|
Friday 02 July 2010 |
Following on from The Lancet’s landmark Series on Health in the occupied Palestinian territory (oPt) in early 2009, a special series of Comments and Abstracts is to be published annually, with the first collection today. This report provides a detailed analysis of current living conditions for people in Gaza and the West Bank.
The abstracts are the best of those presented at a research conference on Palestinian Health that was held at Birzeit University in March this year, attended by researchers from the oPt and around the world. The Abstracts cover the impact of the 2009 Israeli attack on the oPt, and general health research related to oPt residents.
* STUDY SHOWS DEVASTATING IMPACT OF 2009 ISRAEL ATTACK ON GAZA STRIP
* THE TERROR OF CHILDBIRTH UNDER SIEGE
* THOSE INJURED IN 2009 ISRAELI CONFLICT HAVE POORER QUALITY OF LIFE; MEN FOUR TIMES MORE LIKELY TO BE INJURED THAN WOMEN
* ONE IN FOUR PALESTINIAN CHILDREN GOES WITHOUT BREAKFAST
* WHITE PHOSPHORUS BURNS ON AN 18-YEAR OLD CIVILIAN INJURED DURING ISRAELI ATTACK
* GIVING BIRTH MANY TIMES LINKED TO INCREASED RISK OF HEART DISEASE
* PUBLIC HEALTH STUDENTS IN OPT APPEAL FOR END TO CONFLICT AND ADVANCES IN RESEARCH
* AID TO PALESTINIANS LOOKS LIKE AN INAPPROPRIATE POLITICAL TOOL
* THE BATTLE TO BE RESEARCHERS IN THE oPt
* 18 MONTHS ON FROM THE LANCET SERIES ON HEALTH IN THE OCCUPIED PALESTINIAN TERRITORY
* OTHER ABSTRACTS
STUDY SHOWS DEVASTATING IMPACT OF 2009 ISRAEL ATTACK ON GAZA STRIP
The devastating impact of the 2009 Israeli attack on the Gaza Strip is detailed by one of the Abstracts published Online by The Lancet this week, written by Dr Niveen Abu-Rmeileh, Institute of Community and Public Health-Birzeit University, West Bank, occupied Palestinian territory, and colleagues.
The authors analysed health-related quality of life in terms of health before and after the invasion, and factors associated with poor quality of life; and the most urgent needs of a representative sample of adults living in the Gaza strip. They collected data using a randomly selected survey of oPt households, which consisted of questions in three sections about demographic, socioeconomic, and health information about all members of the household; housing characteristics, amenities, access to basic services, and events taking place during and after the attacks; and quality of life, distress, insecurities, and threats (with focus on adults ≥18 years). Some questions were specifically about the periods 6 months before the invasion, during the invasion, and 6 months after the invasion. The prevalence of all injuries and disabilities irrespective of the cause were extracted from different questions.
A representative sample of 3017 households (1% of total households within the Gaza Strip) were visited, with a response rate of 97%. Almost a third of the sample population was displaced during the war, while 39% of these 3017 homes were completely (1%) or partly (38%) destroyed. Three quarters of these homes had yet to be repaired at the end of the study (by August 29, 2009). 137 (0·7%) household members had injuries from various causes: Three-quarters of these were caused by the war (from the start of the attack until the time of the survey [July 14, to Aug 29, 2009]); and 4% of 321 disabilities were caused by the attack. More than seven in ten homes were reliant on food aid.
Quality of life was rated as less than good (out of five categories very good, good, neither good nor poor, poor, very poor) by half of respondents at the time of the survey compared with 39% during the period before the war. 52% of men rated quality of life as less than good versus 48% of women. Other factors also came into play in respondents’ answers on quality of life. 69% of respondents with no one working at home rated quality of life as less than good versus 41% with one or more household members working full-time; 60% of respondents with damaged homes rated quality of life as less-than-good versus 43% of those with intact homes. Finally 57% of respondents whose families received food aid versus rated quality of life as less-than-good versus 30% of respondents whose families did not.
Furthermore, 85% of respondents had moderate or high levels of insecurities, fears, and threats, whereas half reported moderate or high levels of distress. Respondents were also assessed for their level of suffering in a number of categories on a scale of 0 to 10 where 10 was the worst. 92% of respondents rated their suffering as 8 or higher due to the siege at the time of the survey (Jul to Aug 2009); 90% rated their suffering as eight or higher due to the Israeli occupation, 85% as 8 or higher due to the latest war, and 83% rated their suffering as 8 or higher due to internal Palestinian fighting.
