Acute and Chronic IllnessAcute Illness and Injury
All respondents were asked whether they had experienced any illnesses or injuries during the last month. 25% had been ill and less than 1% had been injured (table 4.2). This corresponds roughly to 3 episodes per man per year and 3.1 episodes per woman per year (Feachem et al, 1992).
For illustrative purposes we will briefly cite results from similar studies conducted in other countries. In a Norwegian health survey (Norwegian Central Bureau of Statistics, 1987) that was conducted in 1985, respondents were asked whether they had been ill during the last 14 days. The survey included children. Men reported 2.4 episodes per year and women 2.9. In the Pakistan National Health Survey (Pakistan, Federal Bureau of Statistics, 1986) respondents were asked about illness during the previous month. 14 % of the men and 17% of the women reported having been ill, which translates into 1.7 episodes per man per year and 2.1 episodes per woman per year. In the Thai Health and Welfare Survey (Thailand, National Statistics Office, 1983) the result was 0.7 episodes per man per year and 0.8 per woman per year (table 4.1). The criteria were the same as in the Pakistan survey.
Table 4.1 Self-reported incidences of acute illness and/or injury per woman per year and per man per year in different countries
Feachem RGA. et al. The Health of Adults in the Developing World A World Bank Book: Oxford University Press, 1992.
Norway, Central Bureau of Statistics. Health Survey 1985 Oslo 1987. FAFO 1993.
Since the salience criteria vary between the different studies, caution is called for when results are to be compared. In the surveys from Pakistan and Thailand the criteria were stricter than in the surveys in the occupied territories and in Norway. It is difficult to determine the exact extent to which the differences shown in the table are caused by differences in criteria. However, it seems reasonable to assume that the level of perceived illness in the Palestinian population is not lower than in Norway. There can be many different explanations to this. However, if rates are actually lower in Pakistan and Thailand, it is probable that the high rates in the occupied territories are not caused by actual higher prevalences of disease, but rather by factors like feelings of distress, factors related to the role of being ill or access to health care services. Interpretations are by no means conclusive, as the data and the populations they are derived from cannot easily be compared.
Those who report that they have had illnesses or injuries during the last month were also asked whether their illness or injury was so serious as to prevent them from carrying out their normal duties for a period of three days or more (table 4.2). Nearly 3/4 were prevented from carrying out their normal duties. This result indicates that almost 1 out of 5 adults in the Palestinian population were away from regular work and other duties at least three days during the last month before the interviews were conducted.
Table 4.2 Illness and/or injury and absence from normal duties 3 days or more last month, per cent.
Prolonged Illness and Handicaps
13% of those who have prolonged illnesses have severe difficulty going out without assistance of others, and to 27% it is a bit difficult (question 222). In table 4.3 those who report some difficulties and severe difficulties are grouped into one.
Table 4.3 Prolonged illness and problems going out on his/her own, per cent
Specific Groups of Prolonged Illnesses
Table 4.4 Specific groups of prolonged illnesses Cases of selected prolonged illnesses and afflictions due to injury or handicap. Per cent of total population (respondents)
Men tend to have higher rates of physical handicaps as well as of hearing, speech or sight impairment than women do. In most international studies (Feachem et al, 1992), injury is an important cause of mortality and morbidity among male adults. Hence, injuries may also be the main cause of the high prevalence of disability among men in the occupied territories.
It seems that the prevalence of non-communicable diseases is relatively high, as witnessed by the frequencies of hypertension, heart disease and diabetes. Diabetes is regularly underreported by at least 20-50% (clinically diagnosed) in studies of self-perceived illness. A prevalence of 10% (95% confidence interval: 8-12%) in the age group of 40-59 is comparatively high, but still not surprising in the Middle East (King and Rewers, 1991). Apparently the high frequencies of gastrointestinal diseases (9%), respiratory diseases and 'other diseases' (5%) reflect instances of infective and parasitic diseases as well as of non-communicable diseases.
Variations in Rates and Patterns of Illness
Differences and inequalities between men and women are salient features of Palestinian society. This is reflected in the health problems and the utilization of health services. Some results, nevertheless, show less differences between men and women than what could be expected (table 4.5). There are no differences between men and women in the rates of acute or chronic illness. Nor is there any difference between the sexes in the seriousness of acute episodes as measured by the rate of absence from normal duties. Only 1% of the adults in the total sample were injured during the last month. Out of these, 2/3 are men, indicating that injury is a more common problem among men than among women. The rate of injured adults is particularly low in view of the very high rate of children that have been seriously injured in the last two months before the interviews took place (see below).
Table 4.5 Years of education, illness last month, prolonged illness. By age. Per cent (respondents)
Age is a major determinant of health conditions, and no results concerning health should be interpreted without control for age. The rate of acute illness rises from 17% among those aged under 20 to 46% among those aged over 59. Prevalence of prolonged illness steadily increases from 10% in the youngest (15-19 years) to 74% in the oldest group (60 years or more). All specific causes of long term disease, and problems inflicted by these, also increase in frequency with age.
