Border Closures and Nutrition in Gaza

By Dr. Adnan Al-Wahaid

Dr. Al-Wahaidi is a paediatrician based in the Gaza Strip. Originally working for Terre des hommes since 1987, he is now Medical Director of Programming for its Palestinian successor, Ard El-Insan.

The continued support of Terre des hommes, Karim Rida Saed Foundation-UK, Medical Aid For Palestinians- UK, ECHO and the Swiss Government is gratefully acknowledged.

This article describes the nutritional and health consequences of the closure system in Gaza, as experienced by a paediatrician working there.

The political situation in the Gaza Strip has resulted in a high level of international media attention. The vulnerability of the Palestinian people is easy to see by walking through the streets of the overpopulated Gaza Strip, especially in the refugee camps. Population density is estimated at 3,278 individuals per square kilometre, one of the highest in the world. The 362 square kilometres of the Gaza Strip are inhabited by 1,196,591 Palestinians, with one-quarter of the land occupied by less than 5,000 Israeli settlers who began arriving in 1967. The Israeli settlers consume the majority of underground water, which is derived from the coastal aquifer. More than 66% of the Gaza Strip population are refugees who lost their homeland 'Palestine' when Israel was formed in 1948.
Poverty has drastically increased over recent years, while Israeli activities continue to undermine the already poor resource situation of the Palestinian National Authority (PNA). Poverty and poor access to employment have been most responsible for an alarming deterioration in the nutrition and health status of Palestinians, affecting more than 65% of the Gaza Strip population. Local, national and international organisations have implemented well-intentioned interventions in order to address existing food and nutritional problems. However, the quality and relief focus of this work has, on occasion, drawn criticism, particularly with regard to sustainability.
Ard El Insan Palestinian Benevolent Association (AEI) is the Palestinian counterpart of the Swiss organisation Terre des hommes (Tdh). Many international organisations4 contribute to AEI to support its activities in advocacy, child and family health and community nutrition. Recognising the interdependence of nutrition with health and other sectors, AEI undertakes a variety of preventive and curative health care activities, as well as work aimed at improving the nutrition and food situation of the Palestinian people, especially during stress periods.

Food security in the Gaza Strip

AEI have four operational centres in Gaza, where they work closely with the Ministry of Health and other health providers to incorporate longer term national nutrition strategies

Palestinians are well known for being generous. Their hospitality is, to some degree, measured by the variety of foods served to their guests. However, nowadays, people partly define their grinding poverty in terms of no longer being able to serve their guests a diverse meal. The population is now dependent on rations or food donations from outside. The loss of self-sufficiency, and absence of land that allows choice of food, creates a strong sense of indignity. These difficulties are compounded by political and military actions, which can result in border closures and demolition of houses, crops and gardens.
Most people in the Gaza Strip buy their food from the market since they lack land for cultivation. Although there are many types of food in the market, supplies are irregular. Unemployment has reached catastrophic levels in the Gaza Strip (more than 60%). This has translated into very limited purchasing power for food. Dependency ratios have increased dramatically and in many families, food purchase is sacrificed for other urgent needs such as treatment of diseases or paying back debts and loans. Other factors which constrain access to food include difficulties in importing/exporting goods due to disrupted logistics caused by Israeli activities, prolonged sieges, curfews, border closures, road blockades and the direct impact of military operations, incursions or raids.
The lack of capacity to cook food on a daily basis is another big problem, often caused by inability to buy the gas or fuel, which is more expensive in the Gaza Strip and the West Bank than in any of the surrounding countries. People are therefore forced to borrow the fuel or borrow cash for fuel purchase. There are also numerous occasions when fuel or gas cannot be imported into Gaza, or may not even be allowed to be conveyed from one area to another inside the Gaza Strip, simply because of border closures lasting from hours up to several days. Electricity supplies are also problematic due to the poor infrastructure, resulting from decades of 'disabling' Israeli regulations and the complete dependency on Israel. Poor households cannot pay the bills and may lack refrigerators. Hence they are deprived of adequate storage facilities for fresh foods. Resulting dependence on dry food rations and canned alternatives, in addition to poor quality water, are direct causes of micronutrient deficiencies like iron deficiency anaemia and rickets.
This tragic situation has dramatically affected the nutritional and health status of the Palestinian people. Contributing factors to malnutrition include poverty, poor infrastructure, low levels of sanitation and high levels of food insecurity. Vulnerable groups such as children and pregnant or lactating women are compromised further as a result of inadequate nutritional supplementation, leading to higher risk of stillbirths, premature deliveries and low birth weight babies. Chronic nutritional deprivation is adversely affecting the majority of the Gaza Strip children and other vulnerable groups, ensuring a legacy of poor health status as well as impaired physical and mental development.

