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					Healthcare in Palestine




        Nader Hebela, MD

The Palestine Children’s Relief Fund
            February 2004
                Overview
• Children in the context of world health

• Organizations delivering medical care abroad

• Healthcare in Palestine

• Palestine Children’s Relief Fund

• Pediatric orthopaedic surgery in Palestine
                     About me

• Parents emigrated from Alexandria,
  Egypt to Jersey City, NJ
• Born in Bayonne, NJ
• Dartmouth College
• Resident, Dept. Orthopaedic
  Surgery, Hospital of the University
  of Pennsylvania
• Interested in international medicine
• Orthopaedic healthcare in Palestine
• Currently live in Philadelphia, PA
              World Wealth
• Poverty: living on less
  than $1 per day

• 1.1 billion people live on
  less than $1 per day

• 2.7 billion people live on
  less than $2 per day

                               Source: http://www.worldbank.org/research/povmonitor
                        World Health
             Under-five deaths 2000 United States
                                  Rates
             Cause          (per 100,000)
Accidents                          11.1
Congenital malformations             3.6
Malignant neoplasms                  2.7
Assault (homicide)                   2.6
Diseases of the heart                1.4
Influenza & pneumonia                0.7
Septicemia                           0.7
Perinatal conditions                 0.5
Neoplasms                            0.4
Cerebrovascular diseases             0.3
All other causes                     9.5
                                                                                            Source:
All causes                         33.5     http://www.cdc.gov/nchs/data/nnvsr/nvsr51/nvsr51_05.pdf
                     World Health
        Under-five deaths 1993 developing world
        Cause          % of Total
ARI                           25
Diarrhea alone                23
Malaria alone                  6
ARI - Measles                  5
Neonatal tetanus               5
Tuberculosis                   2
ARI - Pertussis                2
Measles alone                  2
                                                                           Source:
Diarrhea - Measles             2    http://www.childinfo.org/cmr/Kh98/kh8chap1.pdf

Pertussis alone                1
Total                         73
               World Health
   Under-five deaths 1993 developing world



     “A large majority of these lives
         being lost could be saved.”

 Kenneth Hill, Rohini Pande (Johns Hopkins University),
 Gareth Jones (UNICEF), Trends in Child Mortality in the
                       Developing World: 1960 to 1995
                Overview
• Children in the context of world health

• Organizations delivering medical care abroad

• Healthcare in Palestine

• Palestine Children’s Relief Fund

• Pediatric orthopaedic surgery in Palestine
 Foreign Medical Relief Organizations

• Doctors Without Borders

• Operation Smile

• Palestine Children’s Relief
  Fund (PCRF)

• Gaza & the West Bank
Foreign Medical Relief Organizations

• Treat patients

• Find care for
  patients abroad

• Educate healthcare
  providers
Give a man a fish, and you feed
him for a day. Teach a man to
fish, and you feed him for a
lifetime.
                Chinese proverb
        Palestine & Israel
        Geography & Demographics
• Israel
   Area: 20,770 sq km
   Comparative: slightly smaller than NJ
   Population: 6,116,533 (including settlers)
   Growth rate: 1.39%


• Gaza, Palestine
   Area: 360 sq km
   Comparative: 2x Washington, DC
   Population: 1,275,868 + 5000 settlers
   Growth rate: 3.89%


• West Bank, Palestine
   Area: 5,860 sq km
   Comparative: slightly smaller than Delaware
   Population: 2,237,194 + 364,000 settlers
   Growth rate: 3.30%
                                                 Source: http://www.odci.gov
               Palestine & Israel
             The Occupation & the Intifada

• Intifada: the abrupt &
  sudden waking up from
  sleep or unconcerned
  status
• Came to symbolize the
  Palestinian uprising against
  the Israeli occupation

• Kids throwing stones

• September 2000
                         Palestine & Israel
                          The Intifada & Healthcare

• The Intifada has had a
  detrimental effect on the
  overall delivery & quality of
  healthcare to the average
  Palestinian man, woman, &
  child
• As of May 10, 2004:
  2,886 Palestinians dead
  25,755 Palestinians injured*
  977 Israelis dead
  6,314 Israelis injured†
  *Source: Palestinian Red Crescent, http://www.palestinercs.org/
  †Source: Israeli Ministry of Foreign Affairs, http://www.israel.org/mfa/go.asp?MFAH0ia50
                Overview
• Children in the context of world health

• Organizations delivering medical care abroad

• Healthcare in Palestine

• Palestine Children’s Relief Fund

• Pediatric orthopaedic surgery in Palestine
Checkpoints
         Healthcare in Palestine
    Checkpoints Sept. 2000 – Dec. 2002

