C W 8

1 Septsmber 1949

OMGrnAL: ENGLISH

WORLD HEALTH ORGANIZATION

SECOND SESS ION

REPORT BY DR. J.D. C-L, C m MEDICAL OFFXCH1 AND WHO FEPRESENTATIVE U.N.R.P.R. - BEIRUT

----I

A document entitled n A . P r e U m i n a r y Report on Health Conditions of Palestine Refugees and Estimate of cost of h b U c Health and Banitary S e m i ~ e s ' ~ was presented to t he in&~gural meeting of tbe Eastern Mediterrahean R e @ o d C d t t e e in Febmary.

The purpgde. of this report ia,to sta te the progress made up to date and; as far an possible, outline the problems of the future.

On 19 November 1948 the U.N. General Assembly adopted a resolution requeatfng %he Secretarydeneral to M e all necessarg ateps to ex- tend eid to Palestine Refugees ,,. InvitSng the a e e i a h o e of the .... specialized Agenelea of U.N. ........ the International C d t - t e e of the Red Croas, the League of Red Crose societies and other voluntary agencies f i . . . . . . . and to appoint a Director of U.N. Relief for Palea- t ine Rehgeeaw .

On 5 Decmber 1948, Mr. Stanton Griff'ia, UmSr Ambassador to Egypt was appointed Direct or, U N m , aid by ndd-Doomber agrementa were signed with the Inte-tiomal C d t t e o of the R e d Cross, the League of Red Cross Societies and the American Friend's Service Conmaittee appinting than "apprmprfate o p e r a t i d .. . . ,, agencies t o implement an agroed plan of diatribuuon in tho meld. Them agon- oies were rquired Itacting as o undort&e reapon- aiblllty under his (tho Dfroc ng and co-ordination, for tho conduct of reUof distribution in t h o field".

On Jamary 5 , 1949, at tho request of t h o Director, and on tho lnvltamtion of the throo operating apncios, WHO appointad Dr. J.D. C o t b l l to nco-o&nato plane for d o d n g with the PubUc Hoalth and Hygiona aspects of t h o r-o reUaf programno, md t o addse their (the operating agencies) Held Staff in theae mattersm. Dr. Cot t r e l l arrived in Calro on 9 Jameq and Boirut on ;L3 Jam- 1949, On 28 Jarruar~r 1949 a mootPng wa8 held attended by the medical represonh- tivels of tho operating agoncioe, t h o C h i o f of Minsion of UMCEF, M.E. and a repreeentatlve of tho Lebanone Govorrrmont, ad an observer. A pemment co-ordim* o d t t c e waa set up consisting of ropreson- h t i v o s of oach of the. 'agencies and of UIVICEF under t h o Chairmanship of the WHO Representative. Thir o d t t o o haa contimed b meet at lntervala of 3-4 weeks, /.....

WHO d a o soaon8od Ilr . dormo Peterson, a h b U c Health spsuia l l~t fran Elm Ymk, w chiof n&cal officer to tho h6r5oah Friend*# S e ~ c o Coamaittoe*

It should bo notdd thoro is a -nu distinctfon bobmen tbe p a i t i o n s of the two WHO rspxosorifatives - Dr. Petarson t3d.w wn nxccutive officer with oparatioml reepwibi l i ty , nhersas Dr, Cottrall is roaponsible for planning m d '60-ordinat- tho work parformod by three autone~~oue op~xatfng q h o i a s .

wt AU the territory both Arab and Jowisb hold, onclosad within t h e boundaries of the old mandatod atato of Palestino, sxcludiqg the Gaza enclave. m: Lebanon, Syria the Hashamito $in@an of Jordan and Iraq (circ 15 ,OW rof\lgeea onlg.j mr Tho Gasa onclavo, UMtPR distribution can bo sa id to have ccmrmmced on 15 3- 1949,

Tho lateat of Ficial census fa Palestino is that roportod in the Gwerrpnent of Palostino Blue Book for 1937, which gavo #,Q Arab popu- latfon of Palestine wa 973 ,MK). In 1948 the Gowrrrment of Palestino made an oatim-to of Arab ~ q d a t i o n as 1,200,090 (Authdtyt- Pereod. cammication from ex-Dir~otor of Hodth, Governant of ~rrlestfno), It should be not& that between 1922 and '1937 the Arab poplatiLon Incrwaod by 2%,6&,

Tho aperating agoncica raport tha follwing mbers of rogistcred raftag~os: -

This figuro i a Wttodly t o o high owing t o d q b l e registratlona, registrations of porsons not truo,rahzgcoe ctc., and UNFPR at present ismas 940,000 rations.

It i a probablo the real figure Uos bokwoon 30,ODO and I,OOQ,000. The Govemmont of Jor&qp.clposcs sh&tly t o eako a census of refug~ee in t e r r i t o r i o a controll@ try Jordan, rathor more than 505 of the as- timetted total rsfigeo poplation.. Of the t o t a l refugee po@aUan a b t 33% are in campa and tho reat trrc Udng In tawna an8 mattered ovur h n k e d b of vi l lagas.

