Section 2 – Health

Introduction

On September 13, 1993 I happened to be in Gaza city, the day when the Oslo agreements were signed in Washington, D.C. by President Clinton, Chairman Arafat and Prime Minister Rabin, shaking hands at the White House lawn. In Gaza, people went crazy with joy. Everyone was on the streets – walking, dancing or riding cars and honking their horns. Big smiles on everyone’s faces.

I took a taxi to go to a friend’s house. On the way I asked the driver what he would like to have in the newborn Palestinian state. He said: my hope is to get good health-care, good education for my children and good roads. Anything else, I asked him. No, he answered. That's all I hope for. I said – Insha'allah, let it be.

Now, twenty years later, if I could meet this driver again, what could we say to each other? There is no Palestinian state; the Gaza Strip became a huge prison, health-care delivery is much worse, the same goes for education. Above all – the big hope and big smiles disappeared and gave way to profound despair.

Hope! I feel an urgent itch to say something about it. I'm afraid many readers might not like what I want to say, and yet, it is important for me to say what I think: hope works like poison. It poisons mainly the weak and the oppressed, those who mostly use it.

Hope tells them what they want to hear; therefore, they love hope and cling to it. At the same time hope misleads them to believe that what they hope for will actually be realized somehow in their lives.

Hope is a tool used by the mighty to manipulate the weak and to control them. Heads of churches do it, kings do it, generals do it, dictators do it and their subordinates swallow the sweet candy instead of doing something to change their misery.

My take on the Pandora's Box mythos is that hope, the last item at the bottom of her box, is different from all other evils contained there only by taste: the evils are bitter but the hope is sweet, though not less harmful.

I came to this conclusion as an outcome of my observation and analysis in women's psychotherapy. Time and again I heard a woman saying (to me and to herself): I hope he will see how much I love him. I hope he will realize how much I sacrifice for him. And more of the same. The bottom line of the inner dialogue of hope is: and then he will love me/come back to me/stop being aggressive/will not kill me. (The last one is my addition to this discourse of hope.)

Hope, in too many cases, prevents the person (or the collective) from investigating her real situation and trying to act effectively to change it for her own good. A realistic examination, not tainted by hope, would tell her that all her efforts are in vain: that his aggressive or neglectful conduct will not stop but will go only to a higher point. If she could think this way, she might find out that the best way for her would be not to please him but to go to the police, to leave home, to find a lawyer, etc. Instead, she will say time and again – but he told me he loves me (equivalent to we want peace) or – he promised not to beat me up again, ever. How many times he said those words to you, I ask, more than once? Oh, so why do you think that this time it will be different? The answer is: I hope it will be different this time.

I saw in my own eyes the overwhelming, huge tsunami of hope covering Gaza on that evening. I even felt it myself. What a pleasant, sweet feeling, almost irresistible. I saw the embarrassed Israeli soldiers standing there next to the army posts cradling their weapons, silent, perplexed, not knowing what to do when young Gazans approached them so close as to hand them olive branches. Any other day they would have fired at them before they could get that close. It was a totally crazy scene, a scene of triumph of joy and hope over misery and oppression: everything was going to be so much better. But it didn't.

Palestinian leadership was not vigilant, not careful, not seeing reality. They were blinded by the hope they would get independence and a free state. But hope is a bad adviser.

Dr.Haider Abdul Shafi headed the Palestinian delegation to the Madrid peace conference in October, 1991. He resigned from the Palestinian delegation when he understood that the Oslo agreement would not “redirect our energies and resources from the pursuit of mutual destruction to the pursuit of joint prosperity, progress, and happiness."

Dr. Haider, my dear friend, was not blinded by hope. He saw clearly what other people on both sides couldn't and wouldn't see. "This agreement is a recipe for disaster for the Palestinians," he said at his home on September 13, 1993, to the many people who came to hear what he thought. I was there, too. Most didn't agree with him. They couldn't understand how he failed to see what they saw – a sparkle of hope, a new beginning, one that promised the benefits of peace and an independent Palestinian state. Everyone wanted so much to hope that it blinded them all.

Since 1967 Israel has used health and medicine as an instrument of control, oppression and blackmail of the Palestinian people and leadership in the occupied Palestinian territory. By not allowing the Palestinians to develop a medical infrastructure and medical services of their own, they become increasingly dependent on Israel, which has contributed to maintaining Israel’s position of power and domination.

The health-care system that has evolved during the occupation lacks coordination and strategic planning, resulting in an irregular and distorted health-care system. Entire spheres of medicine–such as oncology, hematology, pediatric cardiology and problems resulting from metabolic disorders–remain either nonexistent or function only partially and inadequately and are dependent upon specialists and modern medical equipment in Israeli hospitals. Rehabilitation services are insufficient to meet the needs of the disabled population. As for diagnosis, pathology and imaging facilities are almost nonexistent.

According to the Oslo agreements, the Palestinian health care system, one of the five civil institutions, were transferred to the Palestinian Authority (PA) in June 1994, but neither they nor the Cairo agreements earlier in February 1994 seriously addressed the question of health-care and medicine. In fact, the infrastructure of the health system was not mentioned in the agreements.

Essentially, the PA has continued the patterns established during the occupation.

This new form of occupation after Oslo was actually worse, since the new “balance” saddled the Palestinians with material costs while giving them only the illusion of power. Therefore, in October 1993, PHR-Israel issued an 11 point proposal setting out what we considered to be the primary means of fulfilling the above areas of responsibility. It spoke in terms of the responsibility and obligation of Israel towards the Palestinians, and it focused on two main areas:

1. Immediate concern for the welfare of the individual patient, until an adequate Palestinian service had been developed: this must take into account the dependence upon Israeli medical services that has developed, and ensure that referral to Israeli medical institutions continues.
2. Cooperation in the development of an independent Palestinian health-care and medical infrastructure.

(Editor’s note: these 11 points are described on p. xxxxxxx.)

PHR-IL suggested that Israel assist in the “development of an independent medical capability in the West Bank and Gaza Strip by purchasing missing equipment for diagnosis and treatment, and by developing an infrastructure via the training of staff for the operation of such equipment.”

To be responsible and powerless is an extremely miserable condition. The best analogy to it that I found in my work as a feminist psychotherapist is the role of the dependent “classical” wife who is responsible for most of the household chores but has no control over money, decision-making and interactions with the larger world. With so much responsibility and so little power she has no control over her life.

In the relationship between oppressor (the powerful Israeli partner) and oppressed (the weak Palestinian one), the oppressor always sees responsibility as resting in the oppressed and not in himself. The powerful partner, as I learned in psychotherapy work, will usually not give anything to the weak partner. If anything is given it is given partially, too little, too late and without respect to the oppressed partner.

During the years of the negotiations after Oslo, Israel increased its power and control over the Palestinians and got rid of its responsibility toward them. Israel continues treating the Palestinians as an occupied people, and does not fulfill even the minimal agreements dealing with health-care, such as safe passage for patients and medical professionals between Gaza Strip and the West Bank and East Jerusalem. Such passage is especially critical during periods of closure and curfews. Israel has also failed to grant the free passage of medicines, medical equipment, and supplies.

Conflict with the Israeli medical establishment

Another issue is the complicated and conflicted relationship between PHR-Israel and the Israeli Medical Association (IMA).

On July 21, 2009, Dr. Yoram Blachar, President of the Israeli Medical Association (IMA), published a letter in which he explained to doctors who are members of PHR-Israel why IMA had decided to sever all contacts with PHR-Israel: "The infuriating reality is that the activities of PHR-Israel constitute fertile ground for anti-Israeli [activities], anti-Zionist (sic) and anti-Semitism."

IMA also threatened to sue me and PHR-Israel for slander. Our board members were frightened by this. I wrote back to my friends on September 22, 2009: "Please do not be intimidated by IMA. This is not the first time that IMA has threatened to sue me. It happened twice in the past and twice IMA withdrew from this intention. I wonder what will happen this time." The IMA didn't sue me or the organization this time as well.

But the trouble with the IMA started 20 years before this letter. The first time an IMA's chair threatened to sue me was in May 1989. Then, chair Dr. Ram Ishay, had issued a report saying that the health situation in the Gaza Strip was good and that the Israeli army had not violated any human rights. (It was the first year of the first Intifada). He traveled together with the Israeli Minister of health on an international campaign justifying Israel policy. I accused the IMA's Chair of covering up for the government and toeing its line, giving wrong and misleading information. I also wrote to the World Health Organization and many others that Dr. Ishay wrote his misleading report without visiting the Gaza Strip at all. It ended up by Ishay threatening to sue me. I told him: Go ahead. Sue me. He did not.

The second time was four years later, in 1993. I published an article in a daily newspaper (Hadashot) saying that Jewish-Israeli psychiatrists who examined Palestinian prisoners were providing improper diagnoses time and time again, and therefore, in my opinion, this was not simply an error on their part—it was intentional.

I discussed the principle and moral significance of the way Jewish-Israeli psychiatrists have systematically related to mentally ill Palestinians as manipulative imposters. The prisoner is regarded as a terrorist, an enemy, a person endangering the state of Israel and its citizens and its soldiers, rather than as a person who has lost his sanity. As a result, I argued, mentally ill Palestinians are serving their full sentence imposed upon them by a military court. Most of them are incarcerated in solitary confinement since the prison authorities do not have the proper means to handle them.

The psychiatrist I mentioned in the article wanted to sue me. The IMA lawyer advised him to withdraw the civil suit and to bring the case before an inner IMA court. The doctor mentioned in the newspaper followed his advice. The inner trial went on for two years. I was found guilty and required to write a letter of apology to appear in the IMA's newsletter.

