The Palestinian Tipping Point

It was a chilly, wet Monday. Some 20 of us sat around a long table. There were snacks and bottles of fruit juice in front of us. Someone joked nervously about where the juice came from. Was it Israeli or Palestinian?

We were at the headquarters of the ministry for health in Ramallah on the West Bank. The deputy health minister, Dr Anan Masri, presided at one end of the table. At the other end was a television screen. We were videoconferencing with his boss, the Hamas minister for health, Basim Naim, who was in Gaza City.

Mr Naim sat with another dozen or so conferences. By road, they were less than two hours' drive away. But no one, least of all senior Palestinian politicians, could travel between Gaza and the West Bank without spending many long hours - often days - applying for permission to leave and enter, and then many more hours waiting at unpredictable border crossings and road blocks. Hence the video conference. There were no snacks or drinks on the table in Gaza, where basic food supplies were running low.

The minister had called together representatives of NGOs with an interest in health. I was visiting with a UK-based charity called Medical Aid for Palestinians (MAP). We were small-fry compared with others at the table, who included representatives of the World Health Organisation, other UN agencies, Care International, Médicins sans Frontières and Save The Children.

It was the week when Daniel Barenboim delivered the fourth of his BBC Reith Lectures - this one on how music demonstrates the need for people to understand and respect each others' voices. It was due to be delivered in Ramallah but, thanks to "growing tensions in the West Bank", the venue shifted to east Jerusalem. In fact, Ramallah was not particularly tense. But no one could enter the city without a close encounter with the eight-metre wall and the humiliating checkpoints, without experiencing at first hand the contrast between smooth order on one side and rubble-strewn, pot-holed disarray on the other. And Palestinian guests from other parts of the country would have had no end of trouble getting to the lecture.

The minister had a round, fresh face, a neat moustache, an air of reticence tinged with alarm. No wonder he wanted to meet the NGOs. Health services were in meltdown. When Hamas was elected to government, the United States, the European Union and the state of Israel responded by withdrawing funds from the Palestinian Authority. So it lacked $4.5m (£2.4m) a month to buy essential drugs, medical treatment and equipment - never mind the salaries of doctors and nurses that hadn't been paid since February. It had put out three appeals and by that time had received just $1m, from the Islamic State Bank.

NGOs' role

The NGOs were asked to do two things. The first was to help persuade the PA's erstwhile donors to rescind their "premature decisions", on the grounds that health, as a humanitarian issue, should be set aside from politics, and that burgeoning illness in the Palestinian territories, when children are not vaccinated and diseases thrive in deepening poverty, could soon spread through the whole region, including Israel.

The NGOs were also asked to coordinate their efforts more closely and do what they could to bridge the gap in services. All were willing to help. But all agreed that NGOs couldn't substitute for a state-run health system. It would be rather like asking Oxfam to take over England's hospitals. And many were worried that their current programmes would suffer. Médicins Sans Frontières, for instance, pointed out that they had been trying to tackle the "psycho-social and economic causes" of illness in Gaza. Shifting resources to bail out the PA could mean pulling back from that kind of preventative work.

MAP had recently abandoned the heroic-rescue style of charitable intervention that involved shipping in medical supplies and volunteer doctors. Instead, it had switched to a preventative, developmental approach now favoured by most aid agencies. It channelled funds to local voluntary organisations, who identified health needs and sought community-based solutions. It helped women in a Gaza refugee camp make a living by setting up an enterprise to dry, package and sell locally grown fruit and vegetables. It helped disabled people to cope with day-to-day life in their own homes. It helped villagers west of Ramallah who have become dependent on Israeli-based water suppliers, to reactivate a spring-fed well. It helped train community health workers in east Jerusalem. And more.

MAP was, in any case, too small to make any noticeable dent in the PA's deficit. So for the time being, the team decided to launch an appeal in the UK, release emergency funds and ask its local partner organisations what they need in the way of extra assistance. Anything MAP did could only help a handful of Palestinians. But every effort it made, every project it funded, was deeply coloured by the political crisis.

Improvements near Jericho

We travelled to Jericho, north-east of Ramallah. There were long, hot queues at the border, then two more checkpoints before we headed out into the Jordan valley. Israeli settlements dotted the hilltops - unmistakable with their red roofs, green trees and windows glinting across the parched landscape. We passed more checkpoints going in to Jericho. There was a new rule that stopped Palestinians leaving the place, so most residents were trapped in the city.

MAP was funding a mobile clinic for a local Islamic health organisation, Islah, which worked with the Bedouins whose semi-permanent tented villages surrounded Jericho. We accompanied the medical team to a primary school - a row of tin huts perched high on a windy hill, to which children as young as five walked six kilometres to and from their homes. The main health risk for Bedouin children was anaemia, which was linked with the traditional nomad diet - strong on goat's milk and easily stored staples, weak on fresh fruit and vegetables. Islah was planning to introduce a 'school fruit scheme', based on the English experiment which gives children under six a free portion of fresh fruit or vegetable each day.

