Assessment Report Gaza, September 2006
Tim Forster, HSP - Public Health Engineer, Capacity Building Pantaleo Creti, Food and Nutrition Adviser Graham Henderson, Public Health Promotion
(External Version 16 October 2006) Table of Contents Acknowledgements ...... 4 Executive Summary ...... 5 Findings and recommendations: ...... 6 Acronyms ...... 9
1.0. Introduction...... 10 1.1. Map of the Gaza Strip...... 10 1.2. Background Country Information...... 10 1.3. Background and Objectives of the Visit...... 11
2.0 Methodology...... 11 2.1. Health...... 11 2.2. Water and Sanitation ...... 12 2.3. Food Security and Livelihoods...... 12
3.0. Findings...... 13 3.1. Health...... 13 3.1.1. Literature review...... 13 3.1.2. Demographic indicators...... 13 3.1.3. Health Status Indicators ...... 13 3.1.4. Health Services ...... 15 3.1.5. Assessment observations...... 16 3.1.6. Public Health Promotion ...... 17 3.1.7. A Gaza Case Study – The Swedish Village Story ...... 19
3.2 Water and Sanitation...... 20 3.2.1 Access to Safe Drinking Water through CMWU ...... 20 3.2.2. Access to Wastewater Treatment Services through CMWU ...... 22 3.2.3. Water for Drinking, Making Tea and Cooking...... 23 3.2.4 Excreta Disposal in Rural Areas...... 24 3.2.5 Solid Waste Management ...... 25 3.2.6 Water for Agriculture...... 26 3.2.7 Water Quality Surveillance ...... 26
3.3 Food Security and Livelihoods ...... 27 3.3.1 Food Security Context ...... 27 3.3.2 Food availability...... 28 3.3.3 Livelihood groups ...... 32 3.3.4 Changes in food and income sources / coping strategies ...... 36 3.3.5 Nutritional status...... 37
4.0 Conclusions...... 37 4.1 Health ...... 37 4.2 Water and Sanitation...... 38 4.3. Food Security and Livelihoods ...... 38
2
5.0. Bibliography/References ...... 40
Annex I – ToR for the Assessment...... 41 Annex II - Surveillance and Monitoring, WHO Newsletter...... 44 Annex III - Surveillance & Monitoring, Acute Bloody Diarrhoea 51 Annex IV - Surveillance & Monitoring, Acute Watery Diarrhoea 53
3 Acknowledgements The assessment team would like to say a special thanks to Yasser Nasser, Oxfam GB Project Officer in Gaza (OGB), for all his support and assistance during the assessment visit, in particular arranging all the meetings and field visits. A special thanks also to Andy Hill, Programme Manager, OGB Jerusalem, who kept a careful eye on the team’s security and led us into Gaza. Thanks also to Kamal, the friendly “OGB Driver” for Gaza, who made sure we arrived in the right place at the right time and that the table was full at mealtime. Thanks also to Amani Abu-Ramadan and Eleina Qleibo for their support in translating and sharing their knowledge and experience of Gaza. Many thanks to Alyssa Boulares, Humanitarian Programme Co- ordinator in Jerusalem, for writing the ToR and for inviting the team to Gaza. A big thanks to all the OGB team in Jerusalem for all their support during the visit to the oPT. Lastly, a special thanks to all those in Gaza who supported the team with information and advice during the visit, especially the those working at a community level who allowed us access to the humblest neighbourhoods.
COVER: Beit Lahiya Water Treatment Works Under Attack from Israeli Shelling, Aug 2006
4 Executive Summary The occupied Palestinian Territories have a low HDI, and ranks number 102 in the 2005 Human Development Report (UNDP 2005), with 67% of the population living below the monetary poverty line. In 2006, the unemployment is given as 40%, being expected to rise to 47% in 2008. The World Bank estimated that growth per capita in the occupied Palestinian Territories would fall by 27 percent in 2006, while personal income would decline by 30 percent. The economy has been severely affected since the democratic election of the Hamas government. Currently, 1522,000 government employees of the PNA are no longer being regularly paid. Since 26 June, and the start of Israel’s “Summer Rain” operation, an estimated 226 Palestinians have been killed as a result of Israeli military operations. According to official Palestinian sources, 118 of the dead, including 80 women and children, were civilians. An estimated 200 – 250 tank shells are being lobbed daily into the Gaza Strip. Damage to the economy and to infrastructure alone is estimated to be US$ 46 million from 28th June to 27th August 2006. Damage to municipal infrastructure (including bridges, water and wastewater lines and roads) is estimated as US$ 8 million, while damage to agriculture (including olives, citrus orchards, greenhouses, poultry, livestock farms, and water wells) is estimated as US$ 23.5 million. The situation has been particularly exacerbated by substantial damage to the main power station caused by an Israeli air attack. Gaza has a surface area of 375 km2 40% of which is under cultivation. Despite this sizable proportion the total cultivable surface is small. Gaza has developed an intensive, market oriented agriculture sector. The main cash crops - strawberries, flowers, and cherry tomatoes - are cultivated using greenhouses, high inputs, and irrigation. These crops represent the majority of Gaza’s agricultural exportation to international markets. Other crops, including squash, eggplants, potatoes, cucumber, pulses, onions and citrus, are cultivated in open fields and commercialised domestically. The Gaza Strip is a coastal plain located in a semi-arid area. The annual average rainfall varies from 400 mm in the north to about 200 mm in the south. The entire population depends totally upon groundwater. The agriculture consumes around two thirds of groundwater pumped through more than 6,000 wells located over all Gaza Governorates (PWA, 2005). The reminder is used for industrial and domestic water supplies. The quantity and quality of groundwater is deteriorating. The aquifer is continuously over-pumped and the gap between demand and supply is increasing yearly. Groundwater is being contaminated by leakages of cesspits and by residues from fertilizers. The levels of chloride and nitrate in the aquifer are increasing. An estimated two thirds of the population in the Gaza Strip are served by sewage network systems, with the remainder discharging into cesspools, open drains and vaults, especially in the rural areas. The existing 3-wastewater treatment plants, Beit Lahiya, Gaza and Rafah are overloaded and pose serious environmental threats. There is now a master plan, introduced by donor countries, to construct three new WWTP’s in Gaza Strip to replace the existing ones by year 2020. The health status of Palestinians compares well with neighbouring countries in the Middle East. The estimated life expectancy (at birth) of Palestinians living in the occupied Palestinian territories in 2004 was 72.6 years (WHO 2006). The leading cause of death is cardiovascular disease. Infectious diseases accounted for 10.1% of total deaths in 2004 (WHO 2006). Infectious diseases associated with poor living conditions, overcrowding, and poor hygiene - such as viral hepatitis, enteric fevers and intestinal infections - are common (Yassin et al 2001; Ab Mourad 2004; Astal 2004; Issa et al 2005; Kuhail & Tulaib 2005; UNRW 2006). Anaemia continues to be an important concern in Gaza (UNRWA 2006; Halileh and Gordon 2005; PNA 2005). The health care facilities network is well developed in Gaza, with 125 registered Primary Health Care Centres in 2004. In addition, there were 28 maternal and child health clinics, 89 specialised clinics, 44 family planning clinics, and 31 dental clinics (WHO 2006). However, the current crisis in Gaza has put this network under great stress. Whilst there have been no major outbreaks of infectious diseases resulting from the current crisis, WHO health sector surveillance indicators show an upward trend in the prevalence of anaemia and cases of acute watery diarrhoea in children (WHO 2006a). Some evidence indicates an increase in psychosocial problems in the Gaza community. There is a serious risk of major outbreaks of infectious disease and other health problems if the structural violence perpetrated by Israel continues at its current level. Since 2000, the Gaza Strip has been in crisis, with frequent Israeli incursions, shelling and air strikes into the Strip. Much of the water and sanitation infrastructure, particularly in the Northern Governorate (Beit Hanoun, Jabalia, Beit Lahiya), east of Khan Younis and southeast of Rafah, has been destroyed or damaged. On top of this, around 360 agricultural wells (legal and illegal) have been destroyed during the incursions and other military operations.
Findings and recommendations:
Existing government structures in water, sanitation and health in Gaza (CMWU, MoH, MoA, MoE, PWA, SWMC, the municipalities) often have the required human resources and technical expertise but often lack financial or material resources to undertake their activities. The freezing of international donor funds since the election of the Hamas government, has had a major negative impact on the ability of government structures to function. In many cases, employee’s salaries are not being paid, with obvious consequences to morale, living standards, families, and the local economy. There are many local NGO’s in Gaza (for example, UHWC, UAC), and consequently there is good potential to develop positive relationships with these local actors. However, more investigation is required into their efficiency, effectiveness and capacity to function, as it wasn’t possible for our assessment team to get a complete picture due to time limitations. We found strong interest by both the governmental and NGO organisations in Gaza to work cooperatively with OGB in the future. In view of the existing relationships and possible new relationships with both government and the NGO sector, there are several opportunities for expanding the current OGB activities in Gaza, both in urban/peri-urban and rural settings.
The core recommendation of the assessment team is to work in partnership with the existing relevant government structures, and to supplement this with partnerships from the non-government sector. Such structures would benefit from OGB’s community participation approach in undertaking their work at a community level, particularly targeting and working with the poorest sectors.
Key priorities for short to medium-term interventions in public health are: • Rehabilitation and/or extension of existing community water and sewage networks that have been damaged by the Israeli incursions and/or shelling, and related PHP activities around this.
6 • Improvements in wastewater management for poor people in areas with no wastewater collection system, particularly in isolated areas, again with the related PHP activities. • Ensure the poorest families in the target communities have access to health related NFI’s such as, buckets, bowls, hygiene kits, soap, and other items necessary for practicing good hygiene behaviour. • Strong emphasis on PHP activities at Gaza wide level using existing government structures such as schools, NGO’s, mass media; utilising traditional Palestinian cultural activities including theatre, dance, music and story telling. • Monitoring and surveillance of relevant health indicators using epidemiological data and trend analysis in partnership with WHO, to facilitate an evidence-based approach to OGB PHE and PHP interventions. • Providing appropriate support for the monitoring surveillance role of the PH laboratory in Gaza City. • Establishing and strengthening community participation approaches to our PH work in association with our local partners, particularly around consultation with the target communities prior to implementation. • Supporting existing solid waste management strategies in the Gaza strip, particularly in relation to PHP activities. • Rehabilitation of agricultural wells and/or water ponds that have been damaged by the Israeli incursions and/or shelling. • To cooperate with the UNRWA job creation program to provide meaningful public health activities as part of OGB PH interventions. The Health Recommendations are: • Strengthen capacity and increase the level of PHP activities with existing health structures in the Ministry of Health, and Ministry of Education. • Strengthen capacity and increase the level of PHP activities with existing health structures at the municipal level. • Strengthen capacity and increase the level of PHP activities with existing health structures at the community level with local NGO’s. This would include small case studies of particularly vulnerable sections of the community. • To develop and utilise culturally appropriate approaches to the delivery of PHP messages as a strong component of work in the Gaza Strip. • Provide PHP support for community health-related activities such as MCH, family planning, and immunisation programmes. • Strengthen PHP awareness programmes around existing solid waste management systems in the Gaza. • Seek adequate funding for medium to long-term professional tertiary education programmes on PHP training and capacity building for all existing and future health professionals working in the Gaza strip.
The Water and Sanitation Recommendations are: • The rehabilitation of water and wastewater networks destroyed by IDF incursions, in partnership with the communities, municipalities and CMWU (see Annex I priority list of locations). • Extend water and wastewater networks to serve enclave communities, such as Seafa, and the construction of wastewater collection networks in isolated
7 communities in partnership with the communities, CMWU and municipalities (see Annex I priority list of locations). • Repair or replace roof water storage tanks of poor families damaged during the IDF incursions, as and when required. Document such cases. • The rehabilitation of communal agricultural wells and water ponds destroyed by the IDF incursions in partnership with the community, MoA, PWA and UAC • In the medium term, provide capacity building to CMWU and municipality engineers on community participation, gender and other soft issues. Seek to develop such training with institutions such as WEDC. • Explore options for future interventions in schools. Activities would target older schools lacking a reliable water supply and/or with poor sanitation infrastructure. • In the medium term, investigate options for increasing the surveillance of desalinated water being distributed by private water tankers. Any such work should be undertaken in partnership with PWA and MoH. • Seek adequate funding for medium to long-term programmes to extend wastewater coverage in rural areas through the use of appropriate on-site methods and training to contractors and builders.Seek funding for a medium to long-term programmes to promote large-scale industrial composting for organic waste. Link NGO sector, SWMC, private sector, communities and farmers, using a sustainable micro-ente
The food security recommendations are: • The Gaza Strip is facing a complex livelihood crisis manifesting itself in high unemployment and loss of production. It is not suffering a nutritional or food crisis. Levels of acute malnutrition are low. The population is experiencing a human rights crisis, with peoples’ rights to livelihoods and dignity denied on a daily basis. • Immediate response. Implement cash for work activities to increase purchasing power of the most vulnerable households. • Medium-term. Support agricultural production and diversification through the rehabilitation of farm infrastructure and production capacity. Building opportunities for groups of women in food processing would improve the income of the most vulnerable groups.