My letter was never published, nor did IMA deal with my complaint against what I considered a general malpractice. (Editor’s Note. For a further discussion by Dr. Marton of her “apology,” see the article, “The Right to Madness,” pp. xxxxxx.) The fact that the IMA has never discussed this issue is a reflection of the socio-political needs of many individual psychiatrists as well as of the organization that unites them, the IMA. I'm talking about the hegemonic worldview of the Israeli-Zionist which sees Palestinians as the enemy and terrorists. This worldview is so powerful that it does not permit a mentally ill Palestinian any means of deviating from this preordained image, not even deviation by way of insanity, of madness.

The common denominator of the three accusations mentioned above (and many more through the years) is to accuse PHR-Israel and me personally of being “political” as opposed to being a good “objective” doctor. The first time this occurred was in 1989, when Dr. Ram Ishay and Dr. Yizhak Petersburg, health officer in the Gaza Civil Administration Headquarters, accused the PHR-I (then AIPPHR) of being political. Instead of dealing with their misinformed and misleading report, they attacked us despite the fact that the use of medicine as a means of control and punishment was dramatically demonstrated in 1988, the first year of the first intifada.

In another case, where an Israeli psychiatrist diagnosed a psychotic Palestinian youngster as malingering, I brought the case to the media. Dr. A. said: “Her request is political. As opposed to her, I am not a political personality, but rather a specialist in legal psychiatry and an Arabic speaker.”.¹ The meaning of his words is that my diagnosis was tainted with politics and therefore untrue.

The problem is not whether one takes sides, since everyone takes sides all the time. The problem is when a person does not see that he/she is taking sides. Most recently, when Dr. Blachar urged IMA members to sever their relationships with PHR-I, we retorted: "By not opposing the occupation, it is Blachar who is taking a political stand while claiming to be apolitical." IMA sees itself as “neutral” – a clean term that stands for the acceptance and covering up of what is happening in the occupied Palestinian territory.

Those who value the principle of the sanctity of the welfare of human’s body and soul can never accept the fact that the Israeli authorities – through the Israeli armed forces and the Civil Administration – use people’s bodies as means of punishment by injuring, harming, killing and flooding them with tear-gas as well as brutally beating them, and breaking their limbs. Moreover, the authorities use the medical services themselves as means of punishment.

Recent history illustrates what happens when the white robe is used as a barrier between the physician and his conscience.

— Ruchama Marton, M.D., Tel Aviv, 2013

Articles

[Articles follow in chronological order.]

THE WHITE ROBE AS A BARRIER

[Presentation at Palais des Nations, Geneva, August 1990]

Late October, 1989. We arrived at Al Ittihad Hospital in Nablus, a small group of physicians, members of the Association of Israeli-Palestinian Physicians for Human Rights (the original name of Physicians for Human Rights-Israel–Ed.). We were familiar faces in Al Ittihad. The welcome was warm, though hasty. Doctors are always pressed for time.

We visited Mrs. Manua El-Bakri, 45-year-old woman, who looked much older than her age. She was struck in her abdomen by a live high-velocity bullet; her liver, spleen, stomach and intestines were severely injured. Her kidneys were badly damaged and she needed three dialysis treatments.

The State of Israel, responsible for her injury, did not express the slightest interest in her and did not, financially or otherwise, take care of her medical treatment. Mrs. Manua El-Bakri was due to go to Amman for treatment, providing that her condition would allow her to make the journey. The appointment for treatment in Amman was scheduled for October 26. However, due to a debt her husband’s nephew owed the income tax authorities, the Civil Administration refused to issue a permit allowing her to go to Amman. Mrs. Bakri died in Nablus in November, 1989.

In another room lay a 50-year-old man, Muhammad Sallah Jaber, a resident of Jenin. He was wounded a few days before our visit. While walking around his goat shed, he stepped on a mine. How the mine get there he did not know.

In the bed next to him was an 18-year-old youth suffering from severe burns on his face and hands, especially the hands. A mysterious object he was holding had burst into flames. These mysterious objects were to be found lying about in the Nablus area or else thrown at people. The injured, all of them, were shepherds.

The first youths got burned during the previous year (1988). Members of AIPPHR-IL took photographs and collected evidence, which were promptly released to the Israeli press. The Army issued denials and evasions with regard to the exploding objects, but in the end did admit to partial responsibility for these injuries, which were caused by the IDF’s missile-decoys. The IDF authorized compensation for four of the 14 children who suffered from burns at that time.

There, in Al Ittihad Hospital, a year later we found new, painful evidence of the fact that the IDF’s missile-decoys were still scattered in the area, causing severe burns to the young shepherds.

We went back to Tel-Aviv as the evening fell and immediately sat down to write a report describing what we had seen. We did not have many illusions. It was quite clear that no newspaper would agree to print our report, nor would the Israel Medical Association (IMA), numbering 12,000 members, publish our report in its bulletin. The IMA usually does not protest against the medical and human injustices committed daily in the occupied Palestinian territory.

Nevertheless, our medical and human rights activity has been echoed both in Israel and around the world.

The Association of Israeli-Palestinian Physicians for Human Rights was founded in March 1988. It was formed during the outbreak of the uprising, Intifada, at a time when the public at large was not yet familiar with the term. In March 1988, we, a group of 11 physicians, went to visit Shiffah Hospital in Gaza. It was a first visit there for all of us. It was a shocking experience for physicians working in Israeli hospitals: The squalid wards, the unbearable stench of the overflowing sewage in the bathrooms – resembled a nightmare rather than a hospital. The wounded, casualties of the uprising, were the first wave of people injured by the cruel beating by Israeli soldiers and by the uncontrolled dispersion of tear-gas inside and around people’s homes. Some of the patients had been hit by bullets fired from live-ammunition weapons, such as the high-velocity bullets.

After a few hours at Shiffah Hospital, we went to a café near Gaza Strip. We were suffering from shock and totally exhausted. We felt a great need to discuss what we had just seen. It was at that spontaneous meeting in a road café that the Association was actually born. We decided that as physicians who value human rights, it was imperative for us to take action. We had to find ways of transmitting the information we collected to the citizens of Israel, and in particular to people of the medical profession. It became very clear to us that in the occupied Palestinian territory health, medicine and human rights are inseparable. Those who value the principle of the sanctity of the welfare of the human being and his/her body and soul can never accept the fact that the Israeli authorities – through the Israeli armed forces and the Civil Administration – use people’s bodies as means of punishment by injuring, harming, killing and flooding them with tear-gas as well as brutally beating them, and breaking their limbs. Moreover, the authorities use the medical services themselves as means of punishment. A passive acceptance of the current state of affairs in the oPt amounts, in fact, to relinquishing the principles the medical profession is based on, as well as the moral code without which we stand to lose our own humane image.

Our work involves tedious fieldwork, resulting in more failures than successes, though there are a few of the latter, too.

We were, however, successful in the case of Jamal Ahmed Sha’at. He was detained in November 1988, four days before he was due to undergo a scheduled kidney operation. While detained for investigation in Ansar 2 prison, he did not receive adequate medical treatment. A military judge had instructed the prison authorities to transfer him to a hospital so that he could undergo surgery. Surgery was scheduled for the morning of February 26th, 1989. Sha’at was indeed brought to the hospital on that date, but in the afternoon, instead of the morning, and therefore missed the time scheduled for the operation. He was taken back to the prison. A new date was set for surgery, at the end of March. At that point, the family turned to the AIPPHR and asked for our help. We sent telegrams to the prison commander and to the prison physician, protesting against the negligence and warning them of the grave consequences the postponement of surgery might have. The telegram announced that if the detainee was not operated on the scheduled date, we would start a public campaign in Israel and abroad. Following our appeal, Jamal Sha’at underwent surgery as scheduled and received proper medical treatment.

The “threat” we employed, namely that we would appeal to physicians’ associations in Europe and the USA, and other organizations concerned with human rights, was not an empty threat. Our Association has gained the respect of such organizations all over the world.

The AIPPHR has undertaken, to the best of its ability, to defend the rights of physicians from the oPt. The AIPPHR conducted a public campaign for the release of Dr. Zakria Al-Ag'ha, chairman of the Arab Medical Association in Gaza, who was the first of at least 14 physicians to be placed under administrative detention since May 1988. Our intervention resulted, in some cases, in reducing the detention terms and, in one case, in the release of a group of physicians. Regretfully, when dealing with other cases we failed. Some physicians were detained in prison for terms lasting more than six months while charges were not being brought against them and they were denied the basic right of appearing before a judge.

In May 1988, the AIPPHR-IL published a report on the use of tear-gas in the Gaza Strip. The report indicates that gas was used not only to disperse demonstrations, but also in hospitals and “closed spaces,” i.e., people’s homes. As a result, infants, old and sick people, who could not escape the gas fast enough, were badly hurt, and there were even several cases of death.

The report was sent to Amnesty International and released to the local and international press. It created an outcry as a result of which the use of tear-gas was reduced – a state of affairs which lasted for several months.

In August 1988, when the IDF started using plastic bullets, a group of physicians, members of AIPPHR, visited hospitals in the occupied Palestinian territory in order to find out whether the announcement Defense Minister Yitzhak Rabin made, to the effect that the plastic bullets used by the IDF cause light injuries only was, in fact, true.

The findings were grave: The hospitals were full of people suffering head wounds. X-rays clearly show the plastic bullets which penetrated the skull and lodged in the brains. Some of them died of the injuries; others remained severely handicapped for the rest of their lives. The British government, for one, had issued an order to stop the use of plastic bullets in Ireland because of the serious injuries they inflict.

