World Health Organization Organisation mondiale de la Santé FIFTY-FIRST WORLD HEALTH ASSEMBLY Provisional agenda item 30 A51/INF.DOC./5 8 May 1998
Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine
At the request of the Permanent Observer of Palestine to the United Nations and Other International Organizations at Geneva, the Director-General has the honour to transmit the attached report1 to the Fifty-first World Health Assembly.
1
See Annex.
A51/INF.DOC./5
ANNEX
State of Palestine Supreme Palestine Health Council Palestine Ministry of Health
HEALTH CONDITIONS OF THE ARAB POPULATION IN OCCUPIED ARAB TERRITORIES, INCLUDING PALESTINE
Report submitted to the Fifty-first World Health Assembly
March 1998
3
A51/INF.DOC./5
Annex
INTRODUCTION The World Health Organization, in developing its strategy of “Health for All by the Year 2000”, set a noble goal which involved provision of support to countries to enable them to overcome obstacles to the attainment of this goal, including the expertise and assistance needed to catch up with other countries of the world. Our Palestinian people have faced special circumstances, well known to the rest of the world. They continue to suffer under the yoke of the hateful occupation with its ever-worsening manifestations that have obliterated any hopes raised by the Oslo accords, seen as the first step on the road to liberation, the building of the Palestinian State and the triumph of justice, so that our people could enjoy, along with other peoples of the world, the human rights that had been denied them. Palestinians, prompted by this hope, were looking forward to a future that would compensate for past suffering, affirming that their century-old battle of liberation would turn into a campaign for the welfare of humanity, the building of institutions, and the rehabilitation of health facilities to provide health security for the Palestinian people. Serious efforts were made by all concerned to found the necessary health infrastructure. We started with the implementation of the Supreme Health Council’s national plan and continued cooperating with WHO and other international bodies to this end. Cooperation with ministries of health in other parts of the world was initiated also, to lay the foundations of our health institutions, beginning with the Palestine Ministry of Health, under the Palestinian Authority, so that all could help to implement the national plan aimed at improving health and health services in all parts of the country that are within the Palestinian Authority’s jurisdiction. The Ministry of Health has provided numerous basic services, and in cooperation with the Palestine Red Crescent Society (PRCS) and other nongovernmental organizations, it achieved considerable progress in the field of outpatient services, primary health care, hospitals, and services for the disabled, etc. But continued Israeli occupation, continual blockades, intransigence and brutal treatment of citizens have all hampered implementation of the national health plan and disrupted health development; in fact the occupation is an obstacle to all types of development, education and training of health personnel. We call upon the international community to take all necessary action to implement inter-nation resolutions, and peace accords already concluded and signed; and continue providing assistance to the Palestinian people until the realization of their legitimate rights, including the right to life and health, the establishment of a just and lasting peace for all peoples of the region, and the exercise by the Palestinian people of their right to selfdetermination and the establishment of their independent State with holy Jerusalem as its capital.
Dr Fathi Arafat President of the Palestine Red Crescent Society President of the Supreme Palestine Health Council
4
Annex
A51/INF.DOC./5
BACKGROUND Health services were transferred to the Palestine National Authority four years ago, after Israeli military occupation of the West Bank and Gaza Strip since 1967. Responsibility for the health services was handed over as part of the complete transfer of authorities under the terms of the agreement concluded in Oslo (Oslo 1) between the Palestine Liberation Organization and the Government of Israel, which was signed in Washington on 13 September 1993. The entire world considered these developments positive steps towards peace in the Middle East. Consequent events and Israeli procrastination in honouring the said agreements, however, coupled with Israeli refusal to withdraw from the greater part of the West Bank, difficulties in the provision of health services to the population of areas still under occupation, the prohibition of any activities by the Ministry of Health in Jerusalem, and the continued shouldering of the health responsibilities in the City of Jerusalem by nongovernmental organizations, hindered the implementation by the Ministry of Health of activities in all parts of the West Bank, the Gaza Strip, and even inside territories under Palestinian rule. Such were the obstacles that they hindered efforts to establish central departments of the Ministry to provide services in Palestinian territories. Tension returned to the region and the Palestinian people were once again under attack, resulting in health teams being called upon to handle emergencies instead of concentrating on rehabilitation, construction, the reinforcement of health infrastructure, and the implementation of health programmes supported by WHO and other international organizations for protecting people from disease and ill-health. Yet Palestinian health teams are determined to provide services to their people, and build health institutions capable of meeting the needs of the population with the support of the world health community and friendly nations of the world.
