WORLD HEALTH ORGANIZATION FIFTY-FIFTH WORLD HEALTH ASSEMBLY Provisional agenda item 18 A55/INF.DOC./3 16 April 2002
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 2001.
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ANNEX REPORT OF THE DIRECTOR OF HEALTH, UNRWA, FOR 2001
INTRODUCTION 1. With a total number of 1164 locally recruited staff and a modest budget of US$ 28.5 million allocated to the programme in 2001, UNRWA provided comprehensive health care services to about 1.5 million Palestine refugees in the Gaza Strip and the West Bank through a network of 51 primary health care facilities in and outside camps supported by outsourced hospital services. UNRWA also provided environmental sanitation services in 27 refugee camps. Moreover, UNRWA continued to provide health care to an additional number of about 2.4 million refugees in Jordan, Lebanon and the Syrian Arab Republic, with emphasis on expanded maternal health and family planning, child health care and integrated control of communicable and noncommunicable diseases. 2. By the end of 2001, 15 months into the continuing crisis in the occupied Palestinian territory and with little sign that the cycle of violence will end, the Palestinians were facing a grim and uncertain future. Ever-tightening restrictions on freedom of movement, prolonged curfews, military incursions deep into population centres, demolitions of houses, the destruction of agricultural crops, the uprooting of citrus and olive groves and widespread damage to infrastructure had left behind a heavy toll on the economic, social and psychological well-being of the people as well as service delivery and quality. 3. Among Palestinians, refugees have been the most vulnerable. In Gaza Strip there are 865 000 refugees registered with UNRWA and in the West Bank the figure is 618 000, constituting over 50% of the Palestine population (70% in Gaza Strip and 30% in the West Bank). UNRWA, the United Nations agency whose sole concern is the welfare of the Palestine refugees, had, therefore, to face the double burden of responding to the emergency humanitarian needs of the population whom it serves while struggling to sustain its regular programme activities and prevent breakdowns in service delivery and quality. This task could be described as anything but easy in the light of the extraordinary measures imposed on the occupied territory and the obstacles to humanitarian access. 4. The devastating effects of the continuing crisis disrupted and reversed nearly four years of economic recovery and undermined considerable gains in building Palestinian physical and institutional infrastructure. The resulting conditions would require years of relief assistance in order to recover from conflict through peace and development, even if there was a glimmer of hope to move towards a just, comprehensive and durable peace based on the relevant United Nations resolutions and the agreements signed by the Israeli Government and the Palestinian Authority.
IMPACT ON HEALTH 5. According to the Palestinian Red Crescent Society, the casualty rate during the period September 2000 to September 2001 was 866 per 100 000 population and the crisis-related death rate was 18 per 100 000 population. The Society reported a total of 892 deaths and 23 231 injuries during the period 28 September 2000 to 20 January 2002, of which 357 deaths and 8476 injuries were in Gaza and 537 deaths and 14 755 injuries were in Jerusalem and the West Bank (see figure below).
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Breakdown of the monthly deaths and injuries September 2000 to December 2001 Deaths 400 5062
Injuries 5500
Deaths 300 3838
Injuries
4000
200
2500
100 933
781 471
598
727
715
932 319 394 474 657
407 304 160
1000
0 0 20 121 123 63 20 23 39 40 57 24 40 45 69 91 48 72
Sep Oct Nov Dec Jan 2000
Feb Mar Apr May Jun July Aug Sep 2001
Oct Nov Dec
6. More than half the Palestinians killed by the middle of January 2002 were refugees registered with UNRWA. Of the total number of deaths 33% were individuals under the age of 18 years. More troubling is the fact that, since the start of the intifada, 25 students enrolled in UNRWA schools in Gaza Strip and four in the West Bank have been killed, 11 of them between the ages of six and 12 years. 7. Another 545 students in Gaza Strip and 245 in the West Bank have been injured. Owing to the severity of injuries, it is expected that a large proportion of those injured will sustain permanent disability. The psychological effects of loss of loved ones, mass destruction and excessive use of military force have been devastating for vulnerable groups, especially women and children. Coupled with the generalized socioeconomic hardship, disappointments and frustration, feelings of fear and insecurity generated new conditions in which post-trauma stress disorders had become common place. 8. The Israeli authorities have imposed the most severe and sustained set of restrictions on the movement of people and goods on the occupied Palestinian territory. Mobility has been directly restricted between the territory and Israel, within the West Bank and the Gaza Strip, and between the territory and international borders. In addition, the broader climate of uncertainty and insecurity also has had an impact on mobility. The restrictions, often resulting in delays in or prevention of delivery of services, continue to obstruct seriously the fulfilment of UNRWA’s mandate, with adverse humanitarian implications. Obstacles to UNRWA’s service delivery adversely affect the supply of humanitarian goods, while mobility restrictions adversely affect accessibility of beneficiaries to UNRWA distribution points, health centres, schools and the like. The impact of impediments to humanitarian access of both beneficiaries and UNRWA may have long-term implications.