An apprdnuto percantago diatrtbution of the e a t i o n by epeoid aategorias l a as fohlwst-

0-U months 5% 1-15 pars 4%

Prognant women and nursing mothers 6%

V&& $ t a w : Por m i m e rcaaons, dl attontpts t o colloct accurato v i t a l atatistias havo f a l e d . Tho monthly rehwna of deaths frcm camps in various areas are coneiertently + d e n t t o a orfid~ anaud rato of 10-12 pcr 3000, It is known this f i w o i s too low as

doaths aro conceclcd to kocp up the family ration etrongth! A l l camp rn&ca;l staff havo bocn rquestod to watch for donths as closely as possible, No groat opfdmics are occurring and no avidancc of high douth rato ie ever roportd, Taldng a l l factors i n t o consideration, tho doath rate can not be moro than at an nnrrud. rate of 20-25 per 1,000, nnd is probably less, m: This is am- parable t o the pr~scnt annual death r n t o fn Egypt,

In the resolution of' t he General Assunbly on 19 November, a t o t d expen- dlturo of $29,500,000 (plus #2,500,000 for administrative coats) was npprovd t o provlde rol ief ' for 500,000 rofUgecs for 9 monthe from 1 Decmbor 1.948. The Mediator's report rocommended that $3,500,000 of this bo mado available for h d t h servfccs. As at 15 August 1949 the Spoclnl Fund instituted by the Gonerd Assembly had roceivod domuons .in cash and ldnd to an npproldmto value of @I, 524,016. To this must bo added $6,000,000 domtcd by UNICEF and part expendod bef ora UNRFR took war. A hr thc r $4,675,000 muy be avail~blo from USA on n 'batchinq boais.

On 25 January 1949, in.thc l i g h t of the fnc ta as thon knonn, including t h o bUef that there were only about 600,000 rcfhgces, the WHO Reproeentativo proaentcd a budgat to the Director for a t o t a l sum of $2,252,000 for Health Caro. In tho outcome it is probable that a t o m sum of a p p r b t o l y jf1,300,000 dll bo avnilnWo for expendiwe on hodth eerviaos from 1 January 1949 to 30 October 1949. T h i s sum is derived as fo1lowa:-

UNRPR ~1,000,000 UNICEF $ 310,000 WHO 50,000

To this mat be added tho cost of special consultants ns d a r i o l o g i s t s , defray& by the WHO, contributions in cash and kind mado t o the agencioa m d sanitation works B ~ C . perfonnod by govormcnts nnd militnrg.forces. On the basis of 9&,000 persons, it can bc ar id tho henl th services of the agcncios arc attemp- ting t o care f o r DOUBU THE NUMEIB OF REFUGEES WITH HALF THE AMOUNT OF MONEY ORIGINALLY RECWMDED. On a population basia of 940,000 the haalth aorvicas at proeont a r e costing U..5c, por rcfugcc per month. It must bo stressed, however, that oxpqndlturo $or mcdicc? purposes cannot bc truly estimated on c per capfta basts and a reduction Sn the nupbcr of rohgces would only m e a n reduccd expondi- ture on health services if c o r t d n c o d t i e s or groups-wcro excluded from rocoiving UNRPR a id ,

ThrougHout i t s cdstoncc, UMRFR has l ived on a hand to mouth basia, and the Diroctor h i d d m tho policy that he would only allow funds to be committed, %hen the cash waa in tho bankll. T h i s v i s e f inancial policy made the execution of plans for health care oxtrmoly difficult, In the early days whon M a wore urgently needod, t he resaurcoa were barcly avdlablo for tho feeding propnmte. It ie against this b d c k p w d that the vnluo of tho UNICEF ruad WHO contributions must be assessed, It wns finally possiblc to allot n 1st Quarter Budget of @60,000, derived as followe: -

WSCW 150,000 (madical supplies) UNRPR 60,000 WHO 50,000

-

TOTAL 260,000

Tho following table givos an W a i a of t h a oxpantlibre ,on hoalth taro:-

Mdical and hospital auppliss 34.9%

Sanitation & Water supplies 23.6%

TOTAL 103 %

In gonard, i t m y bc stated it haa provcd poasiblo to ostabUsh a fnirly adoquato fmorgoncy hoalth s e r ~ c e in tho cmps and tho vlllagea nearby, but in the groat totma nnd remote villagos kho, henJth care has had to r a d n in a largo part the responsibility of t h ~ Govcrrmonts concernad, From 1 Decmber 1S4& to 31 July 1949, . f t is oatimntod tho Arab States have contributed ame $6,000,000 directly or indirectly, toward~l tho carc and dntonanco of the rcf'ugoaa.

On the above rostrictod budgot it has beon impossible adequately to aolve many impartmat problwns, e.g, tuberculosis and nntexllal rtnd ihfmt care.

Tho agoxlcies oporate with both imported and local a t o f f . The Eastern Moditorranom Regional Cormnftteo mceting tn Cairo on 8 February, rsqueated:-

"those b d o s uhlch havo oporationcl responsibility t o employ l o c d h o d t h porsonnol whcnevor possible.

As tho following table will show thoro h e boon n good rasponso by tho aganciorr to t h i a ros~lution,

• i O C U I I F ~ ~ ~ ~nerppctor m

UmCY .t Doctor : - - - t Nuso : Mtrae aid : ToaMcitsn etc. *Local Imp.: Lbcd Imp, : Local Imp. : Local Imported : 4

CXCR i 12 l3: 1Q :

ms : 21 4 : 11 : .

AFSC : 8 3 : 20

TOTAL : 4 l 2 0 : W

Bocruitnont of Pnlostinian parsonnol h a boon rather disappointing, m q have boon very reluctant t o go to the noro rmoto areas as Jordan and Gaaa, and others hnwr refused to aomc mqwhoro but in largo towns. Novorthelese the health sarvicos of the agondoe now mpZoy many skillad an8 hard-working Pales- tininn doctors and nurses.

RC2M8 Fage 5

A t t h o ccom;lencmont of the operati~n, 1% was hopod that the h o d t h somicee of tho agencioa would help "kwp alivorf something of tho pubUc hmlth structure bui l t up by the d a t e Govermment against the day for repatrlation.r>r re- s c t t lment . This idea l hag not been Mly r o d l s d nawerthclees q l o p n t is being giwn to nmy ex-mployeos of t h e Public Hcdth Depmbnent including doctors; nuraaa, pharmncista, a a n i t ~ r y inspectors otc., Md the nucleus of a public k d t h soryico is boing kept in edatonco.

finally., it- is doafrd t o pay a special tribute to the inportod nembers of the nedlcal stpff of t h o agoncios, Thoso men and wmen havc workod long hburs in tho'worat of conditions with a mininun o f medical supplies, Eepocially in Syria and Jordan they hnve Uvad in dlscmfor t In tents attached to the camps or in iaolated n a t f ~ o vlJTngee nnd everywhore they havo won tho affection omd a b i r a t i o n of t h e i r xefugoo chclrgos,

Tho madScal supply problm has boon one of tho most difficult in tho ope- ration nainly bocausa certain oountdes oar-marked sum Prom their contribution t~ be used to purchase modical supplios and then tho aontrilmtions wro aubj'ected to appropriation delays for mny nonthe.