POPULATION DISTRIBUTION The current count of the Palestinian population stands at 2 638 963 distributed as follows: 1 660 868 in the northern governorates including Jerusalem, and 1 023 095 in Gaza (according to the Central Statistics Department). The rate of population growth in 1997 was 5.6%. The estimated number of Palestinian refugees and exiles in Jordan, Syria, Lebanon and Egypt is 3 000 000. Some 7000 Palestinians are still held in Israeli prisons.
DEMOGRAPHIC INDICATORS Births The birth rate in the Palestinian territories under the National Authority was 37.4 per 1000 people in 1997, one of the highest in the world. The Palestinian society in the West Bank and Gaza is a “young” society. An estimated 47% of the population is under 15 years of age. Some 50% of Palestinians are members of families comprising at least seven people, with an average family size of 7.6. Nine per cent of Palestinian families live in overcrowded homes, i.e., more than one person in each room. One to sixteen per cent of the population face chronic water shortages; only 29% of homes are connected to the public sewage system, which adversely affects the health of the urban population. Sixty-four per cent of the Gaza population and 27% of the West Bank population are registered refugees.
Education The literacy rate among those of 15 years of age and above in the Palestinian territories is 84%.
Fertility The overall fertility rate is about 6.24, one of the highest in the world.
5
A51/INF.DOC./5
Annex
Mortality In 1997 the mortality rate was 3.5 per 1000 in Palestinian towns and governorates. Mortality rates have decreased steadily in recent years since the National Authority took over the provision of health services; infant mortality is 25 per 1000 live births. Estimated maternal mortality attributable to pregnancy and delivery is 41 per 100 000 births. Life expectancy at birth is 69 years for men, and 71 years for women. Infant mortality: low birth weight is the major cause of infant mortality (25.3%) of overall infant mortality, followed by respiratory diseases (23%) attributable to the weakness of the economic and social infrastructure, primary health care services, and environmental pollution generally, followed by congenital malformation at 18.6%. Mortality among children under five years of age is attributable mainly to respiratory infections which account for 16.7% of the overall death rate, followed by road accidents at 12.2%, poisoning and injuries at 14%. The main causes of adult mortality are cardiovascular diseases (50.4%), cancer (12.4%) and respiratory infections (8.2%).
Disease prevalence Low birth weight in Palestine is observed in 8% of all newborns, malnutrition in 15.7% of children, respiratory tract infections in 40%, influenza and diarrhoea in about 16%. There are communicable diseases such as tuberculosis, hepatitis A, B and C, Maltese fever, typhoid, viral conjunctivitis, and intestinal infections, particularly diarrhoea. There are reported cases of meningitis, influenza, mumps, whooping cough, and other conditions. The most common parasites are entamoeba, giardia, and ascaris. Reporting of communicable diseases is sketchy at times, hence figures appearing in official reports do not cover all cases, as some remain unreported. Environmental health is most unsatisfactory. The prevalence of the above-mentioned diseases is an indication of the deteriorating environmental conditions due to inadequacy of the waste collection system and the central sewage network, as there are many areas without such services. Water is another problem; there are numerous contaminated wells in Gaza. Salination is increasing, especially in the south, not to mention the water shortages in many towns and villages in the Palestinian governorates.
HEALTH CARE PROVIDERS The Palestine Ministry of Health is responsible for the provision of health services to the Palestinian people in the National Authority territories. It provides, in collaboration with other partners, preventive, diagnostic, curative, and rehabilitation services. The most important partner it has in this field is UNRWA, which provides preventive and primary health care services in the refugee camps situated in Palestinian governorates. Nongovernmental organizations, both domestic and international, also provide some primary health care, preventive and curative services. The Palestine Ministry of Health has established a number of other services such as Women’s Health and Development, and the Department of Mental Health. The Palestine Red Crescent Society provides emergency and primary health care services, especially secondary level services, to Palestinians in and outside Palestine.