8
Acronyms AFD Agence Française de Développement CEH Centre for Environmental Health, University of Surrey CHW Community Health Worker CMWU Coastal Municipalities Water Utility EIB European Investment Bank EPI Expanded Programme of Immunisation GDP Gross Domestic Product GIS Global Information System GPS Global Position System Hb Haemoglobin HDI Human Development Index HPC Humanitarian Programme Coordinator IAF Israeli Air Force IDF Israeli Defence Forces INGO International Non-governmental Organisation LoA Letter of Agreement MCH Maternal and Child Health MMS Military Medical Services (part of PNA) MoA Ministry of Agriculture MoE Ministry of Education MoH Ministry of Health MoU Memorandum of Understanding MSF Médecines Sans Frontières NFI Non Food Item NIS New Israeli Shekel NGO Non-governmental organisation OCHA (UN) Office for the Coordination of Humanitarian Affairs OGB Oxfam Great Britain OPT Occupied Palestinian Territories PHAST Participatory Hygiene and Sanitation Transformation PHE Public Health Engineer PHP Public Health Promotion PNA Palestinian National Authority PWA Palestinian Water Authority SWMC Solid Waste Management Council TIM Temporary International Mechanism TOR Terms of Reference UAC Union of Agricultural Committees UAWC Union of Agricultural Work Committees’ UHWC Union of Health Work Committees UNDP United Nations Development Programme UN - DSS United Nations – Department of Safety and Security UNICEF United Nations Children’s Fund UNRWA United Nations Relief and Works Agency WEDC Water, Engineering and Development Centre WHO World Health Organisation WTO World Trade Organisation WWTP Wastewater Treatment Plant
9 1.0. Introduction
1.1. Map of the Gaza Strip
1.2. Background Country Information
1.2.1. The occupied Palestinian Territories have a low HDI, and was ranked 102 in the 2005 Human Development Report, with 70% of the population living below the monetary poverty line (UNDP 2005). Poverty is a problem for the majority of the population, particularly women. 1.2.2. Following the kidnapping of an Israeli soldier in June 2006, the Israeli Defence Forces launched their “Summer Rain” operation. Since 26th June an estimated 226 Palestinians have been killed as a result of Israeli military operations1. According to official Palestinian sources, 118 of the dead, including 80 women and children, were civilians. An estimated 200 – 250 tank shells are being lobbed daily into the Gaza Strip. Damage to the economy and to infrastructure alone is estimated to be US$ 46 million2 from 28th June to 27th August 2006. Damage to municipal infrastructure (including bridges, water and wastewater lines and roads) is estimated as US$ 8 million, while damage to agriculture (including olives and citrus orchards, greenhouses, poultries and livestock farms, water wells) is estimated as US$ 23.5 million. 1.2.2. At the economic level, the situation is below normal especially since the freezing of international financial aid. In 2006, the unemployment is given as 40%,
1 OPT: Gaza – ICRC Bulletin No. 06/2006 - Latest report on ICRC activities in the field – ICRC (12/9/06) 2 Assessment of damages caused by the Israeli defence forces operations in the Gaza Strip – UNDP (6/9/06)
10 being expected to rise to 47% in 20083. The World Bank estimated that growth per capita in the Palestinian territories would fall by 27 percent in 2006, while personal income would decline by 30 percent - a one-year contraction of economic activity equivalent to a deep depression. The economy has been severely affected since the democratic election of the Hamas government. Currently, 152,000 government employees are no longer being paid by the PNA . Gross National Income is given as US$ 1,120 per year. In the Gaza Strip, unemployment is higher than in the West Bank, affecting more than 70% of the population, particularly the poor and women. 1.2.3. In 2004, the share of land under cultivation in the OPT amounted to some 1.8 million dunums. Of this, 90 per cent was in the West Bank, where rain-fed agriculture dominates, and where livestock contributes to nearly half of agricultural output. Although Gaza has been developing an export-oriented agricultural sector, the Palestinian agriculture sector as a whole continues to be characterised by small- scale, mainly family-based, farming, with average plot sizes of 20 dunums. 63.8 percent of arable land was cultivated with fruit trees, mainly olive trees, whereas field crops, primarily wheat and vegetables, represented 26.6 per cent and 9.6 per cent respectively. In 1996, there were 180,000 dunums available for agriculture in the Gaza Strip. According to figures by UAWC, this has dropped by 45 per cent to reach 100,000 - 110,000 dunums in 2005, because of the Israeli army’s destruction of more than 60,000 dunums of cropland since September 2000. The Beit Hanoun area has been particularly affected, were cultivated land has reduced by 62 %4. 1.2.5. Oxfam GB has already been working in Gaza though an ECHO programme. The ECHO intervention started in March 2006. The principal activities are: the rehabilitation of existing water supply networks, water storage capacity for schools and coordination activities.
1.3. Background and Objectives of the Visit 1.2.1. Due to the current humanitarian situation in the Gaza Strip, the aim is to assess public health and food security needs following the Israeli military operation “Summer Rains”, which started 28th June 2006. 1.2.2. The purpose of this visit as agreed with the OGB Humanitarian Programme Coordinator based in Jerusalem was to assess: • The public health and food security needs of the population affected by the recent Israeli army operations in Gaza Identify and design rapid response activities as appropriate, • Serve as a basis for further development of the water and sanitation and food security program in Gaza.
2.0 Methodology
2.1. Health 2.1.1. Relevant reports and other related literature were obtained and examined
3 World Bank sees worst year for Palestinian economy – Reuters Press Release (14/9/06) 4 FARMERS UNDER OCCUPATION - Palestinian Agriculture at the Crossroads, OGB (Unpublished), June 06 11 2.1.2. Meetings were held with relevant staff of government and UN agencies, local municipalities, INGO’s and LNGO’s, and community members. 2.1.3. Baseline and surveillance health data were obtained from the Gaza Strip office of WHO and UNRWA, and analysed. Historical rainfall records were obtained from the Ministry of Agriculture. 2.1.4. When security allowed, field visits were made to various locations throughout the Gaza Strip. 2.1.5. Visual observations and photographs were taken when allowed and with the consent of subjects involved. 2.2. Water and Sanitation 2.2.1. During the field visits, the main techniques of information collection were key informant interviews, focus group discussions and observations from visits to the neighbourhoods. Unfortunately due to the prevailing security situation in Gaza, field visits were reduced to a minimum. As a result, much of the information was collected from secondary sources and official reports.
2.2.2. In Gaza City, an existing OGB staff member based in Gaza City, (Yasser Nasser) arranged a series of meetings with UN bodies (UNWRA, UNICEF, WHO, etc.) with INGO’s, with Water/Waste Management Utilities, with government departments (PWA, MoH, MoA, etc.) and with municipalities, amongst others. At a central level, meetings took place in Gaza City, while some meetings with the utilities and the municipal authorities took place in the Governorates. The head of the Coastal Municipalities Water Utility (CMWU) was also interviewed in Gaza. The team investigated problems related to; quantity of water, water quality, damage to infrastructure due to incursions, wastewater collection and disposal, waste management and hygiene behaviour. The cost of water, wastewater collection and health expenditure were also investigated.
2.3. Food Security and Livelihoods. 2.3.1. The assessment started in Jerusalem with a review of existing literature and briefings with OGB staff and international actors in the Gaza Strip. The field visit to Gaza took place between the 17th and the 23rd of August. Meetings were held with local and international organisations, partners5, local authorities and key informants to collect secondary information and appraise our partners’ capacity to respond to the crisis. Visits to communities and household interviews were conducted with different livelihood groups and in vulnerable areas affected by recent incursions. Preliminary interviews with key informants were conducted to get a better understanding of the affected communities, the working context, and their perspective on local food security. Key informants included local government representatives, members of community-based organisations, and people who were able to provide specific information on the local food security context. The household interviews gathered information on changes in expenditures and incomes in the last month crisis, food habits, and on the extent of coping strategies adopted in response to the crisis. Limitations. The limited time spent in the field and the lack of a local assessment team did not allow enough time to assess all the livelihood groups or gather quantitative information.
5 See annex XI for the meeting list. 12 3.0. Findings 3.1. Health 3.1.1. Literature review The literature review findings are based on key reports, papers, and websites referred to during the assessment (Behrens 2006; UNRWA 2006; US Census Bureau 2006; UNOCHA 2006; WHO 2006; PNA 2005; Issa et al 2005; 3.1.2. Demographic indicators The population of the Gaza Strip in June 2006 was estimated to be 1,443,814 (712,586 females, 731,228 males), with a population density of about 3,962 persons/km2 (www.ochaopt.org, June 2006)6. The number of Palestinian refugees registered in the Gaza Strip at the end of 2005 was 986,034 (68.3% of the estimated total population). Of these, 48.6% lived in camps and 51.4% lived outside camps. The average family size is 5.75 persons, and the total fertility rate is 4.6 (UNRWA 2006:109). Figure 1 shows a population pyramid of the estimated population of the Gaza Strip in 2006. This shows the percentage of women of reproductive age (15-49 years) is 44%, the percentage of the population aged 19 years and less is 59.5%, and the percentage of the population aged 50 years and above is 7.5% (US Census Bureau 2006). The Gaza Strip has a young population compared with many developed countries, reflecting the high fertility rate and lower life expectancy in the Gaza Strip.
Population pyramid of Gaza Strip, 2006
80+
75-79 Males Females 70-74
65-69
60-64
55-59
50-54
Age group 45-49 (years) 40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
-10-8-6-4-20246810 Per cent of total population
3.1.3. Health Status Indicators Life expectancy at birth in 2004 in the occupied Palestinian territory was 72.6 years, 70.7 years for males and 73.8 for females (WHO 2006; MoH 2004). Maternal, under- 5, and infant mortality rates were 10.6 per 100,000, 28.3 and 24.2 per 1000 live births respectively (WHO 2006). The neonatal mortality rate is 17.1 per 1000 live births. The mean birth interval is 32.4 months. The prevalence of anaemia among children aged less than 3 years is 54.7%. The mean marital age for women is 19.1 years. The prevalence of anaemia among pregnant women is 35.7%, and among nursing mothers is 45.7% (UNRWA 2006:110).
6 The population of Palestine (Gaza and West Bank) is growing at a rate of 3.4% per year, a rate of natural increase among the highest in the world (C. Haub, 2005 World Population Data Sheet (Population Reference Bureau Data Sheet, 2005). 13
3.1.3.1. Mortality The leading causes of death in the West Bank and Gaza according to the Ministry of Health Annual Report of 2003 are shown in Table 1 (cited in Behrens 2006:15). Disease group % of all deaths Cardiovascular diseases 36.1 Prenatal 9.7 Cancer 9.0 Accidents 8.8 Senility 5.7 Pneumonia and respiratory diseases 4.8 Diabetes mellitus 4.1 Renal failure 3.4 Congenital malformation 3.2 Infectious diseases7 2.9 Table 1: The ten leading causes of death in Gaza and the West Bank The leading causes of reported infant mortality in 2005 for Palestinian refugees were low birth weight and prematurity (31.2%), congenital malformations (21.1%), and acute respiratory infections (19.7%). Sixty-two per cent of these reported infant deaths were during the neonatal period, with the majority due to prematurity (UNRWA 2006:71). The leading causes of reported child mortality (1-3 years) in 2005 for Palestinian refugees were congenital malformations (28%), respiratory infections (24%), heart diseases (13%) and accidents (8%) (UNRWA 2006:72). Thus, over the life course, non-communicable diseases, particularly cardiovascular diseases, are the main causes of death. This profile of mortality shows an epidemiological transition in the oPT from predominantly communicable diseases to predominantly non-communicable diseases. 3.1.3.2. Morbidity The main morbidity data we obtained during the assessment was for registered Palestinian refugees (i.e. 986,000 persons in Gaza) (UNRWA 2006). Vaccine- preventable diseases are well under control. No cases of poliomyelitis or tetanus neonatorum have been reported in the last 10 years. Malaria has been eradicated, and tuberculosis and HIV/AIDS are of low endemicity. Viral meningitis outbreaks occur in Gaza, mainly between April and July (Issa et al 2005). Communicable diseases associated with poor environmental living conditions are highly prevalent, for example viral hepatitis, enteric fevers and intestinal infections (UNRWA 2006:5). A recent study of 600 children aged 3-17 years in Beit Lahiya found an overall prevalence of parasitic infections of 77.7% (Kuhail & Tulaib 2005). Specifically, the prevalence of Ascaris lumbricoides was 40.8%, Strongylloides stercoralis was 19.8%, Entamoeba spp was 9%, Giardia lamblia was 5.7%, and Hymenolyptis nana fragment 11 was 1.8%, and Trichuris trichiura was 0.5%. The authors found a significant association between infection and sewage disposal and animal breeding in the home. Other papers have also reported on intestinal parasites in children and households in Gaza (Astal 2004; Abu Mourad 2004). The incidence rates of reported cases of communicable diseases per 100,000 registered refugee population (986,034) in Gaza in 2005 were acute flaccid paralysis (0.5 or 5 cases), water diarrhoea (children 0-3 years) (12,737 or 125,591 cases), bloody diarrhoea (643 or
7 * WHO (2006) stated that communicable diseases accounted for 10.1% of all deaths in 2004? We did not have time during our assessment to investigate this apparent discrepancy. 14 6,340 cases), viral hepatitis (59.2 or 584 cases), mumps (4.5 or 44 cases), and typhoid fevers (3.9 or 38 cases) (UNRWA 2006:91). The prevalence of the non-communicable diseases diabetes mellitus and hypertension amongst registered refugees aged 40 years and older in 2005 in Gaza was 3.6% and 6.6% respectively. The prevalence of diabetes and hypertension combined was 4.5%. There is probably a low detection rate among refugees (UNRWA 2006:94). Acute malnutrition affected 2.8%, 1.4%, and 1.9% of young children in the occupied Palestinian territory in 1996, 2000, and 2004 respectively. Stunting increased from 7.2% of children aged under-5 in 1996 to 9.4% in 2004, representing a mild public health problem. More than 25% of children aged under-5 and 31.1 % of women of childbearing age have iron-deficiency anaemia. The prevalence of anaemia in school children in Gaza in 2005 was 23.9% (compared with 14.7% in the West Bank (UNRWA 2006:75; see also Halileh and Gordon [2005]). Other micronutrient deficiencies concern vitamin A (26.5% of children in Gaza), vitamin D, and iodine. Rickets is widely reported in Gaza (WHO 2006). A recent report summarizes the nutrition situation of Gaza (PNA 2005). The prevalence of common mental disorders (post-traumatic stress, anxiety, mood and somatoform disorders) in the occupied Palestinian territory in 2003 were 40.3% among the 59% of the population that had been directly exposed to violence compared to 12.6% among the 31% of the population that had not had such exposure (WHO 2006:6). 3.1.4. Health Services The health facility network in the occupied Palestinian territory is well developed. The Palestinian Authority has succeeded in preventing and controlling most infectious disease through public health programs of immunization, health education and epidemiological surveillance. In 2004, communicable diseases accounted for 10.1% of total mortality (WHO 2006:6). There are four distinct providers of health care services in the Gaza Strip: the Ministry of Health, non-governmental organisations, UNRWA, and the private for- profit sector. According to Behrens (2006:8), ‘the health care system is fragmented, uncoordinated, inefficient, and experiences inadequate revenues, insufficiently trained staff, overcrowding in many facilities, long waiting times, out-of-order equipment, and periodic shortages of drugs and supplies’. The public system suffers from problems associated with centralised decision-making, line item budgets, and rigid civil service rules (Behrens 2006:8)3.1.4.1. Primary Health Care coverage For registered refugees in the Gaza in 2005, the percentage of pregnant women who received antenatal care was 98.1. The percentage of pregnant women who paid at least four antenatal visits to UNRWA MCH clinics was 94.3. The average number of antenatal visits was 7.6. The percentage of deliveries in health institutions was 99.7. The percentage of pregnant women protected against tetanus was 99.1 percent. The percentage of infants 12 months old fully immunised was 99.9. The percentage of pregnant women delivered by trained personnel was 99.8. The percentage of children 18 months old who received all booster doses of EPI vaccines was 99.6 (UNRWA 2006:111) 3.1.4.2. Health infrastructure In 2003 there were 103 registered Primary Health Care (PHC) Centres in the Gaza Strip (in 2004 this was 125 [WHO 2006:6]). The MoH operated 54 of these centres. The non-profit NGO sector (non-governmental and private voluntary organisations) operated 32 centres. UNRWA operated 17 centres (Behrens 2006:16). By the end
