WORLD HEALTH ORGANIZATION FIFTY-THIRD WORLD HEALTH ASSEMBLY Provisional agenda item 16 A53/INF.DOC./6 13 May 2000
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 report to the Fifty-third World Health Assembly.
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State of Palestine The Supreme Palestine Health Council – Palestinian Ministry of Health
HEALTH CONDITIONS OF, AND ASSISTANCE TO, THE ARAB POPULATION IN THE ARAB OCCUPIED TERRITORIES, INCLUDING PALESTINE
Report submitted to the Fifty-third World Health Assembly
April 2000
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INTRODUCTION The Palestinian people have long aspired to occupy their rightful place in the community of peace-loving peoples of the world; hoping that their dream would materialize, after long years of injustice, inequity and deprivation, so that they could exercise their legitimate rights which have been guaranteed by international laws and covenants. The hope was that a state of just and comprehensive peace would prevail throughout the region, and would light their way to liberation, return and the construction of their State; that the future would compensate for all their years of suffering, that they would enjoy their freedom and independence, their long-lost rights, and their liberty like other nations; and that after a century of relentless struggle, their efforts would be dedicated to the welfare of their citizens, the construction of their institutions and the provision of health, and of social and economic security to all Palestinians. Enormous efforts have been made, in cooperation with the World Health Organization and numerous international agencies, as well as ministries of health in other countries, to achieve this goal. The first step in that direction was the establishment of a supreme health council which developed a comprehensive national health plan aimed at creating health institutions and leading to the formation of the Ministry of Health of the Palestinian National Authority, with responsibility for providing health services to the Palestinian people, and extending such services to them. But the persistence of Israeli occupation, and the continued blockade imposed on areas under the National Authority, oppression and brutality have all been basic factors in hindering the implementation of the National Health Plan, as well as other development, education and training activities. With the ongoing peace process, and the end of the transitional period on 4 May 1999, the Palestinian people had made the necessary preparations to declare their independent Palestinian State in May 1999, but the requirements of peace compelled the Palestinian leadership to postpone the declaration. The Palestinian people continue to look to the entire world to stand by them and to support them in the declaration of their State, with a view to occupying their rightful place in the world community of peace-loving nations.
Dr Fathi Arafat Chairman, Supreme Palestine Health Council Chairman, Palestinian Red Crescent Society
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DEMOGRAPHIC INDICATORS Population The number of Palestinians in 1999 stood at 7 317 493, of whom 1 109 745 are in the Gaza Strip, with a population density of 3065 persons per square kilometre; in the West Bank there are 1 913 608 people, where the population density is 347 per square kilometre. But if the vast areas of land on which Jewish settlements have been established are taken into account, the population density becomes much higher than that. In the territories occupied in 1948 there are some 1 200 000 Palestinians; the remainder, amounting to 3 094 140, are in the diaspora, outside Palestinian territories, and are dispersed in various Arab and other countries.
opulation distribution of the Palestinian people (1998) Arab countries 37%
Non-Arab countries 5%
Gaza 15%
Occupied Palestine 17%
The West Bank 26% WHO 00190
Palestinian society is a young one, the percentage of those under 15 years of age in the West Bank and the Gaza Strip is 47% of the population, those over 60 years of age account for 5%, leaving some 48% between ages 15 and 60. This distribution is clearly illustrated by the wide-base population pyramid, characteristic of most developing countries.
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5-60 years 48%
More than 60 years 5%
Less than 15 years 47%
WHO 00191
Almost 50% of the population belong to families averaging 6.9 persons each, and 91% of families live in overcrowded housing units (2.1 persons per room). Some 14.6% of these units face weekly water shortages; those connected to the public sewage network account for only 31.7% of the total number of houses, which negatively affects the health of the population, leading to the spread of parasitic and epidemic diseases. The Israeli occupation played a major role in the shortage of water supplies to houses, and in connecting them to public sewage systems. Israeli settlements control numerous groundwater sources and hinder the construction of sewage systems, especially in the Gaza Strip coastal area. Palestinians consist of two main categories: refugees whose problem remains one of the most important issues in the final status negotiations and non-refugees; refugees constitute some 73% of the population of the Gaza Strip, and 42% in the West Bank, according to the latest census carried out by UNRWA (1999). The rest are dispersed in various Arab, and other, countries.
