Partnership working for better health in Gaza

RSM
Partnership working for better health in Gaza
Professor John Middleton
President Elect, United Kingdom Faculty of
Public Health

RSM Health in Gaza: Prof John Middleton. Partnership working for better health in Gaza

RSM Health in Gaza: Prof John Middleton. Partnership
working for better health in Gaza
Association of Schools of Public
Health delegation to Gaza June 2015
Middleton J. Cement: Gaza’s
forgotten public health need. BMJ
Blog, July 8th 2015.
http://blogs.bmj.com/bmj/2015/0
7/08/john-middleton-cement-
gazas-forgotten-public-health-
need/
Middleton J. Vimeo slideshow
ASPHER delegation to Gaza.
https://vimeo.com/133947395
Wafa rehabilation hospital ,
destroyed 2014

What I learned 1
We have 35 international
aid agencies and NGOs
[non-governmental
organisations] in Gaza and
not one of them has
brought us one bag of
cement,”
Dr Bassam Abu Hamad,
director of the Gaza School
of Public Health of Al Quds
University.

What is the collective noun for 35 NGOS?

RSM Health in Gaza: Prof John Middleton. Partnership working for better
health in Gaza
What I learned 2 :
Extraordinary talent
Local, enthusiastic resources for public
health
V high educational achievement of
Palestinian people, at all levels
Genuinely multidisciplinary public health

What I learned 3
Asset based community development (ABCD)
What are the assets of Gaza? examples
Great coast and beach
Sunshine
Educated people
Recoverable people
Recoverable infrastructure

What I learned 4?
Fitness and Sugar
‘How do you go for a run among
the rubble? How do you eat
anything fresh when the bombs
are falling?’
Professor Yehia Abed
Sugar is ever present—Danone,
Pepsi, Del Monte, and Nestle are
still allowed in by Israel—which
can hardly help the epidemic
levels of diabetes and obesity.?

What I learned : 5
Extraordinary UK resources :
Toxic Remnants of war project
http://www.toxicremnantsofwar.info/category/blog/gaza/
Forensic architecture :
https://blackfriday.amnesty.org
Empower Gaza: solar power for Shifa Hospital
https://www.indiegogo.com/projects/empowergaza-solar-power-for-gaza-hospitals#/
Wall Street Journal : Surveying Gaza destruction http://graphics.wsj.com/gaza-surveying-
destruction/

Cooperation ?
International recognition
for Public Health leaders
Professor Yehia Abed
Dr Bassam Hamad
Dr Marwan Abusada
Dr Ghada al-Jadba
Twinning relationships
higher education ,services,
and royal colleges

Cooperation?
International recognition for Public Health
leaders -
Courageous Israelis: Physicians for human rights
Israel
Twinning relationships: higher education,
services, and royal colleges

Cooperation?
FPH as a training body : recognise AL Quds for
training ?
FPH as a standards organisation: inspect and
award an accreditation status for public health
services ( in addition to training recognition)

Cooperation?
Remote learning methods ‘Health
knowledge’ - PHAST
( but internet connectivity and power
failure questions)
Support locals to do the work
Raise the money, offer the remote
supervision- but let the locals do it
(basic principle of ABCD)
But also : find ways to support
placements of SPRs and visiting public
health staff – probably not senior and
old

Other lessons
Plan for an outbreak of peace
?
William Beveridge
designed a welfare
state for the UK in the
deepest point of the
Second World War.

Other lessons
Plan for an outbreak of peace ?
Someone has to calculate
how to rebuild, where the
rubble will go, what are
the priority areas for
rebuilding? Residential?
Care facilities? Sanitation?
Desalination? Health
services? How much will it
cost?

Other lessons
Plan for an outbreak of peace ?
For sure, if the cement doesn’t come,
the rockets will likely continue to fly.
Political leaders on both sides of the
concrete wall need to change their
mindsets. If there is no vision the
people will continue to suffer

A public mental health approach
Mental health is less systematically monitored, but is widely acknowledged to be
getting worse. Violence has also been internalised within families. An 8 year old
child has experienced three wars in his or her lifetime; what peace, what fear free
childhood can they imagine? And progressively, with each new bombardment,
education immunises less successfully against the loss of hope. No one is blind to
the daily accumulation of garbage in the streets and the absence of progress to a
better environment. In the US, studies have shown the dulling impact of bad
neighbourhoods. In Gaza, environmental nuisance is a fact of life and a universal
presence. The air is laced with the faint aroma of municipal refuse tip.
Gaza has the world’s highest unemployment rate, 43% according to the World
Bank. Work gives people status, it shows them something they couldn’t achieve
on their own, it fills our time, and gives us dignity. It gives us ambition.
Worklessness impacts on everyone in Gaza. So cement also comes to represent
jobs—something to mobilise a nation in enforced idleness, squalor, dependency,
and hopelessness.

