Select Committee on International Development Written Evidence

Memorandum submitted by Merlin



  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[107]. 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[108]. 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 230,000 settlers[109]. 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.


  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 children[110]: "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."


  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[111] 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.[112]

  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[113]. 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.


  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.[114]

  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."


  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.


  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.[115]

Water Supply

  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 day.

  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).

Environmental Health

  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 insecticides.

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[116]. 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 2003)


  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.


  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:
Commitment 1.1: Ambulances will wait no more than 30 minutes at checkpoints

Commitment 1.2:
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 will:

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 these commitments[117]. 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 basis.


  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 installations.

  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.

October 2003

107   B'Tselem The Israeli Information Centre for Human Rights in the Occupied Territories. Back

108   OCHA Update 1-15 August 2003. Back

109   ICG: The Israeli-Palestinian Roadmap: What a Settlement Freeze means and why it Matters. 25 July 2003. Back

110   Psychological Assessment of Palestinian Children, July 2003, Save the Children. Back

111   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

112   Health Inforum News Volume 2, No.34, 01 September 2003. Back

113   UNRWA Website. Back

114   Health Inforum News, Volume 2, No.35, 15 September 2003. Back

115   United Nations Technical Assessment Mission, October 2002. Back

116   Losing ground: Israel, poverty and the Palestinians', Christian Aid, by David McDowall and William Bell, January 2003. Back

117   Humanitarian Monitoring Report June 2003, and Humanitarian Monitoring Report July 2003. Back

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