Memorandum submitted by Physicians for
HEALTH IN THE OCCUPIED PALESTINIAN TERRITORIES
PHR-Israel was established in 1988 as a non-partisan,
non-profit organization. It brings together volunteer health workers
and human rights activists who work against abuses of human rights
in general, and champion the right to health in particular, in
Israel and the Occupied Territories. Its members and staff attach
great importance to close cooperation with Palestinian civil society,
human rights activists and medical organizations and workers.
In our medical and human rights work we strive to build, even
if only on a small scale, an alternative to violence and hostility,
thus showing that such an alternative is possible.
We are addressing only those issues with which
we are acquainted through our work.
Issue 2. The impact on Palestinian trade,
employment and economic development of customs duties and taxes,
and controls on the movement of goods and people at Israeli ports
and airports and points of entry to the West Bank and Gaza
Medicines: Based on the Paris Protocol
(April 1994) the import of medicines and raw materials to the
Palestinian pharmaceutical industry via international borders
is subject (like the rest of the Palestinian industries) to the
supervision and authorization of the Israeli authorities. This
protocol established a model of "customs union" intending
to preserve the Palestinian economy as integrated and dependent
on Israel's economy.
This, as well as the favoring of Israeli distributors, brings
us to the conclusion that there is an economic and political aim
to the restrictions described.
The Situation of Shipping of Pharmaceuticals to
Over the past few years, products from the West
Bank could be sent via Israel to Gaza through Karni crossing.
Trucks were sealed by Israeli officials at the Israeli border
checkpoint (near Modi'in) to ensure that no products were leaked
into Israel. At Karni, trucks waited in line to unload for an
average of 2-5 days. On various occasions, drivers slept on the
border for weeks.
Israeli products, including pharmaceuticals
waited considerably less time. In effect, a system favouring Israeli
products was established under the pretext of security.
Eg: On 15 April 2003 a Pharmacare driver
was killed while he waited to unload his goods. Following this
incident, Karni crossing was closed until 3 May. New orders were
enacted according to which trucks are allowed into Gaza only with
a special permit.
Karni crossing was completely closed several
more times during this period, even to trucks with a permit. Example:
an application for a permit was sent on 02/09/2003, a permit was
issued for the 15/09/2003 but on the 14/09/03, companies were
informed that Karni crossing is closed until further notice.
Periods when Karni crossing was closedMay:
3 days; June: from the 7th to the 18th and again from the 21st
to the 29th; July: reopened after ceasefire. August: closed for
3 days; September: closed from the 1st to the 7th and then again
from the 10th.
It should be noted that Erez checkpoint is accessible
for Israeli pharmaceuticals, as in the case of TEVA, so while
Karni is closed, Israelis can send their products to the Gaza
Strip via Erez.
Import of Raw Materials:
Palestinian manufacturers are subjected to special
regulations pertaining to import of raw materials according to
which an import license of the Israeli Ministry of Health is required
for raw materials an Israeli manufacturer can import without such
a license. Processing the license usually requires 1-2 weeks.
Due to lengthy Israeli security checks, clearance from custom
is extremely lengthy. Example: In May 2002, all imports were suspended
by order of the Israeli Ministry of Defense. Manufacturers had
to prove that raw materials do not have any dual use in any arms
related industries. This took around one month to clear. Palestinians
estimate that, on average, it takes them three weeks longer to
process their shipments than it takes Israeli manufacturers. PHR-Israel
itself has handled several cases of medical international donations.
For instance, two vehicles donated by the British Council to the
Palestinian MOH were not released from customs for over six months,
for no apparent reason. As a result many products arrive either
expired or with short expiry dates. In many cases, customers over
stock to ensure continued supply.
Effect on the Palestinian Private Sector:
The pharmaceutical industry estimates that Israeli
limitations lead to a 22% increase in distribution costs. As to
raw materials, these new practices have increased the costs of
their import by 4-6%.
Employment in the Pharmaceutical Sector:
The total number of employees in the pharmaceutical
industry is 680. Around 300 additional individuals are employed
by the various drug stores in the distribution/marketing of pharmaceuticals.
Hence, a total of 1,000 individuals are employed in this sector.
The Israeli imports policy creates absurd situations
even in individual cases: Dr Hassan Barghouti, a lecturer at Al-Quds
University in Jerusalem, was suffering from cancer, and his situation
was deteriorating. A hospital in Jordan sent medicine at the recommendation
of his physician in Ramallah. A special courier from the Jordanian
hospital came to Allenby Crossing with the medicine, but was not
permitted to cross to Ramallah. Instead, he left the medicine
at the Israeli desk at the crossing. The Union of Palestinian
Medical Relief Committees (UPMRC) contacted PHR-Israel and asked
us to help release the medicine for this patient. At first, the
Israeli Civil Administration demanded that we arrange for a vehicle
to come to the Crossing to collect the medicine. They could not
decide, however, whether the vehicle should be Israeli or Palestinian,
and whether it should be a private vehicle or an ambulance.