In January 1989, in a press conference held in Jerusalem, the AIPPHR voiced a protest against the cuts in the oPts’ health budgets, a significant reduction of up to 60% of permits issued to oPt residents for hospitalization in medical centers in Israel for cancer treatment, casualties from the Intifada, heart disease and kidney disease. The decision to cut the budget was made by the Defense Minister and was not publicized. Practically, the population of the oPt was denied adequate hospitalization. Alternatively, the residents were forced to pay enormous sums of money for hospitalization. The decision denied proper medical treatment to cancer patients, casualties of the Intifada, patients suffering severe heart conditions, and patients suffering from kidney diseases who needed dialysis treatment. Sixty-five senior physicians signed a petition calling the Defense Minister to withdraw this cruel policy and put an end to the use of medicine as a means of punishing the population of the occupied territories. As a result of the public protest campaign, about 30% of the hospitalization budget was reinstated.

Nevertheless, this should not be regarded as an appropriate solution to the medical problems in the occupied Palestinian territories. Medicine in the oPt is far from advanced. Most of the hospitals are old-fashioned and lack basic modern equipment. In most of the rural areas there are no clinics at all. Moreover, clinics operated by the United Nations Relief and Works Agency (UNWRA) in the refugee camps provide only partial service. The needs for hospitalization in Israel or in Arab countries serve as evidence of the low standard of the medical services in the occupied territories.

Another report we published did, however, provoke a response from the Israel Medical Association. Members of the AIPPHR spent many months in the Gaza Strip gathering information, checking and verifying data. Their findings were published in a yellow, 30-page booklet entitled “Report on the Condition of the Health Services in the Gaza Strip” August, 1989, in three languages: Hebrew, Arabic and English.

Dr. Ram Yishai, chairman of the Israel Medical Association, and Dr. Yizhak Peterberg, health officer in the Gaza Civil Administration Headquarters, were quick to respond, in the Israeli press, to the AIPPHR report. (See pp. xxxxxx for the context of this reaction by officials of the Israeli Medical Association. Ed.) The descriptions and claims of the two are amazingly similar. They rate the medical services in Gaza as adequate-to-good, ignore grave findings, and accuse the AIPPHR of being political and distorting the facts. The Health Officer, despite being a physician, justifies the actions of the Israel Defense Forces and the Civil Administration (who, admittedly, are his employers). That is understandable, perhaps. But how is it that IMA, an organization that represents all Israeli physicians, adapts its position to reflect official propaganda?

IMA has not protested, publicly or otherwise, against injuries of body and soul inflicted on the inhabitants of the occupied Palestinian territory. IMA sees itself as “neutral” – a clean term that stands for the acceptance and covering up of what is happening medically in the occupied Palestinian territory.

Recent history illustrates what happens when the white robe is used as a barrier between the physician and his conscience.

---

THE POLITICS OF HEALTH CARE IN THE OCCUPIED TERRITORIES, 1967‑1997

[Reprinted from Looking Back at the June 1967 War, Ed. Haim Gordon. Praeger, London, 1999]

Israel's non-development of a medical infrastructure and medical services in the Occupied Territories since 1967 has served as a means for fostering the dependency of the Palestinians on Israel. Along with Palestinian economic dependency, the medical dependency created by Israel has contributed to maintaining the Israeli position of power and domination. In the aftermath of signing the Oslo Accords in September 1993, and the subsequent creation of the Palestinian Authority (PA), it is important to examine the PA's approach to the issue of health care. This approach can be shown to indicate the PA's attitude toward basic human rights and toward the welfare of those whom it governs.

The arguments I wish to present are as follows:

1. During thirty years of occupation, the Israeli governing establishment has used medicine as a means of repression, control, and blackmail toward the residents of the Occupied Territories, on both the individual and the collective levels.
2. The Oslo Accords, and the Cairo agreements of February 1994, do not seriously address the question of medicine. Essentially, the PA has continued the patterns established during the occupation, and added some new policies, which have since led to a further deterioration in the quality and quantity of health care.

THE PERIOD FROM 1967 TO 1993

The Establishment of Medical Dependency in the Occupied Territories

The Fourth Geneva Convention (1949) states in Article 56 that "the occupying power has the duty of ensuring and maintaining, with the cooperation of national and local authorities, the medical and hospital establishments and services . . . [as well as] public health and hygiene in the occupied territories." The occupying power is required to make health services in the Occupied Territories equal to those provided in the conquering state. Note that such an approach accords with the first proclamation that the Israeli army issued after entering the West Bank in June 1967: "The Israeli army entered into the region today and took command of insuring public order and security . . . the essential services in the region will function as usual."

Physicians for Human Rights Israel (PHR-IL) was founded in 1988 as a response to the Intifada. From the beginning, we at PHR-IL chose to inquire about whether the occupying power did in fact stand by its promise to ensure the functioning of essential services for the civilian population. The first report published by PHR-IL in 1989 was on the state of the health services in the Gaza Strip. Our basic assumption was that the Israeli Government's general approach toward the Palestinians is expressed through the specific field of health care (in its broader sense). Our report said:

In order to describe the situation of the medical services in the Gaza Strip, one must note two contrasting trends: on [the] one hand, there is advancement in the population's health conditions, which is expressed by a decline in the infant mortality rate (from 86/1000 in 1970 to 28.1/1000 in 1988); a decline in the number of cases of whooping cough among children (30.1 in 1970 in contrast to 0 in 1980). On the other hand, the tendency of stagnation must be noted, especially in the development of independent local health services. Medicine in the Gaza Strip during the entire period of the occupation has been and remains completely dependent on Israeli medicine. Modern equipment and modern medical technology in Israeli hospitals have been at the service of the Gazan residents, but they were not given the chance to develop high‑standard medicine in their own hospitals. The Gaza Strip population has no representation at the decision making level on relevant budgetary issues, or of the development and distribution of resources—which are completely in the hands of the Civil Administration and the Israeli authorities. During the Intifada there was a steep rise in medical needs. Residents in need of medical services are completely dependent on the decisions of the military government and the state leadership and the giving of these services is tied to political, not medical/professional policy.

What does this information mean? First, it demonstrates that in one area of importance to the state of Israel, the immunization of infants, there was significant improvement. The main reason for this improvement was probably based on Israel's fear that contagious children's diseases might spread from the Gaza Strip to Israel. The success of the immunization campaign contributed significantly to the reduction in infant mortality. The infant mortality rate in Gaza, however, is still three to four times higher than in the state of Israel, which is directly related to overall deficiencies in the infrastructure and medical services in the Gaza Strip. A proper sewage system has never been installed in Gaza, and an open sewer flows freely in the streets, increasing the prevalence of infectious disease among infants and children. The risk of infectious disease is high, as infants and children (especially girls) do not receive adequate nutrition. Anemia, for example, is a common health problem caused by substandard nutrition, which often leads to susceptibility toward other diseases.

Second, our report showed that Palestinians were prevented from participating in the decision-making process concerning their own health. The health budget for the Gaza Strip (as well as for the West Bank) was classified information, and therefore not accessible to the public. The Israeli Civil Administration for Gaza made all of the decisions, including firing doctors without reason, deciding on the employment of medical personnel and even on the number of cleaning personnel at a given hospital, and making regulations related to the acquisition and maintenance of medical equipment.

Some Results of Israel's Refusal to Invest in Health Services in the Occupied Territories

At the beginning of the occupation in 1967, Israel took over a health system in which 85 percent of the services were government financed. People in the Occupied Territories were exempt from payment for health services in government hospitals until 1974. This situation continued in the government hospitals that were run by the civil administration of the Israeli army. In 1974, a program of medical insurance was enacted by the Israeli military administration. The administration limited the provision of government medical services to only those people who became insured, and thus reduced the number of Palestinians who could use the health services. Simultaneously, during the following years, the quality of the health services was reduced and the cost of the medical insurance was increased. These health services, run by the civil administration, were financed by the Palestinian population exclusively, through a combination of taxes, insurance, and payment by the uninsured for services at hospitals and clinics. Note also that the list of services covered by medical insurance was never publicized, and a quota system for medical treatment in Israel was employed by the Israeli administration.

With the beginning of PHR-IL's activity in 1988, we demanded from the civil administration a list of medical benefits and rights for the Palestinians who had paid for their medical insurance. Five years went by before we received a response, which was, even then, inadequate. During that time there was an attempt on the part of the civil administration to cover up the fact that no such list of benefits and rights existed.
A turning point for the worse in the quality and quantity of health services took place in the first year of the Intifada, 1988. The percentage of those insured fell from 75 percent of the population to 30 percent of the population in both the West Bank and the Gaza Strip. Most of the insured were now people who were obligated to be insured because they were employed by the civil administration, or were registered workers in Israel, so the payment for the insurance was automatically deducted from their salaries. An additional small number of welfare recipients were eligible to receive coverage for health services from the civil administration. The visible expression of the decline in health care covered by the government was the fact that in government hospitals there was an occupancy rate of only 50‑60 percent, while in private hospitals there was a critical shortage of beds.

In 1990, PHR-IL did a survey comparing the health services in Jenin and Nablus with the municipal health services in Tel Aviv. In Nablus there were two government hospitals, Raphidia and El Watani. These two, together with the private hospitals, served the residents of Nablus, Jenin, Kalkilya, and Tulkarem–a population of 450,000. In Israel, the municipal hospitals of Tel Aviv, Ichilov, Rokach (formerly Hadassah), and Hakirya served a similarly sized population. In comparing Tel Aviv with Nablus, the ratio of hospital beds was 4.4:1. A comparison between public hospital departments in Nablus and those in Tel Aviv shows that less than 40 percent of the units that existed in the Tel Aviv municipal hospital existed in the Nablus government hospitals (see Table 10.1).

