The p&ght of Palestine refugees by Robert Cook Director of Health, UNRWA hree male refugees shot including one aged 14 - two with chest wounds, one with an abdominal wound .. . two male refugees shot with plastic covered metal bullets . . . five males, including two aged 6 and 12, beaten . . . two female refugees, one fourmonths pregnant, treated for tear gas intoxication . . . soldiers entered UNRWA school and exploded tear gas canisters ... This is part of a typical dajly situation report from the field office in the Gaza strip of the UN Relief and Works Agency for Palestine Refugees in the Near East. Since the beginning, in December 1987, of the Palestinian intifada (uprising) up to March 1989, UNRWA clinics in Gaza have treated over 14,000 persons: 6,737 for beatings, 948 for rubber bullet wounds, 4,140 for gas intoxication, and 2,213 shot by live rounds or plastic-covered metal bullets. The figures could be doubled for clinics on the West Bank of the River Jordan. The uprising has put a severe strain on UNRWA's health care programme in the Israeli-occupied territories. The Agency provides basic health care for Palestine refugees, mother and
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child care, supplementary feeding and inoculations. But now many clinics have become more like field hospitals in a war zone. Dr Robert Cook was formerly Senior Medical Officer in. WHO's Division of Family Health in Geneva.
Working with local health care facilities, UNRWA has provided extra equipment for hospitals, such as special splints for multiple fractures and equipment for an ophthalmic hospital in Jerusalem, and much more is on the way. It has established a physiotherapy programme in Gaza with the help of UNICEF in order to rehabilitate injured refugees. Clinics in both the West Bank and Gaza have extended their hours. Professional medical staff has been doubled. Two camps in the Gaza Strip now have round-the-clock medical care available at the UNRWA clinics. And the supplementary feeding programme has been expanded. The situation isn't as dramatic in UNRWA's three other fields of opera· tion: Jordan, Lebanon, and the Syrian Arab Republic. But over the past 14
years in Lebanon, its medical person· nel have had to respond to many serious health care problems, and in some cases the Agency is still providing mobile medical teams to visit areas where refugees have fled for safety. During its almost 40 years of existence, it has had to deal continually with emergencies. Since UNRWA began operations in May 1950, WHO has been responsible for the technical direction of the Agency's health programme. The pro· gramme has always emphasised public health and preventive medicine, and has limited curative services to care at a level generally about equal to that provided by host countries for their own residents. The Agency does subsidise some 1,500 hospital beds in all five areas of operation and provides financial assistance in some cases for specialised curative care. The only hospital run by the Agency is a 36-bed hospital in the West Bank, and eight maternity units - six in the Gaza Strip and two in the West Bank - with a total of 65 beds. Two elderly Palestine refugees contemplate an uncertain future. Photo WHO/P. Almasy
The living conditions of the (cholera, smallpox and typhus) has refugees, in a sub-tropical area condu- been a remarkable - and largely cive to insect-borne epidemics, have unknown - success story. No major made health a major concern. Shelter epidemic of a reportable disease has in the camps initially consisted of ever afflicted the refugee population tents, and proper sanitary facilities for whose health UNRWA has been were .lacking. Today most people live responsible for 40 years, though the in mud-brick or concrete-block margin of safety has always been too houses. There is overcrowding but narrow for complacency. conditions in the camps have gradually improved, thanks partly to the Preventive activities installation of private septic-tank - Preventive health activities have latrines and private water taps. The included, in addition to the environliving conditions of the two-thirds of mental health services in the camps, the refugees who never became camp immunizing children against the comdwellers have also been substandard, mon communicable diseases; materand monitoring their health has pre- nal and child health care ; supplementary food for children, sented a serious problem. UNRWA: Past, Present and Future, pregnant and nursing women, and published by UNRWA in 1986, pro- tuberculosis out-patients; and health vides a vivid description of the health education focusing on personal and situation of the refugees and of the food hygiene. The benefits have been achievements that have been realised: reflected in a reduced demand on the - The displacement of hundreds of curative services and in the reasonably thousands of poverty-stricken re- satisfactory results of nutrition surveys fugees and their re-location in neigh- conducted under WHO auspices every bouring Arab countries, with low- few years. UNRWA operates 100 clinics or budget public health administrations, posed a threat that had to be con- health centres staffed by 158 medical tained. The situation required a conti- officers, 611 nurses and 632 other nuous control operation, against lice personnel. People needing hospital during winter, fleas in spring, flies and care are generally referred to UNRWAmalaria vectors during summer and subsidised beds in private hospitals, but a shortage of funds has made it. autumn. - UNRWA played a major part in the impossible to provide adequate hospieradication of malaria from its area of tal care in all the areas for which the operations in the period 1950-1959, Agency is responsible. and the prevention and control of Given the particular circumstances major communicable diseases of its establishment and continuation, W OR LO HEALTH,