Fortunately 150,000 were inmediately avdlable frm UNICEF and the Director granted d 36,000 for inmediato loca l procurenent. Frm 8 Fob- stocks of r e d l y ossentidl dmge bogon to -rive in the agenciee' atoms. Tho i t cq prmpt purchase and d r shipent of norirly 1/3 of tho supplies domtod by UNICEF m f v a d on 16 k r c h and shortly aftorwards drugs from tho M a s contribution, o m k o d , u n f o h m t o l y , for t h o Red Cross Societies, connanced to arrive.

It can be clnlmcd that essential drugs and dressings have becn in f a i r l y adequate supply since nfddlo February.

A t first, distribution proceeded in rather a slow an8 ha l t ing fashion but i n l t i a l di f - f i cu l t ios h v o been largoly ovorccao.

A large V O ~ W O of appl ies is expected frm Belgiun towarde tha cnd of Septmbor and theso should be sufficicnt*to last u n t i l the end of tho gem, In tho mantino sufficient noney is a d l a b l e to fill in a preaont gap by local purchaae . Endemic and eddenic disease

Mo disease has roachod epidcnic proportions m n g the refugees. Small locallsod outbreaks and sporadic cases of the cormon infoctirrua disease hnvo occurrod and nro briefv noted Inter. Uno OX' the great diffioulties has boon lack of laboratory facilities. The U ,S. N a v a l Medical Resoarch U n i t early supplied a laboratory for use in Gaza and anothcr obtdned.from UNICEF i a in procees of oshblishmnt in Jerusden.

Malaria: Aa a result of t h e DDT reeidual spray p r o w e caaos of prinary Plalaria are very mro in all the cmpa and in thosc villages which it has becn possible to aproy, Even in thasa fw caaoa infect ion can usually be traced to a period spont out of cmp. M q rolapse cases are occurring as these peoplo wero exposod t o much infection during the late mmer and 'cutumn of 1948, Novortholess it is obwioua the diagnosis of ffnalarlall is at tach4 to my shoPt-tarn febrilo illnoss d whoro laboratory fac i l f t ios a r o available thc diagnosis is very often not substanti atod.

Sr;_lal~ox: Sporadic caaoe and mall localiacd outbreaks have occurrod in a l l areaa except Gaza. Thoso cases now are confined mainly t o refugees l iv ing in rmoto villagos,.whore~it $s.difficult t o wccinatc thon, In canps, mccfnation is v f r % d y 100% c-mpletc Md M h s r wt-of-cmp vaccination is procecdi ng.

RC2w8 Page 6

Enteric Fevers,: Again sporadic cams nnd.jxmlT.locdlisod wtbraaks have o c d in dl maas; SL high perbentage of rofugosa in cmpa -18 h m m i ~ e d ht in the absonco of cmpulsf on it i e difficult, t o imnmieo 100% of tho population.

khus FBPTOF: TWO outbreaks are known to have occurred. Tho first was in the Hebron area, where frm Fobruary until tho present datc s a c 175 catres smo known t o have occurrod with d n o r b l i t y of 6%. On tha initiative of Dr.Peterson n number .of Woil-Feux tasts woro c a r r i d out in Gaza and Dr. Sanaonnem rsent others to Beirut. ~ h b t c e t s irldicatod dithar louse-born o r m i n e typhus vfth pos i t i ve t l t r e s t o 0 X 19 (high) Md 0 X 2 (nedium). No rickcttaial ogqlulutinuti teat^ were porfomd and &no typhus i s known t o h v o occurrod In the past hero so the cxact diagnosis mat rmdn in smo doubt,

l+ axtonaive and r o p o a t d DDT dusting c m p i g n has been c&ed cru* in the area and it l a hopod' thts long snouldoring outbreak h a . now subsided.

In Ga& proven cascs were roportod - tho Inst on 3 Hay - with no doatha, Tho a n wtbroak was traced to rcfugeoa fron thc Faluja p a k o t .

MouaLeg: h great nany casos of nonsloe occurred during the wintor and sprlng with an darning m b o r of fatal casos duo to pneunonla amongst children,

a o ; l m : No casos of choleriz have boon dctectod though its presence hua been m u r e d i n the press,

Bilharzia: Tho Gaza laboratory roports tho finding of schistoscaa haematobfm in persona c d n g fron tho coasb l p l d n near Lydda and faffa.

Tuberculosis: The t m o fncidonco o f tuberculosis is unknoun and at present far faci l i t ies are avnilablo for t r c a h o n t , d rocent Mantwx s u w y of some 1500 refigoes of Bedouin origln did not rcvcal an b l a m i n g incfdanae. bt 20 ycara a. 1% wcro positivo, at @ y c m s 62.5% wcro positivo and over 40 yoars 76.8% ware poaft ise .

A BCG cmpafgn organised by UNICEFfiHO w i l l cmonco in February and nore exact infornation w i l l bo available thon,

J'rachom and mandont Coa3unctivitis: These nro very c-on especially in the Jordan valley and Gaza, M a n y c a p s have established eye-clirzfbs predided over by +ltnmargiatl, zrale orderuoa trained by the ox4ovement of Palestine.