Table 10. SEQ Table * ARABIC 1: Comparison of Existing Facilities in Medical Departments at the Nablus Government Hospital and Tel Aviv Medical Center

Department	Tel Aviv Medical Center	Government Hospital Nablus
Internal	+	+
Acute Geriatrics	+	–
Neurology	+	–
Oncology	+	–
Intensive Care	+	–
Dermatology	+	–
General Surgery	+	+
Neurological Surgery	+	–
Orthopedic	+	+
Chest/Heart Surgery	+	–
Urology	+	+
Ophthalmology	+	+
Ear/Nose/Throat	+	+
Oral Surgery	+	–
Long‑term Geriatrics	+	–
Rehabilitation	+	–
Pediatrics	+	+
Psychiatric	+	–
Gynecology	+	–
Obstetrics	+	+
Neonatology	+	–

In the Occupied Territories the number of hospital beds per 1,000 residents in 1967 was 1.8; in 1992, it dropped to 0.6. The total number of hospital beds, 1,477, has stayed the same for twenty‑five years, but the population has doubled. The number of hospital beds per 1,000 residents in 1990 was 6.1 in Israel, and 4.2 in Jordan. In 1992, government expenditures on health services per capita were $500 in Israel and $18‑23 in the Occupied Territories. A common claim made in Israel in public was that during the years of the occupation the standard of living of the Palestinians steadily improved. This claim is seen to be false, at least in the realm of health care, when one is confronted with these findings.

Certain Palestinian individuals benefited from the system by gaining access to quality health care in Israel. The problem was that medicine in the Occupied Territories remained undeveloped and dependent on Israel. The facts described prove that Israel did not maintain the existing level of services, and invested very little in Palestinian health care while discouraging investments from PLO sources.

Medicine Used as a Means of Political Control and Punishment

The use of medicine as a means of control and punishment was dramatically demonstrated in the first year of the Intifada (1988) in an order given by the Israeli minister of defense to cut the budget for hospitalization of Palestinians in Israeli medical centers by 60 percent. This subsequently reduced the number of days of Palestinian hospitalization in Israel from 2,800 per month to 800 per month. In addition, the process of attaining permits for hospitalization in Israeli institutions from the civil administration became long and tedious. Before the Intifada, there was a Palestinian medical committee, which referred patients for hospitalization and obtained final permits from the Civil Administration's Health Officer. After the beginning of the Intifada, a Financial Officer replaced the Health Officer as the person empowered to make the final decision regarding permits for hospitalization. In other words, the minister of defense, the late Yitzhak Rabin, seized the authority over medical care from the Israeli and Palestinian doctors and gave the definitive decision making power to a nonmedical officer.

The guiding principles used by the Financial Officer were based solely on budgetary and security considerations. The term "security considerations" was and is a euphemism, which covers up the arbitrary decision‑making processes of the Shabak, the Israeli General Security Service. Such decision processes include several hidden agendas when they are applied to the principles of selection for health care. These agendas were: the use of availability of health care as a method of blackmailing patients or their family members to force them to collaborate with Shabak; demanding from patients and families that they pay taxes unrelated to medicine and to the patient's situation; and finally, the use of opportunities provided by health crises to force an indirect, or "gray" means of "transferring" Palestinians from the Occupied Territories to other countries. Thus, in order to be granted an exit permit to receive medical treatment outside the Occupied Territories (and not in Israel), many Palestinian residents were coerced into signing a legal document obligating them not to return to the Occupied Territories for a period of three to five years.

One example is the experience of Haled Tuballa, in his twenties, a prisoner in Ansar 3 (Ketziot), who suffered pains in his testicles. He was diagnosed by the prison's physician as suffering from an infection and was treated accordingly. A short time after being released from prison he was diagnosed by Dr. Mamduch El Akar as suffering from testicular cancer. There is no oncology unit in the West Bank, but Dr. Mamduch managed to arrange for surgery and oncological treatment for Haled Tuballa in London. The Civil Administration made his leaving conditional on the signing of a commitment not to return to the West Bank for three years. Haled told me, "Who knows if I will live for three years—I want to return home after surgery and treatment." Haled was neither the first nor the last one to be blackmailed in this way. Only after PHR-IL's intervention did Haled receive an unconditional permit.

Medical Dependency Used as a Means for Oppression and Abuse

I have chosen to cite two examples out of the numerous ones available on medical dependency used as a means for oppression and abuse in the Occupied Territories. The first example demonstrates the Israeli military control of hospitals and clinics in the Occupied Territories. In Shiffah Hospital in the Gaza Strip there was a military outpost on the roof of a new wing. The outpost was occupied twenty‑four hours a day by armed soldiers using telescopic instruments. Every person entering and leaving the hospital was observed by the soldiers. In the event that an injured or dead person was brought to the hospital whose injury or death was caused by the use of live ammunition, rubber or plastic bullets, tear gas or the result of beating, an army contingent would arrive at the hospital. The armed platoon would enter all areas of the hospital including the emergency room and the operating room. The soldiers would behave in an extremely abusive manner toward both the patients and the medical team. Often, a patient in the operating room was removed by force before the conclusion of the operation or immediately thereafter, to be taken away for an investigation. The protests of the medical team were totally ineffective.

In addition, on different occasions, Shiffah Hospital and Makassed Hospital in Jerusalem were subjected to the firing of tear gas by Israeli soldiers inside the hospital. Clinics (including those of UNWRA) were exposed to abusive searches accompanied by the destruction of medical equipment. In several cases, private and nongovernmental organization (NGO) clinics and hospitals were closed by military orders and were unable to continue serving the population.

The situation of cancer patients in the Occupied Territories, as exemplified by the above‑mentioned case of Haled Tuballa, is another example of the suffering caused by the Israeli occupation. During the years of the occupation, there was no development of diagnostic and treatment facilities for cancer. Diagnostics such as the imaging procedures of MRI and CT, and cytopathology did not exist in the Occupied Territories. People who were in need of a CT scan were referred to hospitals in Israel. A prominent Palestinian doctor revealed that with the money paid from Gaza to the Assuta Hospital in Tel Aviv for CT procedures during a six‑month period, it would have been possible to buy a CT scanner for the hospital in Gaza to diagnose the people locally. But such independence did not suit Israeli policy. The Palestinians had to wait in long queues for their right to be diagnosed, to beg for entry permits into Israel, to undergo humiliation, and to be forced in many such instances to pay not only for the CT, but also income and utility taxes. I wish to emphasize that a delay of several months in the diagnosis of cancer may contribute to its progression from a stage amenable to treatment to a lethal stage. Hence, it should be stressed again that not one oncology unit was opened by Israel during the occupation in either the West Bank or the Gaza Strip.

Most radiation treatments for Palestinians were given in Tel HaShomer Medical Center. While Israelis who lived nearby received full or partial hospitalization during the radiation treatment, the Gazans had to crowd into a van that began its journey to pick up the patients at 5:30 a.m. The van arrived at Tel HaShomer at 8:00 a.m., at best. The patients were given radiation treatment and in the evening left to return to Gaza. Suffering from nausea, vomiting, and an overall feeling of illness, they arrived in Gaza at night. In addition, for these patients, every closure or curfew brought with it a threat of interruption of their series of treatments. These examples reveal the abusive nature of the medical dependency of the Palestinians on Israel.

The Period following the Oslo Accords, from 1993 To 1997

Israeli and Palestinian peace negotiators who were even slightly acquainted with the health care institutions in the West Bank and Gaza Strip should have recognized that special attention had to be paid to two central areas of responsibility. First, to the immediate concern for the well being of the individual patient until an adequate health care service has been developed in the West Bank and the Gaza Strip. The Israeli and Palestinian authorities should have taken into account the Palestinian dependency upon Israeli medical services, and ensured the referral of patients who could not be treated in Palestinian hospitals to medical institutions capable of treating them. Second, the negotiations should have laid the groundwork for Israeli and Palestinian cooperation in the development of an independent Palestinian medical infrastructure.

Surprisingly, neither of these areas of responsibility was adequately addressed in the Interim Agreement, which was signed in October 1995. In the Article dealing with health, it is stipulated that Palestinians will assume responsibility for the vaccination of its population, and that they will also vouch for the cost of all treatment of Palestinian patients in Israeli medical institutions. For their part, the Israelis will assure safe passage of patients in and out of the West Bank and Gaza Strip. The two sides concluded by agreeing that a joint committee should be established to facilitate coordination and cooperation on health and medical issues. Three pages, out of the 400‑page agreement, were dedicated to the health of the population.

The infrastructure of the health system was not mentioned in the agreement. Only later did the Palestinian Ministry of Health and the World Bank Education and Health Rehabilitation Project assess the situation and determine that in order to develop a sustainable strategy which will transform the health care system into effective institutions, the health sector needed $48.8 million ($21.8 million in the Gaza Strip and $27 million in the West Bank). Such, of course, did not include the estimated recurring costs of $66.2 million per year (at the 1995 rate). The actual health expenditure for 1996 was much higher: $107 million for running costs, while actual health revenue, that is, health insurance premiums was a mere $44 million. This incurred a deficit of over $62 million. It is important to note that in 1996 alone almost $15 million, 14 percent of the expenditure, was paid to Israeli hospitals for treatment of Palestinian patients who could not be treated in local facilities.