Our visit is welcomed as a source of hope—if
inspirational for them, how much more so for us? We
agree to plan an international meeting on public
health in crisis zones next year in Gaza. If we cannot
bring cement, we will nevertheless cement relations.
As one of ASPHER’s past presidents Ulrich Laaser said
on this visit, “Public health should be territory on
which enemies can come together.”

FPH Statement on violence prevention and the
role of public health….
Child abuse
Domestic violence
Elder abuse
Community violence / hate crime
National and international violence / hate
crimes

role of public health
A life course approach
A public mental health approach
An asset based community development
approach
An evidence based policy and intervention
approach….

A real politik approach?
Power may be the only reality-
Political
Economic
Religious

‘Security’- ‘freedom from danger’
Bio security
Food security
Environmental security
Freedom from fear of violence
Freedom from violence
Military security

‘Political significance and symbolism of cement to Gaza. There is extensive documentation of the
destruction as I refer to in the blog. What is needed is a plan for an outbreak of peace-setting
priorities for what rebuilding and redevelopment is most vital, affordable and deliverable, for
the health and hope of the people of Gaza.’
‘If, as Goldberg suggests Hamas are not to be entrusted with the rebuilding of Gaza, then part
of the political negotiation would need to be around which agencies, international or otherwise
can be so empowered. This would, of necessity, test the alleged Israeli policy of de-development
for Gaza. I repeat my final sentence, politicians on both sides of the concrete wall have to
change their mindsets. Where there is no vision the people perish.’

Association of Schools of Public Health in the European Region(ASPHER)
Delegation to Gaza, June 5,6,7th 2015
•Prof. Vesna Bjegovic-Mikanovic, president of ASPHER (chair)
•Prof. Anders Foldspang, past president and chair of ASPHER's Honour's Committee
•Prof. Ulrich Laaser, past president, member of the ASPHER Honour's Committee
•Dr. John Middleton, vice-president for policy, UK Faculty of Public Health
•Mr. Robert Otok, Director, ASPHER
•Ms Marine Buissoniere, Open Society Foundations

Thank you
John Middleton
johnmiddleton@phonecoop.coop

Appendix
ASPHER visit and meeting
Presentations by members of the AL
Quds School of Public Health, Gaza
campus.

Visit of the ASPHER delegation to Gaza 5 and 6
June, 2015
Epidemiological transition in
Palestine, 2015
Dr. Yehia Abed

Examples of communicable Diseases
control in Gaza
• Polio last case 1982
• Measles last epidemic 1987 – 1988
• Last Diphtheria case 1976
• Last cholera epidemic 1994, only one death
1981 epidemic
• In 1977, 40% of child deaths were due to
Gastroenteritis, NOW it is less than 1%
• Tetanus and tetanus neonatorum are under
control.

0
20
40
60
80
No.OFCASES
67
69
71
73
75
77
79
81
83
85
87
89
91
93
YEAR
CASES
Poliomyelitis Cases in Gaza Strip
1967 - 1993

0.0
1.0
2.0
3.0
4.0
5.0
6.0
No.OFCASES(Thousands)
67
69
71
73
75
77
79
81
83
85
87
89
91
93
YEAR
C
Cases of Measles in Gaza Strip
1969 - 1993

Major Current Health Hazards
1. Non communicable Diseases
– Diabetes Mellitus
– Hypertension
–Cardio vascular Diseases
– Cancer
– Chronic Respiratory Diseases
2. Accidents
3. Psychological Disturbance

The 10 leading cause of deaths in West Bank –
Palestine 2013
1- Cardiovascular diseases (31.9%)
2- Cancer deaths (13.3%)
3- Cerebrovascular diseases (12.2%)
4- Diabetes mellitus (6.1%)
5- Accidents (5.5%)
5- Infant diseases and prenatal conditions (5.5%)
7- Respiratory system diseases (5.1%)
8- Renal failure (4.3%)
9- Infectious disease (3.3%)
10- Senility (3.0%)

Prevalence of DM and HTN at UNRWA
5 areas
11.2
9.9 9.8
12.4 12.5
11.4
16.3
19
16.9
19.2
17.3 17.5
0
5
10
15
20
25
Jordan Lebanon Syria Gaza Strip West Bank Agency
%
Prevalence (%) of DM Prevalence (%) of HTV

Reported Cancer Cases in Gaza Strip 1998 -
2008
• Sex Cases Rate per
100,000
Age
Adjusted
Rate
Males 3404 44.6 105.6
Females 3835 51.5 103.0
Total 7239 104

