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Rapporti sulla situazione sanitaria


A Population at Risk of Risks: No One is in a Healthy

State in Palestine


April 16, 2002

Rita Giacaman,

Institute of Community and Public Health

Birzeit University



Following is a quick review of the consequences of the

continuing Israeli onslaught on the state of health of

Palestinians. This onslaught began on the evening of March

29th, 2002, and continues until today, with serious

ramifications on health status, not only in terms of mortality,

injury and disability, but also in terms of morbidity and

vulnerability to disease that affects almost all of the

population as well.


Prior to the Israeli Invasion, the country and its people were

already severely compromised at all levels, including the

domain of health. Uprising conditions, characterized by

Israeli policies of closures, serious siege, periodic re-

occupation, an unprecedented level of unemployment, all led

to substantial collective and individual economic hardship,

and a serious lack of access to health services as well. The

Palestine Central Bureau of Statistics estimated that

household income dropped by at least 48% just six months

after the policies of closures and siege took effect during this

second Palestinian Uprising. That is, other than the

thousands dead and injured, and many with permanent

disabilities, the health status of the population began to

deteriorate prior to this current onslaught, with clinical

evidence suggesting that the important indicator of health

status, malnutrition among children, was rising.


The situation today


1. Death and Injury: it should be noted that from 28

September 2000 until March 29th, on the eve of this invasion,

not less than 1300 Palestinians had died and around 27,000

were injured by Israeli army violence, adding serious burdens

on the existing medical and health care system. Since the

beginning of the current invasion , no one has been able to

ascertain the numbers of dead and injured by army violence

as Israel i continues to deny access to medical personnel,

even those of the ICRC. The numbers killed are probably in

the hundreds, and those injured, mostly civilians, in the

thousands. It is not clear how many of the injured in fact died

because of the blockade imposed on medical assistance

and harassment of ambulances and medical staff, but reports

indicate that probably many civilian deaths occurred as a

result of army violence and as a consequence of the

blockade of medical assistance, with the injured left bleeding

till they died. Reports also indicate without doubt that medical

help and humanitarian assistance were prevented on several

documented occasions and consistently, not incidentally, with

medical staff harassed, stripped naked, terrorized and even

used as human shields by the Israeli army. Reports also

indicate that some of the deaths pertain to individuals who

were shot and killed after they had first been injured, in cold

blood, and left un-evacuated in residential areas, ,

deepening the effects of this onslaught on health in every

way. Thus even by the end of the first week of the invasion,

the situation was becoming intolerable, and various

humanitarian groups, including the International Red Cross,

the EU Special Representative to the Middle East,

Ambassador Miguel Angel Moratinos, as well as many

others, began to call for immediate clear orders to respect

the safe passage of medical vehicles and staff, grant access

to the large number of unattended wounded, and allow the

evacuation of those killed. Please note the grave

consequences of death, injury and disability on families, not

only in terms of the loss of loved ones, but also in terms of the

loss of a principal means of earning income, through the

labor of predominantly breadwinning males.


With Israel 'trying to bury the evidence' of what happened in

Jenin camp, but failing to ' bury the terrible crime it had

committed', and with reports on Israel digging mass graves

to cover up its war crimes increasingly breaking news, the

Jenin camp is now becoming the symbol of this tragedy of

communal slaughter. With about 47% of its inhabitants

children under the age of 15 and people older than 65 years.

and an additional 18% women of child bearing age, the

onslaught on Jenin was bound to affect innocent civilians first

and foremost. Indeed, Jenin Camp, as well as other heavily

affected locales, such as the Old City of Nablus, Bethlehem,

Ramallah and various other locales, can only be seen as in a

condition of 'deep humanitarian crisis', with immediate

action and intervention required to ease human suffering.


The Incapacitation of medical and health services:

severe siege conditions, coupled with re-occupation and

curfew of the main towns that people usually seek for

secondary care have reduced the health care system into a

situation of almost total paralysis, despite the valiant efforts

of hospital staff and medical personnel to attend the

wounded. Patients are unable to reach hospitals; selected

NGO's such as UPMRC and HWC primary health care

centers as well as those of UNRWA are mostly, but not

entirely operational with activities seriously affected by the

current conditions; PRCS and UPMRC ambulances and

emergency relief heroically continue to offer vital services,

despite the great danger associated with manning

ambulances that are shot at by the army, and where health

staff are stripped, detained or used as human shields; the

large majority of the governmental primary care services

have ceased to operate, perhaps because those rely on a

town based command system; the private medical sector

has collapsed; and medications are in short supply, to name

some of the severe consequences of the current conditions

on the health care system.