Already in 1994, PHR-IL formulated an eleven point proposal that anticipated some of the problems that would occur once the health institutions were transferred to the Palestinian Authority (PA). "Permission to enter Israel," PHR-IL wrote, "should be granted to patients on the basis of a recommendation of the Palestinian Ministry of Health, without need of permit of any sort from Israeli authorities, including the Shabak, the General Security Service."

Despite PHR-IL's warnings, the bureaucratic red tape and closures have had fatal consequences for Palestinian patients. Gideon Levy of the newspaper Haaretz, reports that during March and the first weeks of April 1996, at least nine patients, five of them children, died because they were unable to obtain medial treatment in Israel during the closure.

In its eleven point proposal, PHR-IL also wrote that "Israel should supply permits to allow the regular passage of West Bank and Gaza Strip residents who are members of the medical staff working in medical institutions in East Jerusalem." This proposal took into consideration that the largest and most modern Palestinian medical institutions are located in East Jerusalem, including Makassed, Augusta Victoria, and St. John's ophthalmic hospitals. Some 60 percent of the employees of these institutions (1,000 workers in all), which provide care for the population of the West Bank and Gaza Strip, are not residents of East Jerusalem and need entry permits in order to reach the hospital. As of August 1997, no policy had been established to ensure the free movement of medical personnel at all times, and it is still common that the operation of these hospitals is often hindered due to restrictions of movement of its staff.

Other proposals made by PHR-IL were based on our claim that Israel has a responsibility for the neglected infrastructure. For instance, PHR-IL suggested that Israel assist in the “development of an independent medical capability in the West Bank and Gaza Strip by purchasing missing equipment for diagnosis and treatment, and by developing an infrastructure via the training of staff for the operation of such equipment.” This proposal, like most others, has been ignored by the Israeli government, and the PA did not insisted on it being attended to and carried out.

As time goes by, conditions in the Gaza Strip and the West Bank worsen. In an El-Quds newspaper interview on December 29, 1996, the Palestinian Minister of Health, Dr. Riad Za’anun, asserted that all referrals of Palestinian patients to Israeli hospitals have been stopped. Patients, he said, would now be referred to hospitals in Amman and Cairo, since in these medical centers the cost for medical treatment is on average 70 percent less than the rate charged at Israeli hospitals. Such budget considerations directly affect patients. Imagine, for example, traveling twelve hours on a bus from Gaza to Cairo in order to receive radiation treatment; imagine the return trip after the treatment. Israel’s nonchalant attitude toward the Palestinian health crisis indicates that it pays no heed to the historical context of the occupation and to its consequent responsibilities — as if the past is not sediment in the present.

In June 1995, a year after the transfer of the health institutions to the Palestinian Authority, fifteen children from Gaza were dying from heart defects. PHR-IL wrote:
Surgery can save their lives, but nowhere in the Gaza Strip is there a single pediatric cardiologist capable of handling these cases; nor is there a scanner or catheterization room. The only echocardiology machine available is so outdated that its kind has not been used in Israel for over 20 years. An operation that can save these children’s lives cost $12,000 in Israel, the cost of a similar operation in Cairo is $3,000, but even this sum is too great for the Palestinian Ministry of Health…. How did Gaza reach a state in which only five out of 300 infants born annually with heart defects are operated upon?

Since September 1993, when the Oslo peace agreement was signed, 50 percent of the clinics run by Palestinian NGOs were closed as a result of the policies of the Palestinian Authority. The Palestinian Authority put pressure on contributors to transfer their contributions from medical NGOs to the Authority itself. Thus, the PA has been more successful in closing down the health services run by the NGOs than the Israeli administration had been. Another factor contributing to the decline in NGO activities is that the Oslo Accords created in some of the contributors such an unrealistic feeling that peace has been achieved, that they have transferred their contributions to other regions in the world, such as Bosnia and Rwanda. The closure of the NGO clinics plus the reduction in contributions to the PA caused an estimated cut of more than 20 percent in Palestinian health services in comparison with those that existed before the Oslo Accords.

The PA receives contributions from the European Union (EU) and other sources for the development of medical services, but does not publish data on the size of the contributions or the purposes for which they were used; nor does it publish data on the cost of the medical services and medical equipment that were bought with the contributions. In addition to the PA's attempt at centralization and control, private economic interests also have a damaging influence on the health policy. This is illustrated by the story of the CT scanner in the Gaza Strip. In February 1994, during the trilateral conference (Egypt, Palestine, and Israel) about the future of the Palestinian health system, I spoke about the lack of a CT unit in Gaza. The director of the Assuta Hospital in Tel Aviv decided at that point to contribute a used CT scanner from his hospital. The Palestinian ministry of health avoided accepting the gift several times, each time with a different excuse. A year later, the CT was still in storage, and the minister of health, Dr. Za'anun, told me at a conference in Jerusalem that there is now a new CT instrument in Gaza and that another one was on the way, therefore obviating the need for a used one. The new CT scanner, however, is privately owned, and is used on the basis of payment per service. At this time, the public health service of Gaza still does not have a CT unit of its own. This story sheds light on the difficult and painful question of whether the PA is genuinely interested in an independent and adequate public health service.

The situation following the Oslo Accords can be summarized thus:

1. There has been further deterioration in the quality and quantity of the health service in Gaza Strip and the West Bank.
2. Health is not seen as a human right, and there is no commitment to equality in the delivery of services. Two health systems exist: one for the rich and well connected and another for the poor.
3. Israeli suppliers and favored Palestinian monopolists are making financial profits on medicines, medical equipment, and supplies; Israel does not allow the requisition of medical services and supplies at lower cost from other sources.
4. There has not been a serious attempt to plan or develop an infrastructure for the delivery of health services by the Palestinian Authority (PA).
5. The PA does not make public the size and use of foreign contributions targeted for health care.
6. Most recently, Palestinian independence is manifested by not referring patients to Israeli hospitals, except for a small number of Palestinians belonging to the elite. The PA stopped complaining about the difficulties in getting exit permits for patients ("We do not need your favors"). This policy relieves the PA from pressure by its citizens to receive referrals for treatments in Israel.
7. The PA policy of centralization has entailed closing down nongovernmental organization (NGO) care facilities.
8. Israel continues treating the Palestinians as an occupied people, and does not fulfill even the minimal agreements dealing with health care: safe passage for patients and medical professionals between the Gaza Strip, the West Bank, and East Jerusalem is not granted. Such is especially critical during periods of closure and curfews. Israel has also failed to grant the free passage of medicines, medical equipment, and supplies.

Plato said over two thousand years ago that the ability to sustain oneself physically is a necessary condition for realizing political freedom. People living without a guarantee of basic health care are therefore handicapped in their participation in the development of their society. As with the basic rights of security from menace and from starvation, health care is increasingly seen as a basic human right, which must be provided by governments. The idleness of both the state of Israel and the PA, with regard to developing health services for Palestinians, expresses an underlying similarity between Israel and the PA. Each side, for its own reasons, ignores the multiple deficiencies in the present health system, and attempts to profit monetarily from them. Both sides channel most of their efforts and money to their various security forces and fail to take into account, or try to satisfy, the basic needs of those whom they govern.

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PUBLIC HEALTH AS A PROBLEM OF FREEDOM OF MOVEMENT: THE IMBALANCE OF POWER AND RESPONSIBILITY

[With Hadas Ziv (PHR-IL Director of the Occupied Territories Project), at the American Public Health Association, Philadelphia, PA, November 2002]

Following 26 years of occupation, the Oslo agreements were signed between Israel and the Palestinian Authority (PA) in 1993. The responsibility for health and education was transferred to the PA on May 1994. Although the right to health of the Palestinians in the Occupied Territory (OT) had been severely neglected by Israeli authorities, Israel’s legacy of neglect was not accounted for at the time of the transfer of responsibility, and the health system was transferred with poor infrastructure and with no respect for continuity of patients’ rights. Both Israel and the PA chose to overlook social rights in general and the right to health in particular. Israel was unwilling to recognize its responsibility and pay financially, whereas the PA was striving for attributes of sovereignty. PHR-IL’s struggle was therefore modified from a comprehensive world view that demanded Israeli accountability, to merely demanding that Israel avoid hindering the independent functioning of the PA health system. By accepting these political restrictions to its struggle PHR-IL took upon itself the role of “taking care” (responsibility) leaving decision-making (power) in the hands of the Israeli security apparatus. This paper will examine the ways in which such decisions endangered PHR-IL subversive potential, and its gradual reappearance.

The Oslo accords presented a challenge to human rights organizations in Israeli society. Organizations that had addressed issues related to the Occupied Territories knew that their struggle against human rights violations stemming from and accompanied by the Israeli occupation – as well as the occupation itself – would end only by means of an arrangement reached by policy makers. The fact that the Israeli government and the PLO, began to formulate a solution in the Oslo Accords was understood by the organizations as calling for a systemic change in their work. Expectations and hopes led many to forget that a comprehensive change can only be made possible by ending the relations of dominator/dominated and exchanging them for a new state of equality. Regretfully, the accords served instead to preserve the state of inequality, and even to enhance it.

The main question stemming from the human rights organizations' confusion in the mid-'90s was: if the establishment of a Palestinian State by agreement was near, should the organizations gradually cease to exist? This question stemmed from a political outlook that saw the founding of a State to be the answer to all problems.
In a meeting held by the board and staff of PHR-IL in 1995, a decision was made that, despite the fact that there was no certainty that the Oslo Accords would lead to a Palestinian State, the organization should initiate projects within Israel as well. The basis for this decision was a feeling that PHR-IL had nurtured a cadre of people skilled in advocacy of human rights, and that these accumulated abilities should be used to benefit other parts of Israeli society. In subsequent years projects of this type expanded and became a large part of our activities, and to varying degrees, of our identity as an organization.

