Neve Gordon and Ruchama Marton
“If you have come to help me, please go home. However, if you have come because your liberation is tied with my own, then let’s work together.” —Aborigine Australian woman.
Dr. Neve Gordon is a lecturer in politics and government at Ben Gurion University, Beersheba, Israel, specializing in the link between human rights and medical ethics. Between 1992 and 1994, he was the executive director of The Association of Israeli-Palestinian Physicians for Human Rights. He is a graduate of the Hebrew University of Jerusalem and the University of Notre Dame, and has written several articles and reports on human rights issues.
Dr. Ruchama Marton is a leading human rights activist in Israeli society. She is a graduate of the Hebrew University of Jerusalem Medical School and Tel Aviv University Medical School Institute for Psychotherapy, where she continues to serve as an adjunct lecturer and supervisor in psychotherapy. In 1988, she founded The Association of Israeli-Palestinian Physicians for Human Rights, the first professional Israeli health and human rights NGO. She is the co-founder of several associations including One in Nine, Palestinians and Israelis Meeting for Peace and Mental Health Workers for the Advancement of Peace (IMUT).
Dr. Ruchama Marton and Dr. Neve Gordon are both activists and scholars in the field of human rights. In this chapter, they point to the neglect in the development of rehabilitation services by Israel during 1967–1994, while formally responsible for the health of the Palestinian people, and direct a moral call to the government of Israel to assist in filling the gaps for rehabilitation services in the Palestinian Authority.
This chapter compares the nature and scope of rehabilitation services in the West Bank and Gaza Strip with those available inside Israel. Using the Israeli rehabilitation system as a point of reference, we examine the degree to which various rehabilitation needs were met in the Palestinian community. The research concentrates on the period prior to June 1994, the date the authority over health services was transferred from Israeli hands to the Palestinian Authority (PA); it is accordingly confined to the years Israel had full control over the occupied territories and was responsible for the rehabilitation services. Since the adequacy of rehabilitation services reflects, in many respects, the medical system as a whole, this chapter also sheds light on the Palestinian health care system in general.
Our findings reveal that the Israeli government made few provisions for rehabilitating disabled people in the territories, and that prior to 1994, rehabilitation in the territories was provided almost exclusively by Palestinian and international non-government organizations (NGOs), private services, and charitable institutions. While these bodies made impressive progress in the field of rehabilitation, there was a constant disparity between available services and the needs of the population.
The chapter also highlights Israel’s violation of international law, notably the requirement to grant rights to disabled persons “without any exception whatsoever, and without distinction or discrimination on the basis of race, color, sex, language, religion, political or other opinions, national or social origin, state of wealth, birth.” We emphasize international law because we believe that the onus of transforming the dilapidated rehabilitation system into a viable one should not fall solely on the Palestinians. At the heart of our criticism is Israel’s policy of detachment and abdication of responsibility towards the Palestinians it governed for over a quarter of a century. This policy, we believe, lacks moral content and is sowing dragon’s teeth for the future.
OVERVIEW
Every society has disabled members in need of rehabilitation; some are permanently disabled while others may be convalescing from an injury or ailment. Contrary to the prevailing trend of compartmentalizing fields of medicine, rehabilitation has steadily expanded in scope. It currently involves a complex multidisciplinary process, entailing teamwork among a range of professionals. This expansion has been driven by the objectives of rehabilitation, defined as maximizing the independence of the disabled person and facilitating his or her reintegration into society. Rehabilitation therefore combines a range of services: continued medical treatment; medical, physical, occupational, and speech therapy; psychological and social support for both the patient and his/her family; life-skills development; adapted living environment; vocational training; appropriate employment opportunities; special education; and suitable cultural and recreational activities.
Rehabilitative medicine began to develop as an autonomous field between the two world wars. The Israeli Physical Medicine and Rehabilitation Society was created in 1950, two years after the state’s establishment. Rehabilitation initially received little attention and funding, but wars, polio epidemics, an aging society, road accidents, and industrial injuries subsequently served as catalysts for the development of services that today match those of other industrialized countries. Although some services are still lacking, since the 1970s, Israeli rehabilitation has become a vibrant medical field.
