Memorandum submitted by Médecins
du Monde (MdM)
SUMMARY:
1. Since February 2006, the Occupied Palestinian
Territories have suffered the effects of an economic embargo.
The suspension of international aid constitutes a new difficulty
for the Palestinian civilian population, whose living conditions
have been deteriorating since 2000. Furthermore, Operation Summer
Rain, launched by the Israeli army at the end of June 2006, in
reaction to the kidnapping of a soldier by Palestinians, has been
a further destabilising factor.
2. Today, 70% of the Palestinian population
lives below the poverty line, unemployment in the Gaza Strip is
running at 40% and the conditions of access to safe drinking water
and food are worse than before 2000. Furthermore, the destruction
of the infrastructure and major transport routes due to the new
incursion limits distribution of electricity, drinking water and
fuel as well as movement within Gaza.
3. Me«decins du Monde conducted two
surveys in 5 hospitals and 10 health centres across Gaza in June
and July 2006. In light of the findings of these surveys, Me«decins
du Monde calls on the international community to do everything
possible to ensure that the Palestinian population is no longer
deprived of the necessary funds for survival.
INTRODUCTION:
4. Me«decins du Monde (MdM) is an international
medical humanitarian non-governmental organisation which provides
healthcare for the most vulnerable populations suffering from
crisis and exclusion in both developed and developing countries.
Me«decins du Monde has over 25 years of experience in providing
medical assistance and in advocating for better access to healthcare.
Me«decins du Monde UK, registered as a charity in England
and Wales since 1998, contributes to this world-wide work.
5. Me«decins du Monde has been working
in the occupied Palestinian Territories since 1995, running programmes
aimed at facilitating access to healthcare and at bearing witness
to violations of the right to health. Today MdM is working in
Gaza and in Nablus in close partnership with local associations.
In the West Bank, in Nablus district, MdM is
committed to improving the medical care of mental health problems.
Across Gaza, since 2002, MdM's programme "Improving
emergency care in Gaza" has been aiming to:
— Improve pre-hospital care for the
Palestinian population in emergencies and improve hospital care
of those who are injured or sick;
— Improve knowledge of first aid and
the treatment of emergency cases by the civilian population before
the arrival of emergency services;
— Training of trainers for Emergency
Medical Technicians (EMTs) in the two training institutes of the
Palestinian Red Crescent Society at Gaza and Ramallah, as well
as putting in place new initial and continuous training programmes;
— Developing and implementing a reference
document "Emergency plan for an influx of injured or sick
patients" within the emergency services of Shifa hospital
in Gaza city.
Following the incidents experienced in March
2006,[97]
and the current hostilities, the programme in the Gaza strip has
faced several difficulties. Nevertheless, it is from MdM's work
carried out in collaboration with the local team in Gaza that
this evidence has been compiled.
6. Since the beginning of our presence in
the Palestinian Territories, MdM, in line with its principles,
has sought to bear witness to the health situation and to speak
out about any barriers which limit access to healthcare for the
civilian population:
— In 2002, MdM worked with the International
Federation of Human Rights (FIDH) to carry out a survey into the
human rights situation in Nablus and a report was published outlining
the human rights violations during the operations carried out
by the Israeli army at the end of March 2002i;
— In November 2003, MdM put together
a reportii demonstrating the obstacles Palestinian patients and
medical personnel faced between the months of January and June
2003, when trying to reach health services quickly;
— In July 2003, MdM published a studyiii
on the medical, psychological and social consequences of the attacks
perpetrated by armed Palestinian organisations, on civilians in
Israel and in the Occupied Territories
— In May 2004, following Operation
Rainbow carried out by the Israeli army in Rafah, MdM and the
FIDH carried out an inquiry to measure the consequences of this
operation on the civilian population of Rafah, particularly in
terms of access to healthcare and of physical and mental health.
iv
— In February 2005, MdM decided to
describe the implications for the population of the construction
of the wall. Drawing on our work on the ground, we gathered testimonies
to illustrate the difficulties, sometimes insurmountable, that
Palestinians living in the West Bank and in Jerusalem experienced
in trying to access health services. This gave a voice to those
who were confronted on a daily basis by the wall or a multitude
of other barriers when trying to access hospital, primary healthcare
centres or clinics.
