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Source: World Health Organization (WHO)
28 April 1983



WORLD HEALTH ORGANIZATION

THIRTY-SIXTH WORLD HEALTH ASSEMBLY

Provisional agenda item 32


HEALTH CONDITIONS OF THE ARAB POPULATION IN THE OCCUPIED
ARAB TERRITORIES, INCLUDING PALESTINE

Report of the Special Committee of Experts appointed to study
the health conditions of the inhabitants of the occupied territories

CONTENTS
PAGES
1. INTRODUCTION

1.1 Historical background
1.2 The context
1.3 Persons providing information during the visit
1.4 Places visited
1.5 Methodology followed

2. HEALTH POLICY
2.1 Political commitment
2.2 Health system
2.3 Planning
2.4 Health budget
2.5 Involvement of the population

3. ANALYSIS OF THE SOCIOECONOMIC SITUATION

3.1 Demographic data
3.2 Distribution of incomes and standard of living

4. ANALYSIS OF THE HEALTH SITUATION
4.1 Epidemiological situation
4.2 Health infrastructure
4.3 Health activities undertaken (delivery of services)
4.4 Aspects of the health status of the population

5. RECOMMENDATIONS

6. CONCLUSIONS
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1. INTRODUCTION

1.1 Historical background

On 14 May 1982 the Thirty-fifth World Health Assembly adopted resolution WHA35.15 requesting the Special Committee of Experts "to continue its task with respect to all the implications of occupation and the policies of the occupying Israeli authorities and their various practices which adversely affect the health conditions of the Arab inhabitants in the occupied Arab territories, including Palestine, and to report to the Thirty-sixth World Health Assembly, bearing in mind all the provisions of this resolution, in coordination with the Arab States concerned and the Palestine Liberation Organization".

The Committee consisted this year of Dr Traian Ionescu (Romania), who was chosen as Chairman for 1983, Dr Soejoga (Indonesia) and Dr Madiou Toure (Senegal).

On 19 January 1983 a meeting was held in Geneva between the Israeli authorities and a 'representative of the Committee. The purpose of this meeting was to discuss the arrangements for the visit, the spirit in which it would be conducted, the theme of the visit, the methodology to be followed and to determine the territories to be visited.

Moreover, in accordance with resolution WHA35.15, the Committee contacted the Governments of Jordan, Lebanon and the Syrian Arab Republic and the Palestine Liberation Organization, requesting them to supply full written documentation and to make any pertinent suggestions concerning the visit to the territories. Before leaving, the Committee met the Permanent Representatives of Jordan and the Syrian Arab Republic in Geneva. It then went to Amman and Damascus, where it had talks with the competent authorities concerning the health of the Arab populations in the occupied territories and was given various information.

The visit to the occupied territories took place from 6 to 14 April 1983.

The Committee visited the Gaza Strip and the West Bank. This year the Committee once again formally requested the Israeli authorities to enable it to visit the Golan Heights. The Israeli Government granted this authorization -on the express condition that the Committee take note of the reservation put forward by the Government, which was expressed in the following terms: "The WHO mission is meant to collect material for a report on health in the administered areas. It is the position of the Government of Israel that the Golan, to which Israel law, jurisdiction and administration have been applied, is not now such an area. In view of this consideration, approval for a visit of the WHO mission to the Golan is given as a gesture of goodwill without prejudice. The decision to facilitate the visit shall not serve as a precedent and does not contravene the Israel-Government's position.

1.2 The context

The visit by the Committee took place within an unusual atmosphere on account of three major occurrences in the region, which had a marked influence on the health of the Arab inhabitants. One was the recent events in Lebanon, which deeply affected the inhabitants of the region on account of the links between the various populations. Another concerned the settlement policy followed by the Israeli authorities on the West Bank, which was deeply resented by the Arab population. Finally there was the phenomenon that occurred in the girls' schools on the West Bank, interpreted in different ways by different People.

In such a context it will readily be understood that the task of the Committee was not easy.

1.3. Persons providing information during the visit

1.3.1 Israeli authorities

- The Director-General of Health and his staff.

- The directors of health of the occupied territories.

- The civil administrators responsible for administering the occupied territories.

- The directors and medical officers of Gaza and Nablus prisons.

- A hospital architect and sanitary engineers.

1.3.2 Local sources

- The directors of health of the districts visited.

- The directors of the hospitals and institutions visited.

- The Arab doctors and health personnel working in the hospitals, health centers and clinics.

- Patients met in health units.

- Local doctors.

- Mayors and officials of some localities in the West Bank.

- The representative of the International Committee of the Red Cross.

- The directors and doctors of UNRWA responsible for the occupied territories.

1.4 Places visited (in chronological order)

El Bireh clinic and MCH center
Ibn-Sina Nursing School
Jenin Hospital
Jericho Hospital
Health Center at Aqbat Jaber refugee camp
Azariya health center
Terre des Hommes (Bethlehem)
Bethlehem Psychiatric Hospital
Beit-Jallah Hospital
Hebron Hospital
Kiryat Shmona health center
Rajah clinic and MCH center
Rajah waste water disposal system
Masada clinic and MCH center
Majdal shams clinic and MCH center
Gaza prison
Gaza Pediatric Hospital
Sheefa Hospital
Clinic at Rafah refugee camp
Site of new clinic at Tel Sultan
Zawayda clinic
Waste water disposal system of the Middle Camps (Nuseirat, Beireij, Deir El Ballach an Maghazi)
Sheikh Jarrach health center (Jerusalem)
Nablus public health office and tuberculosis center
Nablus prison
Assira Shamalia clinic and MCH center
Tulkarem Hospital

1.5 Methodology followed

In order to follow the health development process in the occupied territories and to measure any progress achieved in applying the strategy and evaluating its efficacy, the Committee adopted the methodology prepared by WHO in the document entitled "Development of indicators for monitoring progress towards health for all by the year 2000".1/

By doing this the Committee could be sure of placing health problems within the general context of socioeconomic development, from which they are inseparable, and thus meeting the requirement of the definition of health: "a state of complete physical, mental and social well-being".

