James Antoon writes on the underlying economics of health systems affected by conflict. 

The effect of war and conflict on local health care systems can be devastating and is often difficult to quantify.  Areas such as Iraq, Sudan, Palestine and Timor, where conflict is long term, all show a failure of the health care system to compensate for the increased need of medical care.  Unfortunately, the inability to survey and monitor as a result of violence and political posturing makes obtaining accurate heath care data difficult.  Qualitatively analyzing the effects, however, is not quite as challenging. (more…)

During the 1970s, subsequent to the oil industry being nationalized, a centralised system of healthcare was established in Iraq (1). This government subsidised system was based upon a Western model. It enabled the entire Iraqi population to access free healthcare (1). The country’s immense oil reserves were used to pay for medication and medical equipment, as well as for foreign healthcare workers (1). It is reported that before 1990, despite a severe curtailment of civil liberties, 97% of Iraq’s urban dwellers and 71% of the rural population had access to primary healthcare (1).

(photograph courtesy of MSF Canada).

The fate of healthcare in Iraq began to change in August 1990 with the outbreak of the first Gulf war (1). Furthermore, the UN Security Council took the decision to implement economic sanctions against the country, on the grounds that these sanctions would weaken Saddam Hussein’s grip on power (2). Within a period of six weeks, the US and its allies had dropped an estimated 88,000 tonnes of bombs, the equivalent of seven Hiroshima explosions, on Iraq (2). Water and sewage treatment plants, which had been damaged in the bombing, were no longer functioning at their optimal capacity (2). Cholera, typhoid and other water-borne diseases became rife (2). The economic sanctions that followed the war resulted in the impoverishment of Iraq and led to a downward spiral in the nation’s health (1).

Chronic shortages of food and medicine became commonplace (2). By 1997, an estimated one million children below the age of five were malnourished (3). Furthermore, as part of the sanctions imposed upon the country, an ‘intellectual boycott’ led to Iraqi doctors being cut off from medical and scientific developments happening around the world (2). This boycott prevented Iraqi doctors accessing the latest literature and restricted them having contact with their counterparts around the world (2).

A decade later, the mortality rate amongst children under the age of five had risen from 56/1000 live births in 1989 to 131/1000 (1). A large increase in the incidence of childhood cancers, widely believed to have been the consequence of depleted uranium shells being used by coalition forces, became noticeable in the years following the first Gulf war (4). Dr Muhammad Hilal, former chief paediatrician of a hospital in Baghdad, has commented that remission rates for childhood cancer plummeted from 70% in 1990 to around 6 or 7% by the end of the decade (2).

The already crippled healthcare system was to take an even greater battering with the onset of the invasion in 2003. In the initial stages of the war, 7% of the nation’s hospitals sustained damage and 12% experienced looting (5,6). The steady exodus of Iraqi health professionals, taking place throughout the 1990s, escalated (6). As the invasion took place without a UN mandate, it was not possible to effectively harness the knowledge of those individuals with expertise in post conflict health planning (6). In Iraq itself, numerous health experts, who were members of the Iraqi Ba’ath party, were dismissed from their jobs as part of the US determined process of ‘de-Baathification’ (6). Furthermore, in contrary to what is prescribed by the Geneva Convention (IV, article 18), hospitals received inadequate protection by the occupying forces (6). In 2004, there were even reports of humanitarian convoys being denied access to the besieged city of Fallujah, by the US and Iraqi army (7). The larger reconstruction contracts were bequeathed to private companies, rather than being placed in the hands of the WHO or UNICEF (6).  There is a risk that involving private companies in the reconstruction effort may lead to an emphasis on profit-making and a consequent detraction from humanitarian needs. Iraqi communities were largely excluded from decision making and planning in matters of healthcare provision (6). A rapid succession of health ministers since 2003, has further intensified the instability (6). Meanwhile, the training of health professions has suffered as medical schools are struggling to remain open. A 2008 report, released by the British NGO Medact, indicated that 5 years after the invasion, Iraq [still] has no comprehensive health policy or funding strategy (6).

(photograph courtesy of landstuhl hospital care project).

Since 2003, three-quarters of doctors, nurses and pharmacists have ceased working and half of these have fled the country (6). It has been estimated that only 9000 doctors and 15,000 nurses now remain in Iraq to serve a population of approximately 25 million (6). According to ‘Save the children’, the death rates amongst Iraqi children under five are approaching those of Sub-Saharan Africa (8). In the year 2005, one in eight Iraqi children died before they reached the age of five (8).

One area of healthcare that is currently much needed in Iraq but that has received inadequate funding since 2003, is that of mental health services (6). The mental health effects of the war upon the civilian population are immeasurable and their long-lasting repercussions are as yet unknown. Adult mental health services are limited while children’s mental health services are non-existent (6).

The toll that the war has taken on the physical and mental health of the Iraq people is perhaps particularly severe among the 2 million Iraqis who have received refuge in Syria, Jordan, Egypt or elsewhere in the Middle East (9). They now face the struggle of finding work and accommodation in their new surroundings (9). Syria, with a population of only 18 million has seen its infrastructure struggle to cope with an influx of 1.5 million refugees (10). As the cost of food and fuel has also risen sharply (10), there is evidence that some sections of the Syrian population have started to harbour grudges against the Iraqi refugees (10). Although the Syrian government has taken measures to limit the flow of refugees from Iraq, it has stated that it will not expel any of the refugees who are already in Syria (10).

Although the healthcare situation in Iraq looks bleak, there are steps that can be taken in order to try to resolve the crisis. For example, it is essential that the Iraqi people be at forefront in making decisions about their own healthcare. As recommended in the 2008 Medact report, Iraqi companies should also be given priority over foreign firms when it comes to bidding for healthcare reconstruction projects (6). Additionally, there is a great need for donors to come forward and provide financial aid for humanitarian projects within Iraq (6). The lyrics of US folk singer Pete Seeger’s Vietnam era song ‘Bring em home’ come to mind; they include the words ‘…the world’s got hunger and ignorance… you can’t fight that with guns and bombs.’

Tomasz Pierscionek
Medical Student
Newcastle Medical School, UK
tomasz.pierscionek@newcastle.ac.uk

References

1. UNICEF. Iraq Watching Briefs. Overview Report. Prepared by Sen B. , 2003.
http://www.unicef.org/evaldatabase/files/Iraq_2003_Watching_Briefs.pdf

2. Cappacio G. How many must die? Rethinking Schools Online 1999;13(3)
http://www.rethinkingschools.org/archive/13_03/iraq.shtml

3. UNICEF report. Situation Analysis of Children and Women in Iraq - 1997. Part two: Child survival, rights and basic needs. UNICEF 30^th April 1998    http://www.casi.org.uk/info/unicef/irqpt2a.pdf

4. Al-Azzawi S. Depleted Uranium Radioactive Contamination In Iraq: An Overview.      Presented at The 3rd ICBUW International Conference Hiroshima. August 3-6, 2006.    http://www.brusselstribunal.org/DU-Azzawi.htm

5. Garfield R. Challenges to health service development in Iraq, The Lancet 2003; 362: 1324.

6. MEDACT report. Rehabilitation under fire. Health care in Iraq 2003-2007. London: Medact, 2008.     http://www.reliefweb.int/rw/RWFiles2007.nsf/FilesByRWDocUnidFilename/EDIS-7B5MCP-full_report.pdf/$File/full_report.pdf

7. Ismael S. Fallujah - one year on. Briefing note. Doctors for Iraq, 2005.    http://www.doctorsforiraq.org/FALLUJA_ONE_YEAR_ON.pdf

8. Save the Children. Saving the lives of children under 5. 8^th annual State of the     World’s Mothers Report. Connecticut: Save the Children, 2007.    http://www.savethechildren.org/publications/mothers/2007/SOWM-2007-final.pdf

9. UNFPA, UNHCR, UNICEF, WFP, WHO. Health Sector Appeal: Meeting the Health needs of Iraqis Displaced in neighbouring Countries - Joint appeal by UNFPA, UNHCR, UNICEF, WFP and WHO. 18^th September 2007.