Continuing with the theme of these reports,
we decided to bear witness to the impact of the suspension of
external aid since February 2005 on the Palestinian population.
Furthermore, given the developments in the political situation
in June 2006, and of the launch of the operation codenamed Summer
Rain, we also wanted to take into account the difficulties faced
by the population of Gaza during to get food, to go to work, or
to reach health services during this period of armed conflict.
Data was therefore collected by means of two surveys carried out
in Gaza in order to illustrate the problems facing Palestinians
on a daily basis since the beginning of 2006.
7. Me«decins du Monde UK welcomes the
International Development Committee's inquiry into the issue of
development assistance and the Occupied Palestinian Territories.
This evidence presents the relevant findings of two surveys carried
out in Gaza in June and July 2006. A summary of these findings
was released to the media in July 2006 (See Annex 1[98])
and a full report will be published in due course. This evidence
also refers to the findings of our report published in February
2005 into the impact of the construction of the separation barrier,
or wall, on access to healthcare in the West Bank (See Annex 2[99]).
This evidence predominantly addresses issues 1 and 6 as outlined
in Press Notice 53.
Impact of the suspension of aid to the Palestinian
Authority and the impact of the temporary international mechanism
for Palestinian basic needs, agreed by the Quartet and the European
Council (Issue 1)
8. Encouraged by the United States and financed
by the European Union, the Palestinian Authority organised legislative
elections on 25 January 2006. The victory of Hamas—considered
as a terrorist group by the international community and the European
Union—caused turmoil in the Palestinian Territories, in
Israel and throughout the Western world.
9. Since the accession of the Hamas government,
Israel has felt threatened and has demanded to be recognised by
the new Palestinian government. Hamas announced that it would
not renounce its charter calling for the Islamisation of Palestinian
society and the destruction of Israel. From the beginning of March
2006, the Israeli government therefore decided to freeze the monthly
transfers of around 60 million dollars of funding which corresponds
to the reimbursement of customs payments and VAT levied on products
destined for the Palestinian Territories. These funds represented
around 30% of the budget of the Palestinian Authority and covered
the salaries of more than 150,000 civil servants. Following the
United States, Japan, Canada and other donors, the European Union,
until then the largest donor, decided to suspend its assistance
to the Palestinian Authority on 10 April. These decisions to suspend
international aid had major consequences because since 1994 this
assistance has represented around 53% of the Palestinian Authority
budget.
10. Thus the budget of the Palestinian Authority
fell by at least 60 million dollars in April 2006 and according
to the World Bank this budget will have to come down even lower
in the coming years and will not exceed 25 million dollars.
11. In light of the economic consequences
of the withdrawal of international aid, which were already noticeable
by April and May, the Quartet approved the implementation of a
temporary international mechanism on 17 June. This programme is
based on support for the health and education sectors via the
World Bank, ensuring that essential goods and services are accessible
(water, fuel, electricity) and implementing direct aid to the
most disadvantaged groups.
12. Me«decins du Monde joined with
many other NGOs and associations to refuse the role of "substitution"
of the Palestinian authority and called on the international community
to reconsider its development assistance policy.
Findings of Me«decins du Monde surveys on
living conditions and access to healthcare
13. The analysis presented here, is based
on data collected in the field during two series of surveys carried
out by Me«decins du Monde France and its local team in June
and July 2006, before and during operation Summer Rain launched
by the Israeli army at the end of June.
14. These surveys were carried out on a
population of 1,490 persons who turned up for a medical consultation
at a sample of 15 health facilities (10 health centres and 5 hospitals)
across Gaza. The selected structures were representative of all
the health facilities in Gaza. The survey focused on unemployment,
overcrowding, access to food and water, access to health services
and to medicines, premature births and psychological trauma.
