Written evidence submitted to International Development Committee inquiry: Humanitarian crises monitoring (impact of coronavirus)

COVID-19 impacts in the occupied Palestinian territory and Palestinian refugee camps in Lebanon: Long-term issues, implications, and lessons to be learned

Submission by Medical Aid for Palestinians (MAP)

8 May 2020

Medical Aid for Palestinians (MAP) is a UK-based humanitarian and development organisation, operating through local partnerships in the occupied Palestinian territory (oPt) and refugee camps in Lebanon to support Palestinians’ rights to health and dignity. Our key areas of work are women’s and children’s health; disability; mental health and psychosocial support; and emergency response.[1]

MAP is currently responding to the COVID-19 (coronavirus) pandemic across all areas of operation, and prioritising infection prevention and containment. This response to the call for evidence from the Shadow Secretary of State for International Development is based on the information provided by our permanent teams and partners in Lebanon, the West Bank and Gaza. They, and our UK-based Advocacy and Campaigns Team, are available for briefings, analysis and updates.

Contents

Summary

COVID-19 exposes long-standing, politically-driven vulnerabilities among Palestinians

Overview: occupied Palestinian territory

Long-standing vulnerabilities: Gaza

Long-standing vulnerabilities: West Bank, including East Jerusalem

Long-standing vulnerabilities: Attacks on Palestinian health workers

Overview: Palestinian refugees in Lebanon

Long-standing vulnerabilities: Palestinian refugees in Lebanon

Long-term impacts of COVID-19 on Palestinian communities

Long-term COVID-19 impacts in the oPt

Long-term COVID-19 impacts on Palestinians in Lebanon

Key lessons for DFID and UK government responses

Immediate needs must continue to be addressed in the medium to long-term

UK aid must support sustainable development and self-determination in healthcare

Aid must be matched with accountability

Summary

Though a widespread outbreak of COVID-19 has so far been averted in the oPt and Palestinian refugee camps of Lebanon, long-standing political and socioeconomic factors mean that a risk of a catastrophic widespread outbreak among vulnerable communities remains high. There are fears that underlying resource shortages and international donor fatigue will reduce the capacity to maintain hygiene, quarantine and testing capacity. Moreover, lockdown measures needed to contain the spread of the disease are having knock-on effects on already vulnerable families, restricting livelihoods, increasing food insecurity, and reducing the ability of individuals with noncommunicable diseases to access the care they need.

Palestinian communities currently face three long-standing threats to their health and wellbeing:

• The direct impacts of COVID-19 in the resource-poor healthcare systems that serve them, particularly in the event that containment fails
• The indirect impacts of COVID-19 prevention measures on families, including restricted livelihoods, increased food insecurity, and reduced availability of other health services
• Continuing and new political drivers of vulnerability to COVID-19, including pervasive violations of international law, including: the illegal closure and blockade of Gaza; the continuing displacement of Palestinian refugees; and ongoing violations as well as threatened de jure annexation in the West Bank[2]

The submission below addresses these key issues, and the action needed from the UK government, and the international community as a whole, to avert further humanitarian deterioration. Section 1 examines the long-standing, socioeconomic and political factors that make Palestinians in the occupied Palestinian territory (oPt) and refugee camps of Lebanon particularly vulnerable amid the pandemic. Section 2 extrapolates from this the likely long-term impacts of the crisis on the health and wellbeing of these communities. Section 3 concludes with three recommendations for UK policy as it responds to the COVID-19 pandemic:

• The UK must continue to address humanitarian needs for the duration of the pandemic, including both COVID-19 prevention and healthcare response, and livelihoods and food security;
• Alongside humanitarian relief, UK aid must support sustainable development and self-determination, particularly in Palestinian healthcare institutions; and
• UK aid must be matched by a foreign policy that meaningfully pursues accountability for violations of international law that undermine attempts to prevent and respond to COVID-19, perpetuate aid dependency, and undermine the rights to health and dignity of Palestinians.