A number of crucial needs were identified by the survey: home repair was urgently needed by 58% of households with homes damaged during the war; a source of livelihood* by 2249 (75%); and utilities (water, electricity, cooking gas) were urgently needed by 56%.
The authors conclude: “The Israeli attack on the Gaza Strip has had a negative effect on the quality of life of adults in the general population, and has resulted in high levels of reported distress, human insecurity, and social suffering. The siege on this region continues to be the main obstacle for improvement of the living conditions and quality of life of the population, and is a priority for action.”
Dr Niveen Abu-Rmeileh, Institute of Community and Public Health-Birzeit University, West Bank, occupied Palestinian territory. T) +972-2-2982020 E)
Full Abstract: http://press.thelancet.com/optaftermath.pdf
Note to editors: * The siege affected the economic development in the Gaza Strip and resulted in a reduction of cash liquidity. The term ‘livelihood need’ is a combination of different needs reported by the respondent and this include the need for liquidity, the need for work for cash, having main a source for income and work rehabilitation. This lack of work opportunities are the result of chronic siege.
THE TERROR OF CHILDBIRTH UNDER SIEGE
One Abstract published Online by The Lancet gives the harrowing accounts of women who had to give birth during the Israeli assault on the Gaza strip in December 2008 and January 2009. The paper is by Sahar Hassan and Laura Wick, Birzeit University, oPt.
Women who had given birth and midwives who assisted births during Dec 27, 2008, and Jan 18, 2009, were identified and a small group of women were asked to tell the authors their stories. With the exception of one woman, who declined, all were relieved to recount their experiences.
Seven of 11 women gave birth in hospitals, one in a clinic, and three at home—seven were vaginal deliveries, three were caesareans, and one woman miscarried. Some of the complications included sepsis, severe back and neck pain from anaesthesia, hypothermia in the newborn baby, and eclamptic fits. The women and five midwives interviewed described childbirth during the bombings, with dead and injured people around them; and how they coped with the violence, fear, uncertainty, and the loneliness and pain of waiting for labour to begin, for the baby to be born, and to be reunited with their loved ones.
One woman described nights as ghouls, saying: “I was not thinking like other people in face of death or shelling…but was only thinking of my case! What would happen if I had labour pains at night? How will I manage? They were shelling even ambulances! Nights were like nightmares. Each morning I breathed a sigh of relief that daylight had appeared.” Another said: “I cannot believe that I did not die. Actually I feel I was sent to life again. Now I try not to think of that time.”
The authors say: “Women felt trapped for fear of death from bombs falling on them or their families in the home, street, or hospital; and from childbirth if a birth attendant was not available or emergency care was not attainable. Midwives expressed their fear of assisting women giving birth under duress, and their lack of preparedness—material and psychological—to attend births outside hospitals. Women came to terms with what they had lived through by focusing on everyday life, as suggested in the writings of Veena Das, and by looking after the survival of their families, which seemed to be essential for reconstructing their fragmented existence.”
They conclude: “Women expressed the severe trauma they had endured, but also their heroic struggles to give or assist birth, and to survive with their families. These women were living a process of healing while surrounded by destruction, and with nowhere else to go, they had begun to remake their lives.”
Sahar Hassan, Birzeit University, oPt. (currently in Norway) T) +47 4639 1217 E)
Full Abstract: http://press.thelancet.com/optlabour.pdf
THOSE INJURED IN 2009 ISRAELI CONFLICT HAVE POORER QUALITY OF LIFE; MEN FOUR TIMES MORE LIKELY TO BE INJURED THAN WOMEN
An assessment of non-fatal injuries appears in one of the oPt Abstracts published Online by The Lancet, written by Dr Nedal Ismael Ghuneim, Ministry of Health, Gaza Strip, oPt, and Yehia Abed, Al Quds University-Faculty of Public Health, Jerusalem, oPt.
The researchers assessed a sample of 274 people treated for war injuries at the EL-Najjar Hospital for their analysis. The ratio of men-to-women was 4:1, with women (mean age 33 years) generally older than men (mean age 25 years). More than one in three of those injured was resting at the time their injuries occurred, and more than three-quarters were injured by jet bombings.
