Memorandum submitted by Merlin
THE IMPACT OF THE ISRAELI OCCUPATION OF PALESTINE
AND THE CURRENT INTIFADA ON ACCESS TO HEALTH CARE BY THE PALESTINIAN
POPULATION OF THE WEST BANK
The second Palestinian Intifada is now in its
fourth year and the Israeli-Palestinian conflict seems perhaps
far away from resolution. The cycle of violence since the start
of the Intifada between Israelis and Palestinians has led to 355
Israelis killed by Palestinians and 2,171 Palestinians killed
by Israeli security forces.
The humanitarian consequences of the current situation can be
seen in every sphere of Palestinian life. A UN mission to the
Occupied Palestinian Territories (OPT) led by Ms Catherine Bertini
(UN-Secretary General's personal envoy) in August 2002 concluded
that this is a "serious humanitarian crisis". The crisis
is "inextricably linked to the ongoing conflict and particularly
to the measures imposed by Israel in response to suicide and other
attacks against Israeli military and civilian targets". Furthermore,
the report went on to say, "the situation is a crisis of
access and mobility".
In the northern West Bank alone there are currently
approximately 388 roadblocks, 48 of which are manned checkpoints
and the rest roadblocks, earth mounds, ditches and gates.
The Israeli government imposes regular closures and curfews over
either the whole of the West Bank or particular towns or villages
which restrict movement between different areas of the West Bank
and/or preventing Palestinians from leaving their homes. The Separation
Barrier is being built deep inside the Green Line cutting of West
Bank residents from their work, lands, water, schools, health
and social services.
In addition to these more recent measures, the
West Bank now has over 120 Israeli settlements which house over
The settlements are linked by a network of roads which by-pass
Palestinian-populated areas, consume Palestinian land and cut
Palestinian populated areas from neighbouring villages and major
urban centres. This combination of factors severely restricts
the ability of Palestinian citizens to move around, get to work,
visit their families and access health care.
Merlin has been working through national health
partners in the West Bank since October 2002. Projects focus on
maintaining access to primary and preventative health care services,
mother and child health screening and training of health care
professionals and local communities in emergency medicine. The
points below illustrate some of the main issues relating to health
in the OPT under the current situation.
2. SAFETY AND
Although not statistically significant in terms
of mortality rates within the OPT, of serious concern is the level
of Palestinian civilian casualties resulting from the occupation.
As stated above, 2,171 Palestinians have been killed by Israeli
security forces (as at October 2003); of these 410 were minors.
B'Tselem reports that "the IDF itself admitted in March 2003,
that according to its statistics, 235 Palestinians were killed
who were not participating in fighting." Many Palestinians
have been killed during curfew enforcements, at checkpoints or
at demonstrations, rather than during military hostilities. The
impact of civilian deaths has socio-economic consequences for
the entire population. Given family size, structure (extended
family) and high fertility rate, the loss of a main wage earner
can have a negative economic effect on a large number of people.
According the Save the Children Fund UK, the current levels of
violence is putting significant psychological strain on Palestinian
"One out of every six children interviewed by SCF reported
that they had been physically injured during the last two years;
one out of five children having reported having a family member
who was injured/disabled and almost one in 10 children reported
losing a family member from the immediate or extended family through
military actions, bombing attacks or assassination attempts."
3. ACCESS TO
The difficulties experienced by Palestinians
trying to travel around the West Bank cannot be overstated. Aside
from the economic and social impact of this situation in terms
of people trying to reach their work place or visit family, it
has a severe impact on the accessing of health care services.
In August 2003 WHO
reported that a household survey conducted late in 2002 on access
to health services revealed that more than 50% of the respondents
had to change health facility. In approximately 90% of these cases
this change was due to restrictions of access.
A recent assessment by Merlin of Imateen village
in western Nablus District shows this clearly. The entrance to
the village had been blocked in two places with rocks and earth
mounds. By 11 July 2003, these had been removed and replaced by
Israeli Defence Forces (IDF) soldiers with military vehicles.
No-one was being allowed out of the village. It can currently
take one day to reach Nablus, the closest city and main referral
point, which is approximately 12 km away. Hajia, a village 3 km
away has a Red Crescent clinic in the evenings, but it now takes
more than 1½ hours to reach Hajia by bus. Villages reported
to Merlin that one woman had given birth at the checkpoint and
a nine-year-old boy had died at the checkpoint. Villagers have
also come under attack from settlers.
