The Lancet commissions Series to highlight clinically important topics and areas of health and medicine often overlooked by mainstream research programmes and other medical publications. Many of the Series have the specific aim of raising the profile of these neglected areas as an advocacy tool to inform health policy and improve human development.
The Lancet, Volume 373, Issue 9666, Pages 837 - 849, 7 March 2009
Prof Rita Giacaman PharmD a , Rana Khatib PhD a, Luay Shabaneh PhD b, Asad Ramlawi MD c, Belgacem Sabri MD d, Guido Sabatinelli MD e, Prof Marwan Khawaja PhD f g, Tony Laurance MA
We describe the demographic characteristics, health status, and health services of the Palestinian population living in Israeli-occupied Palestinian territory, and the way they have been modified by 60 years of continuing war conditions and 40 years of Israeli military occupation. Although health, literacy, and education currently have a higher standard in the Israeli-occupied Palestinian territory than they have in several Arab countries, 52% of families (40% in the West Bank and 74% in the Gaza Strip) were living below the poverty line of US$3·15 per person per day in 2007. To describe health status, we use not only conventional indicators, such as infant mortality and stunting in children, but also subjective measures, which are based on people's experiences and perceptions of their health status and life quality. We review the disjointed and inadequate public-health and health-service response to health problems. Finally, we consider the implications of our findings for the protection and promotion of health of the Palestinian population, and the relevance of our indicators and analytical framework for the assessment of health in other populations living in continuous war conditions.
This is the first in a Series of five papers on health in the occupied Palestinian territory
“The conditions in which people live and work can help to create or destroy their health”.
Commission on Social Determinants of Health1
WHO's Commission on Social Determinants of Health2 has drawn attention to the effects on health of low income, inadequate housing, unsafe workplaces, and lack of access to health facilities. Conflict is an additional hazard to health, not only because it causes injury, death, and disability, but also because it increases physical displacement, discrimination and marginalisation, and prevents access to health services. Constant exposure to life-threatening situations in a conflict setting is an additional, specific social determinant of health, which can lead to disease.3, 4
This is the first of five reports about the health status and health services in the Israeli-occupied Palestinian territory—the West Bank (including Palestinian Arab East Jerusalem) and the Gaza Strip. We emphasise the complexity of factors that contribute to Palestinian health and health-system problems: ongoing colonisation—ie, continued land confiscation and the building of Israeli settlements on Palestinian land; fragmentation of communities and land; acute and constant insecurities; routine violations of human rights; poor governance and mismanagement in the Palestinian National Authority; and dependence on international aid for resources. These and other factors have distorted and fragmented the Palestinian health system and adversely affected population health.
Here, we describe the demographic characteristics and the health status of the Palestinian population living in the occupied Palestinian territory. We have used not only conventional indicators, such as infant mortality, but also subjective measures based on people's experiences and perceptions of their health status and quality of life. We draw on the human-security framework to analyse and understand the effects on health and wellbeing of the sociopolitical conditions in the occupied Palestinian territory.
First developed by the UN development programme (UNDP) for the 1994 human development report, the human-security framework is used to explore multiple threats and new causes of insecurity.5, 6 This framework focuses on people and their protection from social, psychological, political, and economic threats that undermine their wellbeing.7 Also, it emphasises the capability of people to manage daily life, and the importance of social functioning and health. The framework has important implications for health and human development8 because health is a vital core of human security and is susceptible to various threats and insecurities, such as destruction of infrastructure, lack of access to health services, food shortage, job insecurity, and poor quality of health care,9 all in addition to the toll of death, morbidity, and disability caused by war.
We also briefly look at public-health and health-services responses to prevailing health problems, which will be dealt with in detail in the last report of this Series.10 We conclude by considering the implications of our findings for protection and promotion of health of the Palestinian population, and the relevance of the indicators and analytical framework we have adopted for the assessment of health in other situations of constant conflict.