The Dirty War Index*, which assesses the effects of conflict on populations, was found to be 20 for women and 16 for children, on a score of 1-100. For all outcomes, quality of life was found to be low for the study population compared with US and Turkish general populations. Physical, emotional, mental, and functional indicators were all worsened in those injured. Injuries not caused by bombs or shell fragments, and those that were not severe were associated with substantially improved quality of life.
The researchers conclude by calling for more mental health facilities to care for those injured by the war, so that the impact of their injuries can be reduced.
Dr Nedal Ismael Ghuneim, Ministry of Health, Gaza Strip, oPt. E)
Full Abstract: http://press.thelancet.com/optinjuries.pdf
Note to editors: *Dirty war index (DWI): a tool which identifies rates of prohibited or highly undesirable ("dirty") war outcomes, such as torture, child injury, and civilian death. DWI is a ratio and is calculated as: (number of "dirty" cases/total number of cases) x 100. The best possible DWI value is 0, indicating that the objectionable outcome is identified in no measured cases. The worst possible DWI value is 100, indicating that the objectionable outcome is identified in 100% of measured cases.
ONE IN FOUR PALESTINIAN CHILDREN GOES WITHOUT BREAKFAST
The eating habits of children and adolescents are studied in one of the Abstracts published Online by The Lancet, with the disturbing findings that one in four children miss breakfast, one in 10 is anaemic, and one in 17 is stunted. Furthermore, 2% are underweight and 15% are either overweight or obese. This abstract is from a paper by Mrs Kholoud Nasser, Ministry of Education and Higher Education, Ramallah, oPt, and colleagues.
The authors studies a representative sample of 2000 students (aged 9–11 years [young children] and 14–16 years [adolescents]) from the target population living in different districts in the West Bank and Gaza Strip, oPt. Weight and height were measured, and haemoglobin concentration was measured to assess the degree of iron-deficiency anaemia. Information about knowledge, attitudes, and practices was mainly gathered during verbal interviews with young children, and by use of a self-administered questionnaire (written) for adolescents.
6% of 1883 children who were assessed were stunted (8% of 930 boys vs 3% of 950 girls), less than 1% had wasting, 2% were underweight, 11% were anaemic (7% of boys vs 14% of girls), and 15% were overweight and obese (11% of boys vs 20% of girls; overall, 11% were overweight, and 4% were obese). 26% of children did not eat breakfast (the main indicator of healthy eating habits)—32% of 1082 adolescents versus 18% of 801 young children. Lack of appetite was the main reason for adolescents skipping breakfast, whereas in young children the reason was waking up late. Young children scored 47% in tests of nutrition knowledge, 86% in tests of attitudes, and 46% in tests of practices, whereas adolescents scored 50%, 70%, and 23%, respectively. Around three-quarters of young children showed a willingness to change their behaviours and accept advice about healthy eating habits, compared with around one in three adolescents.
The authors say higher anaemia in girls could be due to menstruation not compensated for with a good diet, while more boys could be stunted due to late onset of puberty or poor health since early childhood. They say: “Undernutrition, and high proportions of overweight and obesity might be attributable to children’s poor eating habits and consumption of unhealthy food and snacks. Undernutrition and overweight represent the double burden of malnutrition in the oPt.”
They conclude: “Young children had poor knowledge about nutrition compared with adolescents; however, adolescents were worse in terms of their practices, which could be related to a peer effect. Despite the health benefits of breakfast, it is the meal that is most often skipped, resulting in short-term hunger that affects children’s concentration and performance at school. Comprehensive and effective school nutrition programmes that are targeted at all age groups, with special attention to adolescents and girls, are needed because the data for overweight and iron-deficiency anaemia are alarming.”
Mrs Kholoud Nasser, Ministry of Education and Higher Education, Ramallah, oPt. T) +972-599879503 E)
Full Abstract: http://press.thelancet.com/optbreakfast.pdf
WHITE PHOSPHORUS BURNS ON AN 18-YEAR OLD CIVILIAN INJURED DURING ISRAELI ATTACK
A Case Report in this week’s Lancet details the horrific burns suffered by an 18-year-old male civilian during the Israeli attack on the occupied Palestinian territory during January 2009. The report is by Dr Loai Nabil Al Barqouni, Al Quds University, Abu-Deis, Jerusalem, oPt, and colleagues.
