The Nature of Disability in the occupied Palestinian territories (oPt) and the Impact of Working in a Crisis Zone
Lesley Dawson, PhD, Consultant in Heath Care Training and Education, UK
Correspondence concerning this article should be addressed to Lesley Dawson
The occupied Palestinian territories comprise the West Bank [including East Jerusalem] and the Gaza Strip. The West Bank is 5,800 sq. km. and the Gaza Strip is 365 sq. km., separated by 80 km of Israeli territory (Index Mundi 2017). The population is estimated to be around 4 million, of whom 50% are refugees and 1.4 million reside in the Gaza Strip (WHO 2009).
This discussion is set within the context of an Arab society, with overall literacy rates at around 96% (UNESCO 2017). The major towns in the West Bank are East Jerusalem, Bethlehem, Hebron, Ramallah and Jenin, and in the Gaza Strip are Gaza City, Rafah and Khan Younis, each surrounded by various refugee camps and villages. Most of the population are Muslims with a minority of less than 2% Christians (Tighe 2016). This Arab world cultural and religious context affects the nature of disability in the oPt. Its values are mainly Muslim and the Christian community holds Eastern Christian values, which are closer to Islam than western Christianity (Marsh 2012).
In this context the family is more important than the individual, children are very important within the family, and it is a patriarchal society with great respect shown to older family members, especially men. While in theory disabled people are accepted in Islamic society (Pervez 2013), physical beauty and wholeness are important for marriage prospects, especially for girls (Al Aoufi et al 2012).
The birth of children with disabilities is often seen as a divine punishment and a shame on the whole family, especially the mother (Atshan 1997), and access to rehabilitation for children favours boys more than girls. Disability developed later in life may also be seen as a mark of divine disfavour or testing, unless as a result of an injury sustained in the on-going political conflict (Boston Healing Landscape Project 2012). Those disabled in the political conflict may be viewed as political heroes. Older people disabled as the result of disease will be cared for within the extended family, usually by the women in the family, as is the case in most Arab societies (Al Oraibi et al 2011).
It is not possible to put aside the effects of the political situation when discussing life in the oPt. Occupation, for some residents since 1948, for others since 1967 and refugee status, the effects of the First and Second Intifadas [uprisings against Israeli occupation], the setting up of the Palestinian National Authority, the invasion and subsequent closure of Gaza and the bombing of major towns in the West Bank must be taken into account (McNeely et al 2013, Barber et al 2012, Vitullo et al 2012).
The situation in Gaza is particularly problematic. A report from the International Society of City and Regional Planners indicates that 57% of people in Gaza endure food insecurity and 95% of mains water is unfit for human consumption (ISOCARP 2105). The economic situation has declined dramatically over the last ten years because the Israeli military incursions and blockade have prevented male day workers exiting the Strip to gain work in Israel and there are limited opportunities for work and a lack of resources within Gaza. Unemployment figures for the whole oPt are 29% with 44% in Gaza, which is an increase of 30% since the beginning of the 21st century (World Bank 2017, CIA World Factbook 2015). Access into Gaza for humanitarian aid and other goods is restricted by Israel (OCHA 2017).
Whether the oPt is part of the developed or the developing world is debatable. Because of their proximity to Israel and social interaction with Israelis, it could be argued that the oPt is part of the developed world and the presence of diseases such as stroke and diabetes would confirm this (Mosleh et al 21016, Mikki et al 2012). However the fact that there is a high incidence of malnutrition, high maternal mortality and child developmental disability points towards them having a developing world status. Some researchers have described Palestinian society as one that is in transition, containing elements of both developing and developed worlds (Bargouthi and Lennock 1997, Dawson 1999, WHO 2009).
The health service context within which disability services are set is complex and fragmentary. Government hospital services are located in all the main towns and cities and provide both in-patient and outpatient care. They have suffered from neglect under the Israeli occupying authorities since 1967 and before that by Jordanian government neglect (Gordon 1997) compounded by a lack of regular funding since the return of the Palestinian National Authority [PNA]. The larger hospitals, where major surgery is performed and oncology services are located, are in East Jerusalem and are not easily available to West Bankers because of lack of permission to travel. All health services in Gaza have been affected by the various recent Israeli incursions but it is possible for some patients with cancer to access the hospital services at Augusta Victoria Hospital in East Jerusalem. Community medical clinics are available in some parts of the oPt and some mobile clinics reach to remote villages in the West Bank mostly provided by local and foreign Non-Governmental Organisations [NGOs] (Tucktuck et al 2017). Additionally there is a small private health sector.
All registered refugees [38.6% of the population] are entitled to free outpatient care at the United Nations Relief and Works Agency clinics attached to most of the refugee camps (UNRWA 2016) which have access to government in-patient services when necessary. A very small percentage of the population can afford private treatment.
Public sector workers are insured for consultations and most treatments but not for diagnosis or medications. The number of insured has increased since the PNA took over government health services, while health revenues have decreased. This has resulted in families needing to supplement health expenses from their own resources or unable to afford health care because of high costs and financial hardship (Mataria et al 2009).
