The Committee consisted again this year of Dr. Traian Ionescu (Romania), Dr. Soejoga (Indonesia) and Dr. Madiou Toure (Senegal).
On 26 January 1984, the Chairman of the Committee, Dr. lonescu, met with representatives of the Israeli Government to discuss the arrangements for the visit, the methodology to be followed and the territories to be visited.
In order to comply with resolution WHA36.27 the Committee also had meetings in Geneva with the representatives of the Governments of Jordan and the Syrian Arab Republic, as well a* the Palestine Liberation Organization, to obtain relevant information before carrying out its visit to the territories. The Committee then proceeded to Amman and Damascus to meet with the competent authorities. In Damascus the Committee was unable to meet representatives of the Palestine Red Crescent Society.
The Committee's visit took place from 5 to 14 April 1984. The Committee visited the Gaza Strip and the West Bank, and, as in previous years, authorization was given for it to visit the Golan Heights on the express condition that the Committee again take note of the reservation expressed by the Israeli Government and mentioned by the Committee in its reports of 1982 and 1983, namely: "The WHO Mission is meant to collect material for a report on health in the administered areas. It is the position of the Government of Israel that the Golan, to which Israel law, jurisdiction and administration have been applied, is not now such an area. In view of this consideration, approval for a visit of the WHO Mission to the Golan is given a* a gesture of goodwill without prejudice. The decision to facilitate the visit shall not serve as a precedent and does not contravene the Israel Government's position". The Committee appreciated the arrangements made by the Government and all the facilities granted to it. However, it notes that contacts with the directors of the two UNRWA field offices, particularly in Gaza, were not so easily established as in the past. The Committee thanks the two directors and their staff for the assistance provided. With regard to the programme of the visit, the Government took into account most of the suggestions put forward by the Committee, but the Committee notes Chat it was not able to visit the Hospice Hospital in Jerusalem.
The health system as such consists of a group of internal components: the populations, the pathogenic agents, the health services and the resources. Between these components there are epidemiological, technological, social, economic and operational relationships; out of the last of these relationships arise concepts of accessibility and acceptability.
Within this context the evaluation of health programmes calls for open-mindedncss and a sense of constructive criticism, which can lead to useful proposals for subsequent action. On account of the very nature of the activities governing the health of a population, one of the constraints of health evaluation is Chat results have to be measured in terms of predetermined quantified objectives; it is therefore necessary to make a qualitative judgement on the nature of the activities involved.
In order to do this the Committee reviews the situation and trends, basing its examination of programmes on the "Indicators for monitoring progress Cowards health for all by the year 2000" and on the "Seventh General Programme of Work covering the period 1984-1989" ("Health for All" Series, Nos. 4 and 8). The Committee points out that this review covers all the observations it has made during its six visits to the occupied territories.
For the sake of clarity the Committee has taken as a basis the framework contained in the Seventh General Programme of Work. It considers the following items in turn: situation and trends in the health field and in related socioeconomic sectors; health protection and promotion; and diagnostic, therapeutic and rehabilitative technology.
The Israeli authorities have realized this, because in the occupied territories they are beginning to set up health programming committees which include Arab physicians. In its previous reports, moreover, the Committee pointed out the absence of medium-term and long-term planning, while noting the attempts made in Gaza and on the West Bank.
The operation of a managerial process, the formulation of a policy and appropriate plans, collaboration with other sectors concerned, programme budgeting - in short the entire dynamics of development - can be achieved only to a limited extent within the present context; it is therefore not surprising Chat the principles laid down by WHO concerning the Global Strategy for Health for All cannot be applied in their entirety in the occupied territories.
2.1.2 The management of the health budget in the occupied territories is in the hands of the central authority, without any participation by Chose who are directly concerned by it. The Committee was unable to determine the structure of the health budget in Gaza since - contrary to what was done for the West Bank - it was not disclosed to then by the Israeli authorities.
In any case the galloping inflation in Israel has far-reaching implications for the health budget for the population; at the same time, political considerations are restricting the extrabudgetary funds provided from private sources, and this is producing frustration-among the local health personnel and the public.
