Multi morbid diseases of Palestine childern - nabildeeb-Syndrome - Dr.Nabil DEEB

فلسطينيو العراق2

عدد القراء 3467

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Dr. Nabil DEEB

Arzt – Physician – Doctor

PMI-Registered Doctors'Association

53140 Bonn  /  GERMANY


Multi morbid diseases of Palestine childern - nabildeeb-Syndrome .

The stateless Palestinian refugee children are discriminated in the medical treatment.

                            1.  Anorectal Malformations :-

The little girl, Zaina Mohammed Hussein Al - Gazar was born at 02. November 2009 in Baghdad - Iraq. She is a child stateless Palestinian refugee, and living at the time of political unrest and expelled from Iraq in the UNHCR - the refugee camp in the desert between Iraq and Syria on Syrian territory under temporary in  care and contactor of the UNHCR and waits with her parents and two healthy sisters to live in  a country anywhere in the world through the agency, UNHCR – Geneva .

When the intake of these above mentioned refugees is uncertain and often lasts two to five years waiting in UNHCR - refugee camp in the desert near the Iraqi-Syrian border .

The two-year-old girl suffering from birth under "" Anorectal malformation ""
(= congenital malformations of the rectum and the anus) as a result of the developmental disorder of embryo in the early stages of pregnancy of her mother because of the radiation depleting effect of the environment in the home of their mother in Baghdad .

It was a temporary colostomy (colostomy =) at university hospitals - Baghdad in March 2010 created the child, give the child a temporary chair to give way, which is for her vital moment .

Another treatment for the child in the Palestinian desert in Flüchttlingslager was and still is not possible for many reasons .

The child needs urgent and more vital operational treatment as a pulling operation (posterior sagittal anorectal PSARP = plastic) with a minimally invasive surgery is used .

Such further treatment in a special children's surgery - clinic in Europe, for example in Finland, Norway, Sweden, France or  in the Federal Republic of Germany or in USA , for example possible in the department of pediatric surgery .

The three-year-old girl Zina waiting since her birth to 02 November 2009 with her two little healthy sisters and their parents in the desert between the Iraqi and Syrian deserts in - the refugee UNHCR camp to a reasonable medical surgical treatment in a country .

Without appropriate treatment for the child's life little girl Zina would be destroyed forever because permanent serious infections and cancer degeneration .

In this context, I refer-so called International Humanitarian Law .

In comparison to the treatment of children in the rest of the world as in Europe or the U. S. A. I refer to the latest published medical contribution of colleague Risto J. Rintala, Professor of Paediatric Surgery, Hospital for Children and Adolescents, FIN-00029 HUS, Finland  in Finland and I also add sections of this paper and give the source of this scientific publication for information: -

Journal of Pediatric Gastroenterology & Nutrition:

April 2009 - Volume 48 - Issue - p S79-S82

doi: 10.1097/MPG.0b013e3181a15b5e

Original Articles


Congenital Anorectal Malformations: Anything New?

Rintala, Risto J

Abstract

Management of anorectal malformations, especially that of proximal and more severe forms have developed significantly in the last 25 years. Echography and magnetic resonance imaging have improved the diagnostic accuracy, especially in terms of associated anomalies that are the main cause of fatalities among patients with anorectal malformations. Animal models, novel molecular biological techniques and knock-out gene models have widened our knowledge on aetiology and pathogenesis of these anomalies .

From early 1980s, the posterior sagittal anorectoplasty originally designed by deVries and Pena has systematized the surgical management of anorectal anomalies leading to improved functional outcomes. Surgical mini-invasive techniques are increasingly applied to the management of these anomalies, although their role is as yet not clearly established. Long-term functional follow data are also available today indicating a reasonable favourable faecal and urinary control in the majority of patients with anorectal malformations. For the patients with less favourable functional outcome there are bowel and bladder management options that provide sufficient social continence .

Malformations of  the anorectum include a series of congenital lesions ranging from a slight malposition of the anus to complex anomalies of the hindgut and urogenital organs. The reported incidence of anorectal anomalies range between 1:3300 and 1:5000 live births. In Western communities there is a male preponderance, 55% to 70% of the patients in larger series have been males. The more severe malformations tend to be more common in male patients.
In most cases, anorectal malformations present as an absence of an anus in its normal position. In mild forms of anal anomalies the bowel outlet opens in the perineal region outside the usually well-developed voluntary sphincter complex. In more severe anomalies bowel outlet opens in an ectopic position in the urogenital tract in males or genital tract in females. Neonatal recognition of the type of the malformation is essential for the planning of the surgical management of anorectal anomalies .