The man presented to the Shifa Medical Centre in the Gaza Strip, oPt, after an attack with an incendiary shell. His wounds covered 30% of his body and were on mainly clustered on his right shoulder and legs. A diagnosis of white phosphorus burn was made, and his wounds were cleaned with diluted sodium bicarbonate solution before wet dressing. However, his alarmed doctors noticed a day later white smoke was coming from the wounds, which contained much dead tissue and has extended deep into the man’s flesh. He was urgently transferred to the operating room and had more white phosphorus particles removed; during this process, a particle hit a nurse’s neck and left her with a superficial burn.
Eight days later, the man was relatively well, and, 16 months after follow up, has large, tender scars in the areas of his body that were affected. The authors say: “On contact
with exposed skin, white phosphorus produces painful chemical burns; these typically appear as yellowish, necrotic, full-thickness lesions due to both chemical and thermal components. Because white phosphorus has high lipid solubility, the injuries often extend deep into underlying tissues with resultant delayed wound healing. White phosphorus can also be absorbed systemically resulting in multiple organ dysfunction syndrome because of its effect on erythrocytes, kidneys, liver, and heart.”
They conclude: “We cannot give an estimate of the number of such cases in our
burns unit because it is in a war situation in which no formal recording was done; these burns are rarely encountered in practice and literature describing cases is limited. According to the UN Convention on Certain Conventional Weapons it is prohibited to make civilians the object of attack by incendiary weapons.”
Dr Loai Nabil Al Barqouni, Al Quds University, Abu-Deis, Jerusalem, oPt. T) +970 599770950 E)
For full Case Report, see: http://press.thelancet.com/optcasereport.pdf
GIVING BIRTH MANY TIMES LINKED TO INCREASED RISK OF HEART DISEASE
Palestinian women frequently give birth many times. This has given researchers in the oPt a unique opportunity to study the effects of numbers of births per woman (parity) on risk of coronary heart disease, since previous studies have lacked high numbers of women giving birth more than six times. In this Abstract, the researchers, led by Dr Najwa Odeh Rizkallah, UNICEF Jerusalem, oPT, conclude that parity is linked to obesity, high blood triglyercide concentrations, and increased risk of metabolic syndrome. Any of these factors, alone or in combination, can in turn increase incidence of coronary heart diseases.
The researchers studies women in the Amaari and Kalandia refugee camps in the oPt. They selected a random sample of 515 of all 587 women aged 40-65 who lived in the camps. Women were told by letter the purpose of the project and invited to take part. 15 women who did not give a blood sample were excluded. The other 500 had the blood fats and sugar measured, and assessments of obesity, diabetes, high blood pressure (hypertension) and metabolic syndrome were made.
Mean parity of the women enrolled was 7.3 births. More than two thirds (69%) of the women were obese, 84% had central obesity (waist circumference greater or equal to 88 cm), and over half (52%)had abdominal obesity (high waist-to-hip ratio). One in five women (22%) had diabetes, while two in five (43%) had hypertension. Following data adjustment for age and other factors, each additional birth increased body-mass index by 0.3kg/m2, waist circumference by 0.58cm, and blood triglyceride concentrations by 0.036mmol/L. Women found to have metabolic syndrome (58%) had much higher parity than those without.
The authors conclude: “In Palestinian women, high parity was significantly associated with obesity, triglyceride concentration, and increased risk of metabolic syndrome. Any of these risk factors, alone or in combination, could result in increased incidence of coronary heart disease. Future studies should investigate the effect of birth spacing and intervals.”
Dr Najwa Odeh Rizkallah, UNICEF Jerusalem, oPT. T) +972 54 778 7616 / ++ 970 598 303 225 / ++ 972 2 5840400 ext. 427 E)
Full Abstract: http://press.thelancet.com/optparity.pdf
PUBLIC HEALTH STUDENTS IN OPT APPEAL FOR END TO CONFLICT AND ADVANCES IN RESEARCH
In a Comment, 35 public health masters students from Birzeit Univeristy in the oPt appeal for the end of the conflict, saying that occupation prevents development of a health system suitable for the population. The students, represented by Azza Shoaibi, say: “Despite human-rights violations by the occupier, the international community seems to treat our cause with hypocrisy. We witness leaders from developed-world countries reacting to Israel’s acts with the justification of Israel’s need to protect its ‘security’.”