The ramifications of this state of affairs has had and

continues to have far reaching impact on health. Numerous

reports document cases of severe deterioration in health

status, even death for those that were not able to reach

services because of the blockades and siege, including

mounting evidence of the injury and death of pregnant

women and newborn children because of this imposed lack

of access, or shooting by the army, or both. Indeed the tragic

case reported by a physician friend of ours, as he says, is

only one of many. In this case, Dr. Ali Sha'ar, reports that his

wife began to go into labor at 32 weeks of gestation, two

nights ago at around 4 am . They live in the occupied and

curfewed city of Nablus. He immediately called for an

ambulance to no avail. By six a.m., he managed with a doctor

friend of his to deliver the baby successfully. The baby cried,

and looked healthy, but being premature, urgently needed

incubator facilities. Dr. Sha'ar and his friend did everything

possible to maintain the baby without incubator while

awaiting for the ambulance that never came, as twice, the

ambulance personnel reported trying to reach Ali and twice

being shot at, resulting in their return to their station. By 11

am, the child began to suffer from apnea, and eventually died

at around 1 p.m.


The death of 2 year old Tabaruk Jaber Odeh, a cerebral

palsy patient from Deir al-Hatab village in the north is another

case of many. A child that survived only with great care and

life sustaining medications, siege and curfew led to her

denial of her medications for a period of ten days. By

yesterday, and after many appeals were made and

distributed, the army allowed for her transfer to hospital. This

morning, however, I found out from her father that she had

passed away.


And then of course, there are those with chronic diseases,

such as diabetes mellitus, hypertension and heart disease.

No one really knows the extent to which this curfew, blockade

of medical care, and denial of access has had a negative

impact on the health of such people, but given what is

emerging from various reports, and what happens to our

friends and neighbors, the picture seems bleak. Two nights

ago at 3 a.m, I received a phonecall frmy neighbor, who is

a physician, desperately trying to seek an ambulance to

transport his father to hospital. The father woke up with

symptoms of a heart attack. >From 3 a.m. till 8 a.m, all

attempts to get the man to hospital failed. Finally, at 8.30 in

the morning, the patient was transported successfully to

hospital, still alive. He was more fortunate than others.


Infants, school children and pregnant women's vaccination

schemes have also been either severely interrupted, or

halted altogether during the past 18 days. According to Dr.

Samia Halileh, a practicing pediatrician and faculty member

at the Institute of Community and Public Health at , Birzeit

University, one of the most dangerous diseases affecting

newborns if adequate vaccination is not available or

completed is tetanus. Usually, infants are given the vaccine

three times, at intervals of two months each and beginning at

the age of two months, in addition to a booster at 12 months.

The interruption of such a schedule during infancy, even for a

period of two weeks increases the risk of infants developing

the fully blown picture of tetanus if exposed to these deadly

spores. This is especially true of cases that have never

received the vaccine, but also includes those who have

missed taking the full three doses on schedule, as well as the

booster. Note that the fatality rate for tetanus is in the order of



While pertusis ( whooping cough) was in the controlled state

in the area up till recently, denial of any of the required

vaccinations at 2,4 and 6 months as well as the denial of the

booster increases the risk of acquiring this disease, which

can also be fatal in severe cases. The measles vaccine is

usually given in this country in one dose at 9 months, followed

by a booster at 15 months. Interrupting or delaying either one

of these doses places infants at greater risk of acquiring the

disease, which can also be fatal in severe cases. Finally, the

Hepatitis B vaccine is given at birth, followed by another

dose at one and then three months. This vaccination is vital to

newborns whose mothers have Hepatitis B. Note that a delay

of 72 hours increased the risk of the newborns acquiring this

disease, with severe long-term complications resulting in an

increase in the rate of disability and mortality.