Education Palestinians attach great importance to education because they consider it a true and durable asset since they have lost, and are still losing, their properties and lands on account of aggression and confiscation of land by occupation authorities. The rate of school enrolment among 10-year-old children stands at 84.3%, and some 85.1% of children between the ages of six and 17 attend school regularly.
Births The birth rate in territories under the National Authority was 34.5 per 1000 in 1999, which is an extremely high rate among countries of the world. The largest number of births was in Gaza, and the smallest number was in Jericho.
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Fertility Fertility rates (children/women) are steadily decreasing. The rate in 1994 stood at 7.4/1; in 1999 it was 5.5/1. The highest rates of fertility are among women between 25 and 29 years of age; in the past the highest rate was recorded among women aged between 20 and 24 years. With regard to the level of education of mothers, those who have secondary school education seem to have the highest birth rates.
Population growth The rate of population growth is also steadily declining: in 1995 it was 6%, but in 1999 it was 4.1%.
Mortality Annual mortality rates in the Palestinian territories are declining. They stood at 3.5 per 1000 in 1997, and declined to 3.3 per 1000 in 1999. All age groups witnessed a decline in mortality rates. Infant and child mortality was 22.1 per 1000 in 1999, whereas in 1992 it had attained 31.7 per 1000. Among one- to five-year-old children it was 0.79 per 1000; and 0.4 per 1000 among five to 12 yearolds; for adolescents between 13 and 19 years old it was 0.44 per 1000; as compared with 2.17 per 1000 among 20- to 59-year-old inhabitants. For people over 60, mortality rates were 34.84 per 1000, the highest among all age groups. The leading cause of infant mortality was “premature birth”, accounting for 18.1%, followed by congenital malformation and respiratory disorders, attributable to the weak economic and social structure, and environmental pollution in general. Congenital malformation is the leading cause of mortality among children under four years of age, affecting some 16.6%, followed by road accidents, poisoning and other injuries. Among children aged five to 12 years, road accidents are the major cause of death, accounting for 13.2%, followed by cancer, respiratory disorders and heart conditions. Among people under 60 years of age, cancer is the leading cause of mortality, accounting for 13.7% of all deaths, followed by nervous system disorders at 11.6% and cardiovascular diseases at 7.8%. Finally, in the over 60 age group, nervous system diseases are the leading cause of death, accounting for 12.7% of all deaths, followed by cancer at 11.2% and heart disease at 8.7%. 0 5 0 5 0 5 0 5 0 >1 1-4 5-12 13-19 20-59 60+ WHO 00192
34.84
Mortality rate
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Common diseases in Palestine Some 8% of all newborn babies in Palestine are underweight. Malnutrition affects 15.5% of children, pneumonia is found in 465 per 100 000 children, whereas influenza and diarrhoeal diseases affect some 67 per 100 000. Infectious diseases such as tuberculosis, viral hepatitis (A, B and C), brucellosis, typhoid, and viral conjunctivitis, are the most common. In the Gaza Strip viral meningitis was diagnosed in 12.7 per 100 000 inhabitants. The most common causes of parasitic disease are entamoeba, giardia and escherichia, accounting for 224, 136 and 34.3 cases per 100 000 population respectively. These figures illustrate the substantial deterioration of the environment, particularly in terms of solid waste collection and management, sewage systems which are totally lacking in numerous areas, not to mention pollution of drinking-water, its excessive salinity, especially in central and southern Gaza, and the inadequacy of water supply in many Palestinian towns and villages.
