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Source: World Health Organization (WHO)
28 April 2005

Provisional agenda item 15
28 April 2005

Health conditions of, and assistance to, the Arab
population in the occupied Arab territories,
including Palestine

The Director-General has the honour to bring to the attention of the Health Assembly the attached report of the Director of Health, UNRWA, for the year 2004.




1. Year 2004 has been a continuation of the violence, loss of life and by far the worst levels of destruction since the occupied Palestinian territory was plunged into a severe humanitarian crisis since September 2000. The casualty toll during rounds of military incursions into camps was much higher among the population of the affected communities. According to the Palestinian Central Bureau of Statistics, 3633 Palestinians living in the occupied Palestinian territory were killed from September 2000 to November 2004, with 1467 dead in the West Bank and 1887 in the Gaza Strip, and 28 235 were injured. One particularly tragic aspect of these statistics has been the number of children killed during this period: 315 and 397 respectively in the two territories, representing 19.5% of total fatalities, while over 12 000 were injured. Among those killed, 12 were UNRWA staff members and 155 UNRWA school children, of whom three were killed in 2004 by Israeli fire into UNRWA schools. In addition, a total of 1539 children enrolled in UNRWA schools were injured, of whom nine inside school premises. Since September 2000, Israeli losses have totalled 1001 dead and 6979 injured.

2. Uprooting of trees and home demolition has been another tragic aspect of the crisis. The focus of home demolition as a result of military activity has been in the Gaza Strip where 1304 homes have been destroyed from 1 January to 1 November 2004, with 13 350 persons affected. The cumulative number of homes destroyed since September 2000 has reached 2389, making 22 963 persons homeless in total. Israeli army incursions have seriously damaged water, sewage and power networks. According to the World Bank, physical damage to the occupied territory water and waste water sector from Israeli military actions is valued at about US$ 140 million.

3. The occupied Palestinian territory is controlled by a dense network of fixed and flying checkpoints, road blocks, earth mounds and other measures used to monitor and restrict Palestinian movement. Over 700 closure measures currently restrict movement of Palestinian goods and people inside the West Bank, while the Gaza Strip is often divided into three sections by checkpoints. In addition to closures, curfews had been another cause for mobility restrictions. Overall, according to the Palestinian Centre for Human Rights, the most affected city in this respect during the period June 2002 to February 2004 was Hebron, which was under curfew 40% of the time, followed by Nablus (32%), Tulkarem (31%), Jenin (26%), Bethlehem (18%), Ramallah (17%) and Qalqilia (15%). Severe restrictions are in place on entry and exit of residents, food commodities and building materials as well as the passage of children to schools outside. In the Gaza Strip, 2004 has been the worst year by far since the start of the intifada for the movement of both personnel and commodities. Restrictions on the movement of UNRWA international staff into, and around, Gaza have led to considerable disruptions to Agency operations. In the West Bank, incidents of denied and delayed access continue to affect Agency operations. Delivery of humanitarian assistance has been particularly affected in the “seam” zone which lies between the Green Line and the wall/fence, as the Israeli army routinely require permits from UNRWA staff. Several cases have been recorded where access of food distribution teams and medical teams has been prevented altogether.

4. The wall/fence currently being constructed inside the West Bank is compounding movement restrictions, cutting off Palestinians from their land, work and trade opportunities in Israel. Israel began the construction of the wall/fence in June 2002 as a security measure. It comprises a system of fences, ditches, razor wire, groomed trace sands, an electronic monitoring system, patrol roads, and a “no-go” buffer zone. Over 185 kilometres of this system has already been constructed, and a further 70 kilometres is under construction. In many places, the wall/fence veers east of the 1948 armistice line and into the West Bank, isolating Palestinian families from their land, communities and services. With the barrier, Israel effectively will annex most of western aquifer system which provides 51% of the West Bank water resources.

5. Unlike the trend which prevailed since the beginning of the crisis, the impact of large scale and prolonged military incursions, as well as restrictions imposed on movement of vehicles, personnel and supplies, had a more negative impact on staff/days lost in Gaza Strip than the West Bank, as many UNRWA health personnel could not reach their designated duty stations or reached workplace after significant difficulties and delays. As a result, a total of 18 842 staff hours were lost in the Gaza Strip during 2004. During the last closure of Rafah crossing in December 2004, many Gaza residents were trapped outside the Strip on their way back home. Among them 877 patients who had previously left to be treated in Egypt or Jordan. Among those, 42 children under the age of five and 454 women. The main reasons for their referral abroad were cardiovascular surgery and radiotherapy for cancer. During the waiting period, seven of those patients died and were buried in Al-Arish at the Egyptian border, as the Israeli authorities did not allow the transfer of the bodies into Gaza.