They add: “Sustainable and comprehensive development cannot be achieved without control over local resources, including land, water, and natural resources, with existing movement restrictions, and with the cutting up of the country in to enclaves that make it impossible to build a coherent health system.”
They also call for development of research capacity, which they say needs and up-to-date health-information system and good quality data. They appeal to the oPt Ministry of Health to take the lead in assuming stewardship of the health system, by cooperating with other health providers , and by establishing guidelines and regulations.
They conclude: “With the help of international friends, and collaborators, we can present ourselves positively to the world. We appeal to our friends around the world to work to remove the isolation of Palestinians, and to keep the oPt connect to the world. We invite you to visit us, to be eye-witnesses to conditions here. We also ask you to ensure your government’s aid respects our agenda and causes no harm, and to not fund occupation through your taxes. Health is a universal concept undertood by all. Military occupation, however, is only fully grasped by those who live in occupation. Such visits and other forms of collaboration and alliance building brings us a step closer to affecting change, to making the future ours.”
Azza Shoaibi, Birzeit University, Ramallah, oPt. T) +970 2598198317 E)
Full Comment: http://press.thelancet.com/optstudents.pdf
AID TO PALESTINIANS LOOKS LIKE AN INAPPROPRIATE POLITICAL TOOL
A second Comment address the politics behind aid given to the oPt, and is written by Angelo Stefanini of The University of Bologna, Italy, and Enrico Pavignani, Independent Public Health Consultant, Bologna, Italy.
They say: “Aid to Palestinians looks like an inappropriate political tool, provided to limit the damage created by a political problem that donor countries dare not address.”
The authors point out that the International Court of Justice has ruled that states are under an obligation not to render aid that might maintain a situation created by occupation. They give as an example financing of highly localised health facilities to mitigate the delays caused by Israeli closures, which effectively normalises an unacceptable situation.
They add: “In view of the fact that 45% of aid goes to Israel and the remaining 55% is divided between waste on occupation measures and actual project benefits,8 aid subsidises the Israeli expansion in the occupied Palestinian territory….Generous and unconditional assistance to the health sector has led to punishing levels of donor dependency: 42% of the health expenditure is financed by donors.
The role of donors and beneficiaries is put under the spotlight in the Comment. The authors say: “Donors perceive their role in different ways, as mere cash providers or as active players. Their choice of interventions is often opportunistic, thus fostering a competitive environment in which joint ventures are resisted and open discussion evaded. The resulting aid landscape is not yet populated by the good donor practices embodied in the Paris Declaration. Conversely, beneficiaries tend to favour aid as bilateral deals, biased towards generous donors who avoid awkward questions. Such an environment does not help meaningful consultations, and formal coordination mechanism might be sidelined. The result is that generous aid is taken for granted and services develop free of fiscal constraints, with costs exceeding future foreseeable internal resources. Above all, donors fail to address a crucial health determinant in the occupied Palestinian territory: human security and the structural violence imposed by the occupation.”
They conclude: “What can be done?…Both technical and political aspects should be tackled...Above all, the split between the assistance provided by donors and their geopolitical views should be addressed. Outspoken advocacy is needed to encourage the mutual understanding of the diplomatic and the technical sides. A move towards an approach based on human rights and international humanitarian law is long overdue.”
Angelo Stefanini, Centre for International Health, Department of Medicine and Public Health, University of Bologna, 40126 Bologna, Italy. T) +39 051209400 E)
Full Comment: http://press.thelancet.com/optstefanini.pdf
THE BATTLE TO BE RESEARCHERS IN THE oPt
A third Comment documents the struggle of simply holding a research conference in the oPt, told be Professor Rita Giacaman and Dr Rhana Khatib of Birzeit University. But the academics say that the Lancet-Palestinian Health Alliance is helping to make a global issue of the health of Palestinians, not only regarding traditional indicators but also in the context of occupation.
The day the international visitors arrived for the conference, hundreds of Israeli settlers, escorted by Israeli security forces. The authors say: “There was tension in the air; the smell of violence everywhere; and denial or restricted access from one part of the West Bank to another and to East Jerusalem. And the country was engulfed with an unusual rain storm, which reduced many streets on the West Bank to muddy streams.”
