Chapter 4

Health

Introduction
An important question in the perspective of a living conditions survey is whether there are indications of social welfare systems - particularly in the field of health and education - in the occupied territories that may to some extent counteract general economic and social inequalities and insecurity. In the analysis of employment, household economy and social stratification (chapters 6, 7 and 8) it is shown that important divisions in the Palestinian community exist between camp refugees and refugees outside of camps, and, on the other hand, between Gaza and other areas. To what extent is this true also for the distribution of illnesses, for the utilization of health services, and for symptoms of distress?

Another major question is how and to what extent health conditions are influenced by the Israeli occupation, the social uprising - the intifada - and the sometimes warlike situation that Palestinians experience. Under such circumstances, individuals will experience traumatic events like injuries caused by confrontations with military personnel, arrest and perhaps even torture. Others will react to the general stress of living induced by curfews and restrictions on movement. This topic will be elaborated further in the section on symptoms of distress.

This chapter will first present data on patterns, prevalences and consequences of self-reported acute and chronic health problems, as well as on utilization of health services and health insurance coverage. Second, we will present major concepts concerning psychological and psychosomatic distress, as well as results of the questions on symptoms of distress.

All individuals in the sample were asked questions about their health and health behaviour (were they absent from work or other duties, did they consult health personnel, were they able to go out on their own?). Women answered additional questions focusing on utilization of health services during pregnancy.

The intention here is mainly to report the data collected in the FAFO survey. Only brief references will be made to other studies from the area and international sources. For an overview of literature on health in the occupied territories, see 'Health in the West Bank and the Gaza Strip, an annotated bibliography' (Health Development Information Project, 1992).

Health Transition
Concepts of health and disease, as well as the behaviour and roles related to illness, are cultural inventions. They change through time, and from one community to another. Biological, demographic, economic and social factors determine, and are influenced by, the patterns of mortality and morbidity and of perceptions and behaviour related to health.

The concept of health transition (Feachem et al, 1992) parallels the concept of demographic transition, referring to changes in levels and causes of illness and death that occur in the course of social and economic development. The health transition is the net result of a demographic component (the demographic composition and development of a society), a risk factor component (smoking, alcohol, diet, physical activity, traffic, uprising/conflict and violence) and a therapeutic component (availability and quality of health services). In a recent World Bank Report (Feachem et al, 1992), analysis of the health of adults in the developing world indicates that age-specific rates for both communicable and non-communicable diseases are declining in these countries, while the number and relative importance of non-communicable diseases (hypertension, diabetes, coronary heart disease, etc.) are increasing.

The present survey has not been designed to analyze health transition, but the concept is useful to keep in mind when interpreting the results.

Self-perceived Illness
Measurements of health are traditionally obtained through data on demography, mortality, morbidity and utilization of health services. In level of living conditions studies self-perceived symptoms, functional disability and utilization of services are often measured. In the living conditions survey conducted in the occupied territories, data on mortality or observed measures of morbidity (clinical investigations like weight/height/blood pressure etc., or laboratory tests) has not been collected. Nor do such studies normally include categories of self-perceived illness that can be directly translated into medical diagnoses. Measures of self-perceived morbidity are determined both by the underlying diseases and by perceptions of illness. The ratio of clinically diagnosed morbidity in relation to self-perceived morbidity is not easily predictable, and varies from one medical condition to the other, as from community to community. Rates of self-perceived illness may even be inversely correlated to clinically diagnosed morbidity. This is found in several studies where poor people with high prevalences of clinically diagnosed diseases report less illness than rich people, who may tend to categorize a wider range of conditions as illnesses (Feachem et al, 1992). Studies of self-perceived illness lead to results that are difficult to interpret, and the World Bank report states that on the basis of such studies, 'meaningful comparisons of disease burdens over time or across communities cannot be made' (Feachem et al, 1992). The report nevertheless draws comparisons between studies of self-perceived illness for want of other, more reliable information on the same topic. In this chapter, such comparisons will be made as well.

In spite of these inherent problems, studies of self-perceived illness serve useful purposes. They offer the possibility of relating perceived health problems in a representative sample with a broad range of social and economic factors.

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