On the basis of the foregoing the Committee will consider health policies, the socioeconomic situation and aspects concerning the health status of the population. It will conclude by making recommendations for improving the services. Finally, conclusions will be drawn on the situation prevailing in the occupied territories at the end of the fifth visit by the Committee.

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1/ Development of indicators for monitoring progress towards health for all by the year 2000, Geneva, World Health Organization, 1981 ("Health for All" Series No.4)



2. HEALTH POLICY

2.1 Political commitment

Health policy is a, continuum, "an expression of goals for improving the health situation, the priorities among those goals, and the main directions for attaining them" (Formulating strategies for health for all by the year 2000, 1/ paragraph 17).

"Each country will have to develop its health policies as part of overall socioeconomic development policies and in the light of its own problems and possibilities, particular circumstances, social and economic structure and political and administrative mechanisms. Whatever the process, each country has to specify its health goals and priorities following the identification and careful analysis of its health problems and socioeconomic capacity to deal with them. In the light of this analysis it will be able to indicate the main directions for attaining these health goals" (paragraph 20).

Political commitment is unquestionably the basis for any governmental will to bring about health for all. "The first stages in the establishment of political commitment ...are largely qualitative ...The process can be considered under five aspects: declaration of high-level commitment; allocation of financial resources; degree of equity of distribution; degree of community involvement; and the establishment of a suitable organizational framework and managerial process." (Development of indicators for monitoring progress towards health for all by the year 2000, paragraph 35.)

In the occupied territories, the definition of the health policy and the political commitment essential for achieving health for all are not within the hands of the local authorities. Although there is a policy for health protection, expressed by a certain number of health objectives which need to be tackled and attained, it is not possible in the light of the prevalent situation to speak of a genuine political commitment in the sense recommended above, as will be seen later.

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1/ Formulating strategies for health for all by the year 2000, Geneva, World Health Organization, 1979 ("Health for All" Series, No. 2).



2.2 Health system

As the Committee indicated in earlier reports, particularly document A34/17, the health system in the occupied territories has remained unchanged.

Integration of the Golan into the Israeli health system is being consolidated, whereas on the West Bank this is not happening in the same way. Since the standard of medical assistance is not comparable to that in the Israeli hospitals, those of the local population who can afford to do so often use the services of the Israeli hospitals. However, it will not be surprising if in the long run the Israeli system is applied in full on the West Bank.

2.3 Planning

2.3.1 In its previous report (document A35/l6, paragraph 3.3), the Committee noted the absence of medium- and long-term planning. It at that time recommended promoting the application of health programming as an instrument for the planning and management of health development, by integrating the appropriate health components in the socioeconomic development plans of the occupied territories, with the effective involvement of Arab physicians. A concrete proposal was made: the organization of a seminar on the planning and management of health services.

On the West Bank the situation has not changed.

In Gaza an attempt at planning has been under way since 1982; from time to time the responsible health authorities and the administrative authorities meet within two committees. The Academic Council has general responsibility for defining an appropriate training policy, and the Management Board deals with problems of health administration. This is a first step towards planning and decision-making. The great drawback, however, is the lack of documentation concerning this planning.

During the discussions with the Gaza authorities, WHO was urgently requested to assist in the formulation of health strategies for putting into effect the policies of health for all, i.e. "careful analysis, of ... health problems ... with a view to arriving at solutions that are socially and economically feasible. These solutions can be summed up as the selection and subsequent formulation of health programs that use appropriate technology ... Each countrywide program should include specific objectives and related targets, quantified, if possible, as well as
the manpower, technology,, physical facilities, equipment and supplies required, means of evaluation, and financial estimates, a calendar of action, and ways of ensuring appropriate correlation among all the above." (Managerial process for national health development: Guiding principles, 1/ paragraphs 25 and 26.)


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1/ Managerial process for national health development: Guiding principles, Geneva, World Health Organization, l981 (“Health for All” Series, No. 5).


2.3.2 "Manpower considerations are among the most important elements in the planning of a health development strategy. During broad programming, manpower planning needs to be considered in relation to the development and implementation of feasible priority programs. Projections of manpower requirements covering the program period should be made, taking into account both the expected losses of personnel and the expected increases resulting from existing training programs. Decisions have to be taken with respect to staff recruitment, training, salaries, housing and career development ..." (ibid., paragraph 30).

In the occupied territories there is no manpower plan, particularly for physicians. Many of those who graduate can find no employment in the public health system and are at present out of work, and some of them are forced to take other jobs.

The modest level of salaries for local doctors, particularly the young ones, provides no motivation.

The recent steps taken by the Israeli authorities concerning the formalities for recruitment are not likely to act in favor of the employment of local physicians.

2.4 Health budget

2.4.1 If a strategy is to be viable it is essential to make resources available for the priority activities at the proper time and place. While it must be recognized that national budgetary resources are limited and cannot be stretched at will, it is necessary to submit documentary proposals justifying the proportion of resources to be allocated to the health sector. The United Nations recommends 9-10% of the national budget.

