Public Health Situation in Gaza 2009


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Product of my trip on a medical relief convoy to Gaza as well as research from groups working in the area.

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Public Health Situation in Gaza 2009

  1. 1. Ahmed Ibrahim University of California Irvine Office of Environmental Health and Safety Health Under Siege: The Gaza Model
  2. 2. About Me <ul><li>BS (Biology/Chem)UC Irvine-2006 </li></ul><ul><li>MPH (Epidemiology) UC Davis-2008 </li></ul>
  3. 3. About this presentation <ul><li>Based on my observations in Gaza and the Sinai peninsula. </li></ul><ul><li>Interviews of Gaza’s Minister of Health and medical personnel in Shifa clinic. </li></ul><ul><li>Colleagues </li></ul><ul><li>Reports from UN and NGO’s </li></ul>
  4. 4. The Objective of this presentation is to <ul><li>Underscore the unique public challenges of regions under state-sponsored siege. </li></ul><ul><li>Use Gaza as a model to illustrate the effect of siege in general. </li></ul><ul><li>Identify the critical role that public health professionals play in these environments. </li></ul><ul><li>Discuss possible reforms in the relief paradigm to provide more comprehensive assessment and assistance. </li></ul><ul><li>Doing all of this while keeping you awake! </li></ul>
  5. 5. The objective of this presentation is NOT to <ul><li>Discuss Middle Eastern Politics. </li></ul><ul><li>Discuss the legitimacy of groups. </li></ul><ul><li>Propose a solution for peace in the Gaza strip. </li></ul><ul><li>Represent anyone else’s perspective other than my own. </li></ul><ul><li>Give a presentation about my adventures complete with clearly doctored photos of me performing heroic actions. </li></ul>
  6. 6. OK Just this once!!!
  7. 7. A siege is a military or economic blockade of a city or territory with the intent of conquering by attrition or assault. -Constant -Relatively Low Intensity -One side maintains strong static defensive position. Year Besieged Duration 1982 Beirut, Lebanon 2.3 months 1992 Sarajeavo, Bosnia 4 years 2004 Fallujah, Iraq 1 month 2009 Northern Sri Lanka 4-7 months Year Countries Duration 1986 South Africa 8 years 1990 Iraq 12 years 1997 Burma 13 years 2001 Zimbabwe 9 years
  8. 8. <ul><li>Military Siege </li></ul><ul><li>Damage to public resources and activity </li></ul><ul><li>Destruction of existing infrastructure </li></ul><ul><li>Mass trauma and injury to civilians </li></ul><ul><li>Property Loss </li></ul><ul><li>Typically acute, short term events with high number of deaths. </li></ul><ul><li>Economic Siege </li></ul><ul><li>Disrupt imports and exports. </li></ul><ul><li>Disrupts maintenance or growth of existing infrastructure. </li></ul><ul><li>Material scarcity and rise in cost. </li></ul><ul><li>Lack of confidence from foreign investment. </li></ul><ul><li>Typically long periods with high attrition. </li></ul>Threatens the top achievements in public health Introduces new disease burdens in the population. Siege Types: Blockade vs. Sanctions
  9. 9. What makes a Unique model? <ul><li>Few regions in the world with a civil war, a local war and a regional war. </li></ul><ul><li>Gaza remains under regional sanctions as well as international sanctions. </li></ul><ul><li>Gaza is under particularly heavy land and maritime blockade by Israel. </li></ul><ul><li>Gaza has undergone a heavy military campaign “operation cast lead” with the siege resuming (no occupying power to assume administrative control and be legally obliged by the UN to aid in the relief). </li></ul><ul><li>The aftermath of the war has produced severe and long lasting public health impact. </li></ul>
  10. 10. Geographic 41 Km (25 miles) long 6-12 Km Wide 360 Km 2 (139 mi 2 ) (twice size of Irvine) Demographic 1.5 million residents (July 2009) 85% refugees from previous Arab Israeli conflicts. Pop density 4118/sq mile (2.25 times as Irvine) As of 2007, 80% of Gazans live under the poverty line. Siege of Gaza began in June 2007