COVID-19 exposes long-standing, politically-driven vulnerabilities among Palestinians

Overview: occupied Palestinian territory

1. As of 5 May 2020, 546 cases of COVID-19 (coronavirus) have been recorded in the occupied Palestinian territory (oPt), including 20 in Gaza and 526 in the West Bank, of which 172 are in East Jerusalem.[3] Four deaths have been recorded. The West Bank has been placed under a state of emergency by the Palestinian Authority (PA) since 5 March, with a full lockdown introduced on 23 March. Schools are closed and all non-essential travel is prohibited. The de facto authorities in Gaza closed schools, mosques and restaurants, though restrictions on the latter were relaxed at the start of Ramadan. In Gaza and the West Bank all Palestinian citizens returning from abroad are placed under a mandatory quarantine for a period of 14 days in designated centres. At the time of writing there are 1,092 people in quarantine in Gaza, many of whom recently returned to Gaza through the Rafah crossing with Egypt.
2. Local and international action, including MAP’s intervention,[4] has so far helped to significantly slow the spread of COVID-19 in the oPt, however social distancing and lockdown measures are already having significant negative impacts on communities in terms of livelihoods and food security, and access to non-coronavirus healthcare services. The extreme fragility of the Palestinian healthcare sector, and underlying, politically-driven socioeconomic conditions and poor public health in many Palestinian communities exacerbate vulnerability to coronavirus and mean that a widespread outbreak could have catastrophic consequences.[5]

Long-standing vulnerabilities: Gaza

3. The intensified and illegal closure[6] and blockade imposed on Gaza by Israel since 2007 is a primary driver of local vulnerabilities to COVID-19. Even before the current crisis, MAP assessed that the UN’s warning that Gaza would be unliveable by 2020 has come true.[7]
4. As one of the most densely populated places in the world, effective self-isolation is nearly impossible, particularly in the refugee camps. 70% of Gaza’s population are refugees, who continue to be denied their right to return to the lands they were expelled or fled from in 1947/48. 97% of water is undrinkable, and water shortages make hygiene and sanitation measures to prevent the spread of COVID-19 more difficult.
5. The long-term de-development of Gaza’s health sector[8] has left it without the infrastructure, essential equipment, drugs, supplies, and human resources needed to treat a widespread outbreak of coronavirus. This has been exacerbated by the influx of 8,000 patients suffering gunshot wounds due to Israel’s widespread and systematic use of excess force against protesters at the “Great March of Return” protests between 31 March 2018 and the end of 2019.[9] Between 1,200-1,700 of these patients require costly, long-term treatment involving multiple surgeries.[10]
6. Gaza suffers chronic shortages of essential medicines and disposables, with 39% of essential medicines and 31% of disposables at “zero stock” (less than one month’s supply available) just before the start of the coronavirus crisis. Gaza has just 78 ICU beds and 63 ventilators – many already in use – for a population of 2 million.[11]
7. Gaza has one of the highest rates of unemployment in the world (45%), more than half of all people live below the poverty line,[12] and 80% are dependent on some form of international aid. More than two thirds (68%) of people in Gaza are moderately or severely food insecure, and one in ten children suffers stunting.  High rates of non-communicable diseases (such as diabetes and hypertension), which are often poorly managed in Gaza due to chronic medical shortages, increase the vulnerability of many adults in Gaza to coronavirus.