There is no generally accepted method to classify anorectal malformations. The most commonly used has been the Wingspread International Classification for Anorectal Malformations. Recently, a new simplified classification has emerged, Krickenbeck classification (Table 1), which is based on consensus recommendations of world authorities (1) .


Table 1

The outcomes of patients with anorectal malformations have greatly improved by modern surgical techniques and neonatal care facilities during the last decades. Early survival is today a rule except in some rare cases with cardiac, urogenital, or chromosomal anomalies that are not compatible with life. The overall long-term functional outcome expectancy in terms of faecal and urinary continence is today relatively optimistic. The majority of patients reaching adolescence and adulthood are able to maintain themselves socially continent .

RECENT BASIC SCIENCE

The aetiology of anorectal anomalies is not known. Genetically determined syndromes with anorectal malformations are relatively uncommon. On the contrary, anorectal anomalies occur commonly in multianomaly sequences such as VACTERL or CHARGE associations. The overall incidence of associated anomalies in patients with anorectal malformations is more than 60%. This suggests that the stimuli that induce abnormal development of anorectum operate universally in the developing foetus and may cause maldevelopment of several organ systems. Anorectal malformations may develop in some syndromes that are caused by a mutation of a single gene. These include Currarrino syndrome, which is caused by a mutation in HLXB9 gene in chromosome locus 7q39 and Townes-Brock syndrome, which has a mutated SALL1 gene in chromosome locus 16q12.1 .

The pathogenesis of anorectal malformations has recently been much clarified by modern embryological studies concerning experimental models of anorectal anomalies. Anorectal anomalies occur spontaneously in some animal models (Danforth's short tail mouse) and can be induced by several substances, such as ethinylthiourea, retinoic acid derivatives, and adriamycin. The spectrum of malformations following administration of these substances is variable, but they are valuable tools for embryological studies. The most significant findings in these embryological models are abnormalities or absence of the cloacal membrane. The abnormal cloacal membrane does not allow normal breakdown of the bowel to the perineum. In the animal models a clinically important discovery has been the character of the rectourogenital or perineal communication; the fistulous communication is actually an ectopic anus. This ectopic anus has the characteristics of a normal anal canal including a distal zone of transitional epithelium, anal glands, and the internal anal sphincter, which is a thickening of the circular muscle layer around the bowel outlet. The voluntary external sphincter complex including the levator ani muscle develops separately in a normal position. The voluntary sphincters are always hypoplastic; the degree of the hypoplasia is dependent on the distance of the rectal pouch from the perineum and on the severity of commonly associated sacral deformity .

DIAGNOSTIC MODALITIES

With the exception of those anorectal malformations that are associated with other major structural anomalies (eg, VACTERL syndrome or caudal regression syndromes), prenatal ultrasound diagnosis of it is uncommon. The sonographic features in the foetus are nonspecific and include dilated or echogenic fetal bowel and hydrometrocolpos. Associated cardiac, renal or vertebral anomalies may be detected. Cloacal malformations can rarely be diagnosed by the presence of a septated cystic mass in the pelvis with hydronephrosis and oligohydramnios .

Despite abundance of sophisticated diagnostic imaging modalities, the diagnosis and classification of anorectal malformations remain on the basis of clinical picture and examination. The clinical examination performed by an experienced examiner reveals the type of the anorectal malformation in >90% of the cases.
Classical imaging with inversion or cross-table radiography is useful in selected cases where clinical examination is equivocal; however, there are many possibilities for erroneous interpretation. Ultrasound has not established itself as a reliable method to determine the position of the terminal colon. It provides similar information as the prone, cross-table radiography and has similar limitations. However, ultrasound is extremely useful in detecting abnormalities in the urinary and genital tracts, especially obstructive uropathy and hydrometrocolpos .

Modern computed tomography technology allows multiplanar imaging, however, this comes at a cost of radiation to a newborn child. Although it provides increased detail, especially of the bony structures as well as pelvic musculature, it is not reliable in revealing the anatomy of bowel termination and the rectourogenital communication .

