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  • Volume 377 1719 (2011)
  • May 21, 2011

Healthcare Under Siege: Inside Gaza and the West Bank

fig1 Panel member Sir Iain Chalmers working in the Gaza strip in the 1960s

On Thursday 13th May 2010, the Oxford Society for Medicine held an audience-driven discussion exploring obstacles to health care delivery in the occupied Palestinian territory. The panel brought together six of the leading luminaries of the medical and surgical world, and in today’s article, Omar Abdel-Mannan, president of the OSM, and Imran Mahmud report on the event, and the current status of Palestinian health.

Palestinian health has never been in a worse state…. and it continues to deteriorate. Why and how can we use our resources here in the UK to support medical professionals in the West Bank and Gaza?

On the December 27th 2008, the Israeli Defence Force (IDF) launched Operation Cast Lead, a three week military assault on Gaza. 1366 Palestinians were killed, 313 of whom were children. International doctors, Mads Gilbert and Erike Fosse, witnessed at first hand, “the most horrific war injuries in men, women and children in all ages in numbers almost too large to comprehend” [1]. White phosphorous munitions were fired upon civilian areas in Gaza, leading to widespread severe chemical burns [2].

However, what we tend to forget is that the 18 month sea and land blockade on Gaza, prior to the IDF operation and the siege which continues to this day precipitated the collapse of Gaza’s healthcare infrastructure. This is evident by the lack of basic medical equipment, such as patient trolleys, ventilators and electronic monitors for vital signs in hospitals like Al-Shifa, where Mads and Erik worked. Infant mortality and growth stunting rates in children (representing reliable indicators of health status) have either stagnated or increased between 2000-2006 [3]. A WHO survey on quality of life in 2005 found it to be lower in the occupied Palestinian territory (oPt) than all other countries studied.

Further, malnutrition, unemployment, public curfews and restrictions on movement are daily realities. The separation wall, constructed between Israel and the West Bank and declared illegal by the International Courts of Justice, continues to impede movement of Palestinians during everyday activities, and divides neighbourhoods and households [4]. Reports of patients needing life-saving operations and critical care being denied access and women giving birth at checkpoints are commonplace [5]. The need for travel permits delays access to hospitals for patients, medical students and health workers, with commuting times increasing from 30 minutes to more than 2.5 hours on a regular basis.

fig2 Wall inside Bethlehem

Chronic exposure to violence, humiliation and insecurity has bred pervasive demoralization and despair amongst Palestinians. Yet, within this context, Palestinians have cultivated a collective social resilience to occupation in the face of daily struggles [6].

This sad state of affairs for the health of Palestinians is couched within a larger context of disjointed and inadequate public health provision and healthcare infrastructure that developed over generations of different regimes. A Palestinian Ministry of Health, established after the Oslo accords in 1994 (along with the Palestinian National Authority), inherited a neglected health service from the Israeli military after decades of degradation. Current services remain inadequate for the health needs of the people, due to continuing neglect, poor management and corruption. Israeli restrictions since 1993 on the free movement of Palestinian goods and labour across borders between the West Bank and Gaza have certainly made matters much worse. The lack of any control by the Palestinian National Authority over water, land, and the environment within the oPt has made building an effective health system virtually impossible. To compound this further, the reliance on financial assistance from a multiplicity of donors, complete with their different agendas has also resulted in programme fragmentation [7].

fig3 Erez checkpoint in Gaza

So what is the solution?
Building an effective healthcare system requires command over resources, self-determination, sovereignty and free movement of people, all absent in the Palestinian territories, particularly in Gaza. This is the argument put forward by a number of world renowned academics, doctors and surgeons in a conference organized recently by myself and a number of students at Oxford University: ‘Healthcare under siege: supporting medical education in the occupied Palestinian territories’. In this gathering the expert speakers drew on their decades of personal experiences in the oPt to expose the devastating effect of crippling economic blockades and military attacks on civilian health and access to medical care, especially in Gaza. Who are these ‘experts’? Sir Iain Chalmers – A co-founder of the UK Cochrane Collaboration, Sir Terence English – the first surgeon to perform a heart transplant in the UK in 1979, Dr. Richard Horton – Editor-in-Chief of The Lancet, to name but a few.

fig4 Some of the speakers and panellists who were present at the conference: Oxford Teaching Group Dececember 2009 L to R – Dr Knight, Dr Little, Mr Dudley, Mr Nick Maynard, Dr Marfin, Mrs George, Mr Bruce George

fig5 Oxford Teaching Group April 2008 L to R – Prof Kenwright, Mr Britton, Mr Nick Dudley, Mr Maynard, Mr George

Earlier this year in February, Dr Horton and Sir Iain Chalmers visited Gaza, gaining access with the help of the charity Medical Aid for Palestinians. In his ten minute talk, Dr Horton vividly portrayed the image of a disintegrating healthcare system and a humiliated people: “Going through checkpoints is like going through cattle gate”. One of the pressing needs, as he argued, is to systematically train medical researchers and postgraduate students to build a solid foundation of medical professionals for the future. Supporting the universities, he added, is crucial to better understand the Palestinian case, to understand their needs, and to focus on supporting human rights.