Different organizations responded differently to the change of their previous equilibrium. Common to all their decisions was a general atmosphere of confusion. Some decreased the scale of their work in the occupied Palestinian territory, (oPt) concentrating on other issues. Others defined their mandate as geographical and continued to address human rights violations in the oPt, regardless of the identity of the perpetrator: the Israeli government, the Palestinian Authority or the Jewish settlers.

In general it may be said that the need for hope was so great that for a while, the Palestinians, and with them many human rights organizations in Israel, preferred to live in hope rather than in reality. In the case of PHR-IL this reality consisted of the continued violation of the right to health of Palestinians throughout the Oslo years. Many changes that occurred were for the worst. For example: in times of 'internal closure' every movement even within the oPt themselves now had to be coordinated and authorized by an Israeli bureaucratic mechanism, which grew to be known as “the permit system.”

For comparison, let us look at the response of PHR-IL immediately following the notice of negotiations between Palestinians and Israelis regarding the transfer of responsibilities, in 1993. This response can be described as still stemming from a subversive tradition:

In 1993 PHR-IL published a document titled “A Just Transfer of Health Services to a Palestinian Authority: PHR-IL’s 11-Point Proposal.” It spoke in terms of the responsibility and obligation of Israel towards the Palestinians, and it focused on two main areas:

1. Immediate concern for the welfare of the individual patient, until an adequate (Palestinian) service had been developed: “this” – according to the document – “must take into account the dependence upon Israeli medical services that has developed, and ensure that referral to Israeli medical institutions continues.”
2. Cooperation in the development of an independent Palestinian medical infrastructure.

At the root of this document is the basic assumption that Israel’s violation of every health-related international convention left it with an obligation towards the health system in the emergent Palestinian autonomy.

In this document PHR-IL speaks the language of human rights and social rights, and clearly outlines demands stemming from moral principles, while refusing to recognize the policy of the State of Israel to allow military considerations to determine access to medical services for patients or doctors. Within this discourse of rights, PHR-IL speaks in an equal tone to Israel and to the Palestinians, and criticizes the scant attention both sides had paid to the subject of health.

Although PHR-IL’s proposal was issued to central figures in both the Israeli and Palestinian medical communities and to various entities involved in the peace negotiations, no detailed agreement regarding the transfer of authority of the health system was ever published. Our conclusion was that no detailed negotiation on the subject had ever taken place, let alone negotiations that would demand Israel to assume responsibility for its legacy of occupation and neglect.

Altogether too little attention was devoted in the agreements to social rights in general, and to health in particular. We believe that the Palestinian Authority – led by hope – was preoccupied with building a state and acquiring national characteristics. Therefore, it aims to be the supplier of all services, not asking Israel for what might be seen as a “favor.” The various governments in Israel, for their part, refused to accept responsibility for the severe consequences of the occupation. Both the Israeli and Palestinian leaderships preferred to see, and show, the Israeli Palestinian conflict as a purely national one, and neglect its class characteristics. Therefore, they present separation as the only way for a settlement, leaving no place for the demands of social and economic rights. All the cracks and defects in these agreements were later exposed and expanded over the years, and they remain at the base of the maladies of the health system in the oPt. In summary it may be said that the Palestinian Authority took on a costly responsibility without the requisite power. Israel maintained full power and control over the borders, and restricted movement from, into and within the oPt, so that the Palestinians could not even guarantee free movement to medical centers, hospitals and clinics for their health teams and patients. Moreover, Israel retained its control over access to basic resources such as water, land and employment, all of which are prerequisites for health. This new form of occupation was in fact a worsening of the previous reality, since the new ‘balance’ saddled the Palestinians with material costs while giving them only the illusion of power.

At PHR-IL, added to the feeling of hope was a feeling that Palestinian political power should be allowed freedom of action. From the moment we accepted the assumption that the PA was responsible for health services, we were limited to aiding only individuals cases. The limitations of this position are clearly outlined in the petitions submitted by PHR-IL to the Israeli High Court of Justice during these years.

Applying to the Israeli High Court of Justice places the applicant at a disadvantage vis-a-vis the State. During the Oslo years, Palestinians found themselves trapped in a legalistic discourse that did not leave room for the recognition of a historical injustice which is a precondition for true reconciliation. In a similar way PHR-IL was trapped in local legalistic discourse when applying to the High Court.

Furthermore, the petitioning of the High Court by PHR-IL was problematic, because in fact the organization was requesting assistance from the perpetrator of human rights violations – i.e., the State – and in this way reinforcing its legitimacy. The High Court of Justice confirmed and recognized the transfer of responsibilities for health to the Palestinians, and therefore did not recognize the right of Palestinian individuals to sue the State of Israel for services. For this reason, PHR-IL felt it could not oppose the Israeli policy of human rights violations as a whole, or demand accountability of it, and so limited itself to the attack of specific issues piecemeal.

Between 1996 and 2000 PHR-IL submitted four major petitions to the High Court in response to prolonged closures which prevented medical staff and patients in the occupied territories from reaching their medical centers. The language of the petitions was mixed: On the one hand, it took into account Israeli “security considerations” and at times stressed that it was requesting entry permits for recognized individuals whose identity had been examined by the security authorities. On the other hand, the petitions explicitly related to the fact that it was “the responsibility of the respondents (the State of Israel) to provide for the welfare of the population in the occupied Palestinian territory in general, and for their health and physical integrity in particular, according to international law, so long as the State of Israel retains effective control over the region. This is not a duty that can be annulled or suspended in times of emergency.”

However, major parts of the petitions and court hearings were dedicated to the formation of regulations and criteria the Israeli army should adopt with regard to passage of Palestinian patients and medical staff. Though done very reluctantly, this was, in a way, recognizing Israel’s control of movement between the West Bank and Gaza, between different regions within the West Bank, and between the Occupied Territories and Israel or other countries, for purposes of medical treatment. When regulations were finally formulated by the Israeli military, they provided us with the illusion that a true change had been effected with regard to Israeli approaches to patients at checkpoints, although the authority for medical decisions was still in the hands of a non-medical party. Indeed, time revealed these regulations to be merely more bureaucracy, and even as such they were repeatedly broken by the army.

It is difficult to pinpoint exactly when PHR-IL returned to subversion. There are those who claim that before the Palestinians shattered the illusion and initiated a new uprising, the organization was trapped in the same illusion. However, we believe that the reality was more complex. Had our subversive character died during the years 1995-2000, it may be assumed that it would not have awoken so quickly and so effectively in September 2000.

A review of PHR-IL’s activities in the Occupied Palestinian Territory shows an arena in which its subversive identity is preserved. This activity continued based on the premise that the occupation was still in existence: the mobile clinics to the occupied territories and the direct contact with individual Palestinian patients, the struggle to bring patients for care in Israel, while stressing Israel’s moral responsibility, and other activities – all remained subversive in essence, since through this type of advocacy, the very existence of the individual acted against the alleged authority of the political system. Our work in the area of torture also showed subversive character: we combined local and universal discourse of medical ethics in our campaign, and exerted international pressure on the Israeli authorities by mobilizing the international medical community in protesting this issue.

The continued violations of human rights in the Occupied Territories led to a gradual loss of hope. We realized that in order to fill our role within the struggle for human rights we must act independently and on our own terms.
We came to use the international discourse and international arena as a principle: In 2002, we applied to the World Health Organization demanding that the region be declared a zone of humanitarian crisis.

We used the language of human solidarity when we initiated demonstrations and other acts of civil protest in March and April, in the face of active and direct attacks on Palestinian ambulances, medical services and personnel.

Today, even our petitions to the High Court have changed direction: they are based on the discourse of rights, and no longer cater to the dictates of local laws: the refusal of the high court to rule in accordance with this discourse may be a legal failure, but is at the same time a victory in our struggle to expose the high court as yet another arena in which the occupation subsists.

On April 7, PHR-IL submitted a High Court petition against the paralysis of medical services in Palestinian towns as a result of the Israeli invasion. Emphasis was placed on prevention of evacuation of patients and injured, and on lack of supplies at medical centers. The High Court rejected the petition the next day, on the grounds that "the State had explained that soldiers were instructed to respect humanitarian principles at all times". The Court found this explanation sufficient.

Another petition attacked the Israeli stand—that Israel has no responsibility for the healthcare of Palestinian residents of the Occupied Palestinian Territory. PHR-IL demanded that the State cover the costs of treatment for the child Shams-ad-Din Tabieh, a cancer patient, as no treatment for his illness is available in the Palestinian Authority. The advantage of this petition does not lie in the court ruling – the child ultimately received care via an arrangement that allowed the court to evade taking a stand – but in the exposing of the State of Israel as an occupying power that controls on the one hand, and shrugs off responsibility, on the other, as is clear from the state’s response:

It claimed that "according to the agreements between the State of Israel and the Palestinian Authority, powers and responsibilities in the field of health were transferred from the Military Government and the Civil Administration to the Palestinian Authority…..This included transfer of responsibility for all medical institutions." At the same time it went on to admit that even in the agreements "the military government retained authority with regard to criminal issues (autopsies, investigations, narcotics crimes)." Moreover, apartheid-style policies were expressed explicitly, when the State said that "with regard to Israelis [i.e., Jewish settlers within the Occupied Territories – PHR-IL], the authority regarding health remained in the hands of the State of Israel."

The loss and regaining of subversive nature in the activities of PHR-IL are a warning against loss of identity. For PHR-IL– as opposed to Israeli or Palestinian policy-makers – the basis for action is the politics of human rights, manifest in our struggle for the protection of human rights in the Occupied Territories, and for an essential change in the perceptions of the Israeli public. Any political solution that does not address these basic tenets will be lacking. From the moment that this understanding matured and departed from the framework that had limited us by the acceptance of the language of Oslo, we "returned to ourselves."

