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Palestinians: The Crisis in Medical Care

1.

Nothing is changing,” says Dr. Jamil Suliman, a pediatrician and now the director of Beit Hanoun Hospital in Gaza. On a quiet January morning, he shows me a clean and well-equipped emergency room, modern X-ray facilities, a pharmacy, and a basic yet functioning laboratory. Dr. Suliman oversees a medical team of more than fifty doctors. But the outlook for the health and well-being of his community, three quarters of whom live in accelerating poverty, is not good.

Beit Hanoun sits close to the border of Gaza, a twenty-five-by-five-mile strip of land that is one of the most densely populated and impoverished regions in the world today. As a meeting point between Asia and Africa, Gaza has been fiercely fought over for centuries. With the dismantling of Israeli settlements on the strip in 2005, this tract of land is now wholly Palestinian. Yet its people have hardly any control over their lives, their movements, or their economy. And so Gaza’s troubles have not receded.

Gaza exists in a cage. I entered through the Erez checkpoint at its northern tip. Armed Israel Defense Forces and bored young military conscriptees control the cylindrical steel turnstiles and electric gates that greet visitors. After walking through a three-hundred-meter camera-laden concrete tunnel, one exits into a landscape of bombed homes, blasted roads and bridges, and fields torn apart by armored vehicles. The debris of Palestinian life lines the road into Gaza City. Vans loaded with young Palestinian members of armed militias pass by freely. Men carrying Kalashnikovs stand at most street corners in the center of the city. Gaza feels like a lawless place under permanent siege.

Gaza is also a land of children. Sixty percent of its 1.5 million people are under eighteen. Children spill out of every home onto dusty and dirty alleyways. They drive donkey carts that carry everything from people to bananas. Children weave their bodies and bicycles between the cars that engorge Gaza’s narrow city streets. Young smartly dressed Palestinian girls carry their clipboards to and from school. (With families often having as many as seven children, the demand for schooling is high. Teachers run several classroom shifts daily to meet the rising need.) Early each morning, one can watch children standing in shallow boats on Gaza’s beautiful Mediterranean shoreline, pulling in their nightly catches.

In a survey completed by the Gaza Community Mental Health Program, over 90 percent of children below the age of eleven experience severe anxiety, nightmares, and physical expressions of stress, such as bed-wetting. Half fear that their parents will not be able to provide essential family necessities, such as food and a home. Forty percent have relatives who died during the second intifada, which began in 2000.

Many of these relatives live on as “martyrs,” Palestinians who have died fighting the Israelis. The faces of these young men and women are remembered on billboards and posters covering the walls of almost every building in Gaza, including hospital clinics and Ministry of Health buildings. They are often depicted carrying weapons. They are images that must press on the conscience of every child. It would be hard not to conclude that Gazan children are brought up to revere, even aspire to, the lives of these “martyrs.” There is nothing noble about indoctrinating violence into children. But it is clear how these ideas are fostered and fixed into the collective psyche of Palestinians.

Back at Beit Hanoun Hospital, Dr. Suliman is still learning the lessons from some of the most recent violent Israeli incursions into Gaza. In November 2006, following armed clashes between Palestinians and Israelis, he faced an incident that few pediatricians could have trained for. A little boy, no more than five years old, was rushed into the ER alive, but with charred lower limbs, a badly burned head, and loops of intestine hanging out of his burst abdomen.1 He had been the victim of Israeli shelling. The medical and surgical teams struggled to resuscitate him. At first, the young boy was conscious, moving his head from side to side. But after five days, he died.

When Palestinians and Israelis start firing at one another across the Gaza border, Israel may decide to quell the exchange by entering the strip. When this takes place at Beit Hanoun, from which Palestinian militants frequently fire Qassam rockets into Israeli territory, tanks isolate the town from the rest of Gaza. Israel sends in special forces and armored vehicles to flush out Palestinian militia. In November, the hospital itself was isolated by two tanks. Ambulances were prevented from leaving, says Dr. Suliman. The Israeli invasion cut off water, electricity, and communication to the hospital for seven days. Staff members asked for urgent assistance from the Palestinian Ministry of Health in nearby Gaza City. The Israelis refused their request. Instead, they ordered over a thousand civilians to leave their homes and to take refuge in the hospital.

In their defense, Israeli officials would surely argue that they used appropriate force in response to the rocket attacks from Beit Hanoun. Dr. Suliman understands this argument. But he cannot accept the harm inflicted carelessly on children. After all, he tells me, the inhabitants of Beit Hanoun should not be punished for the actions of a few extremists.

On the eighth day of the Israeli siege, eighteen Palestinians were killed, ten of them children. Israel admitted that its forces had made an error. Prime Minister Ehud Olmert called it a “technical failure.”

2.

