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The Israeli imposed closure

The Effect of Closure on Health Care in the West Bank and Gaza Strip

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Following the outbreak of the Al-Aqsa Intifada in September 2000, Israel imposed a comprehensive closure on the Occupied Palestinian Territories, denying Palestinians residing in the West Bank and Gaza Strip the right to enter occupied East Jerusalem and Israel. Israel also imposed an internal closure impeding movement within the West Bank and Gaza Strip.

Restriction on freedom of movement is part of daily life for the population of the Occupied Territories. Restrictions are imposed by the Occupying army under the guise of Israeli security, and take various forms: checkpoints in the middle of the road, submitting people and their property to strict controls and humiliations, heaps of earth blocking access to roads, trenches encircling villages, curfews of variable duration and “military zones” to which all access is forbidden.

The internal closure enforced through the placement of at least 482
1 permanent military checkpoints, supplemented by an increasing number of randomly erected temporary road blocks and physical barriers, divide the West Bank into 300 clusters, the Gaza strip into 4. These divides have created a series of enclaves reminiscent of South African Bantustans only smaller and in several cases overpopulated. In the West Bank alone, OCHA has counted 734 2 barriers blocking Palestinian roads and towns and severely restricting movement to 2.3 million Palestinian, subdivided as follows 3 :

• 73 manned checkpoints
• 58 ditches blocking vehicular access
• 95 concrete blocks
• 34 road gates
• 33 wall gates for Palestinian
• 464 earth mounds blocking vehicular access

The establishment of these many obstructions enables the Israeli army to completely control and restrict the movement of people, their access to health facilities and the transport of goods and services within the West Bank and Gaza Strip. The effect of such closure on the provision of regular health care services and emergency medical aid has been devastating. Though the beginning of 2003 was marked by a progressive lifting of the curfews and a very gradual opening of certain villages in the West Bank in fact the violence, and occurrence of military incursions, has increased.

On 30 April 2003, the so called US sponsored “Road Map” to peace was established, with the declared purpose of a peaceful settlement of the Israeli-Palestinian conflict, an end of occupation of the Territories and the constitution of an independent Palestinian state by 2005. In parallel with this, since the beginning of the Second Intifada, the humanitarian situation in the Palestinian Territories has become more precarious and continues to deteriorate.

A concrete wall or Israeli termed “security fence” [25ft in height and 30-100m wide, encompassing trenches, barbed wire, electrified fencing, watch towers, electronic sensors, thermal imaging and video cameras, unmanned aerial vehicles, sniper towers, and roads for patrol vehicles], is rapidly being constructed through the West Bank. Started in June 2002, it is planned for completion by the end of the year. In many places this wall penetrates many kilometers into Palestinian Territories, placing further serious limits on the freedom of movement of the civilian population. Currently the wall carves off about 123,000 dunums
4 of land from the Palestinian side of the Green Line. This land amounts to about 2% of the West Bank, and contains at least 16 Palestinian villages and 12,000 residents, according to Israeli and Palestinian human rights groups and the World Bank. This number will rise to 395,000 if all sections of the wall are completed – 17.8% of the Palestinian population 5. The evidence strongly suggests that Israel is determined to create facts on the ground amounting to de facto annexation. Annexation of this kind, known as conquest in international law, is prohibited by the Charter of the UN and the Fourth Geneva Convention.

The wall is rapidly redrawing the socio political geography of the West Bank. Within their steadily shrinking increasingly fragmented space the local Palestinian population is experiencing an unraveling of economic and social networks, with health provision being among the most critical 6 . It goes without saying that the risk this wall poses of aggravating the humanitarian situation within the occupied territories is very real.

Medical Care: Access Denied: Road blockades have directly prevented patients in need from receiving emergency medical care

• More than 991 incidents of denial of access to Palestinian Red Crescent Society (PRCS) and Union of Palestinian Medical Relief Committees’ (UPMRC) ambulances have been reported 7 . UPMRC reports that during the Israeli invasion of spring 2002, their ambulances were stopped on average, three times per day. Since April 2002, mobile clinics have been regularly obstructed by total closures of all access roads; with medical staff forced to carry equipment over checkpoints, posing risks to both personnel and equipment.

• Between 1 September and 15 October 2003 OCHA reported:
22 cases of ambulances delayed from 1hr to 4 hr
21 cases of denial of access
4 cases of verbal/physical abuse on medical crew
4 cases of shooting at the ambulances

• On 6 November 2003, PRCS’ Health Incidents Reported 3 cases of denial of access: two in Khan Younis, and the third in Nablus where IDF soldiers stopped a PRCS ambulance reaching a patient in critical condition. The soldiers ordered the crew out of the ambulance and searched it. They detained the ambulance for 30 minutes denying access to the patient. A second attempt to access the injured person succeeded. However, by the time the ambulance reached the hospital, the woman patient was pronounced dead.