  11. 11. Before Operation “Cast Lead” <ul><li>Two main realities affecting healthcare in Gaza. </li></ul><ul><li>Israeli policies of cordoning and incursions </li></ul><ul><li>Palestinian policies and divisions </li></ul>
  12. 12. Israeli Policies <ul><li>Restrictions on movement of patients and medical resources </li></ul><ul><li>Limited personnel entry or training </li></ul><ul><li>Import restrictions on fuel, energy, construction materials </li></ul><ul><li>Gaza’s impoverishment led to free of charge healthcare services (further burdening the system). </li></ul><ul><li>Military action against civilian infrastructure (including health care). </li></ul>Health in the Gaza Strip: Siege, Fire, and Internal Division Majdi Ashour, MD, MPH Public Health and Health Policy Specialist
  13. 13. Palestinian Division <ul><li>June 2007 following election of Hamas. </li></ul><ul><li>Period of duplicity of power in Ministry of Health. </li></ul><ul><ul><li>Salary and budget cuts by PA Gaza (37% of PA territory) </li></ul></ul><ul><ul><li>Healthcare workers strike and are arrested/tortured </li></ul></ul><ul><ul><li>Heavy security presence in healthcare facilities. </li></ul></ul><ul><li>Hamas take over Gaza from PA. </li></ul><ul><ul><li>Deaths and injuries </li></ul></ul><ul><ul><li>Near collapse of police and paramedic services </li></ul></ul><ul><ul><li>Ministry officials replaced with inexperienced Hamas loyalists who have no clear plan. </li></ul></ul>
  14. 14. &quot;Situation Report From The Humanitarian Coordinator - January 7, 2009, 1700 hours&quot; . UN Office for Coordination of Humanitarian Affairs . 2,360 air strikes -GBU-39: Small diameter missiles carrying DU warheads -2000 lb Mark 84 Bunker Busters along Sinai/Egypt border. 7,000 shells fired More than 50% were MA25A1 (White phosphorous) Ground Invasion Entered through Kissufim border to split Gaza and cutoff resources from the south. Naval Strikes 8 Km range ER missiles Triggered UK to revoke License to sell Israel spare parts. UAV Continues to be deployed over Gaza
  15. 15. Gaza Parliament Building
  16. 16. Petroleum Company
  17. 17. UN Vehicles
  18. 18. UNRWA Food Storage Warehouses
  19. 20. ER wing of Hospital destroyed
  20. 21. American International School in Gaza
  21. 22. American International School in Gaza
  22. 23. Dec. 27-Jan 18 <ul><li>1,380 Palestinians Killed </li></ul><ul><ul><li>31% Children </li></ul></ul><ul><ul><li>8% Women </li></ul></ul><ul><ul><li>61% Men </li></ul></ul><ul><li>5,380 Injured </li></ul><ul><ul><li>35% Children </li></ul></ul><ul><ul><li>15% Women </li></ul></ul><ul><ul><li>50% Men </li></ul></ul><ul><li>100,000 people became newly displaced </li></ul>
  23. 24. Damage to Health System <ul><li>43 of 110 primary health centers </li></ul><ul><li>15 of Gaza’s 21 Hospitals </li></ul><ul><li>29 of 148 ambulance vehicles </li></ul><ul><li>16 health workers killed </li></ul><ul><li>25 injured on duty </li></ul>
  24. 25. Current Healthcare System <ul><li>85% MoH </li></ul><ul><li>15% NGO </li></ul><ul><li>Full administrative Oversight on NGO’s </li></ul><ul><li>55 primary health centers </li></ul><ul><li>12 Hospitals </li></ul><ul><li>2 tertiary health centers </li></ul>Interview with MoH Dr. Bassem Naim 07/16/09
  25. 26. Sustained trauma to population <ul><li>Estimated 6,000 people will die from indirect causes of the conflict </li></ul><ul><li>500,000 will be adversely affect in some way. </li></ul><ul><li>Enduring disabilities/disfigurement due to war </li></ul><ul><li>Food and water-borne outbreaks </li></ul><ul><li>Higher miscarriages and neonatal deaths continue. </li></ul><ul><li>Increase of chronic disease </li></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>Chronic Obstructive Pulmonary Disease </li></ul></ul><ul><ul><li>Heart Disease </li></ul></ul><ul><li>Psychological Trauma </li></ul><ul><ul><li>PTSD </li></ul></ul><ul><ul><li>Unipolar depression </li></ul></ul>Interview with Head Nurse at Shifa Hospital
