Gaza : a health care system impeded

One year after the ‘Cast lead Operation’

© Pauline Beugnies I MDM France

Gaza: a health care system impeded

CONTACT PRESSE Bérénice Van Den Driessche - Communication Officer Médecins du Monde – France in Palestine comoff.mdmpalestine@gmail.com www.medecinsdumonde.org Office: +972 (0) 2 583 8551 I Jawal: +972 (0) 598 92 91 24 I Orange: +972 (0) 54 903 7557

A doctor’s tale from the eye of the storm I remember that Saturday like it was yesterday, and I guess I will never forget it. The first attack started around 11.20 AM: around the time of the prayers, when the schools ended and when the children crowd the streets of Gaza. I was in a training with MDM-F when we heard the first bombing. One time, two times,… six… ten…. And all along we heard the noise of the warplanes… From our tall building, we could see dozens of columns of dark, black smoke. And every minute, a new column appeared. For the first 30 minutes, we thought they were isolated attacks, but later that day, when it did not stop, we understood it was the war.

Our mobiles were off, no one had network and we could not connect with our relatives nor with our base in Jerusalem. I took the responsibility of sending the trainees home. Each one of us needed to feel safe, with our families and children.

I reached my house in Khan Younis after a big traffic delay since the roads were congested due to the panic. But I reached it safely though bombs were hitting more frequently. I joined my wife and my four children, they were frightened. Few minutes later, the Red Crescent hospital of Khan Younis called me: Every doctor of Gaza was called in. My wife was terrified; she did not want me to leave. “You have just arrived with us”, she begged. But I had to go.

24-long hours of unrest followed. Casualties, wounded and burnt victims were rapidly coming in and started flocking the hospital.

Electricity and water were often cut, sometimes for 3 days in a row. Hospital devices were relying on generators. I saw the family of some patients in need of an artificial respirator, pumping manually to provide air to the wounded, until electricity would come back.

Intensive Care Units (ICU) and ER rooms of the main hospitals were overcrowded… Maternities were converted into ICU and chronic patients sometimes sent home to make space for urgent cases.

Every three days, I had to take a 24 hour shift at the hospital. The two other days, I simply stayed at home, confined with my family, tirelessly watching the tragic news on TV… On the third day, 5 members of my family were killed, including a 7 year-old boy. And it went on at this rhythm until the end of the war: hearing airplanes, drones and missiles, recognizing their specific sounds, ensuring the children’s ‘safety’ away from doors and windows, sleeping scared… Listening to the unfolding tragic news, hearing about the losses within families, visiting and treating the countless wounded, the widows, mourning, grieving, and treating the wounded at the hospital…

After a couple of days, humanitarian assistance arrived in the Strip. There were many donations: drugs, equipment, ambulances. But it did not solve everything. Drugs were near their expiry date and generally had a short shelve life. Materials were useful but often old or requiring spare parts that were impossible to purchase in Gaza. As for ambulances, 15 new vehicles were not very useful, when - because of the closure- fuel became scarce.

© Pauline Beugnies I MDM France

Dr. Ahmed Abu Teir is a surgeon from Gaza.

He has been working with MDM-F since 2002 where he is currently the medical base manager

Gaza city, one year after the « Cast lead » operation. The Abed Rabbo neighborhood has been badly destroyed during the military operation.

Today, the material needed to rebuild homes and infrastructures is cruelly missing.

GAZA: A CONTEXT JEOPARDIZING THE DEVELOPMENT OF THE HEALTH CARE SYSTEM At the time of commemorating the one-year anniversary of operation “Cast Lead”, the situation for 1.5 million Palestinians in the Gaza Strip is getting increasingly worse. Yet, the latest Israeli attack must be viewed in the wider context of the increasing isolation and impoverishment of the Gaza Strip.

The high demographics of the Gaza population- the most densely populated area in the world-inevitably causes a lot of pressure to be exerted on the health sector. It must respond not only to the current contextual challenges resulting of the blockade and the previous war, but also to the increasing demands for health services resulting from a rapidly increasing population.

SOCIO-ECONOMIC PROFILE OF THE GAZA STRIP Total population 1.416.539 people (including 69% of refugees)

One year after the end of the offensive, many of the primary health care improvements that have been previously achieved are now at risk. Socioeconomical determinants and environmental factors, compounded by the current emergency situation have increased the demand for health services, which do not meet current domestic resources capacities or substantial international resources.

