March 24, 2015 part one, The Most Massive Child Abuse In The World

UNRWA, the United Nations Relief and Works Agency for Palestinian Refugees in the Near East, has been given an impossible task.  Originally a temporary agency to assist and protect the 750,000 Palestinian refugees created by the war in 1948 with Israel, the refugee population has grown to over five million in Syria, Lebanon, Jordan, West Bank, and Gaza.  Despite the catastrophic conditions in Gaza, UNRWA this week is actually focused on the Palestine refugee camp of Yarmouk in Damascus, Syria, where more war and dispossession and humanitarian crises face an already beleaguered population.

But we are in Gaza and it is a bright sunny day as we head off to several UNRWA facilities, starting in Gaza City.  A quick review of the UN Gaza Situation Report for April 3, 2015 (check UNRWA website and yes I am running behind in the blog effort but last week was a lot like this week and that is the problem), will give you a sense of the challenges ahead:

  • According to the report, movement and access restrictions continued to fragment the occupied territory, undermining Palestinians’ livelihoods and impeding their access to basic services. “Continued occupation undermines the ability of Palestinians to live normal lives. Were these factors removed and related policies changed, international humanitarian assistance would not be necessary here,” The Humanitarian Coordinator concluded.
  • UNRWA continued its exceptional food distribution during the reporting week, with a total of 21,970 families having already received food parcels of flour, oil and rice…The distribution to approximately 35,000 families (bolding is mine) aims at ensuring sufficient access to food for refugees in Gaza; it also serves to inject essential commodities into the local market. The food parcels are provided in quantities according to family size…The distribution comes in addition to the regular food assistance provided to approximately 868,000 refugees and the daily rations that UNRWA is providing to more than 7,000 internally displaced persons sheltering in 12 UNRWA Collective Centres across Gaza.
  • During the reporting week, US $667,199 in funding from the Japanese Government was paid to 199 affected families across the Gaza Strip through local banks. In January 2015, UNRWA was forced to suspend its cash assistance programme supporting repairs and providing rental subsidies to Palestine refugee families in Gaza. This week’s payments do not change the fact that only US$ 175 million has been pledged in support of UNRWA’s emergency shelter programme, for which a total of US$ 720 million is required. This leaves a current shortfall of US$ 545 million.

  • To date, some 60,000 Palestine refugee families have been able to complete the repair of their damaged homes with assistance provided through UNRWA. A further 10,760 families whose homes were totally or severely destroyed have received one TSCA payment typically covering four months subsidy; over 1,300 displaced refugee families have yet to receive even one installment. Of the families receiving TSCA, over 7,600 families also benefited from the $500 reintegration grant. A further 1,270 families whose homes incurred major damage benefited from the reintegration grant. However, more than seven months after the announcement of a ceasefire, not a single totally destroyed home has been rebuilt in Gaza. The GRM, a temporary agreement between the Governments of Israel and Palestine concluded in September 2014, currently allows the entry of building materials for repair but the process for rebuilding totally destroyed homes remains yet to be agreed upon. Whereas import of construction material is banned by the Government of Israel but possible for UN-led projects following a lengthy approval procedure since 2010, the UNRWA shelter self-help programme is completely reliant on the GRM.
  • to date 9,061 Palestine refugee houses have been considered totally destroyed and 5,066 have suffered severe, 4,085 major and 120,333 minor damages. Also, to date, the Agency has only received funding to reconstruct 200 of the 9,061 houses totally destroyed.
  • Youth female unemployment rates amongst Palestine refugee women in the Gaza Strip skyrocketed to 83.3 per cent in 2014, according to recent statistics from the Palestinian Central Bureau of Statistics. Across the board unemployment levels in Gaza sit at 43.9 per cent, the highest rate on record.

  • Whilst the eight year Israeli imposed blockade may have devastated the economy and caused chronic unemployment, it has not blocked the imagination and innovative business ideas of young people in the Gaza Strip. UNRWA continues to pilot its social enterprise, the Gaza Gateway, as part of an ongoing commitment to enhancing employment prospects for young Palestine refugees in Gaza, an initiative that is designed to help young IT graduates gain work experience and employability training, and create new opportunities within the devastated Gaza economy…
  • (the report reviews a series of important UN programs and initiatives…)
  • UNRWA continues to support and provide for the basic needs of 7,072 Internally Displaced Persons (IDPs) living in 12 Agency-run Collective Centres across the Gaza Strip.