  26. 27. Assessments largely ignored long term impact of the campaign <ul><li>Main Focus of UN and NGO’s </li></ul><ul><li>Death from injuries </li></ul><ul><li>Impact from lack of access to health services </li></ul><ul><li>Chronic diseases </li></ul><ul><li>Gloss over the reasons behind chronic diseases </li></ul><ul><li>Ignore other more lasting sources of chronic disease. </li></ul><ul><li>Passive Epidemiology </li></ul><ul><li>More focus on broader PH </li></ul><ul><li>Built environment </li></ul><ul><li>Status environmental Health </li></ul><ul><li>Specific epidemiological questions. </li></ul><ul><li>Make recommendations relevant to the limitations of the environment. </li></ul><ul><li>Ask circumstance-specific questions. </li></ul>
  27. 28. Fundamental PH Perspective <ul><li>Environmental Contamination </li></ul><ul><li>Water resources </li></ul><ul><li>Food resources </li></ul><ul><li>Built environment </li></ul>
  28. 29. Depleted Uranium: GBU-39’s <ul><li>Suspected to have been used </li></ul><ul><li>Remains alleged at this point </li></ul><ul><li>Israel bought 1,000 of these from Boeing </li></ul><ul><li>Allegedly used during air campaigns </li></ul><ul><li>Air campaigns focused on Sinai/Rafah border. </li></ul>Action of Citizens for the total Dismantling of Nukes UPDATED 4th JULY 2009 REPORT On the use of radioactive weapons in the Gaza Strip during « Operation Cast Lead » (27 December 2008 – 18 January 2009)
  29. 30. Medical Evidence <ul><li>Traces of radioactivity in victims and cadavres </li></ul><ul><li>High incidence of cancer in the eastern region of Khan Younis </li></ul><ul><li>No epidemiologist to conduct these studies </li></ul><ul><li>No legal experts to file the reports. </li></ul>Interview with MoH Dr. Bassem Naim 07/16/09
  30. 31. Water Source and Treatment Plants Rafah Governorate Serves 184,000 residents Served by Coastal Municipalities Water Utility 65% currently connected to wastewater system Discharges untreated sewage into the sea Khan Younis Governorate Serves 250,000 residents Served by Coastal Municipalities Water Utility 25% connected to wastewater system Discharges partially untreated wastewater into the sea Deir El Balah (Middle Zone) Governorate Serves 190,000 residents No connection to wastewater system Discharges raw sewage into Gaza Valley and runoff to sea Gaza Governorate Serves 470,000 residents Gaza Waste Water Treatment Plant damaged during the war North Gaza Governorate Serves 255,000 residents Damaged pipe caused flow to bedouin villages
  31. 32. Raw sewage into the Mediterranean. <ul><li>Destruction of buildings causing outflow of sewage into the streets and runoff </li></ul><ul><li>Unmaintained municipal system due to siege restrictions </li></ul><ul><li>Destruction of pipes during military action. </li></ul>
  32. 33. Impact on Ground water supply <ul><li>Loss of water that could be recycled </li></ul><ul><li>Effects accelerated due to drought </li></ul><ul><li>Continued depletion of aquifers (completely depleted in 5 years) </li></ul><ul><li>Aquifers will collapse causing damage irreversible damage to carrying capacity. </li></ul>
  33. 34. Effect on Human Health <ul><li>Depletion of aquifers has started supplying residents with salt water (detrimental for child health). </li></ul><ul><li>Mixing of Sewage with groundwater increases nitrate levels (causative agent for blue baby syndrome). </li></ul><ul><li>Pollution of Mediterranean resources including fish, a major food source. </li></ul><ul><li>Israeli warships enforce 1-2 km limit on fishing ensures fish caught will be contain large amounts of contamination. </li></ul>
