 So, well, my name is Ahmed, and for a little bit about me, I got my bachelor's, like Kelly said, in biology and chemistry, back in 06 here at UC Irvine, with my master's in public health, with an interest in epidemiology and papers. This presentation is really based on my observation of Gaza, and in the Sinai Peninsula. If anyone knows where Gaza is, how many people know where Gaza is on the map? I don't know. Alright. Okay. So, this is really based on my interviews with the Gaza's Minister of Health, and some medical personnel over in the Shepa Clinic, a couple of civilians, and a couple of soldiers. Also, building on the work of my colleagues, as well as reports of UN groups and NGOs in the area. So, the objective of this presentation really is to underscore the unique challenges that public health faces in the siege environment, which is really different from a wartime environment and certainly a disaster environment. The second is to sort of use Gaza as a model for the events that happen under siege, and usually we see the starkest, and we learn the most, from extreme examples. Examples where all the factors are just right, or in the case of Gaza, just wrong, to produce this disaster. The third is to identify the critical role that public health professionals, you guys, play in that scenario. Hopefully open maybe some career paths and choices for you as you continue finishing your degree. Then we can discuss some possible reforms for how the public health assessment system or the machine really works in these situations. And then finally, doing all this, while still keeping you sort of awake and alert and engaged. If you have any questions, just pick an area. This presentation is not to discuss Middle Eastern politics. This issue is very passionate, and it means a lot to different people. So, politics are off to the side. This is also not to discuss the legitimacy of any groups. When I'm going to talk about who's wrong, and what Israel did, and what Hamas did, and what Fatah did, and what any other group might have been implicated with. It's also not to propose a solution for the Gaza Strip. I mean, we only have an hour, an hour and a half maybe, but not an hour. It's also not to represent anyone else's perspectives, but my own. And finally, this is not about me going off the far away lands, you know, giving a presentation about my adventures, complete with clearly doctored photos of me doing heroic actions. Okay, maybe just this one. This is me saving a child in Haiti. I'll clearly see the guy's shocking surprise. The siege denotationally defined is a military or economic blockade of a city or territory. It is characterized by constant work, relatively low intensity of military action, and usually one side maintains a strong and static defensive position against the other. The siege is really very, very old. It predates the establishment of cities if you can believe that. I guess it relates each to a cave, it relates each to a valley. But certainly the records that go back from antiquity tell us that siege is something that's as old as human civilization itself. So let's go over some very recent sieges. And then we'll draw some comparisons and contrast between what are economic sieges and what are military sieges, right? In 1982, Israel, while routing PLO forces, laid siege to Beirut. That took around two and a half months, 2.3 months. In 1992, the Serbian Air Military Forces laid siege to Sarajevo that lasted four years. In 2004, Fallujah, which sort of became the focus of anti-U.S. activity in Iraq, was besieged for about a month. And recently, I thought sort of a big piece of news back in 2009 was that the 30-year-old militia that's known as the Tamil Tigers were finally sort of deposed by General Rajapaksa and his efforts into Northern Sri Lanka. Now, you notice all of these are very short when compared to economic sieges. In 1986, South Africa, being declared an apartheid state, began taking sanctions from the United Nations. And that's really one of the few sanctions that have actually worked. I mean, correct me if I'm wrong, this isn't from the international studies here. Of course, sanctions during the first of all four, lasted 12 years. The one in Burma, 13, and then recently one in Zimbabwe, nine years. All of which are currently still active with the exception of South Africa, with the destruction of the entire country. So, a military siege is really very straightforward, right? It causes damage to public resources and activities, causes the destruction of existing infrastructure for the city. Largely, the damage is mass trauma and injured civilians, property loss, certainly. But it's typically short, acute bursts of events with a high number of casual freezing injuries. On the other hand, economic siege tends to be disruptive when it comes to imports and exports of the region in question, right? It disrupts the maintenance of the existing infrastructure. So, anything that's coming from the outside to keep that system up is largely stopped. Material scarcity and rising costs is usually one of them, one of the light products. A lack of confidence from foreign investment is also another very potent result. And a typical period is much longer than a military siege. But the two, however, as far as we public health people are concerned, is a threat to the top penachievance in public health, right? And introduces new disease burdens in the population. Of course, we all know what the top achievements in public health are, right? Can anyone sound them off? No smoking. No smoking? No smoking, that's one of them, right? Anything else? Clean water and sanitation? Eradication and... Infections and diseases, yeah. Very good. Vaccinations, right? Lead. Lead, that's another one. Fluoridation of water recently, right? So these things have really contributed to the longevity of life that we enjoy today. Back in the 1900s, what was the average lifespan? 