10. Al-Jazeera news report. Iraqi refugees swell pressure on Syria’s social services.       Published on 10^th October 2007. http://www.weshow.com/us/p/19226/iraqi_refugees_swell_pressure_on_syrias_socialservices

Kush Patel reports on the violence that occurred in Kenya following the elections earlier this year.

For many years, Kenya has been considered as a refuge for people fleeing their own country because of domestic turmoil. However, on 29th December 2007, shouts emanated from an angry throng that had gathered on the streets. Marching determinedly towards them was a battalion of riot police. Within seconds, the rioters hurled stones at the police, who counterattacked using bullets and tear gas. In other parts of the country, youths clutching machetes and sticks launched themselves upon opposing tribes. Events such as these set the scene for a blood bath that has resulted in thousands of people injured, dead or homeless. Several camps for internally displaced people (IDP) were set up all over the country. Governmental and non-governmental organisations (NGOs) such as Merlin, Medecins sans frontiers (MSF), the Red Cross, AMREF and others, deployed teams to provide humanitarian aid.

Post-election violence in Kenya results in displacement

photo source: savethechildren.org/au

Trauma victims requiring medical attention overwhelmed the medical facilities. When particularly violent clashes broke out, trucks full of injured or dead people arrived at hospitals, which in-turn became so over-crowded that patients were being treated on the corridors. A system of triage was implemented at many institutions, thus helping to treat the most severe patients first. (2,3) Patients were being rushed in with broken bones, stab injuries, blunt trauma and burns. Doctors reported certain cases where patients had sustained machete wounds that resulted in near-amputations. (3) Flying surgical teams were put on high alert, responding to violence in inaccessible regions. (4) In the worst hit areas, temporary first-aid posts were setup that quickly stabilized victims, while waiting for transport to hospitals. Any person who was critical and needed specialist care was air-lifted to the closest hospital. (3) Many of the victims were (and some still are) mentally traumatized from witnessing the violence or having lost loved ones. These people were given psychosocial support by medical personnel. (2,3)

Cases of sexual violence increased dramatically. These incidents took place both within IDP camps and outside. This will probably result in increased incidence rates of sexually-transmitted diseases, including HIV infection. Counselling and screening for sexually-transmitted infections have commenced in certain areas. (4)

Many people have been displaced and gathered at temporary IDP camps. At these camps severe public health consequences can manifest amongst the IDPs.. Four main reasons behind this are that the population is displaced, food becomes scarce, health care diminishes and living conditions worsen. Studies have shown that mortality rates are usually highest immediately after the migration. (1) Apart from the acute emergencies, an increasingly large number of IDPs need to be accommodated. At each IDP camp, tents were pitched, food and water was provided, sanitation and lavatory facilities were set up and medical camps were established. (2-6) Other essential equipment such as bed nets, (6) cooking apparatus, (3) and clothing, (2,4) was provided to the IDPs. Most IDPs had left their homes without anything. For many, important documentation was lost. Therefore, the task of registering the IDPs and getting new identification cards for them was set into motion. In order to keep the IDPs busy and lessen their emotional stress, some were given responsibilities in the camps such as cleaning. (2) Some NGOs have setup tracing agencies that help reunite lost family members.(4) Planes and helicopters had to be employed to deliver medical and other essential supplies to ill-equipped areas.(3)

The most prevalent diseases amongst IDPs are diarrheal diseases, measles, acute respiratory infections, and malaria. Additionally, many people became malnourished because of the lack of food. This aggravates diseased states and worsens the patient’s prognosis.(1) At a single camp, 541 consultations were done mainly for respiratory tract infections.(3) Most of these patients were children and many had a poor prognosis. Factors that contribute to a high prevalence of respiratory tract infections are: over-crowding, poor ventilation, inadequate shelter, and prolonged exposure.(1)
The measles immunization was provided for children.(3) For those who survive the initial illness, it can lead to malnutrition and vitamin A deficiency. Previously, measles has accounted for high mortality rates amongst children in refugee camps. However, it is less of a threat now compared to before 1990.(1)

Diarrhoeal diseases are a common phenomenon in IDP camps. Factors that contribute to their high prevalence are unsanitary conditions and unsafe drinking water. Cholera and dysentery are the main problems. In some IDP camps, diarrhoeal epidemics had broken out. These were usually treated with oral rehydration salts. However, any serious cases of diarrhoea were referred to a hospital.(4)

Kenya has a high prevalence of tuberculosis (TB) (7) and AIDS. (8) A lot of IDPs with TB or AIDS fled their homes without anything, including their anti-tuberculosis or antiretroviral drugs.(2,3,6) Adding to this, the number of patients attending HIV/AIDS clinics reduced dramatically.(3) This can have serious consequences on their health, as non-compliance results in the development of drug-resistance. Patients also become susceptible to opportunistic infections and their risk of morbidity and mortality increases.(8) One report mentioned a woman trapped at home, unable to gain access to a new dose of anti-retrovirals. As a result, when she was found by relief workers, an infection had set in and she had to be admitted to hospital.(9) Another hurdle with respect to anti-retrovirals is that many HIV patients were not getting adequate nutrition. This resulted in patients unable to tolerate their medication, further increasing non-compliance.(9) Patients with tuberculosis, face a similar scenario where drug-resistance develops.(4,7) The problem with this is that patients then require second-line drugs that are more expensive than first-line drugs.(4) Long-term effects of this may result in increased infection rates within the population. These 2 diseases were a major concern for the NGOs, who constantly held testing clinics, offered counselling and provided medication.(6,2,3) Thankfully this volatile situation has calmed down allowing people to piece together their lives. Medical attention has also improved in most areas. (6)

A correspondent from Merlin gave the following account of a typical day at an IDP camp:
The day usually starts off early, with a meeting discussing the day’s agenda. A clinic is setup wherever space is available (a vacant room or under a tree). Patients are then prioritized according to their level of urgency. Immunizations, HIV testing and counselling and treatment for minor illnesses are provided to those who need them. For those who require referrals to health centres or hospitals, transportation is arranged. Other team members conduct health education sessions for patients while they wait for their consultation.

