The infant death rate in Gaza has increased for the first time in five decades, epitomizing the health crisis of a population under siege.
This new revelation from the United Nations comes on the heels of a statement in July by the United Nations' humanitarian coordinator for the occupied territories, Robert Piper, who said that maternal mortality rates in Gaza "are estimated to have nearly doubled in the last 12 months."
Physicians and aid workers say that Israel's eight-year-long siege on Gaza, which has contributed to an extraordinary lack of basic infrastructure, including restricted access to potable water, electricity, nutrition and specialized health care, is the most likely source of these troubling rates.
UNRWA is the UN agency for Palestine refugees. In Gaza, refugees from Palestinian land taken by Israel since 1948 make up approximately 80 percent of the population. The agency states that although the infant mortality rate has "consistently gone down over the past several decades in Gaza," figures from their latest survey mark the first time rates have increased - from 20.2 per 1,000 live births in 2008 to 22.4 in 2013.
"The rate of neonatal mortality, which is the number of babies that die before they reach four weeks, has also gone up significantly in Gaza, from 12 per 1,000 live births in 2008 to 20.3 in 2013" - a 70 percent increase in the span of just five years, the UN adds.
Indicators of Health and Well-Being
Dr. Akihiro Seita is the director of UNRWA's health department. In the UN's press release, he stated that the rise in infant mortality rates in Gaza is unprecedented. "Progress in combating infant mortality doesn't usually reverse," he added. "The only other examples I can think of are in some African countries which experienced HIV epidemics."
The health sector across the Gaza Strip has been in a constant state of crisis for nearly a decade.
Seita explained to Truthout that the agency's findings are profoundly concerning. "The infant mortality rates are quite often used as an indicator for not just the health, but the well-being of populations. I worry that the general well-being in Gaza is getting worse," he said.
Seita described a similar reverse trend that appeared in Iraq in the 1990s, beginning with the US-led invasion and bombings, which then followed with nearly a decade of sanctions.
The causes of neonatal mortality in Gaza, Seita said, are mostly due to premature births and congenital abnormalities, as well as some infections. "Pre-term births and [babies with] genetic abnormalities need specialist care in hospitals," he told Truthout. "If we see these increasing trends related to these two conditions, our worry is that specialist care needs more improvement."
Seita pointed to the World Health Organization's recent findings, which indicate a general decline in hospital-based specialist care in Gaza.
A Constant State of Crisis
The health sector across the Gaza Strip has been in a constant state of crisis for nearly a decade, as Israel's siege - co-sponsored by Egypt, and with financial and political backing by the US - restricts the import of fuel, construction materials, basic medicines, medical equipment and medical supplies.
Along with infrastructure and health services, another indicator in assessing the overall health of a population is access to clean water. In Gaza, more than 90 percent of the groundwater has been labeled unfit for human consumption for years. Aquifers have been over-pumped and contaminated as raw sewage treatment plants cannot be properly maintained or repaired due to Israel's siege.
During last year's 51-day assault against Gaza, which killed approximately 2,200 Palestinians including 551 children, Israeli airstrikes and tanks targeted hospitals, clinics, healthcare workers and ambulances.
An increasing number of patients in Gaza need specialized care outside of the strip, but obtaining transfer approval by Israeli and Egyptian authorities to leave Gaza can take months. In May, the World Health Organization (WHO) documented the case of an 80-year-old Palestinian woman who died after being stuck at the Rafah crossing, at the Gaza-Egypt border, in soaring temperatures.
In June 2015, the WHO's Gaza office head Dr. Mahmoud Daher said that "equipment exhaustion, limited technical capacity and the chronic shortages of medicines and medical disposables have increased the need for patients to be referred for more costly referral treatment outside of Gaza, primarily to Palestinian hospitals in East Jerusalem. However, access is difficult and is contingent on obtaining Israeli approval which is not always granted."
Dr. Ghada al-Jadba, a Gaza-based physician in charge of UNRWA's chief field health program, told Truthout that she has worked with families who have lost their infants. She described the recent case of a young mother, whom she calls M., who lives in Shujaiya, one of the most marginalized areas east of Gaza City which was heavily bombed during last summer's attack.
