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Source: World Health Organization (WHO)
6 May 1985


WORLD HEALTH ORGANIZATION
THIRTY-EIGHTH WORLD HEALTH ASSEMBLY

Provisional agenda item 32


(Part 2)




HEALTH CONDITIONS OF THE ARAB POPULATION IN
THE OCCUPIED ARAB TERRIT0RIES INCLUDING PALESTINE





/...



DISTRIBUTION OF PATIENTS REFERRED TO ISRAEL
FOR TREATMENT AND HOSPITALIZATION 1970-1984
(Judaea and Samaria)


The number of hospitals, including public voluntary, governmental and private, increased from 14 to 17. Total hospital beds increased from 1282 in 1972 to 1365 in 1983. In 1980, Mt. David Hospital temporarily closed 53 beds for renovations, and Evangelic Hospital closed 20 beds for renovations; Caritas Hospital added 8 beds in that year, for a temporary net decrease in 1980 to 1341. The renovations and reopening of the temporarily closed beds occurred during 1982. Days of care increased in absolute terms, and in terms of rates per 1000 population (from 543 to 347 per thousand population in 1983). Surgical operations performed in local hospitals also increased both in absolute terms (by 46% between 1972 and 1979) and in rates per 10 000 population (from 157 to 191 per 10 000 population in 1983).

General hospital bed supply (1.4 per thousand population in 1983, as compared with 0.86 per thousand in Jordan) has grown to keep pace with population growth, while utilization and occupancy rates have increased to 71% for governmental and 70% for non-governmental hospitals. Hospital deliveries have increased from 12.9% in 1968 to 48.3% in 1983. Increased hospital utilization has been related to the development of the health insurance plan which now covers about 40% of the population. From 1972 to 1983 there has been an increase in hospital admissions from 68 to 90 per thousand population, with a shorter average length of stay (decreased from 7.9 to 3.8 days). With increasing occupancy rates and declining average length of stay, the utilization rate of hospital care has increased, in keeping with the relatively young population by age distribution, and the growing availability of preventive and ambulatory care service.

Treatment of Judaea and Samaria residents in specialty units in supraregional hospitals increased from 30 patients in 1968 to 984 in 1982. From 1967 to the end of 1982, 14 182 patients from Judaea and Samaria were hospitalized in Israel University Hospitals, mostly paid for by the government authority. Referrals and hospitalizations are primarily in cardiac surgery, cardiology for cardiac catheterization, neurosurgery, radiotherapy, renal transplantations, pediatric surgery, pediatric intensive care, and ophthalmology.

At present, building projects are underway at Beit Jallah Hospital, Bethlehem Mental Hospital, Ramallah and Hebron Hospital. The Beit Jallah project includes a new tower of four floors which will include emergency and outpatient services, internal medicine and ICCU, a surgical floor including theatres, intensive care and recovery units, sterile central supply and departments of surgery and orthopedics. When this building is completed, the bed capacity of the hospital will increase by some 20 beds. Following opening of this new unit, renovation of present facilities will be undertaken to include an expanded radiology, physiotherapy, oncology outpatient, day care and inpatient unit, increased pediatric and pediatric surgery departments and increased obstetrics and gynecology services.

Under construction at the Bethlehem Mental Hospital is a new building for chronic patients (male) to replace an obsolete section of the hospital. The Hebron Hospital project has been underway for the past several years. An elevator system was completed in 1982, and during 1984 the operating room section, including recovery and central sterile supply, was renovated and expanded. Planning for these building projects has been assisted by the Planning Department of the Israel Ministry of Health using Israeli standards as a guide.

The Ramallah Hospital has been undergoing a process of renovation and expansion over the past three years, which includes a new floor for all surgical services (theatres, ICU, recovery and central sterile supply), a new laboratory including a central public health laboratory for the area, as well as an elevator and a new laundry. This project was completed during 1984.

In summary, hospital services and utilization have increased quantitatively for the residents of Judaea and Samaria over the years since 1967, with an increasing array of basic and specialty inpatient and outpatient services provided locally by local staff, with the backup of referral services to supraregional teaching hospitals, for services not yet available locally.

Mental Health: Judaea and Samaria

The Bethlehem Psychiatric Hospital provides hospital care for both Judaea, Samaria and Gaza as well as for East Jerusalem, Galilee residents, and occasionally there are cases from Jordan. In recent years the hospital has increased its treatment capacity with fewer beds, as a result of shortened length of stay and greater emphasis on outpatient care (Table 104). New psychiatric services in Gaza reduce the burden of hospitalization of Gaza residents in the Bethlehem Hospital through local ambulatory, day care, as well as inpatient care in a new 25-bed psychiatric unit in the Ophthalmic Hospital.


Table 104: SELECTED INDICATORS OF GOVERNMENTAL MENTAL HEALTH SERVICES,
Judaea and Samaria, 1968 to 1983
Mental Health Services

Psychiatric beds
Admissions
Discharges
Outpatient clinics
Outpatient visits
Total psychiatric and
nursing staff
1968

400
425
449
1
4 778

107
1972

370
533
532
1
5 053

106
1976

320
796
738
3
4 154

129
1980

320
824
807
4
4 495*

128
1983

320
813
830
5
3 241

115

Note: 1. *Outpatient visits only in Bethlehem Mental Hospital. Psychiatric visits from residents of the other districts are included. Data for visits to district clinics not yet available.

2. The decline in admissions and outpatient services in 1979-1980 is a result of the opening of mental health services in Gaza.

Source: Bethlehem Mental Hospital.



Hospitalization for serious mental disorders including psychotic, schizophrenic or depressive states has not increased significantly since 1968. The increase of outpatient psychiatric clinics and diagnostic and referral services has led to increased admissions for psychoneurotic disorders with shortened lengths of stay. The mental health staff in Judaea and Samaria increased even though hospital beds were reduced in order to cope with more active inpatient and outpatient care.

A new building project began at the Bethlehem Psychiatric Hospital in early 1982 to provide an 82-bed chronic care unit to replace an obsolete 60-bed unit which is in current use; the latter facility is to be converted to non-patient care hospital purposes. An overall mental hospital bed requirement review is underway.

Outpatient psychiatric care has been extended in Judaea and Samaria to three locations in 1979, four locations in 1980, and five in 1981. The major psychiatric clinic is located at the Bethlehem Hospital, receiving referrals and follow-up from the central region of the territory. This clinic is staffed by the senior psychiatrist four days a week, with team conferences with all psychiatrists and social workers attending once per week. The psychiatric clinic at Tulkarem is staffed by a hospital-based psychiatrist and social worker one day per week. A similar clinic operates in Nablus serving the northern region, in Hebron for its region, and in Jenin for its district.

A visit by Dr T. W. Harding, a WHO mental health expert, in 1979, assisted the government health service in planning for mental health services, with greater emphasis on development of outpatient and community care for the mentally ill as essential for improved mental health services.

HOSPITAL AND SPECIALTY SERVICES: Gaza

The location of health services in the Gaza district is shown in Figure 6, including governmental hospitals and primary care services as well as UNRWA primary care services.

Hospital services

With changing medical and epidemiological conditions in the area, along with the process of upgrading of hospitals, the Gaza Fever Hospital was redeveloped as the Ophthalmic and Psychiatric Hospital. These changes are evidence of changing health needs in the area, and exemplify the transition phase in health needs from a developing to a developed health status. Similarly, with changes in the prevalence of tuberculosis and improved ambulatory care for TB, the number of beds in the Bureij Tuberculosis Hospital was reduced.

The general hospital bed supply (Table 105) has remained stable (at 1.9 per 1000 population in 1983) with the growth of the population. In Gaza there are six hospitals, of which four are governmental, one is missionary and one shared between the government and UNRWA for tuberculosis. Major strides forward have been achieved in terms of quantitative and qualitative aspects of hospital care since 1967 (Table 106). With shorter lengths of stay and improved outpatient services, hospital services have been effectively increased (Table 107). Refinement and upgrading of specialty and subspecialty services and the addition of increasingly sophisticated equipment are the current focus of hospital service development.

The epidemiology and health information centre analyses current trends in hospital service utilization, including surgical procedures, in periodic epidemiologic reports. This provides an important tool for monitoring of health service utilization and assists in planning for the further development of health services.


Table 105: HOSPITAL BED SUPPLY, Gaza, 1977-1983 (selected years)
1977
1980
1983
General beds
Government Hospitals

El Ahli Hospital (formerly Baptist)

TOTAL
745

75

820
783

75

858
865

60

925
General beds/1000 population

Tuberculosis beds
1.9

1.9

1.9

Bureij Hospital (Government and UNRWA)

All Hospital beds
210

1 030
70

928
70

995



Figure 6: GAZA DISTRICT



Table 106: NEW SERVICES ADDED IN GOVERNMENT HOSPITALS
AND CENTRAL CLINICS SINCE 1967, Gaza
Hospital

Shifa Hospital
(340 beds)
Department or Services

Renal Dialysis
Radiology
ENT (Auditometry)
Medical Library
Gastroscopy
Dermatology clinic
Gynaecology/Obstetrics (expanded and renovated)
Emergency Ward (expanded and renovated)
Physiotherapy
Neurology Clinic
Psychiatric Clinic
Intensive Coronary Care Unit
Medical Records
Gynaecology (expanded 20 beds)
Maxillofacial Surgery
Burn Unit
Enteroscopy Service
Urology Service
Plastic Surgery
Oncology Day Care Centre
Asthma Clinic
Year

1973
1973
1974
1973
1975
1975
1976
1976
1976
1976
1976
1978
1978
1979
1980
1981
1982
1982
1982
1982
1982
Khan Yunis Hospital
(243 beds)
X-ray
Orthopaedics
Laboratory
Physiotherapy
Medical Records
Bacteriology Laboratory
Intensive Coronary Care Unit
Library and Lecture Hall
Dialysis Unit
1974
1974
1974
1975
1977
1981
1981
1981
1982
Nasser Children's Hospital
(135 beds)
Paediatrics
Neonatology Unit
Radiology
Day Hospital
Emergency Ward
Hyperalimentation Unit
1973
1974
1974
1975
1976
1982
Rimal ClinicCentral Laboratory
Oncology Clinic (transferred to Shifa 1982)
Asthma Clinic (transferred to Shifa 1982)
Hematology Service
Medical Information Centre
1973
1974
1975
1980
1981
Sazayeh ClinicDelivery Room
Dental Clinic
1976
1976
Ophthalmic Hospital
(57 beds)
Ophthalmology Unit
Psychiatry and Throat
Psychiatric Outpatient Department
Mental Health Community Centre
1968
1979
1980
1981
Bureij Chest Hospital
(70 beds)
Tuberculosis Treatment
BCG Programme
1953
1978

Source: Adapted from Ministry of Health, Report of the Special Committee on Planning of Health Services, Jerusalem, 1978, and reports by the Director of Health Services, Gaza.



Table 107: TOTAL HOSPITAL UTILIZATION, Gaza, 1977 to 1983 (selected years)
Utilization

Government Hospitals:
Discharges (000s)
Days of care (000s)
Occupancy (%)
Average length of stay
Day care (000s)

Israeli Hospitals:
Discharges (000s)
Days of care (000s)
Average length of stay

Nongovernment Hospital
(El Ahli Hospital):
Discharges (000s)
Days of care (000s)
Occupancy (%)

Total Discharges (000s)
Total days of care (000s)
1977


39.5
216.1
63
5.5
9.1


1.0
14.7
14.0



1.7
15.8
-

42.3
246.6
1980


42.6
201.4
63
4.7
9.1


0.9
12.1
8.6



1.5
9.5
-

45.0
223.0
1983


45.0
200.4
62
4.4
10.5


0.9
11.3
12.6



3.2
12.9
58

48.2
213.1
Total General Hospital Utilization Rates
Discharges per 1000 population
Days of care per 1000 population
Average length of stay
Surgical operations per 1000 pop.
93.6
547
5.9
32.8
98.6
489
4.9
NA
97.6
455
4.6
34.6



Shifa Hospital

Shifa Hospital is a 340-bed hospital located within the city of Gaza which, up to 1967, had medical, surgical, obstetric/gynaecologic pediatric and ophthalmology departments. The latter two departments have since been transferred to specialized hospitals.

The hospital has undergone a series of redevelopment phases which have transformed Shifa into a modern general hospital. Redevelopment of the infrastructure included new water supply and sewage systems, external and internal electrical systems (including an emergency generator), improvement of the kitchen facilities, telephone exchange, central heating and solar hot water heaters. A new entrance with electric gate, information booth, cafeteria and waiting area was opened in January 1983.

Equipment in many departments, in the emergency room and operating theatre has been modernized and expanded, now including central oxygen supply, endoscopic equipment, X-ray, tomography and image intensifier units. A medical photography unit was established in January 1983. New departments that have been added, as presented in Table 106, include an intensive coronary care unit, dialysis, maxillofacial surgery, a burn unit, and a basic pathology service. Additional services include a medical library (with more than 25 regular international journals) medical records, blood banks and others.

At present the new central building is in advanced stages of construction, and due for completion during 1985. The obstetrics unit building project was completed during 1984. The central building will include five ultramodern prefabricated operating theatres imported from England. This building will also include the X-ray department emergency room, administrative offices, operating theatres, intensive care, a surgical wing (50 beds), a lecture hall (150 seats). Completion of this project will greatly improve the overall facility, and is seen as a step toward achieving teaching hospital standards for the Shifa Medical Centre.

An oncology day care unit has been opened (10 beds); a plastics department, urology service, enteroscopy service as well as an asthma unit were added during 1982. Operating theatres were completely renovated during 1982, and new equipment donated by UNDP was installed. Due to the large number of deliveries and deficiencies in existing facilities, a new area was renovated and re-equipped for an expanded obstetrical department. The oncology service was provided by Israeli physicians at the Sheba Medical Centre, Tel-Hashomer, but in 1980, it was transferred to a local oncologist at the Shifa Hospital who has received training at the Sheba Centre and continues to work with physicians there. A tumor board, consisting of the oncologist, the treating physician and radiologist, has been established which reviews every cancer case.

A large new obstetric department as a separate entity is in the process of renovation and new construction to house 100 obstetrical beds, including a new delivery suite with 18 beds, a modern theatre and neonatal section with some 40 beds for premature and sick neonates.

A new function recently added to the Shifa Hospital was an isolation unit for serious infectious diseases. The new sanitary infrastructure of water and sewage systems enabled the development of this service.

Nasser Children's Hospital

Up to 1973 this was a semiprivate hospital for surgery and obstetrics. Based on the high morbidity and mortality rates prevalent for children in the area, it was felt that improved child health care necessitated a specialized children's hospital. The Nasser Children's Hospital was therefore established in 1973. This included an infectious disease service which was continued until 1979, when the adult service was transferred to Shifa Hospital, and child services were integrated into general services of the Children's Hospital, including its outpatient department.

In 1975, a day treatment unit was opened for children in medical need for some hours of care, without the trauma and expense of total hospitalization. This unit was used largely for infusions for the dehydration complication of diarrhoeal diseases, and for treatment of respiratory infections in the winter months.

The Nasser Children's Hospital was expanded in 1978 to 135 beds, including a newborn unit of 16 incubators. The hospital underwent basic renovation including the repair of the sewage, water, electricity and telephone systems. A new radiology unit and central oxygen supply system were installed.

The hospital has become actively involved in providing its services to MCH centres in the community, bringing specialty pediatric care to health supervision of children in the area. This includes participation in the ORS programme, as well as providing general curative services for the child population of the area.

The hospital now consists of three pediatric and one neonatology departments, a day-care observation/treatment unit, consultation and follow-up units.

Specialty services such as pediatric surgery, cardiology, endocrinology and genetics have developed in the hospital in cooperation with specialists from Israeli teaching hospitals.

The neonatal care unit is now being further developed and re-equipped. Professional linkage has been established with the Soroka Medical Centre in Beersheba through patient referrals and bringing of specialists from Beersheba to Gaza for teaching purposes. Eight new nursing positions are being added to the neonatal department and a total of 24 nurses (including the head nurse) are being trained in Beersheba in the Soroka Medical Centre’s neonatal intensive care unit, along with medical staff from Gaza. A local pediatrician returned from a WHO fellowship in neonatology in England, to become head of the expanded neonatology unit. UNDP and UNICEF have provided new equipment for the neonatal unit, including incubators and monitors.

A specialist in pediatrics who returned from England in 1982 where she received her MRCP, has become the new director of the Nasser Children's Hospital.

A new hyperalimentation unit was established in 1982 with a special laboratory operated by a local pediatrician who spent six weeks at Hadassah University Hospital, Jerusalem and other Israeli hospitals for specialized training in this field.