Kush Patel
Imperial College London
kush.p.patel04@imperial.ac.uk

References
(1) Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu.Rev.Public Health 1997;18:283-312.
(2) Kenya Red Cross operations update. http://www.kenyaredcross.org/highlights.php?newsid=61&subcat=1, 2008.
(3) Medecins sans frontiers. http://www.doctorswithoutborders.org/news/report.cfm?id=2470, 2008.
(4) International committee of the Red Cross. http://www.irinnews.org/Africa-Country.aspx?Country=KE, 2008.
(5) AMREF Kenya news and press releases. http://kenya.amref.org/index.asp?PageID=10, 2008.
(6) Merlin newsletters. http://www.merlin.org.uk/Where-we-work/Kenya.aspx, 2008.
(7) O’Boyle SJ, Power JJ, Ibrahim MY, Watson JP. Factors affecting patient compliance with anti-tuberculosis chemotherapy using the directly observed treatment, short-course strategy (DOTS). Int.J.Tuberc.Lung Dis. 2002 Apr;6(4):307-312.
(8) Frick PA, Gal P, Lane TW, Sewell PC. Antiretroviral medication compliance in patients with AIDS. AIDS Patient Care STDS 1998 Jun;12(6):463-470.
(9) BBC news on Kenya. http://news.bbc.co.uk/1/hi/in_depth/africa/2008/kenya/default.stm, 2008.

Rohan Radhakrishna’s study on Uganda’s “night commuters” was one of the winners of the first annual The Lancet-GHEC 2008 prize. An abstract of Rohan’s study - which will be presented at the 2008 GHEC conference - is provided below.

Context: An ongoing 22 year civil war has devastated Northern Uganda’s health infrastructure and caused the displacement of 1.8 million civilians. The displaced itinerant children in war-affected Northern Uganda known as the “night commuters” are a group who flee their villages and IDP (internally displaced person) camps at night for fear of rebel abduction and come into the town center for shelter and security. However, they have never been studied using randomized sampling, control groups, or mixed methods yet numerous policies have been implementing to improve their wellbeing. I arrived in Northern Uganda as a medical and public health student in 2006 working as a consultant for UNICEF and Caritas to conduct a needs assessment of the “night commuters” however the governor of Kitgum Province decided to abruptly close the 13 shelters were 4,500 children were finding sanctuary.

Objectives: To reveal the demographics of the “night commuters,” to understand their motivations for secondary displacement, and to promote evidence-based decision making by government, non-government organizations (NGOs), and humanitarian organizations through including the views of the populations they serve. My goal was also to use our research findings to convince the governor to not abruptly close the shelters and instead to slowly phase out the shelters using a case management approach for the extremely vulnerable children who weren’t able to return home immediately (AIDS orphans, disabled, child-headed households, formerly abducted children, children in congested homes etc.).

Design, Setting, and Participants: A retrospective cohort study of 720 “night commuter” children (aged 7-17) in 13 shelters in 1 district using stratified random sampling and a control group of 410 non-night commuting children (aged 7-17) in villages and camps for IDPS in the same district selected through random cluster sampling during July and August of 2006. Follow-up through an evaluation and prospective cohort study of 120 former “night commuters” in villages and camps in August of 2007. Quantitative surveys were administered in addition to qualitative methodologies using grounded theory: direct observation, key informant interviews (n=45), focus groups in 2006 (n=20) and focus groups in 2007 (n=8).

Main Outcome Measures: Sociodemographic information, housing situation, self-reported health indicators, sense of security, and motivations for displacement.

Results*: Night commuters were more likely to be partial or total orphans than non-night commuters. Lack of accommodation (44% p <.01) was found to be a greater reason for secondary displacement than lack of security (41% p<.01). Respondents cited other causes of insecurity after the rebels had left (thugs and local defense units). Over a dozen push and pull factors influencing their displacement were elucidated.

Conclusions: Respondents cited lack of accommodation and insecurity from non-rebel sources (e.g. thugs and local defense units) as major contributors to their secondary displacement which was not adequately considered by the government or humanitarian groups. Results helped construct a 10 Point Plan for responsible shelter closure adopted in consensus by stakeholders which led the governor to change his policy. I wrote 3 reports from my research leading to increased funding for health centers, schools, and shelter. This study revealed the need for developing minimum standards in population based research for displaced populations during complex humanitarian emergencies to promote more robust research, more representative sampling, and more locally informed decision-making.

*Full results available upon request. Some statistical tests are pending and a manuscript is being submitted.

In the second installment of his experiences, Paul Park tells us more about the situation in the Ugandan refugee camps

The clinic tent

An elementary school in the bordertown of Busia, Uganda housed the 2,000 refugees with each packed classroom inevitably creating a ripe environment for disease. In addition, the threat of violence was still present due to the proximity to the border and the similar tribal demographics in comparison to that of western Kenya. The Red Cross refugee site was located just 1.5 km from the local public clinic. Thus, without any medical infrastructure, Red Cross personnel were sending all refugees with health needs to the clinic. As you could imagine, the Red Cross staff was pleased to learn of my medical background and immediately gave me all clinical and public health responsibilities. I gave health education presentations (sanitation, personal and community hygiene, etc.) and continued to make referrals, in which I would write a brief history and physical to assist the overwhelmed clinic. Additionally, I initiated a patient record system. As a medical student, it is easier to feel competent when the safety net of your attending is always in place, and this scenario was no different. However, that was all about to change. (more…)

The situation in Gaza is forever changing. Anand Bhat interviews, Dorothea Krimitsas, the International Committee of Red Cross’s Media Relations Director for the Middle East and North Africa to find out more about the situation on the ground.

From kidnapped soldiers and BBC correspondents to travel blockades, the Gaza Strip in the occupied territories earns its reputation as a conflict hotspot. This article spotlights the siege of Gaza, the history behind it, and includes an account from the ground from those who work there.

The Gaza Strip is home to 1.4 million people in an area of only 360 square kilometers.  This densely populated land (3 888 people per square kilometer) is envisioned to be part of a future Palestinian nation along with the West Bank.

Gaza and the West Bank have been illegally occupied by Israel after the Six Day War in 1967. (1) (2)  Gaza was run by Egypt between 1948 and 1967 after the partition of the British Mandate of Palestine and the declaration of Independence of Israel.  Afterwards, the state of Israel built illegal settlements on the occupied land. (2)

Three years ago, however, Prime Minister Ariel Sharon controversially and unilaterally “disengaged” from the Gaza Strip by evicting Jewish settlers and withdrawing the Israeli Defense Forces (IDF). (3)  In 2006, the Islamic fundamentalist group Hamas entered electoral politics and won a majority in the Palestinian Authority National Assembly against the secular Fatah Party.  Also in 2006, Palestinian militants kidnapped the Israeli soldier Gilad Shalit which led to Israeli incursions into Gaza.

After political spats and two mini-civil wars with Fatah, Hamas engineered a violent takeover of the Gaza Strip in 2007 throwing out the Fatah-dominated security forces. (4)  The international community condemned and cut off aid to Hamas and looked to the West Bank government for any peace negotiations.  Ending foreign aid to the Hamas Gaza government has caused enormous economic hardship for a very foreign aid-dependent society.  Militants began firing Qassam rockets into Israel from the Gaza Strip.

In response to rocket attacks and the kidnapped soldier, Israel declared Gaza to be a “hostile territory” at war with Israel. (5)   The Strip is now under siege and sealed off from the outside world.  Recently, Israel also announced it would stop fuel from entering the Gaza Strip.