T: Tho incidcnco of dysentery has greatly increased during tho hot woa her; without laboratory assistance it is d1fffmJ.t to differontiate certainly botwoen anoobic and bcillam dyaentory. Evan in Gaza, where a laboratory i a avellablc tho doctors rarely trouble to B e n d ~taols for oxaninqtion. Ample auppliea of aulphagutmidine and othor mlpha-drugs Glld motin0 a r e available.

The f o l l o y l q tablo show tho incidence of infectfoua diaonse'roported for the period 20 June - 20 July.

-ation nt r i ~ k cfrc 450,000.

krona - Canpa and smo villages a l l areas.

Saallpwc 20 C .I .C .R. only Typhus 6 E.rnlaria 2,303 Certainly t oo Ugh, ono village in LJGS area roports

nmo cams than tho total reported frofl a l l other arcas ' nnd cnsea aro drily unchecked- by blood c ~ n a t i o n .

Menslsa Whoopirig-cmgh Syphi l i s Tuborculosrf a rsphoid Para; A Para B

7.294 C .I .G .R. reporting only 206 etates this dof in i to ly too law,

Trachoma 1,266 A.F.S.C. only,

Thoao f iguros do not approach s t r i c t accuracy and give only a qualitative pieturo.

SParitatioa & water Suwddos:

Whon UNRPR and the Opmtfng Agencies took over, mny of t h e c a p s were liCcrn1l.y without m y fo rn of snnitation. S m o hcd not one latrine and whore latrines trorc present thcy had recoivod no care nnd wero foul in tho axtrmo. Tho surroundings woro covered with faoccs, rubbish a d garbage wore lying every- where and nb scavenging syatcm was in opcrati~n. Water mpplioa were too often frw an open irrigation channel i n t o which bleu, or whon it rained, flowod tho a c m l a t e d garbago and faccoe and in whfch persons and olo th i rg were freely mshud.

ConditLons a r o s t i l l far fron parfect but m c h progross has been nads. Hercrly 2000 l a t r inos h c ~ o been crcctcd in the northern areas nnd others in Gaza and tho fact that m y of theso aro now fu l l shows that the paoplo & ueo then,

It has bean found h p o a s i b l c to obtain sufffciont v o l u n t q labour to koep tho conps clean nitd about $10,000 per nonth or 3c. por rehgoo per nonth is spent on paid ~ranitary labour. Thoso labourora hnvo produced a v a s t inprovenant in tho aleanlinoss of the c a p e .

Groat inpr~vmonts have a l s o been nade in canp water supplies, and it can be anid no mtor-born opidmics hcvo occurred. Attmpts arc being nadc to a d - cnte the people in sirrplc snn i tn t ion and posters Rave boon issuad, based on doeigne kindly supplied by tho E m t i a n GovemuJbnt,

28 tons of DDT duating powder have boon supplied through UNRPR and large unknown qmntitics havo boon supplied by the Egypt ian G o v e m n t .

a d a r i a and Anti-Fly Gmmian:

dt tho outsot it was docidod to carry out. a rcaiduul spray DDT cmpaign. This was plannod by two WHO officers, Dr. Rieratcin and Dr. Belioa, and after

difficulties cornoncod i n tho first wock of April. A l l cmps and nost 7villages where tho rcfugoo populatfon oxceods 10% and tho nalarin risk is high, have boen sprayed.

Tho following oqulpont and supplies wore used, and pcraonnol wero trained [Irm anowat tho rofugoes:-

300, Prcasuro Sprayera 2 liotor Sprayora

28 tons DIE .50$ Wettable P.owder 21 ton; DDT 30% b l a i f i n b l o f l u i d

Rc2/EM/8 Page 8

The wettcble powder used is a apecial powder developed by Socony Vacuum, Cairo, uaing colloidal clay, This is rather difficult to mix but gives an extre- mely atable suspension which edherea very well to tents and porous aurfases. It i s inclined to f r o t h in a power-sprayer, therefore emleion was used with these. The campaign was carried out even in large cities and in Damasma 11 schoola and 63 mosques housing refugees together with 221 p b U c latrines were sprrryed,

On the advice of Dr. 1 ~ . Weir of the Rockefellar Foundation, Cairo, 10J$ gMIln8XRne pawder has been distributed for use in prevention of f ly breeding ond is apparently very successful, The following is a brief report on the campaign frm Dr. Farid, a Malariologist lent by the Government of Egypt to WHO:-

"The Mnlariologist has been following the results of the DDT cmpaign or- ganised to envo the refugees f rom thc ravages of malaria which is No.1 publlc health disease in Arab Palestino, Lebanon, Sfla and TransJordan. In Paleatine no control work has beon done since tho end of tho Mandate Power about 20 monthn ago, w h i l e in these other count ria^ rnalaria control has not boen tackled serious- ly. Tho Malaflologist has mado mnlarln aurvey trips to rehgee camps and barracke in the arcas under the medical jurisdiction of tho C .I,C.R., L.R.C .S. and A.F.S.C.

In Palestine he studied the quastion of o i l i ng the cisterns and walls of the old c i t i a s of Jerusalem md Bcthlehc:il, as tho expenses involved in DDT-ing these two c i t i e s wcro prohibitivc, Ha found C, bifurcatua brooding therc, In Gaza area he only found A , m l t i c o l o r broeding nnd foretold of no real dmgor from this mos- quito which has not y c t been incriminated as vcctor.

In TransJordan he found oxtcnsivc broeding placos especially of b. auger- tus near thc r a g o c camps. No mosquitoes, howover, nere found inside the DDT-ed - tents, In Sukhna camp nnd vlllnga he collected S-8 adults from evory rom that was not DDT-ad and from the nomadfc bedouin tents that had campod recently near tho refugees. Ho pointed to tho dangor of these n d a and suggeetd DDT-ing their tents wherever they arc found near the refugee campa.