In terms of reaching emergency health care Palestinian
Ministry of Health (MoH) statistics show that between 29 September
2000 and 30 July 2003, 94 patients have died at checkpoints, 52
women have given birth at checkpoints resulting in 29 newborn
deaths. On 29 August 2003, a woman from Salem, a small village
near Nablus, gave birth at Beit Foureek check-point after Israeli
soldiers had made her wait for 1 hour 15 minutes. She was helped
to deliver by her husband, but the new born baby died after the
umbilical cord was cut using two stones. Once the baby was dead,
the woman and her husband were allowed to pass through the checkpoint
to reach the hospital.
This situation affects not only emergency health
services but access to preventative, chronic and specialized health
care. Merlin's primary health care clinics located in rural villages
(Summer 2003) have reported frequent attendance at clinics of
patients requiring repeat prescriptions of medication for chronic
illness that they are unable to fill due to their restricted access
to health specialists and specialist health facilities in urban
centres. These patients suffer from a range of conditions including
psychiatric, hypertension, and diabetes. In some instances the
doctor is able to prescribe an alternative drug which although
confusing for the patients means that their condition is controlled
and there is a continuation in their treatment. In many cases
however, the clinics do not have access to the medication required
and the patient is left without treatment.
According to the Palestinian MoH between 29
September 2000 and 30 July 2003, 25 health workers have been killed
and 424 injured. Testimony from one of Merlin's partners, the
Union of Health Care Committees (UHCC), of incursions on Nablus
City on 21 August 2003 stating that seven staff members were physically
abused by Israeli soldiers demonstrate the risks run by health
care professionals and paramedics in the course of the work. The
Palestinian Red Crescent Society (PRCS) regularly reports verbal
and physical abuse of staff by Israeli soldiers.
There have also been specific instances of health
facilities being targeted. For example:
(a) On the night of 23 August 2003, the Health
Work Committees (HWC) (a Merlin partner) clinic in the old city
of Nablus which serves over 50,000 people annually was raided
by the IDF. Explosives used to open doors caused severe damage
to the rooms and equipment and according to HWC seven rooms were
almost completely destroyed including the entrance railing and
roof, all the windows, furniture in all rooms, water and electrical
networks and the isolation walls and ceiling. Medical equipment
with an estimated value of US$200,000 was damaged.
(b) On Wednesday, 24 September 2003, Israeli
troops entered an United Nations Relief and Works Agency (UNRWA)
run hospital in Qalqilya and forced medical staff to leave their
patients and duties and lie on the floor. Israeli soldiers searched
the hospital room by room, doors were kicked in by the troops,
locked doors were shot open and a number of windows were broken.
Troops prevented the hospital Director and other staff from contacting
UNRWA's field headquarters. Medical staff was unable to care for
their patients in the hospital during the Israeli army's presence
in the building. The intrusion of the soldiers into all areas
of the hospital, including the surgical theatre, carried the serious
risk of cross-contamination of sterile areas. It is likely that
key areas of the hospital will be out of operation until they
can be rendered sterile.
This action was clearly contrary to the international Conventions
governing the treatment of the United Nations. It is also a breach
of the Geneva Convention and its protocols, which accord hospitals
special protection during conflicts. Hospitals may not be targets
of military operations under the Convention, and the excuse of
"military necessity" is specifically ruled out.
5. ACCESS BY
Emergency services are delayed and denied access
on a daily basis. Reports from PRCS demonstrate this: between
30 August and 26 September 2003, PRCS reported 11 serious incidents
involving emergency services including one instance over 6 and
7 September in Jabalia, Gaza where ambulances were not permitted
to reach a 17-year old male who had been shot in both legs. Access
was granted after 18 hours by which time the man had bled to death.
In relation to ongoing non-emergency services,
health care professionals are finding it increasingly difficult
to reach their places of work. An interview conducted by Merlin
with the Director of Rafidia MoH Surgical Hospital in Nablus revealed
that in order to maintain services staff has to double-shift as
there are such difficulties in travelling from their homes outside
of Nablus City to the hospital. This takes a personal toll both
on the health practitioners involved and their families' lives,
as well as service provision.
The WHO household survey indicates that immunisation
coverage for OPT remains within acceptable ranges. If the current
although declining trend continues however, there will be an increased
risk of an epidemic. This is supported by the discovery of wild
polio virus in the sewage system, raising the risk of polio re-emerging
in the OPT if the immunization coverage declines further. Additionally,
individual cases and small scale outbreaks of communicable diseases
such as rabies, shigellosis and brucellosis have been reported
by the MoH.
WHO states that, "The general conclusion
that immunization coverage has been sustained is premature."
