels of family and community violence.
Health insurance and referrals to non-health ministry centres
75. There is a tendency to institutionalize and boost health insurance by increasing voluntary insurance schemes and applying a concept of full coverage for citizens through a new system of contributions for equitable financing and medical services. Public health insurance now covers 60% of families living in Palestine. This heavy burden has prompted the health ministry to reduce expenditures on referrals to centres not run by the Ministry of Health. Total expenditure for such referrals in 2007 was 238 million shekels. This sum includes referrals from the Gaza Strip since 15 June 2007. The cost of treatment in non-health ministry centres decreased from US$ 3.6 million in 2002 to US$ 3.3 million in 2003 and to US$ 3 million in 2004. Since 2005, referrals to non-health ministry centres have become the third highest item of expenditure for the ministry. In 2007 there were 9000 such referrals costing approximately US$ 59 million. Cancer was the most common medical reason. Other diseases requiring treatment abroad were heart diseases, eye conditions and surgery, followed by referrals for rehabilitation and urinary tract conditions. Table 5 shows the most significant referrals to non-health ministry centres over the last three years.
76. Little significant progress was made in reducing infant mortality during the period 2000–2006. The rate was 25.3 per thousand live births in 2006. Progress was poor also in reducing the mortality rate for children under five years of age, which was 28.2 per 1000 live births in 2006 as compared to 28.7 per 1000 in 2000. This mortality rate was reduced by 5.5% in the West Bank during the period 2000–2006, but in the Gaza Strip it increased by 1.6%. Life expectancy increased between 2002 and 2006 from 71.1 to 71.7 years for men and from 72.6 to 73.3 years for women. The following table shows the most significant basic health indicators in Palestine.
77. Finally, we wish to recall a statement delivered around the end of 2007 by the Commissioner-General of UNRWA, wherein she said that even the most optimistic person would struggle to see a viable form for a Palestinian State in view of the massive land confiscation, the movement restrictions, the separation wall, the clearance system, security inspections, towers, trenches and electrical fences.
78. However, the Palestinian National Authority still considers that peace is the strategic option for both Palestinian and Israeli peoples. Only peace can bring about an end to the long-lasting Israeli occupation and lead to an independent Palestinian State with occupied East Jerusalem as its capital.
79. Therefore, the Palestinian health ministry:
• calls upon the international community to exert pressure on the Israeli Government in order to lift the blockade, avoid exacerbating the human crisis in the Gaza Strip and meet its ethical and legal responsibility to safeguard basic human rights of civilians living in occupied Palestinian territory;
• invites the High Contracting Parties to the Fourth Geneva Convention to meet their obligations under Article 1 of the Convention; to fully abide by the Convention and ensure its respect in all circumstances; to meet their obligations under Article 146 by prosecuting persons alleged to have committed grave breaches of the Convention, keeping in mind that such breaches are to be considered war crimes by virtue of Article 147 of the Convention Relative to the Protection of Civilian Persons in Time of War and of the First Additional Protocol to the Convention, with the aim of protecting Palestinian civilians in the occupied Territory;
• expresses its appreciation for the support provided to the Palestinian people in all areas of activity and appeals to States and international health institutions to support implementation of the recently adopted Medium-Term Health Development Plan, thereby safeguarding the health conditions of Palestinians living in the occupied Palestinian territory, including Jerusalem;
• calls upon the international community to exert pressure on Israel with a view to implementing immediately the International Court of Justice advisory opinion on the illegality of the separation wall built inside the occupied West Bank territories;
• invites all international human rights institutions, beginning with the International Committee of the Red Cross to take urgent and immediate action to compel the occupation authorities and the Israeli prison administration to offer medical treatment to prisoners suffering from illness and from further worsening of health conditions; calls for an international committee of doctors specialized in critical health conditions to offer urgent treatment; and appeals to international civil community-based institutions to exert pressure to ensure that prisoners’ lives be saved; that immediate treatment be offered to patients; that those with severe conditions be released immediately in order to receive treatment abroad; and that Palestinian women in prison be offered the necessary maternal health care in pregnancy, childbirth and the postnatal period; in addition to ensuring for them healthy, humane delivery conditions and assistance by their families.
80. Finally, we wish to express our deep appreciation to donor countries, WHO and humanitarian organizations for their aid to the Palestinian people.
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