48 years. Now it's what? 78. So a significant bump. You take that away from people and then you can sort of understand the scope of the disaster that hits the area. So what makes Gaza a unique model, right? Actually, Gaza is actually very, very unique, almost unprecedented. It's the only region of the world, at least that I know of, where there is a civil war, a regional war and a national war. So Gaza is undergoing a civil war inside of itself because of fringe groups. It's at war with a regional counterpart, which is Tepe, and it's also at war with Israel. So it's very, very complicated. Gaza remains under both regional and international sanctions, so that's another layer of complexity. It's under heavy land and rare time blockade by Israel. I think this is June of 2007, correct? It's also one of the few places in the world that's undergone a heavy military campaign followed by a siege, followed by a heavy military campaign, and then another siege. So it's just constant choking of that one land mass. It's also one of the few regions in the world where certain factors are played in terms of water supply, food supply, and the contamination of the agricultural sector that is sort of on the brink of a disaster that may be, in many cases, irreversible. Let's just look at sort of the city, or the strip. It's about 41 kilometers long from the south, what's this? East, northwest. That goes from the east coast of Egypt to the northeast coast of Israel, over where Eris is. It's about twice the size of Irvine. It has about one and a half million residents as of July of 2009. 85% of these residents are refugees from previous wars, and that's a major, major number. The density is 2.25, which makes it the sixth most densest population in the world. 80% of the Gazans currently live under the poverty line, which means they live under a dollar a day. And, like I mentioned earlier, the siege of Gaza began in 2007, when Hamas more or less consulted in power. What's the biggest concentration of people in all of these cities? The south. The south has the highest concentration, especially in areas of Hanyu and Sinatra. This tends to be largely agricultural land. You can think of this as the San Joaquin Valley, almost. And then the density goes back up when you reach these areas. Although, because of the groves and the farms, it's a bit more sparse than this, but certainly a bulk of the population live here. Simply because it's next to Egypt. So, if you want to evaluate the healthcare sector in Gaza before Operation Castellet, by the Operation Castellet is the military campaign by Israel in the Gaza territories. So, it was the Israeli policies of coordinating incursions. One, and two, Palestinian policies and divisions. These are the two factors that played a sort of lead to the predicament that is the healthcare system of Gaza. Over here you see tanks amassing the border, ready for incursion. And here you see the fights that happen daily in the streets between Gaza and Gaza. So, these Israeli policies really restricted the movement of patients and medical resources. So, as we know, we need primary healthcare facilities, right? If we need more health, secondary, tertiary, it can be something like surgery. And if it's overburdened, then the gods can send their people outside. Either Saudi Arabia, Egypt, Jordan for treatment. But since the siege, they've been more or less unable to move anywhere. The people already inside the medical professionals don't have access to the training. And if they need new personnel, they're recruiting new personnel. They can't do that because they need the training and it's not present currently in Gaza. Which is, I think, an emerging need for telemedicine, right? It isn't. Only the telemedicine. Because of the poverty line, the increasing poverty in the Gaza population, the Gaza government was sort of compelled to, well, the Palestinian Authority, was compelled to make a free of charge healthcare system. So it's, again, burdened the healthcare system because now there's no funding. Now they have to get funding from either NGOs or from private donors in the Middle East or government donors in surrounding countries. Also, the military actions against civilians of infrastructure really overburdened the system. So you have military incursions happening on a daily basis into farms, into houses, the bulldozing of houses, aerial attacks, and then aerial vehicles attacking certain targets which produce human casualties, which ultimately overburden the system. Especially when you move directly from a healthy individual to someone who needs tertiary care. So that overburdened the system quite significantly. Where's the bulk of the cost in any healthcare system? The tertiary services, right? So that's where you need the ICU, that's where you need the surgery, that's where you need a lot of the specialized equipment to keep that person alive. Palestinian division wasn't too helpful either. Back in 2007, Hamas won the pipe vote in the Palestinian Territories, but a lot of their support was in Gaza. So there was this period of duplicity where Hamas sort of felt like it administrated the region. But of course the Palestinian Authority was the official head, so there was this sort of duplicity of powers. You had healthcare workers have their budgets slashed, their salaries cut as sort of a punishment to Gaza by the Palestinian Authority. So really it's a fight between two groups, and the one paying the price are the actual workers. Because of this budget cut, a lot of them started striking. And when the strike occurred, then there were the tensions, tortures, and human rights violations by the Palestinian Authority and Hamas against workers in Gaza. That led to heavy security presence in healthcare facilities, which again sort of drove a lot of people away from seeking services, and finally reached a crescendo when Hamas just blatantly took over the rest of the Gaza Strip. Of course that produced significant deaths and injuries near clots of the police and paramedic services because the two are very much intertwined in the country. The ministry now that had sort of had loyalty to