A crowded nutrition and preventive health centre in the Gaza area_ Photo WHO/ Michel Biihrer
the Agency has always suffered from a certain reticence about publicising its successes. Certainly for many years the infant mortality rate in the camps was kept lower than that of any neighbouring Arab country, which is surprising in the light of the poor environmental conditions. UNRWA pioneered the use of growth monitoring (growth charts have been in universal use since the mid -1950s), and of nutrition rehabilitation centres. It is many years since more than a small fraction of births among refugees were assisted by untrained birth attendants. Another surprising fact, known to very few public health experts today, is that UNRWA pioneered in the 1950s an oral rehydration therapy much like that which WHO and UNICEF promote today. The plight of the Palestinians who lost their homes and livelihood as a result of the Arab-Israeli conflict of 1948 continues to cause grave concern not just in the Eastern Mediterranean Region but throughout the whole international community. UNRWA was established in December 1949 by the UN General Assembly to assist the hundreds of thousands of people who fled into neighbouring countries, seeking what was presumed to be temporary refuge. It has had its 9
July 1989
Checking on the blood pressure of a mother-to-be at a clinic in a poor quarter of Gaza town. Photo WHO/ Michel Biihrer
mandate repeatedly renewed, for the problems of these refugees have yet to be satisfactorily solved. The current mandate runs to 30 June 1990. Unlike other UN organizations dependent on voluntary contributions, UNRWA does not fund projects, but finances the operation of schools, clinics, and feeding centres for the refugee population. Its budget covers a staff of over 17,500, supplies, and other essentials needed for providing health, education and welfare services of a kind generally provided by governments. Moreover, these services have to be continuous: any diminution or termination of a service, even if necessitated by funding deficits, can have political implications and hence serious consequences. As one financial crisis has followed on the heels of another, the UN General Assembly, through the UN SecretaryGeneral and others (for instance, a working group on the financing of UNRWA), has made various efforts to obtain the needed funds. UNRWA's relief services consist of a 10
"special hardship case" programme and a general welfare programme. The former provides food and other necessities to about five per cent of the refugee population - widows, orphans, the aged, the mentally and physically handicapped, and the chronically sick and their dependants. The general welfare programme includes case work, emergency aid, training of adults and the disabled, activities for pre-school children and for women , and promotion of income-generating projects. Relief is also provided on an emergency basis to a wider refugee population after wars and during times of civil strife. Renewed emergency operations The 1982 invasion of kebanon by Israeli forces led UNRWA to mount a US $60.3 million emergency relief programme, which was continued until 1984. Further hostilities called for renewed emergency operations in subsequent years - operations that were carried out under conditions of considerable difficulty and even danger to the Agency itself. Currently in the occupied territories of the West Bank and Gaza Strip, it has extended its relief programme. The UNRWA education system provides the first nine years of schooling
(except in Lebanon, where it is ten years) after which the children can go on to government or private secondary schools to complete 12 years of education. The Agency has some 350,000 pupils in its 635 schools, with a teaching staff of 11,000. Lacking funds for construction, the Agency has been forced to rent buildings as schools that are rarely suited for classroom use. Another major problem at the beginning was a dearth of qualified teachers, so teacher-training began as early as 1952. Since 1956, UNRWA has turned out 12,560 qualified elementary schoolteachers from its centres. And it has developed a programme of inservice training, run by an Institute of Education staffed, at the higher levels, by UNESCO-appointed experts. The development of vocational training began in the early 1950s, but funds raised during World Refugee Year (1959/1960) gave it a muchneeded boost. The number of vocational training places at eight training centres has been increased to more than 3,000 (of which 592 are occupied by women), and some 35,000 artisans, technicians and professionals have graduated from UNRWA's vocational training centres. The Agency also provides 350 university scholarships each year for young • refugees. W ORLD HEALTH,
July 1989