Ophthalmic and Psychiatric Hospital

Up to 1973 the Ophthalmic and Psychiatric Hospital was the Gaza Fever Hospital for infectious diseases. Health service planners decided to close it as a hospital for infectious disease and reopen it as an ophthalmic hospital. It is now a well-equipped facility providing an important area-wide service in an area previously endemic to chronic eye diseases, such as trachoma, which was associated with widespread eye damage. No confirmed cases of trachoma have been reported for some years. The new corneal graft service established in 1975 is able to provide ophthalmic rehabilitation to persons previously blinded by various chronic eye diseases. A referral link and consulting service is provided by an Israeli hospital ophthalmic service at Assaf Harofeh Hospital, providing an important backup service.

The medical staff now consists of six local ophthalmologists, carrying out a wide range of ophthalmic surgical procedures previously referred to supraregional hospitals, so that only a limited number of very complex cases are being referred.

With the decline in acute eye disease such as trachoma and conjunctivitis with complications, it was possible to redevelop part of this hospital for other needed medical functions.

In 1978 a new psychiatric service was added in a separate section of this hospital. Acute psychiatric inpatient care is provided in this 25 bed unit. Chronic patients requiring long-term hospitalization are referred to the Bethlehem Psychiatric Hospital. Outpatient and day-care services have been established as a major element of the psychiatric service. The senior psychiatrist is a local physician trained in England, who is assisted by two psychiatrists trained in Egypt and a team of psychologists and nurses. The psychiatric team also assists in teaching programmes for primary care physicians of the government and UNRWA services. A new EEG unit with 10 channels, donated by UNDP, became operational during 1982.

The psychiatric inpatient unit has been renovated in 1985 and enlarged to 40 beds.

The mental health programme stresses the "therapeutic community" atmosphere designed to help the patient retain his individuality and self-responsibility, with a stress on community mental health services.* The stress is on community rehabilitation, and has been operating successfully for over five years with good patient rehabilitation results.

_____________
* El Sarraj ER, and Lasch EE (1984) Integration of mental health services and the community in Gaza. Presentation of the Fourth International Congress of the World Federation of Public Health Associations Tel Aviv, Israel, 19-24 February, 1984.



Khan Yunis Hospital

Khan Yunis hospital serves the southern part of the Gaza Strip. It has undergone major renovation twice since 1967. In 1967, the hospital consisted of 118 beds providing basic hospital services only. In 1972 the hospital was closed for a two-year period during which a second floor was added. During this process, complete redevelopment of infrastructure services, including water, sewage, central heating, elevator and telephone exchange was carried out.

The hospital now consists of the following departments; internal medicine, surgery, pediatrics, obstetrics, and gynecology and orthopedics. The X-ray department was extended and three new X-ray machines were added. A medical records department, a new emergency room, library, lecture hall and bacteriology laboratory were established. Outpatient consultative services in various specialties were provided. In 1982, a dialysis department with three units was established. For the orthopedics operating theatre, a new portable X-ray unit with large image intensifier was donated by UNDP.

Hospital doctors routinely visit specific community clinics to provide consultative services as part of local preventive and curative services. The regional blood bank operates in the hospital complex.

In early 1985, a hospital infection traced to the surgical theatre resulted in a total rebuilding of the operating wing based on current standards, with the first stage being funded by donations from the local populations.

El Bureij Hospital

This hospital was built in the 1950s as the regional tuberculosis hospital in cooperation between government and UNRWA services. Until 1978 it included 210 beds and served Gaza, Sinai, Judaea and Samaria. The declining incidence of new cases of tuberculosis, in these years, led to a reduction in the number of beds to 70, with a shift in current treatment practices to ambulatory treatment and follow-up.

The hospital staff is actively involved in screening and diagnostic programmes, as well as in mass prevention programmes including BCG vaccination.

Dr Styblo, the WHO consultant for tuberculosis who visited the area in late 1981, confirmed the relatively low prevalence rate for tuberculosis, and recommended strengthening of laboratory confirmatory procedures for suspected new cases and regular visiting consultations of Israeli tuberculosis experts.

There is a continuing decline in the incidence of new reported cases of tuberculosis since 1970.

The El Ahli Hospital (formerly Baptist Hospital

This hospital experienced a very low occupancy rate in recent years, and was transferred to Anglican Church sponsorship which operates the hospital under the name of El Ahli Hospital on a partially charitable basis. It is continuing as a general and surgical hospital of 54 beds, and is now experiencing an increase in utilization, particularly in maternity services.

Laboratory Services

The central laboratory for Gaza is located in the Rimal Clinic. This serves as a backup to all the laboratories of the area hospitals for hematology, bacteriology, biochemistry, parasitology and serology. It also serves as the central public health laboratory. It was established in 1968 with only four practical technicians. Since 1973, new methods were introduced into all laboratories, and internal and external control programmes were begun. The internal control programme is done with known values of normal and abnormal specimens. The external quality control programme is organized by Wellcome Company, irk which sample sera with unknown values are tested and the results forwarded to Wellcome. Results are received monthly. Once every half-year, the laboratories are graded together with participating Israeli laboratories. In 1980, the laboratories were graded 8 out of 22 Israeli laboratories in this quality control system.

New tests introduced were thyroid functions (such as T4 and T3). New micro-methods for bilirubin, LDH, CPK, D-xylose digoxin, triglycerides, and serum iron, total iron-binding capacity, G6PD and lithium. In bacteriology, new serological tests were introduced. The bacteriology laboratory gives results of culture and sensitivity of specimens, including blood urine, pus, sputum, stool, cerebrospinal fluid and wounds.

The laboratory is linked to Israeli reference laboratories, particularly for virology, endocrinology and food monitoring. In 1982 new laboratory equipment was installed, with assistance from UNDP, Israeli government and UNICEF including a 20-channel auto-analyzer, a blood gas analyzer, spectrophotometers, centrifuge, thrombocounter and other equipment.

Other Laboratories

In 1974, the laboratory in Khan Yunis Hospital was opened with the following divisions: biochemistry, hematology, parasitology, and outpatient laboratory. In February 1981, a new bacteriology laboratory was added.

Shifa Hospital Laboratory was newly renovated after 1973 when a fire burned the old one. This laboratory has hematology, parasitology and urgent biochemistry divisions; the rest of the tests are done at the Rimal Clinic.

The Nasser Children's Hospital and Bureij Hospital each have a small laboratory doing all the basic hematology, stool and urine tests. The Shifa Hospital, Rimal Clinic and Khan Yunis Hospital laboratories are open 24 hours daily, and given immediate results in emergencies.

Each laboratory is staffed with two graduate microbiologists with B.Sc. or M.Sc. degrees, and 30 practical technicians (graduates of technical schools of the Ramallah and Baptist Hospitals). In-service training is a key part of the programme, in which lectures and participation in international congresses of biochemistry and bacteriology and visits to Tel Hashomer and Hadassah University Hospital laboratories are conducted to familiarize staff with new and modern techniques.

Blood Bank Services

Blood banks operate both in the Shifa and the Khan Yunis Hospitals. A voluntary blood bank association collects and distributes blood to the hospitals as needed. The Jaffa blood bank supplies the Gaza hospitals with rare blood groups not available locally.

Ambulatory care

In keeping with the overall policy of bringing medical care to the community, instead of bringing the community to the medical care, the government health service built 24 neighborhood clinics throughout the area (two in 1982). UNRWA continues to operate its nine clinics located throughout the area. Today all neighborhoods and settlements have a community clinic. At the same time, the general clinics attached to hospitals were redeveloped as specialty consulting clinics providing backup service to the neighborhood clinics.

The neighborhood clinics have become community health centres providing a growing range of health services, such as general medical services, nursing services, minor treatment facilities, pharmacy and, increasingly, basic laboratory services (blood, urine, stool tests). Some specialty services are also provided through these centres, such as the diabetic service. These health centres are affiliated with hospital specialty departments in internal medicine so that coordination of care for the chronically ill can be achieved. Hospital-based specialist staff visit the clinics regularly to assist the general medical staff in consultations and ongoing service. This applies to internal medicine, obstetrics and gynecology, dermatology, orthopedics, and psychiatry. Pediatric specialists visit the health centres regularly from the Nasser Children's Hospital.

The Sheikh Radwan Health Centre, opened in 1978 in the new residential area developed for refugees (now 20 000) serves as an example of a comprehensive neighborhood health centre. It provides preventive and curative services for the chronically ill. The centre is used as a teaching centre for student nurses in the registered nurses training programme.

Ambulatory visits to physicians in the government health centres have increased over the years - from 610 thousand in 1974 to 971 thousand in 1983. A decline in medical visits experienced in 1976 and in 1977 followed the introduction of visit charges for medical visits. This was, however, followed by rapid increases in visits in 1978 and 1979 as the health insurance plan was instituted (Table 108) which eliminated payments at the time of service, and as participation in the health insurance plan has grown rapidly.

Table 108: AMBULATORY VISITS TO GOVERNMENT HEALTH SERVICES
Gaza, 1972 to 1983 (000s)
1972
1974
1976
1978
1980
1981
1982
1983
Visits to doctors in
government clinics
575
610
552
613
760
891
884
971

Medical services in government clinics are free for children to six years of age and for pregnant women.

An ambulatory hematology service is located in the Rimal Clinic with a local specialist who has trained at the Sheba Medical Centre. Mew equipment, including a teaching microscope and automatic cell centre are available. The service deals with all blood diseases. The clinic building houses the central clinic, the community preventive health office and a community clinic for the local neighborhood.

Since 1982, a major development has taken place whereby specialists from hospital departments of internal medicine and others regularly visited community clinics.

Mental Health Services

Mental health services have up until recently been provided to the Gaza population through the Bethlehem Psychiatric Hospital. A psychiatric service has now been established in Gaza with emphasis on ambulatory care in general medical clinics or in the specialty psychiatry clinic supported by day care and by inpatient care of a short-term nature.

Consultation services are available to hospitals, medical clinics and schools. The day care and outpatient service is located in an unused wing of the Gaza Ophthalmic Hospital. The psychiatrist in charge is a local resident who recently completed specialty training in England.

The 25-bed acute psychiatric inpatient service opened in March 1979, also in the Gaza Ophthalmic Hospital, staffed by psychiatrists and social workers. Fig. 6 outlines the components of this system, including plans for future developments.

Formation of the plan for the development of psychiatric services as assisted by a consultant from WHO (Dr T. W. Harding) in 1979. Assessing mental health of a total population by accepted medical criteria includes hospitalization data, suicide, homicide, accident rates, as well as clinical service data from ambulatory care services. By such measures no evidence of excess mental ill health has been demonstrated in Gaza. Further experience with expanded psychiatric services in the government health services may help to develop more epidemiologic data on this subject. Dr Harding revisited the service in August 1980 and indicated satisfaction with the progress being made.

A detailed review of the mental health programme was presented at the Fourth International Congress of the World Federation of Public Health Associations, Tel Aviv, Israel.*


Figure 6: MENTAL HEALTH PROGRAMME, Gaza

Rehabilitation Centre
Gaza
15 patients
__________
CRISIS CENTRE
Gaza
25 beds
__________
Day Centre
Gaza
12 patients
Outpatient
Service
Khan Yunis
Outpatient
Service
Proposed
developments:

- Polyclinics -
Teaching, rotation
of doctors; case
dection, follow-up

-UNRWA polyclinics
School Mental Health
MATERNAL AND CHILD HEALTH CARE

A network of primary care and maternal and child health services has been established throughout the region as a major focus in public health services, particularly during the last few years.

The public health service of Judaea and Samaria is organized into seven districts. The personal care programme is based on 153 rural and urban clinics and health centres, 110 maternal and child health (MCH) centres in 1984 (increased from 90 in 1983), chest disease clinics, a road safety institute, school health services, sanitation services, and immunization via mobile clinics in villages not yet provided with clinics. Table 31 sets out the general medical clinics and MCH centres in each district. in 1968, there were 89 general medical clinics, now there are 153.


Table 31: MATERNAL AND CHILD HEALTH CENTRES AND COMMUNITY CLINICS
(GOVERNMENT AND UNRWA)
Judaea and Samaria, 1984
District
Population*
(000s)
No. of
government
community
clinics
No. of
government
MCH centres
Agency
clinics
No. of
UNRWA
centres
Total
government
clinic/MCH
centres
Nablus

Tulkarem

Jenin

Hebron

Bethlehem & Jericho

Ramallah

TOTAL
146.4

138.4

123.2

160.8

100.8

130.4

800.0
24

32

23

32

15**

27

153
18

27

16

22

9

18

110
3

2

4

18

11

9

47
3

2

2

2

3

4

16
30

36

29

52

29

40

216

Note: 1. * Population figures are estimates at 1 January 1985.

2. **Including two clinics on Allenby and Damya Bridges over the Jordan River.

Source: Government Health Department, Judaea and Samaria.



Expansion of MCH centres has mainly been based upon adding MCH services in existing primary care community clinics (Table 32). See Figure 7 for the distribution of clinics by district.




Figure 7: DISTRIBUTION OF CLINICS AND MOTHER & CHILD HEALTH CARE
CENTRES BY DISTRICT 1970 AND 1984
Judaea and Samaria


Table 32: NEW COMMUNITY CLINICS AND MCH CENTRES OPENED
Judaea and Samaria, 1979 to 1984

DistrictLocations of MCH centres openedCommunity clinic
opened
RamallahBetunia
Arura
Safa
Beitilu
Ramallah*
Mikhmas
Kfar Naameh
Naalien
Rantees
Betseva
Betseva


BethlehemZaatara
Sawakh el Sharquiya
AzariyaBeit Sahour
HebronSamoa
Beit Awa
Tarkumia
Dier Samet
Al Carmel
Ein Sava
SairSouvif
Edna
Nuba
Alshuikh
Direl Assal
Tafah
Al Khawouz
Beit Avla
Beit Kanel
Kharsa
Kawaz-Hebron
City*

NablusBurka
Beit Furik
Taluza
Balata-Nablus*
Beita
Beit Dagan
Khawara
Balata-Nablus*
Bazarya
JeninAja
Silat el Daher
Bourkin
Al Yaman
Jalkamous
Al Jadidah
TulkaremKfar Tulth
Balaah
Bakah Sharika
Kfar Jamal
Jamaeen
Kefin
Beit Lid
Khabal
Kfar Labad
Zeita
Kfar Kadum
Kifel Khares
Kfar Zibiad
Al Shwika
Rameen
Al Zabadhh
Aqaba
Maithaloun
Al Jadidah
Aqaba
Tulkarem*
Al Shwika
Note: 1.In all locations where a MCH centre was opened, there is already a general community clinic working six days a week.


All general medical community clinics are open from 8.00 a.m. until 2.00 p.m. Each community clinic is staffed by a local nurse (practical) who resides in or near the clinic, and who is available for emergencies. Clinics are visited by a physician - mostly twice a week, and depending on the size of the population, up to every day. The community clinics receive any person requesting medical care. Those without health insurance pay a nominal fee for the service; those with health insurance receive care free, including prescription drugs for a nominal fee. Since 1980 in all urban community clinics, medical specialist services are provided in regular specialty clinics - usually once weekly in each of the major specialties - surgery, ob/gyn, internal medicine, pediatrics, psychiatry. Some urban community clinics also have ENT services.

In the area of maternal and child health the government health programme has achieved the following goals:

(a) establishing a network of MCH centres in urban and rural areas throughout the region;

(b) combining most MCH centres with community clinics to provide both preventive and curative services;

(c) increased hospital deliveries;

(d) improved hospital facilities for deliveries and management of newborns; separated delivery rooms in each hospital with a minimum of three midwives in each department;

(e) increased and improved manpower: midwives, physicians, public health nurses and others;

(f) expansion of the immunization programme;

(g) nutrition and general health education;

(h) development of school health services;

(i) development of a control programme for diarrhoeal disease.

MCH services have been expanded through establishing 67 new centres during the past 17 years, increasing the total from 23 to 90 in 1983. In the past five years alone 60 new MCH centres were opened in urban and rural areas.

MCH programming has established new objectives which are being planned or implemented:

(a) increased supervision and training for village midwives (dayas);

(b) increased focus on healthful infant nutrition, stressing breast-feeding, appropriate supplementation and good nutrition for the toddler;

(c) revision of existing growth charts with analysis of weight-and height-for-age, and weight-for-height for children according to international standards in the MCH centres (partially implemented and being expanded);

(d) expanded efforts to improve the reporting system;

(e) establishment of district infant mortality committees has been proposed to review all infant deaths, in order to improve identification of preventable factors, wherever possible (but not yet implemented);

(f) promotion of health education through the schools, particularly in the primary schools;

(g) expanding the ORS programme through MCH centres, community clinics and hospitals to reduce infant and child morbidity from diarrhoeal diseases (has been implemented);

(h) carrying out a wide-scale preventive programme to eliminate tetanus neonatorum, in cooperation with WHO (being implemented);

(i) measures for prevention of iron deficiency anemia among infants, in addition to the present vitamin A and D supplementation (being implemented).