This positive trend has been confined, however, to the pre-1967 borders; its effects were never felt in the territories occupied by Israel. The lack of services in the territories is particularly harrowing given the high rehabilitation needs of the Palestinian society. In 1992, the Central National Committee for Rehabilitation (CNCR) estimated that between 60,000–80,000 people were suffering from disabilities in the West Bank and Gaza.
IN-PATIENT SERVICES
Despite the high need in the occupied territories, the availability of in-patient rehabilitation services was, as of 1994, significantly lower than necessary. As Table 8.1 shows, the ratio of beds per population for intensive in-patient rehabilitation was 1.6 times higher in Israel than in the territories.
Table 8.1
In-Patient Rehabilitation Services in Israel, West Bank, and Gaza, by Institutions and Beds, 1992
Availability of Services Israel West Bank Gaza West Bank and Gaza
No. of institutions 9 3 None 3
No. of beds 459 128 None 128
Population (millions) 5.2 1.6 0.8 2.4
Beds per population 1/11,330 1/12,500 None 1/18,665
Sources: Data related to the West Bank and Gaza Strip: N. Gordon, Intifada-Related Head Injuries and the Rehabilitation System in the Territories (Tel Aviv, PHR, 1995). Data related to Israel: Inpatient and Ambulatory Institutions in Israel: Statistics on Patients' Movements by Institution and Department (IMOH, Planning, Budgeting and Medical Economics Branch, 1993).
While the majority of beds in Israel were at least partially government funded, Israel provided no funding for in-patient rehabilitation institutions in the territories between 1967–1994 (see Table 8.4). Some patients needing urgent neurological or orthopedic surgery were referred by the Israel Civil Administration to medical institutions in Israel but the Civil Administration rarely, if ever, covered necessary long-term in-patient rehabilitative treatment following these procedures. Excluding mental health institutions, the rehabilitation facilities in the territories were run solely by NGOs and charitable organizations, with all the limitations and donor dependence this type of funding entails.
Furthermore, as of 1994, none of the existing Palestinian in-patient rehabilitation institutions were located in the Gaza Strip. The population of the Gaza Strip represents over one-third of the Palestinian population living in the territories, and its residents need special permits to travel either to Israel, the West Bank, or East Jerusalem, and are often barred from leaving the Strip due to so-called security constraints. Consequently, the total absence of in-patient rehabilitation services in the Gaza Strip lowered the availability per person to such services in the Palestinian population, far more than might be indicated by the limited geographical distance between Gaza and the West Bank or Israel. The prevention of free movement from Gaza to the West Bank, and from both these regions to East Jerusalem, is even more extensive today than it was during the 1987 intifada. This inaccessibility is in violation of the UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities, which states: “All persons with disabilities, including persons with severe and/or multiple disabilities, who require rehabilitation should have access to it.”
A case study comparing the rehabilitation services offered by two leading institutions in their respective communities is revealing. The Beit Loewenstein Rehabilitation Hospital (248 beds) and the Bethlehem Arab Society for Rehabilitation (55 beds) are the largest and most important rehabilitation institutions in Israel and the West Bank, respectively, thus enabling a useful comparison.
Table 8.2
Rehabilitation Centers in Israel and the West Bank: Ratios of Specialists per Bed in the Two Leading Rehabilitation Centers, 1993
Specialists Ratio of specialists per bed
Beit Loewenstein Bethlehem Arab Society
Physician 1:6 1:27
Psychiatrist 1:62 None
Psychologist 1:50 1:110
Physiotherapist 1:7 1:8
Speech Therapist 1:25 1:55
Occupational Therapist 1:11 1:55
Social Worker 1:18 1:27
Source: N. Gordon, Intifada-Related Head Injuries and the Rehabilitation System in the Territories (Tel Aviv, PHR, 1995).
It is evident from the comparison (Table 8.2) that the major Israeli rehabilitation center had a larger ratio of professional staff to beds than its Palestinian counterpart. The Israeli institution employed a total of forty specialists in fields such as neurology, and orthopedic and internal medicine, as opposed to a single rehabilitation doctor and a general practitioner in the Palestinian institution. Unlike its Palestinian counterpart, the Israeli institution also had resident psychiatrists and neuro-psychologists. There were greater numbers of speech therapists and social workers per bed at the Israeli institution, and over five times as many occupational therapists per bed. Accordingly, the leading Palestinian rehabilitation institution was unable to provide adequate medical care. The leading Palestinian institution clearly has an inferior capacity to provide medical care. This, in turn, reveals that Israel failed to fulfill its obligation to “ensure that all medical and paramedical personnel are adequately trained and equipped to give medical care to persons with disabilities.”