ISRAELI VIOLATIONS The life of the Palestinian people, especially their health situation, is made more difficult and complicated by Israeli practices and violations of their basic rights, particularly the right to life, and medical treatment; these include confiscating their land by force, evicting and displacing them, and depriving them of education and a decent life. In 1999 the occupation authorities continued to violate the right of the Palestinians to life; 17 Palestinian civilians, between the ages of 12 and 72, were killed, 15 in the West Bank and two in the Gaza Strip. Eleven of these victims were shot down by the Israeli army and two were blown up by landmines planted by the same army, two died in Israeli prisons, and one was killed by Israeli Special Forces. The most serious incidents occur when Palestinian citizens stage peaceful demonstrations to protest against the destruction of their houses and the confiscation of their lands and dwellings, and are suppressed by the use of excessive force by occupation troops; such confrontations often prove fatal because Israeli forces use live ammunition and rubber bullets against these demonstrators haphazardly and at close quarters, although there is no threat whatsoever to their own life. “Arabized” special forces also continued to liquidate Palestinian civilians unlawfully and in cold blood. Their latest victims were Eyad Al-Battat and Nader Masalmeh from Beit Awa, a town in the province of Hebron. Although 1999 witnessed a decline in the number of civilian martyrs compared with previous years, this is not a result of a change in the policy of killing Palestinians or arranging to have them killed, but because of the withdrawal of Israeli forces from a considerable part of densely populated Palestinian areas, leading to a decrease in direct confrontation and friction between them and the occupation and settler forces. Israel never takes any serious measures to punish these murderers, whether they are soldiers, settlers, or prison officers, but always justifies their killing of Palestinian civilians on flimsy pretexts such as self-defence or life-threatening situations. In the domain of health, Israel resumed the policy of closing off and blockading Palestinian areas, depriving Palestinian citizens of the right to health. The continued geographic separation of the West Bank from Gaza Strip, and the city of Jerusalem, has denied patients all access to health facilities and services outside their own areas of residence. Deliberate neglect by Israel of the health sector in the occupied territories, and restriction of the freedom of movement, particularly to Jerusalem, have
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deprived Palestinians of their right to health; this occurs daily to residents of Jerusalem who go to work or to live in other parts of the West Bank, and whose identity cards are confiscated, depriving them of the right to health and of access to health facilities on the pretext that they have lost their status as Jerusalemites. Other obstacles are raised by Israeli authorities to delay ambulance vehicles transporting patients in critical condition to neighbouring countries. Vehicles are kept waiting for hours, patients are forced out of them, subjected to a prolonged and humiliating process of inspection and search, thereby endangering their life, especially when they try to cross the Allenby Bridge. Israeli authorities also deliberately delay permits for Ministry of Health personnel, the transport of medicines between the West Bank and Gaza Strip, seriously disrupting the work of health centres. Hence the pressing need to transfer responsibility for the health of the population in East Jerusalem to the Palestinian Ministry of Health; this should be done in order to put an end to the suffering of these people, and to remove the totally unjustified obstacles raised by the Israeli Ministry of Health to hinder implementation of responsibilities and measures taken by the Palestinian Ministry of Health in the area of medicines and medical equipment, which constitute an urgent need. Such a move would enhance cooperation and coordination between the Palestinian and Israeli Ministries of Health. As for the right to freedom, Israel still holds Palestinian prisoners in prisons outside their places of residence, in violation of Article 49 of the Fourth Geneva Convention. There are over 1700 Palestinian and Arab political prisoners in 10 central prisons and interrogation centres; 18 of those prisoners are under 18 years of age, and over 250 are elderly people suffering from a variety of medical conditions. There are 14 administrative detainees, and nine prisoners in solitary confinement. Demolition of houses continues unabated. Amnesty International states in a document entitled “Israel and the Occupied Territories”, that since 1987 Israel has destroyed no less than 2650 Palestinian homes in the West Bank, thereby displacing 16 700 people, 7300 of whom are children, leading to profound trauma. Confiscation of land, settlement in Palestinian lands, and the expulsion of their original inhabitants is a policy adopted by successive Israeli Governments, including the present one, all in violation of Article 49 of the Fourth Geneva Convention. There were 22 new mini-settlements by private initiatives in 1999, and two new government-sponsored settlements: “Harezhav” on land belonging to Kafr Eddik and Deir Ballut villages in the province of Selfit and “Ma’ali Modain” on land belonging to the village of Shebtin, north-west of Ramallah. One thousand one hundred and twenty-nine dunums were confiscated to build ring roads and another 9980 dunums in the southern part of the West Bank to establish industrial settlements, in addition to land confiscated for “security and military” purposes. Violations of the right to work are a daily occurrence at the hands of Israeli troops at military road-blocks. In 1999, Ala’a Abu Sharkh, a worker, was killed at a military road-block near Al-Zahiriya; Afif Abu As’aad from Ethna village was callously wounded, along with Khaled Daramneh from Jamala village, Ramallah province, at the hands of occupation troops, on their way to work. Daily assaults against workers are common practice at military checkpoints at entry points to the Green Line. Violations in the field of agriculture and the environment in 1999 included, as in previous years, the confiscation of arable and pasture land on which large numbers of Palestinians depend for their living. Innumerable fruit trees were uprooted and large areas of arable land burned. The inhabitants of 70 villages were served notice to vacate thousands of dunums of agricultural land for the construction of settlements or military posts, some 1200 of them in the village of Tobas in the West Bank. Environmental damage by Israeli institutions is rampant: there is industrial waste and 9
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stone-crushing residue, as well as wastewater from settlements causing soil pollution, damage to agricultural crops, reduction of pasture areas, health hazards, and air pollution leading to serious health consequences among neighbouring populations in zones used as waste dumps. The right to education continued to be violated in 1999 through incessant raids on schools, the detention of numerous students, teachers and academics, raids on student dormitories and the arrest of some 250 students, setting fire to women’s halls of residence in Jerusalem to prevent them from continuing with their university education.