15 of 2004 in Gaza, there were 28 maternal and child health clinics, 89 specialised clinics, 44 family planning clinics, and 31 dental clinics (WHO 2006:6). The private for-profit sector may provide more than half of all outpatient consultations (a World Bank study from 1997 cited by Behrens 2006:16). The secondary sector is smaller than the primary sector. There were 78 hospitals in the West Bank and Gaza Strip in 2003, providing 1.25 beds per 1000 capita (comparing favourably with Israel with 2.2 beds per capita) (Behrens 2006:16). According to Behrens, quality and efficiency is a challenge. Large variations in daily patient load occur in Gaza, where in some clinics 80% of patients are seen in the first 3 days of the month when drugs are delivered, reflecting the lack of drugs often found in PHC clinics in Gaza. Moreover, the majority of patients are seen between 9.00am and 12 noon, and thus the average consultation time with a doctor ranges between 30 seconds and 3 minutes (a 2004 unpublished report by the World Bank cited by Behrens 2006:17). 3.1.4.3. Health protection and promotion UNRWA (2006:51-86) provides information for registered refugees relating to child health care, expanded maternal health and family planning services, surveillance of infant, child and maternal mortality, school health services, nutrition and psychosocial support. 3.1.5. Assessment observations These observations are based on meetings with health professionals and others working in various agencies and organisations in Gaza, including MoH, MoE, WHO, UNICEF, UNRWA, Municipalities, local and international NGO’s, SWMC, and community individuals. 3.1.5.1. Surveillance and monitoring The WHO office in Gaza, in partnership with others including the MoH and UNRWA Department of Health in Gaza, has set up a system of health sector surveillance indicators that are being used during the current emergency. General health indicators include the following: underweight; anaemia among children; anaemia among pregnant women; diarrhoea among children; place of delivery by service provider; non-institutional delivery; hospital services; PHC consultations; number of Hb tests performed; contracting out; salary payment status; transport. WHO is publishing the results in a regular ‘Health Sector Surveillance Indicators’ newsletter, which had reached Issue 5 (dated 17th August 2006) at the time of our assessment. A copy of Issue 5 is shown in Annex IV. The surveillance system in Gaza has shown the prevalence of anaemia in 9-12 month old children (69.4%) and pregnant women (43.1%) in June 2006 has increased from the prevalence in May 2006 (59% and 24.1% respectively). There have been no cases of severe anaemia, with 3/4 of cases being mild and 1/4 being moderate (WHO ‘5th Issue: Health Surveillance Indicators’ newsletter, August 3rd 2006. Refer to Annex IV. The Gaza office of WHO kindly provided primary surveillance health data to the OGB assessment team to assist them to develop an evidence-based approach to possible OGB PHP/PHE activities in Gaza. This data has initially focussed on diarrhoea in children, as shown in Figure 2.
16 Monthly consultations for acute watery diarrhoea and acute bloody diarrhoea in children in 15 UNRWA clinics in the Gaza Strip, 2005-2006
2005 Acute bloody diarrhoea 2005 Acute watery diarrhoea 2006 Acute bloody diarrhoea 2006 Acute watery diarrhoea
2500
2000
1500 Consultations 1000
500
0 Jan Feb March April May June July Aug Sept Oct Nov Dec
Fig 2: Baseline and current data for acute watery diarrhoea and acute bloody diarrhoea in children (0-3 years) in the Gaza Strip. The monitored indicators cover the 5 Governorates. To date, there have been no major outbreaks of infectious disease resulting from the current emergency. However, consultations for acute watery diarrhoea in children at the 15 sentinel UNRWA PHC clinics appear to be trending upwards in 2006 compared with 2005, so continued monitoring is essential. The increases in diarrhoeal consultations appear greatest in North Gaza and Rafah Governorates. Annex VI shows more details of this baseline data. The Gaza Ministry of Agriculture (MoA) kindly provided rainfall records (1985-2005) to the assessment team to enable us to correlate the rainfall data with the epidemiological monitoring data to help in understanding transmission routes of some infectious diseases and how these might be affected during the current emergency. A preliminary graph is shown in Annex VI.
3.1.6. Public Health Promotion The current humanitarian crisis with the disruption of government services (including non-payment of salaries), disruption of electricity supplies, and increased intensity of Israeli structural violence8 (including incursions), obviously has serious implications for health promotion and education activities. The assessment team met with health promotion and health education staff from the MoH, MoE, SWMC, several local NGO’s, and the Municipality of Jabalia (unfortunately, security restrictions on travel within Gaza prevented us from meeting with more municipalities and NGO’s about health promotion, particularly from Rafah, Khan Younis, and Middle Zone, during our assessment). We were able to complete field visits to families in Swedish Village (Rafah Governorate) and Jabalia (North Gaza Governorate). These visits showed the extent to which the lives of families are being severely affected by the current
8 Refer to the writings of Paul Farmer about structural violence, e.g. Farmer, P. 1999, Infections and Inequalities: The modern plagues, University of California Press, Berkeley. 17 crisis in terms of lack of income and all the associated health and well-being consequences (i.e. poverty). The MoH and UNICEF are currently involved in a Gaza-wide health education program focussing on 3 key messages: 1. How to know when food is spoilt. 2. Healthy environments and infectious diseases; 3. Nutrition for women and children. This program involves the training of health educators. Other PHP issues of concern to the MoH include increasing solid waste exposure of children (due to a serious breakdown in solid waste management activities), and safe handling of potable water in homes. The common thread of concern amongst all relevant local PHP professionals who spoke with the Oxfam assessment team in Gaza was their lack of resources to undertake active and effective HP programs, including training and capacity building of staff, coordination of activities and programs, and transport/travel limitations. With 3 universities located in the Gaza Strip, and a significant pool of qualified professionals, there is great scope, with an injection of resources, to develop and extend PHP programs to ensure there is no further deterioration in health outcomes in Gaza.
18 are forced to fish in the polluted inshore 3.1.7. A Gaza Case Study – The waters, thus risking seafood contaminated Swedish Village Story with human faecal pathogens. Swedish Village is a small, relatively isolated, and overcrowded community of about 5,000 persons located on the southern border with Egypt, adjacent to the Mediterranean Sea.
Oxfam GB, with ECHO funding, recently supported an extension of the Rafah municipal water system to service the community.
This community is suffering in the current humanitarian crisis in Gaza, from the inhumane structural violence being perpetrated by Israel and most of the western nations of the world, particularly the USA and the European community (EC). Poverty is at a high level, and many families rely on food aid. Those individuals fortunate enough to have a job (in Some families were unable to pay the particular civil servants), in many cases, Rafah Municipality the household have not received their full salaries since connection fee of 500 NIS, and made the democratic election of the Hamas illegal connections to the new water government in early 2006. Large system. This creates a risk of faecal infrastructure projects in Rafah contamination of the water supply because Governorate (which includes Swedish there is no community sewage system, Village) with approved contracts and and individual houses mostly have simple funding from international donors (e.g. sullage pits for sewage disposal. This is a USA and EC) are frozen. Many major public health disaster, and Public Health water supply and wastewater projects Promotion may not be able to contain any have been halted. Raw sewerage pours potential outbreak or epidemic of into the sea near the village. infectious disease. Israeli gunboats patrol the sea, shooting at Palestinian fisherman who dare to fish beyond 800 m from the shore. The fisherman therefore either do not fish, or 3.2 Water and Sanitation
3.2.1 Access to Safe Drinking Water through CMWU 3.2.1.1. Access to drinking water is regulated by PWA, with the operational side being managed by CMWU, which was set up following the Integrated Coastal Aquifer Management Plan in 2000. CMWU is a para-statal organization and was set-up with support from WB and other main donors. CMWU is a non-profit company, but derives their operational budget from both connection fees and metered water. Surplus funds are re-invested in improving and expanding the network. CMWU is owned by the 25 municipalities in the Gaza Strip, the board of Directors being made up of the mayors from each municipality. The Gaza Strip is a very small area of land with a total area of only 360 km2. It is underlain by a shallow aquifer, which is contiguous with the Israeli Coastal Aquifer to the north. Gaza is the 'downstream user' of the Coastal Aquifer system, and hence water abstraction in Gaza does not affect Israeli water supplies. The Gaza Aquifer has a natural recharge rate of approximately 65 million m3 (MCM) of water per year from rainfall and lateral inflow of water from Israel and Egypt (CAMP, 2000). This aquifer is essentially the only source of fresh water in the Gaza Strip. The Palestinian Water Authority (PWA) was formed in 1995 and given the mandate for managing water in the Palestinian Territories. The PWA, with the help of international donors (principally USAID), drew up a management plan with external support. This resulted in the Integrated Coastal Aquifer Management Plan (CAMP), which was drawn up in 2000. CMWU have essentially been tasked with implementing the CAMP master plan with the support of major donors. The main infrastructure is directly managed by CMWU in partnership with the municipal authorities. Unfortunately, funding for major infrastructure projects, including sewage treatment plants, sewage main carriers, pumping stations, water main carriers, storage capacity and networks (sewage + water) has been put on hold since the election of the Hamas government. Currently, salaries are not being paid to the majority of CMWU employees (except senior mangers and engineers), due to the current economic crisis (i.e. people no longer pay their utility bills). Municipal level employees are not being paid either, as direct funding of the PA structures has also stopped. Fortunately, many CMWU employees, and those in the municipalities, continue to work in spite of the harsh economic situation. According to CMWU, water fee collection efficiency has dropped from 95% before the disengagement to around about 25% now.
3.2.1.2. Much of the potable water supplied in Gaza comes from deep wells tapping the coastal aquifer. As the aquifer has been severely damaged by over pumping in the past, water extracted from the ground can have either high levels of chlorides (>250 mg/l) or high levels of nitrates (>50 mg/l), in excess of WHO drinking water quality standards. The CMWU is responsible for managing the majority of the deep boreholes, however, coverage may be supplemented by municipal wells, especially in the rural areas. As a general rule, there is a tendency for CMWU to replace existing municipal wells through drilling new boreholes, and to also extend services into areas not previously served in a formal manner. This process is on going, and depends on financial resources being available. Well replacement is a tool to try and improve the overall quality of the groundwater through a policy of having a higher number of wells extracting smaller quantities of water. Water quality at some brackish wells may be improved by mixing water from a desalination plant with the well water having high chloride levels. The object is to provide water of an average quality meeting WHO standards. In some areas, especially Eastern Gaza (Middle Area), legal agricultural wells may be used by the community to provide potable water. Such water is used either because there is no CMWU network coverage or because the community consider such water “sweeter” than the water provided by CMWU. CMWU have a number of large projects designed to build inter-connected mains carriers and water facilities to improve water distribution throughout the Gaza Strip. Again, many of these projects are currently frozen due to the current political standoff. All CMWU and municipal wells connected into the network are producing chlorinated water; CMWU promotes the use of liquid sodium hyperchlorite on all of the wells managed by them. Currently 95% of the population in the Gaza Strip is served by the main water distribution system. The main affect of the “Summer Rain” for the CMWU has been serious disruption to operations caused by the attack on the Gaza power station. As a result, CMWU have been forced to run their back up generators as a main power source for 120 supply wells, putting an enormous strain on the back up system (generator hours, fuel and spare-parts, etc.). CMWU have reacted very pro-actively though, initiating a water and sanitation coordination grouping, currently being chaired by UNICEF. Through the emergency water and sanitation grouping (part of e-wash group), CMWU have been able to highlight and target immediate needs effectively. An initial emergency appeal was launched for 21 Mio USD, with new generators and spare parts being high on the agenda. To date9 this appeal has been successful in meeting targets with financial support from a number of international agencies. The main bottleneck now seems to be getting supplies physically into Gaza. The EU (TIM project) have finalised an agreement with CMWU to supply fuel for generators for the next six months (starting August 2006). Other needs are becoming apparent as CMWU teams move into areas affected by incursions and/or shelling. A number of locations where network rehabilitation is required were documented during the assessment (see Annex VII). Such needs are packaged as fully designed mini-projects, with CMWU financing all the design and tender launch procedures (using WB guidelines). Organisations can simply express interest in individual packages, then establish a LoA with CMWU for the work. CMWU prefers to manage the contractors, as they already have considerable experience of working with contractors in high security areas of Gaza. 3.2.1.3. Water storage at a household level in Gaza depends heavily on electricity. Due to move towards high-rise buildings, much of the network storage capacity built in the past (raised water reservoirs) has become obsolete. People now rely on roof tanks, which are filled by small electrical centrifugal pumps, as water pressure is too low to be able to fill roof tanks. This ability to store water at a household level has been severely disrupted by the lack of electricity caused by the attack on the main power station. People have had to modify the quantity of water stored, and the way they store water (in whatever containers they can find), depending on the frequency and reliability of their electricity supply. This has severely disrupted people’s lives, and in particular the lives of women. Electricity is however returning little by little, hence the difficulties would be expected to diminish in the medium-term.