This expansion of MCH services and availability has led to an increasing attendance and utilization of prenatal care, particularly in the villages. The MCH centres are staffed by registered midwives or nurses with training in midwifery. A programme for identification of and intensive care for high-risk pregnancies was started during 1981 and extended during 1983. Recent training sessions with respect to identification of high-risk pregnancies with weekly participation in follow-up of treatment of high-risk pregnancies have been conducted by a specialist in gynecology. UNRWA operated MCH centres serve the population resident in the refugee camps.

Each pregnant woman is registered and followed during and after pregnancy free of charge. A medical record of prenatal care is completed on each case. Laboratory tests (Rh, blood type, hemoglobin and complete urinalysis) are performed at the district laboratory after her first visit. Laboratories for this purpose are available in each district, and are located in Ramallah, Nablus, Tulkarem, Salfit (Health Centre), Jenin, Jericho, Bethlehem and Hebron hospitals.

The pregnant woman is seen in the MCH centre each month until the 7th month, biweekly in the 7th and 8th month and weekly in the 9th month. Weight, blood pressure, heart, breasts, urine for protein, fetal heart and fundal height are all checked and recorded at each visit. Iron and folic acid are given free for prevention of anemia. Home visits are made by the midwife for the first pregnancies and for others where indicated.

The traditional system of home deliveries is still very much part of the health care pattern in Judaea and Samaria, where the village midwife is a known and respected figure. In the villages, some 404 traditional midwives (dayas) provide prenatal and home delivery services, which are reported to the office of the Ministry of Interior through the village Mukhtar. Study days and medical instruction are arranged by the district health offices in order to improve their knowledge and practice of hygiene, prenatal care, high-risk identification and referral, as well as reporting of births and deaths. Dayas are licensed annually by the district public health office. During 1982, supervisors (i.e. staff nurses) were appointed in all districts to supervise the dayas. They meet each days regularly, carrying out training and supervisory activities. New dayas are required to spend some months working in obstetrics units in government hospitals prior to receiving their licenses. UNICEF has provided 80 delivery kits for midwives, some 50 of which were provided to dayas. In 1983 WHO approved a grant to further the project of supervision of dayas, which is being implemented through professional midwife supervisors of dayas for each of the seven districts of the region.

Hospital deliveries have increased from 13.5% to over 50% of all deliveries from 1968 to 1984. The still low rate of hospital delivery, and early self-discharge from hospital is the result of traditional acceptance of home delivery, and heavy home responsibility for mothers of large families. In mid-1983 the hospital charge for non-insured mothers was lowered by 50% in order to encourage hospital deliveries. This has encouraged more hospital deliveries during 1984. A programme designed to prolong hospital stay for at least 24 hours following delivery has been implemented. Maternal education in hospital is being expanded and a new guidebook for mothers in child care has been prepared for this purpose.

The MCH centres examine the infant monthly during the first year of life, twice during the second year and once before the end of the third year. The child is seen by a physician on his first visit and at the end of the year as needed. The MCH midwife or nurse examines the child for growth and development, which are recorded on the child's chart and now on the group chart used routinely in MCH centres to monitor the community patterns of child growth. Stress is placed on nutrition and child care advice to the mother during these visits. Home visits for all registered families in need are arranged by the midwife or nurse. Vital statistics on births and deaths are shown in Table 33.

Hospital care for delivery and care of the newborn have been upgraded by establishing the new school for midwives in Nablus, opened in 1970, which has graduated 88 qualified midwives (6 courses have been completed, each of 24 months duration). Hospital obstetrical departments are staffed by at least three qualified midwives and are under the supervision of obstetricians.

Increased medical nursing personnel in the hospitals and higher levels of training, along with improved equipment, delivery suites, respirators and incubators have also contributed to improved conditions for delivery and infant care in hospitals. A neonatal care unit was opened in 1980 at Ramallah Hospital; Caritas Hospital in Bethlehem operates a neonatal special care unit. Intensive care neonatal care cases are referred to Hadassah Hospital, Mt. Scopus, in Jerusalem. Further development of neonatal care services in the district hospitals is planned.


Table 33: MATERNAL AND CHILD HEALTH STATISTICS
Judaea and-Samaria, 1998 to 1983
MCH
Year
Indicators
1968
1972
1976
1980
1981
1982
1983
Births (000s)
Population (000s)
Crude birth rate
% births in hospital
Neonatal deaths
Postneonatal deaths
Total infant deaths
Infant mortality rates
25.6
583.1
44.1
13.5
197.0
663.0
860.0
33.6
28.8
633.7
45.8
26.5
245.0
817.0
1 062.0
37.0
31.7
683.3
47.4
32.7
257.0
618.0
875.0
28.1
30.4
724.3
43.9
44.8
339.0
562.0
901.0
28.3
30.5
731.8
43.2
43.6
301.0
611.0
910.0
29.0
31.6
747.5
42.3
45.7
-
-
809.0
25.6
30.1
767.3
39.8
48.3
-
-
88.5
29.4
Note:1.


2.


3.






4.
Data from Government Health Department, Judaea and Samaria, Statistics Department.

Neonatal, postneonatal and infant death rates are per thousand live births. Crude birth rate is births per thousand population.

Reporting of infant deaths has improved since the mid 1970s as a result of increased hospital births and increased rural health services. Live born infants are registered for birth certificates, which initiates follow-up by the local MCH centre or by immunization teams which visit each village. Some underreporting particularly of prenatal and early neonatal deaths during and following home deliveries still occurs. Field studies of infant mortality are now in progress.

Births in hospital include local and Israeli hospitals, and maternity centres.


UNICEF has provided many new MCH centres with adult and baby scales, blood pressure apparatus, urinalysis sets, as well as delivery kits for midwives, and equipment for neonatal care units.

In Table 34, reported infant deaths are shown; an apparent increase in 1980 and 1981 reflects better reporting which is the result of a number of factors; increased hospital births; increased supervision of dayas and their reporting of home deaths; home visits by MCH centre midwives; more rural MCH centres and improved acceptance of MCH services; enforcement of required reporting and local responsibility of village Mukhtars in villages not served by an MCH centre, but which are regularly visited by immunization teams. As compared with other jurisdictions, particularly in the Middle East, the child health situation as reflected by the reliability of the infant mortality data and by its completeness has reached a level reflecting a major success for the MCH programme in Judaea and Samaria.

With respect to Table 34, gastroenteritis is still a prominent but declining cause of infant and child deaths, and now respiratory infection is a more significant cause. There was an increase in infant deaths due to bronchitis, pneumonia and heart disease in 1983 over 1982 (mostly in January 1983) possibly related to the severe winter conditions in that month, and "cold injury" syndrome, a phenomenon also noted in Israel in that same month. This observation is being further analyzed by location of residence of the cases and other associated factors. A number of study days have been held involving public health and pediatric hospital staff on "cold injury" as a cause of infant morbidity and mortality. The child and under 5 mortality rates in the period 1981 to 1983 averaged just under 1.5 for children 1-5 and under 7 per 1000 children aged 0 to 5.*

______________
* World Health Organization (1981) Development of indicators for monitoring progress towards Health for All by the Year 2000, pp. 68-69. "In countries with very poor health conditions the under 5 mortality rate exceeds 100. In highly developed countries it is as low as 2." In highly developed countries the child mortality rate (1-5) is around 0.4 per 1000, and over 100 per 1000 in least developed countries.



Table 34: REPORTED CAUSES OF DEATH, AGE 0 To 5 YEARS
Judaea and Samaria, 1981 to 1984
(ages in months)

1981
1982
1983
1984
0-128
12-609
0-12
12-60
0-12
12-60
0-12
12-60
Congenital Malformation1
15
0
20
3
25
5
38
4
Birth injury and perinatal causes2
128
4
102
3
45
1
64
1
Diseases of early infancy and pre-maturity3
112
3
112
7
99
2
96
2
Gastritis, enteritis and diarrhoea4
178
30
163
30
155
18
179
30
Bronchitis and pneumonia5
340
77
250
52
331
49
306
41
Heart disease6
69

910
11

199
46

809
9

157
98

885
19

164
64

864
14

173
Rates10
29.8
1.6
25.6
1.3
28.5
1.4
29.6
1.5
Total under 5
mortality rates
7.3
6.4
6.9
70
Note:










1.
2.
3.
4.
5.
6.
7.
8.

9.
10.
ICD 750-759
ICD 760-762 and 763-778
ICD 766-776
ICD 543 and 571-573
ICD 490-493 and 500-502
ICD 420-422, 430-434, 410-416
Includes 1-6 and all others
0-12 months includes to the end of the 11th month; 12 to 60 months includes to the end of 59th month, i.e. end of 4th year of life.
1984 data preliminary.
For 0-12 months the rate is per 1000 live births in the same year. For the child mortality rate (aged 1-5) the denominator is the number of births for that year and the previous three years minus reported deaths in those years. The total under 5 mortality rate is calculated from all deaths from age of 0 to 5 years, divided by the total number of children under age 5 at the middle of the year.
Source:Judaea and Samaria, Government Health Department, Statistics Division.


A study of vital statistics of the refugee population resident in the 13 (up to 17) camps in Judaea and Samaria by UNRWA indicates a large decline in infant mortality rates between 1975 and 1983 (Table 35). This dramatic reduction (52.6%) over an eight year period is associated with a declining birth rate (from 41.3 to 30.5 per thousand population) and reduced mortality particularly from gastroenteritis, respiratory diseases and prematurity. This is a tribute to the effectiveness of preventive and curative health services for this particular group as well as to improving socioeconomic and sanitation conditions in the area overall.

Acceptance by the population of the need for prenatal care and hospital delivery is not yet total. This, along with the high fertility and birth rates, results in continuing infant and maternal health problems.

Fertility and birth rates of the population of Judaea and Samaria continue to be among the highest in the world. The availability of modern standards of prenatal and well-child care have favorably influenced morbidity and mortality patterns.



Table 35: VITAL STATISTICS - REFUGEE CAMP POPULATION
Judaea and Samaria, 1975 to 1983
1975
1977
1979
1981
1982
1983
Number of camps
Population
Number of births
Crude birth rate
Infant mortality
Causes of infant death:
Gastroenteritis
Respiratory
Prematurity
Congenital and other
13
63 317
2 615
41.3
83.7

73
64
24
58
13
66 724
2 709
40.6
64.2

42
56
25
51
13
70 937
2 724
38.4
46.2

32
36
23
35
15
80 160
2 654
33.1
36.5

24
29
9
35
15
81 457
2 759
33.4
38.1

18
23
16
46
17
87 387
2 717
30.5
39.7

19
15
22
50

Source: Courtesy Dr Husseini, Medical Director, UNRWA West Bank.




Birth Weight and Child Growth

During 1982 and 1983 several pilot studies were undertaken regarding infant growth patterns.* Birth weight data from hospital births are recorded and summarized in Table 36. Birth weight data from home deliveries, private clinics, or hospitals in Israel are not currently available, although it is hoped that through the dayas supervision programme and expanded reporting activities birth weight data will become available also for these births. The distribution of birth weight data available covers 45% of all births in the first 11 months of 1982, and 45% of births in 1983.

___________
* World Health Organization (1981) Development of indicators for monitoring progress towards Health for All by the Year 2000. Geneva, p. 63. "It seems in the least developed countries the percentage of LBW reaches almost 50%, while in some developed countries it is as low as 4%. For the world as a whole the average for 1979 has been estimated at around 17%".




Of these births 1.7% (1.1% in 1983) were below 1500 grams, and a total of 9.3% (6.8% in 1983) were below 2500 grams (i.e., Low Birth Weight or LBW); 12% of all newborns weighed in excess of 4000 grams in 1982 and 7.6% in 1983. In general, primiparas and complex pregnancies are now delivered in government hospitals, while non-government hospitals deliver other patients who choose hospital delivery, as opposed to delivery at home. However, it will be important to expand the data base in order to draw final conclusions in this important parameter of MCH.

Pilot studies of growth patterns of infants and toddlers attending MCH clinics begun in 1982 has now been extended to all MCH centres in Judaea and Samaria. Nurses record height for age and weight for age, as well as weight for height on summary growth curve charts, based on the NCHS growth curves recommended by WHO. During 1985, individual growth curve charting using NCHS growth curves will be introduced in all MCH centres. As a result of the pilot studies in community surveillance of infant growth, the need for mother's education regarding good infant feeding practices has become clear. As a result new educational material on this subject has been prepared for use in MCH centres, by dayas and in hospital obstetrical departments, emphasizing breast feeding and appropriate supplementation practices. Further studies in community surveillance of child growth patterns are being carried out with differentiation for breast fed and non-breast fed infants.

Study days for public health nursing personnel are being conducted to raise the level of consciousness and information of staff in contact with the mothers of important issues in infant and child nutrition.



Table 36: BIRTH WEIGHTS OF NEWBORNS BORN IN HOSPITAL
Judaea and Samaria, 1982 to 1984
To 2499
grams
2500-3999
grams
4000+
grams
Total

No.
&
No.
&
No.
&
No.
&
1982
1983
1984
1 174
884
773
9.3
6.8
7.0
9 891
11 112
9 176
78.7
85.6
83.1
1 514
987
1 096
12.0
7.6
9.9
12 579
12 986
11 045
100
100
100
Source:Government Health Service Judaea & Samaria, Statistical Department.
Note:1.

2.

3.
Based on reports from all government and non-government hospitals. Does not include births in hospitals in Israel, in private clinics, nor home deliveries.
1982 data includes births during the first 11 months of the year; 1982 and 1984 data includes total year.
Represents approximately 45% of total births.



Maternal and Child Health - Gaza

Major emphasis has been placed on improving maternal and child health in the Gaza area. Before 1967 maternal and child care was extremely limited in scope and there were no MCH centres as such (except 9 UNRWA centres). The first MCH centre was opened in 1971 in Sejaya and its success led to the development of MCH centres throughout the Gaza district. Twenty-four MCH centres now operate throughout the area providing prenatal and well-child care to a growing proportion of the population.

In 1975 the government MCH centres began their conversion to comprehensive mother and child care combining diagnostic, curative and preventive services. This has led to a greater acceptance by the population of maternal and child health care. Linkage of the MCH centres to the Nasser Children's Hospital since 1977 has added specialty pediatric services to the centres, and has increased the contact between primary care of children and specialized pediatric services. Pediatricians from the hospital visit all MCH centres regularly, and the MCH centre staff also spend time at the hospital. Strong professional linkages have developed which have benefited both community and hospital care of children.* The interrelationship of the various elements is shown in Figure 8.

______________
* Lasch, E. E., Abed, Y., Goldberg, J. & El Shawa, R. (1984) Child health services in Gaza; an experiment in integration. Presented at the Fourth International Congress of the World Federation of Public Health Associations, Tel Aviv, Israel, February 19-24, 1984.




Priority has been placed on the establishment of the MCH centres for prenatal as well as infant care, and improvement in services for delivery.

Pregnant women on their first visit are examined by a physician or midwife, including a pelvic examination. Blood investigations including Rh, blood group, Coombs test when indicated, VDRL and hemoglobin are done. At follow-up visits (approximately eight) blood pressure, weight, oedema, urine, fundal height and fetal heart tones are examined and recorded. Iron and folic acid are given routinely. Tetanus toxoid is given. routinely in the first trimester. Utilization of the MCH centres has increased dramatically over the years with an average of over 15 visits for each pregnant woman and her infant up to one year of age.

Children followed in MCH centres, in addition to the immunization programmes, are measured for weight, height, head circumference and general development. Hemoglobin is checked at nine months. Vitamins A and D are given routinely and the nutrition education of mothers is stressed, particularly the advantages of breast-feeding. The possibility of routine iron supplementation for prevention of iron deficiency anemia is being examined.



Figure 8: COMPONENTS OF MATERNAL AND CHILD HEALTH programme,
Gaza



Before 1967 more than 90% of the deliveries took place in the home under the care of traditional birth attendants (dayas) who had no formal training or supervision. Deliveries in hospitals and maternity centres increased rapidly to 46% of all deliveries in 1977, 56% in 1979, 65% in 1980 and 72% in 1983 (Table 38).

The increase in medical centre deliveries has been associated with the increased availability and acceptance of prenatal care. Delivery services in hospital and maternity centres are charged at half the regular hospital charge rate for insured persons if the person is not insured, although most deliveries are covered by insurance.

