WORLD HEALTH ORGANIZATION FIFTY-SIXTH WORLD HEALTH ASSEMBLY Provisional agenda item 19 A56/INF.DOC./4 25 April 2003
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 WHO special representative and Director of Health, UNRWA, for the year 2002.
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ANNEX REPORT OF THE WHO SPECIAL REPRESENTATIVE AND DIRECTOR OF HEALTH, UNRWA, FOR 2002
CONDITIONS IN THE OCCUPIED TERRITORY 1. According to the report of the Personal Humanitarian Envoy of the United Nations SecretaryGeneral “a serious and mounting humanitarian crisis is occurring in the West Bank and Gaza. The crisis is provisionally evidenced by rising levels of malnutrition among children, high levels of poverty and unemployment, deteriorating health conditions and an increasing exhaustion of the coping mechanisms. The situation is a crisis of access and mobility. Palestinians are subject to a variety of closures, curfews, roadblocks and restrictions that have caused a near-collapse of the Palestinian economy, rising unemployment, increased poverty, reduced commercial activities, limited access to essential services (such as water, medical care, education, emergency services) and rising dependency on humanitarian assistance. The restrictions affect almost all activities, rendering most Palestinians unable to carry out any semblance of a normal life and subject to daily hardship, deprivations and affronts to human dignity”. 2. The large-scale humanitarian crisis took on a new dimension since the reoccupation of major parts of the Palestinian self-rule areas, and the military incursions into towns, villages and camps after March 2002. Humanitarian conditions in the West Bank and Gaza Strip fell to levels unprecedented in 35 years of occupation. Two military offensives, each in turn greater in scope and intensity than anything that had gone before, left hundreds of Palestinians killed and many more injured. For most of 2002, the Gaza Strip remained totally sealed and was bisected by checkpoints. However, movements within certain geographical areas and inside camps have remained largely unaffected. This has meant that refugees could generally access health care services. Tight closures, curfews, and military incursions have severely affected the population’s access to health and other services in the West Bank. This has been particularly serious where towns and villages have been isolated for considerable periods of time, by permanent and temporary roadblocks, ditches, concrete blocks and the newly constructed separating wall. Not only has this made access extremely difficult for those needing services, it has also impeded service providers such as UNRWA and the Palestinian Authority. 3. The growing rates of poverty, exceeding 55% in the West Bank and 70% in the Gaza Strip, have brought a significant deterioration in the health and nutritional status of the population. The heavy casualty toll, widespread destruction of infrastructure, house demolition and uprooting of trees and crops left thousands of families homeless or without a source of income. According to a USAIDfunded nutrition survey, more than half of the Palestinian population reported having to decrease food consumption, especially food rich in protein, and almost one-third of the population were largely dependent on UNRWA’s food aid, mainly because of curfews, closures, unemployment and loss of income. The study also revealed an alarming increase in the rates of chronic and acute malnutrition among children, and high rates of anaemia among women of reproductive age and preschool children. 4. While the offensive on Jenin camp was under way and for days afterwards, UNRWA and other humanitarian agencies were denied entry to the camp, even to evacuate the wounded and the dead. Twelve days after the assault began and four days after the fighting had ended, personnel from The International Committee of the Red Cross and the Palestine Red Crescent Society, and an UNRWA ambulance were allowed to enter the camp. Approximately 10% of Jenin refugee camp was destroyed. 3
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Some 521 buildings were reduced to rubble, 449 were severely damaged and 3639 were partially damaged. The destroyed buildings housed approximately 450 refugee families who had become homeless. Relief workers at the camp recovered 54 bodies. Meantime, the offensive widened to other towns, villages and refugees camps. The toll of casualties in the old town of Nablus was even higher. While the offensive in the West Bank was ongoing, the Gaza Strip was not spared and was subject to air raids and frequent military incursions, causing mass destruction and human loss. This pattern persisted throughout the year and further intensified during the first quarter of 2003. 5. UNRWA’s medical statistics show that the demand for its primary health care services has increased considerably since the current crisis in the occupied territories. The increased demand is mainly due to the fact that an increasing number of refugees turned to UNRWA, rather than other health care providers, either because of sudden impoverishment or due to problems of mobility and access. While the average daily bed-occupancy rate in the UNRWA-run hospital in Qalqilia, West Bank, and utilization of the services of the UNRWA-contracted hospital in Gaza dropped significantly, due to problems of access, demand increased for UNRWA assistance to support the cost of treatment in other hospitals. At the time when demand for services was at its height, UNRWA’s ability to provide health services was disrupted by the restrictions imposed on movements of staff, vehicles and supplies. The indications of serious breakdowns in accessibility, utilization and quality of preventive services to women, children and patients suffering from noncommunicable diseases and other life-threatening conditions were most disturbing. These findings were ascertained by UNRWA rapid assessments and confirmed by a USAID study begun in August 2002 to monitor health-service