9 PNA/CMWU - Latest Situation Report, Of Water and Wastewater Services Due to Prevailing Security Conditions, Updated on August 22, 2006
21 Water storage in areas were Israeli incursions have taken place are different, not only being affected by the disrupted electricity supply, but also by damage to water storage tanks. This is often caused deliberately by IDF shooting holes in roof tanks. In such cases, it is necessary to visit communities and to identify damage on a case- by-case basis. Both UN and ICRC are providing immediate support to communities affected by such incursions. Close coordination is essential to identify who is responding to such needs. The CMWU highlighted the need for water tanks, especially for poor families.
3.2.2. Access to Wastewater Treatment Services through CMWU 3.2.2.1. Wastewater treatment services are woefully inadequate in the Gaza Strip, due to many years of neglect and under investment. Wastewater collection is given as around 66.8%10, while wastewater treatment is given as being only 2.7%. In a number of locations, raw, untreated sewage is being discharged into the sea. A reported11 20,000 m3/day of raw sewage is pumped directly into the sea (next to Adam Hotel in Rimaal and onto the shore directly under Beach Camp). A further 10,000 m3/day is discharged into Wadi Gaza, where it pollutes the Wadi bed and creates stagnant pools of water, causing problems with vectors. In Rafah, next to Swedish Village, an estimated 8,000 m3/day12 are discharged directly into the sea. Again, wastewater is an integral part of CAMP, with a number of projects having been designed and planned over the past five years. Major components of the “wastewater plan” are new sewage treatment plants in the north, the middle area and the south (near Rafah). Unfortunately, many of these projects find themselves “on hold” due to the current political situation. Plans are going ahead in Rafah to implement the Rafah sewage treatment plant works, with funding reportedly being made by a European government.Work is to be undertaken in 4-phases, with a total budget of 4 Mio Euros. The new Beit Lahiya sewage transfer component (Part A) is ongoing and fully funded by WB and European Investment Bank (EIB) with a total budget of $12.3 million. Construction of a new wastewater treatment plant (Part B) will provide a new wastewater treatment facility. The financing plan for Part B ($33.4 million) has been completed through the AFD, SIDA, EU and Belgium government. During the “Summer Rain” operation, 33 sewage pumping stations (managed by CMWU) where affected by the loss of electricity. Again, these stations required back up generators, so require regular fuel supplies, spare parts and eventually replacement of the generator. In terms of generators and fuel, these needs were included in the initial emergency appeal, which has largely been met. 3.2.2.2. The Northern Governorate WWTP is located 1.5km east of the town of Beit Lahiya in the northern part of Gaza. Construction of the plant began in 1976 and was expanded to reach its peak flow capacity to 5,000m3 per day. The wastewater plant is located in a closed depression without a natural outlet to the sea. The Beit Lahiya wastewater treatment plant serves the population of Beit Lahiya, Beit Hanoun, Jabalia al-Balad and the Bedouin Village (Um an-Nasser). The plant was originally
10 The Palestinian Central Bureau of Statistics issued a press release about the Environmental Economic Survey 2006 11 Briefing Note: Iron Pipes at Karni - 30 May 2006 (Unpublished UNWRA briefing notes) 12 Rafah Emergency Sewage Treatment Plant Project, Vol. 1 Project Proposal – PWA – Finland Project (May 2006)
22 designed to serve up to 50,000 habitants. The total population of the area served by the plant is now between 180,000 and 190,000 people. At present about 16,000 m3 of wastewater passes through the plant each day, into seven smaller basins. The combination of an ever-increasing volume of waste and insufficient capacity has led to effluence overflowing from the basins into the surrounding sand dunes, creating a lagoon, which covers over 30 hectares13. The accumulation of partially treated sewage has mounted to 3 Mio m3. The lagoon has now reached a critical level and now requires urgent action to prevent the lagoons shoulders breeching and flooding the surrounding area to a depth of up to 7 m. Up to 12,000 people and 100 ha of arable land could be affected if the lagoon shoulders are breached. The site also provides a natural breeding ground for mosquitoes and parasites. Uncontrolled effluent has polluted the water and the environment is conducive to the transmission of water-born diseases. A growing number of children are showing signs of digestive and respiratory health problems and skin diseases. Data from the local clinics show over half of stool samples tested are producing positive results for intestinal parasites14. As a temporary solution, CMWU has launched a contract to support the lagoons shoulders, while PWA will launch a contract to connect the infiltration pump station with 16 “ pipes that will divert the wastewater from the lagoons to north of Um an- Naser. Work is currently on hold due to ongoing IDF operations, exposing the area around the lagoons to frequent artillery fire.Oxfam and a number of other actors have pressed the IDF to agree to the resumption of these urgent works, resulting in an agreement being reached with IDF to allow appointed contractors to start work on 28th August. 3.2.2.3. As with the water network, a number of sewage collector networks have been damaged or destroyed by the various IDF incursions, particularly in the area of Beit Hanoun. Again, CMWU has prepared a number of mini-projects where network rehabilitation is required. These locations were documented during the assessment and are shown in Annex VII.
3.2.3. Water for Drinking, Making Tea and Cooking 3.2.3.1 Due to the high levels of chlorides present in much of the water supplied via the CMWU network, many families are buying drinking water originating in privately operated desalination plants. The reason given for using such water is given as being “taste”. Desalinated water is thus preferred for drinking, making tea and for cooking. Network water is used for all other water needs. There are 35 desalination plants used by private operators in Gaza. These plants are licensed by PWA, who undertakes regular monitoring with MoH to check water quality at the inlet and the outlet of the plants. Plants essentially use reverse osmosis technology, and “treat” network water, reducing chloride levels to around 40 – 60 mg/l. The technology used for desalination is essentially imported from Israel, meaning that spare-parts and consumables are prone to closures at Karni crossing. At the outlet of the plant, water has been treated to ensure high microbial quality,
13 Beit Lahia Waste Water Plant, 6 June 2006 – Unpublished UNWRA Briefing Notes 14 Beit Lahia Waste Water Plant, 6 June 2006 – Unpublished UNWRA Briefing Notes
23 however, it is unclear whether plant operators use chlorination, ultra violet or other such treatment techniques? According to the PWA, the weak link in the commercialisation of desalinated water is the distribution chain after production. Much of the water is distributed to consumers through private water tanker operators. At present, there is no effective mechanism in place to license and to monitor water quality from water tanker operators. Based on observations of water being collected from a desalination plant near to Rafah, it is very clear that water is being collected in unhygienic conditions. Distribution points are unorganised and poorly drained, with people arriving on animal carts with a range of “unhygienic” containers to collect water. The likelihood of recontamination from such points is high. Private water tankers, which deliver to water to shops (points of commercialisation), or directly to the home, are again an unknown source of recontamination. More investigation of the problems (water quality) and possible solutions would be required prior to taking a decision as to whether it is possible to intervene and improve water quality at point-of-use. 3.2.3.2 Based on limited information from key informant interviews, the price of desalinated water is around 1 NIS for 4-5 gallons (16-20 litres). Case Study from Swedish Village An extended family of 16 people buy desalinated water for drinking making tea and cooking. On average, the family purchase 2 jerry cans per day from water vendors, spending 2-NIS per day. In total, the family will spend 60 NIS/month, just to buy drinking water. On top of this, the same family will spend 50 NIS/month to clean out their “cesspit”. Cesspit cleaning also requires expenditure of 10 NIS on transport to alert the cesspit cleaner operators that their pit needs cleaning. On top of this, the family will use private doctors, as they are often unsatisfied with the quality of service given by the local MoH clinic. Visiting a private doctor entails not only a consultation fee, but also extra expenditure to purchase prescribed medicines from a pharmacy. Following the installation of a water network in Swedish village, the same family is faced with a 500 NIS connection fee from the municipality. With an average monthly income of 1,500 NIS (monthly allowance given to government employees), the family is unable to buy food, take care of all the other family needs and pay the connection fee. Hence, many such families will end up connecting to the water supply network. Poorly made illegal connections are not only a source of leakage, but a means for wastewater to enter the distribution network.
3.2.4 Excreta Disposal in Rural Areas 3.2.4.1 Many areas in the middle area Governorate do not have sewage collection networks, especially the areas east of Khan Younis. Residents rely on using their individual septic tanks, which in reality are cesspits of varying diameters and depths. The cesspits function as crude infiltration pits, which after a year of use tend to clog and then require cleaning on a fortnightly to monthly basis. Frequency of cleaning will clearly depend on soil type (sand or clay), but on the whole, many families in areas with no collection network are confronted with cesspit cleaning costs. Costs vary widely, being in a range of 50 – 300 NIS, but no accurate data exists to what people actually pay. The majority of the services offered for desludging come from the unregulated private operators, meaning there is little control over where the cesspit
24 contents are eventually dumped. Fuel shortages will invariably impact the ability of residents to be able to afford cesspit cleaning. Overflowing cesspits are invariably a public health hazard, and are of the main causes contamination for water supplies, especially when illegal connections and intermittent services are prevalent. 3.2.4.2 Based on discussions with UNWRA and CMWU, Beni Suheila and the surrounding areas were given as being areas severely affected by overflowing wastewater from individual cesspits. Unfortunately, for security reasons, planned field trips to investigate the degree of the problem had to be cancelled. However, in the short-term there is little prospect of sewage collection networks being installed in Beni Suheila and the surrounding areas. The CMWU stated that many of the planned WWTP’s, sewage pumping stations and sewage carrier projects for the Middle Area are on hold due to the current political situation. Therefore, any proposed action would need to investigate the cesspit cleaning services available, and people’s willingness and ability to pay for such a service. The final disposal of sewage at selected safe sites would be considered as a matter of course.
3.2.5 Solid Waste Management 3.2.5.1 Waste management in Gaza is responsibility of SWMC, being divided into different operational zones. The SWMC for the Northern Governorate covers 4 municipalities, Um an-Nasser, Beit Lahiya, Beit Hanoun and Jabalia. The SWMC’s have been set up with international support from Norwegians, UNDP and GTZ. The SWMC for the Northern Governorate has 170 employees, who have not been paid for the past 5-months. Income for O & M is generated through a fee, collected through the water bill. Clearly, as water bills are not being paid, the SWMC’s currently have little or no income. One international organisation is paying 50% of salary for 5- key staff. Staff continues to work and provide services, in spite of the non-payment of salaries and the difficult economic situation. It’s unknown how long this situation can continue before services start to break down? Apart from the non-payment of salaries, the other major impacts of Summer Rain and Hamas boycott are the destruction of waste collection bins (particularly around Beit Hanoun, Beit Lahiya, etc., were many bins are crushed by tanks and bulldozers), and the lack of fuel for waste collection services and the age of the SWMC vehicles. Normally, the old vehicles should have been replaced in 2002, but were not. Spare parts and maintenance now require USD 15,000 per month to maintain the fleet operational. Recently, the EU through the TIM project, have agreed to supply the required amount of diesel fuel to maintain the SWMC fleet operational. The Norwegian Government through UNDP agreed USD 140,000 for six months to cover operational costs (excluding salaries). Therefore, in the short-term, SWMC is able to maintain waste collection services, providing staff continue to turn-up for work. It should be said though that normal cooperation with major international donors is on hold due to the current political situation. 3.2.5.2 The SWMC in Northern Governorate has an awareness section, staffed by 7- people. Staff works through a network of volunteers in the community, producing educational materials on waste management and organising activities for both communities and children. Awareness activities have been disrupted due to the lack of funds available, and there could be scope to undertake some joint awareness activities with SWMC staff, local NGO’s and the municipalities.
25 3.2.5.3 Due to the limited amount of space available for landfill sites in Gaza, recycling is one method that could be used to reduce the amount of waste actually being land filled. One international organisation have reportedly shown interest in setting up a collection service incorporating separation bins, but it was not possible to investigate how far such ideas have progressed. It is known though, through key informants and observations, that metal, plastic bottles (PET) and organic matter have values and potential markets. The main problem being that such markets are not yet structured and they are still relatively informal (PET collection relies on waste scavenging by children for example). There is interest, particularly amongst local NGO’s, to set up composing projects. Such initiatives would however need a medium to long-term outlook and should be approached from a micro-enterprise perspective rather than a purely waste management point of view. 3.2.5.4 Disposal of building rubble is a visible problem in Gaza. Much of the rubble is dumped on the streets, along the roads, into gullies and wadi beds, such as Wadi Gaza. Periodically, piles of building rubble are cleaned up in environmental clean up campaigns, run by UNWRA, but solutions tend to be short-term and will eventually return. From a public health point of view, building rubble is unlikely to be considered a major public health risk, more a nuisance and a safety hazard. Such visible waste will however is likely to have a psychological impact on people, and the full economic value of such waste is clearly not being fully exploited.
3.2.6 Water for Agriculture 3.2.6.1 Agricultural water is essential for farming in Gaza, with water resources and planning at a macro level being managed by PWA, while at an operational level, responsibility falls essentially to MoA. A database of agriculture wells exists, with all agricultural wells being licensed by farmers. To licence and agricultural well, farmers should pay a one off initial fee of 4,000 NIS, followed by an annual renewal of around 100 NIS.