Population density 4.500 inhabitants per km2 (France: 93,59 hab./km2) Fertility rate 6 (Egypt: 3.5) Life expectancy 73 years © Pauline Beugnies I MDM France

Average family size 6.5 Age structure Around 45.5% of the population is under age 15 Unemployment rate 65% The Al Atatra clinic where MDM-F works has been destroyed during last year’s attacks. Since

Dependence ratio 1:8.5 (one working person sponsors 8.5 persons)

then, MDM-F has been renting a house nearby, until it the initial centre will be rehabilitated.

Today, few families whose houses have been destroyed still live in tents in front of the medical centre.

© Pauline Beugnies I MDM France

The impact of the Israeli blockade on Gaza

The water sewage system has been badly impacted by the War. Today, the sewage is being discharged into the sea.

The ongoing two year-and-a-half Israeli blockade on Gaza has negatively impacted the human rights of the citizens in the Gaza Strip, including the right to health. Since then, healthcare for people in Gaza has dramatically deteriorated at two levels: the provision of health services inside Gaza and access to treatment outside Gaza.

As a direct result of the blockade, Gaza’s economy has all but collapsed, unemployment and poverty have sky-rocketed and essential public infrastructure such as health, water and sanitation networks have deteriorated at an alarming rate, while basic foodstuffs, fuel and medical supplies have been in short supply.

Since June 2007, Israel has been imposing restrictions on the movement of goods and people at Gaza’s border crossings. People, including those in need of medical attention, have not been able to get out, while most of raw materials needed for rehabilitating and re-building health facilities are denied to enter the territory.

Further, the lack of medical equipment and medicines for health facilities aggravate the situation. Hospitals cannot generate electricity to keep lifesaving equipment working or to generate oxygen.

In result of fuel and electricity restrictions, hospitals are sometimes experiencing power cuts lasting for 8-12 hours a day. Frequently, a 60- 70% shortage is reported in the diesel required for hospital power generators. Furthermore, the increasing use of hospital generators implies the maintenance and replacement, which is almost impossible given the lack of spare parts or new equipment.

The large scale military ‘Cast Lead Operation’ on Gaza (27/12/08 – 17/01/09) Recent events at the beginning of the year 2009 resulted in a severe deterioration of the already precarious living conditions of the people in Gaza and have further eroded an already weakened health system.

As a result of the three-long-week “Cast Leadâ€? military operation: t 1BMFTUJOJBOT XFSF LJMMFE BOE BU MFBTU QFPQMF JOKVSFE t "NPOH UIF DBTVBMUJFT IFBMUI TUBGG XFSF LJMMFE BOE JOKVSFE XIJMF PO EVUZ t *OKVSJFT XFSF PGUFO NVMUJQMF USBVNBT XJUI IFBE JOKVSJFT UIPSBY BOE BCEPNJOBM XPVOET t IPTQJUBMT BOE QSJNBSZ IFBMUI DBSF DMJOJDT 1)$$ JO UIF 4USJQ XFSF EBNBHFE EVSJOH UIF TUSJLF BNCVMBODFT XFSF EBNBHFE PS EFTUSPZFE PVU PG .JOJTUSZ PG )FBMUI .P) 1)$$ XFSF DMPTFE QBSUJBMMZ PS EVSJOH UIF FOUJSF QFSJPE PG UIF DSJTJT Access to health care was severely restricted or hampered by security constraints and several general health services at PHCC level were disrupted. Maternity wards and operating theatres were often transformed into trauma units, and speciďŹ c concerns were expressed for the chronically sick as it is estimated that during the military operation 40% of the chronically sick persons interrupted their treatment.

As well, elective surgery and non-urgent routine medical interventions were delayed or interrupted during the crisis, indicating that a growing number of patients, mainly with chronic diseases, are still in need of medical treatment.

Increase of the Environmental health Hazardous factors

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Over two years of blockade and 3 weeks of military operations along with inadequate resources have created a signiďŹ cant public health and environmental problem in the Gaza Strip. According to the last UNEP report, the environmental situation in the Gaza Strip was already serious prior to these events, due to underinvestment in environmental systems, lack of progress on priority environmental projects and the collapse of governance mechanisms. Still, the recent escalation of hostilities caused additional damage such as signiďŹ cant volume of demolition debris that was generated and the serious damage done to the sewage system. The health consequences for the Gaza population remain a serious concern since all these factors increase the risk of disease outbreaks (i.e. watery diarrhea, viral hepatitis‌etc.).