Magnetic resonance imaging provides the same multiplanar capability as computed tomography scan but without the radiation burden. Although magnetic resonance imaging can accurately delineate the level of the bowel termination, it will detect only a small proportion of the rectourogenital fistulas. In newborn, small body size also impedes spatial resolution .

The most reliable and useful imaging modality is still the colostogram, especially if it is augmented by pressure. All patients who have undergone a primary diverting colostomy for a severe anorectal anomaly should have this imaging study to accurately delineate the anatomy of the bowel termination and the fistula. Micturating cystourethrography has still its place in the imaging of a neonate with an anorectal malformation because of high incidence of renal tract anomalies .

Of absolute importance is imaging to detect associated malformations as some of these defects may be life threatening or have a greater impact on survival of the patients than the anorectal malformation. Typical anomalies of this kind are cardiac defects and tracheo-oesophageal anomalies. Chest radiography with a nasogastric tube in place excludes the presence of an oesophageal atresia .

Cardiac echogram is used to screen cardiac anomalies. Ultrasound of urinary tract is performed in each patient with an anorectal malformation to rule out obstructive uropathies and other urinary tract anomalies .

Vertebral and sacral anomalies are common in patients with anorectal malformations. These are commonly accompanied by spinal cord abnormalities. The spinal cord can also be visualized by ultrasound in a neonate. This is usually performed in combination with radiographs that provide information on the bony structure .

MANAGEMENT
A provisional diagnosis of the severity of an anorectal malformation is usually easily made in a newborn. The most important issue is to ascertain the level of the anomaly, because it determines the operative treatment in the neonatal period. There is rarely any urgency, and most patients tolerate the low bowel obstruction without symptoms for longer than 24 hours if the upper gastrointestinal tract is decompressed by a nasogastric tube. Before any treatment of the anorectal malformation is carried out, life-threatening associated malformations should be ruled out .

The aims of surgical treatment are to provide a normally sited anus of adequate calibre and appearance while preserving as much of the normal intrinsic anorectal anatomy and function as possible. In recent years, the posterior sagittal anorectoplasty (PSARP), developed and popularized by Alberto Peٌa, has become the most frequently performed surgical procedure in the reconstruction of anorectal malformations (2). The PSARP affords a relatively standardized approach to all common varieties of anorectal anomalies, enables direct visualization of the structures without the necessity for blind, potentially hazardous, surgical manoeuvres, and offers the opportunity for anatomically precise reconstruction. Functional results are definitely no worse than with traditional surgical techniques, and there is growing evidence that long-term bowel function is superior. The timing of surgery is variable; today many surgeons try to undertake repair as soon as the patient has stabilised from neonatal procedures. There is some evidence that the functional results are better if the repair is performed as early as possible .

In patients with a perineal bowel outlet or fistula (traditional low anomaly) the anorectal repair can be performed safely in a newborn. In males the options are a simple cutback anoplasty or a limited PSARP procedure that requires significantly more extensive dissection than the cutback procedure. Functional outcomes are similar, but there appears to be fewer complications after the cutback operation (3). In females cutback procedure yields unsightly cosmetic result and probably worse outcome than after a limited PSARP procedure.
Patients with more severe anomalies usually receive a diverting colostomy as a newborn. These anomalies are usually repaired with the PSARP procedure followed by closure of the colostomy. A typical male anomaly is an imperforate anus with a rectourethral fistula and a typical female anomaly an imperforate anus with a rectovestibular fistula. The latter may be repaired in a newborn without previous colostomy, but a safer approach would be a staged operation. Recently, some surgeons have advocated neonatal repair without preceding colostomy for severe anomalies as well. This approach has not gained general acceptance and the functional outcomes remain unclear. Theoretically, repair as early as possible could augment development of neurocircuitry between anal canal and brain, resulting in better functional outcome .

Recently, some surgeons have advocated laparoscopy-assisted repair for high anorectal anomalies. The procedure entails laparoscopic mobilisation of the rectal blind pouch, closure of the rectourethral fistula, and pull-through of the bowel termination through the centre of sphincter funnel that has been identified by muscle stimulation. At the moment laparoscopic surgery for anorectal anomalies is at an experimental stage, but the approach is promising, especially because of its mini-invasiveness. Long-term follow-up results are lacking but warranted .