3.2.7 Water Quality Surveillance 3.2.7.1 Water quality surveillance for drinking water supplies is the joint responsibility of PWA and MoH. In practice, water quality samples are collected at a municipal level by trained PH inspectors, and then sent to a central public health laboratory in Gaza City. The laboratory has the capacity to undertake microbial, chemical and physical analysis of water samples. Results from the water samples are collated and re-sent to the municipalities where the samples originated. Individual results are filed, and the municipalities will then act on the results obtained. Duplicate results are in theory sent to both MoH and PWA to build up a “national” picture of water quality. CMWU will also have access to such data on water quality. The laboratory has no virology, protozoa or parasite testing facilities available. Testing of wastewater samples is undertaken, but this is limited to physical properties and membrane filtration testing for thermotolerant coliforms. The Central PH Laboratory is a satellite of the main laboratory in Ramallah and has 18 full-time employees (technicians + administration); many of who have either
26 graduate or post-graduate qualifications in their fields. Laboratory staff have also not been paid for 5-months, but in spite of this, staff continue to work fully. 3.2.7.2. Since 2000, the central PH laboratory has received a considerable amount of support in terms of equipment for water analysis. The support has principally been from USAID. A number of very high-tech machines, manufactured in US, for analysing the chemical (inorganic and organic) and physical properties, have been donated. Unfortunately, for various “political” reasons, the installation (although started) of the equipment has never been completed, meaning the laboratory must rely on old equipment that is in some cases 20-years old. Many of the old machines have technical problems and it is becoming more difficult to repair the machines. There are also difficulties importing reagents, such as strong acids, as entry of these chemicals are restricted by the Israelis.
3.3 Food Security and Livelihoods 3.3.1 Food Security Context 3.3.1.1. Analysis of the underlying and chronic vulnerabilities. The Gaza strip has a population of more than 1.4 million people and is one of the most densely populated regions on earth; with 3,962 people per km2 and the growth rate exceeds 3%. This high population places enormous pressure on the limited natural resources and as a result the local economy is highly reliant on remittances and external aid. Before the Intifada in 2000 remittances from temporary workers in Israel made up most of the national gross income with every working person supporting eight unemployed people. After 2000, the systematic closure of the border with Israel limited employment opportunities and caused unemployment to rise from 15,5% in 2000 to 39,7% in 2004. The drop of remittances increased reliance on public employment, which in turn is completely reliant on external donations to the Palestinian Authority. The public sector employed 73, 437 employees and established social protection mechanisms to support more than 45,000 hardship cases. The lack of natural resources has led to the development of intensive and high profit cash crop cultivation. This has always been a highly volatile sector since it depends primarily on imported inputs from Israel and access to foreign markets, including Israel. The imposed restrictions on the export of goods through the Karni15 border crossing represent an unpredictable challenge for this sector. The closures policy, the delays for goods to cross the border and the high cost of transport make the export of local produce, particularly perishable ones, less competitive with other markets. The input intensive agriculture is also contributing to the depletion of the already limited natural resources, in particular water and soil. The high water quality requirements for cash crops, such as strawberries, compete with already scarce water resources for human consumption and increase the salinity level of drinkable water. The low capacity to produce food locally because of the minimal resources available and specialisation in cash crops makes Gaza entirely dependent on the import of basic staple food products. The border closure policy, small number of suppliers,
15 Karni is the only border for import and export of commercial goods.
27 high transport costs, and the limited stock capacity of local traders could result in problems of local food availability and temporary shortages of staple food. 3.3.1.2. Events that have had an acute impact on food security. The political crisis after the victory of Hamas in the elections in January 2006 and the kidnapping of an Israeli Soldier triggered retaliations at different levels and resulted in the degeneration of the local economic situation. The movement of labour in and out Gaza, already reduced by 20% in the last five years, has now stopped. This has left thousands of skilled and unskilled workers unemployed, and paralysed one of the main income sources for the local economy. After the January elections, the cut of funding to the Palestinian Authority and the non-payment of VAT revenues worsened the local economic situation and led to a financial crisis of the local Authority, which was then unable to pay the salaries of thousands of employees. In the last month a funding window has opened to allowing direct payment to health workers without going through existing administrative structures b As a result, local government structures are unable to maintain social networks for the poorest social hardship cases. The closure of Karni border to the export of agricultural production has caused enormous losses to the agricultural sector. In the last six months Karni border has been open for only 59 days, mainly to allow import of Israeli products into Gaza. Furthermore, the repeated incursions and shelling from Israeli military forces have destroyed greenhouses, orchards and other productive assets. The bombing of the main electric power station has reduced the capacity to supply electricity by 40% and has resulted in continuous shortages of electrical power, seriously affecting productive sectors and the storage of perishable food. Supermarkets are bearing additional costs to store perishables and their price is increasing. Local fishermen ban from accessing the sea has undermined the income sources for the 35,000 relying on the fishing sector and reduced the availability of an important source of protein. In March there was an outbreak of avian flu resulting in the culling of an important number of poultry, which further impacted food availability for vulnerable groups and struck a significant blow to a vibrant poultry industry.
3.3.2 Food availability 3.3.2.1. Food stocks, availability and market prices. Capacity for local production of staple foods is limited and most basic foods are imported from Israel and resold in Gaza. All basic items are reportedly available in local markets, but food stocks have been affected by the closure of the Karni border crossing. The population of the Gaza Strip requires an estimated 450 MT of wheat per day to meet the needs of the entire population; 90% of this is imported from Israel. According to WFP (World food Programme), as of July 12th the available stock was 5,100 MT of wheat, enough to cover the needs of the population for 11 days. At the beginning of July the stocks were able to cover until 17 days16. Market price analysis in September 2006 shows that staple food prices have not increased in the last months. The local price for staple foods seems to be following
16 WFP Vulnerability Analysis and Mapping – Market Monitoring Reports
28 international price movements and the exchange rate of the dollar with Shekel, though additional costs on local transport and storage can cause small fluctuations. Table 2: Prices of staples in Gaza markets. Commodities Sep-Oct 05 Nov-Dec 05 Jan-Mar 06 Apr-May 06 Aug-Sep 06 Increase Wheat Flour (50kg) 71.6 68 89.2 81.1 81.6 + 14% Rice (kg) 3.5 3.2 3.6 3.3 3.7 + 5.7% Olive oil 19.5 22 22.7 21.6 17.7 - 9.2% Vegetable oil (1l) 5.4 5.4 5.7 5.2 5.6 + 3.7% Chickpeas (1kg) 4.5 4.6 6 5.6 4.7 + 4.4% Refined sugar (1kg) 2.6 3 3.9 5.5 5.6 + 115% Source: World Food Programme - Market monitoring The increased cost of sugar is linked to the international fluctuations and exchange rates. The sugar shortage and high costs could affect the local processing industry. The increased cost of wheat flour at the beginning of 2006 was due to the effects of low global grain stocks on international commodity prices. Price increases due to international commodity markets are transmitted directly to Israeli and Palestinian importers and food manufacturers, and in turn passed on to consumers17. Wheat flour prices have substantially decreased in the last months. WFP wheat was observed in the local markets, indicating the tendency of beneficiaries to sell food aid. 3.3.2.2 Food production – Agriculture sector: Gaza has a surface area of 375 km2 40% of which is under cultivation. Despite this sizable proportion the total cultivable surface is small, and so Gaza has developed an intensive, market oriented agriculture sector. The main cash crops- strawberries, flowers, and cherry tomatoes- are cultivated in low plastic tunnels and greenhouses using high input technology and irrigation. These high yield crops represent the majority of Gaza’s agricultural output and are exported to international markets. Other crops, including squash, eggplants, potatoes, cucumber, pulses, onions and citrus, are open field cultivations and mainly commercialised domestically. Many of the citrus crops, located in the border areas with Israel, were destroyed by military incursions, which have also limited farmers’ access to their land. Israel has imposed a No-access Yellow Zone along its border, which extends between 150 m to one kilometre into Gaza, including internal areas that have therefore not been accessible in the last 6 months. Citrus cultivation has thus suffered considerable losses and local sources estimate that 70% of citrus cultivation has been damaged. Groves and production that has been rescued is not sufficient to meet local demand. The rehabilitation of fruit cultivation will require high investments and it will need years to reach a productive stage. These are additional constraints to the high economic risk of investing in areas where access is not guaranteed. Cash crops cultivated under greenhouses and tunnels have also suffered indiscriminate destruction. The impact on livelihoods of the destruction of infrastructure however, is less than that caused by the closure of Karni border during the harvesting period. The lost of export share meant farmers were unable to recover their investments into the production of these crops. As a result they have accumulated debt and will find it difficult to pay for or access the credit necessary to invest in the coming crop season, particularly as they are uncertain to be able to sell
17 WFP Market Assessment Occupied Palestinian Territories - March 06
29 their products. According to the Union of Agricultural Farmers, 15,000 Dunums of cultivated land have been abandoned due to failed income and the lack of inputs to farm in the new season. The four main Cooperatives that provided farmers with agricultural inputs on a credit basis have not been able to sell their produce and so to recover the initial amount invested. This sector requires rehabilitation and economic support for the high initial investment and high maintenance costs. International aid agencies are involved in the recovery of this sector, but the outcomes will again depend on access to export markets in the coming harvest season. In the future, the cash crop sector will need to deal with issues of water availability and quality, and production standards for external markets. The high water requirements for greenhouse production make water deficiency an issue in Gaza. Over 60% of the cultivated area is under irrigation, and crops such as strawberries, require high quality water putting water needs for irrigation in direct competition with human water needs. The amount of water extracted for agricultural and human use is higher than the rainfall supply, and so water availability is rapidly depleting both in quantity and quality. 50% of water used for irrigation is brackish because of seawater intrusion into ground and the uncontrolled discharge of sewage. This highlights the importance of planning and maintaining recycling systems and the collection of grey water. The second layer of the agriculture sector is backyard/ kitchen gardens (including production on terraces) in the peri-urban areas. Though these backyard gardens do not contribute significantly to national income, they have a significant impact on household food security. Not only have these gardens been less affected by the current crisis, its development could improve household food security. 3.3.2.3. Food production - Fishing sector. In the Gaza Strip 35,000 people depend on the fishing sector, which includes fishermen, dependants and fishmongers. According to the Oslo Agreement (94) the Gaza Strip fishing zone extends 20 nautical miles from the coastline; in reality fishing is restricted to 6-10 miles from the coast by Israeli forces and in certain periods access is completely banned; in 2006 fishermen have been able to access the sea for only 60 to 70 days. The two sea corridors bordering Israel and Egypt, 1,5 and 1 mile wide respectively, are completely closed to fishing. This ban affects fishermen in Rafah, which is one of the densest fishing areas. The fishing season extends from April to November. Sardines, the main sea harvest, are caught during the two main seasons, April to June and September to October. Even when access is assured, fishing in the Gaza Strip is not sustainable due to high pressure of fishing and low fish stocks, and most of the fish caught are small and of low value. Lack of sustainability is exacerbated by the use of illegal nets (6mm), which means that fish are unable to reproduce and recover their populations. The fishing is done with boats of different dimensions. Big boats of 11 - 20 m are owned by wealthier fishermen. Small boats of 9 m are owned by smaller fishermen and were numbered at more than 440 in 200518. All fishing inputs are imported from Israel because of the absence of local net making and small production facilities.
18 Opportunities in agriculture and fisheries in Northern West Bank and Gaza. ECORYS-NEY 2006.
30 More than 75% of production is landed in Gaza City, as it is the only protected harbour for vessels. Other landing sites are Dir el-Balad, Khan Younis and Rafah. None of these other locations have cold storage facilities. Local fishing does not cover demand. In 2005 local fish consumption was 2,951 tons of local production and 1,314 tons of imported fish. The theoretical consumption demand is reported to be 12,000 ton per year, and indicating an unsatisfied demand of 7,789 ton of fish for 2005. Fish prices in the Gaza Strip are high, double to triple the prices in other regional markets. The high price and low quality of imported fish is related to safety restrictions, insufficient control at the border and the monopoly of Israeli and Gaza traders.
Visit to Gaza fish market: Dawoud is a fishmonger in Gaza. The fish market is open only a few days a week. He was selling small amounts of gazel, sarruz, denis, pigship, and crabs. The amount of fish on display for sale was small compared to other years. Dawoud attributed this to dropped demand in the local market; people no longer have money to buy fish and the price of fish has increased 20% to the 50%. Dawoud was hoping to sell more fish in the next days due to the coming Christian celebrations. The price of the fish is affected also by the power cuts. Dawoud uses ice to maintain the fish but the cost of a bag of ice has increased from 6 NIS to 10 NIS in the last months.
