Country profiles

The Palestinian Population

Overview

The political and demographic situation is changing rapidly as a result of the Oslo Accord of 1993.

The Palestinian population was 3.2 million in 1995. As of June 1992, the United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA) was caring for approximately 2.6 million registered refugees; of these, more than one-third live in camps, while the rest live in cities, towns, or communities. The registered refugee population is distributed in the "fields of operation", as follows: Lebanon 319 000; Syrian Arab Republic 299 000; Jordan 1 011 000; West Bank 459 000; and Gaza Strip 560 000.

Forceful deportation of Palestinians by the Israeli authorities and the organized massive immigration of Jewish settlers from the former Soviet Union have raised the percentage of new settlers in the West Bank and Gaza Strip to 15% of the population. Until recently, the population of the West Bank and Gaza Strip was predominantly Palestinian. The population density in these two areas is now 497 per km² and 3139 per km², respectively. In 1996, the population below 15 years of age and above 65 years of age was 51% and 1.9%, respectively. Additionally, in 1995, the total adult literacy rate and the female adult literacy rate were estimated at 84% and 77%, respectively. UNRWA estimates the infant mortality rate at 30 to 40 per 1000 live births in a given year among registered refugees, but, in 1995, the infant mortality rate was estimated at 25 per 1000 live births and the under-5 mortality rate was calculated to be 28.1 per 1000 live births. The maternal mortality rate, in 1996, was estimated at 2.5 per 10 000 live births. Additionally, in the same year, the crude birth rate was 44.4 per 1000 population. In 1995, the total life expectancy at birth was found to be 71.3 years. Respiratory diseases are still the leading causes of morbidity and mortality among children and infants. It is estimated that 25% of infant deaths are due to diseases of the respiratory system. Moreover, as a result of the deplorable sanitary conditions in many camps, 12% of infant deaths and 20% of child mortality are due to acute diarrhoea. According to UNRWA statistics, about 26% of infant deaths result from low birth weight or prematurity, while 15% result from congenital malformations.

The intifada (uprising of the Palestinian people against Israeli occupation and oppression) started in December 1987. Continuous incidents of violence and rage have occurred in the occupied territories, causing a great deal of suffering and worsening economic conditions for both refugee and non-refugee populations. Coupled with an increased level of tension and unrest, economic hardship has reached an unprecedented level due to the adverse effects of the Gulf crisis, loss of employment opportunities due to mass immigration of Soviet Jews, restrictions on movement of the population and extended curfews. Per capita gross domestic product declined by half between the beginning of the intifada and July 1990, while the unemployment (and underemployment) rate is estimated to be 30%-40% in the Gaza Strip and in the inner parts of the West Bank.

Because of the dispersal of the Palestinian people across different areas and as a result of the lack of a unified political authority, there are no unified health policy and strategy; rather, the various bodies providing services have their own characteristics. In addition to the public health services available in the countries of residence and those provided by charitable and voluntary organizations, the main providers of health care for the Palestinian population are the Palestinian Red Crescent Society and other Palestinian nongovernmental organizations and UNRWA.

UNRWA’s policy is to provide essential health services to eligible Palestinian refugees, consistent with the humanitarian policies of the United Nations and the basic principles and concepts of the World Health Organization.

UNRWA’s health care programme, which is basically community-health oriented, provides primary health care to the eligible refugee population, including medical care services (both preventive and curative), environmental health services in the camps, and nutrition and supplementary feeding for vulnerable population groups The level of service corresponds the varying needs of the refugees which, in turn, depend upon their living conditions. Camp residents use UNRWA facilities because of ease of access. Many refugees residing outside the camps also use UNRWA health centres, especially for preventive services. Other refugees, living in towns or remote villages situated at a distance from the nearest UNRWA health centre, tend to use local community facilities whether private, voluntary or public health.

UNRWA’s health system is based on three levels. At the primary level, outpatient services are provided through UNRWA’s facilities-general and special care clinics, laboratories and dental clinics, which are integrated at health centre level. The approach is in line with that of primary health care where protective/promotive services are combined with curative medical services and are supplemented by activities to ensure proper nutrition and improved environmental health in the refugee camps.

At the secondary level, referral and support services comprise inpatient care at subsidized hospitals, as well as specialist and rehabilitative care and other basic support services through contractual arrangements or individual patient subsidies. At this level, UNRWA also provides partial subsidy towards the cost of prosthetic devices required to improve the capacity of disabled persons. There is a small UNRWA-operated cottage hospital in Qalqilia, West Bank, inherited from the Red Cross in 1950, which has lately been extended with the addition of an operating theatre and is in the course of being upgraded.

At the tertiary level, UNRWA provides partial individual patient subsidies for emergency life-saving treatment at the specialized health institutions available in the area of operations, provided this does not involve long-term commitment.

The Palestinian Red Crescent Society, established in 1986, has adopted the principles of primary health care. Accordingly, in 1990 the Society formulated a national health plan for the Palestinian population, in coordination with responsible officials in health centres inside the occupied territories as well as with other Palestinian health institutions beyond their borders.