OUT-PATIENT SERVICES
Following discharge from a rehabilitation center, a disabled person often requires follow-up treatment, such as physiotherapy, and occupational and speech therapy. As noted above, services in the psychological, vocational, educational, housing and recreational spheres are also part of the rehabilitation process. Reintegration into society involves not only maximal physical well-being, but also the opportunity to build self-esteem through earning an income and leading as independent and active a life as possible, both inside and outside the home. As mobility is a crucial consideration for disabled people, services provided on an out-patient basis must be available locally for a disabled person to realistically make use of them. This criterion has been recognized by all professionals and has been incorporated into international law as well: “All rehabilitation services should be available to the local community where the person with disabilities lives. However, in some instances, in order to attain a certain training objective, special time-limited rehabilitation courses may be organized, where appropriate, in residential form.”
Table 8.3 compares rehabilitation services for the respective populations of the Tel Aviv/central region in Israel (total of 2.5m. people with 25% under age 14 and 12% aged 65+) and the West Bank and Gaza (total of 2.4m. people with 46% under age 15 and 2.5% aged 65+). These institutions treat injured persons, people with physical, mental, and congenital disabilities, the chronically ill, the mentally ill (excluding in-patient mental hospital care), drug addicts, persons with learning disabilities, and those who are speech, hearing, and visually disabled.
The population of the West Bank and Gaza Strip had access to a significantly smaller number of institutions that provide rehabilitation services than the Israeli population of the Tel Aviv/central region. With the exception of the Community-Based Rehabilitation (CBR) program, specifically developed in response to conditions in the territories, Israel offered more types and larger numbers of rehabilitation services to its citizens. Availability of services in the Gaza Strip was particularly limited, as no institutions provided community housing, and only two provided vocational services; that is about 14% of the institutions serving 33% of the population. Whereas in-patient West Bank services were seldom accessible to Gazans, out-patient services in the West Bank and East Jerusalem were virtually inaccessible to patients from the Gaza Strip. Despite a high degree of need, the Palestinian population was severely restricted in its mobility compared to the population in Israel, due to military constraints not applicable to the latter, and far worse transportation and economic conditions.
Physiotherapy, the most common rehabilitation therapy in the West Bank and Gaza, was available outside urban areas, but only in 17% of villages and refugee camps in the West Bank. In 1993, only 56 physiotherapists worked with Palestinians in the West Bank and East Jerusalem¾one physiotherapist per 30,250 persons. In contrast, there were 2,100 members registered with the Israeli Association of Physiotherapists¾approximately one physiotherapist per 2,500 persons. In sum, the number of physiotherapists per person in Israel was twelve times larger than in the West Bank. Specialized therapists in other fields were also in short supply: only four speech therapists and eleven occupational therapists served the West Bank; figures for Gaza were not available. Other services such as movement, music, and art therapy existed in Israel but not in the territories.
Table 8.3
Availability of Rehabilitation Services (# of units) in Tel Aviv (1992) and the West Bank and Gaza (1994)
Rehabilitation Services Tel Aviv/central region (1992) West Bank (1994) Gaza
(1994)
Therapy 99 61 10
Vocational Services 66 12 2
Community Housing 39 5 None
Special Education 257 22 13
Mental Health 30 26 2
Recreational Services 77 Unknown Unknown
Services for Veterans 27 None None
Sources: Rehabilitation Services Guide: Tel Aviv and the Central Region (Tel Aviv: Almog and JDC-Israel, 1992); Mustafa Barghouthi and Ibrahim Daibes, Infrastructure and Health Services in the West Bank: Guidelines for Health Care Planning (Ramallah: The Health Development Project, 1993); and the Survey of the Gaza Branch of the Planning and Research Center, provided to Physicians for Human Rights and cited in Neve Gordon, Intifada-Related Head Injuries and the Rehabilitation System in the Territories (Tel Aviv: PHR, 1995).