3.3.2.4. Imports/exports. Agresco, an Israeli-owned company, has the monopoly on agricultural exports and buys flowers, strawberries and vegetables for export from local cooperatives. The Gaza Strip has two cooperatives each for flowers, cherry tomatoes, and strawberries. No Palestinian companies are able to export these goods to many Arab countries but do export citrus to Jordan, and tomatoes, squash and sweet potatoes to the West Bank and Jerusalem. For the last two years, Karni border has been closed for export. Despite an international agreement that allowed 150 trucks for export in 2006 and then 400 trucks the following year, between August 2005 and August 2006 only 70 trucks were able to cross the border. Even when Karni crossing is open the long delays drive up transport costs and affect the quality of produce. As a result, products from the Gaza Strip cannot compete in quality and price. Border closures also limit import of inputs from Israeli, which can delay the cropping season. According to Paltrade there is a need of new markets for Gaza products. Twenty factories have already transferred business to Jordan and Egypt in the last years. 3.3.2.5 Food aid: Food aid is provided by several international agencies and it’s difficult to assess the total amount supplied to the Gaza Strip. The two main organisations that deliver food are UNRWA (United Nations Relief and Works Agency) and WFP, with UNRWA exclusively targeting refugee populations. Together they are able to reach close to 900,000 people, more than 70% of the total population. Food aid is delivered using different mechanisms (general distributions, food for work) and with different rations. This substantial food aid cushions the effects of the economic crisis and ensures food security for the most vulnerable households as well as limits the adoption of distress coping strategies. WFP targets 81,000 refugees and non-refugees with general distributions. In September WFP plans to increase this number to 135,000. The WFP food basket reaches the SPHERE standard of 2,100 Kcal and is provided bi-monthly. It includes wheat flour, chic peas, vegetable oil (olive oil during harvest period), and sugar. After the avian influenza crisis, WFP has occasionally included cans of meat and fish in
31 the food basket. WFP targets a further 97,000 beneficiaries through Food for Work and Food for Training interventions. The targeted population are unemployed farmers and Bedouins. This programme is conducted through the MoA (37,000 beneficiaries) and CHF Cooperation Housing and Finance (60,000 beneficiaries). Eventually, WFP will implement institutional feeding targeting vulnerable groups (disabled, orphanages, hospitals) with two meals per day. WFP is also planning some school feeding programmes in government schools. UNRWA had been supporting 135,000 refugee households until June 2006 when it increased its beneficiaries to 158,000 for a total of 731,000 persons. The current food basket covers 69% of household needs (based upon the number of persons in a household). The food ration is delivered to a household of 1-2 persons every 45 days and includes 30 kg of flour, 3 kg of rice, 2 litres of vegetable oil, 1 kg of raw milk powder and 2 kg of lentils. UNRWA targets all refugees with a registration card and that do not benefiting from other programmes. Refugees who qualify as hardship cases receive a food basket that covers 80% of an individual’s food needs. Part of the food aid is sold cheaply on the market, sometimes because it is not considered appropriate and so is exchanged with other food items and other times to cover other household needs. There is a seasonal trend for selling food; in the coming months sales will peak as household expenditure increases due to the start of the school year in September (to buy clothes and pay fees) and to cover expenditure during religious events such as Ramadan and Eid (October/ November).
3.3.3 Livelihood groups 3.3.3.1 In an urban and overpopulated area like the Gaza Strip is difficult to distinguish livelihood groups since people living in the same area can adopt a variety of livelihoods. After the analysis of secondary information and discussions with key informants, it was decided to define livelihood groups as a household’s main economic activity or income source. Further livelihood distinctions could result from geographical location (rural/ urban), social (refugee status), religious (Muslim/ Christian) and ethnic (Bedouins) differences. These characteristics influence peoples’ vulnerabilities, but factors such as income source, productive assets and social networks seem to be the main determinants in a person/ households’ ability to cope with the current economic crisis. The main livelihood groups were identified as farmers, fishermen, ex-workers in Israel, public employees, and traders. The limited assessment time didn’t allow an assessment of public employee and trader livelihood groups. 3.3.3.2. Ex-Palestinian workers in Israel. This group includes workers with some level of education, who prior to the 2000 Intifada entered Israel daily. They were involved in the construction sector, worked as mechanics, carpenters or other skilled activities. Households belonging to this group have experienced a sharp drop in incomes. Most have found alternative work that is often underpaid and seasonal. Some of them, such as the elderly, haven’t found alternatives and live from savings or support from relatives. Most of those interviewed still hope to restart former jobs in Israel. Before the complete closure of the border, this group was comparatively well off since a skilled worker could earn 4,000 - 7,000 NIS per month compared to the present average salary of 1,000 NIS in Gaza. This income allowed them to build assets and
32 savings; most of the people visited owned their own house and maintained productive tools and assets. They usually have free health service from their Unions, and refugees can rely on some relief aid and free schooling for their children. The few better off are those that have been able to start a new income activity or employment that allows them to cover their basic expenses. A salary of between 1,000 and 1,500 NIS is a minimum to satisfy an average (6 persons) households’ needs. Below is a case study of Mohammed, a former construction worker in Israel who is working on an organic farm in Beit Alhaiya.
Mohammad worked in construction in Israel for twelve years until 2001 when Israeli officials didn’t renew his work permit. He then started work as a taxi driver in Gaza City where he earned only 15 NIS per day. This money was not enough to maintain his family of five so he had to rely on support from his father. Now he is employed on an organic farm where he earns a monthly salary of 1,500 NIS. This salary covers his household expenses (1,000-1,300 NIS), including food and non-food expenses (health, fuel, school fees and other essential needs). He cannot pay water and electricity fees to the local municipality and has accumulated 15,000 NIS of debt. When Mohammed stopped working in Israel he received a compensation of 13,000 NIS that, together with his savings, enabled him to buy a small piece of land. This land represents an asset that would be useful to Mohammad in the future.
In most of the cases Palestinians who used to work in Israel are struggling in underpaid employment that rarely covers the households’ immediate needs. They are forced reduce their expenses, use savings for essential needs and take on credit. Below is the case study of Saber, a mechanic who worked in Israel for 12 years and now relies on his savings to cover the needs of his 10-member family.
Saber is 43 years old and worked in Israel as a mechanic between 1988 and 2000. He now works as a mechanic in Gaza and earns 800-1,000 NIS per month. This covers half of his households’ needs. Saber owns a house in Jabal camp and receives food aid from UNWRA twice a year. He buys the rest of his food from the local market. According to Saber meat prices are increasing, while those of vegetables and other staple foods fluctuate depending on the season and border closures. While he can afford to buy meat twice a week he has had to reduce the quality of the food he buys. He relies on his savings (1,000 NIS per month) to ensure household food security, which will only last another two years. Saber’s two sons cannot marry, as he cannot afford the 30,000 NIS that the marriages would cost him and tradition requires he pay.
Some of those formerly employed in Israel cannot rely on their savings; they must ask for credit and support from relatives and friends, as in the case of Ilham’s husband.
Ilham’s husband used to work in Israel as a mechanic and earned 4,000 NIS per month but was not able to renew his permit. He recently found a job in Gaza but is paid only 400 NIS per month. Ilham’s family is struggling since all their savings were used to build the new house. She is able to cover monthly food expenses for the family of six with the 400 NIS, but only by sacrificing quality and quantity of food. Only rarely she can afford frozen meat and fresh fruits. Ilham has a daughter in university and gone into debt to pay her schools fees and daily transport. Despite her financial problems she is committing to supporting her daughter to finish her studies, and hopes that one day her daughter will be able to help the entire family.
33 The poorest of those who formerly worked in Israel are those unable to find employment and consequently are exhausting their savings or relying exclusively on relief aid and kinship support. Abdul , a former carpenter in Israel, is an example of one who has not been able to find new employment and is living off the last of his savings. His household food security will be seriously under threat in the next months if he doesn’t receive social assistance.
Abdul is a 62-year old former worker in Israel, where he worked for 19 years as a furniture maker. He lives with his wife in Beit Lahiya. After the Intifada in 2000 he was unable to get a working permit and so for the last six years has continued his trade on a small scale but making only 100 NIS per month instead of the 5,000 Shekel per month he was able to make in Israel. His monthly expenditures are around 1,000 NIS per month, mainly food and medical expenses, and he must rely on his savings to cover these expenses. He owns a well-furnished house and has medical insurance from the trade union. He cannot pay his electricity bills and has already accumulated 5,000 NIS debts with the local municipality. He buys his food on the market in small amounts but he doesn’t buy on credit. He has refugee status and his family receives a monthly food ration from UNRWA every four months. Abdul has been forced to sell some of his carpentry tools for cash. He has no debts and while he has relatives in Egypt and Saudi Arabia he doesn’t receive remittances. He has no option for further employment due to his age, no children to support him and only 4,000 NIS remaining in his account
3.3.3.3 Farmers. Farmers’ livelihood groups can be divided into landowners, renters and seasonal labourers. According to Beit Alhaya municipal authorities one third of the people involved in the agricultural sector own their own land and the remaining two-thirds is rented for 400 NIS per dunum per year. The poorest of this group are the seasonal workers. Their daily wages have dropped from 60 to 30 NIS per day. The renters and seasonal workers are usually unemployed people who seek some from of income from the agricultural sector. Landowners are better off even though their income is threatened by border closures and the systematic destruction of their productive assets. The wealth level within this group depends on the land and assets owned and on their ability to access water. Farmers that have been able to diversify their production are better able to absorb economic losses. Land ownership in east Maghazi consists of between 5 and 40 dunum. A typical farm may include 2 dunum under greenhouses, 3 dunum of fruit production, 3 dunum of open field vegetables and poultry. Production capacity depends on water availability. Mohammad is an example of a wealthy farmer affected by the destruction of his productive assets by Israeli incursions.
Mohammad is a farmer and with a family of 10. His income derives entirely from farming. His farm consists of 6 dunum of fruit production, 6 dunum of olive trees, 1 dunum of vegetables under greenhouse, and 2,000 chickens. His seasonal income depends on market prices but he is usually able to earn between 1,000 and 2,000 NIS per month. He sells his produce through middlemen or directly in the local markets. Part of his crops and poultry coops was destroyed by Israeli incursions one month ago. They also destroyed a well that served 120 farmers.
34 Before this incident he bought half his food from the market and consumed his own poultry, and agriculture produce. After the destruction of his land and assets he buys most of his food from the market and a quarter of his food comes from aid:
Sources of food before incursion Sources of food after the incursion
Aid Agric. Aid Agric. 10% 18% 23% 5% Poultry Poultry 27% 0%
Market Mar ket 45% 72%
His family expenses used to be 300 NIS per month. He is now unable to pay water and electricity bills and receives aid from UNRWA and local authorities.
The food security of labourers in the agricultural sector is the most vulnerable. They are often unemployed seeking seasonal work in local farms. In rural areas they are usually able to rely on extended families and strong social networks.
Adullahim is a former worker in Israel and is now struggling to ensure a minimum income for his family of six. He can only find work for 10 to 15 days per month at a daily wage of 30 NIS. His family lives with his 60-year-old mother who is supporting them. She receives aid from UNRWA and Hamas since her husband is permanently sick. With the total household income of the extended family they are able to purchase 100 NIS of food per week from the local market. This, together with the food aid, allows them to meet their food needs. They are able to access a diverse diet that includes vegetables, protein and meat on Fridays.
3.3.3.4 Fishermen. 35,000 people in the Gaza Strip rely on fishing. This group has been the most affected by the recent crisis; lack of access to the sea has completely undermined their only source of income. The most affected are fishermen living on the borders with Egypt and Israel, where access to the sea has been most restricted. Villagers in the “Swedish village” in Rafah area near the border with Egypt reported that their access to the sea was 10% that of a normal year. 90% of the 4500 people living in Swedish village are involved in fishing activities. Three main wealth groups were identified based on their asset ownership. Fishermen owning big boats (few, better off) These fishermen own fleets of 15 m and 7 m boats and employ other fishermen during fishing seasons. Remuneration consists of half of fish and some cash. In a normal year, a fisherman could earn a few thousand NIS a day. Many are now heavily indebted due to the cost of maintaining their boats. Fishermen owning small boats (7 m). These are able to catch a smaller amount of fish but as they tend to own their business they are able to earn a good living. Employed Fishermen. (Poorest) These represent over 50% of fishermen and have limited means to make an income. At present their income is derived from what they can catch from the shoreline; it allows them to procure some food and an extra 30 - 40 NIS that is barely enough to cover some of their expenditures. For this group the ownership of different types of nets can represent a vital difference in attaining a minimum income to survive. 10% have tried to migrate to seek other employment, despite the fact that as fishermen have limited marketable skills and capacity to adapt them. Some have found seasonal work in farming (sweet potatoes) but the
35 economic crisis is also affecting this sector and the salaries are very low. This group is relies on support from wealthier relatives, neighbours. Migration is the only option they see for the future.
3.3.4 Changes in food and income sources / coping strategies Household interviews identified food as the main household expenditure, with the poorest spending the majority of their income on food. The poorest families were observed to have adopted a strategy of substitution of food and reduction of food quality. Some have reduced the number of meals per day, decreased the consumption of meat or only eat frozen meat weekly, and decreased consumption of fresh fruits and vegetables. Households with higher incomes have renounced non- essential food such as snacks and eating at restaurants. All households visited were able, using different strategies, to ensure their minimum food intake in terms of quantity and variety of food. A common strategy adopted by all the groups has been to postpone payment of water and electricity bills. The resulting debt is as high as 10 - 15,000 NIS and. households expect that one day they will have to pay the amount due. Purchasing goods on credit is a common practice in the urban centres but is not used by the poorest groups; this strategy seems to be primarily used by groups who expect to receive a substantial income at the end of the month and pay back the debt. Spending savings is a typical strategy used by households that used to have bigger incomes and but are now unemployed or underpaid. It is a reversible strategy and indicates that a household is still able to cover its needs but it is not clear what will happen when the savings are exhausted. Even when households are resorting to damaging coping strategies such as debt accumulation, there were no reported cases of families selling major household assets. There two likely reasons for this: the first is the lack of market for luxury items and the second is that people still believe that they will be able to recover their former employment, particularly those who worked in Israel, and that they will be able to repay any accumulated debt. Debt and relying on kinship and social networks to ensure household food security are two most common coping strategies for the poorest households. These networks are stronger among rural farmers while credit and cash support are more common in urban areas and among ex-workers in Israel. Reliance on families and redistribution of food and aid seems to be normal practice. A group of women involved in a food for work programme reported that food aid was often shared among up to three families. The extended family network represents an important safety net for Palestinians and is successfully used despite the economic crisis. Note that this is dependant on resources available and links among the extended families. Fishermen are adopting a migration strategy within the Gaza Strip to find employment. Our interview with a poor unemployed fishermen revealed that the reduction of income did no necessary mean a reduction of non-essential items. Even if he was not able to get enough income to maintain his own family needs and needed to ask credit to his relatives, his expenses in cigarettes represented an important proportion of his expenditures. He explained that since he is unemployed he has been smoking more.