In Gaza, 16% of the respondents had suffered illness or injury during the last month, and all had in fact consulted a doctor. In the West Bank, 32% had experienced illness or injury, and in Arab Jerusalem the rate was 22%. There are no significant differences between the West Bank (32%), Gaza (27%) and Arab Jerusalem (28%) when it comes to prevalence of prolonged illness. If there is, nevertheless, a real difference, this would probably be accounted for by the lower average age of respondents in Gaza as compared to the West Bank. In Gaza, however, there is a closer correlation between reported acute illness and both utilization of health care services and absence from regular duties, than there is in Arab Jerusalem and the West Bank. A possible explanation is that people in Gaza tend to consider themselves ill only when their ability to perform regular duties is affected. People in Gaza may therefore have a higher threshold for reporting illnesses, implying that low levels of reporting do not necessarily reflect low actual rates of disease.
Refugee status does not seem to influence the rate of reported illness and injury. Nor do refugees in camps report significantly different rates of illness than others living in the same area, be it Gaza or the West Bank. When assessing these results, one should bear in mind that a possible tendency to report more illnesses among people that are better off may outweigh possible higher prevalences of clinical diseases in camps. On the other hand, people belonging to households in the lowest wealth group report more acute and chronic illnesses than those in the upper third. This indicates that within the Palestinian community there is not a tendency towards more liberal definitions of illness among the rich than among the poor. About one third of those in the lowest third and one fifth of those in the upper third had been acutely ill last month. Approximately one third in the lower and one fourth in the upper wealth group have prolonged illnesses. This finding is difficult to explain in view of the regional differences mentioned earlier, but these are probably not so important when corrected for age. Persons with chronic diseases in the lower wealth group report having great difficulty going out on their own nearly 3 times more often than persons in the upper wealth group. The same pattern appears when people are asked about absence from normal duties because of acute illness. One out of four persons with acute illness are prevented from performing their normal duties if they belong to the lower third stratum, while only one out of eight in the upper wealth category could not carry out their regular tasks. The present data cannot tell whether this reflects that the duties of the latter are easier to perform, or that their illnesses are less serious.
The rate of acute and chronic illness falls dramatically with an increase in years of education. However, this correlation is much weaker when corrected for age.
When corrected for age, people who live alone tend to have a higher mortality and morbidity than people living in families (Feachem et al, 1992, Norwegian Central Bureau of Statistics). In Palestinian society almost everybody lives in households with more than one person. Only 1% report living alone, and half of these people suffer from prolonged illnesses. With increasing family size there is a fall in the reported rate of both acute and chronic illness among women, but not among men. This finding needs further analysis in order to be interpreted.
The connection between marital status and health is also difficult to depict, since almost everybody aged over 39 is married, and even when they are not married they do not live alone. There are no obvious differences in rates of reported health problems between married and unmarried people, even when corrected for age. This is a remarkable finding in view of what is regularly found in international studies.
In European and Northern American studies, employment and the role that a person plays in the labour market are regularly found to relate to health problems. The correlation between employment and health is more complicated in the occupied territories because of the complicated structure of the labour market and labour activities in this area.
Acute Illness, Chronic Illness and Symptoms of Distress
Table 4.6a Acute and prolonged illness and degree of distress, per cent
Table 4.6b Prolonged illness and degree of distress by age, per cent
In the FAFO survey (table 4.7), very few women (2%) and nearly half (47%) of the men report that they smoke. Smoking is more prevalent among women in Arab Jerusalem (9%) than outside camps in Gaza (0%) and in the West Bank (3%). In camps only 2% of women smoke. Among men there are no differences between the different areas. The rate of smoking among women increases with the degree of exposure to the outside world, but, interestingly, it does not correlate with their status in the labour market, years of education or religious attitudes and behaviour. About 1 out of 2 men tend to smoke, irrespective of social background. Religiosity is the only variable showing a significant correlation with the degree of smoking among men. 60% of men with secular attitudes and behaviour smoke, while only 40% of those who are religiously active and express religious attitudes (see chapter 9) do.
Table 4.7 Smoking, per cent
The differing smoking habits of Palestinian men and women are striking, deviating radically from the much smaller differences found in European studies (Schuval, 1992). In Sweden, 24% of the men and 28% of the women aged 15 years or older were smokers in 1986. In Italy, the rates were 46% for men and 18% for women in 1983.
Smoking is the sole risk factor covered in the questionnaire. Alcohol and drug consumption are sensitive topics in all societies, and even more so in Islamic communities. It would have been difficult to get valid data on these topics with the method employed in the FAFO study.