15. During the first survey, 482 interviews
were carried out by the MdM-France team and the health professionals
involved. During the second interview, 1005 people were interviewed.
Some results only concern those interviewed in the first survey,
before the incursion. Other results only concern those interviewed
in the second survey, during the incursion. In all cases, we specify
which population and which survey we refer to, and particularly
specify the number of responses considered (n=).
DEMOGRAPHICS
16. There were more women (56%) than men
(44%) coming to the health facilities for consultations (n=1482).
The age was relatively young, with an average age of 29 years
(n=1481) and one in five of those coming for a consultation was
under the age of five. One in three was below 15 years old. The
population aged between 0 and 14 years represents 48% of the total
population of the Gaza strip.
17. We can observe that the population interviewed
in the health structures was younger during the second survey
period (average age of 28 compared to 31 before). This can by
explained by a significant increase in the 15-35 age group (of
which, 60% are women) which increased from 22% to 34% from the
first to the second survey. This probably indicates restrictions
on access to medical consultations for the most vulnerable (children
and the very old) during Operation Summer Rain.
LIVING CONDITIONS
18. The Gaza Strip, populated by 1.4 million
Palestinians, is one of the most densely populated areas in the
world (6,000 inhabitants per sq km). This overcrowding can be
seen in each apartment or house: those surveyed during the first
survey (n=480), declared an average of 8.4 people per dwelling.
One third shared their accommodation with more than 10 people.
19. In general, the larger the family, the
harder the living conditions. According to data from the Palestinian
Centre of Statistics, poverty is highest among families with more
than 10 members—among these families, 33% suffer from extreme
poverty.
ECONOMIC SITUATION
20. Although we have not evaluated the economic
situation of people interviewed, many studies have demonstrated
the negative impact of the suspension of aid on the economic development
of Gaza.
21. In May 2006, for example, the IUED recorded
that 70% of the population of the Palestinian Territories was
living below the poverty line (2.37$ per person per day). This
compares to 30% before the second Intifada. An increase in people
living with less than 1.35US$ per person, per day (54% in Gaza,
34% in the West Bank) was also recorded. In the Gaza strip, the
proportion of the population living with less than 2.37US$ per
person per day has now reached 79%.
22. In our first survey (n=478), 65% of
respondents declared at least one person in economic activity
in the home, compared to 35% of households without employment
or any regular income. Over half (52%) of those interviewed were
surviving thanks to external financial support, in half of the
cases from the United Nations, in 25% of cases from NGOs and in
the other 25% of cases, from family members or other people.
23. The rate of Palestinians without work,
at the end of the first quarter of 2006, was 31.1%, compared to
20% in 2000 and 24% in 2005 according to PCBSv. This rate reached
almost 40% in the Gaza strip and has doubled since 2000. The areas
most affected are Deir El-Balah (42%), North Gaza (39%) and Gaza
city (32%). According to World Bank forecasts, the unemployment
rate could increase further in the months and years to come and
could reach 47% by 2008.
24. The journeys of Palestinian workers
with jobs in Israel have been severely restricted since the beginning
of the second Intifada (the number of people from Gaza working
in Israel or in the settlements has been divided by 30 since 2000).
This has also contributed to the increase in the unemployment
rate and the poverty level, along with the suspension of international
aid (more than 150,000 employees of the Palestinian Authority,
had not been paid since March).
ACCESS TO
WATER
25. Access to water was considerably reduced
from the first days of the Israeli incursion: 70% of those interviewed
(n=480) had access to running water in the first survey. The second
survey found that this had fallen to 32% (n=991) at the beginning
of July. In general, access to running water was only possible
for several hours per day. In Gaza city, for example, more than
300,000 people were living in buildings with inadequate water
supply due to restrictions on the electrical supply.
26. Access to drinking water for the population
of Gaza was limited in the second survey (n=1003) with worrying
consequences. Consumption of bottled water, very expensive in
this disastrous economic context, increased greatly while the
net consumption of water from wells had declined overall.