PHR-Israel insisted that there was no point
arranging for a vehicle until authorization was received to release
the medicine. The Civil Administration then asked whether the
medicine was intended for one patient or more; whether it was
donated or purchased; whether it was in a box or a bottle; what
legend it bore; who sent it; and so on. The authorities then demanded
medical documents proving that this specific medicine was indeed
required for Dr Barghouti, as well as the precise name of the
medicine. While we were attempting to collect all these details,
the authorities informed us that the people who were to come from
Ramallah to collect the medicine from Allenby Crossing must leave
in a Palestinian vehicle. In Jericho, they must board a bus that
would take them to the Allenby terminal. There was no point in
their doing so, however, since authorization had still not been
granted for receipt of the medicine. The Medical Coordinator for
the Civil Administration, Dalia Bassa, also demanded medical documents
before approving passage of the bottleor box. Two days
later, we telephoned our colleagues at UPMRC to update them, only
to learn that Dr Barghouti had died. At the same time, a telephone
call arrived from the Civil Administration, asking for yet another
medical document in order to issue the permit for the passage
of the medicine. We informed them that the coordination was no
longer necessary. Dr Barghouti would probably have died in any
case, but the medicine might have alleviated his suffering.
The Israeli authorities were in no rush, and
had every opportunity to ensure that the package did not contain
an incendiary device or explosives. Thus they could have protected
Israel's security needs and forwarded the medicine without any
need for endless interrogations. Could it be that the real factor
here was not Israel's security, but rather force of habit: the
habit of controlling the life and death of Palestinians?
Further medical education is also restricted:
Since Israel controls every exit and entry into
the Occupied Palestinian Territories, a person wishing to travel
to professional conferences, advanced medical studies etc., must
be approved by the Israeli security apparatus.
Dr Iyad Zaqout works as a psychiatrist at the
Gaza Community Mental Health Programme. He applied and was accepted
for further education in Egypt. His first attempt to leave Gaza
was refused by Israeli authorities at Rafah checkpoint due to
his agenot yet 35. An appeal by PHR-Israel (24 April 2003)
overcame this barrier, and he was told that he could now leave
via Rafah. However, when trying to do so (1 May) he was again
refused. In an answer to our inquiry, we were told that the Israeli
General Security Service has "changed its mind". Following
the intervention of an advocate, we received the answeragainthat
Dr Zaqout can leave, and he again traveled to Rafah checkpoint
(6 May) only to find it completely sealed. Another attempt, (8
May), was again refused. Only following further efforts was he
finally allowed to cross (9 May) to Egypt and arrivelateto
Aside from the tedious bureaucracy described,
other cases PHR-Israel has encountered show that the permit system
is sometimes used by the Israeli security forces as a way to exert
pressure on Palestinians requesting permits, to collaborate and
Issues 3 to 4 The impact of the wall and of
the network of settlements in the occupied territories on movement
of persons and goods
We chose to present the wall and settlements
together since we believe that the settlements are one of the
main reasons for the wall as well as for the internal closure.
Israel invests considerable efforts in order to enable freedom
of movement for its Jewish citizens in the Occupied Palestinian
Territories (army presence to guard settlements and escort of
settlers' transportation, building by-pass roads, building the
wall to the east of the green line in order to annex de-facto
many Jewish settlementsall with significant costs). At
the same time, Israel hinders and blocks the Palestinians' freedom
of movement, while investing next to nothing in solving the resultant
Israel's approach was proclaimed by Major Amos Gilad, former Coordinator
of Government Operations in the Occupied Territories. According
to his vision, Palestinians will be able to "keep their head
above the water" even when the IDF is present: "The
education, health and municipal services will continue to operate
. . . with funding from the international community."
The policy of prevention of freedom of movement
within the West Bank has created economic paralysis and the gradual
disintegration of the daily lives of Palestinians. It is impossible
to maintain a logical and reasonable medical system with no freedom
of movement and decentralization/sharing of resources; it is equally
impossible to maintain an economic system, an educational system
and family life.
The security considerations cited justifying
this policy seem to be merely a pretext for a system of humiliation
and violation of human rights. There is no doubt that a healthy
person smuggling explosives with harmful intentions can cross
barriers, ditches and mountains and will not bother to apply for
a permit or pass through a checkpoint, whereas it is the weak,
the elderly, the disabled and the sick, who are denied passage
by these obstacles. In this policy the state of Israel deviates
from the balance it claims to maintain between its security needs
and the humanitarian needs of the Palestinians.