2.2 Health system infrastructure
2.2.1 Health system development
In previous years the Committee saw a large number of structures, and made repeated visits to the same type of unit. On the West Bank, for example, the hospitals at Ramallah, Bethlehem, Hebron and Nablus were visited five times; the Tulkarem hospitals four times;
the Jericho hospitals twice; while in Gaza the Sheefa hospital was visited five times. Other health units or premises of social or economic interest (schools, markets, rehabilitation centre) were also visited.
In analysing the health system infrastructure, it is noted that it is developing in accordance with a system which, so the Arab doctors claim, would have been quite different if they had been making the decisions. From the medical and technological viewpoints, according to these same sources, the West Bank hospitals 30 years ago were among the leading establishments in :he area, whereas they have now fallen behind Chose of neighbouring countries.
In its previous reports the Committee described the infrastructure of the occupied territories in detail. In substance, there has been no significant increase in the number of beds; new services have been created through the redistribution of beds; the bed utilization indices are still low in many hospital units. Although some units have recently inquired sophisticated equipment, the diagnostic equipment is on the whole still antiquated. :The old buildings (Tulkarem, Hebron, Jericho, Nablus) are still experiencing problems with electrical equipment, heating and laundry facilities. In particular, the Committee noted that the old Nablus hospital, which it visited this year, urgently requires improvements.
The increase in the day charge for hospital accommodation, when set against the limited number of quality services that the hospitals can provide on account of the present status of their facilities, places the hospitals in the occupied territories in an inferior position to the units of the same level in Israel and neighbouring countries. In order to obtain paraclinical examinations or certain prescribed drugs, patients are sometimes obliged to apply to health units located outside these territories.
The district hospitals which are designed to provide the basic specialities operate on a territorial basis and in accordance with the "centrifugal" principle; they provide specialist consultations for outpatients, either in the hospitals themselves or in clinics attached to them.
The patients treated in the clinics and the maternal and child health (MCH) centres may be referred to the hospitals. On the West Bank, for example, the hospitals are supported by 141 clinics, 58 of which carry out MCH activities, while 18 engage exclusively in curative care; in the Gaza region the activities are carried out in five hospitals and 21 clinics. In the Golan the clinics regularly visited by the Committee, i.e. Bakata, Masada and Hajdal Shams, show no major new features; they are linked to Kiryat Shmona and to Sfat hospital as referral units.
In the course of the Committee's discussions with the health programming committees mentioned above, a project for the restructuring of hospitals was described by the Israeli directors responsible for health development 'in the occupied territories. On the West Bank three structural levels are planned. There will be two hospitals of the highest level in the health hierarchy of the region: Ramallah hospital, which will increase from 124 to 160 beds, and Belt Jallah hospital. At this level there is also the psychiatric hospital in Bethlehem, where the new section can accommodate 82 beds. At the second level there is Hebron hospital, which has four central departments but is less developed than the first-level establishments. Finally, the third level comprises the Tulkarem, Jenin and Jericho hospitals; the first two will be regarded as small level I hospitals (four basic departments receiving regular visits from specialists), while the last-named (Jericho) is a secondary hospital of level II (low level of activities, 48 beds shared among four small basic departments). It is planned to convert Jericho hospital into a public health centre, keeping a few beds for emergencies; its largest section, the orthopaedic department, will probably be converted into a physical rehabilitation centre. In Gaza the project in progress, scheduled for completion in 1986, is the large Sheefa hospital which should constitute a high-technology referral centre. It covers an area of 6000 m2 and has four storeys: on the ground floor will be the anaesthesia/resuscitation department; the first floor will accommodate the administrative offices and reception, with a small operating theatres; the second floor will consist of hospital wards; and the third floor will contain five operating theatres, one of which has already almost been completed. Alongside the hospital, the former maternity centre is undergoing substantial alterations.