OUTCOMES
Long-term functional outcome following repair of anorectal malformations with a perineal opening (low malformations) is good in the majority of patients. The bowel function does not equal that of healthy people, but most patients have a good quality of life without social restrictions. The most common complaint especially during childhood is constipation, which is usually manageable with oral laxatives .

Patients with more severe anomalies have somewhat more guarded functional prognosis (4). Although it is evident that modern methods of repair yield superior functional results compared with older techniques such as abdominoperineal or sacroperineal pull-through, a significant percentage of patients still experience abnormal bowel control. These patients can be helped significantly by bowel management programmes that often include formation of a continent catheterisable conduit from the appendix that is used to empty the bowel regularly. With the help of bowel management regimens a majority of patients with severe malformations gain a good quality of life. Novel technical innovations such as artificial anal sphincters, electrically stimulated sphincters, or sacral nerve stimulation have been used in some selected patients with promising outcomes. However, similar cleanliness as with antegrade bowel washouts is rarely achieved .

The patients with anorectal malformations need careful follow-up throughout their childhood. Functional complications such as constipation should be detected and treated early to achieve optimal outcome. The treatment of defective continence should be started well before the child reaches school age to overcome the devastating social consequences of faecal soiling and to integrate the child to the social context of his peers. Because the management of anorectal malformations requires years of commitment and special knowledge concerning the anatomical and physiological characteristics of this complex group of congenital malformations, these children should be treated by specialised medical personnel in specialised referral centres .

I .

REFERENCES  of colleague Risto J. Rintala, Professor of Paediatric Surgery, Hospital for Children and Adolescents, FIN-00029 HUS, Finland  :-


1. Holschneider A, Hutson J, Peٌa A, et al. Preliminary report on the International Conference for the Development of Standards for the Treatment of Anorectal Malformations. J Pediatr Surg 2005; 40:1521-1526.
Cited Here... | PubMed | CrossRef


2. Pena A. Anorectal malformations. Semin Pediatr Surg 1995; 4:35-47.
Cited Here... | PubMed


3. Pakarinen MP, Goyal A, Koivusalo A, et al. Functional outcome in correction of perineal fistula in boys with anoplasty versus posterior sagittal anorectoplasty. Pediatr Surg Int 2006; 22:961-965 .

Cited Here... | PubMed | CrossRef


4. Rintala R, Lindahl H. Is normal bowel function possible after repair of intermediate and high anorectal malformations. J Pediatr Surg 1995; 30:491-494 .

Cited Here... | PubMed | CrossRef


II.
My REFERENCES : -


http://www.aerztezeitung.de/politik_gesellschaft/gp_specials/pid/article/626203/fdp-will-zulassung-pid-werben.html

Nabil DEEB , nabildeeb, pmi , In the pre-implantation diagnosis, the medical indications and the decisions of the European Court of Human Rights (ECHR) in Strasbourg are considered .


Nabil DEEB , nabildeeb, pmi , Dans le diagnostic pré-implantatoire, les indications médicales et les décisions de la Cour européenne des droits de l'homme (CEDH) à Strasbourg sont considérées .


http://www.springermedizin.at/artikel/19708-denken-ohne-affekt


Nabil DEEB , nabildeeb, pmi , Human right to health also applies to the people of Gaza Strip .


Nabil DEEB , nabildeeb, pmi , Droit à la santé de l'homme s'applique également à la population de la bande de Gaza .


http://www.aerztezeitung.de/politik_gesellschaft/gp_specials/pid/article/626883/wachsende-zahl-pid-befuerworter-cdu.html


Nabil DEEB , nabildeeb, pmi , Human right to health also applies to Berlin, despite the various party lines .


Nabil DEEB , nabildeeb, pmi , In deciding on the approval of preimplantation genetic diagnosis (PGD) and on health care reform, human rights, international law and the fundamental law of the land without limits .


Nabil DEEB , nabildeeb, pmi , droit à la santé de l'homme s'applique également à Berlin, malgré les lignes des divers partis .


Nabil DEEB , nabildeeb, pmi , n se prononçant sur l'approbation du diagnostic génétique préimplantatoire (DPI) et sur la réforme des soins de santé, les droits de l'homme, droit international et la loi fondamentale du pays sans limites .


http://www.aerztezeitung.de/medizin/krankheiten/hormonstoerungen/schilddruesen-erkrankungen/article/608829/erhoehtes-risiko-fehlgeburten-leichter-hypothyreose.html


Nabil DEEB , nabildeeb, pmi , The interaction of beta-hCG with the TSH-receptor. & Angiogenic factors in pathogenesis and prediction of preeclampsia .