36 3.3.5 Nutritional status The prevalence of global acute malnutrition (wasting) among children under-5 in the Gaza Strip is low and decreased from 2.8% in 1996 to 1,9 in 2004. There were no indications of an increase in acute malnutrition at the time of the assessment visit. Chronic malnutrition (stunting) among children under-5 has increased from 8.2% in 1996 to 11% in 200419. Prevalence of stunting in refugees was higher than non- refugees (13.2 and 10.6 respectively), probably due to higher levels of poverty and overcrowded conditions among refugees. This level of chronic malnutrition indicates a low public health problem according with WHO standards (WHO < 20%). Our observations of substitution of the normal diet with cheaper options could result in an increase of stunting. Iron deficiency and anaemia among children under two and pregnant and lactating women are endemic in the area. Anaemia rates of 46% were found among children attending government clinics in the Gaza Strip. Surveys have found that anaemia is higher among refugee children and the poor. It seems to be linked to complex factors and cannot be explained only by diet.
4.0 Conclusions 4.1 Health 4.1.1.1. Individuals and families were suffering greatly under the prevailing living conditions during our assessment. Lack of payment of salaries of government employees, high unemployment, increasing levels of poverty, greatly reduced economy, and the increased intensity of Israeli shelling, incursions and other structural violence has made the population more vulnerable to poor physical and social and emotional well-being outcomes. The WHO health sector surveillance indicators are showing an upward trend in the prevalence of acute watery diarrhoea in children, and an increase in anaemia in children and pregnant women. These are sensitive health indicators. Psychosocial problems appear to be increasing in the community. MSF was providing psychosocial counselling in some locations during our time in Gaza. 4.1.1.2. There is a good basic curative health system in Gaza. However, the system is struggling under the current circumstances. Lack of funding, resources, staff support, more difficult access for patients, and the inhumane structural violence perpetrated by Israel is pushing the health system to its limit. The existing burden of morbidity in the community will likely increase in the short term at least. There is a strong need for enhanced activities in the area of health promotion. 4.1.1.3. The existing burden of infectious disease appears relatively low. However, we can anticipate an increase, possibly as outbreaks, as water and particularly wastewater infrastructure deteriorates further as large infrastructure projects are frozen by the current funding crisis. The large wastewater lagoon in North Gaza is a case in point. Should remedial work be interrupted further by Israeli shelling, the possibility of wall collapse would have serious consequences for many low-lying
19 This trend is based on a series of three Demographic and Health surveys, which have been carried out by the Palestinian Central Bureau of Statistics. The State of Nutrition West bank and Gaza Strip 2005.
37 households in North Gaza (Palestinian authorities estimate that up to 12,000 people would have their homes flooded with 3 million m3 of infectious waste water).
4.2 Water and Sanitation 4.2.1.1. In view of the existing relationships with existing partners, there are several opportunities for expanding the current OGB activities in Gaza. 4.2.1.2. Opportunities for further medium to long-term actions are possible, providing they are thoroughly researched and properly funded. Ideally, such actions should be undertaken within a framework permitting longer project cycles. Ideally funding should be for more than 1-year, thus allowing for stronger community participation, and as a result, lead to more sustainable solutions.
4.3. Food Security and Livelihoods 4.3.1. People in the Gaza Strip are facing a complex livelihood crisis that manifests itself in high unemployment and losses of production. The current crisis is severely affecting the populations’ purchasing power and minimising their ability to cope with further shocks. 4.3.2. Gaza is not suffering a nutritional or food crisis. The levels of acute malnutrition are low, food is available in local markets and the price of staple foods is not on the increase. Rather, the population in the Gaza Strip is experiencing a human rights crisis, where peoples’ rights to livelihoods and dignity are denied on a daily and systematic basis. 4.3.3. Even if international agencies are investing heavily to rehabilitate land and provide productive infrastructures, these efforts are in vain if access to natural resources and international markets are not guaranteed. 4.3.4. The main livelihood groups are affected differently by the crisis and are adopting different coping strategies. The poorest households in each livelihood group are increasing the debts and reducing the quality and quantity of food intake to ensure their household food security. The unemployed or under-employed with exhausted savings and a lack of assets are most affected by the crisis and adopting damaging coping strategies. Their capacity to cope depends on the strength of their kinship networks and the resources available to it. 4.3.5. The high prevalence of food aid is preventing a major food crisis. Nevertheless, our assessment found that food aid for the poorest families actually only covers around 20% of their needs. Targeting is weak, evidenced by many households selling food aid in local markets. Households need cash to cover other expenses such as health, utilities, school fees, fuel, and clothes. There is a need to shift from a commodity based aid to a more integrated cash / commodity support that would provide people with choice and that support the economy of the Gaza Strip. 4.3.6. Improved targeting requires better analysis of the identifying characteristics of poverty and vulnerability. Humanitarian targeting is mainly based on refugee status and on household numbers. The refugee criterion is no longer related to poverty, as some are employed and own significant assets; almost 65% of the population claim
38 refugee status. Factors such as unemployment, income, savings and assets should be investigated for better targeting.
39 5.0. Bibliography/References Abu Sada, C. 2006, ‘FARMERS UNDER OCCUPATION - Palestinian Agriculture at the Crossroads’, Unpublished Research Paper, Oxfam GB. Abu Mourad, T. 2004, ‘Palestinian refugee conditions associated with intestinal parasites and diarrhoea: Nuseirat refugee camp as a case study’, Public Health 118, 131-142. Astal, Z. 2004, ‘Epidemiological survey of the prevalence of parasites among children in Khan Younis Governorate, Palestine’, Parasitol Res 94, 449-451 Behrens, L. 2006, Willingness to Pay for Improved Quality of Care in PHC Clinics in the GS, Palestinian National Authority, Ministry of Health, Health Sector Support Programme. A project funded by the European Commission. Unpublished Report. Halileh, S. and Gordon, N. 2005, ‘Determinants of anaemia in pre-school children in the occupied Palestinian Territory’, Journal of Tropical Paediatrics 52 (1), 12-18. Issa, A., Mahdi, R., Awad, Y., Abushaaban, S. and Hammad, B. 2005, ‘Viral meningitis outbreak in Gaza. Clinical, epidemiologic and laboratory characteristics’, Palestinian Medical Journal 1 (2), 78-83. Kuhail, S. and Tulaib M. 2005, ‘Intestinal parasitic infection in Beit-Lahai town – Gaza Strip’, Palestinian Medical Journal 1 (1), 1-4. Ministry of Health 2004, Annual Report, Ministry of Health, Palestine National Authority. PNA 2005, The State of Nutrition: West Bank and Gaza Strip. A comprehensive review of nutrition of West Bank and Gaza Strip, PNA/WHO/UNICEF. UNDP 2005, Human Development Report 2005, Oxford University Press, Oxford. UNRWA 2006, Annual Report of the Department of Health 2005, UNRWA, Amman, Jordon. US Census Bureau 2006, www.census.gov/ipc/www/idbpyr.html (accessed 12.09.2006) Yassin, K., Awad, R., Tebi, A., Queder, A. and Laaser, U. 2001, ‘The epidemiology of hepatitis A infection in Palestine: a universal vaccination programme is not yet needed’, Epidemiol. Infect. 127, 335-339. WHO 2006, Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan: progress report, Fifty-Ninth World Health Assembly Provisional agenda item 13, A59/24, 18 May 2006, WHO. www.who.int/gb/ebwha/pdf_files/WHA59/A59_24-en.pdf (accessed 12.09.2006). WHO 2006a, Health Sector Surveillance Indicators, Issues 1-6, WHO, Jerusalem. WHO, Bridges Magazine, www.bridgesmagazine.org (accessed 12.09.2006). Assessment of Damages Caused by the Israeli Defense Forces Operations in the Gaza Strip, from 26/06/06 to 28/08/06, UNDP (undp-opt-06sep.pdf)
40 Annex I – ToR for the Assessment Terms of reference Option 2 – Assessment of public health and food security needs in Gaza following the Israeli military operation Summer Rains (started 28 June 2006)
1. Purpose of the assessment The purpose of this assessment is: • Assess the public health and food security needs of the population affected by the recent Israeli army operations in Gaza, • Identify and design rapid response activities as appropriate, • Write project proposals accordingly, • Serve as a basis for further development of the watsan and food security program in Gaza. The evaluation will be managed by the Programme Coordinator with support from the CPM, HD (HO, HC) the RC (RHC, RPM) The assessment team will focus on the needs resulting from the military operation Summer Rains and Oxfam ‘s potential response.
2. Background20 Context Analysis: The humanitarian situation continues to deteriorate in the Gaza Strip due to shortages of electricity and water, caused by the 28 June bombing by the Israel Air Force (IAF) of the Gaza power plant and the continued sporadic opening of only some of Gaza’s crossing points. Electricity supply to households and institutions remains severely depleted. Gazans are receiving on average, 6 – 8 hours of electricity per day and for most families living in urban areas 2 – 3 hours of water per day. Palestinian Authority (PA) national and municipal services, which have been financially struggling since the withholding of VAT transfers by the Government of Israel and the cutting of assistance by western donors, are unable to provide essential services to the population on the regular basis required. IAF air strikes continue to target PA institutions in the Gaza Strip. Gaza’s high poverty (79% of households are living under the poverty line2) and unemployment (40%) levels have sharply limited households’ ability to buy supplies, fuel and water. Almost half the population in the Gaza Strip are children, who are living in an environment of violence, fear and insecurity. Since 28 June, 71 Palestinians have been killed and 197 injured during Israel Defence Forces (IDF) incursions and artillery shelling, IAF air strikes or in disputed circumstances. In the same period one IDF was killed and 4 others injured. Since 28 June, Palestinians have fired 127 homemade rockets towards Israel and the IAF have conducted over 120 air strikes. IDF artillery shelling continues along the north and eastern borders of the Gaza Strip with Israel. Food ‐ Fishermen have now been unable to access the seas since 25 June meaning there are no longer fish stocks in the local market place. ‐ WFP reports that the main food security concern remains local purchasing power and not food availability as food has recently entered the Gaza Strip. Very few people are bringing home enough money to cover their families' basic food needs. Any increases in prices of basic commodities and vegetables (as have been seen in past weeks) have a severe impact. Vegetable shops are reporting that their customers have reduced vegetable purchases by 50% due to inflated prices, resulting from the current operation.
20 From OCHA and CMWU sitreps Water and sanitation ‐ Most of the water wells and 33 sewage-pumping stations were powered through the destroyed GEDCO national electrical grid. Given the reduced electricity supply, generators are being increasingly relied upon to power water wells, threatening sufficient daily water supply to Gazan households. ‐ 3 wastewater treatment plants are not operating due to shortage in electricity and fuel. So, there is a growing possibility in pollution of the aquifer, the seashore and threatening of a marine life. ‐ Electrical fluctuation has resulted in water pumps malfunctioning ‐ Due to power outage, the household are not able to pump the water to high story buildings. ‐ The operation and maintenance teams who are managed by CMWU are not able to move properly due to fuel shortage for cars and military operations. ‐ Water networks, manholes, valves and house connections have been damaged in eastern Beit Hanoun, Al-Atatra, Al-Seiafa and Al-Israa areas in Beit Lahiya, Wadi Al-Salqa ‐ Water storage tanks (communal and household) have been destroyed in Beit Lahia and Beit Hanoun. ‐ Sewage network, manholes septic tanks have been destroyed in Al-Atatra, Al-Seiafa and Al- Israa areas in Beit Lahia and Beit Hanoun. ‐ In principal the EU has agreed to supply the needed fuel for water and wastewater facilities in Gaza Governorates for six months period and is committed to finance the emergency maintenance materials needed for the water and wastewater facilities.
3. Assessment Method(s) The assessment will involve a mix of desk and field research with face-to-face interviews of stakeholders: • Review of previous assessment reports, • Review of project proposals from partners, • Review reports and publications (OCHA, CMWU, PWA, other NGO publications), • Field visits and interviews with stakeholders, including CMWU, PHG, PWA, Ministry of Agriculture, Food Security partners, village councils, beneficiary women, men, children, • Contacts with other NGOs at village level who have not been partner organisations, e.g. women’s groups, women’s committees, farmers’ committees etc.
4. Key activities o Guided by the assessment tools in the Emergency Response Manual, determine the threats to the public health and food security of the affected population in Gaza caused by the recent Israeli military operation. o Identify the needs of the affected population and assess the capacity of the local authorities and national and international agencies to respond effectively to the needs. o In particular for PH: identify how the affected families have adapted their health and hygiene practices as a result of the recent destruction of the water and sanitation infrastructure and determine the risks that these changes may pose to their health. o In particular for FS: identify how the affected families have adapted their eating practices as a result of the recent destruction of agricultural land, reduced imports, dysfunction of markets, drop in income and reduction of movements and determine the risks that these changes may pose. o Ensure as far as possible that the needs and perspectives of women, men and children are considered during the assessment and that the specific needs of people who are particularly vulnerable due to age, disability or lack of community support are considered. o Depending on the analysis of risks and needs and existing response capacity, make clear recommendations as to Oxfam’s response. If, in consultation with the programme team and the RMC it is decided not to initiate response activities, a report outlining the findings of the assessment and justification of the recommendations should be produced.
42 o If the assessment recommends the implementation of humanitarian response activities, the team will be required to contribute to writing a project proposal using the format in the Emergency Response Manual. o A decision to implement may require the team to initiate rapid response activities once the needs have been determined. If appropriate local organisations with whom we can work should be identified and their capacity assessed. o The assessment should be coordinated with the local authorities and other agencies and the findings and any proposals for response activities shared with them as appropriate.
5. Assessment team It is suggested that the assessment team includes 3 people: - One PH Engineer, - One PH Promoter, - One Food Security specialist. The team will be assisted by Oxfam Project Officer in Gaza and by a member of the West Bank team if access is granted.
