HEALTH IN THE OCCUPIED PALESTINIAN TERRITORY – Part one: ‘A people enduring a chronic health crisis’

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TOP British medical journal The Lancet, the has published a series of detailed research reports on the health status of 3.8 million people living in the Occupied Palestinian Territory (OPT).|

The Lancet says the OPT is ‘one of the most important flashpoints not only in Middle East politics, but for global security’.

News Line is reproducing the extensive Lancet press release on these scientific papers in three parts.

The Lancet report, took two years to research and produce. It is the most up-to-date and comprehensive assessment of Palestinian health yet produced.

The report has been written by a team of health scientists in the OPT, together with international colleagues from the WHO, associated UN agencies, and academic institutions in the USA, UK, Norway and France.

1. A people enduring a chronic health crisis – a snapshot of the ailing health landscape in the Occupied Palestinian Territory:

The first paper in the Lancet Series on Health in the Occupied Palestinian Territory, is written by Dr Rita Giacaman, Birzeit University, Ramallah, West Bank, and colleagues.

The authors look in detail at how the demographic characteristics, health status, and health services of the Palestinian population have been affected by 60 years of continuing war conditions and 40 years of Israeli military occupation of the West Bank and Gaza Strip.

Although health, literacy, and education are better for the 3.8 million residents in the OPT than in several Arab countries, all are at substantially lower levels than in Israel.

Some 52 per cent of Palestinian families (40 per cent in the West Bank and 74 per cent in the Gaza Strip) were living below the poverty line of US$3·15 per person per day in 2007. Since 2000, life for Palestinians has become much harder, more dangerous, and less secure.

Unemployment in the Gaza Strip was around 33 per cent in 2007, rising to 38 per cent in 2008.

Food insecurity has continued to rise, reaching 56 per cent in 2008; and 60 per cent of households regard emergency assistance as a secondary source of income even before the December 08–January 09 invasion of the Strip, and with the crisis intensifying since then.

As with other nations, the OPT is undergoing an epidemiological transition, in which cardiovascular diseases, hypertension, diabetes, and cancer have overtaken infectious diseases as the main causes of illness and death.

But the OPT is faltering where other modern, western nations are progressing. Infant mortality in the region has stalled at 27 per 1000 live births during 2000-06; the same level as that reported in the 1990s.

The rate in Israel is 3.9 per 1000 live births. The rate of stunting in children under five years has risen from 7.2 per cent in 1996 to 10.2 per cent in 2006.

From 1999 to 2003, the rate of tuberculosis in the OPT has risen by 58 per cent and meningococcal meningitis by 53per cent

Mental disorders have risen by around a third from 32 per 100,000 in 2000 to 43 per 100,000 in 2003.

The current Palestinian health system is made up of fragmented services that grew and developed over generations and across different regimes.

At present, all four main health service providers (the Palestinian Ministry of Health, United Nations Relief and Works Agency (UNWRA), non-governmental organisations, and the private medical sector) contribute to all areas of health care.

However, various factors, including lack of development under Israeli military rule together with poor governance and mismanagement by the Palestinian Authority, mean that Palestinian health services are inadequate and many patients must be referred elsewhere (Israel, Egypt, Jordan).’

The authors say: ‘We have shown that, after a period of improvement in Palestinian health in the occupied Palestinian territory, socioeconomic conditions have deteriorated since the mid-1990s, with a humanitarian crisis emerging in the Gaza Strip and intensifying as a result of the Israeli army invasion in December, 2008, and January, 2009, because of destruction of homes and infrastructure, the death and injury of civilians, and shortages of food, fuel, medicines, and other essentials, requiring urgent world concern.’’

They conclude: ‘Hope for improving health and quality of life of Palestinians will exist only once people recognise that the structural and political conditions that they endure in the occupied Palestinian territory are the key determinants of prevailing health conditions.’

Author Dr Rita Giacaman, Birzeit University, Ramallah, West Bank.

2. The Urgent Health Struggle of Mothers and Children in the Occupied Palestinian Territory

Maternal and child health in the occupied Palestinian territory (OPT) faces challenges that are common to many low-income and middle-income countries, such as poverty, poor nutrition, and an overburdened public-health system, as well as unique challenges of military occupation and continued warlike conditions.

Access to unrestricted 24-hour emergency care and other services, though vital for effective provision and protection of maternal and child health, is complicated by the living conditions there, especially the Israeli-imposed system of several hundred checkpoints.

These issues and others related to maternal and child health trends and services are discussed in the second paper in The Lancet Series on Health in The Occupied Palestinian Territory, written by Dr Hanan F Abdul Rahim, Birzeit University, Birzeit, OPT, and Qatar University, Doha, Qatar, and colleagues.

Roughly 40 per cent of the Palestinian population are women of reproductive age and children under 5 years.

Fertility rates in Palestinian women are among the highest in the world, at 4.5 births per woman (Israel figure is 2.8). Around 28 per cent of Palestinian women are married to a first cousin, which can have adverse health implications for children.

The authors analyse maternal and child health in the OPT with reference to Millennium Development Goals 4 (MDG4) which are to reduce by two thirds, between 1990 and 2015, and the under-five mortality rate. MDG5 – to reduce by three quarters the maternal mortality ratio and achieve universal access to reproductive health.

They discuss how, following decades of improvement, infant mortality in the occupied Palestinian territory has not fallen much since 1990, nor has mortality in children under 5 years.

In the occupied Palestinian territory, interventions that are fairly simple to schedule and deliver have high coverage.

These include antenatal care, skilled attendance at birth, and childhood immunisations. Those that require a well-functioning health system 24 hours a day—such as emergency obstetric care—have lower coverage.

There can be no time more delicate and crucial than labour for a pregnant woman.

But between 2000 and 2006, the Ministry of Health reported 69 cases of Palestinian women giving birth at Israeli checkpoints. Ten per cent of pregnant women in labour were delayed for 2-4 hours on the road to the maternity facility, whereas the average time without roadblocks to reach health facilities was 15-30 min.

These numbers do not reveal women’s anxiety throughout the pregnancy about reaching a place of birth and returning home safely.

The rate of caesarean sections has risen from 6·8 per cent to 15 per cent of all births in the past decade. The rise in the rate of caesarean sections is cause for concern because of deteriorating health service conditions.

Gaps in the quality of health service provision are partially due to interactions between restrictions on mobility and the legacy of occupation which has stifled the development of good governance and the culture of accountability.

Maternal and child health services in the public sector are perceived to be of lower quality and are not always in accordance with best evidence.

Human resources are scarce in some specialisations, such as neonatology and paediatric surgery, but there is also a problem of ineffective use of human resources.

The authors make a range of recommendations, some immediate and some long-term, to improve maternal and child health in Palestine.

They conclude: ‘Lives cannot be saved without access to 24-hour curative services to deal with unpreventable complications.

‘Such an achievement requires a political solution of unrestricted mobility, ensuring access to services.

‘Availability of emergency obstetric care and high-quality birth attendance for all depends on a strengthened health system, which can only be achieved through a concerted effort and the commitment of the Palestinian National Authority, donors, and political decision makers to overcome the external and health-system constraints.’