Hamas, sort of kicked out all the people from the PA who were experienced and replaced them with Hamas loyalists who were not necessarily experienced in what they were doing and didn't have a clear health plan for administering health and safety in the region. And then comes Operation Castile, right? So this, for whatever reason, I'm not going to discuss the politics, but Israel decided to embark on a major land maritime and air campaign against Gaza. And it really started with just heavy air strikes. I think it was a hundred times of explosives were tossed on the Gaza Strip within the first, what, nine hours? A hundred times, a lot of them concentrated on the border of Egypt and Gaza, so sort of at the rock-off border. And the reason behind that is that's where a lot of the tunnels work. So if you attacked this area first, then you can coordinate the rest of the area for targeted operations and stop any flow of weapons during the campaign. That was one. Following that, you had both coordinated artillery and naval strikes. So you had maybe Israeli warships over where North Gaza and Gaza is, as far south as Dar al-Balla, attacking these regions. At the same time, you had the artillery, especially over in the Rajah crossing, Kisafim, and as far south as the Rafah border, basically pummeling specific targets. Of course, the law of all this was the pending ground invasion, which basically came here and sort of split Gaza into two. They wanted to coordinate off the south so they can be able to take care of the rest of the north. Because again, there's one route that goes throughout this whole strip, and that's the main sort of supply line for anything going up and down. So that happened for around, I think, nine days. Once they were sure that everything, all the targets have been, quote unquote, softened, then they sent in the infantry. So the infantry, again, marched through the Kisafim crossing stop, and then paratroopers were placed both in Gaza and in Fenyunus. They stayed until the offensive was launched and they rejoined their groups. The numbers that you see are sort of the number of deaths of people, number of which were women and children, number of injuries. And this is sort of the number of strikes per kilometer squared. So you can tell that a lot of the attacks came in areas of high density. So a brief look at the weapons that were being used, I think it's just... What I read in the newspaper is that these numbers of casualty are disputed. So where are these, where's the origin of these data? So the origin of this data comes from the one RWA. It also comes from, my eyes certainly correctly, the Medical Arab Union, which is an office in Gaza. And that's where the numbers are disputed. But the window is actually quite narrow. So it's between 12 and 21, being conservative and somewhere around 1500, being sort of overboard. A brief look at the weapons that are being used, and that's really important when it comes to public health, because the weapons used sort of tell you what you should be looking for when you start assessing the damage. When it comes to airstrikes, the GVU-39, still the sort of george still out and whether or not it's actually being used, but this actually carries the cleaning uranium. And if the cleaning uranium was used in Gaza, then that opens a whole new can of worms. And the other issue in question is the use of white phosphorus shells. These are incendiary devices that sort of spray white phosphorus, which is very volatile when mixed with air. Of course, up until today, they're using the unmanned aerial vehicles. And you can tell that they're there because you hear this distant humming noise. It's somewhere between the sound of a single engine sestane and a toy plane. These are some of the pictures that we took while we were there. So this is the Gaza Parliament building. A primary target of the attack, or obviously government escalation. This is a petroleum company. So a lot of the infrastructure that was destroyed really was water and power. So the petroleum company was destroyed, the cement company that was destroyed, and some of the water treatment plants were also struck. And the idea behind that is, well, if you hit the cement and the energy company, that stops the building of tunnels and so on and so forth. Unvehicles were also targeted. As you see, this vehicle was struck with tank machine and fire. This is a food storage that was struck with, I think it was an artillery shot. So this is just one of the bags of food that was sort of recovered from the wreckage. This actually comes from France, and I think it's a bale of sugar. So one of the other targets in Operation Castellet were the hospitals. I'll tell you sort of the level of destruction later, but you can see that this is sort of the emergency room in the hospital, struck with, I think, also an artillery shot. This is the American School, the American International School in Gaza. That too was destroyed, but this was destroyed by a missile coming from the sea. And thankfully it was struck when school was up. The damage wasn't too much. Mosques were also struck. Most of the minarets were usually targeted because, you know, according to Israel this is what they used for launching the missiles. So really it was just a blanket attack. And because of the blockade, the UN announced that this is really one of the few places in the world where you really have nowhere to go. Iraq could have escaped. Afghanistan could have escaped, but here, just because of the geography and the sheer control over the region, it was very difficult to be safe anywhere. So this is the numbers that are coming from the United Nations, just to be accurate. 