Supervision of the 145 dayas currently serving the district has increased with annual licensing, including inspection of equipment and a growing emphasis on hospital training programmes for them. A proposal for increased training and supervision of the dayas has been approved by WHO, which would help to establish a strong linkage between the dayas and the MCH centres. Among the benefits that hopefully will be gained by continuous exposure of the dayas to modern HCH care will be improved prenatal care, risk identification, better hygiene and care at the time of delivery and improved reporting of birth weights, stillbirths and neonatal deaths.

Reporting of births and deaths has traditionally been incomplete in Middle Eastern countries, but has improved in the Gaza area as a result of increasing community acceptance of prenatal care, hospital and maternity centre deliveries and improved access to and utilization of preventive and curative services for children. With very high levels of contact for prenatal and well-child care, as well as improved supervision of dayas and follow-up of non-attenders to the well-child care programme (Table 37), reporting of births and deaths continues to improve. A new system was instituted in January 1981 whereby each clinic receives a report from the dayas, hospital or maternity centre on each birth within the MCH centres' jurisdictions. Follow-up is the responsibility of the MCH centre, including home visits where necessary.

The birth rate in Gaza remains very high, about 45 per 1000 population. The widely accepted advantages of spacing pregnancies have been adopted by the UNRWA health services in recommending family planning. High fertility, grand multiparity, short spacing between births, and high or low maternal ages are all factors in continuing high-risk levels for infants and mothers. Improvements in sanitary home conditions, improved standards of living, and greater access to prenatal care have all contributed to declines in the risk level for infants.

The infant mortality rate in Gaza prior to 1967 has been estimated at over 150 per 1000 live births. The reported infant mortality rate in 1967 was 86 per 1000 and has declined steadily; reported neonatal and postnatal mortality rates are both 19.2, with a total infant mortality rate of reported deaths at 38.2 per 1000 in 1983. Investigation for unreported neonatal deaths is carried out jointly by the government and UNRWA health services, resulting in a rise in reported neonatal deaths in 1981 to 25.2 per 1000 live births with a subsequent decline in 1982 and 19.2 in 1983 (Table 39 and Figure 9). Studies to assess completeness of reporting are being developed by the Gaza Epidemiology and Health information Unit in cooperation with the Israel Central Bureau of Statistics. Other studies by the Health Information Unit are focusing on identification of risk groups based on leading causes of morbidity and mortality.

Neonatal intensive care is being developed by expanding staff, establishing training programmes for doctors and their staffs (in Beersheba and abroad) and re-equipping of the units. Attendance of neonatologists at high-risk or difficult deliveries, along with immediate skilled intensive care for low birth weight and other high-risk neonates, will also help to reduce neonatal and infant mortality.



Table 37: VISITS TO GOVERNMENT MCH CENTRES, TYPE OF VISIT
Gaza, 1981 to 1983 (000s)
MCH centres
Total
visits
New
patients
Vacci-
nation
Paedia-
trician
visits
Gynaeco-
logist
visits
All
specialist
visits
Children
1981
1982
1983
239.9
257.8
266.7
10.3
10.2
9.6
42.6
49.2
53.9
187.0
187.1
191.7
-
-
-
187.0
187.1
191.7
Pregnant women
1981
1982
1983
13.2
14.8
17.6
4.8
5.0
5.4
-
-
-
-
-
-
8.4
9.8
9.9
8.4
9.8
9.9
Clinics
General visits
1981
1982
1983
618.3
509.8
560.5
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Specialist
1981
1982
1983
19.5
101.9
125.5
-
-
-
-
-
-
-
-
-
-
-
-
19.5
101.9
125.5
Subtotal
1981
1982
1983
637.8
611.7
686.2
-
-
-
-
-
-
-
-
-
-
-
-
19.5
101.9
125.5
TOTAL1981
1982
1983
890.0
884.2
970.5
15.1
15.2
15.1
42.6
49.2
58.9
187.0
187.1
191.7
8.4
9.8
9.9
214.9
298.8
327.3


Table 38: BIRTHS BY AGENCY MATERNITY CENTRE AND HOSPITAL DELIVERY
Gaza, 1977 to 1983
UNRWA
maternity
centres
Baptist
hospital
Government
health
services
Total births
in medical
centres
(000s)
All
births
(000s)
% hospital
and maternity
centre
deliveries
1977
1978
1979
1980
1981
1982
1983
3 782
3 764
3 915
3 834
3 628
3 530
3 670
70
69
107
122
135
176
413
5 948
7 822
8 619
10 033
10 441
12 671
12 224
9.8
11.7
12.6
14.0
14.2
16.4
16.3
21.4
22.9
22.6
21.4
20.4
22.2
22.6
46
51
56
65
70
74
72
Note:1.


2.
Medical centre deliveries are based on monthly returns from hospitals maternity centres; UNRWA centres report quarterly.

Total births data are based on notifications received from the Interior Department since 1 January 1981, and include both medical centre deliveries and babies born at home or elsewhere.



Table 39: REPORTED MORTALITY RATES, MATERNAL AND CHILD HEALTH
Gaza, 1969 to 1983
1969
1971
1973
1975
1977
1978
1979
1980
1981
1982
1983
Stillbirth rate
Neonatal mortality
rate
Postneonatal
mortality rate
Infant mortality
rate
11.9

25.7

60.3

86.0
10.2

25.9

60.0

85.9
7.2

20.9

56.2

77.1
3.5

21.5

47.8

69.3
3.9

14.4

46.9

63.0
3.3

13.8

37.0

50.8
4.4

15.0

32.0

47.0
5.0

15.0

28.0

43.0
5.2

25.2

27.1

52.3
7.6

20.1

23.0

43.1
NA

19.2

18.7

37.8

Note: Reporting of infant mortality has improved in recent years particularly as the proportion of births in hospitals has increased (75% in 1982). Neonatal death reporting has been under review by a joint committee of the government health services and UNRWA. The effect of increased case finding is seen in the increase in reported neonatal mortality in 1981 and 1982, in which years the reporting has been strengthened. The steady decline in reported postneonatal mortality represents improved contact between the community and local health services and the follow-up systems have been strengthened over recent years.

Source: Health Information Unit, Gaza Health Department.




In 1982, steps have been taken to include birth weights in hospital and non-hospital delivery reporting. A sample of some 85% of total births, in June 1983, is shown in Table 40, indicating a low birth weight (under 2500 grams) of 5.2%. This is well below the 10% low birth weight rate considered a target for developing countries and is indeed lower than the low birth weight rate of many developed countries.*

______________
* World Health Organization (1981) Development of Indicators for monitoring progress towards Health for All by the Year 2000, Geneva, pp. 64-65.



Table 40: BIRTH WEIGHTS OF NEWBORNS BORN IN MEDICAL CENTRES
Gaza, June 1983
0-1500 grams
1500-2500 grams
2500-4000 grams
4000+
Total
Number
%
15
1.0
65
4.2
1 184
76.8
278
18.0
1 542
100
Note:1.



2.
These data are a sample of births in various medical facilities throughout the Gaza area during the month of June 1983; this represents approximately 85% of average total monthly births in the area for that month.

The high percentage of birth over 4000 grams is partially due to the large number of grand multipara deliveries.
Source: Health Information Unit, Gaza Health Department.




Figure 9: REPORTED MORTALITY RATES
MATERNAL AND CHILD HEALTH, Gaza




Continuing emphasis, however, is being placed on prevention of postneonatal mortality, in particular from diarrhoeal and respiratory diseases. Many aspects of the public health programme apply to prevention of postneonatal morbidity and mortality, such as the infusion centres, oral rehydration programme and improved access to preventive and curative services.

A standing infant mortality review committee has been established with participation of public health and clinical pediatric personnel to review both individual cases and the epidemiology of infant death in order to identify preventable factors in infant deaths, including cases occurring in hospital and at home.

HEALTH EDUCATION, Gaza

In 1972, 13 persons were trained in a three-month programme conducted in Ashkelon (Barzilai Medical Centre) to be community health educators. After experience in various programmes throughout the region, each has now been attached to an MCH centre to develop and implement health education activities within the centre and involving the centre's staff. Emphasis has been placed on personal hygiene, environmental sanitation, home accidents and home economics.

Since 1978, greater emphasis has been placed on a programme of oral rehydration for infantile diarrhoeal diseases. This programme has rested largely on health education activities to increase the mothers' awareness of the problem and how to make use of the ORS (oral rehydration solution) and MCH support systems to prevent the serious complications of the ordinary diarrhoeal diseases of infancy. The response and acceptance of this programme is in large measure due to successful health education throughout the governmental and non-governmental health system, through the public media, with widespread use of newspapers, radios and mobile broadcasting.

Future developments in health education will stress the inclusion of health subjects in the school curriculum, particularly at the primary school level. This will be designed to increase health knowledge and promote positive health attitudes and practices in the areas of hygiene, nutrition, accident prevention, healthful living habits, and other subjects of importance.

EXPANDED IMMUNIZATION PROGRAMME/CONTROL OF CHILDHOOD INFECTIOUS DISEASES: Judaea & Samaria

The focus in care of infants has been on an expanded programme of immunization and in control of childhood infectious diseases. More of the children are being reached in the well-child care programme and the range of immunizing agents has been expanded (Table 41).

The system of immunization of mothers and children has been completely changed by the increasing availability of MCH centres providing easier access and improved utilization. In
villages where there are still no MCH centres, immunizations are carried out by regular visits by health teams and nurses who visit the villages approximately every six weeks.

For newborns not under care during the mother's pregnancy, an invitation to attend the MCH centre is forwarded; if the mother does not bring the child, the MCH midwife or nurse visits the home and attempts to educate the mother as to the importance of supervision in the MCH centre and of immunization. Legal action is undertaken if necessary, under existing public health law. For newborns not attending MCH centres and in all villages where there are no MCH or government clinics, an immunization team, consisting of a nurse and a sanitarian, visits the village on a regular basis carrying out the immunization programme and following up on children who did not appear for their regular immunizations, working from the lists of newborns provided by the village Mukhtar.

Families who are registered refugees under the care of UNRWA are looked after in UNRWA MCH centres, although they have full access to all government health care facilities. Part of the immunization material used in these UNRWA centres is provided by the government health service and routine reporting on immunizations carried out is provided. A small number of children who are under care of private physicians may receive immunizations which are not reported.

Table 41: EXPANDED IMMUNIZATION programme, Judaea and Samaria, 1984
Disease/Agent
Ages Given
Comments
Smallpox

Diphtheria, pertussis
tetanus (DPT)

Triple oral polio
vaccine (TOPV)

Measles

BCG






Salk vaccines


Diphtheria/
Tetanus (DT)

Rubella


Tetanus toxoid
2-3 months

3-1/2, 5, 6-1/2
and 12 months

2, 3-1/2, 5, 6-1/2
and 12 months

12-14 months

School-aged






Infants 3-1/2 and



Children grade 2

Girls grade 6,
aged 12 years

Women at age of
fertility and high
school students
Introduced before 1967, stopped in 1980.

Introduced before 1967.
Now over 90% coverage.

Introduced before 1967.
Now over 90% coverage.

Introduced in 1969. Now over 90% coverage.

Introduced in 1978 at school-age. Tuberculin testing precedes the BCG. Ages covered in 1979: 6, 7, 8 and 9th grades. Routine Mantoux plus BCG was established grade 1 in 1980. All Mantoux positives are investigated, and suspect cases treated and followed.

Introduced in 1978; now routinely given with DPT - over 90% coverage.

Introduced in 1980-81, school year, and continued annually.

Introduced in 1980-81, school aged 12 years year, and continued annually.

Campaign commenced early 1983, fertility and high in cooperation with WHO, and school students expanded in 1984. Tetanus toxoid given during prenatal care (2 doses) in MCH centres.


Coverage by immunization has increased over the years because of the continued emphasis by the health services, active support by community leadership, and increased consciousness of the importance of immunization by the population and the increasing availability of services.

Table 42 indicates immunization coverage (including governmental and UNRWA figures between the years of 1970 and 1982).

Coverage with triple vaccine or DPT (since 1978 with killed polio vaccine for two doses) has increased from 65% in 1970 to 87.5% in 1982. Acceptance of measles vaccination (given between the age of 12 to 14 months) was problematic but the immunization coverage reached 96.1% in 1981. Smallpox coverage was 100% in 1978; it was discontinued in 1980, in keeping with WHO recommendations.

BCG was introduced into the immunization programme following epidemiologic assessment of prevalence of tuberculosis through radiography, tuberculin testing, with follow-up chest X-rays and review of tuberculosis cases presenting. While the overall incidence of TB is thought to be low, the advisability of routine BCG protection for Mantoux negatives was considered sufficiently important to warrant a special campaign in 1979 and 1980 to cover all school-age children, and then to maintain as a routine; BCG immunization of Mantoux negative children in grade 1 is carried out.



Table 42: IMMUNIZATION COVERAGE, AS PERCENT OF INFANT POPULATION
Judaea and Samaria, 1970 to 1981

1970
1974
1976
1978
1980
1982
DPT
TOPV
Salk vaccine
Smallpox
Measles
65.0
86.4
-
-
81.7
70.8
77.3
-
66.3
57.1
87.6
76.1
-
78.1
65.2
71.0 1/
87.1
-
100
72.4
85.8
94.8
87.3 2/
53.9 3/
91.8
87.9
94.8
97.4
-
103.2 4/


Polio

TOPV was used in Judaea and Samaria during the early 1970s, achieving a 76% coverage rate. Polio, however, continued to be a problem with reported cases occurring each year, with attack rates between 3 and 4 per 100 000 population, during the 1970s.

In February 1978, based on advice and recommendations by visiting WHO consultant Professor J. Melnick of the University of Texas in Houston, the government health services in Judaea, Samaria and Gaza began the implementation of a new polio control programme. Up to that time the polio control programme was based on the use of Triple Oral Polio Vaccine (TOPV) for infants aged 3, 4-1/2, 6 and 12 months. A change was recommended because of the continued occurrence of polio cases, even among immunized children. This phenomenon was felt to be due to "interference" of other enteroviruses with uptake of the polio virus and therefore reducing the effectiveness of immunization. As a result, the decision was made to introduce a new and redoubled effort to eliminate polio a combined programme using oral polio vaccine with killed vaccine was undertaken.

An initial mass campaign was carried out to immunized all children up to age two years with Type I oral polio in addition to the routine four doses of TOPV given to infants up to age one, because polio cases were primarily of Type 1. This mass campaign reached a large proportion of children during a two-week period with cooperation of government agencies, government health personnel, UNRWA and others. At the same time, in place of triple vaccine, diphtheria, pertussis and tetanus OPT), a quadruple vaccine (DPTP) was introduced as a routine well-child care measure and is the present routine immunization programme.

Until 1980 polio cases were still occurring in spite of an extensive immunization programme but since then the incidence has fallen substantially (Table 43). In spite of the unavoidable introduction of wild polio virus via travelers from neighboring countries, the combination of life oral vaccine TOPV (Sabin) and the killed IPV (Salk) vaccine provide wide scale herd immunity while also introducing full immunity early in infancy. Thus the interference factor of other enteroviruses present in the area is avoided. The combination of 5 feedings of TOPV plus 2 inoculations of killed vaccine at 3-1/2 and 5 months seems to overcome this interference, and establishes cellular immunity. Professor Melnick and colleagues visited the region in April 1981 and recommended continuance of this combined approach (OPV and IPV).



Table 43: CASES OF PARALYTIC POLIO, Judaea and Samaria, 1968 to 1984
'68
'69
'70
'71
'72
'73
'74
'75
'76
'77
'78
'79
'80
'81
'82
'83
'84
Cases
22
32
23
9
14
8
29
21
35
17
13
3
24
1
0
3
Note: These cases are laboratory and clinically confirmed.



Tetanus

Tetanus neonatorum* remains a problem in Judaea and Samaria on a declining scale, and a programme assisted by WHO is to be carried out starting in early 1983 towards elimination of this disease by immunization of women in the age of fertility. Boys and girls in high schools (grades 9-12) will be immunized in order to reduce the potential of infection among young people entering the labourforce, and to ensure immunity among future pregnant women. Women receiving care in MCH centres during pregnancy will also be immunized for tetanus. This special campaign along with the routine childhood immunization programme should bring the problem under control over the next several years (see Table 44 and Figure 10). Immunization of women in prenatal care in MCH centres requires more health education activities to improve acceptance levels.

________________
* Neonatal Tetanus - WHO Document EM/RC30(82)/12, June 1982 and Expanded programme of Immunization - Prevention of Neonatal Tetanus, Weekly Epidemiological Record, 18, 137-142, 7 May 1982.