In the occupied territories the Committee was unable to find out what proportion of the budget has been assigned to the health sector or to other sectors that contribute to health promotion, in particular some social services or services concerned with sanitation, drinking-water supplies and food.

2.4.2 The budget allocated to health is centralized and administered by the occupation authorities, with the exclusion of Arab health officials such as medical directors of hospitals, program directors and the director of health.

The distribution of the budget by area of activity in Gaza is not known. The local officials express needs discussed at district level, and these needs are generally met.

On the West Bank 55% of the health budget is claimed to be allocated to services and 45% to staff salaries. Of the activities quota, 70% is allocated to hospitals, 28% to public health, and 2% to training.

2.4.3 The absence of program budgeting is connected with the inadequacy or lack of overall programming in the occupied territories.

2.4.4 The inadequacy of the health budget in the occupied territories could be partly offset by voluntary contributions from local associations, benefactors and donors; however, the procedures for the acceptance of such contributions by the Israeli authorities, particularly the stipulation that 30% of the donation must be allocated to general development, are not likely to encourage goodwill. Nevertheless, there have been some considerable achievements as a result of these donations: extensions to the Beit-Jallah Hospital (West Bank), part of the construction of the Sheefa Hospital (Gaza).

The Council of Ministers of Health of Arab States is reported to have substantial funds that it is willing to invest in the occupied territories provided that these funds are used directly for improving local services for the welfare of the Arab populations. it is possible that relevant programming, through the good offices of WHO, would enable this money to be mobilized.

UNDP makes a substantial contribution to the strengthening of health services (equipment, training grants).

Local physicians expressed deep regret at the absence of WHO from this field of cooperation and at the discontinuation of the UNICEF programs.

2.4.5 Problems associated with the health budget

A very large number of physicians with whom-the Committee talked stressed the problems connected with the health budget and technological progress. However, it is not appropriate to regard health as dependent solely on technological progress and on the budget allocated to it. The contribution of modern technology to the progress of medicine is by no means negligible, but those who still see health progress only in terms of technological progress are making a big mistake. It should be borne in mind that health depends not only on physicians but also on eating habits, use of toxic substances, life style, culture and the environment.

2.5 Involvement of the population

Involvement of the public and of medical staff in the planning, management and organization of services and in the preparation and implementation of the budget is very limited or even non-existent. Because of the political situation and the fact of occupation according to the medical director of a large hospital in the occupied territories every action or gesture has a political connotation, and this does not permit adequate involvement of the population in the management of its own health.

The Committee holds the view, already stated in previous reports, that the aware and free involvement of a population in efforts to build up a society is possible only under conditions which, it has to be acknowledged, are not present in the territories concerned.

3. ANALYSIS OF THE SOCIOECONOMIC SITUATION

Health development is both a determinant and a result of economic and social development. Consequently every health policy must form part of the overall development policy and reflect the socioeconomic objectives. It goes without saying that health and the economy are inter-linked.

As in the previous report the Committee felt it advisable to assess the socioeconomic situation before considering the health situation.

The basic data concerning the socioeconomic situation are obtained from sources with different and even contradictory viewpoints, which makes them difficult to interpret. For this reason some of them will be quoted verbatim. They are based on demographic, economic and social data such as the distribution of income per capita and the problems associated with the health budget and technological progress.

3.1 Demographic data

In the occupied territories, according to the official data, the indicators for fertility and birth rate are some of the highest among the statistical data published by the United Nations for different parts of the world. On the other hand, the indicator for general mortality seems very low by comparison. As a result of the fall in general mortality and the maintenance of fertility and birth rate at constant levels, natural growth according to the Israeli authorities averages 39.8 per 1000, which in the absence of migration abroad would correspond to a mean population growth rate of 3.9%.

Analysis of the data available to the Committee shows that there are still some inadequacies in recording and in the data on population structure. It is consequently trot possible to determine the true death rate, since corrected data cannot be arrived at and it is only on the basis of corrected data that the true rate can be determined. Moreover, there are some discrepancies between the population structure expressed by the proportion of individuals under 15 years of age and the proportion over 55 years of age; these discrepancies are connected with the very low figures for general and infant mortality. At the same time, according to the same data, the increase in the population living in the territories was lower by a factor of 2.5 than the mean annual rate of population increase during the same period (1968-1971). This last aspect raises the problem of the reliability of the date used for calculating the population and the reliability of the population records; the problem of emigration from the occupied territories on account of the occupation conditions remains open.

Whatever the existing inadequacies, already mentioned in earlier reports of the Committee, the available data indicate that of all the demographic processes which have determined the dynamics and size of the population in the occupied territories, the principal role has been played by the birth rate.

In view of the fact that, when the figures are adjusted, the death rate stabilizes at 10 deaths per 1000 inhabitants or slightly higher, the rate of population increase in the occupied territories will in future depend primarily on the movement in birth rate.

However, the Committee wonders whether the phenomena currently observed in the occupied territories may not be likely in the medium term to modify the natural demographic trend observed by the Committee.

3.2 Distribution of incomes and standard of living

The distribution of per capita income, and in particular the gross national product per capita, is around US$ 1200 according to the official sources.

Similarly, the official data on the mobility and utilization of the work-force indicate that 99% of the available manpower is in employment. 33.52 of the total Arab work-force available in the territories are employed in Israel.

The official data also show an increase in the construction of dwellings and a food ration that provides a total of 2500 calories per head.

No essential changes have taken place by comparison with previous years, and particularly the information given in document
A34/17.