• Medical personnel often face serious difficulties in reaching workplaces: non-attendance at rural clinics due to closure has been reported at 35-40% in some cases
8. In 2003, this continued to be the primary reason for health service suspension 9 .

• PRCS reports severe understaffing both in Emergency Medical Service stations and in Primary Health Care clinics
10 . The United Nations Relief Works Agency (UNRWA) has hired 100 new staff members, and reports an increase of 6000 hours of extra work to help NGOs experiencing extreme difficulties in getting to work.

• General restrictions on movement, curfews and damage to the health sector have led to acute blood shortages in hospitals.

• Medical staff’s inability to access patients has affected implementation of Ministry of Health and UNRWA vaccination programs. The unavailability of vaccination programs in some isolated communities, and delays in delivery of programs, will increase the risk of preventable disease such as Hepatitis B. The Ministry of Health normally carries out vaccinations for Hepatitis B at birth, yet it is clear that in several areas, particularly those now isolated by the wall, a significant number of mothers will not have access to such services

Attacks on medical services

Attacks on those attempting the provision of medical services are frequent in the Palestinian Territories. Attacks have been reported on medical personnel, establishments and health related vehicles. During the 2002 Israeli invasion, the UPMRC reported daily attacks, detentions and humiliation of their staff; on several occasions medical staffs were forced to strip and lay on the ground, others endured severe beatings. Other such incidents have continued on a regular basis:

• On Wednesday, January 28, 2004 Israeli forces withdrew from al-Zaitoun south of Gaza City leaving eight dead. One of the casualties was a medic, killed when the ambulance he was in, transferring injured to hospital, was hit by Israeli fire

• On 11 January 2004, a PRCS medic was beaten, detained and threatened with fatal harm by Israeli soldiers during a routine transfer of patients from Nablus to Ramallah Hospital. The ambulance was carrying a child with a cardiac condition and a disabled person suffering leg injuries

• On September 9 2003, in Nablus, Israeli soldiers stopped a Palestinian Medical Relief ambulance on its way to Salem village. They used it, and the first aid volunteers it was transporting, as a human shield. Standing behind the ambulance, they opened fire on Palestinians. When the ambulance driver protested, they viciously attacked him. The ambulance and staff were only released after much negotiation from Israeli Physicians for Human Rights. Earlier on the same day, Israeli soldiers detained a patient and driver of an ambulance for four hours

According to article 18 of the 4th Geneva Convention, civilian hospitals must be respected and protected. Under the principle established by this article, not only must hospital facilities not be the target of military attacks, but the belligerents have the general obligation to do everything possible to protect them from any attack.

• On 2 March 2003, the Nasser hospital at Khan Younis was targeted during a military operation. This was one of fifteen such attacks since the beginning of the second Intifada. On each occasion, patients, visitors and medical personnel have been wounded by firing which has penetrated inside the hospital.

• Since the spread of the current Intifada at least 290 hospitals and clinics have been attacked and damaged.

Between the 29th of September 2000 and the 14th of October 2003, the Israeli occupying forces carried out the following attacks on Palestinian medical services:

• 121 ambulances were attacked and damaged 36 ambulances were damaged beyond repair
• 991 cases of ambulances being denied access to the injured

• 25 medical personnel were killed by Israeli soldiers

• 425 medical personnel were injured

• 71 emergency personnel were arrested

• 290 counts of hospitals and clinics attacked & damaged

Palestinian civilians denied access to health care facilities

o Restriction of passage through checkpoints has prevented Palestinians requiring medical treatment from accessing health care services. Over 70% of the Palestinian population lives in rural areas that cannot provide hospital services; closure therefore severely restricts the majority of the population from secondary and tertiary health care facilities.

o More than 83 deaths have occurred due to prevention of access to emergency health care or treatment of chronic diseases, 27 of these were children, 19 newborns. The victims were not involved in clashes. During the last Israeli invasion, Palestinian ambulances were repeatedly denied access to the sick and wounded and in many cases the injured were left to bleed to death. In other instances, those requiring treatment (for example for cancer or kidney failure), suffered extreme hardship when they were prevented from leaving their villages to receive treatment.

o In the last three years there have been numerous cases of Palestinian women in labor delayed at checkpoints or refused permission to reach medical facilities resulting in 52 women giving birth at checkpoints. Since the beginning of the Intifada a 29% increase in home deliveries in the West Bank has been recorded.

o At least 90 Palestinians requiring medical treatment abroad have been prevented from leaving the country.

o Hospitals report a decline in access to services, for example St Luke’s hospital in Nablus reports a 49% decline in GP patients, a 73% decline in specialty services, and a 53% decline in surgery. The only ophthalmic hospital in the West Bank is in Jerusalem; closure has therefore prevented West Bank inhabitants from accessing this specialized service.

o The Ministry of Health also reports a 60% decline in implementation of school health programs.