31% of deaths were children, 8% were women, 61% were men. Of the injured, the numbers are quite similar. And stunning from that, around 100,000 people became new in this place. The numbers sort of shock me after the attack on the mission because Israel, you know, says that it has a lot of precision-guided weapons and they do. You look at the profiles of their missiles and their operations and they seem very, very surgical almost. And yet you come up with these really gross numbers. I mean, nearly half of the casualties were women and children who are value and regulation of non-combatants. And that's not mentioning those of the men who were non-combatants as well. In terms of damage to the health system, so there are around 110 clinics in Gaza, 43 of which were destroyed. 15 of Gaza's 21 hospitals were destroyed and 29 out of the 148 ambulance reports were destroyed. Down with the minister, his niece came up and told me that her brother, so they were raised in Germany and they came back during the war. They came back to help with the relief effort. One of the 29 ambulance vehicles that were, you know, shoveling the injured to and from were struck with one of those artillery shells and her brother died and that's that vehicle. So it's very, very compelling to see just the impact of the war on people who were actually just there to help. 25, 16 health workers were killed during that operation and 25 have been injured. So during my interview with Dr. Besin, he said that currently 85% of the health services are administered directly by the Ministry of Health, right? 15% of them are NGOs. It used to be much higher, but because of the war, a lot of NGOs had to pull out. One of the things that happened when Hamas took over is that they also took over some of the NGOs to sort of nationalize them. You can choose to use that term. Currently, there are 25 primary health centers, 12 hospitals and two tertiary health centers, which is more or less half of what they have to be given. Of course, the numbers that you see here are the ones that people always think about, right? They always think about what's the trauma of the population and what's the acute effect, right? So the estimation was, and this is from the head of a CHIPA clinic which is one of the tertiary hospitals located in the north, around 6,000 people will die from direct causes of the conflict. Half million will be adversely affected in some way. There is the enduring disabilities, so people that have lost limbs, people that have suffered neurological trauma and so on and so forth, food and waterborne outbreaks because of the lack of sanitation and so on. But one of the things that she didn't mention and she kept repeating over and over is the high number of miscarriages that she's seen. Around 3,500 births took place during the three-week warm-dose test into the high fertility rate of the area. But a lot of them, well, a significantly higher percentage ended up either ending in a miscarriage or higher near an adult death, right? And one of the things that they also noticed is an increase in chronic disease such as asthma, COPD, heart disease, but asthma in particular. And of course the psychological trauma of PTSD and unipolar depression. Unipolar depression she cites to be primarily because of the really, really high endpoint rate. In Gaza you either work for two groups, you either work for Hamas or you work with the relief effort. And there's very little else in between other than the merchants. There has been some attempt to correlate the use of depleted uranium with birth defects. Did she mention that in the miscarriage? No. But actually the head about she said one last one I spoke about. He seemed to be the more aware of the injury. She spoke mostly about the white hospitals. That's the thing that you see on the topic. All right. So this is where sort of the UN and the NGOs and the public health people sort of split, right? The UN is interested in deaths from injuries, impacts of a lot of access health services, chronic diseases and so on. As well done as the reports are about the environment, they gloss over the reasons behind the chronic diseases and they ignore the lasting and the potential for the emergence of chronic diseases as well as environmental damage. Really, what I would like to characterize their epidemiology is really passive epidemiology because they come in with the same questions for every reason they say okay what happened and they test for the same things. I was reading the report by the environmental wing of the United Nations and they didn't test for uranium for some reason. Despite the fact that there were a lot of suspicions that depleted uranium had been used and that sort of paradigm was the same one that they used back in the north of Sri Lanka. Now the Sri Lankan army doesn't have depleted uranium but the Israeli army does. So you really have to make a full assessment and know exactly what you're walking into to be able to measure everything that's needed. From the broader health perspective, I was thinking about what the built environment now looks like. What is the status of the environmental health? What are the specific epidemiological questions that we have to ask? And from the recommendations, these recommendations need to be relevant so we can't say oh great decision. It's not something that you can do. Certainly it's not something that you want to do but you have to make recommendations that can be done on the ground and immediately. So going back to the top 10 achievements of public health, environmental contamination, water resources, food resources, the built environment, these are all factors that have contributed to more or less the doubling of the life expectancy of Americans back from the 1900s all the way to the end of this past century. So when you take away these things, those fundamental things, this is where you expect the human loss to be the most. Not from as damaging as they are, the military action and not from the injuries but really from the infrastructure that you've taken away from people, now you've brought them back to the 1900s. So going back to the pleaded agreement, I mentioned this first because it has implications and all the things that are dispensable. They're suspected to have been used and the only reason why they're suspected is because the cadavers and the victims had a high radiobacteric count. They