As can be seen, the health system in the occupied territories is becoming increasingly complex with the addition of a new type of health unit to the chain. The appearance of first- and second-level health centres or hospitals introduces new links into the organizational system, which is a move Cowards decentralization; however, an essential driving component is missing, i.e. deconcentration. If decentralization within a pyramidal system is to be viable and operational, it has to assume complementarity of skills; this means Chat each level should be effectively equipped and sufficiently responsible to solve the problems within its area of competence. In the present state of affairs the operation of the system is suffering at all levels on account of numerous restrictions which prevent the various units from rising above a modest level of quality. This forces the patients themselves to go to Israeli hospitals and in some cases to Jordanian hospitals. Moreover, it sometimes happens that the hospitals in the occupied territories, realizing Chat it is impossible for them to provide the necessary services, themselves send patients to external hospitals, since within this pyramidal and hierarchical system in the occupied territories there is no referral unit capable of providing the population with the services they need at an adequate level of quality.
Besides the government health units, the Committee visited private hospitals of a different type and standing: the Caritas Paediatric Hospital of the Swiss German Catholic Society, the Mount David Orthopaedic Hospital run by the Holyland Christian Medical Mission (USA), the Terre des Hommes Nutritional Rehabilitation Centre, and the St. John Ophthalmic Hospital, all located on the West Bank.
2.2.2 Health manpower
The successive reports of the Committee have drawn attention to the problems regarding health personnel, stressing the need to improve the quality of their training and their socio-occupational conditions.
Activities have been undertaken in this respect. In Gaza: postgraduate training; two types of training programmes for nurses - for qualified nurses (one year's duration) and postgraduate courses; traditional nurses can become qualified after two years of practice; training of nurses in intensive coronary care; courses for sanitary engineers. On the West Bank there are plans for a nursing school at Bethlehem, to be sponsored by UNDP; two courses in resuscitation have been given and a further course will start later. Because of the lack of anaesthetists UNDP is encouraging the training of physicians in this field in the United Scales: 10 candidates have been selected; continuous medical training is provided by Israelis; fellowships have been requested from WHO and other organizations, but are very limited; the training of specialists in Israel is under consideration; however, 12 candidates were selected for a five-year period and all of them withdrew. In this respect the Committee received complaints from Arab physicians during its visit to Rafidieh concerning promises made by UNDP to grant 35 fellowships for physicians and nurses. It is alleged that, after interview of the candidates, some of whom occupied relatively high hospital posts, none were selected. It is intended to convene a committee to settle the question of the training of local specialists in Israel; this training is not yet recognized by the competent Israeli authorities. Although many activities have been undertaken, the following problems remain in the foreground: living conditions; private practice; postgraduate training in specialist subjects; unemployment of doctors: award of fellowships; training of nursing and technical staff; and working conditions, particularly the inadequate salaries.
2.3 Health science and technology: research promotion and development
"The health system infrastructure provides the human and material means for delivering health care, but its impact on health depends on the substance of what is delivered".1 The techniques for the prevention and treatment of disease include diagnostic, treatment and rehabilitation techniques, together with methods for the prevention and reduction of specific groups of diseases.
In Gaza the health programming committee described to the Special Committee its study programme on the prevalence of coronary diseases, arterial hypertension, respiratory diseases, evaluation of prenatal care, and head injuries caused by road accidents. The Israeli authorities indicated their interest in WHO support, but stated that a research project submitted to the Organization was rejected last year. According to these same authorities a request for a consultant, Dr. Cook, submitted six months ago met with' no response. The Special Committee asked the Israeli authorities what had been done in response to its recommendations concerning the sending of consultants in certain fields. It was told that, besides the above-mentioned case, three other requests had been submitted; for epidemiological surveillance to evaluate the immunization status of children; for the study of the causes of diarrhoeal diseases; and for mental health. In the first two cases the requests do not seem to have been followed up. As regards the third case, it seems that it was decided to send a consultant, Dr. Harding, but the Israeli authorities subsequently stated that his visit was completely unnecessary.
