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
Top Related