Nutritional status of Palestinian children

AEI have four operational centres in Gaza, where they work closely with the Ministry of Health and other health providers to incorporate longer term national nutrition strategies

The deterioration in nutritional status of Palestinian children has become well recognised at both national and international levels. Results of a nutrition survey carried out in August 2002² found 13.2% of children in the Gaza Strip suffering from acute malnutrition. This compares unfavourably with survey figures from 1995, where only 5.7% of children under 5 years were acutely malnourished (<-2SD of the reference weight for height)³. More recently in March 2003, provisional findings from a study by AEI and Accion contra el Hambre (Madrid) indicate considerable food insecurity and economic vulnerability in the Gaza population⁴.

AEI activities

The main target groups of AEI are those living in the most needy areas, those who reside near the Israeli settlements, and areas subjected to military Israeli incursions. Alongside relief and medical care, community health programmes have been developed which include intensive breastfeeding counselling plus health and nutrition education. This approach aims to increase people's capacity to cope with the ever increasing nutritional and health demands, while working closely with the Ministry of Health and other health providers to incorporate longer term national nutrition strategies.

AEI have four operational centres in Gaza - one at Nusseirat middle camp, one in Khanyounis and Rafah, one in the south and one in the north (Jabalia camp of refugees). The community health team operate as two mobile groups, one in the north and another in the south, and comprises 24 community health workers. These work in support of the centre-based activities and outreach services into more inaccessible areas.

Each operational centre comprises:

• a medical and nutritional assessment unit
• a growth monitoring unit (GMU) which provides follow-up of severely and moderately malnourished children, and nutrition education
• a special care unit for specific nutritional treatment, such as nutritional anaemia, coeliac disease, and rickets
• a breastfeeding counselling unit, for mothers who present with breastfeeding difficulties.

During 2002, 8,163 new cases were managed at the centres, of which 6,750 were undernourished and/or anaemic children. Overall, 40% of new cases (n=3265) were assessed at the medical and nutritional assessment unit, 589 cases (7.2%) in the special care unit, 604 cases (7.4%) in the GMU and 16.4% (n=1344) in the breastfeeding counselling unit. In the community, 3,116 undernourished children were treated in the same period.

The unprecedented magnitude of the health/nutrition and socio-economic problems currently seen in the Gaza Strip has led to an expansion and strengthening of AEI services. New staff members have been recruited and more activities have been directed to the deprived areas and locations where life has become extremely difficult due to Israeli military activities, e.g. Rafah, Beit-Hanoun, and areas close to the settlements. However, our capacity remains stretched, while a combination of food insecurity and safety problems continues to pose enormous challenges to the Ministry of Health and non-governmental organisations (NGOs). Many of the challenges to food security and nutrition, including the role of the Israeli 'occupation', the safety of Palestinians and the deteriorating food nutritional situation, were raised in a UN meeting 'food as a human right', attended by AEI and Palestinian NGOs in Gaza in July 2003.

Concerns for the future

Continued and prolonged food deprivation will clearly lead to further deterioration in the nutritional situation of Palestinian children and other at risk groups. This will in turn lead to higher morbidity, e.g. respiratory tract infections, diarrhoeal diseases and intestinal parasites and resulting mortality. Unless steps are taken to ameliorate the situation, this will have significant and unacceptable nutrition and health implications for future generations of Palestinians.

For further information, contact: AEI, email: aei-pal@hally.net or Mr. Khalil Marouf,Tdh, e-mail: khalil.marouf@tdh.ch

¹Contributors to AEI include Medical Aid for Palestinians UK (MAPUK), Karim Rida Said Foundation UK (KRSF), Terre des hommes, ECHO, NPA, IRFAN Canada and IBFAN

²Nutrition survey, Johns Hopkins University School of Public Health, Gaza, August 2002

³Nutrition survey, Terre des hommes, 1995

⁴Nutrition survey, Accion contra el Hambre and AEI, March 2003