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THE RIGHT TO MADNESS: FROM THE PERSONAL TO THE POLITICAL—PSYCHIATRY AND HUMAN RIGHTS

[Reprinted from The Margins of Globalization, Neve Gordon, ed., Lexington Books, 2004]

Forewords

The psychiatric establishment is an agent of social supervision, discipline, and control, due, inter alia, to the part it plays in determining societal norms. Society has turned psychiatry into an authority with quasi-judicial powers, which has the ability: (1) to determine a person’s fitness to stand trial; (2) to determine whether an individual’s behavior is dangerous or not; (3) to enforce confinement in mental health institutions; and (4) to set and evaluate various skills, including the intelligence of individuals. At the same time, psychiatry produces the rules informing its own position of power, a power that is both judicial and executive. These different social roles provide the psychiatric establishment—both as a whole, as well as individual psychiatrists—with extremely significant powers that extend well beyond the professional medical definition of diagnosis and treatment of mental illnesses and disease.

Importantly, human rights are historically connected with the advent of psychiatry. The French physician Philippe Pinel was responsible for the release of mentally ill inmates from French jails. The role of understanding mental illness, distinguishing it from criminal activity, and protecting the rights of the mentally ill, is today still part of psychiatry’s function. Society has compelled psychiatry to be the field that determines fitness to stand trial and fitness for imprisonment, and this responsibility gives rise to an additional duty: namely, upholding the rights of prisoners—the mentally ill in particular, and detainees in general. Human rights and their protection are therefore an integral and substantial component of psychiatry. The awareness or lack thereof of this function dictates, to a considerable extent, the use psychiatry makes of its own power.

The question of where psychiatry situates itself in relation to the state and the individual is a socio-political question that depends on the degree to which it is aware of its role as a protector of human rights. Simultaneously, though, psychiatry’s location in the social landscape also stems from and is subject to the theoretical position which it adopts. According to classical theory, which has informed psychiatry from its inception, the intrapersonal is the principle dimension of the therapeutic relationship. During the last few decades of the 20th century, however, theoretical developments have stressed the significance of the interpersonal dimension. From the perspective of classical psychiatry, which assumes that everything takes place within the personal field, the socio-political dimension—i.e., the super-personal—is considered outside the borders of psychiatry and therefore is not included within the boundaries of its discourse. Obviously, this theoretical position, which ignores the socio-political dimension, is, in itself, political. As we will see the inclusion of the super-personal dimension within the psychiatric discourse is crucial for both increasing awareness of and in providing the necessary theoretical tools for dealing with human rights.

The theoretical term used here to conceptualize the super-personal dimension is intersubjectivity. The intersubjective relationship between the patient and the psychiatrist provides room not only for the individual or personal dimension, but also for both parties’ socio-political background. It enables the psychiatrist to broaden his or her spectrum when looking-inward—allowing an in-depth examination of the system of motives, emotions, fears and prejudices informing the psychiatrist—as well as his or her rapport with the patient. This chapter will underscore some of the dangers resulting from the exclusion of the super-personal dimension from psychiatry, particularly those that entail the violation of human rights. I shall examine how psychiatry employs its immense force, asking whether it uses it in order to protect human rights, the rights of the mentally ill and of prisoners, or whether it uses its power perversely by toeing the establishment’s line, while disregarding the rights of the individual. Using Israel as a case study, in the following pages I explore some practical and theoretical aspects of these questions. I focus on the rights of prisoners, while analyzing decisions made by individual psychiatrists, the Israeli Psychiatric Association and the Israeli Medical Association (IMA) regarding three issues: 1) the mental illnesses of Palestinian prisoners; 2) the Israeli medical establishment’s ethical obligation regarding solitary and segregated confinement of prisoners; and 3), the IMA’s ethical obligations regarding the use of torture.

I. The Diagnostic Relationship in Prison—A Theoretical Perspective

In classical psychiatric language, the psychiatrist is the “subject.” The psychiatrist brings to the diagnostic or remedial relationship his own view of reality, whether consciously or not. This view of reality constitutes a large portion of the power and knowledge used in understanding the patient, the “object.” In far too many cases, this causes the personality of the object, the prisoner, to be reduced so as to accord to the needs of the psychiatrist; the object is reduced by the subject to just one aspect of all of his traits. The subject (the psychiatrist), in a blindness that serves parts of his subjectivity, sees only a part of the object (the patient), yet considers it to be the whole. The object is nothing more than a “criminal,” an “Arab,” a “terrorist,” a “woman,” a “mother.” This view eliminates the object’s individuality and transforms him into nothing more than the representative of a group with stereotypical characteristics, which stem from the psychiatrist’s prejudices.

When therapeutic theory and practice provide room for two subjects—one being the classical subject or psychiatrist, and the other the patient as subject (replacing the classical object)—this is much more than mere semantics. In such instances, the patient and psychiatrist are both treated as subjects, each of whom has his own view of reality, including his own personal, social, political, and cultural background. Relating to the patient as a subject, with all of the factors characterizing a subject, is the best antidote to the distorted view psychiatrists often have of their patients. In Jessica Benjamin’s words: “Most important, this [intersubjective] perspective observes that the other whom the self meets is also a self, a subject in his or her own right, as an other who is capable of sharing similar mental experience.” This intersubjectivity is supposed to exist in all types of relationships, according to Benjamin, including relationships between countries, between societies, within families, among spouses, and friends, as well as relations characterized by diagnosis and treatment.

Just as a surgeon works with a knife, a psychiatrist works with his personality. The psychiatrist-subject is required to be aware of his own subjectivity, to recognize that his own subjectivity is ever-present, and not to rely merely on classical theory which considers him to be an objective and neutral observer. Only then does the patient have a chance to stand alongside the psychiatrist, instead of opposite him. The prisoner-patient will no longer be an object, in the sense of a person standing opposite, or in opposition, which gives rise to feelings of enmity and a state of war. Transforming the classical view, which assumes that psychiatrists can be objective and neutral people, involves the introduction of a new and different concept of counter-transference. A “continual deconstruction and analysis of counter-transference,” according to Stephen Mitchell, “is a powerful, very influential form of announcing the psychiatrist’s values and concerns.” When the psychiatrist is not at all interested in developing self-awareness regarding the values and concerns he brings to the relationship, then Mitchell’s helpful advice will have no effect. The opposite is the case: Instead of looking inward, into his own personal, social, cultural and political world, or in Mitchell’s language, his concerns, the psychiatrist will make a critical decision, preferring, as it were, outsight to insight.

Outsight is a system of ideas including points of view that come from the outside. In the aggressive, political game that the Israeli state is playing to silence and oppress the other, there is a constant danger that the psychiatrist will maintain a blind spot regarding his complicity in this process. This blind spot enables the psychiatrist to ignore his professional-ethical obligation as a physician whose role is to protect the rights of the patient, the prisoner, the “other”—any person whom the social order knowingly silences. As a result of his blind spots, the psychiatrist acts as an agent for the authorities, the powers that his blind spots do not enable him even to see; and so he is uncritically accepting of the government’s worldview and system of ideas. This specific blindness allows him, in turn, to consider himself apolitical, while any person who does not identify with the government’s worldview, or who objects to it, is considered to be acting according to “political motives,” which counter the purity of the psychiatric profession.

As is well known, psychiatrists have identified with government power throughout history. In Nazi Germany, the Soviet Union, Argentina, Chile as well as other countries, psychiatry was employed as a tool by the authorities. It is both theoretically and practically important that the Israeli psychiatrist recognize the fact that he is positioned on the aggressive side within a concrete socio-cultural-political reality: healthy versus ill, Israeli versus Palestinian, free versus imprisoned, white collar versus convicted criminal—and frequently, wealthy and educated versus poor and uneducated—and (although changes have taken place over time and there has been progress) man versus woman.

II. Psychiatry as Determiner of Fitness to Stand Trial

In Israel, psychiatrists are responsible for diagnosing and assessing people who are about to be tried, in order to determine their ability to stand trial. This responsibility raises important questions, since psychiatry’s boundaries are not always clear. There are the questions concerning the prisoner’s responsibility, will, and ability to understand the difference between right and wrong, as well as whether he is dangerous to the public and/or to himself and what the motives or reasons for his actions were. The motivations for the act ascribed to the patients, derive not only from the mental-personal field and therefore cannot be accounted for by simply invoking mental theory. Motivations are always informed by the socio-political and cultural spheres, and the borders between them are neither sharp nor clear. In this respect, as with other issues, the psychiatrist’s counter-transference is of considerable significance.

One should bear in mind that mentally ill prisoners are a minority within a minority, and they often suffer from very severe violations of human rights. When mentally ill prisoners are members of a different cultural and national group than that of their psychiatrist, the difference becomes a decisive factor in the diagnosis and treatment. This raises the question concerning the psychiatrist’s personal stance when his patient is from a different culture or nationality. What is the psychiatrist’s position when the patient is a Palestinian—not only a foreigner, but the enemy? Is the psychiatrist aware of his subjective position, which perceives his patient as a “terrorist,” i.e., as a real threat to society’s security? Such a view might be so encompassing as to conceal all other parts of the patient’s humanity. The specific role ascribed to Israeli psychiatry, to protect “public security,” can obscure the boundaries between the psychiatrist’s professional judgment and his political beliefs, and this may occur without sufficient self-awareness.
After all, a Palestinian patient, who is considered by the psychiatrist to be a terrorist, most certainly constitutes a threat to public security. Palestinian mental illness can therefore fall within the blind spot of the Jewish-Israeli psychiatrist—unseen and undiagnosed. The patient’s (potential) threat to the public is visible, but as opposed to other cases—in which non-Palestinian prisoners are diagnosed—the origin of the threat is political, not mental illness. The crucial question here is the extent to which the Jewish-Israeli psychiatrist is at all aware of his own blindness. In psychiatric language one might say that insofar as the psychiatrist’s counter-transference does not undergo processing and is not raised to the level of consciousness, he is unaware of his motivations.

