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Source: World Health Organization (WHO)
21 May 2009



WHO Specialized Health Mission to the Gaza strip

As mandated by the Executive Board of WHO
in its Resolution EB124.R4 adopted on 21 January 2009

Extended report 1

Geneva 21 May 2009



Executive summary

On 21 January 2009 the Executive Board (EB) of the World Health Organization (WHO) passed Resolution EB 124.R4. This requested the Director General of WHO to dispatch a specialized health mission (SHM) to Gaza to identify urgent health and humanitarian needs from the 22 days of Israel’s military operations (IMO CL22) that started on 27 December 2008. The Director General quickly nominated the SHM members. After studying a large number of reports on the issue, the SHM team visited Gaza during four days in March, observed the destruction on the ground, met with a large number of representatives of international and national organizations, and spoke by telephone with the Minister of Health of the Palestinian National Authority (PNA). The main findings of the SHM team are as follows:

The 1 .5 million people living in the Gaza strip have for a long time been subjected to a long-standing blockade by the occupying power, Israel; a blockade that has been particularly severe since 2007. As a consequence, the economic and social conditions for the civilian population have deteriorated, with increasing poverty and almost total dependency on external aid, leading to a worsening of the health conditions of the population.

When Israel attacked on 27 December 2008, the subsequent human toll inflicted by IMO CL22 was severe indeed2 ; 1 417 Palestinians were killed, 313 of whom were children and 116 women. Over 5,380 were physically injured, of whom 1,872 were children and 800 women. How many of the injured will be permanently disabled is not yet known, but it is expected to be a high number as the injuries often were very severe. The already worrisome mental health situation was made worse by the multiple deprivations caused by widespread damage to many sectors and the sharp increase in insecurity from the 22 days of attacks. This has since been further exacerbated by the more limited, but frequent, military incursions that Israel subsequently has continued to carry out3.

The consequences for many families were severe indeed: 1,700 households lost their breadwinner from death or injury, and over 15,000 homes were totally or partially destroyed. 100,000 people fled their homes and neighbourhoods due to the military attacks, half of whom were taken in by UNWRA-organized shelters. The remaining IDPs found refuge with other families, adding to the overcrowding that already characterized many apartments in the Gaza strip. The civilian population suffered further from damage to electricity, water and sewage systems. Damage to 15% of agricultural land, remnants of unexploded ordnance in ruins, destruction of many small industries and damage to essential public service infrastructures further added to the problems.

The health services also suffered from direct attacks. Fifteen of the 27 hospitals were damaged, some extensively. In addition, 43 Primary Care Centres were damaged or destroyed. Twenty-nine ambulances were damaged or destroyed; 16 health staff was killed and 25 injured.4

However, in spite of the damages to the health services infrastructure and the large number of seriously wounded arriving over a short time period, the health service institutions rallied rapidly and effectively to face the huge crisis. Hospitals were quickly reorganized to give room for the arrival of mass casualties, and all staff leave was cancelled. Through an efficient mobilization of the Egyptian Ministry of Health’s Rapid Response Team, a good cooperation with the Egyptian Red Crescent Society, a strong action by the ambulance teams of the PRCS and the MoH ones, and with support from the ICRC a large number of seriously wounded patients were evacuated to Egypt (and some to third countries), thus relieving the workload at the Gaza hospitals.5 Medical supplies from stocks in the West Bank and foreign donations (mainly coming via Egypt) were sent to Gaza to help with the acute rise in demand.

Both the Palestinian National Authority in Ramallah and the de facto local authorities in Gaza quickly organized emergency structures to help manage the situation. The Inter-Agency Standing Committee (IASC) mobilized the Cluster system, thus creating an organized mechanism for extensive information exchange and practical cooperation among UN agencies, NGOs, and local authorities that were interested in contributing to supporting a particular sector. Thus, the WHO-led Health Cluster, the UNICEF-led WASH Cluster and the WFP-led Logistics Cluster played important roles in helping to coordinate the external aid which poured in. WHO also contributed by making additional staff available from its Regional Office and the HAC Cluster in its Headquarter, and already on 16 February the Health Cluster had completed a Gaza Strip Initial Health Needs Assessment for the health sector..6

The crisis also revealed serious deficiencies in the health services in the Gaza strip. Some essential tertiary care level services were simply not available anywhere within the Gaza strip, a problem of increasing concern due to the Israeli blockade. While in general, emergency care for casualties at the frontline was admirable in view of the extremely difficult and dangerous situations confronting the ambulances and their teams, the often very serious injuries and other factors also meant that at times the emergency care could have been better. Overall coordination of the health sector suffered from the lack of a well thought-through disaster management plan and a more advanced communication system.