put a gargoyle counter to some of their tissue and it goes through the wound. So that's usually an indication of the pleaded agreement. The only other possibility that these missiles might have carried is tungsten. The reason why the pleaded uranium is used in the beginning and this is a depleted uranium head being fired on around, I think it's three feet of steel reinforced concrete is because it has a high penetration power and that's something that you use to bust a bunker or bust a tunnel and you can see just the penetrance of this missile and it destroys even the structure from the inside. So it seems to make sense that they would use a weapon like this especially because we also know that Israel bought a thousand of these from Boeing right before the war and these missiles were mounted only during an air campaign and if you look at the density of where these air campaigns were done i.e. the Rafa-Izian border and the emergence of cancer incidences in eastern fan units it becomes evident that there is depleted uranium in the area and if that's the case then it makes a world of difference I hate to admit this but I used to work for aerospace and my husband was in charge of manufacturing of these depleted uranium bombs excuse me and I know that they would do the testing in Chinamills with the dean bombs and then they would dig up the dirt and ship the radioactive dirt up to Washington state but he did say that they were used strictly as armor piercing so I guess the DU just goes through it like butter exactly the depleted uranium was first developed back in 1970s by the Pentagon and it was first deployed in the 1st Gulf War because the Iraqis were using Russian tanks with thick armor the only way you can pierce through this armor is if you have something that is denser, heavier and that can pierce with a small enough diameter i.e. depleted uranium again, tungsten is the other option that might have been used but tungsten is not radioactive A, B, tungsten is carcinogenic either way you have reaching into the water sources the land sources, the air in very fine nanoparticles which no N95 by the way could filter and the half-life is what? a couple of billion years it makes a huge difference anyway, any other questions? yes you're very selective on your choice of wording and you said they're suspected it's a perfect one suspected by whom? it seems very vague yeah, so this was let me go back to this story so this was this was a study published by Action of Citizens for the 12th Estandeming of Means speak up mother I can't hear you sorry, it's the so the group's name is Action of Citizens for the total dismantling of nukes this was a group out of France who visited the Gaza Strip recently with a French delegation and this was performed in 2008 this was performed in 2008 2008 I'm sorry, 2009 2009, sir are there dates probably? yeah, right there so this was the 18th of January and there's already been seen a high incidence of cancer in France which is sort of further north okay and this was also a stanza of course this was also confirmed by the head of a shift of clinic who did find for the elevated radiation levels in the patients do you know of France? then like a study that on the various like water quality and different parts of radioactivity and chrysanthemum there has been but the studies didn't mention any radioactivity what about chrysanthemum? so they saw a couple things they saw a high amount of hydrocarbons they also found a large amount of nitrates but nitrates come from euclation so it's present in the apparatus anyway they also found a high amount of chrysanthemum as well can they see any correlation with a lot of radiation? the studies are really really lacking at this point that's one of the things that the minister pointed out he says they just don't have the expertise that somebody might provide one day in assessing the damage okay so let's move along here the next question is the water sources in the treatment plants now the Gaza Strip is separated into five governors and each of these are served by either one or two water treatment plants if you look at the numbers though if you look at the people served by these water plants you can tell that the numbers are very low the highest is being 65% so 65% of rough off for instance has access to a sewage system the biggest problem is in each of these six sites you have water leaking sewage water leaking straight into the Mediterranean Sea that causes a compounded problem first of all the water being dumped into the sea comes from aquifers and as the occupancy level of Gaza increases you're really not you're not getting into this water back because you're not recycling it and the aquifers are being depleted right so you're not getting any of the water back again that's number one number two because it's untreated sewage it goes into the Mediterranean Sea it contaminates the resources in the only fish to sort of compound that right so and the other issue is of course is you have sewage leaking into the streets because of either backed up piping because it's not being maintained or because of pipelines that have been attacked but the Israeli military also imposes distance curfews on fishing ships so one day it's one kilometer another day it's two kilometers I think the switch but that ensures that you get the most contaminated fish because you're fishing in areas that have the highest amount of pollutants so the image that I want to show you is really the the image in purple is really the concentration of coastal aquifers for Gaza this is sort of the strata of any aquifer right now the Gazans are somewhere around here which means that the water is very salty it has a high amount of nitrates and nitrates for children is very hazardous water anyone heard of blue baby syndrome? right exactly so in five years time it's trajectory about being aquifer's world completely dry unless the infrastructure rebuilds itself and unless much of the materials can come into the city or come into the region to rebuild that