PHA-Exchange> report medical fact-finding mission Palestine

[Bert De Belder]

Dear friends,

We have just finished the compilation and writing of the preliminary report of the Medical Fact-Finding Mission to Palestine we co-organised in the last week of June. Please feel free to use and circulate this report, which can hopefully serve to enhance solidarity with the Palestinian cause.

Bert De Belder
Medical Aid for the Third World, Belgium

Road Map to peace or Roadblock for health care?

Report on the health situation in the Occupied Palestinian Territories
June 2003

Denied entry: medical doctors not welcome in Israel!

 

After 36 years of Israeli occupation and colonisation of East-Jerusalem, the West Bank and the Gaza Strip, after almost 3 years of enhanced Palestinian resistance and enhanced Israeli repression, the living conditions, including the health care system, of the Palestinian population have reached an intolerably low level.  The international community, including the United States of America and the European Union, has understood that a "normalisation of Palestinian life" is a necessary condition to find a peaceful solution. This concept is clearly written in the text of the first phase (May-June 2003) of the "Road Map", under the subtitle "humanitarian response": "Israel takes measures to improve the humanitarian situation. Israel and Palestinians implement in full all recommendations of the Bertini report to improve humanitarian conditions, lifting curfews, and easing restrictions on movement of persons and goods, and allowing full, safe, and unfettered access of international and humanitarian personnel." 

 

Despite these good intentions, our Palestinian colleagues informed us that they did not see any improvement of the restriction, imposed by the Israeli Defense Forces, on the Palestinian health care system. Accessibility of health care had already been pointed out as a major problem by a Belgian "Public Health Mission" to the Occupied Palestinian Territories in April 2002. A group of Dutch and Belgian medical doctors therefore decided to perform a "Medical Fact Finding Mission" to Palestine at the end of June. Since both the Israeli government and the Palestinian Authority officially support the "Road Map", we felt that there should be no reason to hide the purpose of our mission. However, at the border control of Tel Aviv airport, four out of six of us were "denied entry" for "security reasons": the Belgian doctors Guido Vanham (internist/immunologist) and Sofie Blancke (general practitioner), and the Dutch doctors Tariq Shadid (surgeon) and Henri van de Vall (internist). Only Gretta Duisenberg was allowed entry, but returned after one day in solidarity with her Dutch co-researchers. This meant that the "Medical Fact Finding Mission Palestine", sabotaged by Israel, had to be abandoned. However, one Belgian colleague and original delegation member, Dr Colette Moulaert (pediatrician), was able to pass the Israeli border control and made it to the Palestinian Territories. She was able to collect evidence during one week (25 June-30 June 2003). 

 

This report contains an overview of the present health situation, based on various sources. In addition, it contains the recent evidence, collected directly by Dr Moulaert and provided by a number of Palestinian and some Israeli physicians, whom we contacted by telephone or e-mail. The data clearly show that obstruction of health care is continuously being used by the Israeli army to deny the fundamental rights of  the Palestinian population. Needless to say that this situation constitutes a blatant violation of international law, including numerous UN Security Council resolutions as well as the Fourth Geneva Convention. Clearly, under international humanitarian law, it is Israel's duty, as the occupying power, to protect the Palestinian population.

 

Israel and West Bank: The International Committee of the Red Cross (ICRC) extends emergency relief (Press Release 03/42, 17 June 2003): "Under the Fourth Geneva Convention, an occupying power must ensure that the basic needs of the civilian population are met. The provision of humanitarian aid in no way relieves Israel of its obligations toward the population of the territories it occupies. The ICRC therefore once again urges the Israeli authorities to meet their legitimate security needs in a manner that complies with international humanitarian law, by minimizing the adverse effects of their security measures on the civilian population in order to allow Palestinians to live as normal a life as possible.

In view of the recent escalation of violence, the ICRC reiterates its urgent call for civilians to be spared and insists that all those concerned respect and ensure respect for the rules of international humanitarian law."