6. According to the latest figures available from the Palestinian Central Bureau of Statistics, unemployment in Gaza rose from 15.5% in the third quarter of 2000 to 36.8% in the third quarter of 2004. Unemployment in the West Bank rose from 7.5% to 22.3% in the same period. Inevitably, this has led to a sharp increase in poverty. As of 2004, poverty rate in Gaza Strip based on World Bank data, was 65%. Subsistence poverty (those who can not afford or hardly afford the basics of survival) was 23%. Statistics from the Central Bureau show that in the latter half of 2004, 62.5% of all households in occupied Palestinian territory are living below the poverty line. In real terms this means that over 2.2 million people are attempting to subsist on less than US$ 2 per person per day, which puts them below the World Bank’s globally defined poverty line. Refugees are particularly hard hit as they have traditionally been more dependent on wage labour in Israel, have fewer assets that they can sell and have been hit by repeated Israeli army incursions into camps, leading to further depletion of their resources. According to the World Bank, the Palestinian economy has lost all the growth it achieved in the preceding 15 years, with real gross domestic product (GDP) now below its 1986 level. Cumulative real GDP per capita in the Gaza Strip declined by 40% between 1999 and 2004.

7. According to the World Food Programme, as of mid-2004, approximately 1.3 million people in the occupied Palestinian territory, or 38% of the population, were food insecure. A further 26% of the population, or 586 000 people, were at risk of becoming food insecure. Again, refugees were more at risk; 39% of refugees were estimated to be food insecure, against 36% of non-refugees. Food is generally available in Gaza Strip and the West Bank, but access to food is limited for physical (curfews, closures) and economic reasons (high unemployment, depletion of resources, exhaustion of coping strategies and strained social support networks).

8. Notwithstanding the extraordinary efforts that were exerted to prevent breakdowns in service delivery and quality, there were indicators of deterioration of the health and nutritional status of the population. UNRWA studies on the prevalence of iron deficiency anaemia among children aged six to 36 months, pregnant women and nursing mothers revealed that anaemia rates in Gaza Strip were as high as 54.7% among children, 35.7% among pregnant women and 45.7% among nursing mothers. The corresponding rates in the West Bank were 34.3% among children, 29.5% among pregnant women and 23.1% among nursing mothers. A study conducted by USAID funded project revealed that 22% of children were found to have low vitamin A plasma levels. The estimated prevalence would be considered to fall into the severe category (≥ 20%) according to WHO criteria for judging that vitamin A deficiency in a community constitutes a public health problem.

9. A serological survey conducted by the Ministry of Health in collaboration with UNICEF and UNRWA for measles, rubella and hepatitis-B vaccines on children aged nine months to five years revealed that about 33% of children had low seroconversion rates to measles antibodies (more in Gaza Strip than in the West Bank). Since December 2003, there was a large outbreak of mumps in Nablus area that affected a total of 2278 refugee children, mainly below 15 years of age, of whom 72.9% were previously immunized. In total, more than 4000 children, both refugees and non-refugees, were affected. The outbreak reached its peak during April and May 2004, subsided thereafter, but spread out to other districts in the West Bank. Both the low seroconversion to measles vaccine and the mumps outbreak were attributed to possible breakdowns in the public sector cold chain system due to frequent power cuts. In areas of the West Bank most affected by closures and movement restrictions, immunization coverage with full primary and booster doses of programmed vaccines was below the target of above 95% achieved in other localities. The rates for infants below 12 months of age were 85% in Jerusalem health centre and even lower in Hebron and Dheisheh. Likewise, immunization coverage with booster doses for children below 18 months of age was 75.6% in Jerusalem health centre, and 79% in Kalandia health centre. In spite of the sustained high immunization coverage overall, the decline in immunization coverage in certain localities is cause for concern because it leaves pockets of unimmunized children, which could cause disease outbreaks among highly immunized communities. Similar to immunizations, non-attendance rates at clinics for non-communicable diseases were higher in localities affected by closures and restricted movements such as Jerusalem and Hebron.

10. A study conducted by a USAID-funded project revealed that one out of a thousand pregnant women delivered while stranded at Israeli military checkpoints during labour. UNRWA data revealed that the progress achieved in family planning services over several years started to be reversed in Gaza Strip, which is a common phenomenon under crisis situations. In addition, there was a drop in coverage of postnatal services.

11. According to the latest report from the Graduate Institute of Development Studies, 36% of parents reported aggressive behaviour among their children, 31% noticed bad school results, 25% mentioned that their children are bedwetting and 28% reported their children having nightmares.1 All four types of behavioural problems are most explicit in the Gaza Strip, in refugee camps and among the poor segments of the society. Adolescents (ages 10 to 19) are becoming more vulnerable than other groups to aggression, rebellion, risk-taking behaviour, helplessness, frustration and withdrawal.