The nature of disability in the oPt
Using “the narrow definition” of disability which includes only persons with significant disability, the World Bank (2016) and the Palestinian Central Bureau of Statistics (2011) indicate that 2.7 % of the Palestinian population are affected by disability. This figure rises to 7% when all persons with disability [PWD] are included (Madans et al 2011). Overall prevalence includes visual, hearing, communication, intellectual and mobility disabilities, with the highest percentage being mobility disabilities at 48.4% and learning disabilities at 24.7%. Disability rates are higher among the 75 year and above group at 32%, and prevalence of disability among children between 0 – 17 years is 1.5%. Over one third of PWD 15 years and older have not been to school, despite inclusive education possibilities for the past 16 years and despite 5% of public sector jobs being reserved for PWD, the vast majority of PWD do not work (World Bank 2016).
Some rehabilitation services are provided by the Palestinian Ministry of Health at national level and NGOs and the United Nations Works and Relief Association for the Middle East [UNWRA] at intermediate and community levels, but much of the long term rehabilitation of those with disabilities is supported by international NGOs (Harami et al 2010) such as Handicap International [HI], Medecins sans Frontieres [MSF], Medical Aid for Palestinians [MAP] and the International Committee of the Red Cross [ICRC].
Palestinian society has concentrated its attention mainly on physical disability. People with sight and hearing impairments are well served with centres in Jerusalem and major towns in the West Bank and Gaza Strip, as are children with developmental problems (Bar-Haim et al 2010). As a result of disabilities sustained during the First Intifada, other centres dealing with spinal cord injuries, head injuries and limb gunshot wounds were established, initially by international NGOs which were later transferred to local staff and funding. The model of disability espoused by the Ministry of Health is still mainly a bio-medical one, although the development of Community-Based Rehabilitation [CBR] indicates a move by many rehabilitation personnel towards a social model of disability, by promoting empowerment of PWD, advocacy of human rights and social inclusion in the community, alongside the provision of appropriate physical rehabilitation, This change has come about through the work of local NGOs such as Palestinian Medical Relief Society (Layton 2009). The establishment of the Palestinian General Union of People with Disability in 1991 has also moved this agenda forward with the assistance of INGOs such as Diakonia and Sida (PGUPWD 2017).
Long term mental illness and cognitive disabilities were much slower to be recognised and provided for. The impetus for mental illness provision was from depression among adult males unable to gain work, children witnessing confrontations between the Palestinian young male civilians and the Israeli Defence Force [IDF] and by psychological problems encountered by released prisoners (Giacaman et al 2005, Wahbe 2009). Cognitive/learning disabilities account for 24.7% of PWD in the oPt overall, 23.6% in the West Bank and 26.7 in the Gaza Strip (World Bank 2016) and are provided for through NGO services such as Star Mountain and L’Arche (Baroody 2016).
A lack of provision of facilities has affected the status of disabled people. The number of rehabilitation personnel is said to be similar to Jordan at less than 1 per 10,000 of the population (WHO 2011, page 109). This figure includes physiotherapists, occupational therapists, speech and language therapists, psychologists, CBR workers and rehabilitation doctors. Training and education of many of these professionals was initiated by international NGOs and foreign universities, particularly during the First Intifada and is now continued by local NGOs and local educational establishments. In the West Bank UNRWA, Arab American University in Jenin, Bethlehem University, Palestine Alahliya University and Al Quds University are educating rehabilitation professionals and in Gaza such education and training is being undertaken by the Islamic University, UNRWA and Palestinian Red Crescent Society amongst others. The bottle neck preventing these graduates entering the work force is too many student places, lack of job opportunities in the public sector, limited funding for jobs and low wages (Palestine Central Bureau of Statistics 2004, O’Connor 2015, Giacaman et al 2003). In Gaza those who work for the Ministry of Health may not be paid at all (Halabi 2015).
The location of rehabilitation centres are in the main conurbations, such as the Amira Basra Centre for Disabled Children in East Jerusalem, the Bethlehem Arab Society for Rehabilitation in Bethlehem District, the Star Mountain Centre and Abu Rayah Spinal Injuries Centre in Ramallah in the West Bank. The main centre in Gaza City, El Wafa Rehabilitation Centre, was destroyed during the Israeli military incursion in 2015 (Barrows-Friedman 2015) but rehabilitation is still available at MOH out-patient clinics and HI and MSF clinics there. The PRCS Al Amal Centre in Khan Younis provides rehabilitation in the south of the Gaza Strip. There are UNRWA clinics that include rehabilitation in each refugee camp that deal with the whole range of physically impaired and disabled patients (UNRWA 2016). Many disabled people live in rural areas with limited transport and problems of movement from area to area, as a result of checkpoints and closures. There are also gender issues, with some clinics (especially UNRWA clinics) maintaining a policy of staff only treating same gender patients.
