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Source: World Health Organization (WHO)
14 June 2012

Jerusalem: June 14, 2012
Five Years of Blockade:
A Political Determinant of Health in Gaza

An Integrated Health System
The Palestinian health care system is an integrated whole, covering West Bank, East Jerusalem and Gaza. The Palestinian Authority, based in Ramallah, supplies drugs and disposables for Gaza and pays salaries of most of the staff. The East Jerusalem hospitals are the main specialized centers for patients from West Bank and Gaza. Health staff need to travel between West Bank and Gaza for training and to provide care. The health system cannot function effectively when Gaza is subject to a blockade and cut off from the West Bank and Gaza Strip.

WHO has joined other international organizations and UN agencies in calling for an end to the blockade.

Attack on Gaza, December 27, 2008 January 18, 2009
At least 1,300 persons were killed in the 22 days of sustained Israeli attacks on Gaza at end 2008 and January 2009. Patients with conflict-related injuries requiring specialized care outside Gaza were evacuated exclusively through the Rafah border crossing into Egypt. During the Israeli attacks 15 out of 27 hospitals (56%) and 43 of 134 primary health care (PHC) clinics in Gaza were damaged (27 MoH, 7 UNRWA and 9 NGO clinics). One damaged health facility is still under repair, work slowed as a result of the difficulties obtaining building materials.

Humanitarian access out of Gaza for critically ill
Erez checkpoint is not open 24 hours, 7 days per week, despite the fact that it serves 1.6 million people as the main humanitarian access route for the critically ill. The partial operating hours mean that patients may not exit Gaza for treatment after 2:30 pm, or on Fridays after 12:30 pm or on Saturdays. Exceptional access for critically ill patients requires considerable time for coordination with Israeli officials and can delay emergency treatment by at least two hours.

Ambulance transfers out of Gaza require special Israeli coordination. If the transfer occurs outside regular Erez opening hours, the required Israeli procedures are lengthy and unpredictable. They take a minimum of 2 hours. This is not compatible with a patient’s rights to unimpeded humanitarian access.

Shortages of Essential Medicines and Disposables
June 2012, the Ministry of Health (MoH) in Gaza central pharmacy stores report 42% of essential medications are at zero stock, with an additional 13% at low levels sufficient for less than 3 months. The MoH can no longer supply patients with drugs for severely debilitating chronic diseases such as multiple sclerosis or first-line antibiotics at primary health clinic level. At hospital level, shortages have affected oncology treatment, surgeries and dialysis.

Chronic drug and disposable shortages have been reported in Gaza since 2006, caused primarily by political divisions between the West Bank and Gaza and exacerbated by the blockade on Gaza. More recently shortages have increased due to financial shortfalls in the Palestinian Authority budget. Patients now frequently purchase many medications from private pharmacies or seek donations from charities. Patients with life-threatening diseases or chronic disease who need maintenance medications, and poor and elderly patients, are especially affected and may risk disease complications by foregoing treatment. The need to obtain prior Israeli approval for importing drugs and medical supplies into Gaza mean receipt is delayed by several months. The MoH is not permitted to send medical equipment for repair, nor to return expired or surplus medical material

Fuel and Energy Shortages
Since the Israeli destruction of the main power plant in June 2006, follow by restrictions on equipment and fuel imports, Gaza’s electricity has been unstable. The 12-hour to 16-hour daily power cuts directly affect MoH health services. In early June 2012, hospitals were functioning with only 11% (3-4 days at current rate) fuel reserves. They depend on back-up generators (which require increased fuel supplies to continue operations) and independent battery units for critical hospital equipment. Unreliable power can damage medical equipment. While Ministry of Health hospitals, with ad hoc donor assistance, have made efforts to maintain fuel reserves to ensure a constant supply of electricity for critical units and fuel for emergency vehicles, they operate under increased technical and financial strain. At household level, electricity cuts cause disruptions with daily life needs: water supply, refrigeration needs and other areas affecting health. Restrictions on imports of equipment and fuel have led to inadequate capacity of power plant turbines serving the Gaza Strip for many years.

