Years of living dangerously
AL-AHRAM Weekly, 31 Oct. - 6 Nov. 2002 Issue No. 610
Armed conflicts have exacerbated the health situation across the region. HALA SAKR investigates the relationship between health and war and highlights the problems created by the US use of depleted uranium in Iraq, and interviews the WHO chief
ALTHOUGH THE END of the Cold War was supposed to usher in a more peaceful and stable world, conflicts have erupted in virtually every continent, with devastating consequences for the civilian population. As the technology of war advances, the situation becomes more desperate. The way armed conflicts interfere with people's physical and mental health, their basic human rights, and the environment in which they live is alarmingly varied, and it outlasts conflicts. The heavy toll includes "Loss of life, disability, loss of infrastructure and resources, displacement, migration and... the constant tension, which has led to an increase in mental ill- health," according to Hussein Al- Geziary, director of the Eastern Mediterranean Regional Office (EMRO) of the World Health Organisation (WHO).
Wars and disturbances in this region have left a variety of visible and invisible traumas in many countries. Palestine, Iraq and Afghanistan are obvious examples. According to EMRO, war claimed the lives of 39,000 people in the region in 2000.
EMRO held their annual regional meeting in Cairo earlier this month. Another meeting was organised by the Islamic Organisation for Education, Science and Culture (ISESCO) in collaboration with EMRO to discuss the impact of occupation and assault on the mental health of civilians, in Cairo on 22 October.
In both meetings Palestine was high on the agenda. No occupation other than the Israeli occupation and no civilians other than the Palestinians were mentioned on any of the three days of the second meeting.
During the regional committee meetings Iraq's problems were briefly discussed, but not at length, to the disappointment of Iraqi health officials. Only Iraqi experts brought up the problematic issue of depleted uranium (DU). In fact, one of EMRO press releases (26 Sept 2002) singled out Libya, not Iraq, as an example of the adverse impact of sanctions.
Sohaila Seddiq, the first woman to ever serve as public health minister in Afghanistan, was among those who attended the EMRO meetings. She was not available for interviews, however.
Increased regional turmoil has placed exceptional responsibilities on the UN and WHO. A June 2001 report, entitled WHO's Core Commitments in Emergencies, lists the agency's mandate in troubled zones. It says that the WHO should advocate and negotiate for secure humanitarian access, and for the neutrality and protection of health workers, services and structures. The WHO's goal is to reduce avoidable loss of life, burden of disease and disability in emergencies and post-crisis transition. Yet to what extent do shifting global moods affect the work of the WHO and other international organisations?
The Palestinians are critical of the WHO. "The core of the issue is that they are not really interested. It is all words and no deeds," said Imad Said Taraweyeh, director general at the Palestinian Ministry of Health. "They are not fulfiling their humanitarian and medical responsibilities when the need for their support is crucial," he charged.
The Iraqi delegation echoed the same sentiment. "The WHO should have a stronger presence in the current crisis of the Iraqi people, even if its work is haunted by political and institutional sensitivities," said Iraq's Health Minister Umeed Medhat Mubarak. What the Iraqi delegation encountered in the 55th World Health Assembly of the WHO, held in Geneva last May, is one explicit example. "With the support of Russia, we were supposed to be among the main speakers on the issue of depleted uranium and were allotted 20 minutes," the minister recalled. As the meetings proceeded, the whole issue was rolled back to the very last session, which took only 45 minutes of the whole assembly. "We were informed that we would only get three minutes. Yet the discussions continued for two and a half whole hours. There has been a substantial change in public opinion," Medhat Mubarak said.
This same assembly requested a personal visit by WHO Director General Gro Harlem Brundtland to the occupied Palestinian territories to assess the health situation on the ground. According to Brundtland, she was "not given" that "opportunity". "The Israeli denial of the director general's visit is a clear indication of Israel's continuous non-compliance to UN or WHO resolutions," said Abdel-Aziz Saleh, former deputy regional director and consultant to EMRO.
That the Israelis should obstruct such an assignment came as a surprise to Mustafa Al- Barghouti, director of the Union of Palestinian Medical Relief Committees. "Unlike Jenin, this visit was not linked to an investigation of a massacre or anything. It was very general," he remarked. "In fact, I have asked Brundtland twice to pay us a visit but she never did."
The WHO director general asserted that the visit would enable her "to assess further the findings... and facilitate an appropriate response". But what if the visit cannot be made? Al-Barghouti told Al-Ahram Weekly that "no further clarification is needed. All the factors necessary to declare the Palestinian territories as a humanitarian disaster area are available."