The new cancer cases reported in Gaza
Strip 1998 – 2008
Cancer statistics for Gaza Strip 1998 – 2008
632
558
616
647 637 669 654 651
727
806 820
0
100
200
300
400
500
600
700
800
900
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Casestoll

Risk Factors for NCD
• Cardiovascular diseases,
• Cancer,
• Chronic obstructive
pulmonary diseases
• Diabetes mellitus
• The prevention of these diseases should therefore have
a common focus of controlling these risk factors in an
integrated manner
.
• .
Preventable risk factors
related to lifestyle
Tobacco use,
Unhealthy diet
Physical inactivity

EMR/NCD RISK FACTORS
• Smoking 16-65%
• Hypertension 12-35%
• Diabetes 7-25%
• Over weight-obesity 40-70%
• Dyslipidemia 30-70%
• Physical Inactivity 80-90%

Logistic regression analysis with hypertension As dependent variable and
socio-demographics factors and diet as independents variables
Abed Y, Abu-Haddaf S, Jamee A, 2015

Conclusion and Recommendations
1. There is clear evidence for epidemiological
transition in Palestine. Non communicable
diseases and their risk factors are identified and
no need for duplication of prevalence and risk
factors studies. Action researches are required
2. Evaluation of the Management facilities for
prevention and treatment of NCDs: (health
providers, resources, protocols, guidelines,
organizations, clients)
•

Recommendations
3. For Health Sector: Development of the national
Strategic Plan for control of NCD (Manpower –
facilities – Training –– Public Awareness)
 Development of the protocols and guidelines for
communicable diseases
 Training of the Health staff for proper management of
the non communicable diseases
 Support of the Referral System among different levels
of the health care system
2. For Education Sector: Integration within the
curriculum issues related to NCD, accidents and their
risk factors. (Healthy diet – Physical exercises –
Smoking hazards)

3. For Youth and Sport Sector: Involvement of youth in
different sport activities and clubs facilities
4. For Transport Sector: Application of laws and
regulations to ensure safe traffic movement (Vehicles
and motorcycles – Drivers – Roads)

Areas for future cooperation
1.Teaching: Curriculum development for Non
communicable diseases – Staff and students
exchange
2. Training: Data management - Surveillance of
NCD – Cancer Registry - Collecting data that
helps to modify screening protocols for breast,
cervical, colon, and prostate cancers according
to the variables in our community

3. Research for Non-Communicable Diseases
1. Change in the prevalence studies for: Cardio-vascular
disease, Diabetes Mellitus, Hypertension, Cancer,
Trauma, Respiratory diseases
2. Identification and Prevention of risk factors for NCDs:
Smoking, Obesity, Physical inactivity, Stress, Unhealthy
diet, Dyslipidemia
3. Evaluation of the Management facilities for
prevention and treatment of NCDs: (health providers,
resources, protocols, guidelines, organizations, clients)

Continue ……
• Assessment of the real need and availability of
tools and instrument needed for early
detection of diseases.
• clients awareness and health education

Public Health Gaps in UNRWA
prospective

Public health described as
“The science and art of promoting health,
preventing disease and prolonging life through the
organized efforts of society.”

public health is about:
• Protecting against community health risks and threats
• Preventing illness,
• Promoting health and wellbeing
There are two things that generally distinguish public
health from other health areas:
• Keeping people well
• Focuses on groups of people, not individuals.

UNRWA United Nations Relief and Works Agency for the
Palestine refugees in the Near East (UNRWA)
• Has been established in 1949 with a mandate to respond to the
needs of Palestine refugees until a durable and just solution is
found.
• Started its operations in 1950
• Provides assistance, protection and advocacy to registered
Palestine refugees in the Near East

UNRWA Services
• Health
• Education
• Relief & Social Services
• Micro-financing
• Camp infrastructure &
improvement
• Community support
• Microfinance, and
• Emergency response
during the times of armed
conflict
Slide 53 of 6

Health Programme in Gaza
UNRWA provides
comprehensive Primary
Health Care services:
• 3 major Components -
• Maternal and Child Health
Care
• Non Communicable
(diabetes & hypertension
• General Clinic
• And Psychosocial support,
mental health and
protection.
Slide 54 of 6

• Served refugee population by UNRWA health
programme is about 1,227,156
• (90.9%)
• Geographical distribution covers all areas in
Gaza.
• Ratio of PHC facilities per 100,000 population:
1.6
• AN coverage :95.5%

Population health approach:
UNRWA response and prospective:
• Community participation
– HCs’ friendship committees
– More community involvement
– Participation in planning
• Community awareness and health educations
– Community outreach
– MCI Micro Clinic International (community awareness
related to DM
– Diabetic campaign
– campaigns o other public health importance health events

•Address Crosscutting issues
• FHT helps address cross-cutting issues that
impact health, such as diet and physical
activity, education, gender-based violence,
child protection, poverty and community
development.
Still a challenge -----
.