The term Palestinians refers to the people who lived in British Mandate Palestine before 1948, when the state of Israel was established, and their descendants. As documented by several Israeli historians,11 more than three-quarters of the Palestinian population were forcibly dispossessed and expelled between 1947 and 1949, becoming refugees in neighbouring Arab states.12 This traumatic situation—called the nakba (or catastrophe) by Palestinians—is engrained in the collective memory, and is still felt by third-generation refugees, especially those living in refugee camps.13 Since then, Palestinian identity has been reinforced through resistance to dispossession and extinction.14
Palestinians identify themselves as Arabs because of the common language and culture with other Arab nationalities, but maintain their distinctive identity as Palestinians.15 Most Palestinians are Muslim (94%), about 6% are Christian, and only a few are Jewish.16 At present, about 4·5 million Palestinians are refugees from the 1948 Arab—Israeli war and their descendants are registered by the UN Relief and Works Agency for Palestine Refugees in the Near East. Almost a third of Palestinian refugees still live in camps inside and outside the occupied Palestinian territory,17 although these camps are now urban settlements, not tents.
The occupied Palestinian territory is the term used by the UN for those parts of Palestine occupied by Israel after the Arab—Israeli war of 1967 (panel).18 It consists of the West Bank, including East Jerusalem (figure 1), and the Gaza Strip, and has a population of 3·77 million, 1·8 million of whom are registered refugees.
A brief history of the occupied Palestinian territory
The Balfour Declaration stated that the British Government favours the establishment of a home for the Jewish people in Palestine, emphasising that nothing should be done to undermine the civil and religious rights of non-Jewish communities in Palestine.
British Mandate of Palestine.
First Arab—Israeli war. Creation of Israel on most of British Mandate of Palestine, with two-thirds of Palestinians forcibly dispossessed and dispersed, and made into refugees in neighbouring Arab countries.
West Bank annexed by the Hashemite Kingdom of Jordan. Gaza Strip came under Egyptian military administration.
Arab—Israeli war. Israel occupied the rest of Palestine (the West Bank, including Palestinian Arab East Jerusalem, and the Gaza Strip) and parts of Syria.
First Palestinian popular uprising (intifada) against Israeli military occupation.
The signing of the Declaration of Principles on Interim Self-Government Arrangements (the Oslo Accords), and handing over of selected spheres of administration, including health care, to an interim Palestinian National Authority. This authority was intended to govern parts of the West Bank and Gaza Strip during a transitional period when negotiations of a final peace treaty would be completed.
Interim political solution exploded with the second Palestinian uprising, fuelled by widespread discontent with the failure of the Oslo Accords to address accelerating Israeli confiscation and colonisation of Palestinian lands in defiance of international law, and by the shortcomings of the Palestinian National Authority.
Israel's military incursions of the West Bank, and the ransacking of several Palestinian ministries and institutions, including the Palestinian Central Bureau of Statistics, the Palestinian Ministry of Education and Higher Education, various other research and cultural institutions, and radio and television stations.
Israel withdrew its settlements from the Gaza Strip in August, 2005, but continued to retain control over access to the Gaza Strip by land, sea, and air.
Democratic election of Islamic Hamas to majority in the Palestinian National Authority. Israel and key western states responded by boycotting its administration.
Diplomatic ties and international donor funding were cut, and Israel withheld Palestinian tax revenues, which together form about 75% of the budget of the Palestinian National Authority.
Israeli military closure policies intensified, and fragmentation continued to be reinforced. By February, 2008, and after the Annapolis summit, the closure system was tightened even further and included over 600 checkpoints and barriers erected by the Israeli military on roads to restrict Palestinian movement, compared with about 518 such barriers to movement in 2006.
November, 2008 to January, 2009
The truce with Hamas is broken (Nov 4, 2008). Israel invades Gaza Strip (Dec 27, 2008). Destruction of infrastructure and buildings, including homes, universities, schools, clinics, mosques, and welfare organisations. Hundreds of civilians are killed and thousands injured, intensifying Gaza's humanitarian crisis.
Figure 1 Full-size image (90K)
Governorates in the occupied Palestinian territory
In 1991, a peace conference on the Middle East was convened in Madrid between Israel and Palestinians and Arab states. Several subsequent negotiations led to mutual recognition between Israel and the Palestine Liberation Organisation and, in 1993, the Declaration of Principles on Interim Self-Government Arrangements,19 otherwise known as the Oslo Accords.