The SHM team has highlighted the unique nature of the crisis that affects the Gaza strip. Unlike most other disasters in the world, this is not one that follows the normal pattern of an initial crisis, which then is followed by recovery and development. Rather, the long standing, very severe blockade, the chronic insecurity from more limited IDF military incursions - interspersed by incidents of sudden large-scale attacks - the split in the internal political leadership in oPt, and the steadily worsening socio-economic environment have created a downward spiral that best can be characterized as a complex, chronic disaster of catastrophic proportions.

Since that situation also has direct negative effects not only on the health sector, but on the fundamental health determinants, a strategy to improve the health of the 1.5 million people living in the Gaza strip must also deal with the more fundamental ills of the current situation.

Therefore, the SHM team’s recommendations (see Annex I) for improving the situation are of 2 types:

The first recommendations address the political imperatives of creating a stronger security arrangement with Israel and lifting the blockade, as well as reconciling the Palestinian political forces. If these recommendations are followed, the impact on health and health care for the civilian population of Gaza will be profound.

The remaining recommendations deal with the more health sector specific issues; some recommendations deal with more immediate actions, and the last ones address the somewhat longer term:

Immediate recommendations include the need for ensuring priority repairs of damaged hospitals and health centres and the reliable provision of equipment and supplies to re-establish a quality function. A systematic identification of the many injured from the Israeli military operations is necessary to ensure that they get the treatment and services they need. Although there have been no epidemics in the wake of the December/January attacks, it would be prudent to plan for such an eventuality as the season now changes towards warmer weather and brings a higher risk of epidemics from the damaged water/sanitation/food infrastructure. In view of the negative effects on mental health that the overall crisis creates, a special effort to alleviate this trend is called for. Investigations to clarify clinical and environmental effects of weaponry used should be undertaken. Finally, monitoring of health, health determinants and health care delivery needs improvement.

Longer term recommendations include the development of a disaster preparedness plan for Gaza, supported by institution-specific ones. Preparing for the increasing number of disabled requires a broader strategy for creating a Handicap Friendly Society, including a full complement of services for the handicapped. Finally, a more fundamental revision of the health service infrastructure and function of the Gaza strip could in all likelihood lead to a substantial improvement in competence, cost-effectiveness, and quality of health care – as well as a greater independence to rapidly meet the medical care needs, should another acute, large crisis strike in the future.


Notes
1 A short version of this report has been submitted to the 62nd World Health Assembly (A62/24/Add.1)
2 The Israeli Defence Forces (IDF) named the 22 day military operations “Cast Lead”, and the abbreviation IMO CL22 is used throughout this document to identify that particular attack. Any other IDF incursions – taking place before or after IMO CL22 - will be labelled IMO.
3 Occupied Palestinian territory, Gaza, Situation Report No. 19 (29-30 January 2009), No.20 (31 January-5 February 2009), No. 21 (6-12 February 2009), No. 22 (13-19 February 2009), Geneva, United Nations Office for the Coordination of Humanitarian Affairs, 2009; Field update on Gaza from the Humanitarian Coordinator, Vol. 17-23 February 2009, Vol. 24 February 2009-2 March 2009, Vol. 2-9 March 2009, Vol. 10-16 March 2009, Vol. 17-23 March 2009, Vol. 24-30 March 2009, East Jerusalem, United Nations Office for the Coordination of Humanitarian Affairs, 2009.
4 Gaza Strip, Initial Health Needs Assessment, Prepared by the Health Cluster, Gaza, World Health Organization, 2009:2.
5 Humanitarian Assistance, Rehabilitation and Reconstruction of Health Infrastructure on the Gaza Strip: A Post- conflict Preliminary Assessment, Contribution by the Egyptian Ministry of Health and Population (MoHP), Cairo, 2009: Chapter III.6.
6 Gaza Strip, Initial Health Needs Assessment, Prepared by the Health Cluster, Gaza, World Health Organization, 2009.


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