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1.  Health in the Arab world: a view from within 1 
Lancet  2014;383(9914):343-355.
Since late 2010, the Arab world has entered a tumultuous period of change, with populations demanding more inclusive and accountable government. The region is characterised by weak political institutions, which exclude large proportions of their populations from political representation and government services. Building on work in political science and economics, we assess the extent to which the quality of governance, or the extent of electoral democracy, relates to adult, infant, and maternal mortality, and to the perceived accessibility and improvement of health services. We compiled a dataset from the World Bank, WHO, Institute for Health Metrics and Evaluation, Arab Barometer Survey, and other sources to measure changes in demographics, health status, and governance in the Arab World from 1980 to 2010. We suggest an association between more effective government and average reductions in mortality in this period; however, there does not seem to be any relation between the extent of democracy and mortality reductions. The movements for changing governance in the region threaten access to services in the short term, forcing migration and increasing the vulnerability of some populations. In view of the patterns observed in the available data, and the published literature, we suggest that efforts to improve government effectiveness and to reduce corruption are more plausibly linked to population health improvements than are efforts to democratise. However, these patterns are based on restricted mortality data, leaving out subjective health metrics, quality of life, and disease-specific data. To better guide efforts to transform political and economic institutions, more data are needed for healthcare access, health-care quality, health status, and access to services of marginalised groups.
PMCID: PMC4176927  PMID: 24452043
2.  Quality of life, human insecurity, and distress among Palestinians in the Gaza Strip before and after the Winter 2008–2009 Israeli war 
This study investigates changes in the quality of life (QoL) of Gaza Palestinians before and after the Israeli winter 2008–2009 war using the World Health Organization’s WHOQOL-Bref; the extent to which this instrument adequately measures changing situations; and its responsiveness to locally developed human insecurity and distress measures appropriate for context.
Ordinary least squares regression analysis was performed to detect how demographic and socioeconomic variables usually associated with QoL were associated with human insecurity and distress. We estimated the usual baseline model for the three QoL domains, and a second set of models including these standard variables and human insecurity and distress to assess how personal exposure to political violence affects QoL.
No difference between the quality of life scores in 2005 and 2009 was found, with results suggesting lack of sensitivity of WHOQOL-Bref in capturing changes resulting from intensification of preexisting political violence. Results show that human insecurity and individual distress significantly increased in 2009 compared to 2005.
Results indicate that a political domain may provide further understanding of and possibly increase the sensitivity of the instrument to detect changes in the Qol of Palestinians and possibly other populations experiencing intensified political violence.
PMCID: PMC4213857  PMID: 23479210
Quality of life; Distress; Human insecurity; Palestinians; Gaza strip; Comparing QoL
3.  Sources of Human Insecurity in Post-War Situations 
Journal of human security  2011;7(3):10.3316/JHS0703023.
This paper explores classical and war-related factors associated with human insecurity reports in the Gaza Strip following the winter 2008–09 Israeli attack. A cross-sectional survey was conducted six months after the Israeli attack with adults from 3017 households. Results demonstrate that persons with greater human capital and socioeconomic resources were somewhat protected from human insecurity associated with the attack and siege. Results also underscore the significance of including both classical and war-related factors in assessing human insecurity in conflict, and the link between individual and communal/national security. While it is important to intervene by supporting Gazans with food and aid, interventions should also address the violence of war and ongoing siege as one of the causes of human insecurity.
PMCID: PMC3884905  PMID: 24416084
Gaza strip; human security; displacement; distress
4.  Health-related Quality of life of Gaza Palestinians in the aftermath of the winter 2008–09 Israeli attack on the Strip 
Background: We document the health-related quality of life (HRQoL) of people living in the Gaza Strip 6 months after 27 December 2008 to 18 January 2009, Israeli attack. Methods: Cross-sectional survey 6 months after the Israeli attack. Households were selected by cluster sampling in two stages: a random sample of enumeration areas (EAs) and a random sample of households within each chosen EA. One randomly chosen adult from each of 3017 households included in the survey completed the World Health Organization Quality of Life instrument, in addition to reported information on distress, insecurities and threats. Results: Mean HRQoL score (range 0–100) for the physical domain was 69.7, followed by the psychological (59.8) and the environmental domain score (48.4). Predictors of lower (worse) scores for all three domains were: lower educational levels, residence in rural areas, destruction to one's private property or high levels of distress and suffering. Worse physical and psychological domain scores were reported by people who were older and those living in North Gaza governorate. Worse physical and environmental domain scores were reported by people with no one working at home, and those with worse standard of living levels. Respondents who reported suffering stated that the main causes were the ongoing siege, the latest war on the Strip and internal Palestinian factional violence. Conclusion: Results reveal poor HRQoL of adult Gazans compared with the results of WHO multi-country field trials and significant associations between low HRQoL and war-related factors, especially reports of distress, insecurity and suffering
PMCID: PMC3857916  PMID: 23012310
5.  Mortality Patterns in the West Bank, Palestinian Territories, 1999-2003 
Preventing Chronic Disease  2008;5(4):A112.