Along the same line, Soheir Morsi, professor of medical anthropology, places the dilemma in a global context. "At a time when the UN itself is under siege, the WHO is no exception. It is subject to pressure, not from governments, but from the 'Government' of the unipolar world," she said, referring to how US policies affect the work of international agencies. "WHO has abandoned its own Alma Ata Declaration of 1978 which established the right of all people to affordable, accessible and comprehensive health care. This orientation was undermined by Structural Adjustment policy imposed by the World Bank and IMF," Morsi argued.
"The emphasis has drifted away from the conceptualisation of health as a public good to its consideration as a private matter best promoted through market mechanisms. Health rights were thus undermined by the policies of international financial institutions," Morsi said, noting that even within the besieged UN, there are people who oppose the newly imposed directives.
Ambassador Zoheir Al-Shelly, veteran Tunisian diplomat and honourary head of the United Nations High Commission for Refugees (UNHCR) in Tunisia, however, argued that "in a global atmosphere, in which international law and international legitimacy have lost their essence, any attempt to improve already existing frameworks is apt to fail."
The only positive comment came from the Afghans. Abdullah Fahim, head of the international relations department of the Afghan Ministry of Public Health, spoke briefly to Al- Ahram Weekly. "We have a one-year action plan with WHO. They are our all-time partners in the health sector. They help us to develop different policies and strategies," he said.
EMRO's Abdel-Aziz Saleh underlined that the WHO managed to work in Afghanistan for a long time through all the political changes and conflicts. "Our approach was to keep politics aside. We were only concerned with health systems. Hence, we were accepted and respected by all political factions and under all regimes," he explained. "Nevertheless, the problems of Afghanistan are very complex. There is a great need for more efforts."
Abdullah Fahim recounted his country's ordeal. "In Afghanistan, we have extremely high maternal and child deaths. Tuberculosis, Malaria and communicable diseases are quite prevalent. Malnutrition is no less of a problem with percentages of up to 50 per cent for chronic cases and 25 per cent for acute ones. Let alone the complexities linked to the post-conflict situation; mental health and disabilities."
The WHO may have steered away from politics in Afghanistan, but the agency had less luck in Iraq and Palestine. The Palestinians have been striving to survive a brutal and unchecked military occupation, one that continues to ignore UN resolutions with apparent impunity, and one that seems to be intentionally targeting the health system and infrastructure on an unprecedented scale.
"A recent US study showed that Israel was number one in the whole world in terms of total violations to Security Council resolutions," said Al-Barghouti of the Palestinian medical relief committees. In a press conference he held last May, Al-Barghouti pointed out that Palestinians have been deprived of medical care and treatment since the beginning of the Intifada, due to military closures, siege and curfews. "Emergency health personnel have been repeatedly attacked and humiliated. Hospitals and clinics have been shelled and ambulances shot in order to obstruct the medical services and paralyse the health sector," he said.
According to Palestinian Health Minister Riad Al-Za'anoun, 40,000 people have been wounded since the beginning of the Intifada. Of those, 5,500 are now disabled. The dead are 2,500, including 780 children.
"The International Committee of the Red Cross and UN agencies, including the WHO, have seriously failed to conduct what would normally be their duty in any occupied territory due to political reasons. They are absolutely frightened of the Israeli reaction," Al-Barghouti said.
EMRO's Abdel-Aziz Saleh admitted that the WHO faces many obstacles on the Israeli side. "Our support remains limited. We cannot claim that we are really doing what should be done, but definitely things are beyond our control," he said.
Rita Giacaman, director of Community Health Programme at Birzeit University, pointed out that due to certain political peculiarities, problems surface even when international aid is available, "There are pre-conceived ideas about what should happen here and preset policies, defined in the country of origin and in line with how priorities are seen there, not here," she said. To her this adds "insult to injury as those [policies] are not integrated into a hole that makes sense on the ground".
In Iraq, things are not any better. The health sector has been hit hard by the 1991 conflict and the subsequent economic sanctions. According to the WHO, the quality of health care has been put back by at least 50 years. Hospitals are falling apart, Iraqi doctors cannot get the drugs they need, and medical equipment is rendered useless by the constant lack of spare parts.
"The impact of the aggression/embargo and the interplay between both elements are vividly clear when one deals with the case of Iraq," points out Ashraf Al-Bayoumi, professor of chemistry at Michigan State and Alexandria universities and former head of the observation unit of the World Food Programme.