Nabil DEEB , nabildeeb, pmi , interaction de la beta-hCG avec le récepteur de la TSH . &

Facteurs angiogéniques dans la pathogenèse et la prédiction de la preeclampsia .


http://www.aerztezeitung.de/politik_gesellschaft/gp_specials/pid/article/624740/embryonenschutz-kann-spaltpilz-koalition.html


Nabil DEEB , nabildeeb, pmi , Preimplantation genetic diagnosis up2date in user knowledge society .


Nabil DEEB , nabildeeb, pmi , up2date diagnostic génétique préimplantatoire dans la société les connaissances des utilisateurs .

 

http://www.aerztezeitung.de/medizin/krankheiten/neuro-psychiatrische_krankheiten/depressionen/article/632090/neues-portal-depressiven-stoerungen-netz.html


Nabil DEEB , nabildeeb, pmi , The psychiatric patient in the pregnancy. Unipolar depression, antenatal and postnatal .


Nabil DEEB , nabildeeb, pmi , Le patient psychiatrique de la grossesse. La dépression unipolaire, prénatals et postnatals .


http://www.aerztezeitung.de/politik_gesellschaft/gp_specials/pid/article/635081/meisner-vergleicht-pid-kindermord-bethlehem.html


Nabil DEEB , nabildeeb, pmi , Preimplantation genetic diagnosis up2date in our knowledge society must be based on the German constitution and set up European law .


Up2date diagnostic génétique préimplantatoire dans notre société de la connaissance doit être fondée sur la constitution allemande et mettre en place la législation européenne .


http://www.aerztezeitung.de/medizin/fachbereiche/innere_medizin/article/626363/expertenchat-thema-schilddruese.html


Nabil DEEB , nabildeeb, pmi , The interaction of beta-hCG with the TSH-receptor. & Angiogenic factors in pathogenesis and prediction of preeclampsia .


Interaction de la beta-hCG avec le récepteur de la TSH. & Facteurs angiogéniques dans la pathogenèse et la prédiction de la preeclampsia .


http://www.paliraq.com/index.php?option=com_content&task=view&id=3759&Itemid=49


Nabil DEEB , nabildeeb, pmi , The leukemia and traumatic injury in the toxic war with depleted uranium , Dr. Nabil  Abdul Kadir DEEB , Arzt – Physician – Doctor .


http://www.springermedizin.at/artikel/16612-die-schizoaffektive-stoerung-validitaet-und-reliabilitaet


Nabil DEEB , nabildeeb, pmi , Schizophrenia, race theories, natural law and the diaspora population genetics in the world financial crisis .


Nabil DEEB , nabildeeb, pmi , Shizophrénie, théories de la race, la loi naturelle et la génétique des populations diaspora dans la crise financière mondiale .


http://www.springermedizin.at/artikel/9522-neues-genetisches-verfahren-fuer-erfolgreiche-kuenstliche-befruchtung


Nabil DEEB , nabildeeb, pmi , PID–Trias & Konnexit
نt zwischen نrztlicher Tنtigkeit und der ـberzeugung von Würde und Schutzwürdigkeit menschlichen Lebens von der Zeugung .


http://www.aerztezeitung.de/medizin/krankheiten/krebs/article/610766/lange-telomere-geringes-krebsrisiko.html


Nabil DEEB , nabildeeb, pmi , The telomerase may play a central role in the carcinogenesis of human cells .


Nabil DEEB , nabildeeb, pmi , La télomérase mai jouer un rôle central dans la carcinogenèse des cellules humaines .


http://www.springermedizin.at/artikel/360-schwierigkeiten-bei-der-evakuierung-aus-krisengebieten-bedarf-an-einheitlichen-und-einfach-anzuwend


Nabil DEEB , nabildeeb, pmi , Human right to health also applies to the people of Gaza Strip .


Nabil DEEB , nabildeeb, pmi , Droit à la santé de l'homme s'applique également à la population de la bande de Gaza .


http://www.aerztezeitung.de/praxis_wirtschaft/klinikmanagement/article/629322/patient-hakenkreuz-arm-juedischer-arzt-verweigert-op.html


Nabil DEEB , nabildeeb, pmi , Human right to health and personal development of our science in society .