This plan is based on the following:

development of:

• infrastructure and management of the various Palestinian health institutions

• primary health care facilities through the expansion of existing ones, as well as training of required human resources and purchase of necessary equipment

• a mental health programme

• rehabilitation centres

• a health human resources plan

• a drug policy (together with preparation of a list of essential drugs)

• construction and administrative organization of hospitals

• encouraging international societies as well as local organizations to be more involved in health matters.

The Palestinian Red Crescent Society channels its services through 200 health centres providing primary health care facilities and 15 maternal and child health care centres. Secondary and tertiary health care facilities are made available through a series of hospitals located in places with large Palestinian population densities.

However, according to a special committee of experts that reported to the World Health Assembly in 1989, the health situation of the Palestinian population has remained disturbing, despite the praiseworthy efforts made by the health workers concerned. The Committee found that this situation was largely associated with the lack of a structured health system designed to provide appropriate primary, secondary and tertiary care. This, in turn, is largely due to the fact that the health system is not specific to the territories, nor is it independent, but is regarded as an extension of the Israeli system. This dependency is at the root of the non-existence of long-term health planning, which can be undertaken only within the framework of an economic and social development plan, and in the present situation, this can only be the Israeli plan.

Since the start of the intifada, many people’s committees have been formed in villages, towns and refugee camps to help the implementation of health programmes. These committees are concerned with health and social, emergency and ambulatory services. Furthermore, syndicates, unions, religious groups and charitable and voluntary organizations contribute to the implementation of health programmes such as those for safe drinking water, sanitation, environmental health, health education, immunization and maternal and child health activities and campaigns. In addition, intifada committees have played a vital role in combating drug trafficking and addiction and in distribution of food rations during curfew periods.

The per capita UNRWA health expenditure in 1991 was US$ 20 per registered refugee. UNRWA runs 118 health centres, 61 dental clinics, 62 laboratories, 38 specialist clinics and 204 special care clinics (for diabetes and hypertension). The total number of health staff employed by the Agency in 1992 was 3180; of these, 215 were physicians, 51 dentists and 683 nurses.

The Palestinian Red Crescent Society runs 16 hospitals (with a total of 1500 beds), 45 field hospitals, 200 clinics, 15 maternal and child health centres, 20 dental clinics, 10 rehabilitation centres, 3 nursing schools, 15 blood banks and 28 laboratories. Health staff associated with the Palestinian Red Crescent, at present, number 364 physicians, 41 dentists and 280 nurses, in addition to 405 health technicians serving the Palestinian population outside the occupied territories.

A growing number of behavioural disorders have been observed, especially among young people, who account for 69% of those wounded during civil disobedience. Moreover, the present situation is expected to produce disturbances harmful to the psychosocial and behavioural development of the population, especially children.

According to the data received by the expert committee concerning an evaluation of the quantity and quality of services conducted in 1987 in 17 public and private hospitals in the West Bank, the following services suffer from lack of coverage to the extent indicated below: 100% for morbid anatomy, 94% for physiotherapy, 82% for psychotherapy and dialysis and 58% for stomatology.

For an improvement in the health status of the Palestinian population, a long-term political settlement to the problem of Palestine is essential. The confiscation of land, the difficulties of access to drinking water and water for irrigation, the establishment of settlements, the application of collective sanctions, the demolition of houses, the insistence on compulsory identification before an injured person can be cared for, and the use of various weapons, including gas, against the population, are all stress-producing and repressive measures which are certainly not conducive to good health.

MENTAL HEALTH

Concern over the mental health of Palestinian refugees extends back many years. However, it is striking to note that, against a background of very good health services development, the mental health component has received very little formal attention. Until 1990, there were no formal mental health services in the health centres in the camps. Cases suspected or diagnosed of serious mental illness were referred to either government or private psychiatrists and/or mental hospitals. The health staff had very little knowledge of mental health problems in the community and had hardly any expertise to recognize and deal with these problems.

Interestingly, there was an appreciation of children’s psychosocial and behaviour problems among schoolteachers. There was also concern about children with scholastic backwardness and children who suffered from family problems. In some schools, there were counsellors, but they were not very effective as many of them had had very little training. In addition, they had insufficient time to carry out any counselling with problem children, as they had to also carry out the same amount of teaching work as other, non-counsellor, teachers did.

Epidemiological data on mental illness among the UNRWA population is not available. However, reports by psychiatrists working in some of the field areas, reports of brief visits by child mental health consultants and results of an exploratory study confirm that there is a high frequency of mental health problems in the refugee population. The Director of Mental Health Services, Gaza, reported in 1989 that there was a high incidence of hysteria, anxiety, depression and psychosocial problems presenting with somatic complaints. Discussing the increasing incidence of mental health problems, the report says that

… scattered throughout the world, the Palestinians do not feel at home anywhere. They are unwanted everywhere and are regarded as a source of potential trouble. Their anger and fear are turned into aggression. Daily life is a continuous story of fighting. Violent demonstrations are common occurrences in the life of Gaza and the West Bank. Cases of anxiety, depression and psychotic reactions are frequently seen following confrontations. Children’s problems like outbursts of temper and aggressive behaviour, sleep disturbances and anxiety are also on the increase.