Between such violence on both sides, I found the 2007 report by the Red Cross, “Dignity Denied,” interesting. (6) The International Committee of the Red Cross (ICRC) declared that humanitarian aid is insufficient for the situation in Gaza and urged a political solution, an intriguing break with its neutrality in such conflicts.  From the report it reads:

“Throughout the occupied Palestinian territories, in the Gaza Strip as well as in the West Bank, Palestinians continuously face hardship in simply going about their lives; they are prevented from doing what makes up the daily fabric of most people’s existence. The Palestinian territories face a deep human crisis, where millions of people are denied their human dignity. Not once in a while, but every day…

“The dignity of the Palestinians is being trampled underfoot day after day, both in the West Bank and in Gaza.  Israel’s harsh security measures come at an enormous humanitarian cost, leaving those living under occupation with just enough to survive, but not enough to live normal and dignified lives.”

To find out more about the situation on the ground, I interviewed the person in charge of the International Committee of Red Cross’s Media Relations for the Middle East and North Africa, Dorothea Krimitsas, on the siege in Gaza and its medical and humanitarian implications as opposed to the media’s usual focus on the political, ethnic, and religious implications.

Q:  What is the situation right now in the Gaza Strip and why should young medical professionals care?
“The Israeli blockade, although not fully hermetic, remains quite tight. With the decision taken by the Israeli Supreme Court allowing cuts to fuel deliveries to Gaza, no improvement can be expected. In other words, supplies reaching Gaza are still strictly limited to essential humanitarian shipments. The number of trucks currently entering the Strip is down to a trickle compared with the situation before June 2007 [when Hamas took over]. As a result, the needs of the population are far from being met. The amount of goods currently entering Gaza has fallen down dramatically and the downward spiral of conditions for Gazans will continue until all parties concerned reach a solution to the current impasse.

“Hospitals facilities are directly hit by these shortages. They are still operating on the emergency mode only, as their fuel reserves do not allow them to run all services, which would be needed for a population of 1.5 million inhabitants. Chronic diseases and non-urgent interventions are no longer dealt with. Drugs and disposables are on short supply, although the ICRC is keeping a constant watch on their needs and is re-supplying their stocks as quickly as possible. It is hard to say when the situation will get any better for the medical profession and their patients in Gaza.”

Q: How does the siege affect doctors, hospitals and patients?  Do you have any figures on patients harmed by the power cuts?
“Doctors, nurses and patients are all affected by the present situation. The shortage of fuel and electricity is the major problem they are facing. Patients in Gaza used to benefit from a better level of medical care until the restrictions became fully effective in June 2007. Since then, and in a more acute way with the additional electricity cuts, the medical profession is experiencing severe lacks affecting the treatment of ordinary surgical or medical cases, and the follow-up of chronic diseases. This is a major concern for a population already weakened by all sorts of deprivations.

“We know of one ventilated patient who died at Ahli Arab hospital during the process of switching over from the main power plant to the generator. The ICRC does not have statistics on how the restrictions are affecting health.”

Q: What are the casualties on either side of this conflict?  What is the status of the kidnapped Israeli soldier?
“There are ongoing hostilities between Palestinian fighters and Israeli soldiers, with almost daily casualties. In Gaza, most cases can be treated on the spot. People wounded by rockets in nearby villages in Israel such as Sderot are also treated on the spot or evacuated to better equipped Israeli hospitals if needed.

“So far, ICRC delegates did not get access to the Israeli soldier in Palestinian hands. The priority for the ICRC is to get at least a sign of life. Despite all efforts this has not yet materialised.”

Q: Are any international laws or treaties being broken on either side?
“In its recent publication “Dignity Denied”, ICRC emphasized the immense suffering caused by decades of occupation in the West Bank and Gaza Strip. Non-respect of international humanitarian law applicable in occupied territories (the Fourth Geneva Convention) is a constant concern for ICRC delegates who are monitoring the situation of the Palestinian population.

“Likewise, ongoing hostilities putting at risk the life of Israeli civilians have to be considered. Legitimate security concerns, on one side, and the right to live a normal and dignified life, on the other side, are the minimal requirements.”

Q: It is alleged that Palestinians use ambulances to smuggle weapons to attack Israelis.  Israel has bombed ambulances in the past.  Are these charges true?  Is attacking medical personnel against international law?  “Attacking medical personnel is forbidden under international humanitarian law.  Medical  personnel, facilities and vehicles, must be protected at all times, thus the importance to respect red cross and red crescent emblems, and the ‘magen david adom’, which is the emblem of the Israeli national society. The ICRC regrets that, in many conflict situations, misuse of emblems or lack of protection of the medical mission are reported.

“To improve the situation, its delegates around the world keep disseminating the most important rules to be respected in times of conflict. For instance, throughout 2008, the ICRC is running a campaign to raise awareness on the specific rules which are linked to this obligation of respect. It will address the Palestinian Territories and also Israel Defense Forces.

“As a matter of policy, the ICRC does not comment publicly on specific events or violations of international humanitarian law, but discusses its findings and recommendations directly with the parties concerned. Whenever the ICRC is aware of attacks on medical personnel or facilities, it intervenes with the parties concerned.”

Q: What is Egypt’s role in the sealing off of Gaza?
“Egypt is a sovereign country which is sharing part of its border with the Gaza Strip. After the recent events, it has imposed a close control of this border. It is not up to the ICRC to comment any further.”

Q: Did Israel truly disengage from Gaza in 2005?  Do Gazans have the right to use their coast, airport, and borders?
“As a matter of fact, in spite of the departure of Israeli occupying forces from Gaza, Israel still imposes a very strict control of all access roads to the Strip, be it by air, sea or ground. As a result, no trade can be operated by Gazans. Only essential humanitarian goods are allowed, and even this vital aid is sometimes subject to further restrictions.”

Q: What are you asking from the international community?  Why has the Red Cross made such a statement?  Is there something fundamentally different that warranted the need for a “political solution?”   

“The ICRC has been continuously present in Israel and the Occupied and Autonomous Territories for the last 40 years. The situation on the ground is further deteriorating. To prevent more hardship for the population, it is necessary to go back to the same levels of access for humanitarian goods and personnel, which existed before June 2007, and the delivery of essential humanitarian goods must be secured in the long run. But it is high time that those responsible within the international community and among the direct actors realise that humanitarian action is no substitute for political action. As the ICRC’s head of operations for the Middle East and North Africa said in a statement on 13 December 2007, “In the current situation, humanitarian assistance alone is insufficient. It cannot and should not be a substitute for political action.

“The ICRC firmly believes that only prompt, innovative and courageous political action can change the harsh reality of this long-standing occupation, restore normal social and economic life to the Palestinian people, and allow them to live their lives in dignity.”

Conclusion
Will the situation improve any time soon?  Will there be a political solution?  A recent poll of Israelis by the newspaper Ha’aretz finds that 64% of Israelis now favor direct negotiations with Hamas with only 28% are opposed, (7) a faint sign of hope for the region.  It is only too logical to ask for peace and dignity for both sides.

Anand Bhat
Second year Medical Student
University of Texas Medical Branch
Texas, US
akbhat@utmb.edu

(1)  U.N. Security Council Resolution 242

(2)   “Forty years on.“  The Economist : March 24, 2007

(3) Oliver, Mark.  “Soldiers evict Gaza settlers.“   Guardian : August 17, 2005.