Diphtheria

An outbreak of diphtheria occurred in the town of Salfit in 1976 with six cases confirmed by laboratory diagnosis. All schoolchildren in grade 1 in the area were given DT booster immunization and DT at grade 2 age was subsequently added to the entire immunization programme. From 1981 to 1983 only one case of diphtheria has been reported each year, an attack rate of 0.1 per 100 000 population (see Tables 44, 46, and Figure 10).



Table 44: INCIDENCE RATES FOR SELECTED REPORTED INFECTIOUS DISEASES
Judaea and Samaria, 1968 to 1984
(No. of cases reported per 100 000 population)

Disease
1968
1970
1975
1977
1978
1979
1980
1981
1982
1983
1984
Diphtheria
Measles
Pertussis
Polio
Tetanus
1.6
164.4
8.0
4.7
53.3
0.3
56.3
4.0
3.3
2.3
0.8
51.6
12.2
3.2
3.5
0.4
26.2
1.6
2.5
2.8
0.4
33.5
1.3
1.9
2.0
0.9
45.9
2.3
0.3
4.1
2.7
10.2
1.6
3.4
2.3
0.1
73.2
0.7
0.1
3.2
0.1
137.8
0.8
0.0
1.5
0.1
6.9
1.2
0.4
0.5
0.3
92.0
4.1
0.1
0.4
Note:1.For comparable annual incidence rates for Expanded programme of Immunization (1975-1980) in countries of the Eastern Mediterranean Region WHO - see The Expanded programme of Immunization in the Eastern Mediterranean Region: An account of progress - WHO EM/RC30(82)/11, June 1982, Table 6, pp. 37-42.
Source: Statistics Department Government Health Service, Judaea and Samaria.





Figure 10: INCIDENT OF REPORTED INFECTIOUS DISEASES
Judaea and Samaria
(No. of cases per 100 000 population)

Measles

Measles immunization was introduced in 1969. Coverage was over 81% in 1970 but declined in the period 1974 to 1978, but since 1980 has been over 90%. In 1982 coverage was increased by doubling of the immunization during the post-1981 epidemic period. In 1981 the government health service provided over 25 thousand measles immunizations, UNRWA 4400, for a total of over 30 thousand out of a total of 31.3 thousand live births minus 912 reported infant deaths, over 96% immunization coverage.

An outbreak of measles occurred in 1981, in conjunction with an epidemic in neighboring areas. It was located particularly in the Hebron area, where there were 325 cases out of a total of 530 reported cases for the whole area. The outbreak continued into 1982. Measles immunization was brought forward to seven months of age with boosters at 14-15 months. The epidemic continued in 1982 with over a thousand cases, then subsided; in 1983 only 49 cases were reported (6.4 per 10 000 population), but in 1984, 736 cases were reported. Full control of this disease will require continued maintenance of high immunization levels for some years ahead.

Sero Survey 1983

In June 1983 a sero survey of protective antibodies was carried out by the National Virus Reference Laboratory at Tel Hashomer Hospital on a sample of schoolchildren aged 7-9 in urban and rural schools in each district of Judaea and Samaria. The results of these tests show protective antibody levels for polio (96.7%), measles (90.6%), tetanus (98.0%), and using rubella as a control disease not included in the routine immunization programme with 48.8% antibody levels (see Table 45).



Table 45: ANTIBODY LEVELS AMONG SCHOOLCHILDREN (AGED 7-9)
Judaea and Samaria, 1983
%
Polio
German Measles
Measles
Children Tetanus
Hebron
Jericho
Bethlehem
Nablus
Jenin
Ramallah
Tulkarem
95
95
100
100
90
100
-
50
40
80
60
40
40
40
100
100
80
90
89.5
83.3
-
-
-
-
-
-
-
-
%
Number
96.7
120
48.8
125
90.6
117
98.0
100

Note: Polio neutralizing antibody levels against Type 1, 11 and III at 1:4 dilution. German Measles antibodies tested by HIG method. Measles tested by neutralizing antibodies at 1:4 dilutions. Tetanus antitoxin antibodies are tested by ELISA method; the positive range is from 0.02-1/0 International Units per ml.



Rubella

From 1980, rubella immunization of 12 year old girls in schools has been carried out so that nearly all girls between age of 12 and 16 are now immunized. This project will be expanded during 1985 with Wito assistance.

OTHER COMMUNICABLE DISEASE CONTROL

Major progress has also been achieved in control of other communicable diseases in Judaea and Samaria. This has been largely based on improved sanitation, investigation and epidemiologic reporting systems, and an extensive immunization programme (Table 46).

Malaria

The area was endemic for malaria where the Anopheles mosquito was prevalent, but malaria control and surveillance activities succeeded so that the territory, except for the Jordan Valley, was declared malaria-free by WHO in 1970. Mosquito abatement activities continue, along with surveillance activities regarding vectors, and investigation of suspected human malaria cases. All new cases in recent years have been imported cases.

Cholera

Cholera returned to the Middle East in recent years with a major outbreak in 1970 and minor ones in subsequent years. In 1970, 66 cases were detected, with the sources traced to transfer from neighboring countries. Special attention was given to the problem of disease transmission through use of untreated sewage water for vegetable irrigation, a widespread practice until recent years. This practice is much reduced as a result of strict enforcement of the law and by destruction of crops irrigated with sewage water. Use of sewage water for irrigation is permitted only for selected fields and orchard crops. As a result, during 1971, 1972, 1976, 1977 and 1981 when there were cholera outbreaks in Jordan,, Syria and other neighboring countries, there were few cases in Judaea and Samaria (1971 - l case; 1972 -7 cases; 1976 - 0 cases; 1977 - I case; 1978 - 0 cases; 1979 - 8 cases; 1981 - 7 cases, 5 of them imported).

In 1981 there was a large-scale outbreak in Jordan of cholera. The health service of Judaea and Samaria organized a team consisting of a doctor, nurse and sanitarian to be stationed at each bridge over the Jordan River in order to interview and examine the thousands of travelers entering the territory. A written description of the disease was provided to all entrants. All food carried by entrants was destroyed so that undetected infection could not be imported. Suspect cases were referred to the nearest hospital (Jericho for the southern bridge, and Nablus for the northern bridge). Epidemiologic teams of a doctor, nurse and sanitarian were established in each district on 24-hour standby to investigate all suspected cases reported to the district health office. The epidemiologic investigation teams visited the homes of the suspected case, collected stool samples and instituted preventive and curative services on the spot, as well as instituting sanitary control measures.

All hospitals and district health offices were alerted and made ready for receiving patients with special units in several hospitals. Where laboratory proof was established, the families were quarantined for three days, given prophylactic treatment (tetracycline per os) under observation of the sanitarian. As preventive measures, sewage-irrigated fields were destroyed in Hebron, Bethlehem, Nablus and Tulkarem districts. Hundreds of tests were taken of drinking-water, sewage, and vegetables from the market in order to maintain surveillance on the problem.

As a result of this surveillance and intervention programme in 1981, only 7 cases of cholera were detected, of which 5 were imported, with 2 additional secondarily spread cases within the families of the primary cases. one death occurred in the case of an elderly man with heart disease. No immunizations were carried out during all the above-mentioned outbreaks; control by surveillance, epidemiologic and environmental sanitation techniques have proved to be successful.

In 1982 and 1983 no cases were reported. Nevertheless, bacteriologic surveillance activities continue, as well as preventive activities regarding illegal usage of raw sewage for irrigation of ground crops.



Table 46: NOTIFICATIONS OF SELECTED INFECTIOUS DISEASES
Judaea and Samaria, 1968 to 1984

Disease
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
Measles
Chicken pox
Dysentery, para-typhoid
and typhoid
Pertussis
Diphtheria
Poliomyelitis
Superperal fever
Meningitis
Relapsing fever
Scarlet fever
Erysipelas
Typhus
Malaria
Infectious hepatitis
Tetanus
Tetanus neonatorum
Syphilis
Rabies
Brucellosis
Tuberculosis1/
Leishmaniasis
Cholera
Rubella
Encephalitis
Bilharziasis
Mumps
Gonorrhoea
Rheumatic fever 2/
901
306

270
44
9
26
21
32
14
1
10
-
2
75
292
-
-
-
-
-
-
-
-
-
-
132
1
NA
428
471

231
122
6
31
18
18
24
1
3
-
-
105
14
-
-
1
-
-
-
-
-
-
-
426
-
NA
340
467

124
24
3
20
14
24
15
18
6
-
10
84
14
-
-
-
-
-
-
61
-
-
-
872
-
NA
108
458

128
17
-
9
11
17
5
5
3
-
5
44
27
-
-
-
-
109
-
1
-
-
-
720
1
NA
529
331

112
96
8
6
11
20
-
-
2
1
7
66
18
-
-
-
-
108
23
7
-
-
6
643
2
NA
59
391

42
11
1
8
9
11
3
2
-
-
2
46
12
-
-
-
1
77
11
-
89
-
-
158
-
NA
95
232

93
20
3
29
10
33
1
6
-
-
4
113
29
-
-
-
1
129
5
-
4
-
-
340
-
NA
342
109

128
81
5
21
9
64
7
5
1
-
20
97
23
-
-
-
15
119
17
-
1
-
-
1252
-
NA
82
118

294
32
2
35
10
31
2
9
2
-
22
141
22
-
-
-
13
130
9
-
-
-
-
430
-
NA
178
229

390
11
3
17
3
39
3
4
5
-
19
92
19
-
1
-
14
159
14
1
2
-
-
301
-
NA
231
303

124
9
3
13
1
38
1
3
1
-
18
294
5
9
2
1
31
141
24
-
35
3
-
907
-
NA
321
166

61
16
6
2
-
48
-
13
1
-
12
146
7
22
-
-
59
145
8
8
18
8
-
406
-
NA
72
175

106
11
19
24
1
36
2
4
1
2
15
692
8
8
1
-
51
191
38
-
46
2
1
310
-
NA
530
371

261
5
1
1
1
61
0
4
1
0
7
392
10
13
2
-
194
139
83
7
34
1
0
708
-
6
1020
858

136
6
1
0
0
55
1
3
3
0
4
240
6
9
0
0
176
136
57
0
33
3
0
1064
0
7
53
680

348
9
1
3
0
94
0
0
0
0
0
495
4
10
0
0
141
95
36
0
52
6
0
770
0
8
736
2948

349
33
2
1
0
58
1
19
0
0
0
467
3
10
0
0
186
NA
44
0
288
5
0
1354
0
4
Note:1.


2.

3.


4.




5.
Tuberculosis cases are reported without necessarily having bacteriological confirmation; the figures are considered to represent over-reporting of active tuberculosis.

Reporting of Rheumatic fever commenced in 1981.

Reporting of diarrhoeal and gastroenteritis is for the age group 0 to 3 years only; this was commenced in 1981.

Reporting of infectious diseases is improved as a result of continuing education of medical staff of the importance of reporting as a basis of epidemiologic surveillance. As in other jurisdictions many infectious diseases are under reported, nevertheless this data serves as a valuable monitor of trends.

1984 data include complete year. 1983 data corrected to include final report for total year.



Leishmaniasis

Leishmaniasis exists primarily in the Jordan Valley and the Salfit area. In the Jordan Valley, the vector control focused on spraying of the sand-fly (Phlebotomus). In the Salfit area, epidemiologic investigation reveals that the disease is endemic even though the geographic conditions are not ideal for its propagation. A team involving sanitarians and hospital-based skin specialists has carried out surveillance, case finding and vector control activities in the area.

The area is endemic for this disease, and as a result of long familiarity with it, reporting for care by those contracting the disease is relatively complete. In 1981 attempts to improve sand-fly control were carried out by adding ethoxychlor to the traditional DDT used. In spite of control measures there was an increase in the number of repeated cases in 1981 (83), mainly in the Jericho area.

Cases reported declined to 57 cases in 1982 to 57, 36 cases in 1983 and 44 cases in 1984. Vector control activities have been stepped up. No effective vaccine is currently available.

Tuberculosis

Two tuberculosis centres in Hebron and Nablus have served Judaea and Samaria for many years. A new clinic recently opened in El Bireh and serves patients from the Ramallah and Jericho districts. The Hebron tuberculosis and chest disease centre was renovated and reorganized in 1979.

Tuberculosis control has focused in the past on case finding and treatment. In 1977, an epidemiologic survey in Hebron was carried out based on tuberculin testing, microfilm X-rays and follow-up X-rays on suspect cases in relatively high-risk populations (e.g. Bedouins, ceramic and glass industry workers).

Tuberculosis control is now combined with an active immunization programme for the susceptible child population. Case finding is based on the referral to chest clinics of patients with symptoms. These clinics examine the referred patients, and the contacts of newly discovered index cases. A few cases are also detected by group examinations. In 1980, 10 469 persons were examined and 109 active cases of tuberculosis were discovered (some 15 cases per 100 000 population). Of these many were cases of doubtful activity and very few (5) were far advanced. Bacteriological confirmation was not being carried out systematically in Hebron and generally was not carried out in Nablus, so that many reported cases were not confirmed. During 1982 bacteriologic testing for confirmation of suspect cases was arranged with a reference laboratory, and this is now being carried out routinely.

In 1978, a plan to carry out BCG immunization of schoolchildren was prepared and in 1979, all children in grades 6-9 were Mantoux tested (over 90% coverage), then Mantoux negatives were given BCG. Mantoux positives (1.6% of those examined) were sent to the local tuberculosis centres for further assessment. Several active pulmonary and extrapulmonary tuberculosis cases were identified and were placed under treatment and follow-up. The BCG campaign for schoolchildren in 1979 examined nearly 55 000 children (94% of the children in the grades tested) of whom 98.4% were negative and immunized with BCG (see Table 47). Of the Mantoux positives, follow-up investigation revealed 10 new cases of pulmonary tuberculosis, 3 new cases of extrapulmonary tuberculosis, 31 cases of inactive tuberculosis and 5 suspected cases. The BCG programme continues based on Mantoux testing.

In 1980, schoolchildren in grades 2-6 were Mantoux tested and followed up similarly. A routine Mantoux testing and BCG programme for grade 1 students started in 1980 and continues. The numbers tested and showing positive Mantoux tests are shown in Table 47, indicating low conversion rates in children at ages of grade one. Clinical health services are alert for case finding and referral of new cases of tuberculosis. The cases reported and confirmed are shown in Table 48.



Table 47. TUBERCULIN TESTING IN SCHOOLCHILDREN AGED 6-15 YEARS
PRIOR TO BCG VACCINATION
Judaea and Samaria, 1979 to 1984

Indication of 9 mm
or more
Year
Age group
(grades)
No. tested
No. read
% read
No.
%
1979

1980

1981

1982

1983

1984
11-15
(grades 8-9)
6-11
(grades 1-6
6-8
(grade 1)
6-8
(grade 1)
6-8
(grade 1)
6-8
(grade 1)
57 294

137 396

21 468

23 908

12 066

20 667
54 957

131 356

20 532

23 832

11 778

20 157
96.0

96.0

95.6

99.7

97.6

97.5
837

576

45

38

23

NA
1.52

0.44

0.22

0.16

0.20

NA

Note: Data for 1979 and 1980 quoted in Styblo, K., op.cit. Data from 1981 to 1983 from Health Services Statistics Department.



Table 48: NEW TUBERCULOSIS CASES DIAGNOSED, Judaea and Samaria, 1970 to 1984

Site
1970
1972
1974
1976
1978
1979
1980
1981
1982
1983
Pulmonary

Extrapulmonary
154

117
166

42
129

86
121

9
127

14
132

13
105

86
86

53
101

27
95

26
TOTAL
271
208
215
130
141
145
191
139
136
121

Source: Judaea & Samaria Statistics Department, Health Services.


Dr K. Styblo, Director of Scientific Activities of the International Union Against Tuberculosis in Paris, visited the area in 1981 as a WHO consultant and - conducted a detailed review of the tuberculosis situation. Dr Styblo noted a low prevalence of tuberculosis infection among children. He recommended continuance of BCG vaccination at school entry age following Mantoux testing in order to monitor the Mantoux conversion rate. The rate continues to remain very low for the age 6-8 group in grade 1-throughout the area (averaging 0.19% over the three-year period).

Some possible over-reporting of unconfirmed cases in the Hebron area is noted, and bacteriological examination for confirmation of suspect cases is recommended, as well as shortening the duration of chemotherapy. Dr Styblo's report on the situation in Judaea and Samaria concludes that the area "may now be classified with low prevalence countries the programme there is sound and the results are satisfactory; however, the minor improvements mentioned above are desirable".*

_______________
* Styblo, K. - Assignment Report: Tuberculosis programme in Israel 9-21 January 1982, World Health Organization EM/TB/157 EM/ICP/SPM/00l/RB May 1982.




