Child health in the context of political and economic exclusion: The Palestinian case

1. Child health in the context of political and economic exclusion: The Palestinian case Mohammed Shaheen Alquds University School of Public Health 9- September 2008 Bratislava-Slovakia mohammed shaheen/alquds university/September 2008

2. The focus of the presentation • The likely impact of Israeli occupation’s political and economic measures of exclusion on the health and well being of Palestinians including Children. mohammed shaheen/alquds university/September 2008

3. The political exclusion and its impact on the health of Palestinian children • Beall & Piron defined Social Exclusion as being excluded from social, political and economic institutions resulting from a complex and dynamic set of processes and relationships that prevent individuals or groups from accessing resources, participating in society and asserting their rights”.(1) (1) Source: (Beall & Piron, 2004). mohammed shaheen/alquds university/September 2008

4. Impact of conflict on human development • At least half of the least developed countries have suffered serious internal conflict over the past 25 years • 8/10 of the worst performers on human development (or GNP per capita) have been at war in the past decade or are currently at war. Causal processes work both ways, • But studies have shown that conflict leads to serious reductions in growth, human development and poverty • Usually countries in conflict get sicker and less able to enjoy healthy life style. Source: (Azam et al., 1999; Stewart and Fitzgerald, 2001). mohammed shaheen/alquds university/September 2008

5. Domination of Land and resourcesThe separation wall as a political and economic exclusion of Palestinians • Completely surround 100,000 people in 42 towns • Reduce the available water supply by 1 billion gallons (52% of water resources is annexed). • Confiscate hundreds of thousands of acres of land • Severely restrict travel to jobs, hospitals and schools • Adversely affect 4 out of 10 Palestinians mohammed shaheen/alquds university/September 2008

6. -Derailing movement weaken economies and weaken ability of people to regain control and political power balance -The number of checkpoints and fixed impediments has risen from 376 in August 2005 to 563 in January 2008; in the 12 months to February 2008, the number of flying checkpoints decreased from 455 to 243. Source: World Health Organization (WHO) Date: 13 May 2008 mohammed shaheen/alquds university/September 2008

7. The 8-meter high, 436-mile long wall is a part of the growing geography of occupation and control. A UN survey of 57 communities said that 60% farming families are cut off from their lands due to a lack of permits- United Nations Report (2007 450,000 settlers in 149 settlements in the West Bank and East Jerusalem Geopolitical separation and fragmentation mohammed shaheen/alquds university/September 2008

8. Huwwara Check point- Nablus West bank Restriction of movement is a measure that ensure economic and social exclusion). -Almost all Palestinians require at one point to cross checkpoints either for work, education, visit family, care of their farms, buy commodities, sell products. receive health services,..etc. -More than 20% of Palestinians in the West Bank need to cross daily the Israeli checkpoints, -30-40 occasionally and almost -40% would not need to cross regularly unless there is a medical emergency or traveling outside. mohammed shaheen/alquds university/September 2008

9. confiscation and control of land • Israel has expropriated agricultural land and keywater resources in the Palestinian West Bank for itsown use. • Control most of Palestinian water sources (85%) • More than 38% of the territory now consists0f Israeli settlements, outposts, military bases andclosed military areas, highways linkingsettlements to Israel, • Source: Mona Elfarra. Occupation: the siege and health in Palestine Wednesday, March 26, 2008, mohammed shaheen/alquds university/September 2008

10. Selected indicators • Israel controls almost all borders with Palestinians, and used security claim to strangulate the local economy. • Israel through its policies and the fragmentation of the land and continuous closures promoted further dependence of Palestinians on its economy and trade policies where almost 2 billion dollars of imports annually come from Israel, which is almost half of Palestinian GDP. mohammed shaheen/alquds university/September 2008

11. International Aid: policy of marginalization • Aid also helped in arresting a political settlement in the region. Palestinians receive more assistance per capita (Approx $300), than any other people on Earth, and live in one of its most violent spaces. • Source:Daniel Hannan.EU aid to Palestine is funding the conflict Friday, August 22, 2008. Telegraph Blogs.Co.UK mohammed shaheen/alquds university/September 2008