infrastructure alright food supply in the study done by the United Nations there was around 700 impact freighters from either artillery or military ships or navy ships fighting missiles into agriculture areas that is sort of resulted in around 180 greenhouses destroyed these are 17% of the total agriculture land completely degraded and here's one more of these factors that make it very very dangerous the Gaza Strip is a desert and more or less an area client it's very ecologically vulnerable so that unless you keep irrigating the land and you take care of it the certification happens very rapidly and once it happens the amount of resources that has to go back in to make it fertile again is immense so you see everything is sort of time constrained that's the condition that you have to work with under a siege this is a satellite photo of sort of the middle of the Strip in Gaza this is the cultivated land before the war this is after the war you can tell that the military sort of built ramparts in those that you see sort of winding around where tanks that drove up and down into the area completely eroding so the core of the siege was December to January is there a rainy season what is the I know they've been having droughts so that's typically not the time when you'd have a lot of precipitation generalism maybe I don't know like here I know right after the war there was a lot of rain more rain but right now the drought is actually selling pretty solid I'll back it up once more did you say what the cultivation is before what kinds of crops what kinds of I'm not sure I know we just wanted to I know there are a lot of trees there so now let's focus on the built environment right at the end of the war there were around 3,500 homes that have been completely destroyed 2,800 that have been heavily damaged and 5,400 5,400 that have been likely damaged collectively this affects around 325,000 civilians ok now the effect of housing on the condition of public health is immense it has implications on mental health, perception of security psychosocial disorders, social bonds and the list goes on sleep, air quality, high growth and low control accidents and injury, malnutrition and you know its effect is very relevant to what we are seeing today which is infectious disease chronic disease, injury, mental health child development and the list goes on so this is an image of a sort of makeshift house that was established next to the rubble of this one this here is somewhere in the north one of the children made sure that we'd stamp this picture especially the victory sign so here's the thing for I'd say around 20, 20 years 20, 20 years electricity has been more or less consistent in gossip but when electricity is gone people have to sort of more primitive ways of lighting in this case there was a kerosene in mind but because this child has never really had to use kerosene up to the floor and this sort of ended up in an asset for him and this is something that's seen quite common these injuries because of having to use resources that have never been used before certainly more primitive than the one that they're used to the case of this child really with burns over 50% of the body the doctor told me because of the infection that might ensue survival has actually varied so now in the context of all of this there is a greater threat the safety and security of people of Gaza than the immediate damage that we're all seeing that we all are usually used to seeing the scope of the damage is not linear because if the aquifers dry up if the degree of injury reaches the environment then the longer the siege the higher the death there's more active actually we need more active and educated surveillance to be able to see exactly what the scope of the damage is we need to ask the right questions do the right tests and come up with pragmatic conclusions and these decisions will be advised both to public health professionals in Gaza as well as outside of Gaza that have the resources to be able to make the assessments quickly we know sieges to be more leisurely than war because back then the weapons weren't as advanced but public health needs to sort of catch up with the way modern warfare is done in much of the same way that the siege has been done until now exactly what the long-lasting risks are and addressed and if this teaches us anything really is that economic terraces equal these reasons so now the question comes is the Iraqi predictive model after operation desert shield then operation desert storm and then 10 years of sanctions more or less and then the war again there have been around 1.5 million deaths due to combat sanctions disease and continuing but admittedly in their own words you and the WHO admitted that they hadn't seen the threat until they started seeing the cases right so when the cancer rates shot up dramatically and the sanctions prevented the MRI machine and other medical people from coming in the the effect of cancer was too high to ignore the reason and they did the study and it turned out that it was completely draining among other persons in the soil during the war the damage remains lingering today and the question is will we as public health professionals catch up with the modern forms of aggression to be able to forecast what their needs are there's two subliminal messages here public health is a very broad brush very broad and in this topic alone we've covered you know epidemiology, nutrition, public health policy environmental science and here's the message that I want to convey to you in a very uncontroversial way of course you're all doing your MPH degrees but for you keep going but to me I feel like an MPH is an accessory to me what do I mean by that? I mean that you almost need another skill to be able to push public health with it and if you're at the politics and you have an engagement that's great we need a lot of public health if you're an engineer that's excellent that helps us with the built environment if you're into law then you know exactly what violations