Gastroenteric Diseases

Gastroenteric disease still remains a public health problem. Improved water treatment and distribution, sewage collection and treatment, garbage collection and disposal as well as improved public health supervision of food, public eating places all have contributed to the reduction of gastroenteric disease. In the event of gastroenteric infections disease outbreaks, active epidemiologic investigation takes place so as to identify and eliminate sources of contamination.

Recent emphasis on reporting of communicable disease by local physicians, and epidemiologic investigation of outbreaks is developing a stronger basis for assessing the extent of gastroenteric infection. The continuing cumulative effect of environmental sanitation provides the long-term potential for reducing this problem. A proposal for the epidemiologic surveillance of infectious hepatitis (HAV) is under consideration as a project for the Health Services Research Centre.

Gastroenteritis among infants remains a special problem. During 1980 a pilot oral rehydration ORS project was carried out in Ramallah district. In June 1981 a general programme was introduced to provide ORS through all health centres, with referral to hospital for severe cases. Study days were carried out for doctors and nurses in each district, with emphasis on prevention, diagnosis and treatment of dehydration in infants. Special forms for cases under observation were established for follow-up and evaluation, including those referred to hospitals.

In total, ORS was provided through 150 MCH and community clinics with some 800 treated cases, of whom 200 were referred to hospitals for care. Oral rehydration mixtures are widely available and highly publicized in order to initiate the earliest possible effective measures against dehydration through MCH centres, community clinics, hospitals as well as in private pharmacies and clinics.

Emphasis on breast-feeding as a preventive measure, boiling of milk and water for infants, basic hygienic practice and the oral rehydration system are all being stressed in the MCH programme education activities as important aspects of prevention of gastroenteritis among infants.

In 1981, gastroenteritis for the age-group 0 to 3 years was added to the list of reportable diseases. Gastroenteritis as a cause of death among infants and children up to age 5 declined for 208 cases in 1981, to 193 in 1982, and 173 in 1983 (17% less over the three-year period).

Rift Valley Fever

Rift Valley Fever reached Egypt from Central and East Africa via Sudan for the first time in 1977 and 1978, causing a widespread epizootic and human epidemic. This caused much concern, and special precautions were necessary in order to prevent the entry of this
disease into this area. In coordination with the Steering Committee on Rift Valley Fever of the Israel Ministry of Health, surveillance and control programmes were established during 1978. This programme consisted of active surveillance (including blood sample surveys),
immunization or large animals, vector control activities (anti-mosquito spraying), preparation of special laboratory and hospital facilities as well as control of (possibly infected) meat products. The veterinary services carried out a vast vaccination campaign of all animal herds (including sheep, goats, cattle and camels) in Judaea and Samaria in conjunction with a similar project in Israel and Gaza. Every animal was marked after being vaccinated to ensure full coverage of vaccination. Local butchers and cattle farmers in risk areas were examined periodically in order to discover possible infection with this disease. * Pilgrims returning from their pilgrimage to Mecca, Saudi Arabia, in November 1979, 1980, 1981 were examined by medical/nursing teams when entering the region via the Jordan bridges. Febrile, patients were referred to Jericho Hospital where investigations were carried out. No cases of Rift Valley Fever were discovered.

Surveillance by blood sampling of farmers and butchers, as well as Bedouin flocks show no evidence of the disease.

____________
* Tulchinsky, TH (1983) Preventive management of threatened epidemics, World Health Forum, 4, 74-78, 1983.



Brucellosis

Brucellosis control activities have recently been increased by widespread immunization of cows and sheep. Blood sample surveys by workers in contact, with animals are being conducted routinely. A focus of the animal disease was found in the Hebron district, and a large number of, infected animals and animal products were destroyed in order to contain the spread of the disease. Tests of dairy products in the markets were negative, but some self-prepared dairy products of Bedouins were found to be contaminated.

Active veterinary and medical surveillance have identified more cases in recent years. Improved veterinary control on animal slaughtering practices has been aided by the new municipal slaughterhouses although unauthorized practices in this area remain common, in the villages in, particular. Use of unpasteurized milk is still common in the area., This disease remains a problem.

Bilharzia

Bilharzia control activities were carried out by spraying against snails along the Jordan Valley when information was received of cases occurring in Jordan in 1981 (in September and October). No cases have been reported in recent years.


EXPANDED PROGRAMME OF IMMUNIZATION IN GAZA

An expansion of the immunization programme for children has been the cornerstone of the infectious disease control programme, supported by improved environmental sanitation and treatment services. Emphasis on polio, DPT, BCG, measles and smallpox (stopped in 1980) vaccination has led to widespread coverage and over 90% of the children are reached during infancy, early childhood and school-age. Tables 49 and 50 outline the development of immunization coverage achieved in the region and current coverage rates.

Reporting of infectious disease, has, improved in the Gaza area, particularly as health services operated by the government health services have been expanded to reach more of the population. A new reporting system for infectious diseases was established in January 1981. In Table 52, reported cases of selected infectious diseases are given. In Table 51, the attack rates (per 100 000 population) of some of these diseases are shown. In spite of improved reporting resulting from the increased availability and accessibility of services and their increased, utilization, the incidence rates of these diseases - measles, pertussis, polio and tetanus - have declined substantially.



Table 49: EXPANDED IMMUNIZATION PROGRAMME
Gaza
Disease/Agent
Pre-1967
Post-1967
Diphtheria, pertussis tetanus (DPT) vaccine

Live triple oral polio vaccine (TOPV)


Smallpox vaccine


Measles vaccine



BCG vaccine


Inactive IPV




Diphtheria-tetanus

Tetanus toxoid
Commenced prior to 1967

Not used prior to 1967


Given since 1948
very good coverage

Not used prior to 1967



Given to school-children only


1965-67 special
one-dose campaign
with Salk vaccine
50% coverage
Coverage increased; now over 90%.

Started in 1967. Coverage over 90%. Special TOPV campaigns were carried out in 1974, 1976, and 1978.

Stopped end of 1980.


Started in 1970, with low coverage of some 50%: 80% coverage achieved in 1978, and over 90% in 1979. Given at age 10-12 months to assure higher coverage rate.

Since 1974 given to infants with coverage over 90%. Also given to Mantoux negative schoolchildren.

Since 1978 two doses given to infants (with DPT) in addition to TOPV: coverage over 90%



Given to school-age children.

Since 1977 given to pregnant women in MCH centres (2 doses eventually + one dose postnatally). Since 1982 given to young persons applying for work through labour exchanges. A campaign in high schools was carried out in 1984, and will be continued.

Note: Includes immunization through government and UNRWA MCH services. The government supplies all vaccines to UNRWA, which follows the same immunization schedule, and reports to the government health office on coverage.



Table 50: IMMUNIZATION COVERAGE IN GOVERNMENT AND UNRWA HEALTH SERVICES
Gaza 1984 (000s)
Vaccine

DPTP
DPTP
DPT
DPT
Order

1
2
3
4
UNRWA

13.3
12.8
11.8
9.9
Government

9.1
8.5
8.1
7.1
Total

22.3
21.3
19.9
16.9
%

98.8
94.2
87.8
79.8
TOPV*
1
2
3
4
13.6
13.1
11.9
12.5
9.1
8.5
8.1
7.1
22.6
21.7
20.0
19.5
100.0
100.0
88.5
86.4
BCG
15.8
8.9
24.6
108.0
Measles
11.2
7.5
18.6
82.5
Note:1.




2.


3.
DPTP = diphtheria, pertussis, tetanus and polio (Salk inactive).
TOPV = triple oral polio vaccine (Sabin attenuated live virus).
BCG = Bacillus Calmette, Guerin.
Births in 1981 - 20.4 thousand: 1982 - 22.2 thousand, and 1983 - 22.6 thousand.

* Fourth doses of TOPV include extra booster doses given during reinforcing campaigns.

In cases where coverage exceeds 100%, this is due to repeated immunization in the same population group.


Table 51: INCIDENCE OF SELECTED REPORTED INFECTIOUS DISEASES
Gaza, selected years, 1968 to 1984
(No. of cases/100 000 population)
Year
Disease

Diphtheria
Measles
Pertussis
Polio
Tetanus*
1968

0.0
471.2
55.9
14.3
14.6
1970

0.0
604.6
30.2
12.5
13.6
1974

0.0
82.5
0.2
18.4
10.8
1975

0.2
136.7
11.0
4.3
10.8
1976

0.5
167.6
5.8
18.0
17.7
1977

0.5
182.0
2.5
2.9
16.1
1978

0.9
102.0
0.0
2.7
8.4
1979

0.0
90.6
0.2
2.1
12.2
1980

0.0
0.7
1.4
2.9
6.3
1981

0.0
135.5
27.0
0.2
4.0
1982

0.0
329.3
10.2
0.2
2.4
1983

0.0
16.1
15.1
0.4
1.2
1984

0.0
3.0
52.1
0.0
1.8

Note: *Includes tetanus neonatorum and tetanus cases.



Table 52: INFECTIOUS DISEASES REPORTED FROM HOSPITALS
AND CLINICS, Gaza, 19867 to 1984
Disease

Typhoid 1/
Salmonellosis
Meningitis 2/
Diphtheria 3/
Tetanus 4/
Pertussis 5/
Poliomyelitis6
Syphilis
Gonorrhoea
Measles
Infectious
hepatitis
Cholera
1967

119
3
65
3
56
125
37
17
6
651

874
0
1968

78
8
19
0
52
199
51
42
6
1677

676
0
1969

36
4
16
0
25
30
59
22
8
1465

875
0
1970

26
2
13
0
50
111
46
19
5
2223

1130
243
1971

50
4
9
0
38
2
22
33
1
5552

1069
0
1972

55
4
6
0
43
31
27
25
5
1359

1039
0
1973

63
11
5
0
28
4
27
12
2
475

686
0
1974

12
5
19
0
44
1
75
5
0
337

337
0
1975

5
2
28
1
45
46
18
0
0
572

327
0
1976

3
0
41
2
76
25
77
0
0
719

357
0
1977

7
12
35
2
71
11
13
12
3
803

158
0
1978

10
30
36
4
38
0
12
0
1
459

96
0
1979

10
16
26
0
53
1
9
0
0
392

54
0
1980

5
0
45
0
28
6
13
0
0
3

33
0
1981

0
6
60
0
18
122
1
0
7
612

333
161
1982

0
3
35
0
11
47
2
0
0
1515

NA
7
1983

50
1
76
0
6
72
1
0
4
77

369
25
1984

25
3
54
0
9
257
0
0
1
64

671
0
1.

2.

3.


4.


5.

6.

7.
Typhoid and paratyphoid cases are based upon laboratory confirmed reports.

Meningitis includes meningococcal, haemophilus influenza, pneumococcal and unspecified.

Diphtheria cases have been reported exclusively from isolated Beduin groups living in central Sinai.

Includes both tetanus and tetanus neonatorum. Tetanus neonatorum cases occur mainly among Beduins; in 1980, 17 cases occurred; in 1983, two cases were reported.

Pertussis - clinically reported, not bacteriologically confirmed.

Polio data corrected by results of lameness survey carried out in 1982.

Measles cases are those clinically reported, but are not confirmed by laboratory.



COMMUNICABLE DISEASE CONTROL/EPIDEMIOLOGY

A centre for epidemiology and medical information was established in 1981, staffed by a trained physician epidemiologist (a Master of Public Health graduate from the Hebrew University School of Public Health), a nurse and trained medical records staff. A monthly epidemiological bulletin which began in 1981 reports birth data, deaths, by cause and age-group, immunizations, reported infectious diseases, including laboratory data, hospitalizations and ambulatory care information. The unit is responsible for investigation of infectious diseases of public health importance, and for development of health surveillance systems.*
___________
* Abed, Y., Lasch, E. E., Hassan, N. A. & Goldberg, J. (1984) Community and Local Involvement in the Control of Infectious Diseases of Infancy. Presented at the Fourth International Congress of the World Federation of Public Health Associations, Tel Aviv, Israel, 19-24 February 1984.



Poliomyelitis

Oral polio vaccine has been used in Gaza since 1968. In spite of 80-90% coverage of the susceptible infants by the mid-1970s, polio cases, now fully reported, and investigated, occurred in waves, including cases among immunized and partly immunized children. The mean annual incidence continued to be around 10 per 100 000 population. Two outbreaks occurred in 1974 and 1976 involving 75 and 77 infants respectively, an incidence of 18 per 100 000 population. In the first epidemic, 34% of the paralyzed children had received three to four doses of TOPV; this percentage increased to 50% in the second epidemic and to 61% in 1977. A correlation was found between the prevalence of diarrhoeal disease and vaccine failure, and a causal effect was postulated.

As a result of this dilemma, a consultation with Professor J. L. Melnick, a WHO consultant,** was carried out. To overcome this problem, Professor Melnick recommended that a programme of immunization be carried out, combining both live and killed polio vaccines. This combined polio vaccination programme has been carried out since 1978 with apparent success in reducing the annual and peak year attack rates of this disease. The average annual incidence rate of the disease between 1978 and 1980 was 2.5 per 100 000 population and has declined to an average annual rate of 0.26 since 1981. Furthermore, almost no cases of paralytic disease have been reported among children who have received the combined vaccine. In 1981, only one case was reported and it was in a non-vaccinated child; in 1982 two cases occurred in fully vaccinated children where investigation revealed technical faults in procedures of use of IPV. These procedural difficulties have now been corrected. A survey of lameness was carried out in 1982 to confirm the polio incidence rates of the 1960s and 1970s.
______________
** Melnick, J. L., Distinguished Service Professor of Virology and Epidemiology, Baylor College of Medicine, Houston, Texas. Assignment Report: Recommendations for the Control of Poliomyelitis in Israel, West Bank and Gaza Strip, 28 October 1977, EM/Vir/7/EM/Epid/54, December 1977.



Measles

Measles vaccination was begun in 1970 and was received with a low level of public acceptance. Due to the development of preventive services and of public understanding and acceptance, coverage has now reached 90%. As a result, the incidence of measles has declined substantially from the high prevalence rates of the early 1970s. This vaccine is given in the first year of life in order to maximize early coverage. Only two hospitalizations occurred for measles in 1979. Coverage of the measles vaccination has improved drastically in recent years as a result of continuing health service development and improved public acceptance.

An outbreak of measles occurred in Gaza in 1981/1982, simultaneously with a similar outbreak in neighboring districts in Israel. The outbreak started in October 1981 and continued for six months. Altogether, 1859 cases were reported to the Department of Public Health. Analysis of 354 cases revealed that 61.3% has not been vaccinated - out of these 217 cases, 86 (39.6%) were below the age when measles vaccine is administered. Out of the 137 vaccinated children who contracted the disease, 30% were vaccinated below the age of nine months. Seventy children died, a case fatality rate of 3.7%. Twenty out of 22 fatalities in whom vaccination status could be determined were not vaccinated.

Epidemiological assessment suggests that measles control should improve considerably in the few years ahead following the 1981/1982 epidemic and the extensive measles vaccination coverage of recent years. Only 77 cases were reported in 1983 (16.1 per 10 000 population).

Tuberculosis

Tuberculosis control programmes have been carried out in this area for many years and include routine BCG vaccination of newborns (since 1974), and of school-aged children after Mantoux testing, in keeping with current WHO recommendations. In the last 10 years, cases reported are entirely among the older population (Table 53); no cases of miliary or meningeal tuberculosis were reported in children.



Table 53: CASES OF TUBERCULOSIS, Gaza, 1972 to 1984
Tuberculosis1972

1973

1974

1975

1977

1978

1979

1980

1981

1982

1983

1984

Pulmonary
Extrapulmonary
TOTAL
179
20
199
116
14
130
147
20
164
141
23
164
125
12
137
108
14
122
99
11
110
59
0
59
90
0
90
61
0
61
57
0
57
36
0
36

Note: 1972 - Gaza only.
1977-1979 includes cases from Gaza and South Sinai.




Dr K. Styblo,* Director of Scientific Activities of the International Union Against Tuberculosis in Paris, visited Gaza in 1981 as a WHO consultant, and recommended certain improvements in monitoring, case confirmation, standardization of treatment and closer cooperation between Gaza chest physicians and those in Israel and in Judaea and Samaria. He recommended strengthened efforts of case identification through primary care clinics and continuance of the successful BCG programme associated with hospital births and Mantoux negative schoolchildren. Dr Styblo's recommendations are in process of being carried out.

There has been a steady decline in the incidence of new cases of tuberculosis particularly since 1980.

______________
* Styblo, K. (1982) Assignment Report: Tuberculosis Control programme in Israel; 9-21 January 1981, WHO EM/TB/157, EM/ICP/SPM/ODI/RB, May 1982.


Malaria

No indigenous cases have been identified since 1972; surveillance of suspected cases is carried out in the public health laboratories.