THE HEALTH SYSTEM The Palestinian Ministry of Health is the prime and major provider of health services to the Palestinian people in the National Authority areas. In cooperation with other health service providers, it organizes and offers all preventive, diagnostic, curative and rehabilitation services. UNRWA occupies second rank as a provider of health services, as it offers preventive and primary care health services in refugee camps in various parts of Palestine, in addition to covering the cost of secondary care in Palestinian hospitals. It is in need of increased support to enable it to continue the provision of the health services needed by refugees in the camps in various areas. Private sector, civic and nongovernmental, as well as international institutions, play a lesser role in the provision of health services, especially in the Gaza Strip, and offer mainly diagnostic and curative services. Despite major obstacles and difficulties, the Palestinian Ministry of Health continues, in cooperation with the Palestinian Red Crescent Society and nongovernmental organizations, to fulfil its responsibilities in the treatment of patients and the victims of daily confrontations with occupation forces, as it builds new health institutions, develops existing facilities and supplies them with modern medical equipment which they lacked under occupation. It works to develop human resources and increase the number of health personnel through organizing study and training courses, granting scholarships abroad, and through other efforts to meet the increasing needs in the field of health and to provide better and more comprehensive services.
HEALTH FACILITIES Primary health care The Ministry of Health operates and manages 300 primary health care centres in the West Bank, and 39 in the Gaza Strip, all of which provide preventive, diagnostic, and curative services, including immunization against communicable diseases, and comprehensive maternity care, in addition to delivery wards and the provision of supplements. Complicated pregnancies are attended to throughout the antenatal and postnatal period free of charge. The Ministry also meets the cost of follow-up, treatment and delivery. It collaborates in this connection, as in immunization campaigns, with clinics run by UNRWA, which provides the vaccines purchased by the Ministry. A number of these centres also run radiology units, laboratories and dispensaries. Services are provided virtually free of charge to citizens who are covered by health insurance, and patients contribute only a small part of the expense incurred. Children under three years of age are entitled to free medical care, and are exempted from health insurance premiums.
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Hospitals The Ministry of Health also runs a number of public and specialized hospitals in both the West Bank and the Gaza Strip. In the former there are eight public hospitals and one psychiatric hospital with a total capacity of 1098 beds, i.e. one bed for every 957 citizens. In the Gaza Strip there are four public hospitals and one psychiatric hospital with a total capacity of 1058 beds, one for every 880 people. The number of beds is far below the needs of the population, resulting in overcrowding and a heavier workload. The non-public sector has contributed significantly to the alleviation of this burden. In the West Bank there are 28 national, civic, benevolent and private hospitals with a capacity of 1163 beds. In the Gaza Strip the non-public sector has increased the number of existing facilities by seven such hospitals, with a capacity of 246 beds. Yet the shortage in hospital care remains acute, and the Ministry of Health is developing a variety of projects to remedy the situation, including the expansion and modernization of a number of hospitals such as the Jericho, Jenin and Tulkarem hospitals in the West Bank, and the Nasser/Khan Yunis hospital in the Gaza Strip. Work is continuing in preparation for the opening of the European hospital with 260 beds in the southern part of the Strip. The non-public hospitals include those of the Red Crescent in most Palestinian cities, Al-Makased in Jerusalem, Kalkilya of UNRWA, and Al-Ahli Al-Araby and Al-Awda, and Friends of the Patient hospitals in Gaza.