In Syria A , elutus and IL . sumrpictua werc found extensively breeding in many placos noar s o ~ o of tho camps. Hc invostigatd now malaria cnaos roported among rcfugce adults l iv ing in Hama, and found that they contracted it rocently from a labouror's c q where thoy wero transforrod by the contractor to a mlwdou vi l lage , In the lattcr therc wore marry A , olutus ins ide the non-Dm-ed tents. He pointed to the dangerous breeding places near big towns l lko Hams and Aloppo so ae the Municipalities thcro could help in oiUng them.

In Lobanon, Dr. Farid made s m o y s in the malarious d i s t r t c t s like Tyre and h j a . In tho former ho noticed t he scarci ty of brcoding of J~nophoUne in spite of the extensive breeding placos. This he attributed t o tho offsct of residual spraying-in eliminating the hibornatlng mosquitoes that werc there.

In his m a y ho collected data by which he could assoss tho results of the DDT campaign, In table 1 h i a findings in t h ~ DDT-cd premiaea are campared with tho non-DDT-ed onoa.

ThBm 1. Mbsauitn Collections in DDT-ed and non-DDT-ed Premfso~

DDT-ED NON DDT-ED Tents Booms Stables : T ont s Roms Stnblos

NO NO. No. NO, NO* N O * : NO. NO. NO. M o o NO. NO. hophe I 6noph. Lnoph. . Anoph. linoph. h ~ p h .

RC2W8 Page 9

Dr. Farid regards the cr i te r ion of tho ultlmate mccesa of this DDT cm- paign is in eliminating atry new mclaria trmsmission. He has dono blood oxamin- ations for nwly born infnnts and compared t ho i r malaria incidonco with older children. Tho rosultls up to now arc quito encouraging, l m g 194 infants b o d in the refigea camps no. malnrin positivc blood was found, while among 131 older children (8 months t o 2 yoars) 11 casoa wore oncounto~ad. Those reaults are shown in Tablo 2.

Malaria Incidence Ilmong Refugee Infants- Bclou 8 Months And Amow thoso 8 Months - 2 Yea OM,

INFANTS BEUkl 8 MONTHS INFANTS ,8 MONTHS - 24 MONTHS No.Exam. No ,positive Tota l % -No.Eurm. No. wai tive Total. 58

v i v a f d c i p m a l ; vivax fn lc ip . ml.

ht a time whon many of tho doctors of the different organizations were acapticnl about tho reaults of the DDT campaign, Dr. Fmid tried t o gfvo evldonce after evidence of the success of that campaign until in the mooting of t h o Chief MedLcaZ Officers on the Uth July, 1949, it was unmimoualy agreed that on tho whole the campaign had been successful. Dr. F w i d will be following the Issues of th i s campaign u n t i l the end of the malaria sooson, ond w i l l bo doing some c h w c a l analyais of the realdud quantitfos of DDT in thoae tents. It i a t o be hapod that enough data w i l l be collected on tho results of the biggost DDT campnign ever done on tents in this part of tho world,

In the meantime the Malariologist is f o l l d n g tho r o d t s of tho 1@ Gammexane-Rockphosphate duirting campd.gn against flios . Very encouraging results are boing obtained and we 'hopo that thcsc will bc maintained in the late gummer wavo of the fly preva1enca.t'

pospitds , Clinics. etc.

On tho present budgot it is irapossiblo f o r UNRPR to aasume t he entire bur- den of providing anadequate number of hospitul beds - at most, it can supplement the provision made by the Governments concerned, and, oapecially, proviQe reason- able hospital care for the rofugccs in camps who are, presumably, tho moat needy. Emergency surgery can now be carried out within reach of almost dl camps.

Tho following table shows the number of beds maintained, or nssiatod, by the Agcncles .

Bethmy 45 Salt 49 C 85 Hcbron 65 ~o'raa 20 Red Crescent Austrian

50

Hospi co 88 hleppo 20 I solation 30 Bethlehem 20 B m 20 Jerusalem 150 TJrr 50

~ o t a 386 159 165

RC2/%f/8 Page 10

Hospital equipanent to tho value of $30,000 - $40,000 has beon mpplied by UNICEF and is ppsently arriving. f~Polyelinicrr~ have bean entabllshed in all the camps and they aro staffed according to tho size o f the grou aerved, but iA'genera1 thera are on0 or more doctors, msos , ~rurae-aids, and o en an opht- c tltamnrgi It . f!

Owing to ahortage of staff only slow propeas has been mado i n building up a sories of Public Health CUnics ( ~ a t d t y , Infant Welfare, School, etc., cUnica), In addition local ly trninod doctors and nuraels do not have a npubUc health outlookt1. Addiuond training in Public Health i e now being planned in both Beirut Modica3. Schoola, In Arab pals st in^ a number of Public Health CUnScs established by the Mandato Govomcnt contimc t o &st and do good work; it is obvious the Paloetine Arab woman sjill and doee attand a Maternity or an Infant Wolfare c u n i c ,

L -11 numbor of mobilo.clinics operate in different rogiana.

Tho followtng tablo shows tho prosonf o f f i c i a l d ie t ,

C amdl ty Daily ration Protci n Calories in grams in grma

Flour Pulses O i l / f ats Sugar Skim Milk A d d protoin a (ox rico)

T o t a l 50 1,505

a hnimal protein f a not at presant iamed.owing t o high cost.

The rat ion is distributed par capita irrespective of 'ago,

The d i e t is ~lhor t of protein, iron and certain fitamins. A nutr i t ion survey has been carried out by Dr, Abbasy, FAO, in Gam, kt at tho time of writing this report is not y c t to hand.

Reports frm camp modicrtl. staff indicate ~ndor~nutrltion is fairly comon but malmjtriti~n is rare, and I s W n l y aeon in sick infante.

UNICEF mpplment tho children',a diet by giving 50 grame powdered whola nflk to infants 0-1 and 40 grams skin milk to childron 1-15 plue cerwn Wpplo- ments. There, i s no doubt in many instmcoa the whole family, share the milk.

