The plight of Palestine refugees

The p6ght of Palestine refugees T?re~ ~ale .:re· fu. gees shot mclttdimg: one: ag.ed 14 - two with c hest wounds, one with an abdominal wound ... two male refugees shot with plastic covered metal bullets . . . five mal1es. inclu:d'fng two aged 6 and 12, beaten . . . two female refug,ees, one fom- months pregnant, treated for tear gas intox:lication . . . soidiers entered UNRWA school and expfoded tear gas canisters . . . This is part of a typical dai-ly situation report from the fiefd oilice in the Gaza strip of the UN Relief and Works Agency for Palestine Refug,ees 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 beat- ings, 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 by Robert Cook Director of Health, UNRWA child care, supplementary feeding and inoculations. But now many clinics have become more like field hospitals in a war zone. DT Robert Cook was for- meriy Senror Medlcat Officer in WHO's DivisLon of family H~a~th in Geneva. Working with local hea}th care factl<ities, UNRWA has provided extra equipment for hospitals, such as spedan splints for multiple fractures and equPpment for an ophthalmic hospitaft in Jerusalem, and much more ts on the way. It has established a physiotherapy programme in Gaza with the hefp of UNfCEF in order to rebabmtate mjwed refugees. Clinics in both the West Bank and Gaza have extended their hours. Plrofessional medical staff has been doubled. Two camps in the Gaza Strip now have round-the-dock medical care available at the UNRWA clinics. And: the supple- mentary feedfng 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 1.4 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 provid- ing mobile medical teams to visit areas where refugees have fled for safety. During its almost 40 years of exist- ence, 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 medi- dne, and has limited curative services to care at a level generally about equal to that provided by host coun- tries for their own residents. The Agency does subsidise some 1,500 hospital beds in all five areas of operation and provides financial assis- tance 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 - srx in the Gaza Strip and two in the West Bank - with a total of 65 beds. Twa elderly Palestine refugees contem- plate an uncertain future. Photo WHO/P. Almasy The living conditions of the refugees, in a sub-tropical area condu- cive to insect-borne epidemics, have made health a major concern_ Shelter in the camps initially consisted of tents, and proper sanitary facilities were Jacking. Today most people live in mud-brick or concrete-block houses. There is overcrowding but conditions in the camps have grad- ually improved, thanks partly to the installation of private septic-tank latrines and private water taps. The living conditions of the two-thirds of the refugees who never became camp dwellers have also been substandard, and monitoring their health has pre- sented a serious problem. UNRWA: Past, Present and Future, published by UNRWA in 1986, pro- vides a vivid description of the health situation of the refugees and of the achievements that have been realised: - The displacement of hundreds of thousands of poverty-stricken re- fugees and their re-location in neigh- bouring Arab countries, with low- budget public health administrations, posed a threat that had to be con- tained. The situation required a conti- nuous control operation, against lice during winter, fleas in spring, flies and malaria vectors during summer and autumn. - UNRWA played a major part in the eradication of malaria from its area of operations in the period 1950-1959, and the prevention and control of major communicable diseases WORLD HEALTH , July 1989 (cholera, smallpox and typhus) has been a remarkable - and largely unknown - success story. No major epidemic of a reportable disease has ever afflicted the refugee population for whose health UNRWA has been responsible for 40 years, though the margin of safety has always been too narrow for complacency. Preventive activities - Preventive health activities have included, in addition to the environ- mental health services in the camps, immunizing children against the com- mon communicable diseases; mater- nal and child health care ; supplementary food for children, pregnant and nursing women, and tuberculosis out-patients; and health education focusing on personal and food hygiene. The benefits have been reflected in a reduced demand on the curative services and in the reasonably satisfactory results of nutrition surveys conducted under WHO auspices every few years. UNRWA operates 100 clinics or health centres staffed by 158 medical officers, 611 nurses and 632 other personnel. People needing hospital care are generally referred to UNRWA- subsidised beds in private hospitals, but a shortage of funds has made it impossible to provide adequate hospi- tal care in all the areas for which the Agency is responsible. Given the particular circumstances of its establishment and continuation, 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 moni- toring (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 pio- neered in the 1950s an oral rehyd- ration 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 con- cern not just in the Eastern Mediter- ranean 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 The plight of Palestine refugees 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 vbluntary contribu- tions, 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 gov- ernments. Moreover, these services have to be continuous: any dimi- nution or termination of a service, even if necessitated by funding defi- cits, 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 Secretary- General 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 in- cludes 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 Lebanon 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 dan- ger 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 pro- vides 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 second- ary 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 in- service 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 much- needed boost. The number of voca- tional training places at eight training centres has been increased to more than 3,000 (of which 592 are occu- pied by women), and some 35,000 artisans, technicians and profession- als have graduated from UNRWA's vocational training centres. The Agency also provides 350 university scholarships each year for young refugees. • WORLD HEALTH, July 1989