Long-standing vulnerabilities: West Bank, including East Jerusalem

8. The discriminatory planning regime imposed by Israel on Palestinians in East Jerusalem and communities in Area C of the West Bank has stifled the development of Palestinian healthcare. There are no permanent Palestinian health facilities in Area C, the 60% of the West Bank under full Israeli military and civil control, much of which the Israeli government aims to illegally annex as early as 1 July.[13] In Area C, 50% of Palestinian communities are more than 30km away from a clinic,[14] and most Palestinian communities are not connected to the water network so must purchase water in tanks at up to five times the cost of piped water. Water scarcity undermines essential hygiene and sanitation practices to prevent the spread of infectious diseases.
9. In Bedouin communities, rates of malnutrition and micronutrient deficiency are high among pregnant and breastfeeding women, and 23% of children under five suffer stunting, increasing their susceptibility to infectious diseases.[15] High rates of poorly-managed non-communicable diseases such as diabetes and hypertension increase the likelihood of complications from coronavirus in older adults.
10. A significant proportion of Palestinian men work as labourers in Israel and settlements, where rates of coronavirus are much higher. This places them in the position of either having to risk contracting the disease and spreading it in the West Bank, or not working but having no source of income for their families. According to the PA, more than 70% of Palestinian coronavirus cases have come from Palestinians working in Israel or settlements.
11. Long-standing patterns of violations also undermine COVID-19 response. Demolitions of Palestinian homes and property including WASH facilities continue despite the coronavirus pandemic.[16] These are not only illegal under international humanitarian law and cause immense hardship for the victims, but also frustrate attempts at social distancing necessary to prevent the further spread of coronavirus. Attacks on Palestinians by settlers and armed raids of Palestinian homes by Israeli forces, have surged despite the lockdown in the oPt, as ever with impunity. [17]
12. In March, Israel dismantled and confiscated a coronavirus clinic in the north Jordan Valley.[18] On 14 April Israeli police shut down a Palestinian testing clinic run by volunteers in Silwan, East Jerusalem.[19] Israeli police have reportedly dropped off sick Palestinian workers at checkpoints without proper concern for their health and safety,[20] and in April arrested the PA Minister for Jerusalem Affairs Fadi al-Hamadi – subjecting him to abusive, harmful and humiliating detention including by forcing him to wear a used, bloodstained mask[21] – and PA Governor of Jerusalem Adnan Ghaith while they were reportedly engaging in coronavirus preventive activities.[22] During April, Israel denied several Area C communities access to basic primary health care.[23]

Long-standing vulnerabilities: Attacks on Palestinian health workers

13. The global discussion on COVID-19 response has not yet adequately addressed how the long-term failure of the international community to ensure respect for international law has chronically undermined the capacity of health systems in regions affected by conflict and occupation. As the ICRC has recently highlighted: “the extreme vulnerability of people in conflict zones to COVID-19, the culmination of degraded or collapsed essential services such as water, sanitation, and health care, is in significant part the result of a disregard over many years of States’ and other belligerents’ obligations – as set out in international humanitarian law and international human rights law – towards populations under their control.”[24]
14. This is particularly clear in the oPt, where the protected status of hospitals and medical personnel under international law has not been upheld for many years. Attacks against Palestinian hospitals, clinics, ambulances and health workers by Israel were carried out with impunity in the 2008/9, 2012 and 2014 military offensives in Gaza.[25] Since 30 March 2018, at least three health workers have been killed and more than 800 injured by Israeli forces in the context of Israel’s widespread and systematic use of excess force against civilian protesters.[26] In the same period, 112 ambulances and seven health facilities were damaged.
15. In March 2019, UN independent Commission of Inquiry into the ‘Great March of Return’ protests in Gaza described the oPt as “one of the most dangerous places in the world to be a health worker”.[27] It further concluded that “the Government of Israel has consistently failed to meaningfully investigate and prosecute commanders and soldiers for crimes and violations committed against Palestinians or to provide reparation to victims.” The repeated health worker casualties which occurred in 2019, and continuing impunity for these and previous attacks, underline the importance of accountability to ensuring non-repetition.

Overview: Palestinian refugees in Lebanon

16. As of 6 May, 750 cases of COVID-19 have been recorded in Lebanon and 25 deaths.[28] The Government of Lebanon has imposed a strict lockdown and night-time curfew across the country in order to contain coronavirus. Six Palestinian refugees have so far been diagnosed with the disease, all living in one area of Wavel Camp in the Bekaa Valley. The chronically poor socioeconomic and public health conditions faced by Palestinian refugees in the country engender dual fears of both potentially disastrous health impacts of a widespread outbreak of COVID-19 in the camps, and deepening poverty amid lockdown-restricted livelihoods.