ACCESS TO
SANITATION
27. In our surveys (n=1475), 97% of those
interviewed said that they had access to sanitation (WC etc),
However, as with water distribution, the waste removal network
depends on electricity and is therefore at risk of serious disruption
in the short term.
ACCESS TO
ELECTRICITY AND
TO FUEL
28. We did not evaluate the access to electricity
in the survey. However, it is clear that the Israeli bombardments
destroyed the only electricity plant in Gaza at Nuseirat. The
consequences of this destruction are serious because this plant
supplied two-thirds of the population of Gaza. It will take nine
months and more than 15 million dollars to repair this plant.
All the restrictions on energy supply are very serious, because
they have multiple consequences—affecting, for example,
the health system and the economic development of Gaza.
ACCESS TO
FOOD
29. In the survey population, we witnessed
a deterioration in the food security situation as illustrated
by a significant drop in the average number of meals: 2.56 during
the second survey compared to 2.98 before. The number of people
interviewed who had only eaten two meals the day before the interview
had doubled between the two surveys (41% during the second survey
versus 18%) and there were five times as many people who had only
eaten one meal the day before (12% compared to 2.5% before). The
size of meals cannot be measured precisely but many people described
a decrease in the rations available.
30. The reasons for the low number of meals
in the second survey, since the start of Operation Summer Rain,
were essentially economic for 84% of those interviewed (n=590).
For 11% of respondents, health problems (including psychological
effects linked to the incursion) were given as a reason for this
drop. Health problems and dietary problems are interlinked: health
problems can lead to undernutrition and undernutrition can lead
to health problems.
31. This deterioration in the dietary situation
can also be explained by the following factors:
— Economic difficulties: drops
in stocks, increases in prices, impoverishment of the population
and a reduced purchasing power. Fearing a new surge in prices,
some households attempted to stockpile basic foodstuffs, and most
of them reduced their daily food intakes;
— Closure of the Karni border crossing:
Regular closures of the Karni crossing point, which goods
have to pass through, made the importation of foodstuffs more
and more difficult. Between 25 June and 30 July, Karni was only
opened for 17 days. Furthermore, the difficulties of transporting
merchandise in the Gaza strip contribute to restricting access
to basic foodstuffs for a significant part of the population;
— Drop in local production: The
destruction of farms during Operation Summer Rain reduced local
production and the presence of Israeli warships along the coast
restricted fishing activities. Fish represents the only source
of protein available for the population of Gaza, particularly
since the Avian Flu epidemic led to mass slaughter in poultry
farms;
— Poor conditions for food storage
due to electricity shortages: Many businesses (butchers, fishmongers)
had to close their shops. Furthermore, these poor storage conditions
risk the development of infectious disease.
32. This deterioration in the dietary conditions
is particularly worrying in a context which was already very fragile:
in effect, chronic malnutrition already affected 10% of children
under 5 living in the Palestinian Territories, equivalent to around
70,000 children. Anaemia, strongly linked to poor diet, affected
70% of children in the Gaza strip in April 2006, compared to 52%
in December 2005. vi
ACCESS TO
HEALTH SERVICES
33. The first survey, in June 2006, seemed
to show relatively satisfactory access to health structures for
the population interviewed (n=477). Among those interviewed, 92%
were covered by health insurance, 94% of those who were seen and
were referred for additional tests during their last consultation
were able to have the tests done and 87% of those who were prescribed
treatment during their last consultation were able to take the
treatment prescribed.
34. However, these results must be treated
with caution. Firstly, the population interviewed were those who
had come to a hospital or health centre for a medical consultation
and this implies a potential selection bias. It was not possible
for us to measure access to healthcare for the general population.
35. Moreover, it is interesting to note
which health services these patients had chosen to consult. Public
facilities were used more for consultations while a substantial
number of complementary tests were carried out in private health
facilities, where they are more expensive. NGOs and the Palestinian
Red Crescent Society are often asked for medical treatment, as
are private organisations.