 

 

Denied rights: overall socio-economic effects of the war in Palestine

(www.palestinemonitor.org/factsheet) 

 

One thousand days of violence have killed just over 3,000 people (2,398 Palestinians and 704 Israelis) and left over 28,000 injured (23,150 Palestinians and 4,849 Israelis). Amongst the Palestinians, the number of permanently disabled is estimated at 2,500, of whom 500 are children 



Today, mid 2003, the Palestinian economy is still heavily dependent on Israel and has been ruined. Because the Palestinian territory is sealed off, 125,000 Palestinians are prevented from going to work in Israel. In addition, the many curfews ad roadblocks prevent the normal function of the internal Palestinian economy.  As a result, unemployment in Gaza is 67% and in the West Bank 48%. Seventy-five percent of Palestinians live in poverty (with an income of less than $2 a day): 84.6% in Gaza and 57.8% in the West Bank.


The agricultural sector has been heavily damaged. The Israeli army has destroyed over 30,000 olive and fruit trees and burned 3,000 hectares of cultivated land. The agricultural production has experienced a 70% decline in production. 

 

Other factors contribute to the overall feeling of insecurity and fear in the Palestinian society. 

-          Over 1,300 houses (of which over 600 in the Gaza Strip) have been completely destroyed and 13,000 were seriously damaged. Thus over 100,000 people are affected by house demolition. 

-          Between 29 March 2002 and mid June 2003, 15,000 Palestinians have been detained, 
6,000 of whom remain in prison. 350 Palestinian children are currently held in Israeli prisons.

 

Interview with Dr Youssef, 25 June, Ramallah: "The suffering has continued to increase after the Oslo Agreements. We are trying to make statistics about the psychological effects of the shellings, the invasions of the Israeli Army into the cities. The prisons are horrible. In the Negev desert prison, it takes the visitors hours to pass the checkpoints for a visit of 45 minutes. My son has been arrested in Jerusalem and condemned to 20 months in prison. He has been accused of being a member of the PFLP (Popular Front for the Liberation of Palestine), without any evidence or trial. Me, his father and my wife, his mother, we are not allowed to visit him, for "security" reasons, only his sisters have managed to get there once."

 

Nevertheless, these figures only represent the direct effects of the armed actions of the Israeli occupation forces and the Palestinian resistance. The Israeli policy of curfews, checkpoints and obstruction of medical care causes a lot of additional damage to the public health in Palestine that will affect the next generation as well.

 

 

Denied access to health care 

(see documents of Palestine Red Crescent Society: http://www.palestinercs.org/) 

 

1)       Curfew: since May of last year, the end of the so-called operation "Defensive Shield", Palestinian cities have been under curfew for 40% of the time. The general closures policy imposed by Israel continues to be a violation of international law, and the closure and curfew imposed on Palestinian towns and villages is a form of collective punishment against the civilian population. Obviously, medical care is impossible during a curfew, since everybody who moves in the street risks to be shot.

 

2)       Closure of the Occupied Palestinian Territories towards the rest of the world: the present medical mission is not the first to be refused. We know of several Belgian and European medical doctors, involved in direct patient care (e.g. cardiac surgery on children), who have been denied entry in the country. Last year, a coalition of Belgian NGOs organised "An Airplane for Gaza", full of humanitarian goods, including medical supplies and an ambulance. Part of the goods were not allowed entry, although the Palestinian medical staff in Gaza desperately needed them.

 

3)       Checkpoint delays: There are 120 military checkpoints in West Bank and Gaza, which divide the Palestinian Territories into 220 separate clusters. The effects are the following:

 

Ø       Medical teams cannot reach hundreds of thousands of civilians. Ambulance crews attempt many routes and back roads, at considerable risk to their own safety, often to be turned back by Israeli soldiers when only meters away from the sick and wounded. 

 

Ø      The response times of ambulance has been stretched.  For example, an acceptable time lapse of  7 minutes has been increased to 30 minutes or more. In Gaza, the situation is even worse, e.g. the response to a cardiac case in south Gaza can take up to 1 hour to deliver to a hospital with appropriate medical equipment. 

 

Ø       738 disabled children have been prevented from reaching rehabilitation centres because of Israeli Army-imposed curfews, checkpoints, etc. To add to this tragedy, PRCS has witnessed a number of disabled children who have been caught in the clashes, and because of their mental capacities, hearing or physical impairments, were unable to save themselves and have been killed by Israeli soldiers.