(4)  Shult, Christoph.  “Hamastan” vs. “Fatahstan“  Der Spiegel : June 19, 2007.

(5)  Ravid, Barak and Shlomo Shamir.  “Cabinet declares Gaza ‘hostile territory.”   Ha’aretz: September 20, 2007.

(6) Dignity Denied. ICRC 2007

(7)  Verter, Yossi.  “Poll: Most Israelis back direct talks with Hamas on Shalit.” Ha’aretz:  February 27, 2008.

James Matheson interviews some experts on the potential of this exciting new specialty

In May 2006 the American Board of Physician Specialties announced board-certification in Disaster Medicine and, in the United States, a new specialty was born. The Florida hurricanes and a heightened awareness of the terrorist threat in the wake of 9/11 had demonstrated America’s vulnerability to disaster and concerns were high about the ability to respond.

Dr Maurice A. Ramirez, founder-chairman of the American Board of Disaster Medicine (ABODM) explains why: “The most ominous words ever uttered by a disaster preparedness expert were that given the current state of hospital preparedness and the rate at which facilities are becoming disaster ready, there will be no meaningful level of preparedness in this decade unless someone blows up a hospital.

(more…)

Kayvan Bozorgmehr gives an account of his experiences following Cyclone Sidr in Southern Bangladesh where he was working with the Bangladeshi NGO, Gonoshasthaya Kendra

The devestation in Kakchira village, Patharghata District

On 10^th November the International People’s Health University of the People’s Health Movement took place in Savar, Dhaka in the North of Banagladesh. On the campus of the local NGO Gonoshasthaya Kendra (GK- Gonoshasthaya Kendra- People’s Health Centre is a Bangladeshi NGO founded in 1971, which provides people-oriented health management, primary education and women’s empowerment programmes), more than 40 health professionals, activists and scientists from 15 different nations came together to discuss and exchange their experience on the social, political and economical determinants of health.

Five days later Cyclone Sidr threw a shadow over the country. In Dhaka, telecommunication, internet services and electricity supply broke down. Government officials were unable to provide the number of casualties in the worst affected areas, but with every passing day, news about the vast impact of the cyclone emerged. While international donors made the first financial comittments to the Government of Bangladesh, the stunts of US helicopters at the Bay of Bengal dominated the media - we were observers of a CNN-effect just being launched.

Another scene from Kakchira Village

I joined Dr. Rezaul Haque, the Rural Health Coordinator of GK on his assessment mission to the South in order to get an impression of the impact of the disaster on public health, the needs of the people and the coordination of the humanitarian relief. While the public health consequences associated with tropical cyclones include many factors like storm-related mortality, injury, infectious diseases, psychosocial effects, displacement and homelessness, damage to the health-care infrastructure, disruption of public health services, transformation of ecosystems, social dislocation, loss of jobs and livelihood, and economic crisis (1), it is known that these outcomes disproportionately befall developing nations, with human factors strongly influencing the observed disparities. (2)

It was too early to assess the economical losses, but I had the feeling that this disaster combined with its counterpart of extreme poverty, international debts and corruption was going to increase the sufferings of millions of affected people for a long time - especially as Sidr affected areas are surplus areas for production of rice to feed Bangladesh. (3) Despite some success in cushioning exreme poverty to a limited extent in rural Bangladesh, the process of poverty reduction in such Bangladesh is always fragile and the livelihoods of rural areas are fraught with vulnerability that stems from a variety of factors, ranging from natural to social arenas and macro to micro levels - like floods, economic shocks, death and illness in the household, insecurity of life and property - all these and other factors can offset the gains in the poverty frontier. (4)

On day 8 after the cyclone, we headed for the south with a public bus from the Saidabad bus terminal in Dhaka - with generic antibiotics and other essential drugs on the roof of our bus. At that moment GK had 10 doctors and approximately 40 paramedics in the Southern regions, who were already providing health care services.

After two hours we reached the river Padma. The stream, which springs from the Himalaya and the Ganges, carried us on a ferry towards the Bay of Bengal passing a beautiful landscape. Two more hours passed until we left the ferry and continued our ride on the bus. We crossed the river Payra with a second ferry and reached a stoney, torn road, on which we continued our trip. We followed the track of devastation, passed thousands of broken trees and power poles bent like blades of grass. Finally we reached our destination after 10 shaking hours - the subdistrict Patharghata in the district Barguna.

Mr. Selam Khan, the UP Officer of Patharghata and the authority in charge for the subdistrict, was responsible for the coordination of the support in the seven unions of the subdistrict and for the communication with the 20 NGOs, which worked in these areas. He explained the comprehensive Cyclone Preparedness Programme (CPP) provided by the Ministry of Disaster Management and Relief and the Bangladesh Red Crescent Society, while Dr. Haque informed him about the intentions of GK in the nearer future.

According to Mr Khan, “As one of the worst affected areas, Pathargatha has been hit by the eye of the cyclone with a speed of 220 miles per hour for a duration of 3 to 5 hours, accompagnied by a tidal wave with the height of 15-17 feet (approx. 5meters). 95 % of the houses, a total number of 35.700, are lost. 283 people died, 205 are still missing. 36.000 livestock have been killed. 190 educational buildings, 626 kilometers of road and 39 bridges are destroyed. There has been a warning 48 hours before the disaster, so we succeeded to evacuate 24.000 people - but many refused to be evacuated.”

The death toll of Sidr was relatively low compared to the 1991 Bangladesh Cyclone, one of the deadliest tropical storms on record that killed nearly 140.000 people. (5) Sidr was not less severe than the 1991 Bangladesh Cyclone, but due to preventive actions of the government and local NGOs, the building of cyclone shelters and embankments, and the appropriate action of evaquating 1.5 million people of an estimated 5 million people in the costal areas, the death toll could be reduced this time.

Apparently lessons learned from previous cyclones, namely that the risk of dying was related to the type of shelter (6) and that easy access to shelters was a significant factor in reducing the risk of dying (7) had led to an emphasise on preventive actions. But we noted, that there is still a lack of shelters, especially of multifunctional ones. In the whole subdistrict of Patharghata, an area of 387 km², there were only two official cyclone shelters - for many people too far to reach. Mr. Khan agreed with us that additional shelters for animals could increase the willingness of people to be evacuated as that would decrease the loss of livestock - a loss which can impoverish a whole family.

Among the 20 NGOs, only one was dealing with mental health problems. The lack of awareness of mental health problems after disasters may lead to delays in the psychosocial rehabilitation (8) or even to Post Traumatic Stress Disorder among the survivors. The impact of Sidr on the psychological status of the people revealed itself, when we strolled through destroyed villages in Kakchira, Bodma, Horinghata and Djintola and talked to desperate people, each with individual stories of beloved, but lost family members.

We also saw the effects of well-intentioned but poorly implemented aid: for example youngsters from Dhaka throwing clothings randomely from the roof of a building towards a crowd, creating scenes of fighting women and screaming children. There was also a camp organised by a leading NGO, with the capacity to supply 200 children with food for one day over a period of one month. But how can you pick 200 children out of the many in need for help? The information about the camp had been announced in the few schools which had outlasted the cyclone. Lots of children had walked many kilometers to reach the place. I remembered a scene from Bodma, a fishing village in 11 kilometers distance: a 4 year aged child with a spoon in his small hands scratching out a green coconut and feeding the last bits of the precious coconut-flesh to his crying brother with ascites, who was younger than himself. I wondered if those children, who could walk such a distance were those in most urgent need of help. And what about newborns and infants? Among 200 hundred children there were only 8 newborns, all carried by their brothers or sisters - parents or mothers were not allowed to stay in the camp. There were no sanitation facilities for the 200 children.