Long-standing vulnerabilities: Palestinian refugees in Lebanon

17. Some 450,000 Palestinian refugees are registered with UNRWA[29] in Lebanon. More than half live in the 12 official Palestinian camps across the country, where overcrowded, unsanitary conditions make effective self-isolation and other containment measures extremely difficult. According to Saria, a MAP community midwife working in Ein el Helweh camp: “Social distancing is impossible in the context of the camps due to over-crowdedness and the proximity of houses to one another. In Ein el Helweh camp, we are talking about one square kilometer hosting over 80,000 refugees. If one person gets sick, the whole camp is likely to get the disease.”
18. Decades of marginalisation, discrimination, and poor access to basic services and economic opportunities have increased the vulnerability of Palestinian refugees. Before the outbreak of coronavirus, the country was experiencing what the World Bank has described as “the worst economic crisis in recent history.”[30] Palestinians are legally and practically barred from working in 39 “preferred” professions, including most healthcare jobs. 87% receive no paid sick or annual leave, and nearly half (48%) are paid daily.[31]
19. High levels of chronic malnutrition (stunting), poorly managed noncommunicable diseases, and pre-existing high rates of respiratory illness are high due to dampness and poor housing conditions make camp residents particularly vulnerable to coronavirus.
Palestinians are largely excluded from accessing the Lebanese health system or social care system. Instead, they rely on a fragmented and under-resourced network of UN (UNRWA), Palestine Red Crescent Society, NGO and private healthcare. UNRWA has stated that it will cover the costs of medical treatment for refugees with confirmed coronavirus, but suffers a chronic budgetary shortfall that is likely to challenge its coronavirus response in the event of a widespread outbreak in its areas of operation. Only one third of UNRWA’s $1.2bn annual budget has been secured, with officials warning that it is “operating on a month-to-month basis”.[32] It has also launched a three-month (March – May) emergency appeal for $14,145,000 to cover COVID-19 prevention and response.[33] As of 10 April, only $4m had been received.[34]

 

Long-term impacts of COVID-19 on Palestinian communities

Long-term COVID-19 impacts in the oPt

21. Reduced services across the health sector: As the Palestinian health sector has pivoted to COVID-19 response, access to other health services has reduced. In Gaza, breast cancer screening has stopped and is now limited to diagnostic services only.[35] Routine management of non-communicable diseases is also postponed, as well as early child growth and development services, and physiotherapy. Sexual and reproductive health services have been scaled back across the oPt, increasing the risk of disability and death amongst women, girls and neonates.[36] According to UN OCHA, over 9,000 patients in Gaza could also face postponements to their elective surgeries, 3,000 of which are urgent.[37] In the West Bank, over 4,000 elective surgeries are also expected to be postponed each month.
22. Restricted referrals out of Gaza: The limited services and resources of Gaza’s health sector means that certain medical specialties are only available at hospitals in East Jerusalem, the West Bank, or abroad, including joint replacement surgery, open heart surgery and radiotherapy. Many patients therefore require referral outside for treatment, and must navigate Israel’s bureaucratic permit regime which the WHO has termed “neither transparent nor timely”[38] – adding to suffering and an obstacle to potentially life-saving treatment.[39] Since the outbreak of coronavirus, only emergency cases and cancer patients have been allowed to travel out for treatment, however they face significant disruption. UN OCHA has reported that approximately 1,000 patients in Gaza cannot be referred for specialist treatment outside Gaza.[40] Some patients still able to travel outside for treatment are unwilling to make the journey as they fear that upon returning to Gaza, they would need to spend 21 days in a quarantine centre.[41] Others face lengthy separations from their family.[42] According to the WHO, in March the approval rate for exit permits for patients to travel for care outside Gaza decreased to 58%, from an average of 69% for January and February.[43] The number of patients applying for permits also decreased over the month, with 72 applications per day in the first third; 51 per day in the second; and 18 per day in the last.
23. Negative impacts on mental health and wellbeing: Insecurity and uncertainty has foreseeable negative impacts on mental health and wellbeing of children and adults, and is expected to increase rates of psychological distress that are already high among a population chronically impacted by occupation, blockade and displacement.[44] The lockdown also limits the ability of those affected to access services to help them cope with these issues.
24. Gendered impacts of COVID-19: Compounded economic impacts are felt especially by women and girls who are generally earning less, saving less, and holding insecure jobs or living close to poverty. MAP’s partners also report a fear of a growth of gender-based violence (GBV) amid sweeping lockdown measures, while shelters and local organisations have been forced to downscale interventions. The Women’s Center for Legal Aid and Counselling report a 69% increase in consultation calls from Palestinian women to its GBV helpline compared to March.[45]
25. Exacerbated barriers for people with disabilities: People with disabilities face additional health and wellbeing vulnerabilities due to pre-existing discrimination and barriers to the full enjoyment of their human rights. Many Palestinians with disabilities depend on services that have been suspended and families report not having enough money to stockpile specific foods and medicines.[46]
26. Increasing food insecurity: In Gaza, 68% of households are severely or moderately food insecure,[47] and one in ten children suffers stunting.  Among Bedouin communities in Area C of the West Bank, rates of malnutrition and micronutrient deficiency are high among pregnant and breastfeeding women, and 23% of children under five suffer stunting.[48] Significant restrictions on livelihoods resulting from COVID-19 social distancing measures, alongside the long-term economic impacts of Israel’s illegal closure and blockade of Gaza and restrictive policies in Area C, are likely to exacerbate these issues and see more families going hungry during the course of the pandemic.[49]