The Rahma Primary health care centre (PHCC) in North East of Gaza is supported by MDM-F. At the beginning of each month, patients are waiting for the new arrival of medications. Since the blockade imposed by Israel to the Gaza strip, medicines are in short supply.

GAZA’S HEALTH SECTOR IN 2009 Compared to other countries at a similar level of economic development, the Palestinian population’s overall health status outcomes are relatively good. They are noticeably better than the neighboring Arab states (Jordan, Egypt, and Syria) and reect strong performances on most basic public health and primary health care functions.

The strengths of the Palestinian health system includes a relatively healthy population, a high societal value placed on health, qualiďŹ ed and experienced health professionals and national plans for health system development. Still, in Gaza, human resources in the health sector are below regional standards and the achievements that have been made over the past three decades are now being dramatically eroded, placing the Gaza strip in a state of almost chronic emergency over the last three years.

IN 2009, HEALTHCARE SERVICES IN THE GAZA STRIP HAVE BEEN FACING THE FOLLOWING CHALLENGES: t 1SPWJTJPO PG IFBMUI TFSWJDFT JOTJEF UIF (B[B 4USJQ SFNBJOT IJHIMZ EFQFOEFOU PO JOUFSOBUJPOBM BJE t "DDFTT UP &NFSHFODZ $BSF TFSWJDFT SFNBJOT MJNJUFE UP PWFSMPBEFE IPTQJUBMT t "DDFTT UP UFSUJBSZ IFBMUI USFBUNFOUT (i.e specialized health care requiring surgical procedures, technological resources and multiple specialists and subspecialists) inside and outside the Gaza Strip remains extremely limited due to the blockade further impacting the lack of (new) surgical expertise t &OWJSPONFOUBM IFBMUI IB[BSEPVT GBDUPST JODSFBTFT UIF QSFTTVSF PO UIF QSJNBSZ IFBMUI DBSF TFDUPS

A Primary Health Care sector highly used but largely neglected In Gaza, the Ministry of Health (MoH) has established a large network of 56 primary health care centers geographically spread throughout the Gaza Strip. Those centers provide general health care services to a large part of the Gaza’s population, providing preventive, promotional and rehabilitative treatment for adults, children and babies.

A continuous lack of resources (manpower, equipments, drugs and training)‌ Nevertheless, despite a reasonably extensive coverage network, PHCCs are suffering from a lack of resources at all levels: no reliable supply of essential drugs (no buffer stock), medical equipments, materials, instruments, consumables, and manpower. t )FBMUI QFSTPOOFM QFS DBQJUB JT MPX 'PS JOTUBODF JO (B[B UIFSF BSF OVSTFT QFS JOIBCJUBOUT XIJMF JO *TSBFM BOE Europe the ratio reaches respectively 579 and 713. t JUFNT PO B MJTU PG FTTFOUJBM ESVHT BSF VOBWBJMBCMF TUPDL MFWFM BU +VOF

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According to a MDM-F pilot study carried out within 6 PHCC’s across the Gaza Strip (November 2009) 1: t (&/%&3

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The pilot study was carried in the PHCC’s of Jabalia Martyrs (North area), Zeitoun (Gaza city), Sabha (Gaza city), Deir Balah (Middle area), Khan Younes (South area) and Rafah (South area) on 343 patients.

MDM-F’S RESPONSE: t Supporting 25 out of 56 MoH primary healthcare centers (PHCC), training the medical staff, providing basic rehabilitation, drugs, as well as medical and non-medical equipments in order to prevent drug shortage.

- 170.000 patients per month attended consultations in the PHCCs supported by MDM-F - 1.800.000 consultations have been carried out by MDM-F PHCC’s in Gaza during 2009 t Organizing health education awareness activities in 25 health centers.

- About 10.000 patients beneďŹ ted from awareness sessions in Health Education during 2009, targeting speciďŹ cally women and children.