 

Interview with Dr. George Abdo, Director of the Revalidation Center Abu Raia, 26 June, on the differences between the first and the second Intifadah: "During the first Intifadah, the Israeli Army mainly used "rubber bullets" (with a steel core) resulting in spinal lesions. Now they mainly use "real" bullets and target the head, the eyes (we have many blind people as a consequence) and the chest. There are many victims with para- or tetraplegia (paralysis of both legs or of the four limbs). In total we have already served 1,500 in-patients and about 15,000 out-patients. We provide psycho-social assistance to the families and we do home visits to educate the family on how to assist the handicapped person.The problem for the in-patients is their psychological isolation, because the families have enormous problems to visit them. Some patients don't see their family for 5 months." 

 

Ø       There are 940 documented cases of denial of access to hospitals and 80 people died at the checkpoints as a result. 

 

Latest victim of Israeli soldiers preventing access to medical treatment, 15 June: 

Muhammad, from Yatta, a diabetic, suffered a heart attack; unable to provide him with the necessary treatment, the local doctor sent him to the nearest local hospital, which is in Hebron. However, when the ambulance arrived at the Israeli military checkpoint, the soldiers prevented Muhammad and the ambulance from crossing. After an hour spent with the ambulance driver and doctor trying to negotiate entry, Muhammad died. According to data from The Palestine Monitor, Muhammad is the 80th Palestinian to die from prevention of access to medical treatment. (http://www.palestinemonitor.org/updates/update_cover.htm)

 

Ø       Medical doctors are also retained at checkpoints. We know of a surgeon in Gaza City, who works also in the Rafah (southern part of the Gaza Strip). Each time, he needs three days: one day to travel the 30 (!) km from Gaza to Rafah, one day of operations and one day to travel back. 

 

Interview with Dr Munzer Sharuf, Vice-Minister of Public Health, 26 June, Ramallah: "The most important problems are curfews and roadblocks that affect health care at all levels.

- Often, the medical teams cannot reach the 420 health centers.

- The preventive medicine: the vaccines to 500,000 children cannot be administered because of the difficulties to get into the villages, and there are problems to keep the vaccines (maintainance of the cold chain). 

- The program of maternal protection is blocked, as is the program of environmental control. We see for instance cases of leishmaniosis (a parasitic skin disease, transmitted by sand flies), because the Israeli prevented us from spraying pesticides. 

- The pharmaceutical factories cannot distribute medication, the transport of oxygen doesn't reach the hospitals: how can you perform surgery under those conditions? There are 7 pharmaceutical factories in the West Bank, covering 45% of the needs, but the rest must come from abroad, even from Israel.

- Problems of access to hospitals: 67 deliveries at checkpoints with several casualties.

Cancer can no longer be treated. Israel refuses to perform radiotherapy on our patients and they get no permit from the Israeli authorities to travel to Jordan or Egypt. 

In the West bank, we have 50,000 handicapped people, of whom 10% with a severe disability. - The revalidation is expensive and we lack space in our centers"

In the final analysis, it is a political problem: the curfews and the checkpoints have to be lifted."

 

4)       Ambulances, medical infrastucture and medical personnel are targets of the Israeli Army:

 

Ø       Since September 2000, 335 attacks on ambulances were noted. As a result, 100 ambulances have been damaged and 28 destroyed. 

 

Ø       Eighty medical personnel were detained, 419 were wounded and 24 were killed.  In addition, ambulances and their personnel were used as human shield in several instances. 

 

The Israeli occupying army stopped a Palestine Medical Relief Ambulance at gunpoint. The soldiers got into the ambulance and forced the team at gunpoint, to drive around the village. The soldiers used the cover of the ambulance to try and arrest people. After 20 minutes, the ambulance team refused to carry on and announced that they would rather be shot, than be forced to help the soldiers arrest the villagers. The soldiers threatened them by saying that if the ambulance team revealed that the soldiers were in the ambulance, then they would shoot them. The soldiers also confiscated the Identification Cards of the ambulance team. Since yesterday, the ambulance team have not been given their ID's back, despite numerous appeals being made to the army by Israeli Physicians for Human Rights. Without their ID's the team is unable to function." (UPMRC Press Release, 14 June)

 

During the Israeli invasion in March/April 2002, a large number of hospitals and medical clinics were attacked throughout the West Bank. The complete computer system of the Ministry of Health (containing data on personnel, hospitals, vaccinations, disease registration,.) was destroyed. 