1. Access

  • 47 deliveries at
    checkpoints

  • 28 newborn
    deaths at
    checkpoints
                       Source: http://www.moh3.com/annual/2002/Intifada.pdf
       Healthcare in Palestine
         Emergent Medical Issues

“The Occupying Power shall afford civilian
medical personnel in occupied territories every
assistance to enable them to perform, to the
best of their ability, their humanitarian
functions. ...”
The First Additional Protocol of the
Geneva Conventions, Article 15
         Healthcare in Palestine
     Checkpoints Sept. 2000 – Dec. 2002
2. Access
  • 81 patients died
    at checkpoints

  • 720 ambulances
    prevented from
    reaching
    patients or        Source: http://www.moh3.com/annual/2002/Intifada.pdf

    hospitals
        Healthcare in Palestine
           Emergent Medical Issues

“The Occupying Power has the duty to ensure
that the medical needs of the civilian population
in occupied territory continue to be satisfied.”


The First Additional Protocol of the Geneva
Conventions, Article 14
         Healthcare in Palestine
     Checkpoints Sept. 2000 – Dec. 2002
3. Access

  • 22 ambulance
    drivers killed

  • 35 ambulances
    destroyed

                     Source: http://www.moh3.com/annual/2002/Intifada.pdf
        Healthcare in Palestine
          Emergent Medical Issues

“If the whole or part of an occupied territory is
inadequately supplied, the Occupying Power
shall agree to relief schemes on behalf of the
said population, and shall facilitate them by all
means possible. Such schemes ... shall consist,
in particular, of the provision of consignments
of foodstuffs, medical supplies and clothing. All
Contracting Parties shall permit the free
passage of these consignments and shall
guarantee their protection. ...”

The Fourth Geneva Convention, Article 59
           Healthcare in Palestine
         Emergent Medical Issues
• Emergent medical
  issues
  1. Access, access, access
  2. MVI, supplements,
     equipment
  3. Pediatric surgical
     specialists

• Urgent medical
  issues
  1. Supplies to hospitals
  2. Training to physicians
…and we do not expect people to be moved by
what is not unusual. That element of tragedy
which lies in the very fact of frequency, has not
yet wrought itself into the coarse emotion of
mankind; and perhaps our frames could hardly
bear much of it. If we had a keen vision and
feeling for all ordinary human life, it would be
like hearing the grass grow and the squirrel’s
heart beat, and we should die of that roar
which lies on the other side of silence.

                   George Elliot, Middlemarch
Guest House, Gaza
                Overview
• Children in the context of world health

• Organizations delivering medical care abroad

• Healthcare in Palestine

• Palestine Children’s Relief Fund

• Pediatric orthopaedic surgery in Palestine
 Palestine Children’s Relief Fund
                  About the PCRF

• American-registered non-
  political, non-profit
  organization established in
  1991

• Address the medical crisis
  facing Palestinian children
    Palestine Children’s Relief Fund
                       About the PCRF

•    Provide free medical care in the
     U.S & Europe for children who
     cannot adequately be treated in
     their homeland

•    Send volunteer medical missions
     to the occupied territories from
     the U.S. & Europe to treat
     children & train Palestinian
     healthcare workers

•    Donate urgently needed medical
     equipment & supplies
Palestine Children’s Relief Fund
       Missions to Palestine 2001 & 2002

• 2001: Plastic (63),
  cardiac (40),
  ophthalmic, &
  orthopaedic surgery,
  NICU, EMT training

• 2002: Ophthalmic (79),
  cardiac (18), &
  orthopaedic surgery,
  ER, NICU, EMT, OT
  training
Palestine Children’s Relief Fund
        Overseas Program 2001 & 2002

• 2001:
  North America (29)
  Europe (20)
  Middle East (35)

• 2002:
  North America (40)
  Europe (40)
  Middle East (12)
                            Nour at Shriners Hospital of
                            Philadelphia, March 2003
Palestine Children’s Relief Fund
      Humanitarian Projects 2001 & 2002


• Summer camps for
  handicapped children

• Women empowerment
  project

• Medical supply
  donations
                 Palestine Children’s Relief Fund
                          Information for Potential Donors


• The PCRF is a registered 501(c)(3) non-political,
  non-profit organization
• Tax Exempt Identification no. : 93-1057665
• The PCRF complies with Voluntary Best Practices
  for U.S.-Based Charities, issued by the U.S.
  Department of the Treasury following the tragic
  events of 9/11*

  *Source: http://www.treasury.gov/press/releases/doc/tocc.pdf
                Overview
• Children in the context of world health