The Zeitoun clinic in Gaza city is a primary health care centre supported by MDM-F. Nurses and doctors have to take care of several patients at the same time as a result Š Pauline Beugnies I MDM France

from the blockade and the lack of resources it involves.

+FBO 1IJMJQQF 3JHBVE FNFSHFODZ USBJOFS “I came to Gaza in order to train Gaza’s doctors and nurses with regard to the management of respiratory emergencies. Our aim was to update their knowledge and attitudes regarding respiratory distresses and to practice – on dummies- the intubation procedures required to access the respiratory tracts and proceed to artiďŹ cial ventilation. Once this essential step was learnt, doctors were ready to practice their newly acquired skills within the surgical units and ER. In Gaza, theoretical knowledge is solid but there are still real needs in terms of updated knowledge regarding respiratory emergencies.â€?

An emergency sector chronically overloaded Hospitals remain the ďŹ rst place of choice for the majority of patients seeking emergency care. As a result, emergency services in hospitals are overloaded, which contribute to a disruption in the quality of the delivery of health care.

On a practical level, during operation “Cast leadâ€?, the Gaza strip was cut into three enclaves, increasing the difďŹ culty for the ambulances to access injured people as well as to transport or transfer casualties to hospitals, if located into two different zones. As a result, lessons learned from such a context led to the development of emergency rooms within 11 PHCC’s scattered in districts throughout Gaza Strip, aiming at alleviating the pressure on the emergency services of the main hospitals, and providing treatment at the local level.

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According to a MDM-F pilot study carried out in the 11 above-mentioned Emergency Rooms (ER) across the Gaza Strip (October 2009 2):

A health education session in Zeitoun PHCC, supported by MDM-F in Gaza city.

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t 5:1& 0' %*4&"4& Among the most frequent reasons for visiting the ER room in PHCC: 52% of the patients suffered from respiratory problem 33% of the patients suffered from trauma and injuries

2 The pilot study was carried out in the PHCC’s of Jabalia Martyrs (North area), Zeitoun (Gaza city), Sabha (Gaza city), Sheikh Radwan (Gaza city), Old Bureij (Middle area), Old Nuseirat (middle area), Deir Balah (Middle area), Khan Younes (South area) and Rafah (South area), Bani Souheila (South area), Rafah (South area) and Tal Sultan (South area) on 376 patients.

MDM-F’S RESPONSE: t Strengthening the emergency response capacities and the management of emergency cases by supporting emergency rooms of 11 primary health care centres (PHCC), through providing speciďŹ c items, medicine and essential medical equipments and providing training (practical and theoretical) adapted to Gaza’s complex and chronic humanitarian crisis context.

- 90.000 emergency care consultations have been conducted in the 11 MoH Primary Health Care Centers equipped by Emergency Room and supported by MDM-F during 2009 - 44 emergency staff (22 doctors and 22 nurses) from PHCC-ERs have beneďŹ ted from theoretical, practical and in-service emergency medical care training t Developing a referral system between PHCC’s providing emergency services and hospitals.

Impeding the surgery sector 4IBEB JT B ZFBS PME DIJME TIF XBT CPSO XJUI A4DPMJPTJT DVSWBUVSF PG UIF TQJOF which has been the cause of her suffering GPS ZFBST -BTU NPOUI .%. ' QFSGPSNFE TVSHFSZ PO 4IBEB BU UIF &VSPQFBO (B[B )PTQJUBM MPDBUFE JO ,IBO :PVOJT

Since the blockade imposed on the Gaza Strip, hospitals in Gaza continue to lack vital medical equipment along with a shortage of medicines (including anesthetics) and medical supplies, as well as trained personnel to carry out advanced medical treatment, including many surgical operations, such as cardiovascular surgery, orthopedic and neurosurgery. As a matter of fact, in addition to a serious lack of resources, Palestinian surgeons are mainly facing a lack of knowledge and experience regarding certain specialties in the surgery sector.

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In 2007, Professor Sylvain Terver (FR), a specialist in orthopedic care, conducted an assessment of the orthopedic services within the main hospitals of the Gaza Strip: Shifa medical compound, Nasser, Al Aqsa and the European Hospital in Khan Yunes. The assessment conďŹ rmed an important lack of medical equipment needed for orthopedic surgery, a lack of maintenance of instruments (spare parts not available) and a shortage in adequate professionals, especially in orthopedic spinal surgery, and pediatric orthopedic.