12. Violation of basic Human including Child Rights (CRC)- a strong form of exclusion • Child rights in Palestine is seen by Palestinians as part and parcel of the essential human rights and any attempt to separate them is seen as giving lip service to them. • Article 12 of the Human Rights Covenant on social rights recognizes the right of everyone to "the enjoyment of the highest attainable standard of physical and mental health. • Land Confiscation and Settlements – Israel occupies the entire surface of the West Bank (some 5,860 km2) and has confiscated or de facto annexed more 3,350 km2 source: BADIL Resource Centre, Survey of Palestinian Refugees and Internally Displaced Persons 2006-2007 (2007) ( • As a result of the land confiscation and demolitions more than 115,000 people are estimated to have been internally displaced during the last four decades of Israel's occupation in the 1967 Palestinian territories source: BADIL Resource Centre, Survey of Palestinian Refugees and Internally Displaced Persons 2006-2007 (2007) • CRC recognizes the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health, and that no child is deprived of his or her right of access to such health care services (1). Source: Convention on the Rights of the Child –General assembly resolution November, 1989 mohammed shaheen/alquds university/September 2008

13. Violation of Human and Child health rights-continued • In article 6, it is stated that a child has the right to life. Governments or occupying powers should "ensure that children survive and develop healthily". • Article 19 states that governments should "ensure that children are properly cared for, and protect them from violence, abuse and neglect by their parents or anyone else who looks after them". • Further to this is article 27, which says that a child has a "right to a standard of living that is good enough to meet its physical and mental needs". The government should help families who cannot afford to provide this. • Finally, article 38 concerns the right to receive "special protection" in war zones. • Source:The Wall and the psychological impact on children Adri Nieuwhof, The Electronic Intifada, 24 October 2005 mohammed shaheen/alquds university/September 2008

14. Impact of Political and economic exclusion of Palestinians: Excessive burden • Prolonged military occupation and conflict have Prevented Palestinians to exercise the right of self determination and thus inability to control own resources. This led to unprecedented poverty and exclusion of large segment of the Palestinian society. • Foreign Aid although focused on humanitarian assistance, helped to save lives and support survival of the the PA. However, Aid is used also as a political tool to influence political and social policies that lead to increase dependency on outside resources and maintain status quo of weak political control and weak economy. Aid in many way (directly or indirectly) helped to subsidize occupation and prolong the conflict. • Consistent violation of Human rights including child rights by Israeli occupation including local Palestinian national institutions resulted in the decline of quality of life, poor health and psychosocial conditions of Palestinians and their children. • Fragmentation and confiscation of the land, settlements, checkpoints, separation wall, control of borders, control over water and continuous destruction of the infrastructure aggravated environmental and health condition, access to services, nutritional status, mental conditions and compromised efforts to viable health care system. • Weakened Palestinian ability to build sustainable national systems and policies that address the needs, demands and well being of Palestinians including children. mohammed shaheen/alquds university/September 2008

15. Poverty among children • In 2005, poverty "reached unprecedented levels," the report says, "with around 53 per cent of households (with an average size of six members) living below the national poverty line of $385 per household per month." In 2006, unemployment remained high at 30 percent (1): (1) source: OPT-ISRAEL: Weak Palestinian economy having direct humanitarian impact - UN official IRIN, august 31, 2008 • 2-3 children in each household of poor families bear the brunt of poverty and carry the burden of helping their families. source: A press release issued by the Palestinian Central Bureau of Statistics On the Occasion of “Palestinian Children’s Day” ِ April 5 2008 mohammed shaheen/alquds university/September 2008

16. Child Labor • Children working age 5-17 has almost doubled in 2004 (5.3%) compared to (3.5%) in 2001.(world bank 2004) • In 2005/2006 survey by PCBS, almost half of mothers targeted in WB and GS indicated that they witness violence among their children 5-17 mohammed shaheen/alquds university/September 2008