The medical support and food distribution in the areas we visited was disproportionate. While the international NGOs mainly concentrated on central areas, they were underrepresented in remote areas and duplication of aid occured more than once - despite the CPP and the general effort of the NGOs to coordinate and to cooperate with the governement. In general, the governmental primary health care stations were very poor equiped - a few antibiotics, some paracetamol, some waterpurification tablets. The GK teams and other NGOs were fairly better equiped. But still there was a lack of many things, e.g. gloves for the staff, simple surgical instruments, local anaesthetics and tetanus vaccines in some NGO camps.

I met Zaman, a young doctor of GK. He had reached the affected areas as one of the first teams and had been working in remote areas for the last 8 days. He described the situations he had faced shortly after arriving, the dead bodies, the seperated hands and limbs lying around in the villages, unpassable roads and severe fractures. He said that the main problems now were diarrhoea, pneumonias, colds and fever, and major water and sanitation problems.”  In fact all the 451 ponds in the subdistrict used for drinking water were damaged.

Dr. Amal Chandra Roy, the Union Health and Family Planning Officer, was in charge for the coordination of health and medical supply for all the seven unions in the subdistrict Patharghata. By the light of a lantern, we sat in his office, a small room of the only hospital in an area of 387 km² with a total sum of 31 beds. 18 doctors of the government were working in this area since the disaster happened - 18 doctors for an estimated population of 162.000 people. “That is almost one for 10.000 people”, he told us. “Before the disaster there were only two doctors in the whole area, this is a 9-fold increase”. He would appreciate a better cooperation with NGOs, especially with international ones, to avoid duplication.

Experiences from 1991 show, that in the post-cyclone period, the affected areas actually received a much higher level of health-services than they had ever before. Nevertheless, 6 months after the cyclone 1991, there was a significant rise in the prevalence of severe malnutrition in the affected areas for children aged 1-5. This suggests that there were deficiencies in the post-cyclone medium to long term health response. (9) This is the time when the international and national media coverage of the rehabilitation process usually fades - and with them the CNN-effect of pulsative aid, leaving behind the need of sustainable aid to turn relief into self-relience. There is a urgent need to solve not only disaster related problems, but also longterm, global problems - the manmade parts of natural disasters.

I left Dr. Roy’s office and stepped into the room next door, the emergency room of that hospital, where a paramedic sewed an injury close to a man’s eye by the pale light of a candle while a doctor, one of the eighteen, examined a crying child. “We are used to this darkness”, he said.

Kayvan Bozorgmehr
Globalisation and Health Initiative (GandHI)
German Medical Students’Association
bozorgme@stud.uni-frankfurt.de

(1) Shultz JM, Russell J, Espinel Z. Epidemiology of Tropical Cyclones: The Dynamics of Disaster, Disease, and Development. Epidemiol Rev. 2005;27:21-35

(2) United Nations Development Programme. Reducing disaster risk: a challenge for development. New York, NY: John S. Swift Company, 2004

(3) Emergency Response Programme of Gonoshasthaya Kendra : SIDR - 2007. Available from: http://www.medico-international.de/projekte/bangladesh/nothilfe_sidr_2007.pdf

(4) Islam Aminul S. Overcoming Poverty in Bangladesh: Search for a New Paradigm. Bangladesh e-Journal of Sociology. Volume 1. Number 2. July 2004.

(5) http://en.wikipedia.org/wiki/1991_Bangladesh_cyclone

(6) Bern C et al. Risk factors for mortality in the Bangladesh cyclone of 1991. Bull World Health Organ. 1993;71(1):73-8 Avaiable at: http://whqlibdoc.who.int/bulletin/1993/Vol71-No1/bulletin_1993_71(1)_73-78.pdf

(7) Siddique AK, Eusof A. Cyclone deaths in Bangladesh, May 1985: who was at risk. Trop Geogr Med. 1987 Jan;39(1):3-8.

(8) Choudhury WA, Quraishi FA, Haque Z. Mental health and psychosocial aspects of disaster preparedness in Bangladesh. Int Rev Psychiatry. 2006 Dec;18(6):529-35.

(9) Rahman  MO, Bennish M. Health related response to natural disasters: The case of the Bangladesh Cyclone of 1991. Soc Sci Med. 1993 Apr;36(7):903-14

Anne Aspler and Greg Queyranne take an indepth look at the atrocities currently being committed again women and girls in this troubles country

More lives have been lost in the conflict in the Democratic Republic of the Congo (DRC) than in any other conflict since World War II (1); surprisingly, it has not generated significant media attention. (2)  The little media coverage it does receive too often fails to address issues unique to women and girls, perhaps the greatest victims of the war in the Congo, to whom large-scale rapes and sexual slavery are almost exclusively reserved.  When the international community analyzes the human effects of wars, they tend to focus either on the combatants, comprised nearly entirely of men, or on the victims as a whole; seldom do they take into consideration the specific victimization of women.

In this article, we discuss how women have been affected by the war in the Congo in a qualitatively different manner, with a focus on the extent and consequences of sexual violence.  While there is no internationally agreed upon definition of sexual violence, we will focus on one of the most extreme forms - rape - which the WHO defines as “physically forced or otherwise coerced penetration…of the vulva or anus, using a penis, other body parts or an object.” (3)  We include both a practical guideline for the acute management of rape victims, and conclude with a few suggestions for an appropriate response from the international community.

Overview of the Conflict
Before discussing the impact of sexual violence on women, it is helpful to provide an overview of the conflict itself.  The origins date back to 1996, when Rwanda and Uganda backed a rebellion to overthrow Mobutu Sese Seko, then dictator of Zaire, as DRC was known until that time.  In 1998, Rwanda and Uganda then invaded and occupied large parts in the east and north of the Congo, (4) a country roughly the size of Western Europe. (2) The ensuing war, which Angola, Burundi, Namibia and Zimbabwe soon joined, (4) has led to the deaths of approximately 4 million people, mostly from disease and malnutrition, as insecurity has restricted access to basic healthcare services and sanitation. (5)

Much of the war has been fought over access to minerals, including gold, diamonds, and coltan, (1) a mineral essential for the high tech-industry; coltan is found in every cell phone, computer, iPod, DVD player and jet engine. (6) At least 85 multinational corporations have benefited from the war: a UN Panel of Experts has concluded that “[c]ompanies trading minerals…[are] considered to be ‘the engine of the conflict in the Democratic Republic of the Congo.’” (7)

Sexual Violence in the Conflict
Although peace accords and recent democratic elections have given the impression that the conflict is abating, violence in the eastern provinces continues. It has been determined that approximately 38,000 people die every month. (5)

Sexual violence against women and girls has been found to be “the most common form of violence” and “the most widespread form of criminality” in the war in the DRC. (5)  In a 2002 report on the subject, Human Rights Watch described sexual violence as nothing less than “a weapon of war [used] by most of the forces involved” in the conflict. (8) It is so widespread that the UN estimates that in the province of South Kivu alone, approximately 27,000 women were raped in 2006 (9) and 45,000 women in 2005, (1) though these may only be fractions of the total number in the Congo. (9)