Meanwhile, Prof Colin Green from University College London (and UNESCO Chair of Cryobiology with the Ukraine Academy of Science) was a key player in the extraordinary construction of a medical school from scratch based at Abu Deis in the West Bank in 1994 (with an original intake of 34 students), which today has grown to over 800 students in four campuses. As he highlights, family practice in the area is very poor and it seems that all doctors end up in the hospitals: “We need champions of primary care,” enthused Prof Green. More specialists are also need in the region, with only 1 pathologist and 2 cardiologists in the whole of the West Bank and a clear lack of Psychiatrists.

So why should we care about this region?
I personally believe, as do all the speakers, that the UK has a special responsibility towards the people of Gaza and the West Bank, due in no part to our historical ties. The Balfour declaration of 1917, which involved Britain giving away a country that didn’t belong to us, to two different national movements, was always bound to end in tears. It is thus our politicians’ responsibility today to clean up this mess, and to uphold the promise made in that same declaration that ‘nothing would be done to harm the civil and religious and human rights of existing non-Jewish communities in Palestine’.

1Wall alongside road in West Bank

By discussing the UK’s wider role and moral responsibility towards the Palestinian people in Gaza and the West Bank, I am confident that we will develop and implement innovative strategies to make a positive on-the-ground difference to civilian health, access to medical services and medical education there. Oxford Brookes University’s historic decision in March to establish a scholarship programme for Gazan students (set up with the help of Dr Iain Steadman, Director of Development and one of the attendees at the conference) is one such example of the tangible difference that can be made through academia. In fact, within hours of the conference ending, a number of enthusiastic medical and humanities students from the university had already formed a student movement aiming to push through a number of short and long term proposals; including the facilitation of twining Al Quds University medical school (based in Abu Dies) to Oxford University medical school. I very much hope that this will promote elective exchanges, the sharing of ideas and teaching materials, and act as a catalyst for similar programmes at other UK medical schools.

I couldn’t help think during the conference: Why have such distinguished members of the medical elite, with hugely successful careers in their respective fields, invested so much energy in this cause – sometimes putting their jobs on the line as a result? These are people with no political, religious or cultural affiliation to the Palestinian issue, fighting for a cause that is thousands of miles from their doorstep. The simple answer is that at the end of the day, doctors and surgeons work in the business of helping people – the original Hippocratic Oath clearly states: “I will keep them (the sick) from harm and injustice”. That is undoubtedly a political statement. All medics should be championing human rights and tackling injustice across the world, wherever it rears its ugly head.

While a political solution remains distant, ordinary Palestinians in Gaza and the West Bank continue to suffer. The physical, psychological and social well-being of Gazans will remain poor, whilst the structural impediments and barriers to development remain in place. As the WHO’s Commission on Social Determinants of Health states:

“The conditions in which people live and work can help to create or destroy their health”.

The situation is grave, but it is not impossible. Within all the darkness, beacons of light across remain bright across both sides of the wall. The Director of the Institute of Community and Public Health at Birzeit University (in the West Bank) wrote in a statement to the audience at Oxford University, that all of us can individually do something to help: by supporting medical education, by visiting the region to see at first hand the challenges of daily Palestinian life, and by advocating for justice and human rights, we can make a difference.

For me the heartfelt passion and commitment of the speakers resonated with my core values as a future doctor and reminded me of why I chose medicine in the first place. Inspired by this event, I am taking the first steps on a journey that will take me to a land of challenges and resilience. I truly believe that every medic should go the occupied territories and see with their own eyes the health of ordinary, innocent people under siege.

Omar Abdel-Mannan and Imran Mahmud are both fifth year medical students at Oxford University
omar.abdel-mannan(at)medschool.ox.ac.uk

References:

1. Gilbert M, Fosse E. Inside Gaza’s Al-Shifa hospital. The Lancet 2009; 373: 200-202

2. James Hider, Sheera Frenkel. Israel admits using white phosphorous in attacks on Gaza. The Times. 24th Jan 2009

3. Rita Giacaman Rana Khatib, Luay Shabaneh, Asad Ramlawi, Belgacem Sabri, Guido Sabatinelli, Prof Marwan Khawaja, Tony Laurance. Health status and health services in the occupied Palestinian territory. The Lancet 2009. 373; 837-849

4. United Nations. Gaza Strip inter-agency humanitarian fact sheet. March 2008 http://domino.un.org/pdfs/GSHFSMar08.pdf (accessed Aug 2, 2008).

5. Hanan Abdul Rahim, Laura Wick , Samia Halileh, Sahar Hassan-Bitar, Hafedh Chekir, Graham Watt, Marwan Khawaja. Maternal and child health in the occupied Palestinian territoriy. The Lancet 2009; 272: 967-977

6. M Rutter, Resilience in the face of adversity: protective factors and resistance to psychiatric disorder, Br J Psychiatry 1985; 147: 598–611

7. Rajaie Batniji, Yoke Rabaia, Viet Nguyen–Gillham, Rita Giacaman, Eyad Sarraj, Prof Raija–Leena Punamaki, Hana Saab, Will Boyce. Health as human security in the occupied Palestinian territory. The Lancet 2009. 373; 1133-1143

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