Advanced medical care Having had to refer patients to health facilities abroad for medical care not available locally, especially for heart surgery, cerebral and neurological disorders, as well as cancer, the Ministry of Health had to bear enormous expenses, in addition to the burden of services provided locally.
Development of human resources Human resource development is a high priority in the Ministry of Health, with a view to achieving an extremely important goal: training sufficient numbers of human resources to provide high-quality health services, and providing them with the skills or specializations needed in various parts of the country. Convinced that investment in human resources is the optimal and most durable investment, the Ministry has established a department for human resource development. Work in this department has expanded, and now covers, in addition to Ministry of Health personnel, those working for non-public institutions, and the Ministry has concluded agreements with external partners to strengthen the structure of the department and benefit from the experience of others for human resource development in Palestine. Activities of the department in the current year include study courses covering a wide variety of medical fields such as intensive care, heart disease among children, the use of specula in surgery, pharmacy, laboratories, medical secretarial training and computer science. Two nursing schools have been established in Ramallah and Gaza and a public health school in Gaza awarding M.Sc. degrees.
Health education and promotion programme The main purpose of this programme is to undertake the planning and implementation of health promotion activities and health education in the community. A department has been established for this purpose and has become a major source of health education materials and dissemination of health information, it also prepares programmes for transmission by the various media in order to raise health awareness in the community, especially with regard to maternal and child health. The department has implemented the European programme and a United Nations funded programme to disseminate
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knowledge of reproductive health and family planning, training for schoolteachers to become health educators, community training, the establishment of a database to monitor the behaviour of schoolchildren, and the distribution of a number of publications to raise health awareness.
Mental health programme This programme provides training and education to develop the necessary human resources in the field of mental health in Palestine. The programme also offers curative services at the community level as well as in hospitals. Two centres for community mental health services have been established to deal with the thousands of captives, ex-prisoners and their families, as well as their children, who have suffered traumatic shock and oppression under the occupation. Health research is also carried out in the context of this programme. The Ministry also supports the development of numerous health programmes such as women’s health, family planning, environmental health, school health, oral health and medical laboratories. It is also endeavouring to expand coverage by health insurance schemes, which now include 52.5% of the population of the Gaza Strip and about 40% of the population of the West Bank. Prepared by Information and Statistics Department Palestinian Ministry of Health
CONCLUSION Despite the need for financial resources, the weakness of the infrastructure left by the occupation forces, the lack of sanitation, especially in villages and refugee camps, not to mention excess salinity and pollution of drinking-water, and the depletion of limited natural resources in Palestinian territories by settlers, health indicators in Palestine have improved in the past five years since the Palestinian National Authority took over control of the liberated areas. Mortality rates among all age groups have declined, especially infant and child mortality, as well as maternal mortality in the perinatal period. Immunization coverage of children against the seven targeted diseases recommended by WHO has increased to almost 95% (diphtheria, poliomyelitis, whooping cough, tetanus, measles and tuberculosis [sic]). The Ministry of Health covers the enormous cost of immunization campaigns in both centres run by the Ministry and UNRWA centres. The project to improve and monitor the quality of health services has been most useful; it is already yielding results, demonstrated by better services for the Palestinian people. Several international organizations and countries have provided support and assistance in the provision of basic health services and the prevention of disease. But assistance was often hampered by Israeli measures which increased the heavy burden borne by the health system, and the spread of infections and disability among Palestinian people. The health situation of the Palestinian people cannot, therefore, be improved until occupation is completely ended and the Palestinians are allowed to exercise their legitimate right to establish their own State, complete sovereignty over its territories and natural resources, and unhindered freedom of movement in all parts of their country, with links with all countries of the world. The Palestinian people appeal to all countries of the world to support them in aspiring to exercise their rights and to attain the goals of the World Health Organization.
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