Cholera

During the 1970s, imported cases with secondary spread have occurred, with two outbreaks in 1970 and 1976.

After having been cholera free from 1977 to 1981 an outbreak occurred in the summer and fall of 1981 caused by secondary spread from cases imported from Jordan. Altogether, 161 cases were reported, an incidence of 37 per 100 000 population. Most cases were mild to moderate and not a single case fatality occurred.

Following the appearance of the first cases, an extensive preventive system was instituted. All direct contacts were given doxycycline as a preventive measure and latrine sampling was performed in neighboring homes. During the outbreak, constant monitoring of water, sewage and vegetables was performed; only on one occasion was a. sample of sewage found to be positive. In 1982 a small outbreak of cholera occurred which was confined to one family was identified and no further spread occurred; in 1983 a small outbreak of 25 cases occurred.

Tetanus

Tetanus is a declining problem in Gaza. However, an expanded programme of tetanus immunization is being carried out in conjunction with WHO, in order to further control and, in time, to eliminate the disease. Pregnant women being cared for at MCH centres and UNRWA centres are being given tetanus toxoid, as are women in the age of fertility in Beduin camps. All children in care of government and UNRWA health centres are routinely given tetanus toxoid. A campaign to immunize the population over age 16 was carried out in the southern part of the district.

Rheumatic Heart Disease

Rheumatic heart disease is an important but declining component of the overall cardiovascular disease picture. Increased primary care services and health insurance enhance early care of infectious diseases including streptococcal disease, and affect the occurrence of rheumatic fever with its cardiac sequelae.

Trachoma

Trachoma has completely disappeared except for some suspected cases of trachoma reported by UNRWA staff, which have not been confirmed by laboratory diagnosis.

Diarrhoeal Diseases Control

In 1978, the ORS programme designed to reduce the mortality and morbidity of diarrhoeal diseases among infants was launched with WHO assistance, and with a high degree of cooperation between the government health services and those of UNRWA.* This programme was centered on use of the WHO oral rehydration formula, prepared locally, for early care of infantile diarrhea in order to prevent dehydration with its attendant mortality and morbidity. In 1979, the advice and encouragement of Dr Cook and Dr Barua from WHO assisted in programme expansion to cover all of the 60 000 children under the age of three years in the Gaza population.
____________
*UNRWA, Report of the Director General 1982, Vienna.




This area wide ORS programme is currently one of the largest field experiences under way and under evaluation. Wide-scale publicity through radio, posters and education in MCH and other health centres brought the matter to public attention. MCH centres, routinely visited by pediatricians from Nasser Children's Hospital, are fully involved in the programme as is the hospital staff itself.

A study of the joint ORS programme shows a reduction in mortality, hospital admissions, intravenous infusions and morbidity from diarrhoeal disease among infants. Hospital days of care for infants and young children as a result of diarrhoeal disease has declined from 1977 to 1981 by 42%; the gastroenteritis fatality rate decreased during this period for the age-group one month to 35 months by 53.2%. Diarrhea-related mortality in children below one year of age has declined by 52.2% in the period 1977-1981. A report of the first three years of ORS experience was published in 1983 ** (see Figure VI).
_____________
**Lasch, E. E., Abed, Y., Guenina, A., Hassan, N. A., Abu Amara, "I. & Abdallah, K. (1983)-Evaluation of the impact of oral rehydration therapy on the outcome of diarrhoeal diseases in a large community. Israel Journal of Medical Sciences, 19, 995-997.



Parasitic diseases are present in the form of ascariasis, giardiasis, pinworms, Taenia saginata and ankylostomiasis in some localized areas. In 1971 and 1975, trial projects were carried out in Jabaliya and Dir-el-Balah to screen schoolchildren and to treat positive cases in order to eliminate the disease from endemic areas. In 1976, 2500 schoolchildren were examined for intestinal parasites; 50% were found positive, of which 9.5% showed ankylostoma. Positive cases were treated and a health education campaign was carried out. In 1979, a screening campaign found that of 411 schoolchildren, 62.3% showed intestinal parasites and 7.5% ankylostoma. In 1982, a study of 369 infants with diarrhea indicated a high prevalence of parasites (28.7%). Further studies are being carried out, with a view to establishing a screening and treatment programme.


ENVIRONMENTAL HEALTH SERVICES

Environmental Sanitation: Judaea and Samaria

The district public health offices are responsible for supervision of the local authorities for sanitation, water standards, garbage collection, disposal and assurance of health standards of the building code including town planning.

The government health service employs 45 sanitarians distributed throughout the seven district health offices. They are responsible for general sanitary supervision, drinking-water, trade and industry, and antimalarial prevention and surveillance, food control, approval of building plans, complaints and court actions. They are also active in visiting the villages with no on-site services to carry out immunization of children.

Water Control

Since 1967 over 60 villages were connected to central water supply systems, so that 90 of the largest villages in the region are provided with potable and safe running water to the communities and homes (Table 54). Major population centres including Hebron, Bethlehem, Beit Jallah and Beit Sahur completed major expansions in their water supply systems, involving a threefold increase in the total safe water supply. Nablus, Jenin, Tulkarem and Kalkilya increased their water supply systems with a twofold increase in volume. The increase in supply of public water was achieved by large-scale drilling of new groundwater sources.


Table 54: PUBLIC DRINKING-WATER CONSUMPTION
Judaea and Samaria
City

Hebron
Jericho
Bethlehem/Beit Jallah/Beit Sahur
Ramallah/El Bireh
Nablus
Tulkarem
Kalkilya
Salfit
Jenin
Toubas
Anabta
1967

12.5
13
20
12
15
20
15
8
30
10
13
1980

25-30
26
40
30
25
60-70
50
17
40
32
Source: Government Health Department, Judaea and Samaria.



Monitoring of water standards is carried out regularly by district sanitarians at permanent sampling sites within the water system. The sites were selected based on a plan to ensure maximal supervision of the regional water supplies. These include 70 piped water systems, 131 protected springs, 99 unprotected springs and over 36 thousand wells. Samples are sent for bacteriological examination to the central public health laboratories in Nablus and Ramallah, which have recently been re-equipped for this purpose. Special tests are sent to the public health laboratory in the Ministry of Health in Jerusalem. A preliminary survey was carried out during 1979 for basic fluoride levels in local water supplies in order to prepare for possible future fluoridation if needed to reach preventive levels for dental health of children.

Chlorination of drinking-water is practiced on a preventive basis. Re-equipping of chlorination facilities has improved the capability in those communities where chlorination previously was carried out and chlorination was established in other communities, including Jenin, Tubas, Kalkilya and Anabta. At present, in 90% of the villages where central drinking-water systems have been installed, routine chlorination is also practiced. Periodic chlorination of village wells is being planned and permanent chlorination will be extended in the larger villages.

In 1983, four additional villages with some 7500 population in Nablus and Ramallah districts have been connected to regional water supply systems and two villages in Jenin and Tulkarem districts were connected and began receiving water from the Israeli sources and began chlorination of the drinking-water.

Sewage

Sewage collection systems in most urban areas have been extended and re-equipped. Sewage treatment plants have been built in Jenin (1971), Tulkarem (1972) and Ramallah (1979), and stage one of Hebron's sewage treatment system was completed (1979). Master planning has been completed for El Bireh, Bethlehem/Beit Jallah/Beit Sahur, Kalkilya and Nablus. The dangerous and previously common practice of using untreated sewage for irrigation of vegetables has now been stopped.

Sanitary conditions in the 15 refugee camps in Judaea and Samaria are under the responsibility of UNRWA by longstanding agreement. Although there has been some improvement over the years, many sanitation problems remain. Inspection by government sanitarians requires prior approval by UNRWA's medical director in Jerusalem, so that effective supervision is very limited.

Solid garbage disposal has been altered drastically over the past: dozen years. The practice of refuse disposal along roadsides has been replaced largely by the establishment of municipal garbage disposal sites. Garbage collection in areas has been equipped and carried out by the municipalities on a modern basis in most cities in Judaea and Samaria. Most cities now have supervised municipal disposal sites.

Environmental Sanitation: Gaza

The Department of Sanitation operates through five office: Jabaliya, Gaza, Dir-el-Balah, Khan Yunis and Rafah. Most of the sanitarians attended a course in 1971, with two recently having taken a continuing education course in environmental health engineering. A veterinarian and public health physician also work in the unit. Periodic consultation and advice are provided from the public health office in Ashkelon.

Water Control

Since 1967, research surveys and hydrological measurements have indicated over-utilization of groundwater resulting in falling water-table levels and increased salination due to penetration of sea water inland. A systematic programme of water planning was established with limitations imposed on sinking of new wells and use of water for agricultural purposes. With the introduction of more efficient irrigation systems, widespread information about water usage and new water networks for residential areas, the water supply is improving and growing.

A series of new wells has been sunk near the town of Khan Yunis producing water of low salinity levels for the villages east of the town. Since 1979 a new water system has been in the process of implementation for the middle camps (Nuseiqot, Bureij and Magazi), as well as for the town of Dir-el-Balah. This new system replaces the UNRWA water system which had extremely high salinity levels.

Up until 1970, testing of drinking-water safety was sporadic. Since 1970, an orderly drinking-water testing programme has been carried out and in 1981 the Israeli standards were applied. The programme of regular testing of public water supplies is based on two Escherichia coli per 100 ml of water as an acceptable standard. If more than two E. coli per 100 ml are found, the water is re-tested and, if again more than two E. coli are found, the water source supplying the polluted pipelines is chlorinated for between five and 14 days.

In 1983, as a result of a policy decision, community water supplies will be routinely chlorinated on a continuous basis in order to prevent contamination within the water distribution systems. In most cities and for the majority of rural wells, drip chlorinators have been replaced by automatic chlorinators, so that most of the population is drinking chlorinated water.

Routine testing of water samples for coliform bacteria is carried out for all the deep underwater ground wells of the Gaza Strip. Routine testing of sewage by Moor swabs for Vibrio cholerae and other enteric bacteria was begun in 1981. In cooperation with the Israeli Department of Agriculture, and with equipment of UNDP, a programme for testing the level of dissolved chemicals in the drinking-water is being developed.

The natural fluoride content of drinking-water in the region is generally within the standard recommended for prevention of dental caries (1.0 part per million).

Solid Waste Collection and Disposal

In all urban areas public garbage collection containers (1000 liters) have been provided, with collection either by hand cart, horse cart, and increasingly by tractor cart, truck or modern tip truck. Gaza City, for example, operates 150 public garbage containers, 50 hand carts, 10 horse carts, one tractor cart, one bulldozer, one small truck, two modern tip trucks, three mobile automatic means and has 144 staff (as compared to 60, pre-1967) for garbage collection and disposal.

Although general awareness of public hygiene needs has been problematic, there has been a radical change in the past several years as a result of improved facilities, more efficient collection and cleaning, and generally improved awareness of public health and sanitation.

Additional dumping lots have been opened to accommodate local needs, in areas that will minimize contamination of groundwater. In several settlements, solid waste is being processed into compost for agricultural use.

Sewage Collection and Disposal

Before 1967, only part of the city of Gaza had a public sewage system (approximately 25 km in length) which serviced the old part of the city. All the rest of the area used various types of dry and wet wells, with and without septic tanks. The public sewage system serviced approximately half of the population of Gaza. Up until 1970, some local residents purposely blocked manholes in order to cause the raw sewage to spill into small agricultural plots of land dispersed throughout the city. Since 1970 this has been stopped and there has been constant vigilance to find offenders illegally using sewage water for agriculture.

In the last few years, the sewage system in Gaza has been enlarged and a new system encompassing approximately 47 km of piping, with two new oxidation ponds is in operation. Khan Yunis has a new central sewage collection system and a regional treatment system is in the first stages of implementation. Jabaliyeh's central sewage collection and treatment (oxidation pond) was opened in 1979. A sewage system is now under construction in Rafah, which will solve the problem of the sewage from the refugee camp which is at: present collecting inside the town itself.

A solution has been found for the disposal of the purified water by recycling it for irrigation of citrus groves (non-ground crops). Shati Refugee Camp's solution is complete canalization (i.e., underwater pipes) connected to the central sewage system of Gaza.

Dir-el-Balah is in the process of planning a public sewage system.

In order to ensure that workers are properly aware of their rights and social benefits, and of proper safety and hygiene precautions at the workplace, an intensive information campaign has become a regular part of the activities of the Ministry of Labor and Social Affairs in the Gaza area.

This campaign, now in its fifth year, is sponsored by the Ministry, with the cooperation of the Institute for Occupational Safety and Health and the National. Insurance Institute. The campaign is conducted in Arabic and is directed at factories employing area residents, especially those factories with a strong potential for work accidents and a high risk rating.

In each factory employing workers from Judaea, Samaria and Gaza, one of these workers is chosen to be the factory's safety representative. In larger workplaces there may be a safety committee. These people receive special training so that they may serve as a source of information on safety matters for their fellow workers, and monitor the employer's compliance with safety regulations.

Seminars for these safety representatives are provided to train and update them on safety precautions. In these seminars, the participants are provided with copies of booklets that explain the relevant laws and regulations as well as the rights and duties of the safety delegate in the workplace. They also receive instructions on the proper use of tools and safety equipment, permitted noise levels at workplaces, causes of work accidents, fire prevention and first aid. All this information is in Arabic. Pamphlets, leaflets, broadsides, booklets and posters are regularly published and distributed to workers at workplaces and on their way to and from work. They include updated information on safety and also explain social benefits - what they are and how to receive them - to the workers, explain the benefits of finding work through the employment bureaus and encourage workers to register.

A tetanus control programme has been initiated among workers registering for employment.

Malaria Control: Gaza

Gaza has been free of indigenous malaria cases since 1972. Antimalarial control activities are carried on both by the local city government and by the regional government. Emphasis has been placed on larvicidal spraying, although in emergencies when cases of imported malaria have been discovered, houses, bushes and the surrounding areas are sprayed for adult mosquitoes. Larval typing is performed routinely.

In 1979, vector control activity was increased because of the threat of Rift Valley fever entering the area.

Lead Poisoning in Judaea and Samaria

In late 1982 an outbreak of lead poisoning was detected in two villages near Nablus (Issawiya and Kabalan), from several index cases presenting severely ill and referred to Shaare Zedek Hospital, Jerusalem. A case, family and community-wide investigation has been undertaken by Israeli Ministry of Health and local health personnel with participation of Hebrew University and Shaare Zedek Hospital personnel.

Extensive epidemiological investigation was carried out demonstrating lead in high levels present in flour ground locally in traditional mills with lead parts, from wheat free of lead contamination. A survey of local flour mills was carried out and those found to have lead contamination potential were stopped from milling and alternative flour sources arranged. Physicians and the local population were alerted, and investigation continues into the actual lead source and the extent of the problem in other villages. As a result, contaminated mills were altered or stopped.

A large-scale sero-survey of pregnant women in affected areas and comparison villages was carried out showing little evidence of elevated blood-lead levels. Further follow-up studies of blood-lead levels are planned.

The Arjenyattah Epidemic in Judaea and Samaria

In 1983, during a two-week period in March-April, a large-scale epidemic consisting of 949 cases of an acute non-fatal illness consisting of headache, dizziness, blurred vision, abdominal pain, myalgia and fainting, occurred in three areas in Judaea and Samaria - Arrabeh, Jenin and Yattah. Of the 949 cases, 727 (77%) were among adolescent females. Physical examination and biochemical tests were normal. There were no findings of common exposure to food, water or agricultural chemicals. The epidemiological patterns were pathognomonic of a psychogenic disorder, with an initial trigger mechanism suspected to be the odor of H2S escaping from a faulty latrine in the school yard of the first affected school. No other environmental toxins were found.

Spread of the phenomenon was due to psychological factors including publicity by the mass media and through international agencies. Spread was stopped after temporary closure of schools in the area and the phenomenon has not reoccurred. Investigations carried out by local health services and the Israeli Ministry of Health were greatly assisted by visiting specialist teams from the Center for Disease Control, Atlanta*, and WHO.

____________
* Landrigan, P. J. & Miller, B. (1983) The Arjenyattah Epidemic: Home interview and toxicological aspects, Lance De 24/31 1474-1476.




Food Control: Judaea and Samaria

Supervision of food quality has focused on food production, food marketing and public eating establishments. Public health laboratories in Nablus and Ramallah are equipped for bacteriological examination; other tests are referred to the Medical Standards Laboratory of the Ministry of Health in Jerusalem. Sanitary standards in food production and marketing are. supervised routinely by district sanitarians. Use of food additives not complying with current standards has been stopped. Public health nuisances are investigated by district sanitarians based on complaints or routine observations. The public health laws provide for fines and nuisance abatement upon conviction in local courts. In 1983, 581 court cases were handled by local authority sanitarians and others, with 522 convictions.