  34. 35. Food Supply <ul><li>700 impact craters in agricultural region (concentrated in southeast) </li></ul><ul><li>180 greenhouses destroyed </li></ul><ul><li>17 % of total agricultural area destroyed including </li></ul><ul><li>Ecologically vulnerable to desrtification and sustainable only through careful agricultural handling. </li></ul>Environmental Assessment of the Gaza Strip United Nations Environment Programme following the escalation of hostilities in December 2008 – January 2009
  35. 38. Built Environment <ul><li>3500 homes destroyed </li></ul><ul><li>2800 heavily damaged </li></ul><ul><li>54000 lightly damaged </li></ul><ul><li>Collectively this affects 325,000 civilians </li></ul>
  36. 39. Effect of housing conditions on public health <ul><li>Mental health </li></ul><ul><li>Security </li></ul><ul><li>Psychosocial disorders </li></ul><ul><li>Social bonds </li></ul><ul><li>Identity </li></ul><ul><li>Sleep </li></ul><ul><li>Air quality </li></ul><ul><li>Hygrothermal control </li></ul><ul><li>Accidents and injury </li></ul><ul><li>Malnutrition </li></ul><ul><li>Sanitation </li></ul><ul><li>Accidents and injury </li></ul><ul><li>Infectious Disease </li></ul><ul><li>Chronic Disease </li></ul><ul><li>Injury </li></ul><ul><li>Mental Health </li></ul><ul><li>Child development </li></ul><ul><li>Nutritional instability </li></ul><ul><li>Social determinants of public health </li></ul>Fourth Ministerial Conference on Environment and Health Budapest, Hungary, 23–25 June 2004 Review
  37. 44. Greater Context: Siege is Unique in the Public Health Perspective in that <ul><li>Greater threat on long term chronic effects than on short term ones. </li></ul><ul><li>Scope of the damage is not linear with time as is in war time or natural disaster situations. </li></ul><ul><li>More active and educated surveillance is needed to assess the true scope of the damage. </li></ul><ul><li>More active assessments need to be made to root out possible health concerns to measure. </li></ul><ul><li>Advised decisions need to be made that will influence the decision of all parties involved. </li></ul>
  38. 45. Siege: Redefined <ul><li>Historically more leisurely due to lack of destructive weapons. </li></ul><ul><li>Effects now more lasting than previously thought. </li></ul><ul><li>We need to know exactly what those long lasting risks are and address them. </li></ul><ul><li>Siege variants (economic and military) can be equally as lethal. </li></ul>
  39. 46. Is Iraq a Predictive Model? <ul><li>1990-2003: 1.5 million deaths due to combat, sanctions, diseases, depleted uranium etc. </li></ul><ul><li>UN, WHO, other agencies caught on too late to grasp the scope of the damage. </li></ul><ul><li>Damage remains lingering today. </li></ul><ul><li>Will public health catch up with the modern forms of aggression? </li></ul>International Commission of Inquiry on Economic Sanctions BM 2966, London WC1N 3XX, Britain Release Date: November 20, 1996
  40. 47. Two subliminal messages here <ul><li>Public health is a very broad brush. In this topic alone we covered: </li></ul><ul><ul><li>Epidemiology </li></ul></ul><ul><ul><li>Nutrition </li></ul></ul><ul><ul><li>Public Health Policy </li></ul></ul><ul><ul><li>Environmental Science </li></ul></ul><ul><li>Good on its own, great accessory degree. </li></ul><ul><ul><li>Politics </li></ul></ul><ul><ul><li>Engineering </li></ul></ul><ul><ul><li>Law </li></ul></ul><ul><ul><li>Architecture </li></ul></ul><ul><ul><li>Medicine </li></ul></ul>ALL OF GAZA BELONGS TO ME!!
  41. 48. Last Thoughts <ul><li>Perform your own assessment in any situation </li></ul><ul><li>Ask relevant evidence-based questions </li></ul><ul><li>Be thorough in your analysis </li></ul><ul><li>Be assertive </li></ul>
  42. 49. Thanks <ul><li>People of Gaza </li></ul><ul><li>Colleagues on the VP convoy to Gaza </li></ul><ul><li>Dr. Bassim Naim-Minister of Health Gaza </li></ul><ul><li>George Galloway-British MP </li></ul><ul><li>Staff at UCI EH&S </li></ul>