17. Children Imprisonment • Israel defined Palestinian children those who are below 16 years. • As at the end of July 2007, there were approximately 385 children in Israeli custody . • During the period January 2007 to June 2007, 47.1% of Palestinian children who appeared before the Israeli military courts were sentenced to terms of imprisonment of between 12 months and 3 years or more. • 52.9% of children received sentences of imprisonment of up to 12 months • Source: Palestinian Child Political Prisoners: Semi Annual Report 2007Defence for Children International, September 06, 2007 mohammed shaheen/alquds university/September 2008

18. Child fatalities caused by political violence • the seven years between September, 2000 and August, 2007, the Israeli defense forces killed 4233 Palestinians and Israeli civilians killed an additional 41.  • Even more to the point for people who wish to base their political arguments on the lives of children: during those same years, 857 Palestinian children were killed by Israelis. Source: What's Missing from the New York Times the Deaths of Children By EVE SPANGLER, July 2008 mohammed shaheen/alquds university/September 2008

19. Children Fatalities-continued From September 29 year 2000, in the eruption of the second Palestinian Intifada, through March 16 2008, • At least 1.015 Palestinian children and youths, under the age of 18, were killed by the Israeli army. • More than thousand Palestinian children have been injured, many children have lost their limbs and other body parts. Source: Hiyam Noir, PalestineFreeVoice; March 2008 mohammed shaheen/alquds university/September 2008

20. Would Infant mortality Tell Us about the Well being of Children • The infant mortality rate is 25.3 per 1000 live births, higher in the Gaza Strip than the West Bank (28.8 and 22.9 per 1000 live births, respectively). • The same trend applies to the child mortality rate (28.2 per 1000 live births: 31.8 in the Gaza Strip and 25.8 in the West Bank). mohammed shaheen/alquds university/September 2008

21. Deterioration of environmental health conditions • The number of households with safe drinking water dropped by more than 8% between 2000 and 2007. 1.4 million people currently without access to safe drinking water in Gaza and the West Bank (UNICEF 2007) • Average per capita consumption of water among Palestinians falls well below WHO standards of 100 litres per day and Israel monopolizes 85% of the water from the mountain aquifer which lies beneath the West Bank. • Most Palestinian children live with far less than the recommended daily minimum amount of 20 liters of clean water. In Gaza, it is hard to obtain because salinity and sewage have seeped into the coastal aquifer. • Most Palestinian children suffer from contaminated water causing diarrhea diseases, hepatitis B, Anemia and malnutrition especially worse in gaza. Source: World Health Organization (WHO) Date: 13 May 2008 mohammed shaheen/alquds university/September 2008

22. Poverty and Malnutrition • As of November 2006, 40.2% of Palestinian households lived in “deep poverty” (daily per capita consumption of less than $2.10); in Gaza the figure is 79.8%. The first half of 2006 saw a 38.3% increase in the number of Palestinian households in deep poverty. • In 2004 the World Bank estimated that per capita food consumption declined some 25% in real terms compared to 1999. The decline in food consumption continued, with a further decline of 8% in the first half of 2006 alone. • According to UNICEF, “one in ten children is stunted, one in two is anemic, and 75 per cent of children under the age of five suffer from vitamin A deficiency and low birth weight rates are as high as 8.2%. mohammed shaheen/alquds university/September 2008

23. Food security • Food insecurity on the rise - 49% of the population (refugee and non-refugee) are estimated to be food insecure in 2006 (an increase of 13% since 2005). • More than 50% of children are dependent on food aid and thus malnutrition can go up and down linked to the political desire of donors. United Nations Report (2007) mohammed shaheen/alquds university/September 2008

24. In a study conducted by AlQuds University (2004), found that Calorie intake by Palestinian children is one third below the Recommended intake of 1800 per day mohammed shaheen/alquds university/September 2008

25. Collapsing Health Care System • Continuous shift from development to Emergency due to Israeli occupation and military incursions, economic blockade and the deterioration of the economic conditions. • Double burden phenomenon (infection and chronic diseases) • The emergency services have steadily increased since 2000 with an annual average increase in the last five years of 19.7%. • Frequent strikes by health workers and big shortage of medical supplies due to financial crisis. • Crisis force more allocation to expensive hospital care at the expense of other public health services • Deterioration in the quantity and quality of health services Source: (MoH annual report 2004) mohammed shaheen/alquds university/September 2008