 

Nabil DEEB , nabildeeb, pmi , droit à la santé et le développement personnel de notre science dans la société .


http://www.springermedizin.at/artikel/13103-krankheit-mit-migrationshintergrund


Nabil DEEB , nabildeeb, pmi , Schizophrenia, race theories, natural law and the diaspora population genetics in the world financial crisis .


Nabil DEEB , nabildeeb, pmi , Schizophrénie, théories de la race, la loi naturelle et la génétique des populations diaspora dans la crise financière mondiale .


http://www.aerztezeitung.de/medizin/krankheiten/hormonstoerungen/article/622283/forscher-brauchten-jahrzehnte-bis-erste-erfolgreiche-kuenstliche-befruchtung-gelang.html


Nabil DEEB , nabildeeb, pmi , The serious progress in reproductive medicine worldwide in a knowledge society .


Nabil DEEB , nabildeeb, pmi , Le sérieux progrès dans la médecine reproductive à travers le monde dans une société de la connaissance .


http://www.springermedizin.at/artikel/4764-15-jahre-tschernobyl-kinder-sterben-an-leukaemie-gehirntumoren-und-schilddruesenkrebs


Nabil DEEB , nabildeeb, pmi , Human right to health also applies to the people of Gaza Strip .


Nabil DEEB , nabildeeb, pmi , Droit à la santé de l'homme s'applique également à la population de la bande de Gaza .


http://www.aerztezeitung.de/medizin/krankheiten/krebs/article/589959/massgeschneiderter-bluttest-krebskranke.html


Nabil DEEB , nabildeeb, pmi , Personalized Cancer Medicine in the knowledge society .


Nabil DEEB , nabildeeb, pmi , Personalized Medicine cancer dans la société de la connaissance .


http://www.paliraq.com/index.php?option=com_content&task=view&id=6591&Itemid=72


The right to compensation for Palestinian refugees for damages under general international law against any aggressor state or against    members of the aggressor State - Dr. Nabil DEEB .


http://www.paliraq.com/index.php?option=com_content&task=view&id=6581&Itemid=72

Personalized diagnosis and therapy of cancer in our knowledge society
and the UN, WHO and UNHCR - Dr. Nabil DEEB .


http://www.paliraq.com/index.php?option=com_content&task=view&id=6556&Itemid=72


Dr. Nabil AbdulKadir DEEB

International Humanitarian Law And The Palestinian People Throughout The World

Importance of international humanitarian law ?

 

Dr. Nabil DEEB

Arzt – Physician – Doctor

PMI-ؤrzteverein e.V.

Palنstinamedico International ؤrzteverein – ( P M I ) e.V.

Palestine Medico International Doctors Association ( P.M.I.) registered association .

Department of Medical Research

Département de la recherche médicale

P.O. Box 20 10 53

53140 Bonn – Bad Godesberg / GERMANY

doctor.nabil.deeb.pmi.germany@googlemail.com

doctor.nabilabdulkadirdeeb@googlemail.com

22/5/2012

 

" All Rights Reserved To www.paliraq.com "

 

