Health, peace, conflict: challenges for maternal and child health in the occupied Palestinian territories

Introduction

Since the onset of the second intifada (Palestinian uprising), relations between Israel and the occupied Palestinian territories (oPt) have been palpably tense. Escalations of this conflict and developments in its stalled peace processes reach media attention periodically, while the detrimental effect on maternal and child health persists. This paper, whilst acknowledging the disruption to communities on both sides of the border, focuses specifically on the impact of the continuing conflict on maternal and child health in the oPt. In discussing the health status of the oPt population, it is necessary to appreciate how the social determinants of health have been affected by the regional instability. Solutions to the challenges faced in maternal and child health are not simple. Political negotiations to secure a peace agreement will be crucial to the development of consistent, high-quality health care provision in the oPt. Yet, the universal right to health care should not be neglected in the interim (Giacaman et al. 2009). Furthermore, healthcare professionals may contribute to the peace process by cross-cultural medical initiatives, which foster an atmosphere of tolerance.

Life in the West Bank and the Gaza Strip today is heavily influenced by the last 40 years of Israeli military occupation and the state of conflict in which it has existed for yet more decades still. But the past decade has been a critical period in shaping the oPt and its health services. The second intifada of 2000–2005 saw the Israeli-Arab conflict re-ignited. Once more civilian life was subjected to increased hostilities in the war-like state that ensued. Civilian casualties followed as a direct effect of the violence. Furthermore, there was widespread disruption to health care provision due to the destruction of infrastructure, food shortages and both economic and governmental instability (Giacaman et al. 2009). These problems may have been further compounded by the construction of the separation wall in 2002. With the election of Hamas (Islamic Resistance Movement) in 2006 and its subsequent control of the Gaza Strip, the oPt financial situation has worsened (Giacaman et al. 2009). The status of Hamas as a terrorist organization, according to the United Kingdom and much of the international community, makes cooperation problematic (homeoffice. gov.uk).

As such, life in the oPt remains one of fragility with its precarious political and economic situations spilling over into the health care arena. The importance of examining the status of maternal and child health in the oPt is multiform. The demographic of the oPt is that of a young population, with over 40% of Palestinians in this region of reproductive age or under 5 years of age (Palestinian Central Bureau of Statistics 2007). These age groups have specific health care needs which may be neglected in a conflict zone. The Palestinian territory is also unique in that it has been occupied for over 40 years. It therefore serves as an example of the consequences of long-term conflict on particularly vulnerable members of society. And it is hoped that the lessons learnt in the oPt about maternal and child health, a good indicator of the strength of the health care system, may benefit future conflict zone populations.

The mothers

In order to analyse the health status of Palestinian children, one must first address the health of their mothers. Educational attainment among Palestinian women has traditionally been greater than that of women in neighbouring Arab countries (see Figure 1) (Abdul Rahim et al. 2009). Yet, the fertility rate of the oPt during 2008 was one of the highest in the world, exceeded significantly by only several sub-Saharan African nations and Afghanistan. The high fertility rate, although promoted through social norms, can also be attributed to the ongoing conflict. The economic instability caused by the conflict has contributed to unemployment rates in the Gaza Strip which are chronically high, over 50% among 15–19 year olds. Female participation in the labour market, part of Millennium Development Goal 3, is particularly restricted with only 10% of women in Gaza employed.

Figure 1. Fertility rates in 2008 and literacy rates of women in the occupied Palestinian Territories and neighbouring Arab countries. Available from http://unstats.un.org/unsd/demographic/products/socind/statistics.htm [Accessed 2 February 2011].

The high birth rate poses several difficulties for the oPt and helps illustrate many of the institutional barriers to improving the health status of the Palestinian population as a whole. Firstly, it demands of the health care providers the ability to ensure emergency obstetric, hospital and community-based care throughout the perinatal continuum. These are more conducive in an environment where there is effective, unified governance of the political and health systems, sustained funding and investment in training (Abdul Rahim et al. 2009).

The majority of threats to maternal health arise as an indirect consequence of the conflict. However, the increasingly tight mobility restrictions and the construction of the security wall present a more direct threat. According to the Palestinian Ministry of Health, access to maternity facilities was impeded due to mobility restrictions by up to 4 hours in 10% of pregnant women in labour during 2000–2006. This unpredictable access to maternity facilities is one of the reasons cited for the increase in caesarean sections to 15% of all births. While there are little data on the outcome of the caesarean sections, the cost implications alone are cause for concern where health resources are scarce (Human Rights Council 2007).