House demolitions, destruction and detonation: since

the beginning of this re-occupation and curfew, we have

heard detonations in Ramallah continuing practically every

single day an night, leaving homes without doors, broken

furniture and equipment, and in many instances, with

valuables stolen,

These events are dwarfed by the wanton shelling and

destruction of homes and community in Jenin Camp, the old

City of Nablus, and Bethlehem, among other locales. The

loss of home is not merely a physical loss, as it has important

consequences on health, especially the health of children,

older people and the disabled. Some of the communities that

have been most affected have been dislocated more than

once, leaving behind essentials and belongings, and have

taken refuge in villages or in homes of extended family

members and friends.



Electricity and water: are essential for health and well-

being. What seems like a deliberate cutting off of these two

services have been the subject of numerous reports. In

Ramallah alone, over 100,000 thousand people in the town

and surrounding villages remained without electricity for an

entire week. We have no idea how many remain without

electricity in the West Bank, as we are unable to accurately

ascertain the extent of the problem. However, damage to

poles, lines and other essential pieces of the network

continue until today, with what seems to be like a cat and

mouse game of finally getting approval to fix the damage,

only to have destruction the next day. According to the Chief

Engineer of the Electricity company, serious harassment, and

shooting at crews attempting to fix the different levels of

damage, from power feeders to cut off cords and broken

poles, even when approval to move around and fix the

damage was obtained from the higher echelons of the Israeli

Defense Force, has led and continues to lead to interrupted

service. With only general access to information In

Bethlehem, Nablus, Jenin and Tulkarm, available reports

indicate a major problem there as well. On 16 April, for

example Oxfam reported that specific areas of Bethlehem

(the Old town), the al-Mahed and al- Fawaghreh quarters and

al Khader, al-Doha villages and the west side of al- Dheisheh

camp -are still without water since April 4. Similarly, Oxfam

reported the unavailability of water in other locales as well,

including Qalqilia, Nablus, Tulkarm and other locales.


Destruction of the water pumps, generators, pipes as a result

of gouging out streets repeatedly, in addition to punctured

water tanks on roofs of homes as a result of the shooting all

contribute to a very unhealthy state. In Ramallah, where the

case was followed up closely, the Water Department went

through harrowing experiences attempting to fix the

damages, in the hope of bringing back the vital water supply

to the population. At least 150,000 people, for days on end,

remained without water as the cat and mouse game of

coordinating and successfully gaining approval from the

Israeli Army to fix the damage, only to result with Water

Department crews being shot at and denied entry or arrested

instead continued. A concerted campaign exposing these

activities contributed perhaps in real ways to eventually

allowing the water to run to people's homes in Ramallah

today. However, it appears that currently, the conditions are

quite severe in Jenin and Jenin camp, as well as many other

locales. The size and extent of the problem appears to be

huge, with a water on and water off situation being the norm,

but we have no way of obtaining further information.


Sanitation: since the beginning of this incursion, and curfew,

two outstanding sanitary problems remain unresolved. All that

one needs to do is roam around the streets of Ramallah

when the curfew is lifted to realize the extent of the damage,

broken glass, blown out doors, shattered poles, debris

everywhere, and above all, refuse piling up way beyond the

capacity of garbage containers, spilling out in all directions.

With the temperature now rising to up to 30 degrees

centigrade yesterday, and with flies beginning to come out of

their winter sleep, the situation can only be described as

dangerous to the health, despite initial efforts at garbage

collection when the curfew was lifted and on 16 April in

cooperation with the ICRC.. We have not been spared the

dangers of sewage either. According to the head of the

environmental committee of the Governorate of Ramallah,

around 50% of homes are linked with a public sewage

network, with the rest relying on cesspits that require

emptying regularly, usually, ever 2-4 weeks, depending on

size. The majority of villages remain without a piped sewage

system, again relying on cesspits requiring regular emptying.

Yet the state of siege and curfew have so far not allowed the

proper disposal of this sewage, setting the stage for the

spread of a variety of diseases. The story from Nablus,

Jenin, Bethlehem and their surrounding villages is similar.