26. Increased demand for limited health services • Demand for health services provided by major nongovernmental organizations increased in 2007 by 20% to 30% compared with 2006, • UNRWA increased by 10% between 2005 and 2006 and by another 20% in the first half of 2007. • Per capita expenditure on health declined from $240 in 2000 to $135 in 2006. • This resulted from the inability of the public health sector to provide the ever rising demand. mohammed shaheen/alquds university/September 2008

27. Gov Health insurance HI dropped from 70% to less than 50% since the eruption of Intifada which has an impact on accessibility, quality and coverage of basic health services of children -70.5% for hospitals and 29.5% for the Primary Health Care). - Out of pocket of patients increased No child specific analysis or reporting. source: (MoH 2005) mohammed shaheen/alquds university/September 2008

28. Mothers and their children bear great burden of accessing health services to obtain needed services. Unfortunately, they would skip necessary visits after delivery which can delay timely intervention for her and her child. ِ around 200,000 are isolated west to the wall and cut off from the surrounding health and medical services. Only 20-25% that have access to postnatal care Access to secondary and tertiary care centers in the West Bank is affected by the restrictions on movement as most hospitals are in cities, including 6 hospitals in east Jerusalem (with 20% of the West Bank hospital beds). More than 40% of their revenues came from patients in the West bank. (exclusion from social welfare) mohammed shaheen/alquds university/September 2008

29. Shortage of Drugs • - • In August, there was less than one month’s stock of 107 drugs (out of 432 essential drugs) at the central level (1). • Most hospitals had ten or more items out of stock. Since September, most hospitals’ wards have been closed due to the PA workers strike (1). • (1) United Nations Report (2007) mohammed shaheen/alquds university/September 2008

30. Mental health • In surveys carried out in 2007, 86% of those interviewed reported sleeping problems, 77% reported deteriorating family relations and 72% reported increased tension among children. Almost 40% of people interviewed felt anxious, irritable and frustrated, and about half feared losing their home or their land and being displaced or uprooted mohammed shaheen/alquds university/September 2008

31. Mental health • 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 unable to provide essential family necessities, • Forty percent have relatives who died during the second intifada began in 2000. • Source: Palestinians: The Crisis in Medical Care ByRichard Horton; Volume 54, Number 4 · March 15, 2007 mohammed shaheen/alquds university/September 2008

32. Mental health • WHO conducted a Quality of Life survey in 2006 which showed that 1 in 4 Palestinians are experiencing anxiety, loss of hope and a sense of being fed up with life. It is very much a “red light” for any country when the community begins to feel this way. mohammed shaheen/alquds university/September 2008

33. Trauma exposure • In a 2004 screening of 2,100 Palestinian students from 50 Palestinian high schools,nearly all (97%) of students reported direct exposure to violence, 73.4% through direct experiencing and 23.3% through direct witnessing. • More than one-third (35.6%) were found to have PTSD and an additional 11.7% were found to have partial PTSD. While PTSD prevalence increased with greater exposure, high levelsof PTSD were found even among youth reporting minimal or no exposure. • Half of the youth reported functional impairment in more than one domain. mohammed shaheen/alquds university/September 2008

34. Conclusions • The health status of children is very much influenced by the political and economic measures imposed by Israel and international community. • Health of Palestinian children is linked to and influenced by the violations of Palestinian rights for self determination and their inability to control their own resources. • Traditional indicators of Health are not adequate to capture the real status of children’s health. • Mode of International aid helped to save lives but prolonged the conflict and it is not linked with promoting and advocating and implementing the Palestinian human and child rights. Aid will continue to be ineffective if political and economic exclusions continue to be imposed by outside forces. • Health care policies, resource distribution and mode of health care delivery are mainly mobilized to address the continuous emergency and crisis imposed by the current political instability and domination. mohammed shaheen/alquds university/September 2008

35. Don’t Exclude US from CRC mohammed shaheen/alquds university/September 2008