have been made and who takes the responsibility architecture and medicine so public health is an excellent tool to couple with another skill even we on campus as environmental health we oftentimes find ourselves trying to convince people to do something instead of what we could be doing ourselves and I'm sure she'll watch for that so I really encourage you to see something beyond the MPH or if you have another skill to forward that with your MPH degree you'll find that you'll make a lot more advances and be a lot more last thoughts really the sort of the take on lesson that I took away from you Sincasa is you have to perform your own assessment under any conditions you can take a template and then adapt it to any situation you have to ask the relevant evidence based question just as you're doing evidence based public health you also have to have evidence based questions you have to be thorough in your analysis and you also have to be assertive I don't know how more sort of anyone can be in this scope of disaster like this but as always politics does trauma science and if I end I want to sort of thank the people of Raza for their kindness and hospitality I know we came in at like 2 o'clock in the morning and the Boy Scouts of Raza a lot of people are waiting for us with horns and drums and there's a lot of merriment my colleagues over in the MP Khan Boatigaza Minister of Health who gave me a lot of his time and expertise Member of Parliament British Parliament George Galloway and the staff at UCI H&S who sort of made it possible for me to take this time off and through this little expedition Thank you so much We have your sales speech for public health on tape so we'll be using it now for myself Are there any questions for Yes, yes I have a paper about refugees can condition themselves and I was wondering if you could elaborate a little bit about the conditions of the camps of all these refugees Right, so they're distributed they're very sort of small around bigger sort of slum environments everything there seems to be is communal electricity is municipal at best so the way they're designed is that next to every rubble there's either a camp or there's a mixture of camps and that's very non-traditional from the camps that are already existing in Gaza so the ones that exist in Gaza before the war are kind of like these big they come up like trailer parks but instead of trailer parks they're like tents and you have a central pump where you get the water you have designated eating times and you have like a little small library or a mosque or something like that but in the areas that have been destroyed it's really sparse so you have your rubble and you have your tent and that's how it works Any other questions? I'm curious sharing the knowledge between your expedition to Gaza here versus the recent earthquake in Haiti as far as you know That was a doctorate photo by the way I missed the first few slides Maybe you discussed this before but the short-term disaster long-term economic ecological consequences hurricane season rapidly approaching sea level rise is there some sharing of knowledge that can go either way? That's a really great question The only foreseeable sharing of knowledge is by people who have been in both places and there are things that are alike like the chain of resources and so on in the administration but there are also things that are radically different The water sources coming to Haiti are different from the water sources going to Gaza The food supply profiles are also different That's part of the reason why I said you have to look at the profile to see where the risks are in performing the SWAT analysis and so on but what really helps in sharing of knowledge is reading these really comprehensive UN reports about the city of the environment in Gaza and in Haiti Those provide excellent tools because again, they use the same rubric One has to do with Cuba since sort of off the... Cuba has been under blockade for many, many, many years Have you done any... Has anybody done any research in terms of public health and the Cuban population? That's a great question I certainly have but I do know it's certainly better than the one in Gaza for sure the public health Now, there's a difference not all sieges are alike not all sanctions are When I mentioned that the South African the South African sanctions were one of the few ones that worked it's because a lot of the sanctions fair because not everyone is that old with the sanctions In Gaza it's very hard to go around because you're bordered by Israel the main military power in the region and you're bordered by Egypt which is bound by peace to Israel That's widely different from Cuba because Cuba has a lot... the same way as North Korea is sort of different than Gaza because it has strategic allies Iran you know, countries like that So it really depends on the context of the sanctions but everyone agrees So doesn't Gaza have strategic allies with Iran from us? That I don't know It's quite frankly sort of a shadowy issue No one really knows A, if they're getting a material support and B, if they're getting it how is it happening and who's involved, that's just the politics I know that they have moral support from Iran but how that should be talked about I mean, you're sort of in the gray area So my other half of the question is have you done any since we talked about Gaza specifically, have you done any comparison that Gaza before the 67th war was under Egyptian whatever you call it So they were part of Egypt Has there been any studies to... and they were that UN was feeding them had a lot of similar public health issues So my question is have you done any comparisons it seems to me that would be a really valid comparison to see how was it then and how is it now how much damage was really and will be just interesting I think a more telling person would be back in the 1940s, the 7th because Gaza did switch hand a couple of times before then I'm not really sure what the system 4070 actually existed did not the