Long-term COVID-19 impacts on Palestinians in Lebanon

27. Exacerbating poverty and existing vulnerabilities: High unemployment, and a significant proportion of Palestinians working as day labourers or in other insecure jobs makes these communities particularly vulnerable to the economic impacts of this lockdown and Lebanon’s wider financial crisis.[50] Two thirds of Palestinian refugees in Lebanon live below the poverty line, and 67% live in moderately or severely food-insecure households.[51] These issues are likely to be exacerbated by the current crisis. As a staff member of one of MAP’s local partners explained:

“The situation in the Palestinian camps is tragic. The financial crisis in the country has had a very bad impact on the refugees; many lost their jobs at the time when the prices of goods almost doubled. People are no longer able to buy the essential things they need. Most Palestinian refugees are daily laborers, meaning that when they don’t work, they don’t get paid. The coronavirus outbreak in Lebanon made things worse as it has forced many people to stay home. Many in the camps are now struggling; children might not eat on the day that the father doesn’t work. Thus, despite all the warnings, you find shop owners, vendors, and others insisting on working. Security forces tell them to close and go home, but people say that if they don’t die from the disease, they will soon die from hunger.” [52]

28. Exacerbated barriers for people with disabilities: More than one in five Palestinian refugees in Lebanon has specific needs and their lack of access to adequate services has a wide impact on their overall health and living conditions, particularly given the poor public infrastructure in the refugee camps. A staff member of one of our local partners in El Bass Camp, southern Lebanon, described how COVID-19 has impacted people with refugees:

“Children with disabilities are now staying home all the time which is making them, and their parents, stressed … We noticed that parents’ concerns go beyond taking their children to rehabilitation or therapy sessions. They are now worried about more basic things such as being able to feed their children. With families suffering financial difficulties, there is a concern that the needs of children with disabilities, which tend to be more or higher in cost, including medicine, might not be met. So particular attention needs to be given to people with disabilities in response plans.”[53]

Key lessons for DFID and UK government responses

Immediate needs must continue to be addressed in the medium to long-term

29. In the oPt, the UK has contributed $1 million to support the World Health Organization (WHO) and UNICEF to “purchase and co-ordinate the delivery of medical equipment, treat critical care patients, train frontline public health personnel and scale up laboratory testing capacity.”[54] The UK also continues to be one of the largest international donors to UNRWA.
30. There are, however, fears that underlying resource shortages and international donor fatigue will reduce the capacity to maintain hygiene, quarantine and testing capacity. This aid is essential and must be sustained for the duration of the pandemic and to ensure the disease remains contained and the catastrophic scenario of a widespread outbreak in the oPt and Palestinian refugee camps in Lebanon is averted. UNOCHA has appealed for $42.4 million to contain the pandemic and mitigate its impact, of which $13.3 million (31%) has so far been raised.[55] DFID should increase its support for the UN COVID-19 response plan in the oPt, and encourage other countries to do the same. The UK should likewise support UNRWA’s COVID-19 emergency appeal, and encourage other countries to provide sustainable, multi-year funding to the agency’s core budget.[56]
31. Local and international NGOs are also facing increased challenges to providing continuity of services while also responding to new needs as a result of COVID-19. While none of our programmes have stopped, like other UK charities we have had to put cost saving measures in place due to the threat COVID-19 poses to our income. Financial support for existing programmes is proving harder to secure in comparison to our emergency COVID-19 response, with the potential to significantly impede the delivery of essential health services. These financial impacts are likely to be compounded for local Palestinian civil society organisations who are reliant on UK and other international donors.
32. Alongside supporting the essential work of the UN system, the UK and other international donors should also increase support to civil society actors who are well placed to respond to local needs. Alongside public health measures, donors should also meanwhile work to mitigate the knock-on effects of COVID-19, in particular to livelihoods, food security, and access to healthcare for non-coronavirus needs, to avoid a secondary humanitarian crisis caused by worsening poverty.