Consequences of Sexual Violence
The consequences of sexual violence are many - not only medical, but also long-term psychological, emotional, and socioeconomic effects. (10,11,12)  Health consequences may include physical trauma to the reproductive tract, such as ecchymosis, tears, and fistulas; increased risk of sexually transmitted infections, including HIV; and increased incidence of unwanted pregnancy with subsequent unsafe abortion - which can result in pelvic inflammatory disease, infertility, and even death. (10,11) Manifestations of psychosocial problems range from post-traumatic stress disorder, depression, and attempted suicide, to more subtle signs of fear, anxiety, intrusive memories, difficulty sleeping, withdrawal, and flashbacks. (9,10)

Perhaps the most devastating consequence of rape, however, is the subsequent experience of stigma and discrimination.  Those that undergo the process of medical and psychosocial healing may return to their communities only to face total rejection from their partner, family, and community. (10) Practitioners must, unsurprisingly, be prepared to take on several roles in responding to patients who have experienced sexual violence.  The Box (below the references at the end of this article) provides basic guidelines for the acute care and management of victims. (13,14,15)

Extent of Sexual Violence
Médecins sans Frontières (MSF) has responded to the crisis in the DRC by providing treatment to victims of sexual violence in several regions affected by the conflict.  From August 2003 to January 2004, over a period of just 6 months, they reported more than 550 victims of sexual violence attending an emergency clinic in Baraka. (10) The age of victims attending the clinic ranged from 12-70 with over 75% of attendees reporting multiple aggressors, from 2 to 5 men, at a time. (10) In 2007, MSF reported treating 7,400 rape victims over four years at the Bon Marché hospital in Bunia - with an average of 50-300 women arriving every month for treatment. (16) With emergency missions in over 70 countries worldwide (17), an overwhelming majority - 75% - of rape cases dealt with by MSF are currently in eastern Congo. (18)

Discussion
Sexual violence in the conflict regions of the DRC must be confronted both on a local and international scale.  Locally, extension of health care and support services addressing both the medical and psychosocial effects of sexual violence is needed. (19) Healthcare workers may need special training in order to be prepared to respond with appropriate prophylaxis, counseling and referral for psychological and social support. (11,13) Medical intervention should be part of an integrated approach advocating for peace and security in the region and an end to sexual violence by supporting victims, documenting the extent of sexual assault, and advocating specifically for those affected by sexual violence. (11)

Beyond acute intervention at the medical level, we also have to consider the roots of the underlying conflict itself.  The links between the desire to control areas of mineral wealth and the continuing acts of sexual violence in the eastern regions calls into question how the international community should be responding to help resolve the conflict.  As poignantly expressed by journalist Jan Goodwin: “The commerce in these “blood” minerals, such as coltan, used in cell phones and laptops…drives the conflict. The brutality of the militias - the sexual slavery, transmission of HIV/AIDS through rape, cannibalism, slaughter and starvation, forced recruitment of child soldiers - has routinely been employed to secure access to mining sites or insure a supply of captive labor. “(20)

The more we ignore the victims of this brutal tragedy, and the more rapidly we consume high-electronics without demanding that components do not come from war-afflicted regions of the Congo, the less likely these horrors will end. (21)

Anne Aspler
second year medical student
and
Greg Queyranne
first year political science student

University of Alberta
Edmonton
Alberta
Canada
aaspler@ualberta.ca and queyrann@ualberta.ca

[1] Hari, J. “A Journey into the Most Savage War in the World: My Travels in the Democratic Vacuum of Congo.” The Independent 6 May, 2006. Available from: http://johannhari.com/archive/article.php?id=863

[2] Hawkins, V. Stealth Conflicts: Africa’s World War in the DRC and International Consciousness.  Journal of Humanitarian Assistance. Jan 2004. Available from: http://www.jha.ac/articles/a126.htm

[3] World Health Organization. World Report on Violence and Health. World Health Organization. October 2002:  p. 149. Available from: http://www.who.int/violence_injury_prevention/violence/global_campaign/en/chap6.pdf

[4] Turner, T. The Congo Wars: Conflict, Myth, and Reality.  New York:  Zed Books, 2007.

[5] International Crisis Group, “Beyond Victimhood: Women’s Peacebuilding in Sudan, Congo and Uganda,” Africa Report No. 112, (28 June 2006): p.8-11.

[6] Dena Monatgue. “Stolen Goods: Coltan and Conflict in the Democratic Republic of Congo.” SAIS Review. Vol. XXII no. 1 (Winter-Spring 2002).

[7] United Nations, Security Council. “Report on the Panel of Experts on the Illegal Exploitation of Natural Resources and Other Forms of Wealth of the Democratic Republic of the Congo.” United Nations. 16 April 2001. Available from: http://www.un.org/News/dh/latest/drcongo.htm

[8] Human Rights Watch. “The War Within the War: Sexual Violence Against Women and Girls in Eastern Congo.” Human Rights Watch June, 2002: p. 1.  Available from:  http://www.hrw.org/reports/2002/drc/Congo0602.pdf

[9] Gettleman, J. “Rape Epidemic Raises Trauma of Congo War.” The New York Times. October 7, 2007. Available from: http://www.nytimes.com/2007/10/07/world/africa/07congo.html?ref=opinion

[10] Médecins Sans Frontières.  “Medical, Psychosocial, and Socioeconomic Consequences of Sexual Violence in Eastern DRC.”  Médecins sans Frontières. 2004. Available from:  http://www.msf.org/source/countries/africa/drc/2004/drcreport-nojoy.pdf

[11] Shanks, L. and Schull, MJ.  “Rape in war: the humanitarian response.” Canadian Medical Association Journal. 2000 October 31; 163 (9): p. 1152-1156.

[12] World Health Organization. Violence against women. World Health Organization. July 1997. Available from: http://www.who.int/gender/violence/v7.pdf

[13] Mein, JK, Palmer, CM, Shand, MC, Templeton, DJ, Parekh, V, Mobbs, M, Haig, K, Huffam, SE, and Young,L.  Management of acute adult sexual assault. Medical Journal of Australia. 2003 178 (5): p. 226-230.

[14] Sommers, MS. Defining patterns of genital injury from sexual assault: a review. Trauma Violence Abuse. July 2007 8 (3): p. 270-80.

[15] Brode, S. and Schofield, L.  Emergency Medicine. Toronto Notes: Comprehensive Medical Reference. 23^rd ed. Toronto: University of Toronto. 2007.  p. 34-35

[16]  Médecins Sans Frontières.  Ituri, “Civilians still the first victims”  Permanence of sexual violence and impact on military operations.  Médecins sans Frontières. 2007.   Available from: http://www.msf.org/source/countries/africa/drc/2007/Ituri_report/Ituri_report.pdf

[17] Médecins Sans Frontières. “About MSF: The MSF role in emergency medical aid.” Available from: http://www.msf.org/msfinternational/aboutmsf/

[18] McGreal, C. Hundreds of thousands of women raped for being on the wrong side. The Guardian. November 12, 2007.  Available from: http://www.guardian.co.uk/international/story/0,,2209383,00.html

[19] World Health Organization. Sexual violence: strengthening the health sector response. World Health Organization. 2007. Available from: http://www.who.int/violence_injury_prevention/violence/activities/sexual_violence/en/print.html

[20] Goodwin, J.  Silence = Rape.  The Nation.  March 8, 2004. Available from: http://www.thenation.com/doc/20040308/goodwin

[21] Queyranne, G.  “War for Minerals in the Democratic Republic of Congo.” Antidote. 2007. 4 (1): p. 6.