Referrals of Gaza Patients to Outside Facilities
In the 5-year period between June 2007 and May 2012, 11,727 patients who applied for Israeli-issued permits to access medical treatment unavailable in Gaza through the Israeli Erez checkpoint were denied permits, or their requests were delayed past their hospital appointment date. That is, 23%, one in 5 of the total patient applications were denied or delayed. In the past two years, 618 patients were called for interrogation by Israeli security after applying for a permit.

More than 85% of patients requiring access through Erez checkpoint are financially supported by the Palestinian Ministry of Health for treatment outside of Gaza. The drug and fuel shortages have increased the need for MoH referrals. The 5 most frequent reasons for referrals are for cardiovascular, oncology, ophthalmology, orthopedics, or neurosurgery treatment. Last year, of almost 12,000 Gaza patients who were financially supported by the Palestinian Ministry of Health for referral to facilities outside Gaza, 33% were referred to Egypt through Rafah border crossing, and 23% to Israeli hospitals. However, the majority of the patients required Israeli permits to access health care within the occupied Palestinian territory: either to East Jerusalem hospitals (30%) or to elsewhere in the West Bank (10%).

Figure1 . The five-year trend for patient access through Erez checkpoint reflect the vulnerability of Gaza’s population to
Israeli administrative policies. An average of more than 1 in 5 patents were hindered in access to medical care during
this period.

Restrictions on Movement of Health Staff
Normal movement for medical and other health personnel is restricted between Gaza and West Bank, and to East Jerusalem, dependent on an Israeli-issued permit. This affects health services planning, long-term training for medical and health students at the main teaching hospitals in East Jerusalem, and short-term continuous education, e.g. , 16 Gaza MoH medical staff were denied permits to travel to the West Bank for WHO-sponsored health-related training or meetings in 2012: 4 physicians (all of whom were called for security interviews at Erez checkpoint before being denied permits), 9 midwives, 1 nurse and 2 medical students. In a rapid survey, WHO found that 10-20% of recent requests for permits from health personnel were denied, with no reasons given, or are delayed past the time requested.

Environmental Health Issues
In many areas Gaza sea water is polluted by run-off of raw sewage to the extent that many sandy beaches are unfit for recreational purposes. The import of materials to build planned sewage treatment plants has been restricted for a number of years, exacerbating the problem of safe sewage treatment. Drinking water quantity: Water and sanitation services are affected by the power cuts and fuel shortages. Only 10% of the population receives running water daily (maximum of 8 hours). More than 50% of the population receives running water only twice per week.

Water quality: UNICEF reports that 95% of the water in wells in the Gaza Strip have very high nitrate and chloride levels; nitrates are at 2 to 16 times the WHO recommended maximum levels of 50mg/liter.

5 years = no family visits for Gaza detainees in Israeli prisons
As of June 2012, 1,441 Palestinian prisoners from Gaza were being held in Israeli jails, without family visits since June 2007 when Israel enforced a total prohibition. Since November 2009 Gaza prisoners have been prevented from receiving family support to supplement their food and health needs through the prison canteen. A protracted hunger strike this spring by more than 1,600 West Bank and Gaza prisoners ended in May, after Israeli guarantees of better conditions, among them a resumption of family visits for prisoners from Gaza. According to the negotiated agreement, Gaza family visits and canteen support should be resumed by June 14.

The longest-ever hunger striker, detainee Mahmoud Sarsak, 25, has remained on strike since March 19, and is now in his 87th day (June 13), to protest being held without charge for three years. His lawyer was called on June 10 to Ramle prison hospital to see him due to a sudden deterioration in his condition. Sarsak, a professional soccer player before his arrest, is in a critical health status.

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