3. HEALTH PROTECTION AND PROMOTION
3.1 General health protection and promotion
There are many factors which have a favourable or unfavourable effect on behaviour and life style; among the specific activities necessary for ensuring health protection and promotion the Committee considered Chose relating to nutrition, which is regarded as one of the most important factors affecting the quality of human life; the Committee paid much attention to this problem in its previous reports. Although the latest official statistics show that agricultural production has increased, and despite the observations made on the adequate stocking of markets, particularly as regards fruit and vegetables, inflation is making it difficult for ordinary people to obtain essential foods (animal proteins). In the absence of statistics analysing family budgets or medical surveys of individual or collective nutrition, the Committee was unable to make an objective evaluation of the nutritional status of the population. The visit to schools, where the general appearance of the children indicates satisfactory nutritional status, could not be backed up by indicators of physical development. Nevertheless, it was noted that. the patients hospitalized at the Terre des Hommes Nutritional Rehabilitation Centre include many premature infants and marasmus cases, mainly from the Arab populations of Jerusalem but some also from the Gaza hospitals. In addition to food supplements for children, health and nutrition education is provided for mothers. Birthweight, the principal indicator of the nutritional status of a community, has been recorded only in the hospitals; according to the figures for previous years, birthweight was below 2500 g for 9.3% of children born on the West Bank in 1982, and for 6.8% in 1983; the figure for Gaza in 1983 was 5.2%. Information collected and visits to clinics which provide medical assistance in the refugee camps indicate that protein-calorie malnutrition affects 7% of children aged 0 to 3 years. Finally, as a result of the uneven distribution of protein consumption in the various social strata of the local population, protein-calorie malnutrition is commonly encountered in paediatric practice and in many cases requires hospitalization (report A35/16 of the Committee).
3.2 Protection and promotion of the health of specific population groups
Health protection and promotion for mothers and children occupy a special place.
3.2.1 Maternal and child health; The number of maternal and child health (MCH) centres has increased. A number of programmes have been set up for the care and surveillance of children, despite budgetary restrictions and the shortage of health personnel. The vaccination programme occupies a leading place among these disease control programmes and has produced substantial results. On the basis of an evaluation of the medical care provided for mothers and children, and disregarding the inadequacies noted in the territories as a result of economic, political or administrative restrictions, it may be said that from the viewpoint of the strategy applied basic health care has been essentially directed towards mothers and children.
3.2.2 Health of schoolchildren: The surveillance of the health status of schoolchildren is carried out as part of everyday medical care; in the schools visited, despite the fact that hygiene seemed good and the health status of the children seemed satisfactory, there is virtually no school health service to carry out specific surveillance of the development of the children. Consequently there is no dynamic control or evaluation of the children's growth. The Committee enquired about the after-effects of the phenomenon which occurred in the girls' schools last year, particularly at Jenin; the trouble seems to have abated and there are no obvious sequelae among the people concerned.
3.2.3 Workers' health: In the occupied territories no code of occupational medicine has been issued to deal with hygiene problems affecting agricultural or industrial workers (construction industry and small companies), the sectors in which the majority of the local labour force is employed.
3.2.4 Prisoners' health: Nablus prison was visited on a number of occasions, and the Committee has nothing to add to the statements in its previous reports. The Committee was informed chat a new and more modern prison is being built alongside the one visited, which is overcrowded.
3.2.5 Mental health: The economic situation, emigration, changing life styles and above all the latent tension within the community, claimed by the Palestinians to be a consequence of the occupation, are all exerting unfavourable effects on Palestinian society which take the form of the deterioration of mental well-being, not only in the individual but also within the community.
The mental diseases produced by this situation, in particular the neuroses, have raised the problem of the revision of structures and of the system of providing care for such diseases.
On the West Bank the Bethlehem Psychiatric Hospital is being extended and a new building has been assigned to it; a psychiatric clinic has been set up and the mental health society is very active. Medical consultations for this category of diseases are also provided in Gaza.
Problems remain, however, such as the situation of the health personnel, especially their further training, and the need to draw up a systematic health programme which can cope with the increasingly complex problems arising in the mental health field.
3.3 Disease control
Disease control activities were described at length in reports A35/16 and A36/12. There has been no significant change in the situation. The incidence of the diseases which can be eradicated by vaccination (diphtheria, pertussis, measles, poliomyelitis) is decreasing. At the same time the respiratory diseases, particularly in Gaza, are replacing the diarrhoeal diseases as the leading cause of morbidity and death among children.