The miin nutritional deficf ency appeara to be anamla, which in persons wlth chronic malaria may be extreme. A few cwea of pellagra have been Been and f n Gaza ribo-flavin deficiency is common anong cMl&en - this does not appear to be the cane in nme other areas,

Litkle f a done f o r tho soc ia l welfare of adultr and it I s illegal in moat areas for tho refugooa t~ obtain work. Nevertheless a rrumbor of them have

succeeded in finding jobs, especin1l.y during the harveet aeaeon, A project f o r making rel ief contingent upon work is being considered by menbars of tho UNRPR staff, t h o bridging tho gap betwon tho presont phase of relief and a future phase of rasottlem~nt.

The houaewifc, as always, loads a busy lifo and moat tents, though over- crowded a r e kept oxhomcLy cleau and in - instmcos the clothing of tho children is nstonishingly clean.

There is Uttle discipline in the camps and vcry l i t t l e leadormhip is diaployod by thoso in a posi t ion to do so mongst tho rofigeee, As ntatod above it is imposeiblo to get v o l u n w labour - corporate action for banofit of the children is alnost unknown.

Schools arc now osttlblishcd in most of the camps largoly thanks to a grant fron UNESCO. Unfcrtunntcly prcsont funds All bo oxhaustod by tho end of Septabor ,

In Jer icho the Jerusalem Y ,bL .G .A, run an excellent Boys' instf tut ion for boys from 5-f4. and ovor 900 nttcnd t d l y f o r school, d r i l l and organfeed games. M i l k is disbributed also.

It is not proposed to deal at length with the quostion of resettlment in t h i n report , it is presently tbc provinco of t h e U.N. Conciliation Commiseion and i t s Technical Comi t t ca .

Mono~r and mppl ies at prosent in hand will last un t i l the end of October. It is hoped that tho U.N. Genornl Aaaenbly in Septaber, proceeded by tho Ad Hoc hdtr?.sory Cornnittee will vote a fu r the r sun for interlm aid, which, as nentioned above, my tnke the farm of "work-relief". A sum of 6 - 8 milUon dollars h a boon suggastcd which would carry the operation through u n t i l tho end of March,

b meeting between UNRPR and the agencies haa been called in Geneva for 10th October, 3 . d a deciaion concerning continuntion, or otherwlsc, of the operation w i l l h?vo t o bc taken a t this meting in tho light of decisions taken at Lako Success.

Apart f r o m political constdomtiona, onc pofnt is clear, those hundreds of thousands of refugees reprosent e public health nenaco of the first nagnitude, The prcsont costly noasnos m o noraly deferring the menace. Only one action cnn solve this problen, t h o ronoval of thc rafigecs, qua rofugoos, by permanent rosettlament .

Relations with UMICFZ

It is a pleasure to record br..cfly the very cordial rolationa which havo mdeted at all 13vels with UNICEF mid it is difficult t o over-catiwte tho immense value of t h e i r prompt assistance.

UNICEF has given, up to date, $250,000 to the medical progrme and p r d s u d j?!60,000 more if the operation oxtends aftor Septonbor 1. Moreover, tho value of tho UNICEF aasi~tance was doubled and trebled by being nado availabl~ when almost no other f'unds wero in sight. Tho prmpt purchaeo nnd air-&pent of tho first instalmont of tho UNICEF suppllea may bc said l f t e rnuy to have sawd t h o medical mpply si tuat ton from d i s a s t d ,

15. WHO Contribution.

The WHO nado cvailablo both specialisod personnel and a cash grant of $50,000 frm the UNRPR special fund.

No less than 7 mmbcrs of the WHO staff have been lent t o t h e operation frm t ino to t h o .

ha stated in connection with the UNICEF contriWtion the vduo of the WHO grant was out of all proportion to its size because it was available at the connencaont of the operation whon no other funds were available,

The following table shows the trpprodmto exponditwe of tho WHO grant:-

Sanitation $20, L n t i d m i a cmpaign $22,500

It must bc concluded that a successful mergency relief operation f o r the Arab Rcfigoes has been conducted by UNRPR during tho past 8 months,

During this poriod no opidedcs have occurred, a reasonable health service has been organfaed and opornted by t h o agencies and tho present hea l t h of the refugees as judgod by c l in ic visits and their death-rate caparea favourably wi th that of t h e population of tho surrounding countries.

As the off icer charged with ffcoordinating plans for the Public Health and Hygiene aspects of the Refugee Relief Programeft, t he writer wishes to pay a tribute to tho spirit of cooperation at all times'shown by the Chief Medical Officers of the Operating Agencies and to the s k i l l and hard work displayed by then and their staffs,

It would not be r i g h t t o finish this report without referring briefly t o tM continuous and pronpt assistance affordod tho WHO Reproaontntive by the Acting Assistant Dircctor-Gcnoral f o r Operations and the ent i re WHO Secretariat and a l s o to tho intorest shown andl assistance given by the then Under-Secretary of Hcalth, Government of Egypt, Sir A .T . Shouaha, Pasha,

INTERIM AID TO BFUGEES FROM THE WAR IN PUSTINE

A* Interim aid to t he ref'ugees f r o m the war in Palestine is defined

18 a continuing period of constructive work r e l i e f , under United Nations

mspbcea, between t h e end of the present re l i e f p r i o d and the establishment

md f inandng of permanent plans for resettlement and repatriation through

bcomic developnent in the Middle East,

Work relief is employment upon am economic developnent project,

#ltlmately of permanent value, or in small scale industry neither

nscessarily s e l f supporting and therefore only made immediately practi-

cable by a subsidy in the provision of rel ief supplies to the refbgeo mrker,

A refhgee is defined as a person normally resident in the former

mandated territory of Palestine ~o has moved away from his permanent

home or means of l ive l ihood, as a direct result of t h e ww.

