In the Palestinian territories, refractive error is the main cause of avoidable blindness, according to new research by the St John of Jerusalem Eye Hospital Group, which has not yet been published. Photo by: St John of Jerusalem Eye Hospital Group

BARCELONA — Ongoing violence and limitations to movement in the Palestinian territories pose a threat to the health and well-being of people living within them. Vision issues are particularly exacerbated by the circumstances, according to Dr. Ahmad Ma'ali, CEO of St John of Jerusalem Eye Hospital Group.

Globally, at least 1 billion people — out of the 2.2 billion who have a vision impairment or blindness — have a vision impairment that is avoidable. In the Palestinian territories, refractive error is the main cause of avoidable blindness, according to new research by the St John of Jerusalem Eye Hospital Group — the only charitable provider of expert eye care in Gaza, the West Bank, and East Jerusalem.

Interfamily marriages, which account for 45% of marriages in the Palestinian territories, are likely to blame for the high prevalence of retinal issues such as retinitis pigmentosa, or night blindness, as well as congenital cataracts and glaucoma, according to Ma'ali.

He called interfamily marriage, or consanguinity, and its impact on vision a developmental issue requiring resources at the global level given its prominence in lower-income, conflict-affected areas.

“This is something that needs to be addressed in third world countries and most, if not all, third world countries would benefit from awareness activities,” said Ma'ali.

Although there are cultural, economic, and social reasons as to why consanguinity is so common, Ma’ali said that, for many, Gaza is “a prison” that prevents people from traveling and limits their means of meeting other people. “The likelihood of a man or woman meeting someone outside their family is very limited due to the conservative regimes we have mainly in Gaza,” he said.

A permit is needed to leave or enter the Palestinian territories. According to the World Health Organization, in July 2019, the approval rate for travel permits for Gazan patients to access medical care outside the territories was 71% — 9% were denied and 20% were delayed.

While the 81 hospitals in the Palestinian territories could offer care, the U.N. Relief and Works Agency reports that facilities are overstretched and power cuts often jeopardize the quality of care.

The health care system in the Palestinian territories is impeded by the abnormal living circumstances under military occupation, said Henrik Bronnum-Hansen, who has studied illness in the territories for many years and is an associate professor at the University of Copenhagen’s department for public health.

“Thus, because it is almost impossible to establish a coherent and efficient health care system in [the Palestinian territories], prevention, disease detection, and treatment does not work properly,” he said in an email.

How to tackle poor vision in the Palestinian territories

Bronnum-Hansen said the best way to reduce the number of congenital vision problems in the Palestinian territories would be a political situation that allowed for increased free movement, reduced interfamily relations, and improved health care facilities.

Ma'ali said for now, the best course of action is to generate awareness of the issue, especially among adolescents.

“Education within the society about the problems that might arise from such a marriage, awareness, and public campaigns are something the authority needs to undertake,” he said. “You don’t need to spend a lot of money on these kinds of awareness sessions because it can be a pamphlet, radio chat, or ad.”

St John of Jerusalem Eye Hospital Group, which runs ophthalmic hospitals and community outreach programs in the West Bank and Gaza, has organized a number of activities aimed at discouraging consanguinity. It runs education campaigns that focus on the disadvantages and explains the link to vision issues.

A recent social media post aimed at educating the Palestinian population on the genetic issues from consanguinity said: "For your own good and for your children, keep away from the marriage of relatives!" In the West Bank, mobile teams also screen people and provide health education about all eye diseases including the effect of first-cousin marriages on eye health, while in Gaza the clinic does the same.

“Once you have them on your side, they will buy your message and be your ambassadors. Nobody wants to have children who have devastating and blinding eye diseases,” Ma'ali said.

Targeting youth to get the message across  

Dr. Ala Al'Talbishi, a geneticist at the Retinal Dystrophy Clinic at St John Eye Hospital in East Jerusalem and lead of the Peace For Sight project, which examines hereditary retinal disease, said that it is important to use social media to educate young people on the effects of interfamily marriages as well as distribute information via school visits.

“We believe that the importance of this project is to help our people get the genetic diagnosis and decrease the number of cases through prevention,” said Al'Talbish. Staff take blood samples, identify defective genes, and provide counseling about future offspring to couples.

“Once I diagnose a family with a genetic disease and I know what’s causing it, I can tell them what this mutation or gene is and when they want to have another child or one of them wants to get married to their relative, they can get checked.”

More action is needed at the government level, said Ma’ali, explaining that despite efforts, there’s been little improvement in reducing the prevalence of retinal diseases. While the Palestinian government does require couples to undergo certain examinations before they marry,  Al'Talbish urged the government to require that “future parents” are given advice on the possibility of malformations as a result of consanguinity.

Since the government doesn’t have resources to do this, Ma’ali said it was up to the international development community to invest more resources into low-income and Middle Eastern countries, in particular, to boost awareness of the issues related to interfamily marriage and reduce the number of people with vision problems.

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    Rebecca Root

    Rebecca Root is a Reporter and Editorial Associate at Devex producing news stories, video, and podcasts as well as partnership content. She has a background in finance, travel, and global development journalism and has written for a variety of publications while living and working in New York, London, and Barcelona.