The West Bank in the Palestinian Territories is undergoing an epidemiologic transition. We provide a general description of mortality from all causes, focusing on chronic disease mortality in adults.
Mortality data analyzed for our study were obtained from the Palestinian Ministry of Health in the West Bank for 1999 through 2003. Individual information was obtained from death notification forms.
A total of 27,065 deaths were reported for 1999 through 2003 in the West Bank, Palestinian Territories. Circulatory diseases were the main cause of death (45%), followed by cancer (10%) and unintentional injuries (7%). Among men, the highest age-standardized mortality rates (ASMRs) were due to diseases of the circulatory system, cancer, and unintentional injuries. Among women, the highest ASMRs were due to circulatory disease, cancer, and diabetes mellitus. Of the circulatory diseases, the highest ASMRs for men were due to acute myocardial infarction and cerebrovascular disease. ASMRs attributable to circulatory system diseases were similar for women. Lung cancer was the largest cause of cancer mortality for men; breast cancer was the largest cause for women.
Because of the high mortality rates, the risk factors associated with chronic diseases in the Palestinian Territories must be ascertained. Medical and public health policies and interventions need to be reassessed, giving due attention to this rise in modern-day diseases in this area.
PMCID: PMC2578778  PMID: 18793500
6.  The limitations on choice: Palestinian women's childbirth location, dissatisfaction with the place of birth and determinants 
Analysing the Palestinian Central Bureau of Statistics (PCBS) Demographic and Health Survey 2004 (DHS-2004) data, this article focuses on the question of where women living in the Occupied Palestinian Territory give birth, and whether it was the preferred/place of choice for delivery. We further identify some of the determinants of women's dissatisfaction with childbirth location.
A total of 2158 women residing in the West Bank and Gaza Strip were included in this study. Regression analysis established the association between dissatisfaction with the place of birth and selected determinants.
A total of 3.5% of women delivered at home, with the rest in assisted facilities. Overall, 20.5% of women reported that their childbirth location was not the preferred place of delivery. Women who delivered at home; in governmental facilities; in regions other than the central West Bank; who had sudden delivery or did not reach their preferred childbirth location because of closures and siege; because of costs/the availability of insurance; or because there were no other locations available, were significantly more likely to be dissatisfied with their childbirth location compared to those who birthed in private facilities, the central West Bank, and in locations with better and more available services.
The findings demonstrate that Palestinian women's choice of a place of birth is constrained and modified by the availability, affordability, and limited access to services induced by continuing closures and siege. These findings need to be taken into consideration when planning for maternity services in the Occupied Palestinian Territory.
PMCID: PMC1913630  PMID: 16798783
7.  Can action on health achieve political and social reform? 
BMJ : British Medical Journal  2006;333(7573):837-839.
Public debate about health is rare in Arab countries. But getting the social and political issues underlying health problems onto the agenda could have wider effects on the region's political stagnation
PMCID: PMC1618442  PMID: 17053237
8.  Health sector reform in the Occupied Palestinian Territories (OPT): targeting the forest or the trees? 
Health policy and planning  2003;18(1):59-67.
Since the signing of the Oslo Peace Accords and the establishment of the Palestinian Authority in 1994, reform activities have targeted various spheres, including the health sector. Several international aid and UN organizations have been involved, as well as local and international non-governmental organizations, with considerable financial and technical investments. Although important achievements have been made, it is not evident that the quality of care has improved or that the most pressing health needs have been addressed, even before the second Palestinian Uprising that began in September 2000. The crisis of the Israeli re-invasion of Palestinian-controlled towns and villages since April 2002 and the attendant collapse of state structures and services have raised the problems to critical levels. This paper attempts to analyze some of the obstacles that have faced reform efforts. In our assessment, those include: ongoing conflict, frail Palestinian quasi-state structures and institutions, multiple and at times inappropriate donor policies and practices in the health sector, and a policy vacuum characterized by the absence of internal Palestinian debate on the type and direction of reform the country needs to take. In the face of all these considerations, it is important that reform efforts be flexible and consider realistically the political and economic contexts of the health system, rather than focus on mere narrow technical, managerial and financial solutions imported from the outside.
PMCID: PMC1457109  PMID: 12582108
health sector reform; conflict; Occupied Palestinian Territories

Results 1-9 (9)