2 4 ,The Secretary-General of the United Natfons has on several

occasions stated h i s opinlon t h a t t h e relief for Palestinim refugeect

must contiwe well into 1950; pesumably th i s opinion is based upon

consultations with members of t h e United Nations and with those governments

lJho have been mjor contributors to t h e p a s a n t r e l i e f progratmne.

It is anticipated that t h e forthcoming Meeting of the General

Assembly w i l l take far-reaching deciaions regarding the po l i t i ca l and

economic future of tho Pales t inian refugees, that these decisions will

include plans for economic developnent and consequent resettlement both

in Israel and adjacent Arab countries, Such an overall plan would

require a considerable volume of capital investment, m d it may be well

into 1950 before it can be knom dth certainty that this necessary

oapital will bo available, Whilst it is to be hoped #at t h e present

rel icf ogeration dl1 finally be absorbed into t h e new organisatLon

craatod t o deal with the overall .Egogramme, it is assumed that UNRPR and

UNICEF, in their present form, wuld be the log ica l agencies t o continuo

at least un t i l t h e early months of 1950, if lhere is fm be no break

in the feeding and msdical care of t h e Palestinian refugees, more

especially as the d i r e c t association of the United Nations in this

humanitarian work, in the opinlon of many, considerably auppox*ts tho

work of the Mediator and the Palestine Conciliation Commission in

seeking a permanent peace,

Neverthelese there continuo -to e ~ s t a strong possibility

that a permanent pace will be long delayed and h e d i a t e consideration

should be given to the means thoreby the continuation of United Nhtians

relief might both aid and strengthen the prospects of pace t h i l a t

taking active steps to end 4he p o l y relief stage by the provision of

shbrt t e rm mrk r e l i e f and d ~ o resa t t lment in former threatened areaa,

A realistic appaiaal should be made of t h e powr inherent in moving

a food distribution p i n t and generally t h o p e s e n t s t a u c approach

must be l e r t behind, It may be necessary ta advise Governments af the

area tha t the continuation of United Nations supplies in depndent upon

selected refugees boing moved ta areas a c h povlde opportunities for

developent projects, that no ref'ugee should losa his chance of ultimate

repatr ia t ion by being EK] employed, and that family w i t s would be kept

intact,

The movemmt of refkgeos, security, t h e organization of tranait

work camps d t h medical, sanitary and supply faci l i t ies , muld not

present great difficulties if plans were wrked out jointLy tdth the

Governments of the area, the coopcrating agencies and the United Nations,

including the Specialized Agencies FAO, WO, etc . Such movements muld

a l s o have the advantap of weoding out those who were not genuine

refugees, belioved to number many thousands.

3 1 In v i e w of the increasing stress which it f e proposed should

be laid upon work relief factors in the contiming WRPR p o g r m e , it

is fo r consideration that a central revolving fund m i g h t be authorised

t o p v i d e rawmaterials for refugees to work in to finilshed articles,

such as textiles, rugs, wood-mrkfng, embroidery, shoes, and metal

ware, as well as seeds, otc, for market gwdaning and reforestationl

Certain problems will arise with regard to disposal. of

the finished a r t i c le in bulk may be by way of free distribution

by UNRPR to t h e refugees within the pogramme, by local sales or

by sale overseas, h c a l s a l e ~ t w 3 d p b a b l y raise groat objection

from those normally employed i n the locality, td.lo would regard such

poduct ion as being subsidised competition; overseas sa le might

produce difficulties over export licenses and muld, of course, require

negotiation regarding hprts , although th i s m i g h t be faci l i tated i f

the poduc t could be sold and used for r e l i e f or charitable purposes,

i,e, by UNICEF, t h e International Red Cross, or others,

Initial ly this schmo would bo most vaticable in Camps, and

m i g h t a l s o usefUly develop into vocational trafning, The poblem

of the method of payment for refugee work remains t o be settled; the

present p s i t i on in Gaza of p a p e n t et rates approaching local ones,

whilst continuing to draw refugee rations, i a obviously not capable

of a large scale goncral extension, although accomodation and medical

care would clearly continue to be povided, as well as a higher

r a t ion scale for direct workers, It is believed that substantial

volume of products could be obtained i f authority wore given to use

a revolving find of 250,000 dol lars ,

4 . There is a volume of ~ e l h i n m wrk much of it uneconomic

in the shor t tern, ta bo done before any l ong term economic develoment

can begin, such as We construction of an d l weather mad from Aleppo

to Deir-Esar m d Hassotch and a r d l l i nk to Twlkey; mad building in

t h e Jordan valley and minor irregation projects, drainage of swamps

and a n t i - m a l a r i d projects, etc, Preliminary f i e l d surveys could

be made by WHO, FAO, for the dovelopnent problem is basically a

medical - agricultural one, Refigees directly ernfloyed would require

an a d d i t i o d 600 calorie6 of food daily, These projects would require

p-ovision of c a p i t a l In rolntivoly modest mounts, since the Governments

of t h g arca m i g h t be expected to provide raw materials a d techdcal

personnel on n mnsiderable scale,

It has been proposed to the United Nations Palestine

Conciliation Commission that certain refugeea could return t o their

hones in Paastine, but tha% t h f s proposal can only be implamented

if in t h e first place the UNRPR is preprod to continue t'o distribute

re l ief supplies to rcfigecs in t h o locali tfes from which they came.

