Ahmed IbrahimUniversity of California Irvine

Office of Environmental Health and Safety

Health Under Siege: The Gaza Model

About Me

• BS (Biology/Chem)UC Irvine-2006• MPH (Epidemiology) UC Davis-2008

About this presentation

• Based on my observations in Gaza and the Sinai peninsula.

• Interviews of Gaza’s Minister of Health and medical personnel in Shifa clinic.

• Colleagues• Reports from UN and NGO’s

The Objective of this presentation is to• Underscore the unique public challenges of regions under

state-sponsored siege.• Use Gaza as a model to illustrate the effect of siege in general.• Identify the critical role that public health professionals play in

these environments.• Discuss possible reforms in the relief paradigm to provide

more comprehensive assessment and assistance.• Doing all of this while keeping you awake!

The objective of this presentation is NOT to

• Discuss Middle Eastern Politics.• Discuss the legitimacy of groups.• Propose a solution for peace in the Gaza strip.• Represent anyone else’s perspective other than my own. • Give a presentation about my adventures complete with

clearly doctored photos of me performing heroic actions.

OK Just this once!!!

A siege is a military or economic blockade of a city or territory with the intent of conquering by attrition or assault. -Constant-Relatively Low Intensity-One side maintains strong static defensive position.

Year Besieged Duration

1982 Beirut, Lebanon 2.3 months

1992 Sarajeavo, Bosnia 4 years

2004 Fallujah, Iraq 1 month

2009 Northern Sri Lanka 4-7 months

Year Countries Duration

1986 South Africa 8 years

1990 Iraq 12 years

1997 Burma 13 years

2001 Zimbabwe 9 years

Military Siege1.Damage to public resources and activity2.Destruction of existing infrastructure3.Mass trauma and injury to civilians4.Property Loss5.Typically acute, short term events with high number of deaths.

Economic Siege1.Disrupt imports and exports.2.Disrupts maintenance or growth of existing infrastructure.3.Material scarcity and rise in cost.4.Lack of confidence from foreign investment.5.Typically long periods with high attrition.

Threatens the top achievements in public health

Introduces new disease burdens in the population.

Siege Types: Blockade vs. Sanctions

What makes a Unique model?• Few regions in the world with a civil war, a local war and a

regional war.• Gaza remains under regional sanctions as well as

international sanctions.• Gaza is under particularly heavy land and maritime blockade

by Israel.• Gaza has undergone a heavy military campaign “operation

cast lead” with the siege resuming (no occupying power to assume administrative control and be legally obliged by the UN to aid in the relief).

• The aftermath of the war has produced severe and long lasting public health impact.

Geographic

41 Km (25 miles) long6-12 Km Wide360 Km2 (139 mi2) (twice size of Irvine)

Demographic

1.5 million residents (July 2009)

85% refugees from previous Arab Israeli conflicts.

Pop density 4118/sq mile (2.25 times as Irvine)

As of 2007, 80% of Gazans live under the poverty line.

Siege of Gaza began in June 2007

Before Operation “Cast Lead”

Two main realities affecting healthcare in Gaza.• Israeli policies of cordoning and incursions• Palestinian policies and divisions

Israeli Policies• Restrictions on movement of patients and medical

resources• Limited personnel entry or training• Import restrictions on fuel, energy, construction

materials• Gaza’s impoverishment led to free of charge

healthcare services (further burdening the system).• Military action against civilian infrastructure (including

health care).

Health in the Gaza Strip: Siege, Fire, and Internal Division Majdi Ashour, MD, MPH Public Health and Health Policy Specialist

Palestinian Division

• June 2007 following election of Hamas.• Period of duplicity of power in Ministry of Health.

– Salary and budget cuts by PA Gaza (37% of PA territory)– Healthcare workers strike and are arrested/tortured– Heavy security presence in healthcare facilities.

• Hamas take over Gaza from PA.– Deaths and injuries– Near collapse of police and paramedic services– Ministry officials replaced with inexperienced Hamas

loyalists who have no clear plan.

"Situation Report From The Humanitarian Coordinator - January 7, 2009, 1700 hours". UN Office for Coordination of Humanitarian Affairs.

2,360 air strikes-GBU-39: Small diameter missiles carrying DU warheads-2000 lb Mark 84 Bunker Busters along Sinai/Egypt border.

7,000 shells firedMore than 50% were MA25A1 (White phosphorous)

Ground InvasionEntered through Kissufim border to split Gaza and cutoff resources from the south.

Naval Strikes8 Km range ER missilesTriggered UK to revoke License to sell Israel spare parts.

UAVContinues to be deployed over Gaza

Gaza Parliament Building

Petroleum Company

UN Vehicles

UNRWA Food Storage Warehouses

ER wing of Hospital destroyed

American International School in Gaza

American International School in Gaza

Dec. 27-Jan 18

• 1,380 Palestinians Killed– 31% Children– 8% Women– 61% Men

• 5,380 Injured– 35% Children– 15% Women– 50% Men

• 100,000 people became newly displaced

Damage to Health System

• 43 of 110 primary health centers• 15 of Gaza’s 21 Hospitals• 29 of 148 ambulance vehicles• 16 health workers killed• 25 injured on duty

Current Healthcare System

• 85% MoH• 15% NGO• Full administrative Oversight on NGO’s• 55 primary health centers• 12 Hospitals• 2 tertiary health centers

Interview with MoH Dr. Bassem Naim 07/16/09

Sustained trauma to populationEstimated 6,000 people will die from indirect causes of the conflict500,000 will be adversely affect in some way.• Enduring disabilities/disfigurement due to war• Food and water-borne outbreaks• Higher miscarriages and neonatal deaths continue.• Increase of chronic disease

– Asthma– Chronic Obstructive Pulmonary Disease– Heart Disease

• Psychological Trauma– PTSD – Unipolar depression

Interview with Head Nurse at Shifa Hospital

Assessments largely ignored long term impact of the campaign

Main Focus of UN and NGO’s• Death from injuries• Impact from lack of access to health

services• Chronic diseases• Gloss over the reasons behind

chronic diseases • Ignore other more lasting sources

of chronic disease.• Passive Epidemiology

More focus on broader PH• Built environment• Status environmental

Health• Specific epidemiological

questions.• Make recommendations

relevant to the limitations of the environment.