Following a Presidential decree in 2000, all deliveries in government hospitals were made free of charge. Since then, UNICEF has reported 99% of births were attended by skilled health staff in 2007 (State of the World's Children 2009). However, this does not reflect the quality of care received. There appear to be some discrepancies between evidence-based maternal care and the actual childbirth practices in hospitals in oPt, undermining the quality of care delivered. One such example is the frequent use of oxytocin in normal deliveries, which was attributed by midwives to the high caseloads and chronic understaffing (Wick et al. 2005). Changing practices to those rooted in best evidence requires a coordinated approach across the West Bank and the Gaza Strip.

This fully coordinated approach to health care is lacking in the oPt. The health system is one of many fragile public services and a fragmented one. Officially managed by the Palestinian Ministry of Health, it was inherited from the Israeli military administration in 1994. But, it is only one of several health providers in the country, the others being the United Nations Relief and Work Agency, non-governmental organizations and the private sector. Since then, many improvements have been witnessed in specific areas such as the expansion of infrastructure. Yet, the overall stewardship needed for long-term health planning is still in its infancy (Giacaman et al. 2009).

Secondly, high fertility rates associated with short birthing intervals can accentuate food insecurity, impacting on the nutritional and health status of infants and children (Abdul Rahim et al. 2009).

The children

War and conflict are a dehumanizing presence in the oPt. Article 24 of the International Convention on the Rights of the Child recognizes ‘the right of the child to the enjoyment of the highest attainable standard of health’ (UN High Commission for Human Rights). Yet, several indicators of children's health suggest the conflict is still threatening these fundamental rights. Widely used indicators of the status of child heath within a population often rely heavily on quantitative measures. Indeed, infant mortality rates and the level of malnutrition give a good insight into health care provision. In a conflict zone where psychological morbidity may be high, the framework for assessment must not be narrow and more subjective measures of well being can be of benefit (Abdul Rahim et al. 2009).

Millennium Development Goals (MDGs) 4.1 and 4.2 seek a two-thirds reduction in child and infant mortality, respectively, by 2015. MDG 4.3 focuses on the need for universal measles vaccinations (UN Millennium Development Goals). The oPt is not listed as a priority country, and immunization coverage remains around 99%, higher than in Israel (State of the World's Children 2009). However, the oPt has made limited recent progress with respect to the first two goals of MDG 4. Between 2002 and 2006, the infant mortality rate per 1000 live births was 27.6 deaths. This figure has changed little since 2000. Similarly, the mortality rate among children less than 5 years of age in the oPt in the same time period was 31.6 deaths per 1000 live births and has shown little improvement subsequently. This slow development is particularly apparent by comparison to the neighbouring Arab countries Lebanon and Jordan. In 1990, the differences in child mortality rates of these three countries were less than 5%. By 2005, Lebanon and Jordan achieved an 18% reduction in child mortality to fewer than 20 children per 1000 live births. The reduction in oPt child mortality rate had reached only 2% (Abdul Rahim et al. 2009). Explanations for this stagnation abound. Health determinants, particularly the availability of adequate facilities and training, play an important role. A large proportion of the infant deaths occur within the early neonatal period. In Gaza, communicable and diarrhoeal illnesses still pose considerable neonatal threats. In the West Bank, where infections were once the major cause of infant mortality, low birth weight and congenital abnormalities now predominate (Abdul Rahim et al. 2009). Future reductions in the infant mortality rates will need to consolidate existing care with increased specialist tertiary facilities and freedom of movement to access this treatment (Giacaman et al. 2009).

The Arab-Israeli conflict impedes both. Following a renewed intensity of the Israeli-Gaza conflict in December 2008, direct damage was sustained by 15 hospitals in the Gaza Strip (WHO 2010). While disrupting services, these discrete incidences of damage to infrastructure may threaten community amity towards the occupying power. The indirect effects of this conflict are more pervasive. With a rapid average annual population growth of 3.2% between 2005 and 2010, insufficient tertiary paediatric care facilities will be felt more acutely (Table 1). Current practices of referring neonates needing specialist care to hospitals in East Jerusalem, Israel or referring them outside of Israel and the oPt is both costly and unsustainable for the Palestinian Ministry of Health (Giacaman et al. 2009).