Note: * State benefits included disability/unemployment payments for Tel Aviv and central areas; none for West Bank and Gaza.
The gap in the field of special education was tremendous since the Tel Aviv/central region had over seven times the number of settings than the entire West Bank and Gaza together. Another exceptional gap was found in the field of community housing where the Tel Aviv/central region had almost eight times more such frameworks than the territories.
Also significant was the broad range of services developed by Israel for disabled veterans of the Israel Defense Forces, which was unmatched in Palestinian society. Even more striking was the total lack of government disability allowances for disabled civilians among the Palestinians.
COMMUNITY-BASED REHABILITATION
It should be noted, however, that the Palestinians have¾despite limited resources¾managed to create an effective CBR program. Over the past decade, the World Health Organization (WHO) has promoted CBR to increase access to services, and advocated equal opportunities for the social integration of disabled persons. This approach employs resources within the family and community, along with support from referral services. The first CBR program in the West Bank and Gaza was launched in 1990 by the CNCR and adapted to local needs. It reflects an important shift from institutional care and is strongly linked to community-based care. The CBR program trains rehabilitation workers to work in homes and communities, assisting disabled persons in daily activities, such as washing, feeding and communicating. It encourages social integration by helping the disabled person go back to school, work or play, etc. CBR workers also set up support groups for disabled persons, parents’ groups, and committees for local activists. Thus they attempt to raise awareness of disability issues and promote positive attitudes towards the disabled within the community at large. CBR combines a number of rehabilitation services¾social, psychological, educational, vocational, and lobbying¾at a local, accessible, but fairly general and unspecialized level.
In spite of the CBR’s important achievements, the CNCR summed up the situation in the West Bank and Gaza in 1992 as follows: “Available services in general fail to reach the majority of the disabled population of the country. It is estimated that these limited and scattered services, all together, provide assistance to not more than 10%-20% of the disabled.” The CNCR added that: “All levels of service provision are seriously underdeveloped and uncoordinated [including] educational, social, psychological, vocational and entertainment services, amongst others. The insufficient presence of these services at the level of the community makes it very difficult to eventually rehabilitate and socially integrate the disabled within their own communities”
SOURCES OF FUNDING
While the majority of rehabilitation services in Israel were government-backed, public funding of services in the West Bank and Gaza prior to 1994 was extremely low (see Table 8.4, Chart 8.1). With the exception of two centers established by the Jerusalem municipality, government-provided rehabilitation services in the West Bank were comprised entirely of a small number of physiotherapists and psychologists working in governmental medical clinics. These clinics, providing general medical services, are included in the present analysis as they offer some professional services usable for rehabilitative purposes.
Table 8.4
Funding Sources of Rehabilitation Services in Tel Aviv/Center (1992) and the West Bank (1993) (in %)
Rehabilitation
Services Tel Aviv/central region (1992) West Bank (1993)
Government NGO Other Government NGO Other
Therapies 71 12 17 10 79 11
Vocational 53 26 21 17 83 None
Community housing 26 28 46 None 100 None
Mental health 67 3 30 27 54 19
Special education 74 12 14 14 86 None
Sources: Rehabilitation Services Guide: Tel Aviv and the Central Region (Tel Aviv: Almog and JDC-Israel, 1992); Mustafa Barghouthi and Ibrahim Daibes, Infrastructure and Health Services in the West Bank: Guidelines for Health Care Planning (Ramallah: The Health Development Project, 1993); and the Survey of the Gaza Branch of the Planning and Research Center, provided to Physicians for Human Rights and cited in Neve Gordon, Intifada-Related Head Injuries (Tel Aviv: PHR, 1995).
Table 8.4 illustrates that responsibility for rehabilitation services in the West Bank was borne largely by NGOs, in contrast to Israel where such services received substantial public funding. During twenty-seven years of occupation, the Israeli government hardly provided any services geared towards rehabilitation in the West Bank, despite the high level of need and requirements established by international law. For instance, the UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities calls upon states to develop national rehabilitation programs “for all groups of persons with disabilities. Such programs should be based on the actual individual needs of persons with disabilities and on the principles of full participation and equality.”