Additional examples (outside the period of massive attacks)

  a.. The shelling of the French Hospital, the Al Hussein hospital in Bethlehem, the PRCS Maternity Hospital (Ramallah) and the Ramallah General Hospital 
  b.. Access denied to Khalid Hospital (Ramallah) for several days
  c.. Three different attacks on the Al Alia Hospital (Hebron)
  d.. Live ammunition fired at the Beit Jala Hospital
  e.. Settlers attacked the Augusta Victoria Hospital (Jerusalem).  
In total, there have been 270 reported incidents in which hospitals were affected by military actions.

 

The Medical Staff in Gaza Strip Appeal the World, 15 June: 

The Israeli occupation forces continue the war against our armless people, using missiles, tanks, Apache gunships and F16s. Targeting overpopulated areas at the most overcrowded time of the day, which causes a large number of martyrs and injured. Moreover, the Israeli occupation army uses pin bombs that widely affect the people and duplicate the number of victims (among them 80 children and 30 women), to reach 200 injured and 37 martyrs in 48 hours. Responding to this critical situation, the Palestinian medical organisations working in the emergency field declared the high emergency state.

 

5)       An overall policy of encirclement: Most Palestinian villages on the West Bank are located in valleys.  Jewish colonies are systematically erected on the hilltops, in such a way that many villages are completely surrounded by Jewish colonies. A few roadblocks suffice to completely seal off the village from the rest of the world.  Both our Palestinian colleagues and our Jewish-Israeli colleagues (of Physicians for Human Rights) regularly organise, at great risk, "expeditions" to those villages.  They find that the people barely survive on bread and olive oil. They have no access to heath care whatsoever. The new wall built around the town of Qalqilya is a case in point.

 

On her last day in Palestine, Sunday 30 June, Dr Colette Moulaert went to Qalqilya, north of Ramallah. This small town of some 40,000 inhabitants is almost completely encircled by an eight meter high wall constructed by Israel. Dr Moulaert notes: "The journey of only a few dozen kilometers takes us more than one and a half hour. Four checkpoints in going there, two in coming back. Everywhere along the roads we see flourishing Jewish colonies. In the small clinic of the Health Work Committees, I am received by Dr. Bassem Hashen and Hadeel Qattawi, the dentist. The latter has not been able to leave the town for three years. The sight of the wall is repulsive. I try to imagine my own garden, 20 meters deep, with at the end a wall of 8 meters high, with guard posts on top of it, looking right into my kitchen and my bed-room! The wall separates Qalqilya from the Arab villages in nearby Israel. Before, Arabs as well as Jews would flock into the town. All that is over now, all contact has been lost."

 

According to the Israeli peace movement, the wall under construction in the northwest of the West Bank is just the onset of a much larger project, consisting of two closed walls that will separate the West Bank into two big ghettos, completely sealed off and surrounded by Jewish colonies.  

(http://www.gush-shalom.org/thewall/index.html) (see map).

 

 

Interview with Dr Jihad Mashal (Union of Palestinian Medical Relief Committees), 26 June, Jerusalem: "I see four points:

1. The situation is different in different areas. Gaza is terrible: for the first time they have to import oranges (because the Israeli bulldozers deliberately destroyed so many orange trees) as well as fish (although the city is near to the sea, but the Israeli army does not allow Palestinians  to fish). If you go there, you probably cannot leave (because of the on-and-off closure). The city of Nablus is a disaster. The city of Qalqilya is described as a ghetto, even by the Israeli: the new Wall (10 meters high) encloses the city, the surroundings have been bulldozered, there are no trees left. Ramallah is safe and calm, it does not show our reality.

2. The Israeli notion of "security", the checkpoints, is a collective punishment, which has nothing to do with security. The proof? Nothing has changed. The suicide bombings are going to continue, because the new wall under construction between Israel and the West Bank, is more provocative than the Green Line, the largely invisible 1948 armistice border.

3. It is a catastrophic example of apartheid. Since two years, again 1,000 hectares of Palestinian land have been confiscated and 85 new Jewish colonies have been established. How can one talk about peace? 