Nevertheless, the Committee stresses that it obtained information from other sources which it was unable to check, a reservation that also applies to the official data. Essentially, the developments which have made the social and economic situation of the Arab population in the occupied territories more difficult are as follows; the devaluation of the Israeli currency; the lower salaries paid to Arab workers; the construction of many settlements, where arable land has been taken away from the Arab population; the failure to solve the problem of the utilization of water resources, which at present works to the disadvantage of the local population, and the lack of housing; the large number of refugees still living in the urban areas in the Gaza region, even though the sanitation problems have not been solved and they have no access to the expensive new housing projects; the fact that 36% of dwellings on the West Bank do not yet have sanitary toilets, 36% have no kitchens and about 40% are not linked to the mains electricity supply.

In addition to these various aspects there are a number of other tension factors, stressed on many occasions and frequently mentioned in the press, which have unfavourable repercussions on the health of the population concerned.

4. ANALYSIS OF THE HEALTH SITUATION

4.1 Epidemiological situation

4.1.1 Communicable and parasitic diseases

Communicable disease control is carried out by means of epidemiological surveillance.

Attention has been paid to the surveillance of malaria, cholera, leisbmaniasis, tuberculosis, diphtheria, gastroenteritis and Rift Valley fever. No new aspects have appeared by comparison with the detailed data on these diseases given in report A35/16 by the Committee.

Most of the diseases covered by the expanded program on immunization are decreasing, except for measles which still fluctuates. A study undertaken in Gaza shows that 1859 cases were recorded during the epidemic between October 1981 and March 1982. 61.3% of the cases had not been vaccinated, and the case fatality rate was 3.7%. Although the vaccination coverage recorded was over 90%, the disease is on the increase. A vaccination failure might be responsible for this. When the Committee visited an MCH clinic in the Golan Heights it saw that the vaccine was placed in a cold box. Unfortunately there was no ice in the cold box, so that the temperature inside was not suitable for storage of the vaccine. Viral hepatitis was continuously present, with fluctuations, in Gaza and the West Bank from 1967 to 1983. This disease should be kept under continuous a surveillance and epidemiological studies should be carried out to obtain more detailed information on the pattern of this disease so that appropriate preventive measures can be taken.

From the methodological viewpoint the epidemiological surveillance of the various diseases reveals some inadequacies, because it is approached only in a partial manner, except in the case of poliomyelitis.

The proper way to carry out surveillance is to ensure that case recording and bacteriological or serological tests constantly complement each other in the everyday practice of the health services, but this is not the case for all the communicable diseases included in the epidemiological surveillance plans.

4.1.2 Chronic diseases

These diseases are the most frequent cause of consultations by adults.

The health authorities have paid attention to the problems concerning the recording and management of cancer cases, and progress has been made in recent years.

Similar progress has been noted in the recording of some other chronic diseases, such as cardiovascular, kidney and liver diseases.

Unfortunately it cannot be stated that the problem regarding the treatment of some of these diseases, and the problem of hospitalization in the occupied territories or in Israel, have been solved to the same extent.

The inability to treat certain specialist cases in the hospitals of the territories leads to professional dissatisfaction among the Palestinian doctors and to discontent among the population.

As regards mental diseases, there are still no statistics on incidence and prevalence. However, in view of the degree of stress experienced, it seems possible that mental disorders have increased to an appreciable extent.

In view of its importance this problem deserves special study, with a view to WHO setting up a pilot zone for research on the West Bank and in Gaza, in collaboration with local psychiatrists. This matter was already raised in the last report of the Committee, and the mental health authorities are keenly interested in the creation of such a zone.


4.1.3 Other specific diseases

In 1982-1983 the occupied territories experienced some epidemics.

4.1.3.1 Gastroenteritis

In 1982 a short-lived outbreak of gastroenteritis due to Clostridium welchii occurred in Gaza Prison; 200 cases were recorded, but no deaths. It was blamed on chicken offal.

4.1.3.2 Lead poisoning

In February 1983.200 cases of lead poisoning were diagnosed in the Nablus and Tulkarem districts. The epidemiological survey put the blame on-grain mills.

4.1.3.3 The cases in Jenin and Hebron

On 21 March.1983 a clinical syndrome appeared among girls at Jenin school, who according to the doctors displayed the subjective symptoms of headache, myalgia, epigastric pain, dyspnoea, and weakness in the lower limbs, and the objective symptoms of mydriasis, decreased light reflex, shaking, tachycardia of 120 and cyanosis of the limbs. Loss of consciousness was reported in some cases.

The phenomenon spread rapidly within the districts of Jenin (425 cases) and Hebron (235 cases) and for the most part was confined to primary and secondary school girls. The number of cases is thought to be much higher than the number recorded.

The etiological diagnosis had not been established when the Committee completed its mission in the occupied territories.

Experts were sent by WHO and by the Centers for Disease Control, Atlanta, USA, to carry out investigations in the field.

The Committee notes, however, that there is a public health problem which should not be minimized and recommends that all possible measures be taken, even if no precise diagnosis is reached, to monitor the health of these girls, as it might be disturbed. Such surveillance would best be carried out by WHO.

4.2 Health infrastructure

The situation has not changed significantly since the last visit. UNDP is still contributing to the strengthening of health services by providing equipment and fellowships. The municipalities are contributing to the public health effort, in particular as regards sanitation and drinking-water supplies, but the Committee was unable to find out the amounts invested.

A list of infrastructure was drawn up by the Committee in 1982; only new items or substantial changes are mentioned in the present report.

4.2.1 Ramallah district

The Ramallah public health department serves 130 000 inhabitants, but according to a public health official there have been no relevant statistics since 1962.