THE ISRAELI BLOCKADE AND HEALTH SERVICES IN PALESTINE Israeli blockades of Palestinian territories continued in 1997-1998, as Israel persists in delaying implementation of the peace accords and withdrawal of its troops from the West Bank, and in refusing to honour 6
Annex
A51/INF.DOC./5
its commitments to other parties to the peace agreement. It has yet to release captives, prisoners and detainees, open safe corridors and roads, and permit operation of the airport, or the construction of a Palestinian port. Palestinians are still at the mercy of the whims and fancies of the Israeli authorities; suffering repeated closure of the territories which leads to the aggravation of economic conditions, and near famine among the Palestinian population. Provocations through attacks on the holy sites persist and result in violent confrontations between the Israeli forces and Palestinians. Major events that have had adverse effects on the health of the Palestinian people are the following: 1. Total closure of the territories on 30 July 1997 and the withholding of Palestinian Authority Funds by the Israeli Government. The Israeli Government imposed a total closure and blockade on 30 July 1997, thereby cutting off any communication among parts of the territories, and withheld customs and excise fees and taxes due to the Palestinian Authority which constitute 60% of the Authority’s revenues. The Oslo accords stipulate that Israel collect these taxes on behalf of the Palestinian Authority and hand them over to the Authority during the last week of each month. Failure to transfer these funds completely paralyses the function of the Palestinian Authority, especially in the field of health care. Not only did Israel withhold such funds, it also prevented 40-60% of all health personnel from reaching hospitals and health centres, disrupting thereby the immunization of children. To make matters worse, Israeli forces also stopped patients from reaching hospitals in the West Bank and inside Israel, including cancer patients and children who needed urgent renal dialysis. Conditions were aggravated as a result, some children and elderly people died, and many women gave birth to infants at Israeli checkpoints after Israeli forces prevented ambulances from transporting them to medical facilities. 2. Confrontation with settlers in the occupied Arab territories. The Israeli Government continues to pursue settlement activities in East Jerusalem, Bab El Amoud District and Bethlehem, and the expansion of settlements by confiscating land in Bethlehem, Tulkarem, Kalkilya, Jenin and Khan Younes. Confrontations between unarmed Palestinians and settlers have erupted leading to numerous casualties among Palestinians who resist the confiscation of their land, and the uprooting of the olive trees grown by them and their ancestors for hundreds of years. 3. The Tarkumia incident (Hebron). Israeli occupation forces killed three Palestinian workers and wounded nine others on 10 March 1998 in cold blood at a military checkpoint between Tarkumia and Athna (West Bank villages), some eight miles west of Hebron. The victims were Palestinian workers returning home after a hard day’s work trying to earn a living. Following the Tarkumia incident demonstrations by Palestinian schoolchildren and citizens were met with gunfire and tear gas bombs resulting in 120 casualties, most of whom were children and reporters. Samer Bassam Karameh, a child of 13, was killed on his way back from school. 4. Health and medical teams were prevented from reaching their hospitals and centres in Jerusalem. Ministry of Health personnel were kept from performing their functions in the West Bank and Gaza. Primary health care services, immunization programmes and disease control efforts were thereby disrupted, and health personnel denied access to training courses provided by friendly nations and the World Health Organization. 5. The deterioration of economic conditions was reflected mainly and directly in the health status of the population. Land confiscation and the eviction of inhabitants also affected their psychological health. Unemployment was rampant, and “Terre des hommes” reports indicated increased malnutrition among children. Palestinian Authority territories face the continued deterioration of the economic infrastructure we warned against in past reports. 6. Throughout the months of blockade (June-August 1997) the Ministry of Health had to deal with an outbreak of viral fever among children. It treated 300 children, mostly under five years of age, one of whom died as a result of the fever.
7
A51/INF.DOC./5
Annex
ACHIEVEMENTS Despite all the difficulties, the Ministry of Health, the Palestine Red Crescent Society, and nongovernmental organizations, continued to face the consequences of settlement activities and provide care for victims of confrontation on a daily basis. The Ministry, on the other hand, went ahead with the establishment of PHC centres and hospitals.
1.
Health centres
Ten comprehensive basic health care centres, financed by the World Bank and Spain, were opened (at a cost of US$ 10 million). Work continues on five more centres in various parts of the Gaza Strip, and 18 more are planned for villages, towns and refugee camps (US$ 12 million) in the West Bank thanks to a Saudi grant and a loan from the Arab Development Bank. Twelve modern laboratories were provided with more equipment for the improvement of maternal and child health, and to update renal dialysis machines with financial assistance from Ireland and community participation.
2.
Hospitals
Bids for the construction of hospitals in Tulkarem, Jenin and Khan Younes were invited. Tenders will be decided upon late in 1998. Work on the new hospital in Jericho is due to begin on 1 June 1998 (75 beds) with financial aid from Japan. Al-Amal (PRCS) Hospital in Khan Younes with 150 beds is under construction, and equipment was upgraded in eight hospitals by virtue of funds provided by Japan, France and Spain. Intensive care units, and nurseries for newborn children in several hospitals, were also expanded and improved. Gaza Hospital: recruitment and training of staff will be carried out between 1 June and 1 October 1998. Two hundred new beds will be operational on 1 January 1999, and capacity will be raised to 230 beds by 1 April 1999.