With the high fertility rate, insufficient healthcare provision and the pressure on the economy, malnutrition is one of the greatest threats to child health to arise from this protracted conflict. Food insecurity in the oPt is chronically high and is reflected in household spending patterns. The Palestinian Bureau of Statistics classifies households deeply impoverished as those in which more than 44% of the household's expenditure is allocated to food. A World Food Programme report in 2009 estimated the expenditure to be 49% in the West Bank and up to 56% in the Gaza Strip (UN Food and Agriculture Organization and World Food Program 2009). Acute malnutrition (wasting) in children over the past 10 years has hovered at just over 1%. Chronic malnutrition (stunting), however, has risen significantly, with the Gaza Strip most adversely affected (13.2% of children in 2006) (Abdul Rahim et al. 2009), and this creates several challenges to child health status in the oPt. Undernutrition and micronutrient deficiencies make children more susceptible to common childhood infections. Furthermore, the long-term morbidity associated with chronic childhood malnutrition (impaired cognitive and skeletal development, increased frequency of obesity and chronic diseases in later life) perpetuates the cycle of poverty (Grantham-McGregor et al. 2007, Abdul Rahim et al. 2009).

The psychological distress caused by the conflict is widespread. While depression and anxiety are more prevalent in adults, posttraumatic stress disorder (PTSD) is the most common psychological manifestation among children. One study following the escalation of violence in Gaza in December 2008 reported moderate-to-severe PTSD reactions in 91.4% of children interviewed (UN programme of assistance to the Palestinian people). This was positively associated with exposure to traumatic events. Psychological distress transcends the political border with Israeli–Jewish adolescents living in the West Bank also displaying chronic stress in response to the second intifada (Saggy 2002).

Building bridges

Long-standing violence, insecurity and economic instability have undermined the health status of vulnerable members of society in the oPt. Despite the current barriers, improving the health of women and children in this young population must be a priority and it is possible. In order to secure generational gains in child and maternal health, peace is imperative. Conflict is divisive in its nature. Given the complexities of the Arab-Israeli conflict, it calls for internal, regional and international collaboration to establish a lasting peaceful solution. But, who is implicated in this collaboration?

On an international level, peace negotiations must continue. Maintaining the Arab-Israeli dialogue is crucial in brokering a peaceful and acceptable resolution. The history of this conflict indicates that when discussions falter, violence is quick to re-establish itself. Therefore, the international community, while recognizing the internal political pressure placed on both Arab and Israeli negotiating delegations, must continue to facilitate progressive cease-fire and peace talks. It is hoped that a more stable political outcome will lead to the economic recovery needed to sustain and extend the work of the Palestinian Ministry of Health. While a weak economy persists, there is evidence from the high levels of food insecurity reported in the oPt, that international aid from governments and non-governmental organizations is still very much needed to prevent chronic malnutrition in children.

At an international level, politicians and diplomats are not alone in their responsibility. The medical profession has a key role to play. Some argue that employing medicine as a tool in cross-border peace initiatives leaves the causes of ill health untreated. Yet, the value of these projects extends far beyond the health benefit to individual patients. In equipping health care professionals with the necessary academic knowledge, the oPt will be enabled to form a more sustainable health care service, less reliant on costly external care providers. The need for tertiary training schemes has been recognized and international exchange programmes do exist. Some of the most effective projects though are those in which Arab and Israeli health care professionals can exchange knowledge. These projects can help foster a greater sense of cooperation within the doctors' respective communities (Skinner et al. 2005). Greater collaboration between the Palestinian and international scientific community is also needed in the field of public health. Child and maternal health could benefit directly from targeted health resource allocation informed by more comprehensive epidemiological studies (Abdul Rahim et al. 2009, Giacaman et al. 2009).

Using medicine as a bridge to peace need not be limited to the work of doctors and allied health professionals. To continue the work of existing collaborations, medical students need to be exposed to the benefits of such cooperation in their own countries. Establishing links between Palestinian and international medical students with the use of the internet as a forum is one way of opening such dialogue. While most medical students are not subject to the extremes of insecurity experienced in the oPt, many students will in future work in divided communities. Learning the lessons from the Arab-Israel conflict now may help future doctors gain a greater understanding of the costs of conflict in terms of maternal and child health.

Notes on contributor

Alexandra Matthews is a fourth-year medical student at the University of Manchester with a keen interest in international health and humanitarian aid.