It is believed that further investigation could reveal pockets
of non-immunized communities due to prolonged closures and curfews,
and even if this population did not have a significant impact
on the overall immunization coverage, it would become of substantial
epidemiological significance if not addressed.
In July 2003, the MoH PHC Director for Qalqilia
reported to Merlin that he was concerned that vaccination programmes
were becoming increasingly difficult to maintain due to the inability
of staff to reach the target communities. He stated that previously
the Israeli authorities had always assisted in ensuring that vaccination
programmes were sustained as because of their potential impact
on Israeli communities as well, "Communicable diseases are
not restricted by walls."
6. THE SEPARATION
The affect of the separation barrier on health
and health services in its vicinity are, as yet, unclear. Principally,
the unanswered questions are, how will the MoH and health NGOs
be able to provide health services to these communities isolated
by the barrier? How will individuals access health care including
in emergency cases? What is clear however is the extent of the
population that will be affected. According to UNRWA phase one
of the barrier, which is now complete will have an impact on approximately
60 towns, villages and refugee camps. Fourteen communities inhabited
by 13,636 Palestinians will be located between the barrier and
the Green Line. Fifteen communities will be caught in enclaves
east of the barrier affecting approximately 138,593 Palestinians.
At least 69,091 Palestinians will be negatively affected through
the loss of land, irrigation networks and infrastructure. In total
220,000 people will be affected.
One stark example of the access difficulties
caused by the barrier can be seen in the two villages of Jabara
and Ras which are south of Tulkarem. Jabara is caught between
the barrier and the Green Line, while in Ras the main body of
the village is on the Palestinian side of the barrier with two
houses isolated on the Israeli side of the barrier. The barrier
has gates to allow children from the two isolated houses to get
to school each day. However, during the Jewish holiday of Yom
Kippur this gate was completely closed for four days. Furthermore,
Israelis have now announced that residents on the Israeli side
of the wall will need permits to get into the West Bank, while
residents on the Palestinian side of the wall need permits to
access their lands on the Israeli side of the wall.
7. IMPACT OF
The ultimate impact of closure and curfews on
the population's health status will be clearly shown thorough
future health indicators. However, specific issues related to
reduced access to health care such as the construction of the
separation barrier, combined with the disruption of water and
waste management systems, limitations on the access to the labour
market and subsequent poverty levels are serious public health
hazards linked to basic human rights and may have far reaching
consequences for both the Palestinian and Israeli populations.
A recent survey by the Palestinian Central Bureau
of Statistics (PCBS) provides evidence of a high incidence of
micronutrient deficiency throughout Gaza and the West Bank. According
to nutritional surveys conducted by John Hopkins, CARE and Al
Quds University (June 2002), every second mother and every fifth
child under 5-years of age is suffering from mild anaemia, caused
by iron deficiency. The prevalence of iodine deficiency is 14.9%
in children under 15-years of age, thus three times higher than
the level at which WHO recommends salt iodination. Vitamin D deficiency
is common, and diet-related non-communicable diseases such as
cerebrovascular diseases, ischaemic heart diseases, hypertension
and diabetes mellitus are major causes of morbidity.
Recent reports on water consumption within the
OPT are conflicting, however both sources mentioned below identify
water consumption as a key issue and raise concerns for potential
threats to health particularly in regard to personal hygiene and
the incidence of diarrhoeal diseases. The UN (October 2002) found
the level of water consumption in the OPT half the amount recommended
by WHO of 100 litres per day, with an increasing number of people
in rural areas are consuming less than 20 litres of water per
The Israeli human rights group, B'Tselem reports
a huge discrepancy between water consumption of Israelis and Palestinians.
While the average Israeli consumes 350 litres per day, the average
Palestinian consumes only 70 litres per day (figures include domestic,
urban and industrial use).
Collection and disposal of solid waste has become
particularly problematic in towns and villages under curfew, closure
or restricted by roadblocks and checkpoints. Garbage trucks are
occasionally not able to collect waste and are frequently unable
to access landfill sites. This leads to inappropriate dumping
and burning of waste. A Merlin assessment in Tubas, for example,
discovered a small valley with a stream was being used as a temporary
waste landfill leading to a high potential for the contamination
of water supplies for livestock and the environment. There is
a lack of incinerators for the majority of health facilities leading
to dumping of contaminated clinical waste in municipal rubbish
collections. Despite health care providers claiming that they
autoclave and burn waste prior to disposal, this does not ensure
adequate sterile disposal and raises the risk of needle-stick
injuries for health personnel and members of the local community.