In 1989 UNRWA in collaboration with Rädda Barnen (Save the Children, Sweden) carried out a research study of psychosocial problems in children (health centre interviews, home interviews and child observation) in Jabal al Hussein and Marka refugee camps in Amman, Jordan, which also confirmed the high frequency of psychosocial disturbances among the children. These disturbances were noted to be partly due to lack of stimulation.

The Relief Services Division of UNRWA assists in identifying and managing children suffering from disabilities and mental retardation. With active cooperation of the local community and voluntary organizations, UNRWA has started day care centres for the disabled in Suf, Jarash, Husn Waqqas and Baqa’a camps in Jordan (community centres for disabled children). These centres are administered jointly by UNRWA and nongovernmental organizations such as OXFAM, the Mennonite Central Committee, the Norwegian Refugee Council and DAIKONE, which meet the recurrent costs. The local communities make major contributions in the form of material and volunteer help. These centres play an important role in the camp communities in helping to identify handicapped children, desensitizing the community of the stigma of mental handicap and eventual participation in the care of the mentally handicapped.

The WHO Regional Adviser on Mental Health for the Eastern Mediterranean Region, visited the Jordan field area of UNRWA in 1987 and reviewed mental health problems in light of earlier reviews and consultations. The Regional Adviser arranged for the attendance of UNRWA representatives at an intercountry workshop on training in mental health in primary health care, held in Islamabad, Pakistan, in 1987 and an intercountry meeting on the progress of the national programmes of mental health, held at Isfahan, Islamic Republic of Iran, in 1989. He recommended that a mental health component be introduced into the UNRWA health programme and towards this, a comprehensive mental health programme be developed and implemented.

Against this background, in June-July 1989, a WHO short-term consultant reviewed the situation and developed a draft mental health programme for UNRWA in 1989.It has the following objectives: to provide essential mental health care, which includes not only treatment and prevention of mental disorders, but also promotion of mental health, for all the refugee population; to enhance the use of mental health knowledge, skills and attitudes in general health care and in social development; to add mental health inputs into education and the school health services for amelioration and prevention of social, behavioural and learning problems among children, and to promote healthy psychosocial development of every refugee child; and to encourage community participation in the development of mental health services and generate self-help in the community.

Strategies and approaches identified were: integration of mental health with existing services; training of personnel; mental health tasks for different categories of personnel; strengthening of the mental health infrastructure and building of a referral system; provision of essential drugs for mental health care; development of an information system; services for special groups such as mentally retarded children, preschool children, schoolchildren; rehabilitation care for drug-dependent persons; and administrative support.

The essential first step envisaged for the mental health programme implementation was the appointment of a core officer/group responsible for mental health at UNRWA headquarters. This core officer/committee would assess priorities in mental health as part of general health and welfare programmes, facilitate provision of know-how for the mental health programme and allocate resources and monitor the programme. Similarly, at the field operations level, a mental health programme coordination committee could be constituted with representation from the curative and preventive medical care, nursing, education and relief services sections of UNRWA and other related sectors. The implementation of the mental health programme in each field area was to be the responsibility of this committee.

A plan of action was outlined in 1989 for the first five years starting from 1990.

The recognition of the mental health needs of the refugee population outlined above has resulted in a number of positive developments.

There were two psychiatric hospitals, in Gaza with 34 beds (started in 1979) and in the West Bank with 320 beds (started in 1960). There are two general hospital psychiatric units at Nablus and Tulkarm with 4 inpatient beds each (established in 1980). There are no private psychiatric hospitals. There is a child mental health clinic and the Gaza Community Mental Health Centre . There are no specialized drug dependence treatment centres. Nongovernmental organizations such as the Swedish International Relief Association run facilities for the mentally retarded.

There are 18 psychiatrists, of whom 15 are in government service and 3 in private practice. There are 40 clinical psychologists-13 in government service and 27 in the private sector. There are 17 trained social workers and 72 trained psychiatric nurses are working in the country. An important development has been the deputation of four medical officers of UNRWA for specially planned mental health training at WHO collaborating centres at Manchester, England, and Bangalore, India. These four medical officers completed their training in 1992 and returned to work with the Palestinian population.

The training of undergraduate medical students consists of 20 hours of lectures, 20 hours of clinical work and posting during internship. Psychiatry is included as an examination topic as part of general medicine practices. There is no mental health specialist training facility in the country. In September 1995, a research methodology workshop on priorities of mental health services was conducted. The priorities identified were: epidemiology of mental health problems in adults and children; drug dependence; early identification of mental health problems; trauma-related disorders; and public attitude towards mental health.