April 16, 2002

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 from my 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 90%.

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, nor its 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 truckloads 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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