• Ask circumstance-specific questions.

Fundamental PH Perspective• Environmental Contamination• Water resources• Food resources• Built environment

Depleted Uranium: GBU-39’s• Suspected to have been used• Remains alleged at this point• Israel bought 1,000 of these from Boeing• Allegedly used during air campaigns• Air campaigns focused on Sinai/Rafah border.

Action of Citizens for the total Dismantling of Nukes UPDATED 4th JULY 2009 REPORT On the use of radioactive weapons in the Gaza Strip during « Operation Cast Lead » (27 December 2008 – 18 January 2009)

Medical Evidence• Traces of radioactivity in victims and cadavres• High incidence of cancer in the eastern region

of Khan Younis• No epidemiologist to conduct these studies• No legal experts to file the reports.

Interview with MoH Dr. Bassem Naim 07/16/09

Water Source and Treatment PlantsRafah GovernorateServes 184,000 residentsServed by Coastal Municipalities Water Utility65% currently connected to wastewater systemDischarges untreated sewage into the sea

Khan Younis GovernorateServes 250,000 residentsServed by Coastal Municipalities Water Utility25% connected to wastewater systemDischarges partially untreated wastewater into the sea

Deir El Balah (Middle Zone) Governorate Serves 190,000 residentsNo connection to wastewater systemDischarges raw sewage into Gaza Valley and runoff to sea

Gaza GovernorateServes 470,000 residentsGaza Waste Water Treatment Plant damaged during the war

North Gaza GovernorateServes 255,000 residents Damaged pipe caused flow to bedouin villages

Raw sewage into the Mediterranean.

• Destruction of buildings causing outflow of sewage into the streets and runoff

• Unmaintained municipal system due to siege restrictions

• Destruction of pipes during military action.

Impact on Ground water supply

• Loss of water that could be recycled • Effects accelerated due to drought• Continued depletion of aquifers (completely depleted in 5 years)• Aquifers will collapse causing damage irreversible damage to

carrying capacity.

Effect on Human Health• Depletion of aquifers has started supplying residents with salt water

(detrimental for child health).• Mixing of Sewage with groundwater increases nitrate levels (causative

agent for blue baby syndrome).• Pollution of Mediterranean resources including fish, a major food

source.• Israeli warships enforce 1-2 km limit on fishing ensures fish caught will

be contain large amounts of contamination.

Food Supply• 700 impact craters in agricultural region

(concentrated in southeast)• 180 greenhouses destroyed• 17 % of total agricultural area destroyed

including• Ecologically vulnerable to desrtification and

sustainable only through careful agricultural handling.

Environmental Assessment of the Gaza Strip United Nations Environment Programmefollowing the escalation of hostilities in December 2008 – January 2009

Built Environment3500 homes destroyed2800 heavily damaged54000 lightly damaged

Collectively this affects 325,000 civilians

Effect of housing conditions on public health

• Mental health• Security• Psychosocial disorders• Social bonds• Identity• Sleep• Air quality• Hygrothermal control • Accidents and injury• Malnutrition• Sanitation• Accidents and injury

• Infectious Disease• Chronic Disease• Injury• Mental Health• Child development• Nutritional instability• Social determinants of public

health

Fourth Ministerial Conferenceon Environment and HealthBudapest, Hungary, 23–25 June 2004Review

Greater Context: Siege is Unique in the Public Health Perspective in that

• Greater threat on long term chronic effects than on short term ones.

• Scope of the damage is not linear with time as is in war time or natural disaster situations.

• More active and educated surveillance is needed to assess the true scope of the damage.

• More active assessments need to be made to root out possible health concerns to measure.

• Advised decisions need to be made that will influence the decision of all parties involved.

Siege: Redefined

• Historically more leisurely due to lack of destructive weapons.

• Effects now more lasting than previously thought.

• We need to know exactly what those long lasting risks are and address them.

• Siege variants (economic and military) can be equally as lethal.

Is Iraq a Predictive Model?

• 1990-2003: 1.5 million deaths due to combat, sanctions, diseases, depleted uranium etc.

• UN, WHO, other agencies caught on too late to grasp the scope of the damage.

• Damage remains lingering today.• Will public health catch up with the modern

forms of aggression?

International Commission of Inquiry on Economic Sanctions BM 2966, London WC1N 3XX, Britain Release Date: November 20, 1996

Two subliminal messages here• Public health is a very broad brush. In this topic alone we

covered:– Epidemiology– Nutrition– Public Health Policy– Environmental Science

• Good on its own, great accessory degree.– Politics– Engineering– Law– Architecture – Medicine

ALL OF GAZA BELONGS TO ME!!

Last Thoughts

• Perform your own assessment in any situation• Ask relevant evidence-based questions• Be thorough in your analysis• Be assertive

Thanks• People of Gaza• Colleagues on the VP convoy to Gaza• Dr. Bassim Naim-Minister of Health Gaza• George Galloway-British MP• Staff at UCI EH&S