delivery at primary health care facilities run by the Ministry of Health, UNRWA and nongovernmental organizations in the Gaza Strip and the West Bank. 6. Acceleration of the Israeli settlement activities brought yet another dimension to the humanitarian crisis. The programme was not accompanied by adequate and proper environmental considerations – none of the settlements have developed sewage-treatment plants. The sewerage system of the settlements on the eastern hills and slopes north of Jerusalem has contaminated fresh water supplies for drinking-water and the irrigation of Palestinian areas up to Jericho. Serious risks to health are posed by the chemical waste from Israeli factories in the Al-Naqab area, which passes the valley into the sea, and by the internal sewage leaks from Israeli settlements, which are centred over the groundwater tables in the Gaza Strip. Closures and curfews have at times prevented removal of refuse to dumpsites, posing health risks to camp residents. Military activities have also caused serious damage to the camps’ water and sewerage networks, increasing the risk of disease outbreaks due to cross-contamination. In evidence, an outbreak of Shigella sonnei took place in Balata camp, Nablus area in the West Bank during July 2002 due to cross-contamination of water and sewerage networks. A total of 667 cases were reported, mainly children below 16 years of age. The severe water shortages experienced in many rural areas throughout the West Bank are potentially catastrophic from a humanitarian perspective. 7. Mounting violence, tragic loss of human life, humiliation at military checkpoints and sudden drop into poverty have been sources of acute psychological disorders and post-trauma stress syndromes for Palestinians especially women, children, youth and the elderly. The lack of adequate facilities for psychological counselling and support poses a serious risk of growing rates of violent behaviour and long-term psychological consequences.
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UNRWA’S EMERGENCY RESPONSE 8. Since the beginning of the humanitarian crisis, UNRWA has launched one flash appeal and four emergency appeals to implement a comprehensive programme for emergency humanitarian assistance. These comprised, inter alia, emergency employment generation, emergency food aid, emergency shelter repair/reconstruction and emergency medical care. In January 2002 UNRWA requested US$ 117 million for emergency activities planned through the year. A further US$ 55.7 million were requested in June to meet needs that arose directly after the March-April events, including the military offensive at Jenin and other refugee camps that imposed a new humanitarian burden on a chronically worsening situation. Through these appeals, UNRWA has requested funding of US$ 333.2 million during the period October 2000 to December 2002. Confirmed pledges, both cash and in-kind, amounted to US$ 227.7 million (approximately 68%). However, while the need for humanitarian assistance was increasing, contributions were steadily declining, making it difficult to implement all the planned interventions. In addition, UNRWA launched an appeal for maintaining the programme of emergency assistance, initially for six months in 2003, at approximately US$ 94 million.
Emergency appeals funding status (US$ million) 2000-2001 Appeals Amount requested Confirmed pledges 160.3 133.1 2002 Appeal 172.9 94.6 Total 333.2 227.7
9. Under the 2002 appeal, emergency health and health-related needs were estimated at approximately US$ 3.0 million covering procurement of medical supplies, mobile clinic services, additional hospitalization costs, physical rehabilitation services and additional environmental health services. 10. In addition, the World Health Organization donated 50 new emergency kits, each covering the needs of 10 000 people for essential medicines for three months, at a cost of US$ 500 000. The kits were placed in various locations in the Gaza Strip and the West Bank to meet any unforeseen need in the event that these areas were totally sealed for prolonged periods. The WHO Eastern Mediterranean Regional Office provided the services of a sanitary engineer, provisionally for three months, to assist in rehabilitation of the water and sewerage networks in Jenin camp. This was an integral part of an UNRWA project for camp reconstruction funded by the United Arab Emirates at US$ 30 million. UNRWA also participated in a WHO-led mission in October 2002 to assess the current nutritional status of the population and advise on future intervention strategies. The mission stressed the importance of developing a national food and nutrition strategy addressing the immediate emergency measures and long-term development needs. 11. The capacity of the health care system to deal with emergency and casualty care has been enhanced through provision of additional equipment and supplies to all primary health care facilities as well as to the UNRWA-run hospital in Qalqilia, north of the West Bank. Additional personnel were recruited on three-month contracts to meet the increased demand on UNRWA medical-care services or to replace staff who could not reach duty stations. In-service training courses were conducted to enhance the skills and capabilities of UNRWA health personnel in emergency care. Emergency mobile teams in the West Bank provided essential medical care services to remote localities. In addition, UNRWA primary health care facilities both in the Gaza Strip and the West Bank provided emergency