The health infrastructure consists of 27 clinics and MCH centers, as follows: 12 clinics, 13 clinics plus MCH centers, and two MCH centers.

Some non-governmental agencies have opened clinics: the Lutheran Foundation (six clinics); the International Christian Council; the Red Crescent; and the Society for the Sick.

There are also six private pharmaceutical factories in the district. UNRWA operates three clinics for refugees.

Information received indicates that despite some improvements Ramallah Hospital is still experiencing the same problems that were noted in the previous report.

The Ibn-Sina Nursing School has received teaching materials from UNDP; however, the major problem is to find teachers, because the physicians are not motivated to go and lecture there. The Director of the School requests assistance from WHO in respect of teaching facilities. The students complain of the shortage of teachers and especially of their living conditions, on account of the tiny premises and the lack of heating. It is planned to construct a new building for the School; if the contract is signed it should be completed in two years' time, according to the Director.

4.2.2 Jericho district

Jericho Hospital was recently provided with X-ray equipment, cauterization equipment, an air conditioning plant (solar heating) and a refrigerator for the morgue. The hospital is essentially a center for physiotherapy and the treatment of chronic orthopedic complaints. There is a plan to make it into a paraplegic unit. one physician is at present receiving specialist training in Australia.

4.2.3 Bethlehem district

The Azariya health center was opened in 1982 and provides preventive and curative care for an estimated population of 10 000. The staff consists of a physician (twice a week), a nurse and a midwife. On average it receives 28 patients per day.

The psychiatric hospital is expanding. The new building is progressing-and will probably be completed by the end of the year. The psychiatric clinic at Ramallah, which is supervised by the hospital, has been operating for six months. The Mental Health Society has just been established after a long delay. Training remains a serious problem, however, and fellowships have been requested from WHO.

Beit-Jallah Hospital is undergoing conversions. The extension plan provides for three floors assigned to internal medicine, surgery, emergencies and cardiology. The hospital has acquired some new equipment: proctoscope (UNDP), operating table, anesthesia equipment.

Terre des Hommes runs a center for handicapped children and nutritional rehabilitation. At present it is looking after 40 children.

4.2.4 Hebron district

Hebron Hospital has a capacity of 100 beds and employs 102 people. The problems that have been evident for a long time remain: shortage of staff, shortage of certain drugs, poor electricity supply. The radiography equipment requested almost five years ago has still not been received. The permit to build a new hospital has still not been granted. There is only one ambulance, which is used for all types of transport. On the other hand, the Committee noted the acquisition of an intensive care unit, an aspirator for the operating theatre and a cystoscope.

Hebron district has 85 health personnel, including 12 physicians; health units include 28 clinics (dispensaries), 11 MCH units, a tuberculosis center (Hebron), a psychiatric center with a weekly clinic, and three integrated clinics (Hebron).

The difficulties encountered arise from the budget (low level of funds and slow decision-making), the salaries of the staff in general and the physicians in particular, transport, the age of the buildings (Hebron central-clinic), the water supplies-and the inadequate sanitation.

4.2.5 Nablus district

The estimated population of-this district is 150 (700. The health infrastructure consists of hospitals (Nablus Hospital, together with psychiatric, ophthalmological, ENT and tuberculosis services, Rafidia Hospital and the National Hospital); clinics (three urban clinics, one of which is integrated, and 19 rural clinics); a mobile unit providing MCH care for 10 villages, and some private services (3 hospitals, 63 clinics, 26 dental surgeries, 31 pharmacies and 9 drug stores).

Activities are both preventive and curative. In 1983 tetanus vaccination was introduced for schoolchildren aged 15 to 17 and women of reproductive age.

While there has been an improvement in drug supplies, there are sometimes shortages of products for chronic diseases. Practitioners complain of the inefficacy of the locally manufactured drugs (there are seven factories in the district).

Assira Shamalia Clinic, which includes an MCH center, is housed in two separate buildings, and covers a population of 7000. It receives 180 patients each month. The MCH center conducts check-ups on pregnant women and children up to three years of age. 70% of deliveries take place at Rafidia maternity unit.

4.2.6 Tulkarem district

Tulkarem Hospital covers an estimated population of 100 000. It has a capacity of 60 bids (surgery, medicine, pediatrics, gynecology and obstetrics). Its activities comprise (per month): 300 hospital admissions, 800 consultations, 60 deliveries and 40 surgical operations.

Since the last visit in 1982 the hospital has acquired two operating theatres, radiology equipment, an ergometer and a spectrometer. The bed occupancy rate is; 502, and local doctors attribute this to the increase in the cost of hospitalization.

The personnel includes three volunteer doctors who have not been able to find paid employment. On the West Bank a large number of local doctors are out of work.

4.2.7 Golan Heights

The majority of the health units are linked to Kiryat Shmona. They are: Majdal Shams, In Kernia, Rajah, Masada and Bakata. The clinics visited by the Committee - Rajah, Masada and Majdal Shams - show no major new features since the previous visit.

Rajah Clinic carries out integrated activities (preventive and curative). Consultations number about 30-40 per day, but there is no daily recording of patients. The nurse does not live in the village. Some families are not yet members of the health insurance. The waste water disposal system in the village is extremely rudimentary.

Masada Clinic covers a population of 2500, of whom 1300 are insured (according to the Israeli authorities). There is no ambulance for emergency cases. Wastewater and excreta disposal is into pits which are emptied in the open air.