• Organizations delivering medical care abroad

• Healthcare in Palestine

• Palestine Children’s Relief Fund

• Pediatric orthopaedic surgery in Palestine
 Palestine Children’s Relief Fund
               Mission: October 2002

• Identify pediatric
  orthopaedic needs in Gaza
  & the West Bank

• Identify children who need
  orthopaedic care not found
  in Palestine

• Match children with
  doctors & hospitals in the
  U.S. & Europe
              Case 1, Gaza
• AM, 16F
• Difficulty with ADL
• Severe scoliosis
• Back pain
• Bilateral UE neuromuscular
  abnormalities
• Needs plain films, CT, MRI
• Spinal fusion to halt curve
  progression
            Case 2, Khan Younis
•   DS, 13F
•   Progressive spinal
    curvature
•   Appearance
•   PE suggestive of UMN
    lesion
•   Plain films of entire spine
    & MRI requested
•   Likely benefit from spinal
    fusion
Guest House, Gaza
Palestine Children’s Relief Fund
       Summary: October 2002


        • Lack of specialists

        • Lack of access

        • Lack of equipment &
          instrumentation
          (orthopaedic hardware)
 Palestine Children’s Relief Fund
                  February 2004


• Temperature in
  Philadelphia 40°F

• Temperature in Ramallah
  32°F
    Palestine Children’s Relief Fund
                    February 2004

• Access: assess patients &
  determine level of care
  necessary
• Specialists: see patients in
  need of complex
  orthopaedic care
• Expertise: match foreign
  surgical teams coming to
  Palestine with specific
  cases requiring treatment
Jerusalem
 Palestine Children’s Relief Fund
                  February 2004


• 7 day mission in Ramallah,
  Nablus, Hebron, Jerusalem

• Children from Jenin,
  Tulkarem, and neighboring
  refugee camps

• 100 children with complex
  disorders seen & examined
              Patient Screening
• Scoliosis

• Congenital deformities
  (clubfoot, hip dislocations)

• Neuromuscular disorders
  (cerebral palsy)

• Pediatric trauma
Church of the Nativity, Bethlehem
Church of the Nativity, Bethlehem
Gaza
                      Trauma

• Routine pediatric
  trauma

• High velocity gun
  shot wounds
                     Trauma
• Nour, 15 years old

• Stepped on land mine
  after lunch

• R AKA, L BKA

• Treated at Shriners
  Hospital in Philadelphia,
  2003
     Congenital Abnormalities

• TAR syndrome

• Arthrogryposis

• Club foot

• Hip dislocations
Al Aqsa Mosque, Jerusalem
    Scoliosis
Untreated in Palestine
                  Scoliosis
         Limitations of care in Palestine


• Lack of expertise & training

• Instrumentation (expensive hardware)

• Post-operative intensive care units
                    Scoliosis
       The PCRF role in healthcare delivery

• Hugh Watts: former
  chairman at CHOP, Saudi
  Arabia for 12 years,
  distinguished career at LA
  Shriner’s Hospital

• Lifetime of volunteerism in
  orthopaedic surgical relief
  missions
                    Scoliosis
        The PCRF role in healthcare delivery


• Training for Palestinian
  orthopaedic surgeons
  through fellowships & in
  the field

• Dr. Ala’ Al Sheikh 1 year
  fellowship in Pediatric
  Orthopaedic Surgery at the   “Teach a man to fish”
  L.A. Shriners--emphasis on
  scoliosis surgery
Scoliosis
Before & after
              Nour Revisited
• Philadelphia Shriners
  Hospital

• Physical therapy for 3
  months

• Homestays with 3
  generous Palestinian-
  American Philadelphia
  families
         Shriner’s Hospital
• The Shriners is an international
  fraternity of approximately 500,000

• Shriners Hospitals for Children: a
  network of 22 hospitals that provide
  expert, no-cost orthopaedic, spinal
  cord, and burn care free of charge to
  children under 18.
  Palestine Children’s Relief Fund
                   Future Directions


• Identify areas of
  interest & potential
  training for Palestinian
  orthopaedic surgeons

• Palestinian orthopaedic
  contacts to help deliver
  orthopaedic care            “In the end, my desire to go to Gaza
  efficiently                 stemmed neither from adventurism
                              nor from insanity, but from that dread
                              of being a bystander…”
Palestine Children’s Relief Fund
              Information


The PCRF
P.O. Box 1926
Kent, Ohio, 44240
(330) 678-2645
http://www.pcrf.net
thepcrf@aol.com

hebela@yahoo.com
Thank you

				
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