The Oslo Accords aimed to achieve a resolution to the conflict and established the Palestinian National Authority for a transitional period, during which negotiation of a final peace treaty would be completed.20 On the basis of these accords, the authority assumed control over some, but not all, areas of the West Bank and Gaza Strip. The agreement divided the occupied Palestinian territory into three zones. The Palestinian National Authority assumed control of all civilian administration, including health, and became responsible for security in zone A, which includes the main urban areas of the West Bank, but only about 3% of the land. The Palestinian National Authority has civilian authority, but shares security responsibility with Israel in zone B, which includes about 450 Palestinian towns and villages, and covers about 27% of the West Bank. The authority has no control over the remaining 70% of the occupied Palestinian territory, zone C, which includes agricultural land, the Jordan valley, natural reserves and areas with low population density, and Israeli settlements and military areas.21 Fundamental issues, such as the status of East Jerusalem, refugees and the right of return or compensation, Israeli settlements, security arrangements, and borders were left for later negotiations.22
The Palestinian National Authority did not have, and still does not have, sovereignty over borders, movement of people and goods, and control over land and water.23 Over time, the authority became troubled by other shortcomings, including corruption, absence of collective decision making and integrated planning, and the appointment of excessive numbers of civil servants as reward for the so called revolutionary heroism, political support, or both, causing a major drain on the national budget.24
By September, 2000, the Palestinian National Authority collapsed with the second Palestinian uprising (intifada). The uprising was fuelled by widespread discontent, on the one hand for the shortcomings of the authority, and on the other for the acceleration of Israeli confiscation and colonisation of Palestinian lands in defiance of international laws.25 These developments undermined an already fragile system of public services, including health services.
Since 2000, life for Palestinians has become much harder, more dangerous, and less secure. Under the justification of protecting Israelis from Palestinian violence, a massive wall is being constructed between Israel and the West Bank, incorporating areas of the West Bank into Israel, and hundreds of Israeli military checkpoints have been established accompanied by curfews, invasions, detentions, the use of lethal force against civilians, land confiscations, and house demolitions, all of which have made ordinary life almost impossible. These events entail the systematic collective punishment of the Palestinian population living in the occupied Palestinian territory. According to the Israeli human-rights organisation B'tselem, almost 5000 Palestinians—mainly civilians, including more than 900 children—have been killed by Israeli military action between September, 2000, and June, 2008, and over 1000 Israeli civilians and military personnel have been killed by Palestinians,26 mainly in suicide attacks. Many people were seriously wounded and disabled.27, 28 During the preparation of this report, almost 1400 Palestinians living in the Gaza Strip were killed, and thousands injured, with many civilians among the casualties. The high burden of injury and trauma on individuals, health services, and society is discussed more fully by Batniji and colleagues29 in this Series.
Evidence exists of severe damage to infrastructure and institutions, homes, schools, private businesses, cultural heritage sites, and the Palestinian National Authority ministry buildings, equipment, and data-storage facilities, especially during the Israeli invasions of West Bank towns in 2002. The UN, the World Bank, and the Government of Norway have estimated the loss, due to infrastructural and physical damage during the March to April Israeli military invasions of 2002, at about US$361 million.30 Israeli invasions have also caused widespread food and cash shortages, psychological distress, and serious interruption of basic services, including crucial health services.31
Since 2002, the construction of the separation wall has continued, in defiance of the international commission of jurists' decision that the wall constitutes a serious violation of international human-rights law and international humanitarian law.32 The Israeli high court of justice has repeatedly ruled that the route of the wall should be dictated by security considerations and not by Israeli settlement expansion plans.33 The construction of this wall has meant the confiscation of thousands of hectares of fertile Palestinian agricultural land, restrictions on freedom of movement, division of communities, and worsening economic conditions. In 2006, although still not defining the state's borders, Israel announced that the route of the separation wall followed official aspirations for a new border.34 This means that Israel will have annexed about 10% of the West Bank, including Palestinian farmland and key water sources, and incorporated most Israeli settlements. Israeli military closures and their effects on the movement of goods and people have become increasingly severe in the occupied Palestinian territory, causing an economic crisis (with the gross domestic product per person in 2007 falling to 60% of its value in 1999):35 rising unemployment and a serious decline in living standards,36 all of which are associated with negative health outcomes.37, 38 The Israeli military closures restrict Palestinian access to basic services, such as health and education, and separate communities from their land and places of work. In the West Bank, the physical separation has been tightened even further; by June, 2008, over 600 checkpoints and barriers to movement had been erected by the Israeli military on roads to restrict Palestinian movement, compared with an average of 518 in 2006.39