Majdal Shams Clinic covers a population of about 7000, of whom 4200 are insured according to the Israeli authorities. About 25 patients are seen each day. The mains drainage system is approaching completion.

During the visit to the Golan the Committee noted that the Israeli physicians responsible for the region had been on strike for three months.

4.2.8 Gaza Region

Sheefa Hospital is being developed into a prevention and referral center. It has a capacity of 309 beds and a staff of 74 physicians, 2 pharmacists and 163 others.

Since the last visit the hospital has acquired a burns unit and three sets of equipment, a mobile X-ray unit, a proctoscope and three special mobile chairs for dialysis. A plan for conversion of the hospital is being implemented.

Zawayda Clinic was opened six months ago. It was constructed by the municipality and covers a population of 5000.

4.2.9 Jerusalem district

The Sheikh Jarrach Health Center, which acts as an MCH unit and clinic, provides preventive and curative care, mainly for the Arab population of eastern Jerusalem; it is estimated that 35% of this population is insured. Care is provided free of charge for insured persons. For those who are not insured a visit costs 400 Shekels (US$ 10); welfare cases are treated free. The Kupat Holim (health insurance) provides care in three other clinics in the eastern part of Jerusalem: Wadi George, Damascus Gate and Surbakha. During the visit to the laboratory it was reported that a fairly high number of cases of amoebiasis and anemia had been detected among the Arab population.

4.2.10 Visits to prisons

While the medical infrastructure within the prisons visited was on the whole satisfactory, the Committee was unable to obtain details of the utilization of' the services provided for the prison population.

The Committee visited cells whose occupants were working in the prison kitchens. Hygiene conditions in the kitchens were satisfactory, as were those in the cells visited.

However, the visits to prisons did not really enable the Committee to assess the health of the prisoners.

4.3 Health activities undertaken (delivery of services)

4.3.1 Hospital care

The previous reports contain a detailed description of the health infrastructure providing hospital care.

There has been no significant increase in the total number of beds over the years. The number per 1000 inhabitants ranges from 1.5 on the West Bank to 1.9 in the Gaza region. However, the beds have to some extent been reallocated for the setting-up of new specialist departments.

Although the I number of discharges from hospitals in the two regions increased during the period 1968-1982, the number of bed days per 1000 inhabitants remained almost constant. This latter indicator should be considered in relation to the average length of stay, which was about five days in the Gaza region and six days on the West, Bank.

Comparison of these two indicators (number of bed days and average length of stay) with the bed occupancy rate, which varies in the two regions from 63% to 69%, reveals the need for an in-depth analysis and study of the way the beds are used.

The above observation should be compared with those in the section on planning.

The creation of new hospital departments by breaking up a few basic services and allocating a limited number of beds to certain specialties is not the same thing as setting up specialist services.

A hospital department requires a team of specialists and adequate resources. Only when there is a possibility of medium- and long-term planning can the most appropriate possible decisions be taken.

The Committee stresses that, in its opinion, one important aspect concerning services of this kind in the occupied territories is to solve the problem of the number of beds required for each specialty, and introduce a proper hierarchical structure for the hospital units.

It is not clear that care is economically accessible. On the West Bank in particular the Committee noticed a decrease in the number of hospital admissions, which the local doctors account for by the increase in the price of each day in hospital to 4300 Shekels, about US$ 110; this is a problem for non-insured people who still constitute about 40% of the Arab population. While the cost of the services in the occupied territories is roughly equivalent to that in the Israeli hospitals, the Arab populations who can afford to do so prefer to go to the latter, which are better equipped. It seems that the aim is to get the Arabs to join the Israeli health insurance system, but this is not always accepted.

Social assistance for the needy does exist, but this term would seem to exclude anyone who has a dwelling, whatever its condition.

According to information collected from unofficial sources it would seem that in the Golan access to hospitals is subject to the holding of an Israeli identity card. This claim is denied by the public health authorities of the region. The Committee had already noted in its previous report that the health system in the Golan is integrated within the Israeli system, under the dual responsibility of Kupat Holim (health insurance) for curative treatment and the Ministry of Health for preventive care. There have been no major changes.

4.3.2 Ambulatory care

Primary health care at dispensary level has increased in quantity. Primary health care has mainly been directed to maternal and child health. This policy has been developed in all the regions, but especially in the Gaza region where programs are under way for the provision of prenatal care for pregnant women, for implementation of the timetable of visits to the homes of new-born infants, for the correct use of re-hydration methods for diarrhoeal diseases, and other programs.

The quality of services provided in-the clinics and health centers is uneven because it depends on the presence of the doctor in the clinic, on the round-the-clock manning of the on the drug supply, etc. Increased and long-term efforts will be needed in the future to improve these activities.

Another important aspect of services in outpatient units concerns specialist consultations. In the occupied territories there are no specific structures for providing specialist services in the outpatient units; such consultations are provided in the hospitals or, in the case of some specialties, by means of visit by specialists to health centers. These arrangements do not properly meet the need for specialist care.

An improvement in specialist care has been brought about, however, by setting up emergency wards in each hospital and organizing emergency care in some specialties (in the hospitals at Sheefa, Khan Yunis, Nablus and Ramallah).

4.3.3 Laboratory services

Laboratory services have been extended with the development of the clinical laboratories attached to the hospitals. In general they seem to be satisfactorily equipped, especially in the large hospitals. The lack of medium- and long-term plans for hospital development has a negative influence on the development of clinical laboratories.

The lack of minimum specifications for examinations prevents the application of technology appropriate to the type and level of assistance given to patients.