So, the largely invisible to the western world humanitarian crisis is mind boggling, especially if you consider the budget of the Pentagon or the amount of money Americans spend on health care for their dogs, but we are going to focus on health care in Gaza.  Dr. Ibrahim Mohd el Borsh graduated from Tripoli, has a Masters in Public Health from the Jerusalem University branch in Gaza. He and a female physician, Ghada al Jadba, are briefing us; UNRWA focuses on the immediate needs of the refugees, about 70% of the Gaza population, as well as on human development and protection of the rights of refugees.  The UNRWA health program provides primary care to 1.2 million refugees here. Dr. Ibrahim’s colleague is a refugee but she lives in Gaza City, 60% of Gazan refugees live outside the camp, ie., people do leave when they can economically accomplish the cost of housing, etc.

324-1aDr. Ibrahim Mohd el Borsh and Dr. Ghada al Jadba, physicians working in UNRWA health centers

UNRWA has 21 health centers, “the main component is mostly maternal and child, then chronic diseases like hypertension, heart disease and diabetes. 25% of the population is women in reproductive age; also [because of] political challenges, instability, fertility rate high (4.3 per woman in reproductive age), this is a very high maternal morbidity and mortality. Living in this difficult situation makes those women vulnerable, the situation affects them more, with poverty, low social status; they need more care.  UNRWA provides ante and postnatal care, physical exams, labs, ultrasound.  Midwives, medical officers, and obstetrician-gynecologists rotate to the health center.  The women also receive postnatal care, with a visit one week postpartum. Women are discharged a few hours after delivery,” [Heads up: discharged to what? A shelter? Partially destroyed home? Shack with no water and erratic electricity and a crying newborn?]  Another reality check: on the family health team: the physician sees 80 to 90 patients per day, the nurse 40 per day, the midwife 20-30 per day. (Just do the math for length of appointment and remember that sessions usually end between 2 and 3:00 pm).

324-1bmother and daughter at an UNRWA clinic in northern Gaza

Anemia is a major problem (probably a reflection of malnutrition and lack of adequate supplementation combined with frequent pregnancies). Family planning is “a priority, not that successful, despite measures.  IUDs are preferred, [along with] pills, condoms, and [depo-provera] injections.” It is hard to change cultural expectations regarding family size and the desirability of having many children when people have little else on which to rely and children are expected and celebrated.

Pediatric care is critical as “45% of the population is under 18. This is a fragile community with high dependency needs, the siege affects them. Collective punishment is the most massive child abuse in the world due to siege, crowding, infectious diseases.” Fortunately there is “100% vaccination coverage, but people feel insecure. Vaccines protect their children, but sometimes there is a delay in procurement, mothers come daily asking for vaccines.  Even during the war they came for vaccines, H. flu, etc, prevention for TB, MMR injections.” There are breast feeding counselors, and most women nurse exclusively for six months, this is encouraged by the society.

Mammography has long been a challenge, there is a center at the Ministry of Health with good screeners. “We have agreement with them to refer suspected cases, but is not screening [program due to] budget problem.”  For those nonmedical folks out there, screening and early detection is the main benefit of mammography. I have noted minimal emphasis on preventive health care when a population is focused on food security, housing, etc., although there is some screening for risk factors for cardiovascular disease and diabetes, (both higher than expected in this population but diseases that I consider partially induced by the stressors of occupation, poverty, and lack of traditional exercise in an agricultural society).  Smoking is a big problem; however cessation programs are “one of the future goals.” It seems that they have started with smoke free health centers and at this point most doctors do not smoke.  (Halleluiah.  It used to drive me crazy, not to mention provoke bronchospasm, when I attended medical conferences with Palestinian MDs.)

Funding is an enormous issue. UNRWA has most essential medications, provided according to WHO guidelines. The private centers provide more expensive new medications, the UN is trying to upgrade their supplies.  Of course newer medications are not necessarily better medications, but they are definitely more expensive, but that is a struggle for another time. The medications are imported from pharmaceutical companies in Amman Jordan. There are also societal attitudes of shame towards mental health disorders, problems with drug addiction, and pharmacies that are not well regulated.  (I certainly have been able to get prescription medications in Palestine by just walking into a pharmacy and saying I am a doctor; that sector feels very third world.)

“Infant mortality per 1000 live births in Gaza in 1960 was 160 and it has now dropped to 16.5.” The US stands at 6, Israel at 4, while Afghanistan is 122, Egypt 24, Syria, (probably before the civil war) 15, and the West Bank 14.5 to give you a sense of the distribution by country and level of health care.  http://www.indexmundi.com/g/r.aspx?v=29. UNRWA does growth and development monitoring and finds 10% of children have birth problems, iron deficiency is present in 50% of children under three.  To add to everyone’s troubles, poverty and unemployment is also high, university graduates frequently cannot find employment.