4. You can not ask more from an occupied population. How can we control Hamas, without getting anything? The checkpoints prevent medical treatment. They constitute discrimination. Families don't tolerate that an ambulance is blocked and the patient dies."

 

 
Denied access to water and food 
 

1)       Restriction of access to water: According to PASSIA - Palestinian Academic Society for the Study of International Affairs (http://www.passia.org ) -, 75% of the West Bank and Gaza renewable water is used by Israel. The Israeli water company "Mekorot" controls all the water supply in the region and appropriates it for Israeli use, while restricting supply for Palestinians. Thus, on average each Palestinian has access to only 71 liter of water per day. The World Health Organization (WHO) recognized minimum recommended standard of domestic water consumption is 100 liter. By comparison, per capita consumption by Israelis is 350 liter. Specifically, each Jewish colonist consumes 205 liter of Palestinian water per day.

 

2)       Food: According to a 2002 study by the Palestinian Central Bureau of Statistics, http://www.pcbs.org/english/health/health.htm, 63% of all Palestinian households (144,553 people) face problems of food supply, because of loss of income, the curfew and the siege. The first victims are women of childbearing age and young children. Anemia (shortness of red blood cells, a sensitive parameter of malnutrition) was found in  31.4% of the women of the West Bank and in 36.4% in the Gaza Strip. Similarly, the percentage of anemic children age 0.5-5.0 years was 35.5% in the West Bank and 41.6% in the Gaza Strip. Not surprisingly, the percentage of stunted Palestinian children ("short for their age") increased from 7.7% in 1996 to 8.0% in 2000 and 9.0% in 2002. 

 

 

Denied a future 

 

According to the Palestine Red Crescent Society, 70% of the children in the West Bank and Gaza are experiencing severe emotional and behavioural disorders as a direct result of the Israeli occupation. Indicators include an increase in enuresis (bed-wetting), increased aggression (verbal and physical), sleeping and eating disorders, self-mutilation, developmental expressive disorders and phobias.

 

Interview with Dr Mohammed Brighieth, clinical psychologist, Professor at Al Quds University, 26 June. His private cabinet has been completely destroyed during the Israeli invasion of March-April 2002.

"Since three years, we focus on the effects of violence on children. Those who live in the "hot zones" suffer most:  they experience depression, anxiety, bed-wetting, nightmares, problems to concentrate, memory failures, fear to leave home, all kinds of psycho-somatic symptoms. A child has to feel safe, since 3 years they live in a state of emotional violence.

Women present a lot of health problems too, including sexual dysfunction. They do not support the social injustice, they are depressed and even show signs of schizophrenia, because they continuously have to adapt to another behaviour, in relation to the actual situation. During shelling at night, women have to protect and comfort the kids, while they don't have the possibility to express their distress. In the morning, their husband demands that breakfast is ready, without giving the opportunity to self-expression. We are providing "relation therapy", the stress results in a lot of problems within the couples.

In Gaza, the situation is a lot worse. We cannot communicate with our colleagues in a normal way, we cannot see them, touch them any more, only communication by mobile phone is possible. The checkpoints are a grave error. I transmit to you his profound hope to be able to dialogue as equals with the Jews and to change the mutually negative image, while they have to live together.

We have to work in parallel with the children and the population in a multidisciplinary approach, involving both Israeli and Palestinians. We have to stop the suffering, learn to live together."

 

The inter-generational experience of occupation and war is contributing to an internalised sense of helplessness, low self-esteem and chronic depression among youth and adults. At present, the long-term effects of war and occupation are unknown, however, it is anticipated that the traumatic emotional and mental scars will be far-reaching.

 

Repeated exposure to war-related deaths and injuries has resulted in widespread emotional and psychological trauma in emergency medical service teams, doctors and nurses. Reported indicators of stress and trauma have included severe depression, sleep disorders, isolation/withdrawal, increased aggression and exacerbated fear/paranoia.

 

 

Conclusions

 

It is significant that the Dutch/Belgian Medical Fact-Finding Mission to Palestine was denied entry by the Israeli authorities. They indeed have something to hide from health professionals and the international community, namely: the deplorable state of public health and of the health care system in the Occupied Palestinian Territories, as a result of the direct and indirect consequences of Israeli occupation, colonisation and repression. 