4.3.4 Specific services

Another kind of service is provided for the population on the basis of public health needs. These services consist of:

(a) Programs of maternal and child health care; communicable disease control; tuberculosis control; diarrhoeal diseases control; surveillance of nutritional status; and mental health.

Without going into detail concerning the way these programs are implemented, it may be stated that on account of the various political and budgetary constraints or lack of staff, they do not all run smoothly.

(b) The expanded program on immunization (EPI), which occupies an important place. The Committee noted the results, achieved with regard to poliomyelitis. However, the appearance of cases or small foci of communicable diseases (diphtheria, whooping cough, measles) shows the need for continuous monitoring of the coverage achieved by immunization of the population.

In view of the high level of vaccination coverage mentioned in the statistics, the Committee considers that immunity status should be evaluated by more scientific methods.

(c) Hygiene and sanitation, which are also important for ensuring the health of the community.

Here it should be noted that hygiene inspections are carried out in accordance with Jordanian legislation. There are not many staff to carry out these inspections, and the plan laying down the frequency of inspections is not entirely satisfactory.

Chemical and bacteriological control of foodstuffs and drinking-water is carried out, but the present frequency of water sampling is inadequate; analysis of effluent from treatment plants is carried out irregularly; control of foodstuffs covers only the cleanliness of foods offered for sale, and then only in suspect cases; it is not possible to carry out all the appropriate chemical and toxicological tests on foodstuffs and drinking-water in the public health laboratories of the territories; there is no properly developed information system for monitoring hygiene; the problem of public health laboratories in the territories has not been solved.


4.4 Aspects of the health status of the population

4.4.1 Studies of morbidity/mortality

Leaving aside some contradictions in the data contained in the report 1/ by the Ministry of Health of Israel (see for example Tables 1 and 2 for Gaza, 2 and 32 for the West Bank), the Committee wishes to make a number of comments.

The study of mortality at the worldwide level is known to be incomplete.

In the occupied territories there is no real knowledge of morbidity based on the access. of the population to medical care, and no sample studies have been carried out to correct this shortcoming. It might have been possible, for example, to conduct exhaustive studies on the incidence of general morbidity by sex and age in two dispensaries in each district, or to set up registers for mental diseases in the newly organized specialist clinics. A breakdown of data on subjects discharged from hospital by disease category, sex, age group, mean length of stay in hospital, cost of drugs and type of hospital would have meant that the discussions and the information received by the Committee would have been based not on general considerations but an concrete figures. At the same time, such data if available could have been used to program the response to the demand for medical care and to determine the number and types of specialties required.

Although a study of hospital morbidity, based on clinical records, offers only a biased view of the structure and dynamics of true morbidity, in the occupied territories it constitutes an important source of knowledge that has not been sufficiently utilized.

Although mortality is a negative indicator, it remains the most useful indicator for evaluating health status as the result of all the conditions within a territory.

In the section on demography the Committee discussed the-crude death rate and showed that it was not possible to calculate the adjusted mortality rate by the standard population method.

The best way of standardizing mortality indices is to calculate mortality by individual years of age or by quinquennial age groups. If population mortality had been analyzed by individual years of age and by sex, the indices could have been more comparable between the zones and the neighboring areas. More conclusive data for the evaluation of mortality could have been provided by an analysis by cause of death, correlated with sex and age (age group).
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1/ See document A36/INF.Doc./3.

Although the Committee did not obtain such data, analysis of the data that are available shows that in the occupied territories mortality is still of the "primary" type, and acute diseases of the respiratory and digestive systems (many of infectious origin) still claim many victims among young people. The lack of data prevents the Committee from giving a survey of the different types of mortality in early life, which would have permitted a more realistic evaluation of the causes of death-and of the factors linked to the solution of a medical or socioeconomic and cultural problem. Among the causes of hospital or domiciliary mortality in adults, chronic diseases are beginning to predominate, so that in the years to come mortality in the occupied territories will progress towards an "intermediate" type, with falling indices for mortality from acute infectious diseases and rising indices for-mortality from non-epidemic chronic diseases.

4.4.2 Growth and nutrition

The nutritional status of a population is known to depend not only on the quantitative and qualitative consumption of food, but also an genetic factors, chronic diseases, living and working conditions, and other factors, which exert a complex influence on the metabolism land on the physical development of the population.

As regards the positive factors, it would have been interesting to have information on physical development in terms of anthropometric indicators (height, height. when seated, chest circumference, etc.) far quinquennial age groups sampled within the same locality. This kind of objective evaluation is not possible since there have been no relevant studies. In most cases the indicators of nutritional status were not available in the occupied territories.

According to data collected at the Rafah clinic for refugees, 156 infants out of 2000 (7.8%) were undernourished.

Birth weight is also an important indicator of the nutrition of a community. This information is available only for children born in hospital. In 1982, 9.3% of the children born in hospitals on the West Bank had a birth weight below 2500 grams.

However, these data are only fragmentary. A study is in progress and the results may be available shortly.

Moreover, there are no data reflecting neuro-psychiatric development in general and among children in particular (motor and cognitive development, speech, socio-affective development) on the basis of tests designed to describe the various aspects of mental status, highlighting certain aspects so as to determine whether the status is normal or deviates from the norm.

As regards the negative indicators specifically linked to malnutrition (deficiency or over-feeding), which leads to various metabolic disorders, deficiency diseases, etc., it is not possible to give any precise facts since the morbidity records do not permit an evaluation of this kind.

5. RECOMMENDATIONS

Following its fifth visit to the occupied territories the Committee noted that some of the recommendations contained in its previous report, document A35/16, had actually been put into effect or were being followed up. Those recommendations were:

Sending of a consultant to the area to support a thorough study on diarrhoeal diseases.