Attention is paid to psychological and life cycle support, but “psychosocial increased so much, increased domestic violence, gender based violence in each health center, main category is women and children.  [We see] multiple symptoms that are not organic diseases, are depression, we work with GCMHP for more challenging cases. There are big challenges. The environment is poor, sanitation, all this affects health, endemic parasites, enteric fever, another burden, life expectancy is up to 73,” which can create new age challenges with few resources at the end of life. Just for starters, think accessibility and mobility.

Tramadol addiction is another big issue, people wonder out loud whether Tramadol was introduced by Israelis, did it come via tunnels, what is true? “Why not, not, most of tunnels are now destroyed, a lot of medicine entered Gaza illegally; many of the adolescents are addicted.  I hear the same thing in the West Bank, they [Israeli authorities] encourage the use of these drugs in Jerusalem and the West Bank.”  Since the destruction of the tunnels during the 2014 war by Israeli and Egyptian forces, “now everything is worse. 100,000 people worked in these tunnels, got construction materials and could build. [There was tax collection] from Hamas, now unemployment is much higher, there are no cheap medications or cheap goods, so increased suffering. UNRWA started having more demands for medications and other needs.”

UNRWA realized that with scanty resources, it is critical to be more efficient.  “We have adopted in service delivery, went from fragmented to family teams, Dr Akhiro Seita, [Director of UNRWA health programs] developed this…[with the] family team approach, we have health teams: a medical officer, a practical nurse, a midwife, [each team] meets the health needs of a specific number of families. We are now more efficient, have more relationships, [better] use of resources, and more effective and higher quality.  The doctor knows the family well; there is high staff satisfaction and community satisfaction.  [for official UNRWA statement see: http://www.unrwa.org/newsroom/press-releases/new-family-health-team-reforms-improving-un-health-services-across-middle] Most of the centers, (17), have electronic medical record, knows everything by one click, so this helps family team, the modernization of health care.

UNRWA does “not have our own hospitals, but we go to Ministry of Health, like Shifa Hospital [which was bombed during the 2014 war], most patients have insurance, but the waiting time is very long, so we decided to contract with other hospitals, NGOs, for some surgeries and all deliveries.  In that setting, “70% [of costs] are covered, 90% if abjectly poor.”

We ask about murders and crime rates, “They are low but maybe rising.  Hamas is clever in controlling.”

“In July 2014, we don’t know how we survived, very difficult, we kept most of the UNRWA centers open except if they were restricted by Israel or Hamas.  Like Beit Hanoun, Shejaia, all other centers stayed open, 65% of the workers came under difficult situations.  They were provided with UNRWA cars [which were not really protected from Israeli bombardment despite international law], gave healthcare to refugees and anyone. I have three kids, 17, 14, 10. I was leaving them alone, my husband is a vascular surgeon in Shifa Hospital and he cannot leave the hospital these days. I had to go to work to manage health care and the shelters [UNRWA schools].  I was responsible to provide for them; we had to provide food, safe food, avoid epidemics, surveillance, medical person in each center.  We recruited nurses, an emergency appeal; we highlighted the emergency: hygiene, water supply, lack of electricity, no water or hygiene or sanitation.  We were afraid of cholera and made the community in the shelter to be responsible for these issues, with strict surveillance and we prevented an outbreak.”

“It was like a nightmare, not sleeping due to bombing, I was afraid, no safe place in Gaza.   Even the hospitals, UNRWA, health centers, we were not protected.  When we go out, we left our children not protected, we do not know, anything can happen.  People came from the shelters to the health center, they needed psychological support, many of the Ministry of Health hospitals were closed; they were threatened.  Two health centers in Beit Hanoun [the IDF] bombed the center, we lost eleven staff members in UNRWA and many injured and many, hundreds, lost their houses during the war, and they were displaced to relatives or to school and they still come to health center to serve their people.”

Just checking in that you have not glazed over at the enormity of this catastrophe as well as the decency and bravery of the health care providers who are also victimized by the same bombs as their patients.   The challenge is of course to stay human in the face of inhumanity. I keep trying to imagine what if this was happening to me and my family and where else in the world are there people with similar kinds of stories thanks to the destructive power of our global military/industrial wars for power, oil, hegemony, fill in the blank…

Ghada continues, “The children have had three wars and continuous instability.  The first of the war, my children were afraid of every sound, by the end they were no problem, fed up.  Nothing we can do, waiting, expecting everything, praying all the time, afraid when parents left for work. The most difficult in life this war, all these innocent people killed without any reason. Take care of each other, it’s a joke, frustration, depression, not a big difference between us and the other people.  You don’t know if you will wake up the next day or lose your family members.  I went to shelters and saw people who lost their family members. I met eight year old child and he is sole survivor from Shejaria, [which was completely dessimated].  He was smiling, too shocked, he was injured.  We have a lot of them, 1,500 orphans after this war.  They need a lot of care.

