A/HRC/23/21 21. The gravity of the situation was dramatized recently by confrontations between Gazans and UNRWA as a result of food shortfalls. 10 The United Nations projection of the collapse of Gaza as a viable entity by 2020 was confirmed by representatives of nongovernmental organizations, who even suggested that such a projection was optimistic, especially in relation to water quality and availability, and that 2016 was more realistic. Present conditions are threatening to unleash a health epidemic. There are reports of widespread mental difficulties being experienced by virtually the entire juvenile population. UNRWA felt that it would be only possible to improve the overall situation in Gaza if its annual budget were increased by $200 million to $300 million, which seems unlikely at present. The non-governmental organization Action against Hunger has noted that any prospect for agricultural sufficiency and livelihood capacity will depend on Gaza reclaiming at least 50 per cent of the coastal aquifer. C. Health in Gaza 22. The Special Rapporteur met with health experts associated with the World Health Organization, the United Nations Children’s Fund (UNICEF) and the Gaza Community Mental Health Programme. They presented a grim picture of the health situation in Gaza. One unexpected finding was their shared assessment that the health effects of Operation “Pillar of Defense” were more severe than those that followed from Operation “Cast Lead”, despite fewer casualties. An increased perception of deliberate targeting of neighbourhoods and agricultural settings, more fear arising from recollections of past violence, and greater sensitivity to extreme vulnerability were cited. Mental health experts referred to the extent to which each major violent incursion in Gaza destroys whatever progress had been achieved in recent years and causes a net depressive mood and reality summarized by the word often encountered in such briefings: “de-development”. 23. With regard to medical care, there were reports of an increase in referrals for treatment in Israel and Egypt (for instance, 8,000 in 2007, up from 16,000 in 2011) for persons suffering from cancer and cardiac conditions, as well as other diseases that could not be treated in Gaza. The increase was explained as partly caused by the deterioration of medical equipment in Gaza, the inability to import spare parts and the failure to invest in advanced medical facilities. Despite these shortcomings, health specialists did report some improvement in the overall medical situation following the Mavi Marmara incident in 2010, when it became easier to receive travel permits (95 per cent of requests were approved, although often with harmful delays) and to import certain medical equipment. The Special Rapporteur received reports of tragic deaths caused by delays in issuance or denial of travel permits for those needing urgent treatment. 24. During Operation “Pillar of Defense”, public health facilities were severely strained and the population came to depend on the assistance of non-governmental organizations, amidst reports of a high incidence of physical and mental injuries. Workers at the Gaza Community Mental Health Programme emphasized the degree to which the impact of the siege and wartime violence on the mental well-being of the civilian population had been both adverse and cumulative. They spoke of the high level of stress observed in most Gazans, with secondary symptoms of despair, hopelessness and powerlessness, and somatic complaints originating with acute stress, such as high blood pressure among children. There were suggestions that the stress and economic challenges of sustaining livelihoods seemed connected with a rise in domestic violence, post-traumatic stress and indications that, for 10 Mohammed Omer, “Anger at UNRWA in Gaza grows”, Al Jazeera, 1 May 2013. Available from www.aljazeera.com/humanrights/2013/04/20134294185559594.html. 11