Food Control: Gaza

Food control activities of the public health division of the Gaza health service focus on improving standards of the food industry and hygienic conditions of the community. Although some industries have operated on high standards, most have been working at a minimum or below minimum standard. Recently, much progress has been made in the food industry, particularly through government insistence on the use of refrigerators in meat shops, running hot water in restaurants, general improvement in public buildings and cleanliness.

All food and drink product factories are licensed by the health department and monitored by sanitarians on a periodic basis. There is continual control on standards of bacterial and chemical content of food products, and control of the use of food colors and additives. Table 55 outlines the gradual increase in the number of large food processing and marketing businesses and their control by the Department of Health in Gaza.



Table 55: FOOD INDUSTRY FOOD TESTS AND COURT CASES, Gaza, 1973 to 1983
No. of
No. of
large food
No. of
large
Laboratory tests
licensed
businesses
processing
plants
marketing
businesses
Bact.
Chem.
Total
Court
cases
1973
1975
1977
1979
1980
1981
1982
1983
1 100
1 260
1 440
1 594
1 670
1 695
1 829
5 169
50
54
59
67
70
75
79
89
950
1 206
1 381
1 527
1 600
1 620
1 750
2 068
800
1 160
900
1 100
1 900
1 751
1 350
2 962
233
900
700
1 023
700
600
400
350
1 033
2 010
1 606
2 123
2 600
2 351
1 750
3 112
641
432
422
451
63
86
83
95



Slaughterhouses: Judaea and Samaria

A survey of slaughterhouses was carried out in 1981. As a result, it has been decided to foster the development of regional slaughterhouses operated by local authorities. The Nablus and Tulkarem municipal slaughterhouses were built and function to high standards. The Ramallah municipal slaughterhouse was completed and opened in 1983.

New units are planned in El Bireh and Bethlehem. Repairs are being carried out on slaughterhouses in Hebron and Jericho. Each local authority has refrigerated trucks operating at good standards for transport of meat.

Slaughterhouses: Gaza

New slaughterhouses were established in 1978 by the municipalities (Jabaliyeh and Khan Yunis) and a third in 1983 (Dir-el-Balah); three others were renovated to increase capacity and to institute modern equipment. The latter are also municipally operated and supervised by the public health service.

All imported foods are tested bacteriologically and chemically before release for sale to the public. The public health department veterinarian (with a Master of Public Health degree) works in close cooperation with the veterinary service of the Ministry of Agriculture.

During 1982-1983, a campaign has been carried out to register all food handling businesses, large and small, resulting in a large increase in registered and supervised licensed business.

Drug Control in Judaea and Samaria

Drugs produced in a number of local pharmaceutical manufacturing plants are now tested according to Israeli standards at the Ministry of Health Standards Laboratory and successfully comply with these standards. Their products are used by the government health services. There are now seven local manufacturers whose products are acceptable for purchase for use in government health services.

Road Safety: Judaea, Samaria, Gaza

Road safety as a public health issue has become significant with the rapid increase in mechanization of transportation. Despite large increases in road vehicles, fatalities have decreased in absolute terms as well as in relation to the number of vehicles per 10 000 population (Tables 56 and 57). This is an encouraging development in coping with the problems of modernization in a developing society. It is probably related to improved roads, better driver examinations, improved pedestrian facilities and driving law enforcement.

The government health service Road Safety Institute carries out a systematic programme of medical examination of commercial drivers and of drivers requiring medical supervision for health reasons.



Table 56: VEHICLES, ACCIDENTS AND KILLED, PER 10 000 POPULATION
AND PER 10 000 VEHICLES, Gaza Area, 1978 to 1983

Year
Total
vehicles
(000s)
Vehicles
per 10 000
population
Fatalities
Fatalities
per 10 000
population
Total
accidents
Accidents
per 10 000
vehicles
Fatalities
per 10 000
vehicles
1978
1979
1980
1981
1982
1983
11.0
11.8
17.7
20.4
23.4
28.7
226
266
388
435
491
581
77
93
63
63
47
59
1.7
2.1
1.4
1.3
1.0
1.2
-
-
580
524
445
372
549
442
328
256
190
130
74
79
46
42
28
21



Table 57. VEHICLES, ACCIDENTS AND PERSONS KILLED IN ROAD CRASHES
Judaea and Samaria, 1978 to 1983

Year
Total
vehicles
(000s)
Vehicles
per 10 000
population
Fatalities
Fatalities
per 10 000
population
Total
accidents
Accidents
per 10 000
vehicles
Fatalities
per 10 000
vehicles
1978
1979
1980
1981
1982
1983
17.8
21.1
24.3
27.7
32.2
38.6
384
474
532
590
676
503
97
77
50
98
80
74
2.1
1.7
1.1
2.1
1.7
1.0
-
-
800
821
681
608
452
362
329
296
211
150
54
36
21
35
25
19

Source: Statistical Abstracts of Israel 1984, derived from Tables 27/34, 27/38 and 27/1.



INTERNATIONAL ASSISTANCE IN GAZA

Consultations with WHO experts, including Professor J. L. Melnick, on polio and Dr Robert Cook, WHO regional adviser on MCH and nutrition, Dr D. Barua, special consultant on the WHO oral rehydration systems, Dr T. W. Harding on mental health services, Dr Pisa on cardiovascular diseases, and Dr K. Styblo on tuberculosis have been extremely helpful in outlining progress to date and on recommending programme improvements. The recommendations made by Professor J. Melnick have been implemented with marked success; many of the recommendations made by Dr Cook have also been implemented - including the polio programme, measles immunization, Mantoux testing and BCG, oral rehydration, improved follow-up for infant birth and death reporting, and measures to increase maternal care. The oral rehydration programme being implemented is in keeping with the programme outlined by Dr Cook and Dr Barua. Dr Harding's recommendations have been helpful in developing mental health services.

Assistance from international agencies has totaled about $ 750 000 for equipment, purchase, fellowships and training programmes. UNDP funds have furnished a trauma surgical theatre, orthopedic equipment, a mobile X-ray unit with an image intensifier, an intensive care postoperative reanimation unit, a high-speed centrifuge, an auto-analyzer, a neonatology intensive care unit, a fiber colonoscope, two haemodialysis units for Khan Yunis Hospital, and a 10-channel EEG. Seventeen medical and paramedical fellowships have been approved and two physicians have already started their training, one in public health in London and one in neonatology in Chicago. Twenty physicians will participate in a one-year course for either basic or specialist training, particularly in anesthesiology, in Gaza. The Israeli Government is providing these 20 positions. Five local pediatricians were sent to Vienna for a year of postgraduate studies in mid-1982, funded by the government health service.

UNICEF has provided $ 25 000 for equipment, including a fibro-gastroscope, operating laryngoscope, thrombocounter and teaching equipment (1981).

WHO funded a two-week course in Alexandria, Egypt for 10 Gaza physicians to learn ORS techniques. In addition, a six-month neonatology specialty training course in London was month travelling psychiatric fellowships. "Friends of funded in 1981, as well as two three the Patients" Society was founded in 1981, whose object is to provide extra-budgetary funds for the purchase of sophisticated medical equipment.

HEALTH INSURANCE

Health insurance for employees (and their families) of the administration was established in 1973, and for Judaea and Samaria residents working in Israel. This plan provides comprehensive medical, hospital and prescription drug coverage, including inpatient, outpatient, referral services, laboratory tests and radiologic services. In February 1978, the health insurance plan was extended to open enrolment of family groups for all residents on a voluntary basis.

Insurance premiums for the health plan in 1982 were $ 9.10 (US) for government workers (and their families) and $ 11.30 per month for others. This includes coverage for the family regardless of the number of dependants (to age 18 and elderly parents). These rates are well below comparable insurance costs in Israel. Benefits are comprehensive including hospital and specialist care in local and Israeli hospitals.

In 1984, 298 887 persons (66.3 thousand family units) or 37.4% of the population of Judaea and Samaria were insured in this health plan. The insurance programme has led to an increase in hospital utilization, with increased hospital bed occupancy rates, and rise in hospital days of care per thousand population. It has also increased utilization of ambulatory care services.

Up to May 1981, 36 thousand persons in Gaza (65 thousand family units - an increase from 59 thousand in 1979), were enrolled constituting 83% of the population of the region (an increase from-77% in 1979). The 1982 coverage is 80% of the regional population. The insurance covers primary care government health services, local and referred hospital care including all specialized services not available locally, such as radiotherapy and neurosurgery. Preventive and child-care (up to six years) services and treatment for cancer are free to all.

The health insurance plan is considered to be very important to future development of health services in Judaea and Samaria and Gaza by providing health care on a prepaid basis with participation on a voluntary basis. Further expansion of the plan will occur as the population acceptance increases through greater awareness of the advantages of a prepaid system.

MANPOWER AND TRAINING IN JUDAEA AND SAMARIA

Staffing

Staffing of governmental health services has increased over the years as indicated in Table 58 indicating an overall growth from May 1967 to 1983 by approximately 67.4%. Medical, nursing and paramedical staffing in particular has more than doubled during this period of time.

The increase in health manpower as compared with both the pre-1967 and immediate post-1967 war months was dramatic. Medical staffing rose by approximately 80% since early 1967 and by over 210% since the immediate post-war period. Similarly, large increases in nursing personnel and technical and paramedical staff have occurred during the 1967-78 period, as part of the increased level of service in hospitals of the area.

The new physicians are all local residents who undertook training in many countries including those of Western Europe, America and Eastern Europe as well as the Arab countries. In the past four years more than thirty new physicians joined the service, of which thirteen joined in 1979 alone. Table 59 lists the range of specialties among doctors employed in government health services in Judaea and Samaria. Of all government service physicians, 74 are specialists recognized on the basis of qualifications achieved through training abroad. Recently, specialist services in such fields as pathology, neurology, ear, nose and throat and others have become established as part of the government health programme thereby enriching the programme and Allowing for extension of the range of services available locally. Specialty and post-specialty training for physicians has been a very important factor in development of the service.

Training programmes and short courses in Israeli hospitals and abroad have taken place in many of the specialty fields listed in Table 59.

______________
* El Sarraj, E. R., op. cit.



Table 58: PERSONNEL IN GOVERNMENT HEALTH SERVICE
Judaea and Samaria, 1967-1984

Personnel
May
1967
1974
1978
1980
1982
1983
1984 staff per 10 000 population
Physicians
Nurses (registered and
practical)
Technical and paramedical
Administrative and
support service

TOTAL
97

241
66

508

912
119

308
147

493

1 067
157

599
176

438

1 270
174

620
169

440

1 403
186

655.5
168.5

417

1 427
210.5

671.5
201

450

1 533
2.6

8.4
3.5

5.6

19.2

Source: Government Health Service, Judaea and Samaria.



Table 59: MEDICAL SPECIALISTS IN GOVERNMENT HEALTH SERVICES
Judaea and Samaria, 1984
Specialities
Hospital services
Public services
Total
Orthopedic surgeons
General surgery
Anesthesiology
Paediatrics
Public health
Internists
Cardiology
Chest disease
Cardiovascular surgery
Pediatric surgery
Urology
Endocrinology
Obstetrics and gynaecology
Dermatologist
Allergologist
Ear, nose and throat
Ophthalmology
Psychiatrists
Radiologists

Total specialists2
Total physicians3
3.5
14
2
10
-
10
2
-
1
1
2
0
13.5
1
1
4.5
1.5
4


72
-
1
-
-
3
2
1
-
2
-
-
-
-
1
0.5
-
-
-
-
-

10.5
-
4.5
14
2
13
2
11
2
2
1
1
2
0
14.5
1.5
1
4.5
1.5
4
1

82.5
210.5
Note:1.


2.


3.
Specialists are physicians with recognized specialty training of two or more years and a diploma.

Includes specialists employed both in hospital services and community health services.

Includes specialists and other government health service physicians.
Source:Government Health Service, Judaea and Samaria, Statistics Department.



Nursing staff problems have been very important in the government health services in the region and required the development of a nursing school for registered nurses in Ramallah (opened in 1971) as well as schools for practical nurses and midwives (see Table 60). Most of the nurses added to the government health staff have come from these training programmes. The main government programmes now for nurses are the schools for registered nurses in Ramallah, for midwives in Nablus and for practical nurses in Nablus. In the non-government sector of health services nursing education has also been expanded, including a university level programme.

In 1983 a new Psychiatric Practical Nurse training programme commenced in the Bethlehem Mental Hospital. The course is based upon the curriculum of the Israeli psychiatric practical nurse training. Twenty students include new entries and present hospital staff seeking professional advancement.

Paramedical staff, nearly doubled in number, have come primarily from schools established in the area over the past 16 years. In spite of the loss of trained health care personnel to employment to the oil states, staffing patterns are maintained.

The emphasis at the new School for Registered Nurses in Gaza is on community health, providing a centre of important new sources for manpower orientation to community health needs. These include MCH, primary school, elderly, chronic and mental health care. Recently, nursing administration and teaching methods were added to the programme. All nursing education programmes are under the supervision of the Nursing Division of the Israeli Ministry of Health.

Training for practical nurses began in 1971 in conjunction with a. public health training programme. After these students graduated, an additional 6-month course in anesthetics was offered. In 1973, two waves of students yearly (two classes each of males and females), were enrolled as part of the effort to fill the vacancies in the practical nursing staffs of hospitals, clinics and health centres. Local staff are responsible for the training programmes. Nearly 400 students have graduated from this 18-month course.

Special courses have been conducted in Israeli hospitals in medical records (Ashkelon, 12 graduated from a 1-month course in 1978). In administration courses conducted in various Israeli hospitals, 17 Gazans graduated from a 6-month course in 1979; 13 storekeepers graduated from a 6-month course in 1979, and for health educators (Ashkelon Hospital), 13 people graduated from a 3-month course in 1979. Special training for nursing instructors has been carried out in 1976, 1978 and 1980, with a total of 24 graduates. Physicians in medical administration have completed 6 months of in-service education at Hadassah University Hospital in Jerusalem, with 18 graduating. Physicians in various specialties of medicine have been trained in Israel and abroad with WHO fellowships, and more recently, with UNDP assistance.

Table 63 lists the specialties of local physicians employed in government health services in Gaza. Most specialists received their specialty training in Egypt and hold Egyptian specialty certification. Approximately one-third of the physicians in government health service are recognized specialists in the various fields. A local certification programme for specialists is in the planning stages, including postgraduate training in the area.

The manpower training programmes have prepared large numbers of health workers for local services. However, some have gone to work in Saudi Arabia and the Gulf States, where Gaza health personnel are highly sought after. In spite of this, filling staff positions with trained personnel is accomplished.

Health manpower employed in the government health service in nursing has increased by 144%, in medical staff by 149% and in paramedical staff by 155% over that of May 1967 (Table 62). The increase in health manpower is even more striking if' the change is taken from the situation immediately following the 1967 War when many Egyptian medical and other staff left the area.


Publications and Presentations

Lasch, E. E., Abed, Y., Abdulla, R., El Tibbi, A. G., Marcus, 0., El Masri, M., Hendscher, R., Gerichter, C. B. & Melnick, J. L. (1984). Successful results of a programme combining live and inactivated polio virus vaccines to control poliomyelitis in Gaza. Reviews of Infectious Diseases, 6, 2, 5 467-470

Lasch, E. E., Abed, Y., Gerichter, C. B., Masri, M., Marcus, 0., Henscher R. & Goldblum N. (1983). Results of a programme successfully combining live and killed polio vaccines. Israel Journal of Medical Sciences, 19, 1021-1023

Lasch, E. E., Abed, Y., Marcus, 0., Shbeir, M., El Alem, A. & Hassan, N. A. Cholera in Gaza in 1981: epidemiological characteristics of an outbreak (1984). Transactions of the Royal Society of Tropical Medicine and Hygiene, 78, 554-557

International Congress of World Federation of Public Health Associations, Tel Aviv, Israel, February 19-24, 1984

El Sarraj, E. R. & Lasch, E. E. (1984). Integration of mental health services and the community in Gaza. Presentation at the Fourth International Congress of World Federation of Public Health Associations, Tel Aviv, Israel, February 19-24, 1984

Lasch, E. E., Abed, Y., Geuchter, C. B., Masri, M. E. I., Marcus, 0., Henscher, R. & Goldblum, N. (1983). Results of a programme successfully combining live and killed polio vaccines. Israel Journal of Medical Sciences, 19, 995-997

Recent academic presentations include:

Abed, Y., Lasch, E. E., Hassan, N. A. & Goldberg, J. (1984). Community and local involvement in the control of infectious diseases. Presentation at the Fourth International Congress of World Federation of Public Health Associations, Tel Aviv, Israel, February 19-24, 1984

* * *




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