Over the last year, the overall unemployment level rose from 42 to 54%, the proportion of people living in poverty from 70 to 75%.  Despite the Road Map, there is no visible decrease in checkpoints or roadblocks, the Jewish colonisation is ever increasing, the Israeli Army controls and hinders every aspect of daily Palestinian life, the construction of the Wall continues. 

The main problem for the Palestinian health care system remains accessibility.  It remains difficult for patients to reach the hospital, there are continuous problems to supply and distribute the necessary materials and pharmaceutical products.  Preventive health care (childhood vaccination, maternal care, insecticide spraying,.) are in peril.  The entire population, but especially children and their mothers, is continuously exposed to violence and humiliation at checkpoints, resulting in depression, psychiatric illness and family distress.  Finally, chronic malnutrition and shortage of water renders children and women of childbearing age particularly vulnerable to disease. 

The international community expects the Road Map to lead to a peaceful solution of the Israeli-Palestinian conflict, and to alleviate the human suffering of the Palestinian population in the meantime. But in reality, the Palestinian population sees no improvement is its living and health conditions. Moreover, the Road Map does not deal with the problem of human rights violations and does not provide for human rights monitoring mechanisms.  

On the basis of extensive and intensive research, observations, interviews and testimonies, including contacts with Palestinian health authorities, health professionals and patients and with Israeli health professionals, we have to conclude that rather than a Road Map to peace and health for Palestine, the Palestinian people remain confronted with major and numerous impediments to peace and health - roadblocks for which the Israeli authorities are responsible, and which are in total disregard of international humanitarian law.

Therefore, we call for the lifting of all roadblocks: the lifting of the concrete roadblocks that block access to health care, and the lifting of occupation, colonisation and repression in the Palestinian Occupied Territories that block access to Palestinian statehood, to peace and to public health.

 

 

      Dr Nabil El Aila, Ministry of Health, Gaza, lived between hope and despair during the entire week of the planned mission, because it was not clear whether Dr Moulaert could get into Gaza. Finally, on June 28, it had become clear that a visit to Gaza was impossible. Dr El Aila sent us the following e-mail:  

      "What happened to the group urges me to think. The Israeli government prevents European groups to come here to see the facts and get information about our situation. 

      My idea is the establishment "European Center for Information and Medical Aid on Palestine". The aims of the center: 

      -          Reception of groups from Europe to show them the facts, and organising for them visits to the different places in Palestine

      -          Make studies and reports about the impact of the Israeli occupation on the different medical fields like infrastrucure, mental/psychological health,.

      -          Prepare documented films translated in different languages explaining the suffering of the people with relation with the medical situation and others... 

      -          Make mutual visits between groups from Europe and Palestine

      -          Make co-ordination with the officials in the different ministries and discuss with them issues of interest. A center like this will help us to provide information to NGOs, the media, officials in Europe. 

      -          Provide medical aid for the people who are in need for diagnosis, treatment and follow-up."
     

 

This report was compiled and written by:

 

Guido Vanham, M.D., Ph.D.

Sofie Blancke, M.D.

Colette Moulaert, M.D.

Anne van Mackelenbergh, M.D.

Bert De Belder, M.D.

 

The (aborted) Medical Fact Finding Mission Palestine and this report were an initiative of:

 

  a.. Stop the Occupation - the Netherlands
(http://www.stopdebezetting.nl/international/index.html)

  a.. Medical Aid for the Third World - Belgium (http://www.g3w.be)
  b.. Doctors for Peace, the Flemish affiliate of the International Physicians for the Prevention of Nuclear War (IPPNW) - Belgium (http://www.ippnw.org/)
·         The Flemish Palestine Committee - Belgium

  a.. The Action Platform Palestine, the Flemish umbrella of NGOs and committees in solidarity with Palestine - Belgium (http://www.11.be/)
 

We thank the following organisations for their help and information:

 

Union of Health Work Committees, Palestine: http://www.gaza-health.org

 

Union of Palestinian Medical Relief Centers: http://www.upmrc.org

 

Physicians for Human Rights, Israel: http://www.phr.org.il

 

Red Cross Projects in Palestine: 

http://www.icrc.org/Web/eng/siteeng0.nsf/htmlall/palestine?OpenDocument

 

 

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