The proposal. is made on bohalf of those refugees from weas not under

Israell. occupation, but &ose villages and homes rmre either in areas

of No Man's Land or adjacont to military f r o n t l i n e s or f r o m areas at

one time under Is rae l i occupation but from h i c h Israeli troops have

since trithdrawn, Nbw t ha t amisticc agreements have been concluded,

there f s nothing substantial to prevent the fomar inhabitants of such

wens f t n m returning except t h e fear that relief suppliea may not be

available ,

It is understood that -the estimate for rcfugees from such areas

is approldmately tm hundred thousLmd. I n i t i a l l y t h e proposal rmuld

affect a mdler number of rof'ugccs, nmely those refugees who belong

to the Central area of Pdcstinc, presently under Jordan occupation,

Some refugees, those who arc not completely destitute, have boen

returning on the i r own, most of them, honover, a r e not in a position

to do so u n t i l the i r old home m e n a g d n boconos productive,

The =R should immediately dovise an.intclrim system of

distribution of relief mpplie s mi provision of medical facilities

t o the localitlcs tO which these refugees could return, it is thought

that the cooperction o f t h e Arab lhgion in providing transport could

be obtained,

6 , Thc interim p r l o d could provide a challenging opportunity to

the United Netions as a thole, the conci l in t fon machinery endeavouring

to ostabLish a pmment peace; ~ J R P R and UNICEF maintaining alive the

victims of tho war and, with the cooperation of the Spoci'dized

hgencios, FA0 and URESCO, toge the r uith the machincry for technical

assistznco for ocononic developent of under developed oreas, provfding

plmning and the means for constructive d r k re l ief during tt-is period,

FeiUng an immediate final p n c o settlement the dte rna t ive

t o be fncod is the gmducl end of international. char i ty u i t h t h e

absorbtion of perhnps 60 to 70% of thd refugees into the economy

of t h e country bhcrein they f ind themselves, 16th a probable permanent

lowering of the standard cf l iv ing, 2nd thc dcnth by discass or

s t m z t i o n of the remander.

7. It is pcrhaps c l s o approprictc t o review tho p e s e n t w r k i . ~

relations between t h e Agoncfes cngcgcd upon the owra t ion of t h e

rc l ief p r o g r m c Whilst obvious practiccl d i f f i c u l t i e s muat e S st

when two organizations such as UNRPR c3ld UNICEF a r e each opercting

with the same cccperating agencies under different agreements, and

e r e both supplying food obtcined und,cr c n t i r d y difforont p-ocurmed

pmcticcs, it may be zssumcd t h a t b t h thcsc orgmiaat ions u i l l continuo

d t h the same coopcrating egencics, o r t h e i r successors, in more

or lc ss t h e i r present cont r2ctucl r e l c t i o n s , c 3 t hough ovory c f fort

should be made to achiavc r?. unified United Nations nppmnch both to

the c o o p c r ~ ~ t i n g cgencics engagcd u p n d i s t r i b u t i o n o f r c l f e f supplies

t o Pala stinc refugees m d to thc Govcmonts of the men,

IT IS RECOImmDED :

(a) Thnt UNICEF and U'NRPR have observers in thc f'icld who muld

funct icn as United Nations obscrvcrs 2nd commt upon distribution

af fill supplies rcccived u n d ~ r U n i t c d Nations Auspices.

(b) Thzt UNRPR e p p i n t a t e c h n i c d l y q u d i f i o d l in i t r , n off icer to

each of the cooperating agencies, whose h t y it would be to

v i s i t Ldl wrk pm j ec ts , camps L ~ d distribution points in the

cgencies t c r r l to ry, ~ n d whose primnry responsibi l i ty would be

the dove lopcnt of wrk rc l icf pro j c c t s and the prepaslati. on of

a monthly operat ionel report mich would include a survey o f

productive mrk a d plans for devalopent ,

( c ) That supplies of UNICEF and UNRPR origin be pooled by the

cooperating agenciee, prodded an overaU minimum ration

of 1550 cclories is maintained, it naturally being

recognieod that items such as milk and sugar should

continuo Lo go to t h e present p u p of UNICEF benefici ariee;

thet UNRPR and UNICEF o p e r a t i o n a l procadures, receipting

of supplies, atc , , be uniform as far as possible, to

t h e end t h a t t h e S e c r o t q - k n a r a l may bc provided w i t h a

report as t o t h e Unitod Nations operation in the area as

a whole,

(d) That UMRPR retain t i t l e to r e l i e f sup-plioe u n t i l these

are handed over to the cooperating agencies, oi ther at

ports, main wallehouse in each country, or distribution

points, at UNRPR discretion; UNICEF suppliea to be hmded

over at the port to UNRfR for trLulsmission t o t h e

cooperating agencies and d i a t r f h t i o n in accordance wlth

their agreanent tri tk UNICEF,

( e ) Thct -the UNRPR Chief Medfcal Officer continue to preside

over a C a m m i t h e consisting of the Chief Medical Officers

of the cooparating agandcs, and that a l l medical expenditures

other than salmies, n r e subject his approval,

(f) That t h e cooperat ing rgencies in the north and in t h e

south estcblish l i d s o n machinery with tho UNRPR regional

officos in Beirut md Cdro , for the pr- purpose of

ensuring t h e nvai lcbi l i ty of supplies, phcsed to the

egencies' need m d t h e developing wrk r e l i e f Fogramme,

and thot the agencios are filly informed upon all

relevant' day-to-dajr mattors,

(g) That UNRPR be orgmisod in the f i e l d as at pesont , in ta

a Field D i r e c b r l s Office, with added responsibility for

planning wrk re l i e f action in accordance with Directives

is~lued by the Erector , with regional off ices at Cairo and

Beirut having sections to deal wi th supply p c u r e m e r r t ,

transport accomodation, The cooperating agencies

continuing to bo respns ib lo for distribution and ancillary

matters as at prosent,

(h) That the prosent agency meetings d t h WlPR ~ n d UNICW bo

expanded to include rcpresent~tivcs of WHO, FAO, etc,, and

t h ~ t this meeting becomes a p l a n i n g d v i a o r y board,

executive action regarding t h e work rclief p g r a m m e

rmaining the responsibility of thc M r e c h r nnd the

specialized cgencies in cooperation d t h him.

JAMES KEEN

BEIRUT 26 July 1949.