•Protection issues within PHC services
Protection to vulnerable people –Poor, children, women,
disabled. Their needs to be met.
• GBV-- Gender Based Violence
– UNRWA response by one stop center in the HCs
• Child Protection: a challenge
– UNRWA response: developing a strategy agency wide with
participation of all sectors and departments Health,
education, RSSSP and Community Mental Health –
– Assigning protection officer in each field

Gender Based Violence Cases & CMHP Counseling
Slide 59 of 6
No. Of
beneficiaries
No. Of
sessions
Males Females
GBV 1616 1621 68 1548
CMHP 3342 7732 915 2427

•workforce development and training
The challenge for public health is to evolve
public health focused workforce development
and training.
UNRWA always addresses this need –challenge
due to lack of resources
• Has been put one of priorities in the HP
.

Main Gap in public health of the people in Gaza
is--
• Return Hope to Gaza
• Considering the horrors of what we saw last July and the
very real possibility of it being repeated, we must start
fresh new efforts to return hope to Gaza.
• Otherwise we will be gasping
• UNRWA Advocates for
– Reconstruction
– Lifting the illegal siege
– Help Palestine refugees to fulfill their full rights in
living with dignity and having the right of quality life
and health care

of 6
• UNRWA continues to serve Palestine
refugees despite the challenges to
buffer the effects of health inequalities
and socio-economic hardship.

A Long and Healthy Life
Slide 63 of 6
It is protecting their right to education, health
and social security and enabling them to live
their lives in the fullest, healthiest and most
productive possible way.
Until a political solution is
found, Until
reconstruction of Gaza
until lifting the illegal
siege-- UNRWA is one of
the few hopes for
Palestine refugees.

Dr Marwan Abusada,
Chief Surgeon
Shifa hospital Gaza

Shifa Medical Complex
Surgical
Building

Total injured
people in
GAZA
10870
ER SMC
4195 (42%)
Admission
1792
(42.7%)
Conservative
427 (25.8%)
operation
1080
60%
Admission
to ICU
253 14.2%
Treated at
ER 2403
(56%)

Methodology :4 major events
The massacre against Al Batsh family in Shigaia on 14-
7-2014
The second one on 20-7-2014 Shigaia
Massacre
The third one on 28-7-2014 attack on Children Garden
-Beach Camp
The fourth one attach on Shigagaia market 30-7-2014

Duration of triageMartyrsN. InjuredMassacre
60 min.1725Al Batsh family
12-7-2014
6 hours142804Shigaia-20-7-
2014
60 min.31273Children
garden 28-7-
2014
70 min.33312Shigaia
Market31-7-
2014

Recommendations
• Small ED was the greater challenge to
cope with large number of injured people
so our urgent recommendation is urgent
rehabilitation of our ED with increase of
Triage area

• Assignment senior consultant surgeon or
Senior emergency medicine consultant
to lead the surgical ED

• Training courses for the whole staff in ER
–Administrative ,security ,nursing staff
,and doctors to work as a team

Al- Quds University
Equity in Referrals for Treatment Abroad in
Gaza Governorates: Realities and Implications
Supervisor:
Dr. Bassam Abu Hamad
PhD, Associate Professor- School of Public Health
Submitted by:
Hiba El -Sharif
BSc. of Chemistry – Al Azhar University – Gaza, Palestine

• Referral abroad Services
The purchase of the services from
outside of the Ministry of Health
(MOH, 2013 b)

The total cost of the treatment abroad in 2013
for both the GS and WB was 524,079,618 NIS
GS portion of referral abroad did cost about
208,684,553 NIS in 2013 (MOH, 2013 b)(40 % )
 in 2013 , 17400 referral cases
(16884 referred, 516 non referred )

What do we need to improve ?
General and specific indicators to measure
the equity applications in health practices
need to be designed and integrated in the
national monitoring and evaluation system
of the MOH.
Focus needs to be given on how to decrease
the needs of referrals through increasing
the quality of local services.

The study revealed lack in proper
communication and information access toward
patients following their request, free line phone
number could be put in place to ease the access
of information.
Each central hospital needs to nominate one
person in charge of referrals; this person needs
to be the focal point for the patients, patient
does not need to go himself to follow his file.

Clear procedures to define time needed to get
the answer need to be established.
A system of control and follow up need to
enhanced in order to allow the control bodies
to evaluate the quality of services provided
abroad and to ensure the continuum and
treatment outcome of the cases.

Partnership working for better health in Gaza

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