Emergency appeals

12. Since October 2000, UNRWA launched seven appeals to support its programme of emergency humanitarian assistance in the occupied Palestinian territory, on top of its regular programme activities. Through these appeals, UNRWA requested funding at US$ 739.2 million and received US$ 399.2 million. In addition, UNRWA launched its eighth emergency appeal, to sustain the programme of emergency humanitarian assistance during 2005 at US$ 186 million, which is less than the request made in 2003 because of integration of the cost of emergency medical supplies, hospitalization and psychological counselling and support into the regular budget.

Programme of emergency assistance

13. UNRWA cares for almost half of the population of the occupied Palestinian territory and is the largest humanitarian operation in the region. UNRWA has developed a refined package of measures to mitigate the worst effects of the conflict on refugee communities within available means. These measures comprised employment programmes, cash and in-kind assistance, food aid, reconstruction and repair of conflict-damaged infrastructure, emergency medical care and psychological counselling and support.

14. The objective of the emergency interventions in health is to meet the additional burden on the health care system owing to the newly emerging needs and challenges and to facilitate access to health services in locations affected by closures and the wall/fence in the West Bank. This programme does not run in the Gaza Strip because of its smaller geographical size and the concentration of camp-based refugees who are able to access services locally. During 2004, there were five mobile medical teams in the West Bank, each serving an average of 100 patients during each visit. In addition to maintaining the services of the five teams, the Agency is seeking to create two new mobile units in Nablus and Hebron areas during 2005. These teams will enable 14 000 patients to receive essential health care every month.

15. In both Gaza Strip and the West Bank, additional medical supplies were made available to meet the increased demand on UNRWA treatment services, and a two-month stock reserve was maintained in each health centre to meet urgent needs in case of disruption of the supply chain. In addition, three hospitals were contracted in the West Bank to overcome access problems to Agency contracted hospitals, including hospitals in East Jerusalem.

16. Under its emergency psychological counselling and support programme, the Agency assigned counsellors to schools and health centres throughout the occupied Palestinian territory. Armed conflict, the tight regime of closure and prolonged curfews are the sources of acute psychological stress for Palestinians, both adults and children. The signs of stress, particularly among children, are readily apparent. The Agency provided a range of services aimed at promoting the development of constructive coping mechanisms for refugees in crisis situations and preventing long-term psychological consequences. Programmes targeting schools, health centres, social services and community-based centres were under way throughout the reporting period. Health personnel, social workers and teaching staff received training on early detection and referral of persons who need psychosocial support, and partnerships were maintained with community mental-health institutions in Gaza Strip and the West Bank. The Agency is also seeking to enhance cooperation with other partners within the framework of the national mental-health plan developed by the Ministry of Health of the Palestinian Authority in collaboration with WHO, which assisted in establishing community mental-health centres in Ramallah, Hebron and Gaza.

17. UNRWA participated in the measles and vitamin-A supplementation campaign, which was launched in June-July 2004 in collaboration with the Ministry of Health of the Palestinian Authority and UNICEF. In total 34 459 children aged nine months to five years were vaccinated by UNRWA health teams in the West Bank, and 50 855 were vaccinated in the Gaza Strip. The overall national coverage was 98.2% (97.3% in the West Bank and 99.4% in the Gaza Strip).


18. UNRWA is confronting the enormous hurdles brought on by economic suffocation and relentless violence to the best of its ability. Despite overwhelming desire to be an economically productive and self-sufficient, the refugee population cannot, under the current conditions, support itself, or rebuild its communities. The main challenge to UNRWA during the crisis was to prevent breakdowns of essential services, while addressing development needs with a seriously underfunded emergency budget for more than four years. One of the major consequences of the current crisis in the occupied Palestinian territory is that it gradually diverted international support to the Palestinian people from development assistance to emergency response. This change was inevitable under conditions of a near-collapse of the economy, exhaustion of coping mechanisms, destruction of infrastructure, stunting of civil society institutions, damage to public-sector functions and services and implementation of strict separation and closure policies.

19. UNRWA’s strategic approach is to ensure that developmental and socioeconomic opportunities arising from any positive developments on the ground are effectively utilized to better the living conditions of the Palestine refugees in the occupied Palestinian territory, through a mix of interventions – developmental, rehabilitative and crisis-related.

20. UNRWA maintained close collaboration with the Palestinian Authority and organizations of the United Nations system for preparation of the Consolidated Appeal Process, as well as the medium-term development plan, and is intensifying its links with WHO and local partners for strengthening technical cooperation in priority and commonly defined areas, including nutrition, mental health, expanded programme of immunization, food safety and advocacy. Supported by the international community, the Agency will be prepared to act quickly in response to developments on the ground such as the Gaza disengagement plan as well as impact of the Separation Wall and the planned regime of access of the population within the West Bank and between the West Bank and East Jerusalem through two controlled crossings in Kalandia and Bethlehem.

1 The role of international and local aid during the second Intifada (August 2003 – February 2004). Presentations of the Palestinian Public Perceptions Report 7. Geneva, Graduate Institute of Development Studies, November 2004.

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