5.2 Strengthening of outpatient consultations with specialists at the community level.

5.3 Strengthening of the Gaza public health laboratory.

On the other hand, no solutions have been found for;

5.4 Designation of an epidemiological reference laboratory to assist in evaluation of the expanded program on immunization.

5.5 Organization of a local seminar on the planning and management of health services.

5.6 The whole section relating to budgetary resources.

While stressing the need to find solutions for the above points, the Committee wishes to formulate some new recommendations following its visit.

5.7 Epidemiology

5.7.1 Improve statistical analysis by:

- analysis of specific mortality and morbidity, where possible, by cause of disease and by age group;

- calculation of life expectancy at birth;

- study of hospital morbidity on the basis of clinical records.

Specific proposal: Organize local seminars on appropriate statistical method and data recording.

5.7.2 Introduce proper epidemiological surveillance on the basis of combined tests (bacteriological, serological).

Specific proposal: Send a consultant and propose a reference laboratory to carry out the epidemiological evaluations.

5.7.3 Assist in determining the prevalence of mental diseases by setting up a pilot unit on the West Bank and in Gaza.

5.7.4 Assist in. the approach to psychiatric problems by sending a consultant.

5.8 Development of services

Encourage health programming and the formulation of a health plan with full community involvement.

Specific proposal: In addition to organizing seminars to initiate personnel in health planning, send an expert in planning to assist the officials.

5.9 Health manpower

Work out a plan for health manpower development. This recommendation links up with recommendation 5.8.

5.10 Financial resources

In addition to the recommendations contained in document A35/16 there is a need to introduce program budgeting and involve-the local officials in implementation.

5.11 Hygiene and sanitation

Prepare a plan for sanitation and drinking-water supply in accordance with the recommendations of the Conference of Mar del Plata an the International Drinking Water Supply and Sanitation Decade.

5.12 Cooperation

- Make cooperation with VW more dynamic.

- Stimulate fresh impetus to cooperation by 'other agencies in the United Nations family such as UNICEF.

- Encourage activities by non-governmental organizations, associations and individuals.

- To create goodwill it is necessary to draw up a list of needs in order of priority so a to permit activities in a variety of fields.

5.13 Other recommendations

5.13.1 Preparation, on the basis of a Delphi survey of a list of the specialist procedures that cannot be provided by the medical services in the occupied territories, together with the number of patients who have requested them.

5.13.2 Development of specialist procedures within an organizational system for hospital and outpatient services. Procedures relating to internal medicine, general surgery, gynecology and obstetrics and pediatrics would be provided at the base of the pyramid, and at higher levels the specialties needed to meet the needs of the population would gradually be added.

Specific proposal: Carry out studies on this sitter and publish the results for discussion.

5.13.3 Compilation of a register, at the district level, containing proposals for assistance from abroad and the action taken in response (donations in cash or in kind, drugs, construction of clinics or hospitals, etc.).

5.13.4 Improvement of the recording of births and deaths. Since demographic change is an important aspect of social history, a fertility study using the United Nations methodology is recommended.

5.13.5 The physicians in the occupied territories need a knowledge of WHO publications. The Committee recommends that WHO take steps to send documents on primary health care and on the relationship between health and the new international economic order, on request, to medical societies and Palestinian doctors.

5.13.6 Evaluation of the work of newly created specialist services.

Specific proposal: Analyze the work of the cancer service in 1983 on the basis of indicators: indicators of detection by stage of cancer, detection of cancer of the cervix uteri by cytological screening, of survival time, of very late detection (post-mortem).

6. CONCLUSIONS

The events that occurred before and during the Committee's visit to the territories are significant in every way and place health problems in the context of overall development.

Progress in the health field is assessed not just in terms of the number of units, staff, or activities carried out, but in the light of the appropriateness of the relationships between the different components of the health system, i.e. the epidemiological, technical, social, economic and operational components. This relationship involves two concepts: accessibility and acceptability.

Health promotion activities must be guided by accessibility and acceptability. In the context of the general socioeconomic development policies laid down for the occupied territories (policies for which the health sector is inseparable), and in view of the specific problems and structures of the region, it cannot be claimed that these two conditions of accessibility and acceptability are met for the Arab population.

The ultimate aim is the people of tomorrow, of the year 2000. One of the main tasks of our time is to prepare the future of the children of today who will become the adults of tomorrow. This is the direction that the priority programs aimed at mothers and children must take. And in the maternal and child health field it is necessary, "through preventive, promotive and rehabilitative care, to ensure the healthy physical growth and psychosocial development of children ... A publication on the consequences for adulthood of health problems during the period of growth and development shows how-the foundations for healthy maturity are laid in the earliest stages of human life, the growth and development of girls being especially crucial for future generations . . . Adolescence is a critical period in growth and development; the importance of preparing adolescents for their role as parents is recognized." 1/

The current situation, and particularly the recent events on the West Bank, should be seen in terms of prospective health problems of the future generation, even though efforts are being made in the field of disease control and prevention by means of vaccination.

Every technical activity, particularly in the health field, needs to be accompanied by serious thought; this implies political action and the involvement of other socioeconomic sectors.
(signed)

Dr Traian Ionescu (Chairman)

Dr Madiou Toure

Dr Soejoga

Geneva, 22 April 1983

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1/ The work of WHO, 1980-1981i Biennial report of the Director-General, Geneva, World Health organization, 1982, paragraphs 6.37 and 6.38.

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