3.
Human resource development
The development of human resources is a high priority for the Palestine Ministry of Health in view of its paramount importance in the provision of quality health services. Efforts continue for the training of sufficient numbers with the necessary skills and specializations to ensure better care. The Division of Human Resource Development was established for this purpose; and the Ministry of Health has concluded agreements with partners abroad for the strengthening of infrastructure and the utilization of expertise in this field. Two nursing schools have been established in Ramallah and Gaza as part of the development of human resources for health.
4.
Women’s health
The Division of Women’s Health and Development undertakes policy-making and planning with respect to women’s health and development in cooperation with women’s organizations, with financing by UNFPA and the European Union. Twenty-nine family planning clinics have been established, 16 in Gaza and 13 in the northern governorates. The Division also holds training courses and provides maternal health services, in addition to promoting breast-feeding, and education for women.
5.
Health education and promotion
With financing by the World Bank the Programme for Health Education and Promotion implements plans and activities related to health promotion and education. A centre for health education materials and the dissemination of health information has been established for this purpose. Radio and television programmes are broadcast with a view to raising health awareness, especially in relation to maternal and child health, adolescent health, and disease prevention.
8
Annex
A51/INF.DOC./5
6.
School health
The school health programme, financed by the Italian Government and supported by UNICEF, is a pioneering activity implemented by the Palestine Ministry of Health since taking control of the territories. Medical check-ups are administered to all new pupils in the first and second grades; annual immunization, health education and environmental, social and curative services are provided under this programme to 1000 schools with 850 000 students.
7.
Oral health
The oral health programme provides preventive and curative services to schoolchildren in cooperation with the French institution “L’Ecolier” which has donated three mobile dental units, and with the support of an Italian nongovernmental organization.
8.
Mental health
This programme trains people to provide mental health services in Palestine. Curative services are also provided in hospitals and at the community level, where two mental health centres have been established to deal with thousands of released captives and prisoners, as well as children who have been exposed to traumatic and oppressive experiences under occupation, in addition to health research activities in this field.
9.
Laboratories
Notable progress has been achieved in diagnostic and laboratory analysis services and blood banks. A laboratory specialized in public health has been set up with financial aid from the Government of Italy, and there has been a 150% increase in the number of laboratory technicians. Twelve other laboratories in the villages, camps and towns of the West Bank have been founded or expanded to improve the quality of maternal and child health services.
10. Medical emergency services These are being provided in all parts of Palestine effectively and efficiently despite limited resources. Training courses and workshops have been organized to provide personnel with the skills needed for civil defence activities and emergency response. The Palestine Red Crescent Society is responsible for this important activity in all parts of the country, in coordination with the Ministry of Health.
11. Health budget The budget of the Ministry of Health has risen from US$ 60 million in 1993 to US$ 96 million in 1998 (US$ 30 per capita). The Ministry of Health provides services to three million people in the West Bank and Gaza.
12. Health insurance Health insurance coverage has improved under the National Authority. It included some 25% of the population in 1993, and has now increased to 54%. Insurance premiums and other payments now account for 46% of the total expenditure of the Ministry. 13. Health indicators have improved over the past five years. Infant and child mortality has been reduced, and maternal mortality rates during childbirth have also decreased. Immunization of children against killer diseases has reached 99%, The Ministry of Health covers the high cost of vaccinations provided by UNRWA and in government health centres.
9
A51/INF.DOC./5
Annex
14. With World Bank funding the programme for the monitoring and improvement of the quality of health services is now in its third year, and is achieving good results in improving the quality of services.
CONCLUSION Despite the extremely difficult circumstances that prevail in Palestine, the Ministry of Health is actively strengthening the foundations of an integrated health care system by providing basic services to the population, protecting it against disease, and improving its health status. Numerous international organizations and countries have contributed to these efforts, but assistance has often been delayed by stringent Israeli policies which have hindered external aid and internal construction, creating thereby new burdens for the health care system, aggravated by new casualties and disability in the ranks of Palestinian youth. The recent Israeli practices are further proof that the health of the Palestinian people cannot be improved or be developed except by putting an end to occupation once and for all and granting the Palestinian people their legitimate right to establish their own State and achieve sovereignty over land, water and natural resources, granting them the freedom to travel from one part of their homeland to the other, and to have free access to international gateways to all countries of the world. The Palestinian people look to all countries of the world to support them in order to get their rights and attain the ultimate goal of the World Health Organization: achievement of health for all by the year 2000.
=
=
=
10