Blockade on raw materials

The Israeli blockade on goods entering the Occupied Palestinian Territories has further serious ramifications for Palestinian health services
15 .

o The Israeli Ministry of Defense banned imports of raw materials required by pharmaceutical companies, and on 4 June 2001 pharmaceutical companies reported a supply of less than one month’s raw materials required for production of medicines

o Health providers have faced great difficulties in the distribution of medical supplies to Palestinian towns and villages.

o In November 2003 Medicins du Monde reported that UNFPA delivery kits had been held up at Tel Aviv customs since April, and were unable to reach the West Bank. The branch of the Palestinian Ministry of Health in Nablus has been waiting for delivery kits since February 2003, during which time they have been delayed.

o Medical aid is consistently detained by Israeli border control in both Jordan and Egypt.

Israeli restrictions have closed the pharmaceutical market to international competition therefore the prices paid by the Palestinian Ministry of Health are considerably expensive. The delay of drug deliveries from suppliers and the lack of contact between MoH in Gaza and the MoH in the West Bank, due to movement restrictions have a direct impact on drug procurement. Towards the end of 2002 MoH reported that its facilities were operating at about 30% of their capacity.

Health providers are consistently facing great difficulties with distribution; in the last months the situation has become critical in the villages of the North-western part of the West Bank (Tulkarm, Qalqilya, and Jenin) due to the construction of the Separation Wall.

The impact of the Israeli Apartheid Wall is having disastrous affects upon both the health and social status of Palestinian communities and damaging the entire structure of the Palestinian Health Care System. By cutting deep into the West Bank, encircling Palestinian communities and severing infrastructure connecting them to public services, including water and sanitary networks as well as regional and national health care facilities, the Wall is simultaneously sundering as well as foisting a greater burden on a health care system already operating under considerable strain.

For more information on the Wall and its impact on health please see:

Health and Segregation: The impact of the Israeli Separation Wall on access to health care services (Report issued by The Health, Development, Information and Policy Institute - HDIP)

The Palestinian Economy and Welfare

The second year of the Intifada witnessed a steep decline in all Palestinian economic indicators, a decline that threatens to hopelessly accentuate as the Apartheid Wall is completed.

“The proximate cause of the Palestinian economic crisis is closure, i.e. restrictions imposed by GOI on the movement of Palestinian goods and people across borders and within the West Bank.
19” “More people unable to reach their land to harvest crops graze animals or to reach work to earn money to buy food, will be hungry. The damage caused by the destruction of land and property for the Wall’s construction is irreversible and undermines Palestinian’s ability to ever recover even if the political situation allows conditions to improve.20

The economic crisis has seriously compromised household welfare;o Many families have endured long periods without work or income and many now depend on food aid for daily survival.
o With 13% growth in the population of the West Bank and Gaza over the past three years, real per capita incomes are now 46% lower than in 1999, and poverty, defined as those living for less than US$ 2.1 dollar per day, afflicts approximately 60% of the population (in 1999 they were 21% of the population).

o Regionally, the poor now exceed 75% of the population in the Gaza strip, as compared with 50% in the West Bank. In addiction, poverty has increased in some communities in the northwest of the West Bank, which are being isolated or cut off from the rest of the West Bank by the ongoing construction of Israel’s “Security Wall”.

The health status of the Palestinian population has deteriorated markedly.

• Real per capita food consumption has dropped by up to a quarter compared to 1998 levels.

• UNRWA estimates that 1.7 million people, over half the population of the West Bank and Gaza, are in receipt of food aid.

• The International Committee of the Red Cross (ICRC) is ending its emergency food program in the West Bank, saying the economic collapse there is the direct result of Israeli military closures and that Israel must live up to its responsibility as the occupying power for the economic needs of the Palestinians

• A recent survey found global acute malnutrition (GAM) protein-calorie malnutrition in 9.3% of children across the West Bank and Gaza

• According to HMIS
23 :
9.6% of total births were low birth weight (under 2500)
9% prevalence of stunting children <5 years
2.5% prevalence of wasting children
6.2% of population didn’t have access to safe drinking water
54.2% of population in Palestine is not connected to sewer networks

• As half the Palestinian population has no medical insurance, many Palestinians are now unable to afford medical care.

Concluding remarks

“After more than three years of Intifada, the impact of the occupation and of the closure of Gaza and the West Bank on the health of the Palestinian population is alarming.
24” In the context of general medicine, disaster medicine and surgical programmes in the Occupied Territories, Medicins du Monde has noted in the last few years significant increases in the numbers not only of victims of war injuries but also patients whose state of health has been seriously affected by an absence of, or delay in, receiving treatment: deterioration of a chronic illness for lack of medicines, complications during delivery because it is impossible to reach hospital facilities.