36. Over 12% of patients who had been given
a prescription had not taken the treatment during their last "health
episode". "Economic factors" was the most common
reason cited by 50% of these patients.
37. The time between the beginning of the
"health episode" and when they came to a consultation
was more than a week in a quarter of cases, suggesting an overall
difficulty with access to care. During the second survey, after
the incursion, the conditions for accessing health services had
worsened considerably (n=993). The time taken for journeys to
reach the health services multiplied by four: one and a quarter
hours compared to 20 minutes on average in the earlier survey.
The principal factors cited were fear of travelling (37%), lack
of transport (32%), economic reasons (20%) and general difficulties
relating to going out (13%).
38. The functioning of the health services
was also heavily disrupted by cuts in the electricity supply:
loss of blood products and vaccines, interruption of medical instruments
in adult and neonatal intensive care units, and breakdown of the
ventilation systems. Most health centres had to use generators
to produce electricity to make up the shortfall, but fuel stocks
dropped. Between 3 and 10 July, the partner hospitals only had
electricity for nine hours per day. Al-Assria hospital experienced
great difficulties: at the beginning of July, it received only
three hours of electricity per day and on 10 July it did not have
any electricity all day. During the same period, access to water
was only possible for 12 hours per day in hospitals.
39. In May 2006, 77 basic medicines supplied
by the central pharmacy of the Ministry of Health (anaesthetics,
treatments for chronic disease) were exhausted due to economic
reasons. Stores of medication and medical supplies in the participating
health facilities were relatively well stocked in July. Difficulties
in the supply chain, however, meant that the risks of shortages
were very real.
40. Over half (53%) of those seen in consultation
during the first survey (n=482) were suffering from chronic medical
conditions and of those 93% had to follow a treatment programme.
Furthermore, 87% of these consultations resulted in a medical
prescription. This makes the interruptions in the supply of medicines
or access to healthcare even more worrying.
41. In July 2006, the hospitals had to adapt
to the new constraints because of the war and only emergency cases
were admitted: Al-Shifa hospital reoriented its general activities,
prioritising surgical operations. Some health centres had to suspend
their activities: Ashoka and Beit Lahia centres had been closed
at the beginning of July.
HEALTH STATUS
42. Forty-five per cent of the people interviewed
in the first survey (n=480) considered that their general state
of health was good or very good. However, 35% considered themselves
to be in average health and 20% considered themselves to be in
poor or very poor health.
43. In the first survey, the results of
medical consultations were recorded by participating doctors at
the end of each consultation (n=477). During the second survey,
doctors were no longer available to participate in this data collection,
but the motives for coming for a consultation as expressed by
the patients before the consultation were recorded (n=1005), as
well as the existence of chronic medical conditions. All the data
collected were coded according to the International Classification
of Primary Care (ICPC) which enables the differentiation of symptoms
and diagnostic complaints.
44. The six most common diagnoses recorded
during the first survey were:
| Hypertension | 23.1%
|
| Diabetes | 18.7% |
| Respiratory Infections | 6.3%
|
| Sore throat | 6.1% |
| Gastro-intestinal infections | 5.7 %
|
| Asthma | 4.0% |
| |
These results illustrate that Palestinians presenting to
health services during the first survey tend to suffer from chronic
health conditions. Cardiovascular, endocrine, digestive and respiratory
problems were predominant in the results of the first survey.
These findings are particularly significant because such conditions
require ongoing medical care which becomes more and more difficult
in the economic situation and within the context of armed conflict,
such as the Operation Summer Rain.
45. Even though the data are not fully comparable between
the surveys, they do enable some general distinctions to be drawn:
— Chronic conditions (mainly hypertension, diabetes
and asthma) are more common in the first survey.
— Traumatic conditions were more common in the second
survey and symptoms which could correspond to psychosomatic manifestations
(abdominal pain, headache, vomiting) were common.