Iraq used to have a very strong health system before the sanctions. In 1994-95 the situation was at its worst. "No human being could accept the way things were," asserted EMRO's Saleh. In 1996, the Security Council passed Resolution 986, launching the Oil for Food Programme, which allows Iraq to import food and medicine in return for limited amounts of oil exports. After this, "things have relatively improved," he noted.
Iraqi Health Minister Umeed Mubarak pointed out that mortality rates, particularly among children, have soared. Malnutrition has increased 36 folds. This is because the government's ration cards can only provide the average Iraqi with one third of the daily nutritional needs.
According to surveys conducted in 1999 by UNICEF and the Iraqi government, the death rate of children under five in southern and central Iraq more than doubled in the decade starting 1989, due to the combined effect of sanctions, two wars and the collapse of investment in social services.
During the Gulf War, the allied forces destroyed electric power stations. This was detrimental to water purification and sewage pumping giving rise to numerous public health problems. "Before the war, 96 per cent of our population had access to clean water supply. Now, 86 per cent have no clean drinking water," said the Iraqi health minister. According to Iraq's Ministry of Health, epidemics and flare-ups of cholera, hepatitis and typhoid became common following the sanctions. The same happened in Jenin and Nablus in Palestine.
In Iraq, things may be worse because chlorine, a substance needed for water purification, is considered a "dual usage" item. The so-called "dual usage" items are problematic, noted EMRO's Saleh. "Laboratory media for the recognition of causative micro organisms are rejected for fear of their utilisation in biological weapons. Nitrous oxide, needed for anaesthesia, is rejected for fear of usage in explosives. And so on."
The Iraqi health minister said the WHO should help Iraq obtain anti- cancer drugs and resolve other urgent health issues. Saleh's reply was that the WHO constantly briefs the sanctions' committee and provides technical justifications regarding the essentiality of rejected items and medicines for health. But there seems to be no improvement on that matter according to the minister.
Another serious problem is long-term development. "The problem with the Food for Oil arrangement is that the operation is merely humanitarian, supporting essential commodities. It provides no resources for the rehabilitation and further development of the health system. Perhaps there is better supply of food, drugs and reagents but the basic infrastructure for water and sanitation does not exist," explained Saleh.
The situation in Palestine is complicated in other ways, for there are two de facto Palestinian administrations, one in the West Bank and one in Gaza. Rita Giacaman of Birzeit University pointed out that emergency situations put extraordinary pressure on the health system. This, she argued, does not need to be the case. "Immediate emergency survival should not necessarily contradict longer-term development objectives. The problem is that those two are usually seen as divergent. This adds to the problems of future sustainable development."
"In addition, how can any plans in health be executed without the pre- requisite development by Palestinians of a health policy integrally linked to an overall development policy emanating out of a unified view of what kind of Palestine we would like to build," Giacaman added. "It is very difficult, within this framework, for Palestinians to take the lead in charting out the path of development of their country."
EMRO's Saleh concedes the problem. "Palestine is currently in a very serious emergency situation. We cannot expect a regular programme of cooperation to be appropriate. What we are doing now is keep in regular contact with them. We do our best to provide the resources and means to respond to their needs. But our resources are limited and access is not easy."
Resources pose a problem in Afghanistan as well. The Afghans are not receiving the support promised by the international community after the war. "Out of the $172 million that we were promised this year, we only received $70.5 million. For eight months, we simply received nothing. This is hindering all our health programmes," complained Abdullah Fahim of the Afghan Ministry of Health.
Ismail Al-Tellawy, Palestine National Committee for Education, Culture and Science, voiced the same complaint. "We received only one third of $800,000 promised as an emergency aid by the Arab Organisation for Education, Culture and Science (ALECSO) last June. ISESCO gave nothing for emergency, but we got $200,000 of our usual share of their budget -- $360,000 as decided last December," he said. The UNESCO, however, never provided any of the one million and 135 000 dollars allocated for Palestine by its executive board in July this year. "And if we do receive them, almost 40 per cent will go to their experts and visits and the like," lamented Al-Tellawy.
But regardless of the bleak picture and the negative impact of having a population crippled by dehumanisation and trauma, securing the well being of ordinary people in conflict can never be a luxurious option. It is a basic human right and, in the words of the renowned medical journal The Lancet, "the inescapable duty of any nation that considers itself to have any true meaningful role in world affairs" (April 13, 2002).
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