Medical Referrals within a Fragmented System:
From 1994 until the outbreak of the second Intifada,
the Palestinian Ministry of Health prepared a plan for the development
of specialist services at different hospitals. The plans were
based on the assumption that patients, physicians and emergency
crews would be permitted to move freely. The efficient organization
of health services requires a division of functions between different
units specializing in different fields. Modern models for the
organization of health services seek to ensure that each unit
specializes in certain fields. The alternative is that each medical
center attempts to provide the full range of medical services
available in that countryan illogical demand. Preventing
the movement of civilians between one city and another, or between
villages and cities, destroys the foundation on which this assumption
is based. Today, in order to cope with such a reality, the Palestinian
system is obliged to rely on outside aid, and on its own limited
resources, in order to replicate services endlessly, to the point
at which each field unit can provide a full range of medical services.
While the decision to refer a patient to a particular
medical center should be purely professional, Palestinian medical
professionals constantly encounter Israeli military demands that
prevent the referral of patients. This creates complex situations
relating to movement within the West Bank and Gaza Strip, and
at crossing an international boundary.
The permits policy within the West Bank
While attempting to enable the passage of physicians
or patients, or to obtain medicines, the Palestinian health system
encounters mountains of bureaucracy that constitutes a grave violation
of human rights. Every ambulance that leaves to collect a patient,
however urgent the case, now requires prior coordination. Every
patient requires a transit permit, as does every physician. Hidden
behind the language of procedures, bureaucracy is less glaring
than the checkpoint or the individual soldier who beats a civilian.
Yet it is no less harmful, and it has a devastating impact on
the ability of a health system to function.
Issue 6. The role of NGOs
It is our belief that an active NGO culture
is a vital pillar for a healthy Palestinian society. In times
when the PA and the Israeli government dealt with "security"
matters and both were willing to neglect and ignore human rights
issues, NGOs were there to criticize. At times when individuals
are either too afraid or unable to voice criticism, NGOs are in
a better and safer position to do so, partly due to their international
Israel now limits the NGOs activity, in contradiction
to its declaration according to which it recognizes the right
of human rights organizations to function and to promote their
Limiting the activities of Palestinian organizations, Israel is
preventing the functioning of Palestinian civil society, paralyzing
its independence and increasing its dependence on external aid.
Limiting the activities of Israeli organizations, Israel is preventing
all possibility of Israeli society offering an alternative to
occupation and violence in the form of acts of solidarity, and
preventing criticism from within Israeli society. Limiting the
activities of International organizations the state of Israel
is preventing provision of direct aid to the besieged population,
as well as preventing international criticism.
Issue 8. The role of aid
"The sine qua non of economic stability
and recovery is the lifting of closure in its various forms, and
in particular, internal closure. As long as Palestinian internal
economic space remains as fragmented as it is today, and as long
as the economy remains subject to extreme unpredictability and
burdensome transaction costs, the revival of domestic, economic
and Palestinian welfare will continue to decay." (World Bank
Assessment, May 2003, xvii).
It seems people are grateful for any help they
receive, particularly humanitarian aid. However, in Palestine,
this assistance is problematic, since it addresses a situation
to which the solution can only be political. It is important to
organize the process so donation will not replace or compete with
local products. It is, however, essential that local responses
to distress be accompanied by constant pressure to remove the
closures that cause this distress.
PHR-Israel feels that the time has come for
the international community to approach Israel's government directly
and openly without fear of being regarded as biased. When sending
aid, the international community actually commits itself to a
critical analysis of the source of the need for the aid. When
Sharon requested the UN Secretary General to assist in addressing
humanitarian needs arising from the ongoing Israeli-Palestinian
conflict, did he not take into consideration that an integral
part of assistance has to do with targeting the sources of the
needs? We believe that such action is not only for the benefit
of the Palestinians, but essential to Israelis as well so as to
prevent further deterioration, both moral and practical. As long
as the State of Israel feels it is not held accountable (morally
as well as financially) to its actions in the OT, there is little
motivation for change.
Written by: Hadas Ziv, Project Director, Occupied
We wish to thank Dr Bassem Khouri for making
information on the pharmaceutical industry available to us.
236 www.btselem.org/english/economy/The_Paris_Protocol.asp. Back
The waiting time for the issuance of such permit is 7-20 days
for no apparent reason. Back
The case appeared in an article by Gideon Levy in Ha'aretz,
May 5, 2002, under the title "A Bridge Too Far". Back
For a more detailed description of Israel's permits system see
"At Israel's Will". Back
The cost involved is approximately NIS 12 billion a year, Ha'aretz,
7 August 2002. Back
Ha'aretz, 5 July 2002, Uzzi Benziman. Back
For a detailed description see annexed At Israel's Beck and
Call (Not printed) See www.phr.org.il Back
Israel Report to the UN Human Rights Committee, on the subject
of implementation of political and civil rights. Back