The health authorities are continuing to pay attention to the intestinal parasitic diseases, malaria, tuberculosis and leishmaniasis, and to the chronic noncommunicable diseases, the most important of which are cancer, cardiovascular diseases, kidney diseases, blood diseases and mental diseases.
A problem which local physicians continue to mention is the long waiting list of patients who require special examinations or surgical operations.
A more detailed analysis of the epidemiological situation revealed the following points:
3.3.1 The chronic diseases are increasing from year to year to become the leading cause of morbidity and death among adults. The authorities are undoubtedly paying more attention to data collection and recording in an attempt to obtain more precise statistics. Nevertheless, data on mental diseases are very scarce. The Committee was unable to obtain any figures on their prevalence in 1983.
3.3.2 As regards the infectious diseases, attention is drawn to infectious hepatitis, diseases preventable by vaccination, and gastroenteritis.
The incidence of infectious hepatitis fluctuated between 1967 and 1983, but was always high. In 1983 369 cases were recorded in Gaza, while there were 522 cases on the West Bank, including 100 in October, 100 in November and 67 in December. Consequently this disease should be subjected to special surveillance in order to improve the epidemiological knowledge of its extent, its geographical distribution, and its distribution among the population. Collaboration with the appropriate international agencies in this respect is necessary. In the meantime vaccination against hepatitis B could be undertaken among high-risk groups, such as people working in blood banks or operating theatres and patients receiving dialysis. However, the cost is too high, amounting to US$ 100 per person.
In Gaza and on the West Bank over 90% of the population have been vaccinated against diphtheria, tetanus, tuberculosis and measles. Among school-age children, 96.6% had antibodies for poliomyelitis, 48.8% for German measles, 90.6% for measles and 91.4% for tetanus. Most of the diseases covered by the EPI are on the decline, except for measles: 77 cases were recorded in 1983 in Gaza and 54 cases on the West Bank. Special attention should be paid to the cold chain in order to improve the storage of vaccines, ensure a proper supply of vaccines, and train staff in vaccination strategy. Reference should be made to German measles, 22 cases of which were reported among young girls in Nablus district, where antibodies are present in 60% of the population. The disease follows a cyclical pattern in this region (every 10 years) and an epidemic is predicted, probably in 1985 (the last major epidemic was in 1975). The authorities are requesting WHO support for a vaccination campaign against this disease.
Gastroenteritis remains a public health problem. On the West Bank in 1983, 84 cases of typhoid fever and 266 cases of dysentery were recorded, and there were 173 deaths from gastroenteritis; in Gaza there were 50 cases of typhoid fever and 25 cases of cholera. These diseases arc linked to environmental sanitation, drinking-water and community behaviour. It is therefore essential to improve drinking-water supplies, sewage and waste disposal, and all these activities need to be backed up by appropriate health education.
3.4 Promotion of environmental health
Despite the noteworthy efforts to promote environmental health made by the municipalities and the Israeli authorities - sanitation, drinking-water supply (clinical and bacteriological control of central sources, control of the salinity of water from underground sources), inspection of markets and food stores - some crucial problems remain, especially in Gaza: rodents (rats), despite effective control with anticoagulants, are still causing the authorities concern; the salinity of water and the insufficient water supplies are worrying the municipalities, which would like to use their own budget to dig wells but are refused permission to do so by the Israeli authorities; the chronic problem of the Rafah pond, for which UNRWA has allocated funds, has still not been solved.
The shortage of specialist personnel for the control of hygiene, the lack of a systematic plan for environmental control, the modest quality and level of the few public health laboratories, the need to extend the range of services provided by these laboratories and to improve the legal system and information are all problems which are awaiting appropriate solutions.
4. DIAGNOSTIC. THERAPEUTIC AND REHABILITATIVE TECHNOLOGY
Clinical, radiological and laboratory techniques are essential for the diagnosis and treatment of diseases and injuries and hence for primary health care.
There is a variety of medical equipment in the occupied territories, but it is inadequate in some health units (Ramallah public health laboratory, which is currently being restructured) and adequate in others (Gaza public health laboratory).