Routine spraying against parasitic diseases
such as Leishmaniasis and West Nile Fever, both mosquito borne
infections, have been disrupted due to the problems of importing
Economic Access to Health Care
In March 2003 the World Bank reported that 60%
of the population of the OPT live under a poverty line of US$2
per day. This equates to nearly 2 million people as against 637,000
prior to the Intifada. Half the population requires food aid to
reach daily minimum requirements.
The World Bank states that the proximate cause of the Palestinian
economic crisis is the closures imposed by the Government of Israel
(GOI) which affect the movement of people and goods both within
the OPT and across borders.
Under the current political climate unemployment
and poverty seem likely to worsen and drain the capacity of the
health system to sustain vital services. Therefore the collapse
of the MoH at this stage could lead to grave consequences.
The severe economic problems affects the sustainability
of the health system in a direct way, as traditionally households
significantly contributed to the financing of health services.
In addition, poverty is related with decreased access to food
and water, having a direct impact on health status. (WHO, August
IHL grants special protection to medical units,
personnel, and means of transportation and ensures that medicine
and medical relief must be granted free passage. It also grants
that the Occupying Power (OP), in this case the GOI, has the duty
to ensure that adequate medical supplies are provided, as is essential
to the survival of the civilian population in the occupied territory.
The OP must allow impartial humanitarian organizations, to verify
the state of these supplies in occupied territories, and also
to visit protected persons so as to monitor their condition and
to undertake their own strictly humanitarian relief actions aimed
at the civilian population. The rapid and unimpeded passage of
all relief supplies must be allowed and facilitated. Furthermore,
the fact that humanitarian organizations are delivering relief
in no way relieves the OP of any of its own responsibilities to
ensure that the population is properly supplied.
As the preceding chapters have indicated, the
evidence suggests that the obligations of the occupying power
under IHL are not being adequately fulfilled regarding medical
and public health services.
9. THE "BERTINI
Following the assessment made by Ms Catherine
Bertini, the GOI made several commitments to Ms Bertini aimed
at improving humanitarian access. In relation to health, the following
commitments were made:
||Ambulances will wait no more than 30 minutes at checkpoints
|Mechanisms will be set in place to ensure that patients seeking critical medical services, eg delivery, dialysis, chemotherapy, can quickly pass checkpoints.
Furthermore, in relation to International Organizations, the GOI
Commitment 3.1: fully facilitate the activities of
international organizations with particular reference to UNRWA
Commitment 3.2: agree to review and strengthen the
liaison arrangements between international agencies and the IDF.
UN-OCHA monitors the performance of the GOI in relation to
From UN-OCHA data collected from the field it is clear that the
GOI is in no way meeting its own commitments, although the level
to which it fails to meets these commitments fluctuates on a monthly
1. The overarching recommendation of this document is
therefore that Israel fully complies with its responsibilities
as an Occupying Power in accordance with IHL and specifically
the Fourth Geneva Convention.
2. That the GOI meets its own commitments made to Ms
Catherine Bertini, personal envoy to the UN-Secretary General
3. The GOI ceases all attacks on medical personnel and
4. The GOI allows free access of health care providers
to their work places and to reach the sick and injured.
5. The GOI allows free access of the sick and injured
to health care provision be it emergency, preventative or specialist.
6. That the GOI takes into account and reverses the negative
direct and indirect affects of the construction of its barrier
on the public health of the population of the OPT. Specifically
as regards free and unhindered access to health care, potable
water, sanitation agriculture, markets and employment.
B'Tselem The Israeli Information Centre for Human Rights in the
Occupied Territories. Back
OCHA Update 1-15 August 2003. Back
ICG: The Israeli-Palestinian Roadmap: What a Settlement Freeze
means and why it Matters. 25 July 2003. Back
Psychological Assessment of Palestinian Children, July 2003, Save
the Children. Back
WHO Household Survey: WHO/CDS' working group on communicable diseases
in complex situations (WHO Geneva HQ), the Palestinian National
Authority-MoH, Al Quds University and WHO office in West Bank
and Gaza, 2002. Back
Health Inforum News Volume 2, No.34, 01 September 2003. Back
UNRWA Website. Back
Health Inforum News, Volume 2, No.35, 15 September 2003. Back
United Nations Technical Assessment Mission, October 2002. Back
Losing ground: Israel, poverty and the Palestinians', Christian
Aid, by David McDowall and William Bell, January 2003. Back
Humanitarian Monitoring Report June 2003, and Humanitarian Monitoring
Report July 2003. Back