According to the World Health Organization, with the medical

services not functioning, even in their limited capacity, the

risk of a disease outbreak is increasing due to a general lack

of water and sanitation as well as interrupted garbage

disposal. Furthermore, the WHO reports that the lack of

electricity has begun to destroy blood units and vaccines.

These problems combined with interrupted water supplies,

and coupled with delayed vaccinations, un-evacuated bodies

in streets, and rubble all over, creates legitimate fears of a

potential public health crisis in the country


Mental Health: it is beginning to be clear that the level of

trauma affecting the population here is much higher than

expected. No one really knows the extent of the problem

today, noits ramifications on the future health of the

population, especially children. A priority group for action

continues to be the ambulance and medical workers who

have been exposed to an almost unbearable amounts of

traumatic experiences, whether by simply dealing with the

tragic cases at hand, or by being themselves exposed to

serious harassment and army violence. Children and older

people who live alone or with an older spouse must also be

reached, not merely with physical help, but with trauma

management care as well. Of course, young people, who

have been arrested, then released, and who have witnessed

the death or injury of friends, or who have suffered terribly as

a result of all this destruction around us, feeling totally

helpless and incapacitated, with no vision or hope for a better

future, need real help in both the short and longer terms. And

as we continue listing sub-groups within the population that

needs help, a simple realization emerges: it seems as if the

entire nation needs trauma management.


At this stage, food is plentiful in Ramallah, as truckloads upon


were allowed to enter to feed the hungry who have money, unlike the situation

in Jenin and elsewhere. The problem is the unavailability of cash. People are

either stuck without a job, or without due payments, or without cash. That is,

we are facing a problem of want, with merchandise, mostly made in Israel,

clearly available, but with a dreadful inability to buy what is essential when

the curfew is lifted.


Needs for Assistance


Overall, assistance in the sphere of public health can be divided into

immediate needs and medium/ longer term ones:


1. It is not food that is needed, except in specific circumstances, as is the

case in the Jenin Camp where drinking water is also an urgent necessity. What

is needed is a concerted effort and pressure to be placed on the Israeli

government to lift the curfew, end this re-occupation, end the 19 month long

state of siege, and allow people to pick up the pieces, get back to work,

re-start economic activity, and tally up the enormous losses. Some believe that

it will take years to re-build what has been destroyed.

2. Clearly, immediate financial emergency assistance is much needed, and must

reach the local level. Given that the state of siege has been continuous for 19

months, with no end in sight, even if the Israeli army withdraws from areas A,

and now, a few villages as well, the need in these circumstances is for

supporting decentralization and communal based health care services, especially

those of the primary health care variety. Between the ongoing state of siege

and the collapse of the private medical sector along with the economy, support

for decentralized and highly subsidized local level primary care services is

one of the few remaining options at hand that can assist the population in

surviving these trying times.

3. Replenishment of drug supplies to accommodate need is also imperative.

Perhaps the best way to assist in this area is through financial donations that

can be used to purchase medications locally.

4. There is a need to also immediately embark on setting up emergency

frameworks to assist in bringing in international volunteers to contribute to

the protection of the population.

5. There is much that will be needed in financial and technical terms in the

medium and longer terms to allow for the rehabilitation and reconstruction of a

country, a health system, an infrastructure and an economy that have been

reduced to rubbles as a result of this unilateral war.


1. PCBS 2000, Poverty in Palestine(January-December 1998),

2. MOH, UNICEF and Institute of Community and Public Health, Birzeit

University, 2001.

3. The Palestine Monitor, PNGO Information Clearinghouse appeals and

information briefs.

4. OPT: PRCS Update , 16 April, 2002

5. WHO, West Bank/Gaza Strip Health Update, 15 April 2002

6. Justin Huggler in Jenin and Phil Reeves in Jerusalem , the

Independent,13 April 2002.

7. LAW - The Palestinian Society for the Protection of Human

Rights and the Environment, Information Briefs.

8. UPMRC Appeals and Information Briefs.

9. Oxfam, April 16,2002 , Bethlehem Water Situation, 4-6

April 2002

10. Judy Dempsey and Roula Khalaf, Palestinian economy

deeply damaged, Financial Times, April 16, 2002

11. B'Tselem (The Israeli Information Center for Human

Rights in the OccupiedTerritories) Daily Briefing on Human

Rights Violations

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