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  • Dr. Nabil AbdulKadir DEEB ; to the = Multi morbid diseases of Palestine childern - nabildeeb-Syndrome - Dr.Nabil DEEB . . . . see ::: The Lancet, Early Online Publication, 23 July 2014 doi:10.1016/S0140-6736(14)61044-8Cite or Link Using DOI Copyright © 2014 Elsevier Ltd All rights reserved. An open letter for the people in Gaza Paola Manduca aEmail Address, Iain Chalmers b, Derek Summerfield c, Mads Gilbert d, Swee Ang e, on behalf of 24 signatories We are doctors and scientists, who spend our lives developing means to care and protect health and lives. We are also informed people; we teach the ethics of our professions, together with the knowledge and practice of it. We all have worked in and known the situation of Gaza for years. On the basis of our ethics and practice, we are denouncing what we witness in the aggression of Gaza by Israel. We ask our colleagues, old and young professionals, to denounce this Israeli aggression. We challenge the perversity of a propaganda that justifies the creation of an emergency to masquerade a massacre, a so-called “defensive aggression”. In reality it is a ruthless assault of unlimited duration, extent, and intensity. We wish to report the facts as we see them and their implications on the lives of the people. We are appalled by the military onslaught on civilians in Gaza under the guise of punishing terrorists. This is the third large scale military assault on Gaza since 2008. Each time the death toll is borne mainly by innocent people in Gaza, especially women and children under the unacceptable pretext of Israel eradicating political parties and resistance to the occupation and siege they impose. This action also terrifies those who are not directly hit, and wounds the soul, mind, and resilience of the young generation. Our condemnation and disgust are further compounded by the denial and prohibition for Gaza to receive external help and supplies to alleviate the dire circumstances. The blockade on Gaza has tightened further since last year and this has worsened the toll on Gaza's population. In Gaza, people suffer from hunger, thirst, pollution, shortage of medicines, electricity, and any means to get an income, not only by being bombed and shelled. Power crisis, gasoline shortage, water and food scarcity, sewage outflow and ever decreasing resources are disasters caused directly and indirectly by the siege.1 People in Gaza are resisting this aggression because they want a better and normal life and, even while crying in sorrow, pain, and terror, they reject a temporary truce that does not provide a real chance for a better future. A voice under the attacks in Gaza is that of Um Al Ramlawi who speaks for all in Gaza: “They are killing us all anyway—either a slow death by the siege, or a fast one by military attacks. We have nothing left to lose—we must fight for our rights, or die trying.”2 Gaza has been blockaded by sea and land since 2006. Any individual of Gaza, including fishermen venturing beyond 3 nautical miles of the coast of Gaza, face being shot by the Israeli Navy. No one from Gaza can leave from the only two checkpoints, Erez or Rafah, without special permission from the Israelis and the Egyptians, which is hard to come by for many, if not impossible. People in Gaza are unable to go abroad to study, work, visit families, or do business. Wounded and sick people cannot leave easily to get specialised treatment outside Gaza. Entries of food and medicines into Gaza have been restricted and many essential items for survival are prohibited.3 Before the present assault, medical stock items in Gaza were already at an all time low because of the blockade.3 They have run out now. Likewise, Gaza is unable to export its produce. Agriculture has been severely impaired by the imposition of a buffer zone, and agricultural products cannot be exported due to the blockade. 80% of Gaza's population is dependent on food rations from the UN. Much of Gaza's buildings and infrastructure had been destroyed during Operation Cast Lead, 2008—09, and building materials have been blockaded so that schools, homes, and institutions cannot be properly rebuilt. Factories destroyed by bombardment have rarely been rebuilt adding unemployment to destitution. Despite the difficult conditions, the people of Gaza and their political leaders have recently moved to resolve their conflicts “without arms and harm” through the process of reconciliation between factions, their leadership renouncing titles and positions, so that a unity government can be formed abolishing the divisive factional politics operating since 2007. This reconciliation, although accepted by many in the international community, was rejected by Israel. The present Israeli attacks stop this chance of political unity between Gaza and the West Bank and single out a part of the Palestinian society by destroying the lives of people of Gaza. Under the pretext of eliminating terrorism, Israel is trying to destroy the growing Palestinian unity. Among other lies, it is stated that civilians in Gaza are hostages of Hamas whereas the truth is that the Gaza Strip is sealed by the Israelis and Egyptians. Gaza has been bombed continuously for the past 14 days followed now by invasion on land by tanks and thousands of Israeli troops. More than 60 000 civilians from Northern Gaza were ordered to leave their homes. These internally displaced people have nowhere to go since Central and Southern Gaza are also subjected to heavy artillery bombardment. The whole of Gaza is under attack. The only shelters in Gaza are the schools of the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), uncertain shelters already targeted during Cast Lead, killing many. According