"M. delivered prematurely - two months before her due date," al-Jadba said. "She said that she was displaced in the last war; her house was destroyed. After that, she got pregnant and was living in very difficult conditions. She had both nutritional and severe psychological problems. She was very depressed and didn't want this pregnancy, but she lost her last baby, who died after a premature birth as well."
The baby was born with severely under-developed lungs and could not survive without specialist care and equipment, which is inaccessible to most Palestinians in Gaza. The baby died after just a few days.
M. described her situation as "miserable," al-Jadba said. M.'s husband is one of the approximately 43 percent of Palestinians in Gaza who are unemployed, which had put a lot of stress and anxiety on the couple, who were living in poverty and displaced from their house.
"I sat with her and she talked about how she held the baby and then the baby died, and how she couldn't do anything for him," al-Jadba recounted. "She lost two babies in three years."
She took the case of another mother from Jabaliya, the largest refugee camp in Gaza, who gave birth to a baby boy needing urgent surgery for a heart defect, al-Jadba explained. There are no facilities in Gaza for this type of neonatal surgery, so he was referred to a hospital outside of Gaza. "But [the mother] was told that the referral was delayed," she said.
The baby was finally transferred to a Palestinian hospital in occupied East Jerusalem. Unlike most Israeli hospitals, which offer top-notch care, most Palestinian hospitals don't have the resources they need for such specialist treatment. The baby underwent an operation but developed a blood infection and died shortly thereafter, al-Jadba said.
The doctors told the mother that if they could have received him without the initial delay, the prognosis of his survival would be greater and they could have saved his life.
Risk Factors and the Siege
Dr. Rand Askalan is a Canada-based pediatric neurologist who works closely with physicians in Gaza and has helped procure life-saving equipment for pediatric intensive care units in Gaza hospitals. She told Truthout that there are several factors that contribute to the health and survival of both pregnant mothers and their children.
"During pregnancy, a woman needs a certain level of nutrition and access to clean water - basic stuff," Askalan said. "She shouldn't get infections. She should have adequate iron levels for proper oxygen and proper fetal growth."
"But if you look at the situation in Gaza, where they don't even have clean water, poverty is extremely high and women don't have access to a proper diet and healthy food. And the ages of the mothers tend to be young, which means she's not strong enough in her own development," she explained.
During the nine-month gestation period, Askalan said that these risk factors grow exponentially if a mother is not protected against infection, poor hygiene, polluted water and inadequate nutrition. Screens for genetic abnormalities, which in many other countries are part of routine prenatal care, are also not widely available or used in Gaza.
Labor and birth complications without specialized care are another way mortality rates rise.
"If there are problems, is the medical system ready to face these problems and deal with them adequately so the outcome is better?" she asked. "These problems are magnified in Gaza in terms of volume and in terms of the expertise available to deal with them."
"Now, we're coming to the cause," Askalan remarked. "Why is this situation like this in Gaza? Why don't they have clean water? Why don't they have health care? Why aren't medications coming through and they don't have enough of the medical supplies and medications that they need?"
"The big answer is the siege - the blockade that's been in place for the past eight years," she said.
Askalan is currently raising funds to support the training of Palestinian specialists in neonatal and pediatric medicine in Gaza through the Palestinian Healthy Child Fellowship Program.
A Health System on the Verge of Collapse
At this moment, UNRWA is facing a severe funding crisis that could compound the health care and health education crisis across the Gaza Strip and West Bank. If critical funds aren't quickly channeled to the agency, "the consequences would be tremendous," Seita told Truthout.
In addition, Palestine-based Ma'an News Agency reported on Monday that due to an overwhelming fuel crisis, Gaza's ministry of health has warned that the entire health care system "is on the verge of collapse."
"The hospitals depend on private generators in addition to the power grid, but Israel's eight-year blockade has severely limited the supply of fuel to the coastal enclave," the report adds.
Meanwhile, Askalan said she is putting all of her energy into helping train specialists in Gaza. "After all these years of blockade and siege and inadequate health care, we see the effect on the most vulnerable population," she said. "The children."