The food security specialist will need: o At least 5 years field experience in food security, nutrition and livelihoods programmes in humanitarian programmes preferably with non-governmental organisations and in more than one country. o Experience and/or understanding of nutrition and food security and livelihood related issues in humanitarian and development contexts including food security assessment & surveillance, input distribution and alternatives, the relationship between food security and livelihood support o Knowledge of Food Security and Livelihood prevention, preparedness and mitigation programmes and their development. o Proven ability to analyse complex humanitarian contexts at local and national level, monitor changes and translate into appropriate strategic planning o Demonstrated experience of integrating gender and diversity into emergency response programmes and longer-term strategies. o Good assessment, analytical, monitoring and evaluating and planning skills. o Excellent verbal and written communications skills and the ability to relate to people from all backgrounds. o Good written and spoken English. o Ability to work with diplomacy, tact and sensitivity and experience in working within different cultural contexts requiring cultural sensitivity o Well developed interpersonal and team skills and proven ability to be flexible in demanding situations and ability to work under pressure and in response to changing needs. o Working knowledge of Arabic
6. Timetable The assessment will require 20 working days. See proposed work plan below
7. Outputs and outcomes The outputs will be: A needs assessment report fulfilling the guidelines set out above of not more than 15 pages per sector, Project proposals in line with the ERM format for each sector, A debriefing with Public Health and Livelihoods staff on the findings and problems encountered.
43 Annex II - Surveillance and Monitoring, WHO Newsletter
5th ISSUE: HEALTH SECTOR SURVEILLANCE INDICATORS Monitoring health and health sector in the oPT: August 17th, 2006
In this issue, we focused on few monitored indicators, which had shown a worsening trend during the latest period, as from the last data collection at the beginning of August (see 4th issue on health sector surveillance indicators, WHO, 3 August 2006).
1. UNDERWEIGHT a. Reported problem: Slow upward trend has been observed on underweight, in West Bank during the period January – June 2006, with a prevalence going from 3.4% to 4.2% (on Gaza data was not available). b. Further analysis: District-wise analysis does not show the existence of any vulnerable pockets of areas (Fig. 1). Data on underweight from the newly established nutrition surveillance system are still not available, to contribute in providing possible reasons for that trend (data for both Gaza and the West Bank – related to June and onward - will be available soon)21. c. Conclusions: Available data are still insufficient to draw conclusions. More clarity will be possible, as soon as data from the nutrition surveillance system will be available. In particular, data on Gaza are urgently needed and should be accessible by the end of August. A seasonal variation due to disease patterns (e.g. diarrhoea) and food patterns (e.g. more fresh food/less caloric in summer) could explain the mild trend on underweight reported in the West Bank.
12 January March 10 April May 8 June
6
4
2
0 J,lem Jenin Tulkrm Qalqilia Salfit Nablus Ramlah Betlhm Jericho Hebron WB
Fig. 1: Proportion of children 0-2 years whose weight for age is less than 5th percentile in MOH health facilities in the West Bank22.
21 Records from the growth-monitoring program have been already collected for the month of June and July, and partially entered. Revision of the database showed problems on data entry, requiring a time for data cleaning longer than expected. 22 Source: Primary Healthcare Centre Directorate, West Bank and Gaza Strip, Ministry of Health Nutrition Department. The 5th percentile has been used as a cut off point instead of -2 standard deviations and this data is from clinics and may not give a representative picture for all children 0 -2 years old and is not comparable with data based on Z-score.
44 2. ANAEMIA a. Reported problem: Prevalence of anaemia in oPT is of a severe public health concern. b. Further analysis: New data from the newly established MoH surveillance system on anaemia in 9-12 month children and pregnant women in Gaza, related to June 2006 have been made available. These data show a much higher prevalence of anaemia in both age groups: 69.4% in children and 43.1% in pregnant women (compared to 59% and 24.1% in May) (see fig. 2 and 3). There are no detected cases of severe anaemia. Among all cases, about three quarters have a mild anaemia, and one quarter has a moderate level. A trend cannot be defined when using the previously published data, as the methodology of data collection substantially differs. However, this new data should be more reliable than the previous ones, showing a more accurate prevalence. Similar prevalence has been detected by data from household surveys during previous years. Anaemia in refugee population has been analysed. Data from UNRWA Gaza field office show a prevalence which is comparable with that emerged from MoH data (Fig. 4 and 5). c. Conclusions: Anaemia remains a severe public health problem, although mild anaemia is the prevalent condition, and no severe cases have been reported. Anaemia is a longstanding problem with a regional dimension. Therefore, it is not specifically associated with the current crisis.
80 70 60 50 40 30 20 10 0 Nor th Gaz a Gaz a Khan Younis Rafah Gaz a Str ip
Fig. 2: Prevalence of anaemia in 9-12 months children attending MoH clinics in Gaza during June 2006
50
40
30
20
10
0 North Gaza Gaza Khan Younis Rafah GS
Fig. 3: Prevalence of anaemia in pregnant women attending MoH clinics in Gaza during June 2006
100 January March 90 April May 80 June 70 60 50 40 30 20 10 0 North Gaza Gaza Mid Zone Khan Younis Rafah Gaza Strip
Fig. 4: Prevalence of anaemia in 6-12 months children attending UNRWA clinics in Gaza January – June 2006
70 January March 60 April May 50 June 40
30
20
10
0 North Gaza Gaza Mid Zone Khan Younis Rafah GS
Fig. 5: Prevalence of anaemia in pregnant women attending UNRWA clinics in Gaza January – June 2006
3. DIARRHOEA a. Reported problem: Data show an upward trend in number of children consultations for diarrhoea - especially in Gaza - indicating a possible decline in water quality and food safety23 b. Further analysis: When analysed by district, Northern Gaza and Rafah districts show the greatest increase, (200% increase), from March to June (40% increase was expected from seasonal variation) (Fig. 6).
The proportion of water-contaminated samples, from the MoH surveillance, shows an increased trend from March to May when the highest peak of contamination was detected (Fig. 7). When analysed by district, the proportion of contaminated samples does not correlate with diarrhoea consultations. However, the number of collected samples has been very minimal in some districts and during some months (e.g. July), probably undermining the reliability of the surveillance (fig 8).
23 Data provided by UNRWA field office in Gaza.
46 c. Conclusions: Although limited time and geographical correlation has been found between events potentially undermining water quality and food safety, it seams evident that multiple and overlapping risk factors (financial crisis, worsening of security situation, closures, lack of electricity, decreased access to clean water) have affected these determinants during the latest months, in the whole Gaza Strip and particularly in Northern and Rafah districts.
2400 North Gaza 2200 Gaza 2000 Mid Zone
1800 khan Younis
1600 Rafah Gaza Strip, 05 1400 Gaza Strip,06 1200
1000
800
600
400
200
0 March April May June July
Fig. 6: Monthly no. of consultations for Watery Diarrhoea in Gaza Strip
20
15
10
5
0 January February March April May June July
Fig. 7: Proportion of contaminated water samples in Gaza Strip, January- July 2006
300 January February 250 March April May 200 June July 150
100
50
0 North Gaza Gaza Mid Zone Khan Younis Rafah
Fig. 8: no. of collected water –samples in Gaza Strip by district
47 4. REFERRAL ABROAD: EREZ CROSSING Erez check point was closed during 1-31 July. The number of permits requested by referred patients was reduced as per the new criteria for passage by the Israeli forces since the attack on the 25th of June. Only patients in very critical conditions were considered eligible. A small proportion of them crossed Erez during the first week of July. The restrictions on passages were loosened gradually by time during the other three weeks of July and cancer patients were included in the criteria of passage.
70
60
50
40
30
20
10
0 Week 1 Week 2 Week 3 Week 4
Fig. 8: Number of patients who crossed Erez (out of the total requests) during July, 2006 100 90 80 70 60 50 40 30 20 10 0 Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul
Fig. 9: Monthly percentage of patients who crossed Erez (out of the total requests) during the period 1st September 2005 – 31st July 2006
5. PERSONNEL a. Reported problem: Personnel at PHC centres were reported to have increased their leaves, with a substantial reduction of their presence, to the extent that the service delivery would be affected b. Further analysis: 6 district PHC directorates have been visited or contacted by phone - 3 in Gaza and 3 in the West Bank - during the past and current week, to collect registered information on staff leave (Fig 10 – 16). Among all sampled districts, two districts, North Gaza (Fig. 10) and the Mid Zone (fig.12), demonstrated a pronounced increase in number of day leaves from January to June, compared to the same period of the previous year. The trend
48 is reversed in July; presumably because the state of emergency was declared in Gaza and no leave were admitted. c. Conclusions: A relevant increase in staff leave is evident only in two of the 6 assessed districts. It would be opportune to increase the sample representativeness to drown more accurate conclusions.
1100 1000 900 800 700 600 500 400 2006 300 2005 200 100 0 January February March April May June July
Fig. 10: North Gaza district: Total no. of days of annual, sick and urgent leaves
2500
2000
1500
1000 2006 2005 500
0 January February March April May June July
Fig. 11: Gaza district: Total no. of days of annual, sick and urgent leaves
1000 900 800 700 600 500 400 2006 300 2005 200 100 0 January February March April May June July
Fig. 12: Mid Zone district: Total no. of days of annual, sick and urgent leaves
49
1000 900 2006 800 2005 700 600 500 400
300
200 100 0 January February March April May June July
Fig. 13: Tulkarem district: Total no. of days of annual, sick and urgent leaves
900 800 700 600 500 2006 400 2005 300 200 100 0
y y h il y r c r l une uar Ap May J Ju Mar anua ebr J F
Fig. 14: Jenin district: Total no. of days of annual, sick and urgent leaves
450 400 350 300 250 2006 200 2005 150 100 50 0 y ry h ril y ly ar c a ne u u J nua r Ap M Ju a b Mar J Fe
Fig. 15: Jerusalem district: Total no. of days of annual, sick and urgent leaves
50 Annex III - Surveillance & Monitoring, Acute Bloody Diarrhoea
Acute bloody diarrhoea in children (0-3 years)
Monthly consultations for acute bloody diarrhoea in children in 15 UNRWA clinics in the Gaza Strip, 2005-2006
2005 2006 900
800
700
600
500 Consultations 400
300
200
100
0
y h l e y r r r r ry r ri ay n l st e e a a rc M u u be be u u Ap J Ju g m m mb br Ma e e e Au ve Jan F pt Octob o Se N Dec
Median monthly rainfall (1985-2005) and combined monthly consultations for acute bloody diarrhoea in children in 15 UNRWA clinics in the Gaza Strip, 2006
140 900
800 120 700 100 600
Median 80 500 Clinic monthly rainfall consultations 400 (mm) 60 300 40 200 20 100
0 0 Jan Feb March April May June July Aug Sept Oct Nov Dec
Monthly consultations for acute bloody diarrhoea in children in 2 UNRWA clinics in North Gaza, 2005-2006
2005 2006 180
160
140
120
100 Consultations 80
60
40
20
0 Jan Feb March April May June July Aug Sept Oct Nov Dec
51 Monthly consultations for acute bloody diarrhoea in children in 4 UNRWA clinics in Gaza City, 2005-2006
2005 2006
200
180
160
140
120
Consultations 100
80
60
40
20
0 Jan Feb March April May June July Aug Sept Oct Nov Dec
Monthly consultations for acute bloody diarrhoea in children in 4 UNRWA clinics in Mid Zone, 2005-2006
2005 2006
250
200
150
Consultations
100
50
0 Jan Feb March April May June July Aug Sept Oct Nov Dec
Monthly consultations for acute bloody diarrhoea in children in 2 UNRWA clinics in Khan Yunis, 2005-2006
2005 2006
100
90
80
70
60 Consultations 50
40
30
20
10
0 Jan Feb March April May June July Aug Sept Oct Nov Dec
52
Monthly consultations for acute bloody diarrhoea in children in 3 UNRWA clinics in Rafah, 2005-2006
250
200
150
Consultations
100
50
0 Jan Feb March April May June July Aug Sept Oct Nov Dec
Annex IV - Surveillance & Monitoring, Acute Watery Diarrhoea
Acute watery diarrhoea in children (0-3 years)
Monthly consultations for acute watery diarrhoea in children at 15 UNRWA clinics in the Gaza Strip, 2005-2006
2005 2006
2500
2000
1500
Consultations
1000
500
0
t r r ry ry h ril y e ly s e er er rc a n u b b ua M Ju g nua r Ap Ju m tobe m mb a b Ma Au te J p Oc ve Fe e ece S No D
Median monthly rainfall (1985-2005) and monthly consultations for acute watery diarrhoea in children in 15 UNRWA clinics in the Gaza Strip, 2006
140 2500
120 2000 100
1500 Median 80 monthly Clinic rainfall consultations 60 (mm) 1000
40 500 20
0 0 Jan Feb March April May June July Aug Sept Oct Nov Dec
53
Monthly consultations for acute watery diarrhoea in children in 2 UNRWA clinics in North Gaza, 2005-2006
2005 2006 500
450
400
350
300
Consultations 250
200
150
100
50
0 Jan Feb March April May June July Aug Sept Oct Nov Dec
Monthly consultations for acute watery diarrhoea in children in 4 UNRWA clinics in Gaza City, 2005-2006
2005 2006
600
500
400
Consultations 300
200
100
0 Jan Feb March April May June July Aug Sept Oct Nov Dec
Monthly consultations for acute watery diarrhoea in children in 4 UNRWA clinics in Mid Zone, 2005-2006
2005 2006
600
500
400
Consultations 300
200
100
0 Jan Feb March April May June July Aug Sept Oct Nov Dec
54 Monthly consultations for acute watery diarrhoea in children in 2 UNRWA clinics in Khan Yunis, 2005-2006
2005 2006
180
160
140
120
Consultations 100
80
60
40
20
0 Jan Feb March April May June July Aug Sept Oct Nov Dec
Monthly consultations for acute watery diarrhoea in children in 3 UNRWA clinics in Rafah, 2005-2006
2005 2006 700
600
500
400
Consultations 300
200
100
0 Jan Feb March April May June July Aug Sept Oct Nov Dec
Median rainfall (1985-2005) for Gaza City and monthly consultations for acute watery diarrhoea in children in 15 UNRWA clinics in the Gaza Strip in 2005
140 1600
120 1400
1200 100
1000 80 Median rainfall 800 Consultations (mm) 60 600
40 400
20 200
0 0 Jan Feb March April May June July Aug Sept Oct Nov Dec
55