to Gaza Ministry of Health and UN Office for the Coordination of Humanitarian Affairs (OCHA),1 as of July 21, 149 of the 558 killed in Gaza and 1100 of the 3504 wounded are children. Those buried under the rubble are not counted yet. As we write, the BBC reports of the bombing of another hospital, hitting the intensive care unit and operating theatres, with deaths of patients and staff. There are now fears for the main hospital Al Shifa. Moreover, most people are psychologically traumatised in Gaza. Anyone older than 6 years has already lived through their third military assault by Israel. The massacre in Gaza spares no one, and includes the disabled and sick in hospitals, children playing on the beach or on the roof top, with a large majority of non-combatants. Hospitals, clinics, ambulances, mosques, schools, and press buildings have all been attacked, with thousands of private homes bombed, clearly directing fire to target whole families killing them within their homes, depriving families of their homes by chasing them out a few minutes before destruction. An entire area was destroyed on July 20, leaving thousands of displaced people homeless, beside wounding hundreds and killing at least 70—this is way beyond the purpose of finding tunnels. None of these are military objectives. These attacks aim to terrorise, wound the soul and the body of the people, and make their life impossible in the future, as well as also demolishing their homes and prohibiting the means to rebuild. Weaponry known to cause long-term damages on health of the whole population are used; particularly non fragmentation weaponry and hard-head bombs.4, 5 We witnessed targeted weaponry used indiscriminately and on children and we constantly see that so-called intelligent weapons fail to be precise, unless they are deliberately used to destroy innocent lives. We denounce the myth propagated by Israel that the aggression is done caring about saving civilian lives and children's wellbeing. Israel's behaviour has insulted our humanity, intelligence, and dignity as well as our professional ethics and efforts. Even those of us who want to go and help are unable to reach Gaza due to the blockade. This “defensive aggression” of unlimited duration, extent, and intensity must be stopped. Additionally, should the use of gas be further confirmed, this is unequivocally a war crime for which, before anything else, high sanctions will have to be taken immediately on Israel with cessation of any trade and collaborative agreements with Europe. As we write, other massacres and threats to the medical personnel in emergency services and denial of entry for international humanitarian convoys are reported.6 We as scientists and doctors cannot keep silent while this crime against humanity continues. We urge readers not to be silent too. Gaza trapped under siege, is being killed by one of the world's largest and most sophisticated modern military machines. The land is poisoned by weapon debris, with consequences for future generations. If those of us capable of speaking up fail to do so and take a stand against this war crime, we are also complicit in the destruction of the lives and homes of 1·8 million people in Gaza. We register with dismay that only 5% of our Israeli academic colleagues signed an appeal to their government to stop the military operation against Gaza. We are tempted to conclude that with the exception of this 5%, the rest of the Israeli academics are complicit in the massacre and destruction of Gaza. We also see the complicity of our countries in Europe and North America in this massacre and the impotence once again of the international institutions and organisations to stop this massacre. For the Open Letter to Israel Academics see http://haimbresheeth.com/gaza/an-open-letter-to-israel-academics-july-13th-2014 We declare no competing interests. Supplementary Material Supplementary appendix Open file PDF (62K) References 1 United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Occupied Palestinian Territory: Gaza emergency situation report (as of 21 July 2014, 1500 hrs). http://www.ochaopt.org/documents/ocha_opt_sitrep_22_07_2014.pdf. (accessed July 22, 2014). 2 Webb-Pullman J. Dignity or death—we cannot give up now. http://gaza.scoop.ps/2014/07/dignity-or-death-we-cannot-give-up-now/. (accessed July 22, 2014). 3 Gilbert M. Brief report to UNRWA: The Gaza Health Sector as of June 2014. http://www.unrwa.org/sites/default/files/final_report_-_gaza_health_sector_june-july_2014_-_mads_gilbert_2.pdf. (accessed July 22, 2014). 4 Naim A, Al Dalies H, El Balawi M, et al. Birth defects in Gaza: prevalence, types, familiarity and correlation with environmental factors. Int J Environ Res Public Health 2012; 9: 1732-1747. PubMed 5 Manduca P, Naim A, Signoriello S. Specific association of teratogen and toxicant metals in hair of newborns with congenital birth defects or developmentally premature birth in a cohort of couples with documented parental exposure to military attacks: observational study at Al Shifa Hospital, Gaza, Palestine. Int J Environ Res Public Health 2014; 11: 5208-5223. PubMed 6 Ma'an News Agency. 4 killed, over 50 injured as Israel targets al-Aqsa hospital. http://www.maannews.net/eng/ViewDetails.aspx?ID=715087. (accessed July 22, 2014). a New Weapons Research Group and University of Genoa, Genoa, Italy b James Lind Library, Oxford, UK c Institute of Psychiatry, King's College, London, UK d Clinic of Emergency Medicine, University Hospital of North Norway, Tromso, Norway e Barts and the Royal London Hospital, London, UK

  • thank you

    16

    good job because very important report..... now am can starting for help .....ABO GHAITH ,USA.NY.

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