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9. The restrictions on movement have been compounded by the most severe internal closure measures ever implemented. In effect, the West Bank has been cut up into no less than 64 islands. In the case of severe closures, this has entailed the prohibition on use of primary roads and the placement of physical barriers on many secondary roads between Palestinian villages and towns. During partial internal closures, most secondary roads, but only some main roads, have been accessible to the Palestinians, albeit often with restrictions. The restrictions have hampered UNRWA’s regular operations and emergency service delivery, resulting in cessation of several construction projects, several days of full school closure and delays in emergency assistance delivery, at no small cost to UNRWA. 10. The crisis also had its impact on the Agency’s services. In the West Bank most disturbing was the breakdown in preventive services. The crisis has led to a 10.4% increase in the incidence of low birth weights and a 52% increase in the stillbirth rate. The prevalence of iron-deficiency anaemia among pregnant women in the West Bank increased significantly as they sought antenatal care late in the course of pregnancy and their attendance at UNRWA primary health care facilities was irregular. Four women were reported to have delivered at military checkpoints on their way to hospitals, two from Nablus area and one each from Jerusalem and Hebron areas. In Gaza Strip, medical consultations at UNRWA clinics rose by 29% and dental consultations by 23% as refugees increasingly turned to UNRWA’s services. In both areas, the proportion of patients suffering from diabetes and hypertension, whose conditions were not controlled, had increased owing to irregular attendance. Progress on implementation of projects for development of the infrastructure of camps slowed owing to the prevailing circumstances. 11. Poverty is directly associated with ill-health and adverse health outcomes. Persistently high rates of unemployment (according to the World Bank’s estimates, already 33% by June 2001) have driven increasing numbers of households into poverty. By that date, 47% of households had seen their incomes halved, with almost half the Palestinian population getting by on less than US$ 2.0 a day. According to the Office of the United Nations Special Coordinator in the Occupied Territories, in the third quarter of 2001, the unemployment rates reached 31.5% in the West Bank and 48% in Gaza Strip. According to recent estimates, the Palestinian economy lost as much as US$ 3200 million by the end of September 2001. 12. The destruction to infrastructure was not limited to the Palestinian Authority institutions and industrial establishments but also affected homes of the civilian population, private property and UNRWA installations. In Gaza Strip alone, by mid-January 2002, a total of 660 houses had been totally or partially damaged by the Israeli armed forces, of which 573 belonged to refugees, and a total of 5116 persons had become homeless. 13. While the Agency was largely able to prevent breakdowns in the delivery and quality of its preventive services, it encountered new challenges resulting from the increased demand on curative outpatient and hospital services. This was mainly because increasing numbers of refugees who previously used the services of other health care providers had become unable to utilize them because of either sudden impoverishment or problems of mobility and access. In addition, most families had become unable to pay their cost-sharing for hospital and specialized care. These challenges placed additional financial constraints on UNRWA.