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care through extended evening and night shifts during military incursions into camps. Owing to difficulties in access to UNRWA-contracted hospitals in the West Bank, contracts were concluded with three hospitals in Jenin, Nablus and Ramallah. Additional hospitalization costs were allocated under the programme of emergency assistance to cover the cost of treatment at other hospitals or to meet the additional expenditure due to the inability of many families to contribute to the cost of treatment. 12. After the large-scale military offensives in March/April 2002, UNRWA mounted a relief operation to assist the thousands of refugees who fled from the fighting in Jenin camp and afterwards to families who became homeless or were stranded by tight closures. From 18 April onwards, UNRWA work in the devastated camp of Jenin was supported by specialist disaster personnel from donor countries and the United Nations office for the Coordination of Humanitarian Affairs. The top priority was to remove or de-activate unexploded ordnance and booby-traps, and to support unstable structures that might collapse. This made it possible to start a large-scale operation for removal of rubble while work was in progress to prepare technical designs for camp reconstruction and rehabilitation of infrastructure, including water and sewerage systems. 13. Through its emergency food aid programme, UNRWA provided food aid to approximately 1.3 million people, representing one-third of the population, targeting 127 000 refugee families in the Gaza Strip and 90 000 families in the West Bank. A total of 927 537 food parcels were distributed to families in greater need. By supplying staple food commodities – none of which were produced locally – to the poorest households, UNRWA helped those households to release funds for other basic needs. In this way it contributed to establishing food safety nets in a manner that neither disrupted the local market economy nor helped to perpetuate dependency. In addition, UNRWA maintained its programme of providing iron supplementation to pregnant women and children through its maternal and child health care clinics and fortified wheat flour with iron and folate as part of the strategy to combat iron deficiency anaemia. 14. In collaboration with local partners, UNRWA developed a programme for psychological counselling and support. Focused on a preventive multidisciplinary approach, the programme forged partnerships with national and international nongovernmental organizations working in the area of mental health as well as with grass-root community organizations. Programme activities included group and individual guidance and counselling, meeting parents and other family members, training workshops and referral of difficult cases for treatment at professional institutions. 15. Consistent with its approach of dealing with the emergency within a developmental outlook, UNRWA supported an emergency employment-generation programme focused on implementing environmental self-help programmes for improvement of camps’ infrastructure as well as investments in the health and other sectors. This included paving 346 420 m2 of roads and pathways in refugee camps of the Gaza Strip and the West Bank.
FUTURE CHALLENGES 16. UNRWA is the largest service provider in the occupied territories after the Palestinian Authority. The Agency recognizes the importance of coordinating its activities with the Palestine Authority and other organizations including other United Nations agencies, the International Committee of the Red Cross and international and national nongovernmental organizations, in order to minimize the potential for duplication or gaps and to ensure a more effective emergency response. The Humanitarian Action Plan for the occupied territories prepared by the United Nations Technical
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Assessment Mission, combines the emergency activities of the key agencies working in the region in the context of support to Palestinian institutions, and provides donors with an opportunity to understand the overall future needs for the territories. 17. UNRWA is deeply concerned that, even when the current humanitarian crisis is over, the transition from conflict to recovery and development will place additional burdens on UNRWA and other aid organizations for years to come in terms of capacity-building, rehabilitation of civil infrastructure, post-injury physical rehabilitation, psychological counselling and support and food security. In order to be effective, these health and health-related interventions require substantial resources and need to be complemented by concomitant multisectoral interventions.
Crisis indicators up to 31 December 2002 (A) Indicators of increased demand for UNRWA services1 Gaza Strip (i) (ii) (iii) (B) (i) (ii) Medical consultations Medical supplies Dental consultations Indicators of breakdown in service provision2 Person/days lost (UNRWA PHC facilities) Regular attendance for growth monitoring – Children below two years of age – Children below three years of age (iii) Infants completed primary series of immunization on schedule 2% 3% No change -(6%) -(5%) -(35.8%) 5 159 14 000 61.0% 35.0% 29.7% West Bank 35.7% 25.0% 15.5%
1 2
Overall increase since the last quarter of 2000. Variance between 2001 and 2002.
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(C) (i) (ii) (iii) (iv) (v) (D) (i) (ii) (iii) (iv) (v) (vi)
Health status indicators1 Increase in low birth weight rate2 Acute malnutrition (children 6-35 months) Chronic malnutrition (children 6-35 months) Anaemia among children 6-35 months Anaemia among women of reproductive age Casualties3 Total deaths Total injuries Known disabilities Ambulance staff killed Ambulance and paramedical staff injured Deaths at checkpoints 1 972 21 371 6 188 24 415 87 51 29 169 333 6 32 67 27.5% 13.2% 17.5% 44.0% 52.8% 23.0% 4.3% 7.9% 43.8% 43.9%
(vii) Deliveries at checkpoints (viii) Fetal deaths due to deliveries at checkpoints (ix) (x) (xi) Deaths of women Deaths of children below 18 years UNRWA personnel killed
(xii) UNRWA personnel injured (xiii) UNRWA schoolchildren killed (E) (i) (ii) (iii) Infrastructure 4
Houses demolished Houses severely or partially damaged Damages to UNRWA installations and vehicles = 1 2 3 4
1 295 18 194 55 = =
USAID survey, 2002. UNRWA rapid assessment. Jerusalem Media and Communication Centre UNRWA statistics.
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