I asked why the school wasn't nearer the villages. A teacher explained that it was there to secure Palestinian land rights and prevent another settlement. Lately, the Islah medics had been unable to visit villages and schools that lie beyond the Jericho boundaries. Mohammed, their finance officer, was studying for a management diploma, but couldn't get out to take his exams in Ramallah, due on the day of our visit. At least he was still getting paid, unlike the teachers on the hill, whose salaries depended on the Palestinian Authority.

In spite of increasing restrictions and privations, the people we met in Jericho seemed unperturbed and upbeat. Their city was bustling. It was a long way from the wall. On the other side of Ramallah, the mood was different.

Wall to progress

In villages like Budrus, where water was scarce and unpredictably supplied by Israeli-based companies, MAP was helping to rehabilitate a local well. The health risks were multiple. Water shortages threatened agriculture, hygiene and physical health. The daily anxieties and humiliations that arose from abject dependency threatened mental health. The wall had cut Palestinian farmers off from much of their land, so their livelihoods and food supplies were seriously diminished. The ruthless march of the bulldozers across their neighbourhood, the erection of eight-metre concrete blocks, the arrival of watchtowers, tanks and soldiers - all this had prompted fierce demonstrations, ending rather inevitably in mass imprisonment. In some of the villages west of Ramallah, there were no men under 40 left at all.

In Jerusalem, too, the wall cut through Palestinian land. It cut between homes and jobs, splitting families and neighbourhoods. Houses, apartment blocks, shops, workshops, offices, gardens, streets and playgrounds had been swept away to make room for it. Huge crossing compounds were under construction, with rows of high metal turnstiles - soon to be the only points at which Palestinians could enter or leave.

On the plus side, perhaps, residents of east Jerusalem still lived near to large hospital for Palestinians. Makassad hospital was an independent charity that had long served as the main medical training and patient-referral centre for Gaza and the West Bank, as well as east Jerusalem. Now it was in deep financial trouble. For one thing, many patients could not reach it any more - especially those from Gaza. For another, insurers weren't paying the bills for patients who could reach the hospital. Many were insured via the Palestinian Authority, which had been unable to pay at all.

Routine frustrations

But it was Gaza that bore the brunt of the crisis. MAP's field officer in Gaza, a locally born woman, finally made it to Ramallah during my visit, after days applying for permission and long hours waiting at checkpoints. She reported that her phone had been ringing constantly, with local organisations begging for help. They wanted food supplies, but MAP wasn't geared up for that kind of large-scale emergency. No one in Gaza had any money. Government employment had sustained a large proportion of the population, and for two months wage packets had been empty. Most shops wouldn't give credit any more and the wholesalers had stopped supplying those who did. Flour, sugar, coffee, lentils, rice, milk were almost impossible to find.

The other important source of income for Gaza had been agriculture - fruit, vegetables and flowers sold to Israel. But the main commercial crossing was open so rarely and so randomly that the produce was rotting before it could reach its markets. At least this meant there was a glut of seasonal fruit and vegetables in Gaza itself. You could get tomatoes but you couldn't get bread. And wilting flowers were no good to anyone.

Parts of Gaza were bombarded almost daily by Israeli missiles, to assassinate known militants, or retaliate against missiles launched, far less effectively, in the other direction. Military jets regularly over-flew the strip, sonic booms heightening the effect. But no less terrifying for residents were the gun battles and revenge killings between factions within Gaza: internal terrorism out of control. The Palestinian Authority didn't have the means to keep the peace. Sometimes the Egyptians would intervene to take the edge off the worst of the violence. But life in Gaza was lawless, frightening and perilous for most of its residents.

Many middle-class professionals, including doctors, nurses and teachers, were leaving if they could, to find paid work and safety elsewhere. Local health services could not provide essential drugs and treatments. Getting out of Gaza to go to hospital had become a life-threatening obstacle course. And all this was compounded by the experience of utter powerlessness, and by the routine humiliations and frustrations that undermined both mental and physical health.

In his east Jerusalem Reith Lecture, Daniel Barenboim explained why he and Edward Said set out to recruit young Palestinians, other Arabs and Israelis to play together in an orchestra, the West-Eastern Divan. "Separation between people is not a solution for any of the problems that divide people and certainly ignorance of the other provides no help whatever." Answering questions later, he said it was imperative that "the legitimacy of the Palestinian narration is accepted by Israel, its politicians and all its citizens". What is happening to health and health services in the West Bank and Gaza had become a critical part of the story.

This isn't Darfur or Baghdad. Aids is not yet a major epidemic, nor is bird flu. But it is a place where a cocktail of physical and mental-health risks is relentlessly stirred by politics. Plans by MAP and other NGOs to work with local people to tackle the causes of illness through community-based projects could soon crumble under the weight of need for emergency relief.