During the past twelve months, the health systems in Gaza and the West Bank have begun to disintegrate rapidly. After the Oslo accords were signed in 1993, health became the responsibility of the Palestinian Authority. Without a sovereign state, the newly created Ministry of Health found it hard to devise and implement a coherent policy for the West Bank and Gaza. But until January 2006, when a Hamas government was elected by Palestinians, progress was slowly being made against the odds.2

After the Oslo accords, the Ministry of Health launched a five-year plan to improve primary health care. The failure to proceed rapidly toward final-status negotiations on a future Palestinian state contributed to bureaucratic paralysis. By 2000, the onset of the second intifada finally destroyed hopes not only of significantly upgrading primary care but also of developing much-needed hospital facilities. Instead, according to the health officials I spoke with, the best the ministry could do was to protect emergency services. With no systematic welfare system and over a third of the population unemployed, Palestinians were quickly moving toward a health crisis.

Into this vacuum, thankfully, came international relief agencies and NGOs. I traveled in the occupied territory with CARE International, an aid organization that has worked in the West Bank and Gaza on humanitarian and development programs since 1949. Their presence, together with that of other groups, has been vital for the survival of thousands of Palestinians.

The Palestinian Ministry of Health is now trying to coordinate the complex and often overlapping efforts of numerous different international projects. Since the Hamas government was elected, these challenges have only been compounded. Tens of millions of dollars in aid from the US and European Union to support the Palestinian government have been withheld on the grounds that Hamas is a terrorist organization that does not recognize Israel. Israel has cut off the funds it collects on behalf of Palestinians, money that amounts to half the Palestinian Authority’s total revenue. A strike by workers in the public sector last year in response to widespread international condemnation of the election result added to Palestinian misery still further. Health workers, like many other Palestinian civil servants, have seen their salaries either stopped or severely cut.3 And money for the Ministry of Health now has to follow a politically acceptable but slow and extremely inefficient route—first, through the office of Mahmoud Abbas, the president of the Palestinian Authority, and, second, via the Authority’s Ministry of Finance.

A critical obstacle to improving Palestinian health remains lack of access to specialist care. The occupied territory sends patients to Egypt, Jordan, and Israel for advanced treatment. The costs are great, especially in Israel, creating an unsustainable burden on Palestinian health budgets. The best strategy would be to develop local services for Palestinians, but the present chaotic political circumstances preclude such a solution. With scarce funding, there can be no new facilities and few trained staff. The Authority’s inability to pay salaries has meant that—despite the dire need for medical care—four hundred doctors are already unemployed in Gaza alone. There are desperate shortages of vascular, orthopedic, neurosurgical, and mental health services. Procurement of medicines is difficult. Diagnostic facilities are unavailable to large sections of the population.

Most health workers I spoke with were pessimistic about the immediate future. They saw the political choreography between President Abbas and the Hamas government, which might result in a unified Palestinian Authority, as an unlikely mechanism to deliver genuine benefits for ordinary Palestinians. Unless the recent meetings between Abbas and the Hamas leaders result in an effective government, the most probable outcome over the next two years, they say, is a tense status quo. Hamas will gain support among people dismayed at the lack of concern shown by the international community for civilian health. Israel will continue to build its separation wall and expand settlements in the West Bank. Iraq will remain a medium-term distraction. And, in any case, the world seems fatigued by the Israeli–Palestinian impasse.

The best that might be hoped for right now is a scaled-up response by civil society—people and organizations independent of government. Dr. Yousef Mousa, who chairs the Union of Health Work Committees, offers one example of what can be achieved in the face of apparent hopelessness.

In 1985, he created a volunteer organization to assist marginalized Palestinians in Gaza and the West Bank. He began in two rented rooms in the Jabaliya refugee camp. His organization has now grown to become the largest local NGO, providing primary care and hospital facilities throughout the Gaza Strip. His ambitious goal is to deliver comprehensive programs for physical, mental, and social well-being to all Palestinians. In Gaza, for example, he employs 350 staff members, who include both Muslims and Christians.

Visiting his clinics and the al-Awda Hospital in Gaza City, I was struck by the astonishing scope of Dr. Mousa’s project. He offers legal advice as well as health education to women. He provides a well-stocked library for children of all ages. He organizes dancing and life-skills classes, Internet access, speech therapy, and a safe haven for children to come and play during school vacations.

Dr. Mousa is a large, jovial man. He is not immune to the realities of his work. As we drive the length of the Gaza Strip, he holds a Kalashnikov for security reasons in one hand and a cigarette in the other. He is disappointed by the lack of support he receives from many international humanitarian aid agencies. He is especially scathing about the lack of help he gets from the World Health Organization.

  1. 1

    Hospital staff filmed the events of that evening and I watched them unfold sitting next to Dr. Suliman at his computer.

  2. 2

    In truth, the picture was mixed. Palestinian Ministry of Health figures for 2004 show stable or slightly declining infant mortality rates and falling deaths from heart disease and stroke. By contrast, mortality from accidents and cancer was rising. See Health Status in Palestine: Annual Report 2004 (State of Palestine Ministry of Health, 2005).

  3. 3

    A Temporary International Mechanism is paying public sector employees a proportion of their salaries and also funding essential services. But this relief is likely to be for the short term only; the mechanism is already judged to have failed to ensure the supply of essential medicines.

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