Chart 8.1
Percentage of Government Expenditure in Rehabilitation Services in Israel (1992) and the West Bank (1993)
Note: Based on the same sources as Table 8.4.
Half of the publicly funded institutions in all fields in the West Bank (nine out of eighteen institutions) were located in East Jerusalem. Unlike the West Bank, where health care was run by the Israel Civil Administration, East Jerusalem has been under the jurisdiction of the Israeli Ministry of Health since its annexation in 1967. According to Israeli statutes, therefore, East Jerusalem should receive similar amounts of governmental funding as other areas within Israel. Rehabilitation services provided by Israel for Palestinians in East Jerusalem, however, are much fewer proportionally than those available to the Jewish population. Despite a shortage of definitive information on funding for rehabilitation services in Gaza, the dearth of such services there suggests that government support for institutions there was even lower than in the West Bank.
CONCLUSIONS
This chapter highlights an issue that has been ignored for too long, namely, the predicament of thousands of disabled Palestinians. The findings presented in this chapter reveal that rehabilitation services in the West Bank and Gaza on the eve of the transfer of the health sector from Israel to the PA were significantly inferior to those available in Israel, both in quantity of services and in specialized personnel, while the need for such services was demonstrably high. Gross inequalities are evident in the involvement and investment of the Israeli government in the sphere of rehabilitation. Those rehabilitation services that do exist in the territories were developed almost entirely through the initiative of the Palestinian people and the international community. Thus, the significant rehabilitation needs of the Palestinian population were, and remain, unmet, due to Israel’s consistent policy of maintaining an underdeveloped Palestinian health system under the occupation.
The piecemeal and largely unplanned development of rehabilitation services in the West Bank and Gaza, in response to urgent unmet needs, has resulted in an uncoordinated system with a highly uneven distribution of services. Given the mobility restrictions imposed by Israel, rehabilitation services in the West Bank (other than in-patient hospital care) are virtually inaccessible to Gazans. In addition, it is now difficult for residents from both the West Bank and Gaza to enter East Jerusalem where most Palestinian medical services are based. Shortages are most severe in Gaza, with a total or almost total lack in some fields, such as rehabilitative vocational training or housing. Also evident is the relatively low public awareness of both the concept of rehabilitation and the services available.
Our findings indicate that the facilities and the services could not cope with the needs of the Palestinian population. Israel is not only responsible for the dilapidated infrastructure and lack of services, but also (due to the intifada) for the condition of many people who need these services. Due to systematic discrimination against the Palestinian population, Israeli violated numerous international laws including such basic conventions as the UN Convention on the Rights of the Child.
We accordingly disagree with those who contend that Israel’s policy of not developing rehabilitation services as needed resulted from the belief that the territories would be returned within a short period. We also cannot concur with those who maintain that it resulted from the encounter between First and Third World medical systems. This latter group suggests that cultural differences and medical priorities ultimately led the Israeli authorities to prefer certain medical fields while neglecting others. While we believe this chapter discredits the validity of such explanations, we also think it is important to ask how can one account for Israel’s persistent negligence after five years of occupation, or after ten and fifteen years? In other words, how many years of criminal negligence does it take for one to admit that Israel’s dereliction is not due to an arbitrary decision process, but part of a systematic policy?
We would like to conclude by stressing that it would be a critical mistake for the Israeli government¾which constantly emphasizes the significance of history¾to ignore the history of occupation. This history should inform Israel’s policies in the future, engendering a moral obligation whereby Israel assists in the formidable task of transforming the Palestinian rehabilitation system into a comprehensive and viable one. Israel can begin fulfilling this obligation by providing¾and financing¾professional training for Palestinians.
Finally, Ehud Barak, the Israeli prime minister (1999–2001), made it clear in his election campaign that he intends to pursue peace. The years since the Oslo accords have taught us that making peace is a process that goes far beyond the signing of agreements between political leaders. For real peace to emerge, a rehabilitation process between the two peoples must begin. It would be both appropriate and just for Prime Ministers of Israel to begin addressing the precarious predicament of thousands of disabled Palestinians. Israel should support the Palestinian health care system, not out of charity or even out of a desire to help, but because Palestinian liberation is firmly tied with Israel’s liberation.