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UNRWA RESPONSE 14. UNRWA responded to this unprecedented emergency by launching three appeals for emergency humanitarian assistance to Palestinian refugees during 2001, seeking funding of about US$ 160 million. Confirmed pledges to these emergency appeals amounted to US$ 131 million, of which about US$ 102 million were received. Under this programme of emergency humanitarian assistance, UNRWA provided emergency medical care services, food aid, post-injury physical rehabilitation, psychological support and counselling, cash assistance to needy families, shelter repair and rehabilitation, and it had established a programme for emergency employment creation. 15. Responding to the massive loss of jobs and income, UNRWA’s emergency employment programme provided opportunities for direct and indirect hire through community-based organizations, associated institutions and private-sector contracts. In the period between January and December 2001, a total of 11 787 persons with over 95 000 dependants benefited from three months’ temporary employment under the direct-hire programme in Gaza Strip. In the West Bank over the same period 2669 individuals with over 12 500 dependants were employed. 16. In addition to providing job opportunities for the unemployed, the programme helped to meet the additional demands on UNRWA services due to the emergency. By the end of December 2001, the Agency had paved more than 70 000 m2 of sandy alleyways in the refugee camps of the Gaza Strip under the emergency employment programme, and the paving of a further 160 000 m2 was in progress. 17. Since the beginning of the crisis, UNRWA has made four emergency food distributions to a total number of 127 500 families each in Gaza Strip, and four rounds of distribution in the West Bank, targeting 90 000 families in the first and 50 000 in the fourth round. Over one million metric tons of food commodities, with a total value of US$ 27.2 million, were distributed. By supplying staple food commodities, including flour, rice, sugar, vegetable oil and powder milk (none of which is produced locally), to the poorest households, the Agency helped them to release funds for other basic needs and contributed to establishing food safety nets to avoid deterioration of the nutritional status. 18. The crisis had generated new demands and challenges that needed to be addressed by the Agency. In remote villages of the West Bank, the closures and military checkpoints have meant that many staff and patients are either unable to reach health centres or can do that with great difficulty. Hospitals contracted by UNRWA had become increasingly inaccessible, with the result that patients in need had to be treated at other hospitals and call on UNRWA for financial assistance. UNRWA established three emergency mobile teams, run in close cooperation with nongovernmental organizations, and recruited additional staff to cope with the increase in demand for services at the health centre level as well as in the Agency-run hospital in Qalqilia. Additional hospitalization assistance has been provided to those who cannot reach contracted facilities, and additional ambulances, medical and physiotherapy equipment have been provided to health centres. This support was complemented by in-service training of health staff to enhance the capacity of the health care system in emergency and casualty care. 19. In Gaza Strip, owing to restrictions on the mobility of Agency staff, measures to avoid a decline in preventive services, such as the expanded programme on immunization, maternal health and family planning services, included the hiring of an additional 292 medical and other health personnel. 20. In response to the sudden and widespread psychological distress that resulted from the violent conflict and its social, economic and behavioural consequences, UNRWA carried out a situation analysis and established a programme of psychological support for the Palestine refugees, targeting
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mainly vulnerable population groups such as children, adolescents and women in the West Bank. Because of the Agency’s limited experience in this field, the Foundation for Health and Social Development was contracted to establish the management structure and develop coordination mechanisms in close collaboration with the Agency’s health, education and social services departments and in partnership with local nongovernmental organizations, specialized centres and community organizations at the grass-root level. The guiding principles in implementing project activities revolved around development of a programme that is focused on a preventive, multidisciplinary approach to the emergency situation within a developmental outlook that seeks to integrate the concepts of mental health into primary health care (away from clinical psychiatry), network with national and international nongovernmental organizations working in the area of mental health, involve community organizations and enhance institutional capacity building. 21. Progress so far has comprised development of a training guide, creation of a directory of all organizations working in the field of psychological well-being and community organizations in refugee camps, and reproduction of relevant educational material. Training was carried out by five partner organizations and targeted social workers, health professionals, teaching staff and community workers. In addition, 60 workshops were conducted for children and adolescents. Seventeen community organizations were equipped and empowered to support project activities, and partnerships were forged with UNICEF and Save the Children Fund. Appropriate mechanisms were developed for evaluation, monitoring and follow-up of project activities.
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