territory did not the Gaza as a region of course it did not exist but the Gaza, whatever the strip did not exist because as you mentioned it did not exist Oh, you're saying as a political entity Well, you're talking about a political entity was having trouble It existed either under the Egyptian rule or out of Egypt or existed as its own which it is now so but it's always been fed by the UN is my point and there's always been medical issues and all those kind of issues to get a valid perspective and I think it's important to know I totally agree here's, okay, so the literature that I can find this will go back beyond let's say I think the last one was back in 1982 but here's something however anecdotal back in 1967 my grandfather was a medic with the Egyptian military in Gaza and that's a lot of, I mean, the city was very very prosperous it's almost like Newport Beach of the Middle East just saying much economically it was very vibrant and in fact that's where he had most of his income from when Israeli troops landed in a state of PRW he told me when he came back he said that Gaza changed dramatically a lot of the infrastructure had sort of failed and here's the thing about Gaza and a lot of the things about besieged areas in Iran when the war took on and the territory was taken over then the U.S. had a sort of a UN obligation to take care to sort of pick up the pieces with Gaza there was no one left to pick up the pieces I'm also still standing and the stats go like this so I guess that's anecdotal but I don't have any real intended numbers I think it helps shoot some light on your point to remember the fact that almost 90 percent of the Gaza population are refugees they were you mentioned that in a way but the fact that when you have a country or a strip or whatever or a city whose 90 percent population are refugees who are still looking for to get back to their homes and lands and who are living in miserable situations because of the things that have been going on this civilized with the whole story you are not talking about a country or a city that is in normal circumstances as far as its indigenous yes I'm wondering about like in social justice international relief I think there is a lot of room for healthcare there isn't the same room for education or for political or things like that I think a lot of brands know more about the advantages relief efforts and how it can indirectly or directly address social justice right another great question it's very complex it's very complex because there is more than one player in the Gaza territory when we were walking down the street that main highway we saw a lot of sort of graffiti in Arabic the guide who is this group and who is that group are they different wings of Hamas they said no these are sort of groups that are on their own and certainly after we left what you guys know from the news it's sort of the Al-Qadri thousand dollars tried to establish an emirate with them Hamas came in but I'm trying to tell you it's great because it all depends on who has the aid and how is it being distributed if the aid is coming under the auspices of the Arab Medical Union then yes there's a lot of room for social reform and social justice because now it's being given more or less impartially if you're giving it in the hands of a government entity or another group operating inside Gaza then I would think that it would be stable as soon as more you want to know what the most important health relief item is to Gaza right now actually two things not medicine hospital that's it you have to build the infrastructure again you will get to that big plateau in the very beginning where you establish a good running water system and a decent built environment that's what it costs a lot who is the seeding Gaza right now it's kind of understandable to have the Israelis seeding as it but my question to you since you've been there how do you evaluate the efficiency of the seed that is underway by Arab categories right so Gaza is bordered by Egypt and South it's almost the same minus any other reactions so the gates are sealed there's more order with how things are moving from the Israeli-Gazi border then there is that the Egyptian Gaza border simply because a lot of groups from Egypt trying to get in there and why it's not really possible there's a lot of positions trying to get in there so it does tend to get chaotic sometimes but there are opening and closing times for the opening in between Israel and Gaza here's the thing though things going through Gaza from Israel are nowhere near enough it's barely enough to sustain one third of the infrastructure healthcare-wise at least those are the stocks of medicines that we look at healthcare-wise whereas in the Egyptian Gaza border there's a lot of things and the administration is so poor in taking stock of what things need to go where and how these things are spread so all in all it sort of evens out I mean the seed is a big problem for most times you still have to go through a lot of political groups the Egyptians have tried to accommodate us as much as we can because of tensions that happen usually around the rough Egyptian border some people say that I don't know but there usually are tensions and why do you just break up some they wouldn't have their airports operation their ports no airplanes can go inside Gaza where did you go through Egypt or Israel? Egypt yes we had vehicles emergency vehicles that we wanted to take into Gaza but these were sort of confiscated by the Egyptians that we'll give them to Gaza ourselves just not you because it makes a bad political statement on Egypt itself I was going to ask for with Israel's what's their official policy in terms of what they allow to commit in terms of resources is it like a quota type system or I can't speak on behalf of the Israeli military what I do see on the website is that everything that needs to get in is coming in with the quota that they need sufficient and that's as far as that's at least okay thank you so much are you willing to stay?