— Reasons linked to pregnancy were also more frequent
in the second survey (16% compared to 3.3%), illustrating the
potential impact of the events of July 2006 on pregnant women.
46. From the first days of the Israeli incursion, 85%
of those interviewed (n=1004), said that they had faced at least
one traumatising event. It is clear that the psychological situation
of the civilian population, already victims of political, social
and economic chaos, can only get worse in this context of war.
47. Among those who had faced a traumatising event, there
were many persons who, if these psychological symptoms continued
over time, could be diagnosed with post-traumatic stress disorder
(n=825).
Figure 1
WARNING SIGNS FOR POTENTIAL POST-TRAUMATIC STRESS DISORDER
The impact of the separation barrier and other controls on
the movement of goods and people on employment, poverty, economic
development and on the delivery of humanitarian assistance. (Issue
6)
48. In February 2005, Me«decins du Monde published
a report entitled "The Ultimate Barrier: Impact of the Wall
on the Palestinian Healthcare System". This report (see Annex
2) documents the impact of the separation barrier on the Palestinian
healthcare system by documenting the testimonies of 83 people
living in the West Bank and Jersualem between July and October
2004.
49. These testimonies clearly illustrated the following
points:
— How the Palestinian healthcare system is placed
at risk by the problems of access faced by both patients and medical
staff;
— How the Wall impedes people's access to their
livelihoods, resulting in economic difficulties to pay for healthcare;
— The psychological consequences resulting from
the division of families, increased tension and isolation.
50. In Gaza, there has been a tightening of controls
on movements of goods and people between the Gaza Strip and Israel
since the Hamas election victory. Since the month of February,
the average number of daily movements of workers and traders from
Gaza towards Israel via the Erez crossing decreased. Although
this average had reached a new high in February 2006, there were
no crossings in April and May because of the total closure of
the border crossing.
51. There are several effects of this policy of closure
on the civilian population of Gaza:
— It contributes to a revival of political tensions.
— It plays an important role also in the economic
and social crisis.
— It has repercussions on the physical and mental
health of the population.
CONCLUSIONS
52. In light of the survey findings, Me«decins du
Monde made a series of recommendations, calling on the different
actors involved to address this situation. As well as calling
on both the Israeli and Palestinian authorities to take action,
Me«decins du Monde made recommendations for the members of
the quartet and the international community.
53. Me«decins du Monde calls on the Members of the
Quartet:
— To respect their promises concerning the maintenance
of humanitarian aid that they have committed to provide to the
Palestinian population;
— To re-evaluate the support and aid to the Palestinian
civilian population and to set out a new plan to move away from
the current situation where unexpected interruptions in external
funding threaten sustainable development and the ability of the
population to emerge from crisis.
54. Me«decins du Monde calls on the international
community:
— To do everything possible to bring an end to violence
on all sides;
— To do everything possible to ensure that the Palestinian
population is no longer deprived of the necessary funds for survival,
in view of the direct and immediate consequences of an interruption
in financial aid for the Palestinian health services.
November 2006
NOTESi Me«decins du Monde—FIDH,
Operation "Mur de Protection" Naplouse, 2002.
ii MdM Access to healthcare and the protection of medical
services in the Occupied Palestinian Territories, November 2003.
iii MdM, Israeli and Palestinian Civilians, Victims of a conflict
without end. July 2003.
iv MdM, Operation Rainbow—Impact on the health of the
population of Rafah, Gaza, 2004.
v PCBS, Quarterly Labour Force Survey, May 2006.
vi World Health Organisation, 2006.
97
Two expatriates and one member of the local team were kidnapped
on 14 March 2006, and freed the next day. Since then, all the
expatriates have been repatriated and the mission is managed by
a team of local staff. Back
98
Annex 1: http://www.medecinsdumonde.org.uk/pressreportsevents/pressrelease113.asp?year=1 Back
99
Annex 2: The Ultimate Barrier: Impact of the Wall on the Palestinian
health care system, February 2005. Back
| 