But they add: “Despite these challenges, most of our international and local guests arrived early on March 1 to attend the two-day conference. Full house, and overflowing; and a testimony to Palestinian resilience; to the moral and substantive support and solidarity of international colleagues and friends; and to the resolve of the Palestinian academic and professional community to engage in conducting, disseminating, and using research to assist in improving population health.”
International contributors to the conference came from as far away as Japan, the USA, Sweden, Norway, and the UK, but most papers were presented by Palestinians from the West Bank (Ramallah, Hebron, and Nablus) and East Jerusalem. Some researchers from the Gaza Strip and Lebanon were denied entry. The authors say: “We live, teach, do research, and manage our academic life under Israeli military occupation; and insecurity and uncertainty mean that we never know if we are able to complete a teaching or research task until it gets done.”
Applauding the varied content of the conference, the authors say: “The Lancet–Palestinian Health Alliance placed us and our local and international partners firmly into a new and stronger than ever level, the global level.”
They conclude: “The Alliance conferences will take place every year in early March, and will help to support continued capacity building for health research. These conferences will help in giving Palestinian researchers the strength and the will to continue believing that they can persist in doing research, despite the many hurdles and the impossibility of the context at times; and that they can influence change, even when the political conditions produce generalised feelings of incapacitation. The conferences will also help to humanise images of Palestinians as either terrorists or hopeless victims. We are real, human, a people with agency; we are scientists and scholars who strive to link academic work to societal development; and we are here and, in spite of everything, we are staying put.”
Professor Rita Giacaman, Birzeit University, oPT. T) +972-2298-2019 / +972-599-721841 E)
Full Comment: http://press.thelancet.com/optgiacaman.pdf
18 MONTHS ON FROM THE LANCET SERIES ON HEALTH IN THE OCCUPIED PALESTINIAN TERRITORY
In a fourth and final Comment, Lancet Editor Dr Richard Horton says: “When we published our report in 2009, one key message was that, ‘Hope for improving the health and quality of life of Palestinians will exist only once people recognize that the structural and political conditions that they endure in the occupied Palestinian territory are the key determinants of population health’. That conclusion remains as true today as it did 18 months ago, despite attempts to re-energise negotiations for peace and justice in the region.”
He adds: “We are not na?ve enough to believe that medical and public health research alone can transform what at times can appear to be intractable political paralysis. But we do believe that regular investigations into the health of the Palestinian people can focus an international spotlight on a critical, but hidden, dimension of the Palestinian situation, providing new and compelling reasons to bring political leaders together to devise long-term solutions to the many and varied health injustices that Palestinian people face.”
Dr Horton concludes that progress on health in the oPt will be tracked by annual research-based meetings of The Lancet-Palestinian Health Alliance.
Lancet Press Office T) +44 (0) 20 7424 4949 E)
Full Comment: http://press.thelancet.com/opthorton.pdf
OTHER ABSTRACTS:
Health-service use and choice of health-care provider in the Gaza Strip: a household survey
http://press.thelancet.com/opthealthservice.pdf
Development of a disability programme in West Bank and Gaza Strip
http://press.thelancet.com/optdisability.pdf
Effect of emergency health insurance scheme on place of birth in the West Bank during conflict: a retrospective analysis
http://press.thelancet.com/opthealthins.pdf
Fecundability in newly married couples in agricultural villages in the occupied Palestinian territory: a prospective study
http://press.thelancet.com/optfecund.pdf
Dietary habits of Palestinian adolescents in three major governorates in the West Bank: a cross-sectional survey
http://press.thelancet.com/optdietary.pdf
Lung function and respiratory symptoms in male Palestinian farmers: a cross-sectional survey
http://press.thelancet.com/optlung.pdf
Lung function, respiratory symptoms, skin problems, and chemical exposures in female hairdressers in Hebron City, occupied Palestinian territory: a cross-sectional study
http://press.thelancet.com/opthair.pdf
Storage, use, and cost of drug products for Palestinian households: a cross-sectional survey
http://press.thelancet.com/optdrugs.pdf
Effect of shift work on mental health of Palestinian nurses: a comparative study
http://press.thelancet.com/optshift.pdf
15 years of cooperation in research and higher education between the Faculty of Medicine, University of Oslo, and Palestinian institutions
http://press.thelancet.com/optnorway.pdf
Qaderoon youth mental health promotion programme in the Burj El Barajneh Palestinian refugee camp, Beirut, Lebanon: a community-intervention analysis
http://press.thelancet.com/optyouth.pdf