IntroductionIn its resolution WHA55.2 of May 2002, the World Health Assembly asked me to assess the health situation of the people in the occupied Palestinian territory by paying a personal visit - as soon as possible - to the communities concerned. I have not been given the opportunity to pay a visit in the context of resolution WHA55.2. I have compiled the following brief report based on data received by WHO and supplied by its own field staff, or through UN agencies, NGOs and other bodies working in the communities.
The situation of people in the occupied Palestinian territory is deteriorating as a result of the escalation of the conflict compounded by further border closure and curfews throughout the West Bank and Gaza Strip since March 2002. There have been explicit restrictions on population movements, which hinder the delivery of health care services. Humanitarian relief has been sporadic but the outlook is improving for getting essential supplies, food and shelter into affected areas. However, there is still grave concern at the lack - in some places - of water supply and sanitation.
We do not have reliable community morbidity, mortality and disability statistics for 2002, but nutritional status assessments, particularly of children, do show a deterioration in recent months.
One factor affecting the health status of Palestinians is severe damage to the commercial and social infrastructure, with a reduction in retailing (and thus people’s ability to access the foodstuffs they need), damage to water supply, lack of human waste disposal, and problems with the build up of solid waste. This is further exacerbated by the ongoing conflict with casualties on both sides, which has resulted in continuous physical and mental suffering.
We are concerned that the communities in the occupied Palestinian territory have been in considerable distress and will continue to suffer ill health as long as hostilities continue - even if their plight is less “in the public eye”. It is particularly important that I am enabled to undertake the planned visit as soon as possible so as to assess further the findings from this desk analysis and facilitate an appropriate response.
Basic statistics: An estimated 3.29 million persons are reported to live in the occupied Palestinian territory. Reported rates for 2001 of immunization coverage, child malnutrition, mortality and access to medical services are shown in the table below.
|BCG Immunization rates (%)||97.0||2001|
|DPT3 Immunization rates (%)||97.0||2001|
|Hepatitis B Vaccine rate (%)||97.0||2001|
|Measles Immunization rate (%)||98.0||2001|
|Crude birth rate/1000||20.3||2001|
|Crude death rate/1000||2.8||2001|
|Infant Mortality rate/1000 Live Births||22.9||2001|
|Maternal mortality rate/100,000 Live Births||19.0||2001|
Immunization: The following factors contributed to the good performance of the programme in 2001.
The Expanded Programme on Immunization (EPI) in the occupied Palestinian territory had built up a strong routine service delivery system: it was still able to deliver services despite all the current difficulties.
There is a high level of public knowledge about the benefits of the immunization programmes.
UN staff made major efforts in maintaining the continuity and the quality of the EPI programme.
Reports suggest however that immunization coverage in 2002 has been much lower, especially in remote areas, areas where bedouin live, and places where vaccinations are provided by mobile teams. We have been told that in these areas, there was a period of about six months in which very limited immunization of infants or young children took place. UN system and international NGO personnel and vehicles helped implement catch-up activities in some of these areas when security conditions allowed.
Vaccine cold chains have not functioned fully because of transportation delays - even for UN registered vehicles (usually as a result of delays at check points). For instance, the time required for transportation of vaccines from Ramallah central stores to districts, or between Gaza and the West Bank, has, in recent months, sometimes exceeded one day. Vaccine storage at health facilities and central stores has been affected by frequent - and sometimes lengthy - cuts in electrical supplies. Maintenance personnel have reported that they are often unable to reach damaged vaccine refrigerators or other equipment. The surveillance of vaccine-preventable disease has not been up to the required standard in recent months because of constraints on the movement of personnel and of samples.
Access to medical services: Recent findings in the public health sector also reveal a decline in the accessibility of medical services for people in the occupied Palestinian territory.
Access to food and nutritional status: Two recent surveys, carried out by different organizations and using slightly different indicators and cut-off points suggest that the nutritional status of women and children is compromised. Almost half of young children (6-59 months) and women of child-bearing age are anaemic. A survey by CARE/USAID of 936 children and 1534 women shows that 43.8% of children and 48.6% of women have a haemoglobin level below 11.9, while another survey by the Palestinian Central Bureau of Statistics (PCBS) and UNICEF of 3,684 children and 6,204 women shows that 49.5% of children have a haemoglobin level below 10.9 and 45.4% of non-pregnant women have a haemoglobin level below 11.9.
Both surveys also reveal the existence of childhood malnutrition, although the data are not totally comparable. 9.3% of children in the CARE/USAID survey are suffering from wasting, and 13.2% are stunted, while in the PCBS/UNICEF report, the value given for stunting is 9.2% and for wasting plus underweight 5.5%. Both surveys show an overall deterioration in the nutritional status of the entire child population when compared with the results of surveys undertaken by UNWRA before the current crisis.
Palestinian official sources estimate that 66.5% of the Palestinian population currently lives on less than the equivalent of US$2 per person/day.
A market survey reveals shortages of high protein foods such as fish, chicken and dairy products among wholesalers and retailers in the West Bank and Gaza Strip. Prices of these products are rising.
Survey respondents indicated that shortages in Gaza were primarily due to border closures isolating the Gaza Strip from Egypt, Israel and the West Bank. In the West Bank, survey respondents said food shortages were caused by a combination of road closures, checkpoints, curfews and military conflict.
Public service infrastructure: Much of the infrastructure in the communities concerned has deteriorated, resulting in an increase in environmental health risks especially for children.
Solid waste: Since March 2002 the collection and disposal of solid waste has been particularly problematic in the Gaza Strip. Similar difficulties have been and are being encountered by municipal services of the West Bank towns that have been under intermittent curfews since mid-June 2002.
Water and sanitation: Reports from the USAID-sponsored Emergency Environmental Health Project indicate that the quality of water delivered from water tankers in the Nablus area is below WHO standards for drinking water quality. The Ministry of Health reports problems with contaminated water in Balata and Askar camp due to the destruction of both the water network and sewage pipelines in these localities, causing sewage flow into the water pipeline. The distribution of chlorine to clean the water is reportedly hampered by the closures and curfews making it severely difficult for Ministry staff to reach the affected localities without help from international organizations. An outbreak of shigellosis (over 600 cases) was reported to the Ministry in that area in the past few weeks.
Ongoing hostilities: The Palestinian MOH reports a total number of 2,520 Palestinian deaths from 29 September 2000 until 24 September 2002. According to the Israeli Ministry of Foreign Affairs, 624 Israeli deaths were reported from 27 September 2000 until 26 September 2002. It is possible that substantial mental ill health will be associated with this continuing trauma in all affected populations.
Other key health concerns include the burden on the health system as a result of the excessive number of injured and disabled. The long-term impact of the lack of access to health care, exacerbated by poverty and economic and social insecurity, on the health of the Palestinians must be studied, monitored and addressed in order to alleviate the negative effects on health. Long-term care for those who have been disabled, as a result of this conflict alone, will require extensive financial and structural commitment.
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