The failure to reach a permanent peace agreement and the continuing expropriation of land for settlements and roads, which has continued unabated since 1967, the failure to establish an independent Palestinian state, and the disillusionment of the population with the Palestinian National Authority could explain the unexpected majority of parliament seats achieved by Hamas (the Islamic resistance movement) in elections for the Palestinian legislative council in January, 2006. Despite the overwhelming electoral support for Hamas, Israel and key western countries responded by boycotting and isolating the newly elected administration because of Hamas' refusal to meet three criteria: recognition of Israel's right to exist, renunciation of violence, and adherence to interim peace agreements with Israel.40 Diplomatic ties and international donor funding were cut, and Israel withheld Palestinian tax revenues, which together form about 75% of the budget of the Palestinian National Authority.41
The withholding of taxes and international aid created a severe political and financial crisis, with the Palestinian National Authority unable to pay the salaries of 165 000 civil servants. This situation led to intermittent strikes by civil servants, including health personnel; worsening service provision; severe shortages of medication and equipment; and a health-system crisis.42 Poverty and dependence on food aid increased. The World Food Programme indicated sharply reduced access to food, with evidence that a third of Palestinian households were food insecure and highly dependent on assistance.36 The consequences of this situation were institutional decline, degraded governance, economic crisis, breakdown of social networks, and growing internal violence.
In February, 2007, a national unity government was formed with representatives from the two main Palestinian parties: Fatah (the Palestinian national liberation movement) and Hamas.43 But the national unity government was not accepted by Israel, most European countries, and North America, and soon collapsed.44 An emergency government was established, and Israel and the international community finally ended the boycott of the Palestinian Authority. However, factional clashes continued and in June, 2007, Hamas took control of the Gaza Strip.45 Israel had withdrawn its settlements from the Gaza Strip in August, 2005, but retained control over access to the Gaza Strip by land, sea, and air. A separation wall or fence surrounds Gaza and, since the takeover by Hamas, Israel has maintained a strict siege, with people and goods allowed in or out only for essential humanitarian purposes.41, 44 Incursions by the Israeli military continued until a limited truce was agreed in June, 2008. The truce was broken on Nov 4, 2008.
The effects of the siege on economic and social conditions in Gaza have been devastating. There is a great shortage of fuel and cooking gas, and power cuts are frequent. Economic activity has almost completely ceased. Unemployment was around 33% of the active workforce in 2007, and rose to 37% in 2008. The percentage of Gazans who live in deep poverty has been steadily increasing, rising from nearly 22% in 1998 to nearly 35% in 2006. With the continued economic decline and the implementation of even stricter closures on Gaza, the poverty rate in 2008 is expected to be higher than it was in 2006. Food insecurity has continued to rise reaching 56% in 2008. 60% of households regard emergency assistance as a secondary source of income, with increased numbers of families relying on assistance, making present coverage by main assistance providers insufficient.35, 46 The Israeli military invasions in December, 2008, to January, 2009, of the Gaza Strip severely intensified this pre-existing humanitarian crisis.
Health of Palestinians in the occupied Palestinian territory
Table 1 shows data for the 3·77 million Palestinians living in the occupied Palestinian territory, including comparisons with neighbouring countries. 46% of the population younger than 15 years of age, an indication of the high fertility rate and falling infant mortality. The fertility rate was very high during the 1960s until the early 1990s, then declined. Since 2000, fertility has remained stable at about five children per woman (figure 2). Infant mortality rates fell until the mid-1990s (figure 3), contributing to the high proportion of children in the population.74 Health of children and data quality are discussed in more detail by Abdul Rahim and colleagues74 in this Series.