Shada’s father recollects: ‘’during the war we would all stay indoors. One day I had to take Shada to the hospital for her physiotherapy session. Yet, ever since the siege on Gaza there has been a shortage in fuel, which got worse during the war. I was unable to drive to the hospital, we were also afraid of being attacked on the way‌’’.

When Shada’s parents ďŹ rst discovered her deformity, they took her to a number of specialists in Gaza, who unanimously gave the same verdict: ‘’you need to seek treatment for your daughter outside of Gaza, we cannot perform spinal surgery here’’. Her father continues: â€˜â€™ďŹ nancially, we cannot afford to travel abroad; I have eight children to support, with very little means. The operation costs around $15, 000 and even if I did have the money, we will not get permission to travel’’.

No doubt that following operation ‘Cast Lead’ of last winter, the number of patients suffering from ortho-trauma has risen. However, with 45% of the population under age 15, and considering some socio-cultural determinants, ortho-malformations affecting young children appear as a crucial social and economical concern for the Gazan society as it might increase the number of disable people in the coming years.

A Lack of Resources (operating theatres, medical equipments, implants and instruments)‌ The overall number of operating theatres per hospital is quite limited regarding the increase of needs. As well, many of the instruments and trauma implants are missing or are now out-dated in most of the hospitals in the Gaza Strip. While many of the anaesthetic machines and monitors are not compatible (mainly regarding pediatric surgery), some machines appear out-dated in most Hospitals visited. ‌ And an insufďŹ cient Manpower The recommended ratio of orthopedic consultants per capita is 1 per 20,000 (EU %JSFDUJWF 5IVT B UPUBM PG PSUIPQFEJD DPOTVMUBOUT JOTUFBE PG XJUI UIFJS respective teams of junior doctors and Trainees, would be needed to cover the Gaza’s 1.5 million people.

MDM-F’S RESPONSE:

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t Reinforcing the surgery sector in the 3 main hospitals of the Gaza Strip with regards to adult and pediatric orthopedics. MDM-F organizes training sessions for Palestinian orthopedic surgeons and provides material for orthopedic surgery.

An orthopedic surgery in the European Hospital of Khan

t *n 2009, 5 foreign medical teams specialized in Pediatric Orthopedics, Spinal Surgery, Treatment of Surgical Infections, and War Surgery have been organized, training 20 of Gaza’s orthopedic surgeons and 5 anesthetists. 600 consultations are conducted by MDM-F orthopedic surgeons in order to select 60 speciďŹ c cases to be operated as practical exercise for Palestinian surgeons in Gaza.

Younis, supported by MDM-F. The external ďŹ xator used for the leg of the patient is one of the numerous items missing for orthopedic treatment.

/PVS JT ZFBST PME 4IF XBT CPSO XJUI B TDPMJPTJT DVSWBUVSF PG UIF TQJOF EJTUPSUJOH IFS CBDL /PVS SFDFJWFE USFBUNFOU MBTU month.

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%VF UP UIF ZFBST MPOH CMPDLBEF BOE UIF SFDFOU i$BTU MFBEw NJMJUBSZ PQFSBUJPO the quality of the available health care services has been further affected by the deterioration in the functioning of medical equipment due to the lack of maintenance and spare parts, as well as by shortages of drugs and medical supplies and restricted training opportunities for medical staff abroad.

Oncology, Ophthalmic, Orthopedic and Cardiology interventions count for the majority of referral cases (40%) which might indicate the main concerned sectors needed to be improved in Gaza. This situation can be explained by the lack of advanced diagnostic and interventional services in these areas, either because of the lack of sophisticated equipments or unavailability of trained staff and experts.

Referrals for services that are available in Gaza still continue. This results mostly from the low quality of health services such as Intensive Care Units (ICU) or the non-functioning of equipment due to delays in importing spare parts. As well, many referrals cases are due to a lack of speciďŹ c drugs inside the Gaza Strip.

“From the previous house were we used to live and that was destroyed during the last war, Nour had to walk two kilometers everyday to go to school, with heavy bags on her shoulders.

She was always complaining about harsh backachesâ€?, tells her mother. “She was neither walking nor standing straight. And because of this bad position, her oating hips pressured her lungs and it was painful to breathe too.