No one care about those innocent people, and even the international community.  Israeli claim they are democracy and they kill innocent people.  What about the international community? [We had] massive destruction, many people lost all of their family and houses. The most difficult war since 1948, worse than Nakba, more aggressive, more violent, more inhumane.  During the war half a million displaced from their homes, 300,000 in UNRWA schools. How much the load on UNRWA staff?  So the nightmare of the war itself and those people now under our responsibility.  Two nightmares.” She says, “Dr Seita called daily.”

“No one expected the war would last so long.  Some sharp pain you cannot tolerate for a few minutes, difficult if it continues for days.  This is what happened in Gaza. My son is twelve years old; he was following news on the mobile, reports every ceasefire. I was trying not to be depressed in front of them.   No one cared about that kid.  There was a bombing next to us, near our building; we were so afraid.  A family neighbor was hit, the family of his best friend, he was crying, first time I saw him [cry].  He started to imagine his friend was killed, called him but he didn’t reply, but he was not in the house.”

“We know Hamas and Israel, I will not talk about them. But what about the international community?  They were just waiting and doing nothing, you must not forget what happened in Gaza, but there is no money for reconstruction. And in the news, maybe another war in the summer.  Beit Hanoun, looks like earthquake hit it.  So we struggle, there are increases in skin diseases, no showers, scabies increased, lice, we bought shampoos.”

“We need people like you to make their voice higher, we are isolated from all the world, even from Palestine, we have a lot of disappointed stories, millions.  It would be a disaster without UNRWA,  We educate 250,000 students, we are free at health care and drugs, good quality of care with dignity.”

We continue to a field office, passing tuk tuks loaded with chairs, merchandise of all sorts, street vendors with hanging columns of yellow bananas and pyramids of oranges and potatoes,  pass the Islamic University, the newest medical school in Gaza after al Azhar University. Dr. Ibrahim recounts a funny story that when he was once in Japan, (learning about family centered care) he was a minute late and his Japanese colleagues called the police.  They are clearly unfamiliar with the concept of Palestinian time.

324-1cRefugee children leaving UNRWA school in northern Gaza

The senior medical officer at a health center in the North near Jabalya, Dr. Anad, meets with us for more conversation.  Some additional vignettes:

  1. We meet with a family health team: two doctors, two practical nurses, one midwife, the doctor is smoking, the facility is clean and orderly, their records are improving, they encourage patients to make appointments rather than come and wait.  There is a big blue and white sign: “Great Thanks Go To Greek Government and People.”
  2. We see patient education materials particularly focused on mother/baby care and diabetic foot care.
  3. Most of the cars we see came through the tunnels at the Egyptian border.
  4. A pack of Marlboros used to cost 9 NIS but the price went up to 25 once the tunnels were destroyed.  It may have been a black market economy, but it is clearly cheaper than no economy.
  5. Dr Ibraham reveals that his own house was partially destroyed.  Three meters away, a neighbors house was bombed and he suffered from collateral damage. He lived for 50 days in his mother-in-law’s house.
  6. The thirteen story Albasha Towers was bombed leaving 70 families homeless, we pass a massive crater, the site of the towers.
  7. In Gaza people suffer from Hamas or Fatah.  “We don’t want either.  We need civilized people.  We cannot fight the Israelis. Peace is the solution. Yesterday in Rafah there was a demonstration focusing on the suffering of the civilians due to lack of electricity. Hamas shut down the demonstration.”  The doctor reports that he has four hours of electricity per day and also uses a generator.   As I have mentioned, these generators use fuel which is very costly and are loud and polluting.

324-1dpatient education poster at an UNRWA clinic on the topic of diabetic foot care

As we drive I notice this kind of reckless apathy, pedestrians walk right up to moving cars, people seem totally fearless, cars challenge each other inches apart, traffic rules are kind of optional, I wonder if there comes a point where there is no fear left and death seems fatalistically just one smart bomb or one screech of the breaks away. I repeatedly hear some variant of the feeling that death may be fast or slow, but either way, in Gaza it is coming soon.