Table 1Table image
Demographic and socioeconomic characteristics of the population living in the occupied Palestinian territory and neighbouring countries47—65
Figure 2 Full-size image (53K)
Palestinian total fertility rate and trends between 1968 and 2003
Data are from Khawaja,66 the Palestinian Central Bureau of Statistics,49, 50, 67 and other sources.
Figure 3 Full-size image (49K)
Number of infant deaths per 1000 livebirths between 1945 and 200549,50,67—73
IMOH=Israeli Ministry of Health. UNRWA=UN Relief and Works Agency.
Palestinians are undergoing a rapid epidemiological transition.75 Non-communicable diseases, such as cardiovascular diseases, hypertension, diabetes, and cancer, have overtaken communicable diseases as the main causes of morbidity and mortality. The prevalence of HIV/AIDS is very low, and the population is deemed free of poliomyelitis, as judged by WHO criteria. Communicable diseases of childhood have already been mostly controlled with effective immunisation programmes.76
Standards of health, literacy, and education are generally higher in the occupied Palestinian territory than in several Arab countries, but substantially lower than in Israel (table 1). By contrast with the decline between 1967 and 1987, infant mortality stalled at around 27 per 1000 during 2000—06, the same as that reported in the 1990s (figure 3), which suggests a slowdown of health improvements, a possible increase in health disparities,77 or an indication of deteriorating conditions.78
The rate of stunting in children younger than 5 years (defined as height for age >2 SDs below the median of the US National Center for Health Statistics and WHO Child Growth Standards79) has risen from 7·2% in 199680 to 10·2% in 2006.81 Stunting during childhood is an indicator of chronic malnutrition, and is associated with increased disease burden and death,82 including compromised cognitive development and educational performance,83, 84 and obesity and chronic diseases in adulthood.85
The incidence of pulmonary tuberculosis increased in the Gaza Strip from 0·83 per 100 000 in 1999 to 1·31 per 100 000 in 2003. The incidence of meningococcal meningitis also rose in the West Bank and Gaza Strip from 3·0 per 100 000 in 1999 to 4·6 per 100 000 in 2003, and that of mental disorders rose by about a third, from 32·0 per 100 000 in 2000 to 42·6 per 100 000 in 2003.86 Data for mental disorders are obtained from yearly health reports, which consistently indicate increases in the frequency of most diseases.87 However, whether these data show real changes, including those due to the violence and social damage of Israeli occupation, or due to better information-gathering methods and coverage, is unclear. Furthermore, such data do not distinguish between mild and severe disorders.
To assess the quality of life in Palestinians living in the occupied Palestinian territory, the WHO quality of life-Bref88 was used in a 2005 survey, containing a representative sample of adults from the general population, after addition of some questions relevant to the Palestinian context.89 Life quality in the occupied Palestinian territory proved lower than that in almost all other countries included in the WHO study (table 2). Furthermore, the study showed that most responders had high levels of fear; threats to personal safety, safety of their families, and their ability to support their families; loss of incomes, homes, and land; and fear about their future and the future of their families (table 3).
Table 2Table image
Quality of life scores in the occupied Palestinian territory and selected other countries
Table 3Table image
Insecurities and threats in a random sample of the population of the occupied Palestinian territory
Feelings in the population include hamm—a local Arabic term that combines different feelings, such as the heaviness of worry, anxiety, grief, sorrow, and distress—frustration, incapacitation, and anger. Feelings of deprivation and suffering were also high. Most people reported being negatively affected by constant conflict and military occupation, closures and siege (including the separation wall), and inter-Palestinian violence.
In a study based on 3415 adolescents of the Ramallah district,91 Palestinian students reported the lowest life-satisfaction scores compared with 35 other countries (figure 4). Collective exposure to violence was associated with negative mental health. After adjustment for sex, residence, and other measures of exposure to violent events, exposure to humiliation was also significantly associated with increased subjective health complaints. Such subjective data should be interpreted with caution because subjective measures can be complicated by people understanding and responding to questions in different ways.92 However, self-rating of health measures offer “something more—and something less—than objective medical ratings”,93 especially because of the incomplete understanding of what true health is.