In addition, there has been a general deterioration in the state of the health of patients received in medical centers. This is related to the limit of access to health care.

In the psychological field, most adults and children present clinical symptoms of suffering associated with psychological trauma and stress, namely anxiety, nervous breakdown, enuresis, sleeping difficulties, concentration and behavioral problems, etc.

Palestinian children are growing up with permanent feelings of insecurity, helplessness, persecution and isolation. Research carried out by Save the Children – US and Sweden, with the Palestinian NGO - Secretariat for the National Plan of Action for Palestinian Children found that:

93% of children feel unsafe or exposed to attack
48% have personally experienced Intifada related violence or witnessed an incident affecting a family member
52% feel their parents cannot protect them

Siege, the Medical Services and International Law

The international Humanitarian Law applicable in this context is contained in the Fourth Geneva Convention of 12 August 1949, relating to the protection of the civilian population in time of war, to which the State of Israel has been part since 6 July 1951, and in customary international law.

The General Assembly of the United Nations has asked, in numerous resolutions 26 , for the full application of this Convention by Israel in the Territories. The subject of these legal provisions is the protection of civilian population, in this case the population of the Occupied Territories, against the arbitrary actions of the occupying state. Specifically the articles applicable to the question of access to health care and protection of the health-related services are as follows:

• Articles 3, 13,16,17,18, 20, 21, 22, 23, 27, 33, 55, 56 and 59 of CG4th

• Articles 48, 50, 51, 52, 54, 56 and 75 of additional Protocol 1 OF 1977

(1) The Health, Development, Information and Policy Institute (HDIP)
(2) OCHA Report December 2003
(3) OCHA UPDATE 16-31 October 2003
(4) One dunum = 1,000 square meters = ¼ acre
(5) Palestine Monitoring Group Trend Analysis, Israeli Separation Wall (6) Activity Update December 10, 2003
(6) Health and Segregation: The impact of the Israeli Separation Wall on access to health care services (Report issued by The Health, Development, Information and Policy Institute (HDIP))
(7) Palestinian Red Crescent Society (PRCS), September 2003 and Union of  Palestinian Medical Relief Committees (UPMRC) sources,
(8) Al-Ayam newspaper report, 12 March 2001
(9) HSBR, yearly report May 2002-May2003, n.13 22 June 2003
(10) Palestinian Red Crescent Society, 20 June 2001
(11) Health and Segregation: The impact of the Israeli Separation Wall on access to health care services (Report issued by The Health, Development, Information and Policy Institute (HDIP))
(12) Palestine Monitor Update, January 28, 2004
(13) PRCS Medic Beaten and Detained by Israeli Soldiers Press Release January 15, 2004
(14) URGENT ALERT Palestinian Medical Relief Ambulance Attacked by the Israeli Occupying Forces
September 10, 2003
(15) The health situation in Palestine is “deteriorating as a result of the escalation of the conflict, compounded by further border closure and curfews throughout the West Bank and Gaza strip since March 2002. There have been explicit restrictions on population movements, which hinder the delivery of health care services” by the Director-General of WHO, statement WHO/04, September 27, 2002.
(16) The Palestine Monitor ‘Appeals’
(17) “Access to health care and protection of the medical services in the Occupied and Autonomous Palestinian Territories”, Medicins du Monde, November 2003
(18) Dr Mustafa Barghouthi Health and Segregation: The impact of the Israeli Separation Wall on access to health care services (Report issued by The Health, Development, Information and Policy Institute (HDIP))
(19) Taken from “Twenty-seven months – Intifada, Closures and Palestinian Economic Crisis- an Assessment” issued by World Bank, May 2003. The data following are taken from the same assessment too.
(20) OCHA, “New Wall Projections”, 23 October 2003
(21) Independent, 16 November 2003, by Justin Huggler in Jerusalem
(22) “Nutritional Assessment of the West Bank and Gaza Strip” by John Hopkins University/ Al Quds University, September 2002.
(23) HMIS’ Health indicators 2002
(24) “Access to health care and protection of the medical services in the Occupied and Autonomous Palestinian Territories”, Medicins du Monde, November 2003
(25) International custom and practice is a general and repeated practice which is accepted as law (see article 38 of the statute of the International Court of Justice). It is recognized as a legitimate by all States, and applies to everyone. Failure to comply with it is a violation of international law.
(26) A/RES/53/54, 3 December 1998; A/RES/54/77, 6 December 1999; A/RES/55/131, 8 December 2000; A/RES/56/60, 10 December 2001, among others.

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