Feroze Sidhwa recently spent his elective in the occupied Palestinian territories. Here he discusses the food insecurity issues there

The Israel Defense Forces (the army of the State of Israel) invaded and occupied the West Bank, Gaza Strip and East Jerusalem (the occupied Palestinian territories; oPt) in June 1967. Since then Israel has maintained a military occupation in those territories, with policies that have led to “de-development”, the “structural[] and institutional[] dismantl[ing of] the Palestinian economy…”(1) This has led to the recent sharp rise in food insecurity in the oPt. Please note that in the article, “Palestinian”, “Palestinians”, etc. refers only to the Palestinians in the occupied Palestinian territories.

Current food security status

The World Food Program (WFP) reported in January 2007 that 34% of Palestinian households are food secure, 20% are marginally secure, 12% are vulnerable to food insecurity, and 34% are food insecure.(2) As of November 2006, 40.2% of Palestinian households lived in “deep poverty” (daily per capita consumption of less than $2.10); in Gaza the figure is 79.8%. The first half of 2006 saw a 38.3% increase in the number of Palestinian households in deep poverty. (3)

In 2004 the World Bank estimated that per capita food consumption declined some 25% in real terms compared to 1999. (4) The decline in food consumption continued, with a further decline of 8% in the first half of 2006 alone. (2)

The consequences have been severe and will likely have long-term effects on Palestinian children’s development. In 2004 wasting reached 1.9%; stunting 9.9%; and vitamin A deficiency in children 12-59 months reached 22%. (2) 50.5% of West Bank children under 24 months and 71.9% of Gazan children 9-12 months are anaemic. (5) According to UNICEF, “one in ten children is stunted, one in two is anemic, and 75 per cent of children under the age of five suffer from vitamin A deficiency and low birth weight rates are as high as 8.2%…” (6)

The observed vitamin A deficiency and anemia “are considered by WHO international standards as a severe public health situation…”  The observed rise in malnutrition status is due to decreased food consumption and decreased quality of consumed food over at least the past eight years. (2)

Food insecurity as a consequence of economic de-development

Palestinian food insecurity is highly correlated with the long-term intensity of Israel’s closure regime (severe restriction on freedom of movement within the oPt; see http://www.ochaopt.org/documents/InsertMap_Fragmentation_May07-withCheckpoint.pdf ), the extent of land confiscation, the attendant destruction of assets and infrastructure, and loss of income. (2) Closure and physical destruction of Palestinian economic infrastructure are both core policies of the occupation and lead directly to de-development.(1)

In December 2002 Palestinian gross national income (GNI) losses “reached some US$5.2 billion in 27 months - when one considers that GNI was estimated at US$5.4 billion in 1999, the opportunity cost of the crisis represents almost one entire year of Palestinian wealth creation. Cumulated raw physical damage [from September 2000 to December 2002] has jumped in the last year to some US$930 million, and lost investment to US$3.2 billion.” (7) The UN Conference on Trade and Development reports the loss “of up to one third of the existing physical capital and productive capacity” of the oPt. (8) Real per capita GDP declined another 10 percent in the first half of 2006 alone. (3)

The Word Food Program (WFP) lists nine major risk factors predisposing Palestinian households to food insecurity. (2) Similarly, a joint European Union and UN Food and Agriculture Organization report lists eight reasons for the increasing cost of food. (9) In each risk model, all but one risk factor is due to occupation policies.

The UN Office for the Coordination of Humanitarian Affairs reports closure and fragmentation by Israeli settlements and settlement-related infrastructure “is at the root of the West Bank’s declining economy…. Unless the problems caused by the existence and expansion of the settlements are addressed, the dismal humanitarian outlook for Palestinians will intensify.” (10) Several World Bank reports affirm this judgment. (4, 7, 11)

Roy describes the core policies of de-development as “measures designed…[to] fragment Palestinian society…to render it unviable…include[ing]:…introduction of advanced agricultural technologies concomitant with the steady confiscation of land and water; the introduction of refugee rehousing programs together with the establishment of Jewish settlements on Arab land; [and] improved access to employment in the Israeli economy in conjunction with prohibitions on the development of the domestic Palestinian economy (e.g. restricted access to international markets, control over all forms of indigenous production and over the flow of information, and consistently low levels of government investment in key economic sectors)…”(1)

Possibilities for improvement

Short of an end to the occupation, food security can perhaps be improved with food aid from the international community, but this will require Israeli cooperation on movement of food aid, especially into and out of Gaza, as well as sustained international financial and political support for such aid. Israel’s recent designation of Gaza as a “hostile entity” and US Secretary of State Rice’s agreement with the declaration does not indicate that either international support or Israeli assistance will be forthcoming. (12) Sustainable food security can only grow out of Palestinian economic stability and recovery, which are likely impossible under continued Israeli occupation and de-development. (13)

Feroze Sidhwa
2nd year medical student
University of Texas Health Science Center
San Antonio
USA
Sidhwa@uthscsa.edu

(1) Roy S. The Gaza Strip: The Political Economy of De-Development, 2^nd ed., Washington, DC: Institute for Palestine Studies; 2001.

(2) World Food Programme. West Bank and Gaza Strip: Comprehensive Food Security and Vulnerability Analysis, Jan 2007.

(3) United Nations Relief and Works Agency for Palestine Refugees in the Near East. Prolonged Crisis in the Occupied Palestinian Territory: Recent Socio-economic Impacts on Refugees and Non-Refugees, Nov 2006.

(4) World Bank. Four Years - Intifada, Closures and Palestinian Economic Crisis, Oct 2004.

(5) United Nations Office for the Coordination of Humanitarian Affairs. The Humanitarian Monitor: occupied Palestinian territory, No. 15, July 2007.

(6) United Nations Children’s Fund. UNICEF Humanitarian Action Report 2007, 2007.

(7) World Bank. Twenty-Seven Months - Intifada, Closures and Palestinian Economic Crisis, May 2003.

(8) United Nations Conference on Trade and Development. Report on UNCTAD assistance to the Palestinian people, July 2007.

(9) EC-FAO Food Security Information for Action Programme. Strengthening Resilience: Food Insecurity and Local Responses to Fragmentation of the West Bank, Apr 2007.

(10) United Nations Office for the Coordination of Humanitarian Affairs. The Humanitarian Impact on Palestinians of Israeli Settlements and Other Infrastructure in the West Bank, July 2007.

(11) World Bank. The Palestinian Economy and the Prospects for its Recovery: Economic Monitoring Report to the Ad Hoc Liaison Committee, Dec 2005.

(12) Israel brands Gaza “hostile entity” as Rice visits. AFP, Sept 20, 2007.

(13) Roy S. ‘A Dubai on the Mediterranean’. London Review of Books, Nov 3, 2005.