UK aid must support sustainable development and self-determination in healthcare

33. In the longer term, international aid should support the sustainable development of the Palestinian healthcare system and other institutions, helping ensure that Palestinians have the necessary resources and infrastructure to respond independently to future crises. The UK should support the development of medical sub-specialties, particularly in Gaza, through training and institutional support. Particular attention should be paid to reducing functional and political separation between the West Bank, including East Jerusalem, and Gaza.
34. Similarly, the UK should work with providers of healthcare to refugees in Lebanon – UNRWA, the Palestine Red Crescent Society (PRCS), NGOs and others – to ensure that healthcare is affordable, appropriate, sustainable and comprehensive. It should support professional development and employment initiatives for Palestinian refugee health workers, including through the development and/or expansion of international scholarship opportunities.
35. DFID should ensure it meaningfully consults with Palestinian communities in determining its aid strategies in the oPt. Alongside humanitarian funding through UN agencies, where possible DFID should support Palestinian civil society to implement programmes, particularly in Gaza. UK aid should be guided by upholding the right to self-determination of the Palestinian people.

Aid must be matched with accountability

36. The ill-preparedness of the Palestinian healthcare sector to deal with the COVID-19 pandemic underlines the failure of the international community to address long-standing root causes  of this fragility amid Israel’s 53-year occupation: continuing impunity for violations of international law that undermine health and healthcare, including repeated attacks on Palestinian healthcare.[57]
37. As the occupying power in the West Bank, including East Jerusalem, and Gaza, Israel has the following key duties under the Fourth Geneva Convention:

• Article 55: “To the fullest extent of the means available to it, the Occupying Power has the duty of ensuring the food and medical supplies of the population; it should, in particular, bring in the necessary foodstuffs, medical stores and other articles if the resources of the occupied territory are inadequate”
• Article 56: “To the fullest extent of the means available to it, the Occupying Power has the duty of ensuring and maintaining, with the co-operation of national and local authorities, the medical and hospital establishments and services, public health and hygiene in the occupied territory, with particular reference to the adoption and application of the prophylactic and preventive measures necessary to combat the spread of contagious diseases and epidemics. Medical personnel of all categories shall be allowed to carry out their duties.”

38. The pattern of violations outlined above, including the continuing collective punishment of Gaza’s population,[58] the demolition of Palestinian homes and other essential infrastructure, and barriers to healthcare access are additionally egregious in the context of a global health crisis. They underline the finding of UN Special Rapporteur for human rights in the occupied Palestinian territory, Prof. Michael Lynk, that Israel is “in profound breach of its responsibility with respect to the right to health” in the oPt.[59] In March 2020 Prof. Lynk underscored this duty alongside those of other local duty-bearers.[60]
39. Amid the COVID-19 pandemic it is also more important now than ever that health workers are supported to do their vital work without fear of attack, and the  UK should redouble its efforts to ensure those responsible for attacks on healthcare are held to account.
40. The UK government should therefore ensure its international aid to the Palestinians is matched by an international law-based foreign policy, and diplomatic pressure to address actions by Israel that perpetuate aid dependency and undermine the effectiveness of humanitarian programmes. Specifically, the UK should:

• Ensure that Israel respects its duties as an Occupying Power to deploy all means to combat the spread of contagious diseases in the oPt;
• Demand an immediate and permanent cessation of demolitions and seizures of Palestinian homes, WASH facilities and clinics, and ensure Palestinian health workers can continue their work unimpeded and without fear of attack or obstruction;
• Support genuine investigations into, and legal accountability for, violations of international law in the oPt, including military attacks on medical personnel and infrastructure as a way to prevent future violations and to provide justice;
• Demand Israel end the illegal closure and blockade of Gaza; and
• Urge Israel and other local duty bearers to ensure that any restrictions on human rights implemented to combat COVID-19 are strictly necessary, proportionate, non-discriminatory, and time-bound.

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