CBR programmes have had a pronounced impact on the lives of individuals with disability and their families. They have also had a positive impact on awareness, attitudes and behaviour towards individuals with disability in their communities (Eide 2009, Harami et al 2010). However Giacaman (2009) warns that, (as) such support is expected to be provided voluntarily by women in the family because it is seen as a “pre-defined sex linked role” in the context of a patriarchal society in which women are excluded from economic and social decision making.
Developmental disability in oPt may be linked to a range of issues, such as close family marriage leading to genetic problems, poor obstetric services with a lack of sufficient trained midwives and the effects of tear gas on pregnant women. Maternal exposure to psychosocial, economic and political stressors is associated with low birth weight (Abusalah and Radwan, 2012) and affects the health of pregnant women and new babies. Disability sustained as a result of injury or disease such as stroke or amputation due to diabetes is quite common (Abu-Rmeilah et al 2012, Amro 2012). In general, older people are disproportionately represented in disability populations (WHO 2011 page 35). In a survey of Palestinian people aged 50 years and older, 29% reported at least one disability (Jasser et al 2017) and reflects an accumulation of health risks across a life span (WHO 2011 page 35).
Disability as a result of trauma, such as road traffic accidents, gunshot wounds, injuries sustained during shelling, bombing and landmines is seen in Palestinian society (WHO 2011 page 34). Disability is often exacerbated by delays in obtaining emergency health care and rehabilitation because of barriers to travel. During 2006-2007 during the eruption of the Second Intifada records from three hospitals in Nablus indicate that gunshot wounds were the major cause of head injury (Younis et al 2011). Small towns and villages in the West Bank and Gaza Strip have limited rehabilitation services. They are often inaccessible due to lack of transport or barriers to travel, limiting early treatment for traumatic impairments (McCoull 2008). Of the 40,000 Palestinians injured during the political conflict between 2000 - 2003 25,000 were permanently disabled, of whom 500 were children (The Palestinian Monitor 2003). The present political situation would lead one to believe that these statistics will be similar today.
The impact of living and working in a crisis zone
In whatever context, disabled people are those most likely to be undernourished, neglected and at risk in a crisis situation. Violence and humanitarian crises contribute to disability (WHO 2011, Page 59) as discussed in the previous section describing disability caused by trauma. Conflict situations also make people with disabilities more vulnerable (WHO 2011 page 108) as mobility is often limited and they are less likely to be able to evacuate from violent situations.
There is an obvious impact on patients and their families living outside the main areas of Jerusalem, Bethlehem and Ramallah who face long delays at check points and road closures as they seek to access centres of treatment. The inability to access centres in Jerusalem without the appropriate permits and the need to stay overnight in residential rehabilitation centres causes a dilemma for families with other dependents at home. For Gazans, the near impossibility of gaining permission to leave Gaza (UNOCHA June 2012), the restrictions on travel and the current harsh socioeconomic conditions affect everyone.
There is also an impact on healthcare staff that face similar barriers of check points, road closures and lack of transport to access their work settings (Ramon et al 2006, UNOCHA September 2011). Obtaining permits from Israeli authorities, concern about their family whilst at work in another location and not knowing what will happen from day to day are additional concerns for health professionals (UNOCHA December 2011). Those living in the West Bank, (outside the Separation Wall) and working in Jerusalem may have to cope with long hours of travel to get to work and uncertainties about being allowed access (Keelan 2016). These restrictions on travel particularly affect female health professionals as families may forbid them to travel in conflict situations. All these restrictions contribute to well-trained staff leaving the country because of the political situation.
The nature of disability in the occupied Palestinian territories is a complex issue with many strands. Disability there affects the whole age range, with different causes for childhood and adult disability. Physical disability is better understood than mental and intellectual disability, although the emergence of psychiatric problems among children and adults as a result of the effects of the long-term occupation and political conflict has raised the profile of mental disability but provision for people with intellectual disabilities is still mostly provided by NGOs. Provision for childhood disability continues to be a priority as does that for those disabled as a direct result of political conflict. Disability resulting from non-political trauma or disease receives limited attention.
The increased emphasis on disability in general is beginning to have an impact on Palestinian society, because of the contribution of INGOs and their local partners. The Palestinian Authority has produced national plans for rehabilitation (Ministry of Social Affairs 2011), supported financially by the World Bank (2000) but the implementation of these plans is limited by lack of funding and vision (Giacaman et al 2003) and the limitations on movement on goods and people (Giacaman et al 2009). Individual groups, such as UPMRC, Birzeit University, Bethlehem Arab Society for Rehabilitation in the West Bank and others, Medical Aid for Palestinians, Handicap International and others in the Gaza Strip provide services in different parts but plans are often derived from donor strategies (Ghadour et al 2017) and there needs to be a way for all those concerned and responsible to become accountable (Horton 2012).
The impact of the political conflict continues to negatively influence the lives of people with disability, impacts on the implementation of a national plan for the Disability Sector, the development of disability programmes and affects the work and lives of those who provide rehabilitation services for Palestinians with disabilities. This is borne out by the Commission on Social Determinants of Health who argued that “Where people live affects their health and chances of leading flourishing lives” (WHO 2008).
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