In examining the types of equipment in the laboratories the Committee noted the presence of a large quantity of sophisticated equipment in the hospitals visited, together with an acceptable amount of essential equipment for carrying out basic examinations (leucocyte count, blood sugar level, nonprotein nitrogen level, routine urine tests).
Although the laboratories have the techniques to meet the clinical needs for diagnostic assistance, particularly in support of primary health care, the equipment for diagnosis and functional exploration available to the services is for the most part antiquated, although modern equipment is to be found here and there.
The basic inadequacy, particularly in a health system which sets out to be decentralized, with hierarchical units and specific skills for each level, is reflected negatively in the planning of medical equipment. The unequal distribution and the inadequate utilization of the modern equipment available in the health units, which are unable to use it to the required extent, increases still further the feeling of poverty of resources and dissatisfaction among the patients, not to mention that the growing complexity of clinical care backed up by laboratory tests and radiological examinations is leading to an increase in the cost of disease when patients are transferred to the Israeli hospitals.
In order to make use of laboratory and radiology equipment and technology, and especially in order to maintain this equipment, it is necessary to train appropriate health personnel. The local doctors are aware of this and urge strongly that WHO should assist in such training by sending out experts or awarding fellowships for doctors and nurses.
4.2 Essential drugs and vaccines
The supply of drugs for hospital units is carried out in accordance with a list decided on by the Ministry of Health. The hospitals and dispensaries in the occupied territories have most of the drugs contained in this list, but that does not prevent patients from acquiring some specialties which do not appear on the list.
On the West Bank there are seven small pharmaceutical companies manufacturing drugs for local needs. Since 1967 some 650 drugs have been produced. Unfortunately quality control leaves something to be desired; in the occupied territories there is no reference laboratory to carry out such control. It is important to note that, in accordance with the decision of the World Health Assembly, WHO "will continue to recommend to Member States that they apply the requirements for Good Practices in the Manufacture and Quality Control of Drugs and that they participate in the Certification Scheme on the Quality of Pharmaceutical Products moving in International Commerce" (Seventh General Programme of Work 1984-1989, paragraph 313);
The lack of a list of essential drugs based on the recommendations of a local committee consisting of doctors familiar with the morbidity pattern and the health care needs of the majority of the population is clearly felt. This partly explains the absence of effective management of the supply, storage and general distribution of drugs. There is no doubt that, by selecting essential drugs appropriate to the pattern of disease in the occupied territories, it would have been possible to regulate local production so that it made up for the shortcomings.
Only incomplete information is available on the prevalence of the most common disabilities and infirmities. Nevertheless, activities to promote the concept of physical, mental and social rehabilitation have been observed, particularly at the rehabilitation centre for the handicapped in Gaza and at the Mount David Orthopaedic Hospital.
In the light of the developments described above, the Committee would have liked to evaluate the monitoring of progress in implementing the strategies for health for all by the year 2000, in accordance with the common framework and format recommended by WHO in document DGO/82.1. Monitoring and evaluation are essential components of the Global Strategy for Health for All. Monitoring implies the continuous follow-up of activities during their implementation to ensure that they are proceeding according to schedule. Evaluation is a systematic way of learning from experience and using the lessons learned to improve current and future activities. In this context the Committee endeavoured to reply to the various questions drafted by WHO so as to find out to what extent the national strategies for health for all could be applied to the territories in which the Committee has been appointed by the Health Assembly to evaluate the health situation. To its great regret, and despite sustained efforts, the Committee was unable to furnish relevant replies to the questions formulated by the Organization. It became obvious to the Committee that these questions are not applicable within the context prevailing in the occupied territories. Health promotion requires dialogue between doctor and community that is based on mutual trust; but how is it possible, in a context where relationships are governed by mistrust, to set up an effective health system to achieve the objective of health advocated by WHO? This is extremely problematical, for obvious reasons, in the present situation. However, in spite of the extent of the difficulties the Committee is convinced that the health conditions could be improved if the recommendations it made in its previous reports continue to be implemented; at the same time it is aware that there can be no genuine health promotion without peace, freedom and justice.