Doctors presented me the X-rays showing her spine all distorted. I was anxious. They said she needed surgery but that it was impossible since no orthopedic surgery could be made here. Our economic situation is good, and we would have paid any price to see Nour growing up like a beautiful ower. But there is a siege.

We are lacking specialists and equipment. And Israeli do not give us permits to leave abroad for treatment. We are stuck here, in Gaza�

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Denied Exit: the issue of the medical referrals abroad from Gaza

Further, during operation ‘Cast lead’, routine operations were affected and many elective interventions suspended. Consequently, the need for referrals outside of Gaza grew, restricted by delays and denials of passage. Israel still imposes severe restrictions at the Erez crossing point regarding the exit of patients in need of medical treatment outside Gaza. t *O QFSNJUT XFSF HSBOUFE PVU PG XIJDI EFOJFE 3. t *O UIF mSTU TJY NPOUIT PG QBUJFOUT FYJUFE UISPVHI Erez, the main exit point from Gaza into Israel (on average of 541 a month). t 'SPN +VMZ POXBSET FYJUFE PO BWFSBHF QFS NPOUI 4.

However, of those approved, many were still denied permission on the day of exit due to unexpected closures of Erez because of security reasons and others. At other times, according to local and international human rights organizations, patients were largely questioned

by Israeli security personnel upon exiting through Erez, and often denied exit when refusing to provide information.

According to information provided by the Information and Coordination OfďŹ cer of the WHO OfďŹ ce in Gaza According to a WHO Gaza health assessment carried out in July 2009, available at: http://www.emro.who.int/palestine/reports/monitoring/WHO_special_monitoring/gaza/Gaza%20Health%20Assessment%20(29Jun09).pdf

MDM-F’S RESPONSE: t 3einforcing the general health sector in Gaza by supporting the MoH in ďŹ lling the gaps in the tertiary health care service and priority sectors such as orthopaedic surgery (9% of the total of referral cases).

Facts and Figures on medical referrals abroad t 0WFS QBUJFOUT XFSF JO OFFE GPS NFEJDBM USFBUNFOU BCSPBE (2007-2008). t 5IF DPTU PG UIF USFBUNFOU BCSPBE JT UIF SE IJHIFTU FYQFOEJUVSF in the MoH’s budget since 2005, seriously limiting the Ministry’s capacity to further develop the health services. t $BSEJPWBTDVMBS EJTFBTF DPOUJOVFT UP CF UIF MFBEJOH DBVTF GPS referral outside Gaza, accounting for 16% of the total number of patients seeking treatment abroad. t 1BUJFOUT XIP IBWF CFFO EFOJFE FYJU CZ *TSBFM JODSFBTFE GSPN 10% in 2006 to 44% in 2008. t *O QFSTPOT EJFE BGUFS CFJOH EFOJFE USFBUNFOU PVUTJEF Gaza.

The Invisible wounds: Mental health impact on children

In the street of the Samouni family that has become sadly famous since the loss of 21 of its members during last year ÂŤ Cast lead Âť operation.

Those boys lost both of their parents

MEDICOS DEL MUNDO-SPAIN’S RESPONSE: t Supporting health professionals in Nasser, Kamal Aduan and Shifa hospitals. Likewise, also the Crisis Intervention Team and the Trauma Center in their ďŹ eldwork in the most affected areas. t Providing technical support to Jabalia and Sourani Community Mental Health Centers working with the teams to improve the quality of services for the people who are still suffering from the traumatic events as well as for others who come with different kinds of mental disorders.

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At the mental health level, operation ‘Cast Lead’ exposed children to high levels of stress, as the timing of the attack coincided with the mid-day change in school shifts when the majority of Gaza’s schoolchildren were either in school or in proximity to their schools. Children witnessed horriďŹ c scenes of violence and were deprived of their own protective environments such as their homes and schools. As reported CZ UIF (B[B $PNNVOJUZ .FOUBM )FBMUI 1SPHSBN ($.)1 NBOZ DIJMESFO BSF TVGGFSJOH GSPN 1PTU 5SBVNBUJD 4USFTT %JTPSEFS 154% TVDI as troubled sleep, depression and anxiety, social difďŹ culties, higher rates of delusional, obsessive and scary thoughts, delinquency and violent behavior. These psychological symptoms have persisted, and are still present one year after the end of the offensive.