III. Disregarding the Super-Personal Dimension: A Case Study

The youth Ali Shaban, a resident of the village of Yamoun in the West Bank, was arrested on February 7, 1990, and was incarcerated at Farah prison near Nablus. Information about him reached Physicians for Human Rights (PHR-IL) at the beginning of May 1990. The three months that elapsed from his arrest until a relative contacted PHR-IL reflect the harsh conditions of Palestinian life at the time, and the obstacles that they had to overcome in order to exercise basic rights. Very often the military would not inform the family that one of its members had been arrested or where he was being held. Many Palestinians and Palestinian villagers in particular, did not have the financial resources to obtain legal assistance, and did not know how to contact human rights organizations in order to help them exercise their rights. On a practical level, many of the villages did not even have telephone services not to mention cellular phones. At best, there was a telephone in the home of the Mukhtar—the village head. For this reason, PHR-IL had no idea when, in the course of his incarceration, Ali suffered a severe psychotic attack. In an activity report from that year, PHR-IL wrote:

…[T]he rights group has the impression that the youth has suffered from a severe psychotic attack and from initial symptoms of schizophrenia. The youth has not spoken for a few weeks; he uses his own private sign language, laughs for no apparent reason and then makes desolate-looking faces. It seemed as if he is in his own psychotic world which he expresses by drawing animals and giving them men’s and women’s names, treating them as if they were alive. He kisses his drawings and protects them so that nothing bad would happen to them. Drawings such as these are characteristic of persons suffering from schizophrenia.

In the first months following his incarceration, Shaban did not undergo any kind of psychiatric treatment. The person who finally noticed his dire mental state was a military judge who presided over a hearing regarding the extension of Shaban’s detention. Before granting an extension, the military judge ordered a psychiatric examination to determine whether Shaban was fit to stand trial. It is important to note that it is very unusual for a military judge to request that a Palestinian prisoner be given a psychiatric examination of his own initiative. Following the judge’s referral, a psychiatric opinion was provided by Dr. Yakov Avni, a senior Jewish-Israeli psychiatrist, and director of the psychiatric ward at Hadassah Hospital, Jerusalem. What follows is an analysis of Avni’s psychiatric diagnosis.

“The above, 17 years old, born in Israel” –

Avni employed Israeli medical jargon, transferring it, as it were, to a completely different society and culture. In doing so he effectively colonized Palestinian society. Where was this Palestinian villager born? And what did the doctor mean when he wrote “Israel,” when referring to a person born in the West Bank?

“A resident of the village of Yamoun. Occupation unclear.”—

The youth was a high-school student until the day he was arrested. But why didn’t Avni check whether Ali was a student in his village? It would have been very easy to find out. The vagueness or lack of clarity regarding his “occupation” contains a certain hint about a defect in the patient’s character or behavior.

“Did not respond before the Judge, on March 6, 1990, giving the latter the impression that he was mentally unsound. In the request for issuing an arrest warrant are detailed hostile activities during demonstrations, writing PLO slogans and placing road blockades throughout the past year. Was arrested on February 7, 1990, and according to the Police, ‘confessed, his investigation is not yet complete.’ Sentenced on March 6, 1990 to 47 days imprisonment.”

Parenthetically, it is important to pay attention—even though this only indirectly pertains to our discussion—to the charges for which Shaban was arrested and the way the security forces apprehended him. My experience suggests that in many cases security forces turn up at a Palestinian home late at night with a list of names in hand. This list is obtained from a Palestinian youth in the village, who had been arrested previously, interrogated and tortured; the youth simply gives the interrogators whatever name comes to his head. The interrogators use the list as clear proof of the guilt of other youths. And indeed, the charges are usually general; they do not note the place and time of the event for which the person was arrested, and lack specific and detailed descriptions.

“…hostile activities during demonstrations, writing PLO slogans and placing road blockades during the past year.”

The doctor erases the youth’s subjectivity. Whenever a civilian population is fighting against occupation, youths participate in non-violent forms of resistance such as those that Shaban was charged with. During the period of the British mandate, Jewish-Israeli youths participated in activities almost identical to the actions described. When the psychiatrist and the patient are part of the same group, the youth’s subjectivity will frequently be observed and taken into account by the psychiatrist, but when the psychiatrist and patient each come from hostile groups the language of object/subject is employed.

“…the youth confessed,” according to Avni.

What is the meaning here of “confessed”? Did Shaban confess to the charges brought against him before suffering the psychotic attack? Did he confess to them while he was psychotic, while he was unable to understand what was being said to him? Was his psychotic state a result of the interrogation? I would like to remind the readers that the word “interrogation,” in the language of the General Security Services and the Israeli military is often, far too often, a euphemism for the word “torture.” Did Avni check what Shaban’s mental state was at the time of his “confession”? No, he did not.

“Past history: Unknown. In his records it is written that there are no medical problems. The patient is not providing any information. Upon examination: Theatrical effect… he is of clear consciousness. There is no evidence of disturbance in his perceptions. He does not disclose his thoughts. He supposedly is not aware of time, place or of himself. In summary … based on this examination, it seems to me that Ali Shaban is an imposter, and is not mentally ill. In my opinion, he is fit to stand trial.”

“In his records it is written that there are no medical problems.” –

Did Shaban go to a doctor? Which Palestinian village boy has medical records stating that the boy has “no medical problems”? Why did Avni bother writing that there were “no medical problems”? Might Avni be laying the grounds for the diagnosis which comes later, where he states that, in his opinion, Shaban is an imposter? Since, after all, it is a “fact” that Shaban was healthy beforehand… one of those “healthy” village boys who have papers stating that they have “no medical problems.”

“The patient is not providing any information” –

That is to say, the patient is not talking. Why isn’t he talking? Might it be because he refuses to talk? Or perhaps he was so deeply entrenched in his own internal psychotic world that he had lost all contact with reality and was unable to answer? I wonder why details of Shaban’s behavior during his period in prison don’t appear in the psychiatrist’s report. He was, after all, in prison some two months before the medical examination. The doctor did not bring forth even one piece of information regarding the youth’s past and the state he was in while in prison.

“Upon examination” –

From the short diagnosis one is led to believe that there was some kind of theatrical show; at least that is how Avni understood it. There is an “entrance,” the show begins, the show ends, and afterwards the youth goes back to sit in the corridor in complete silence. And indeed, the following sentence says: “When he enters, he begins to act very theatrically. He tries to pour water into a pocket where he has stuck flowers, to eat toothpaste, etc.” I wonder how Shaban obtained toothpaste in a psychiatrist’s examination room. Could he really have brought toothpaste and flowers from prison as theatrical accessories for the examination? What state were the flowers in, having traveled all the way from Farah Prison near Nablus to Hadassah Hospital in Jerusalem? And what did the psychiatrist mean when he said “etc.”? The psychiatrist would have done better to detail what Shaban was actually doing in the examination room, and whether the eating of the toothpaste and the watering of the flowers actually took place during the examination, or whether those were stories that he heard from Shaban’s wardens, acts which he did not see with his own eyes in the examination room.

“Does not say a word, but sometimes answers with “I don’t know” gestures … Does not know where he is, what day it is, how old he is” –

These are standard questions at the beginning of every psychiatric examination. It is strange, then, that Avni writes, later on, “clear consciousness. No evidence of disturbance in his perceptions.” I am wondering how it is possible to bear witness to clarity of consciousness and lack of disturbance in perception when the patient does not say a word. To readers who are not psychiatrists, I’ll add that it is impossible to discuss a state of consciousness or disturbances of thought when the patient does not speak.

“He does not disclose his thoughts” –

When a person doesn’t speak, it should not be surprising that he does not disclose his thoughts. But there is nothing innocent about this sentence when one takes into account that it was written by a psychiatrist. This sentence is not as straightforward as it may appear. In psychiatric language, this sentence—that a person who does not speak, doesn’t disclose his thoughts—suggests that the patient is willfully refusing to disclose his thoughts, whether because he is an imposter, or because he is paranoid. In other words, it is an “incriminating” sentence.

And the examination ends with a clearly biased sentence:

“He supposedly is unaware of time, place or of himself. In summary: I don’t have any evidence before me of past mental illness or mental treatment” –

Is this true, Dr. Avni? Was there really no “evidence”? The head of Shaban’s village council claimed that the patient suffers from mental illness and that his situation is serious. The military judge sent him off to a psychiatric examination, which in itself is rare. But Avni saw no mental illness before him.

“…based on this examination, it seems to me that Ali Shaban is an imposter, and is not mentally ill. In my opinion, he is fit to stand trial.”

A clear-cut conclusion, which leaves no room for a second diagnosis, although a second opinion is actually common practice in psychiatric examinations. It seems that there was no doubt in Avni’s mind that he was facing an imposter, who was, most likely, a “terrorist” who had, for the last year, been involved in a variety of hostile acts. The person in front of him was not a young psychotic patient, undergoing his first psychotic attack, perhaps a forewarning of schizophrenia.

I wrote a letter to the civil administration officer in charge of health in the West Bank, asking that he urgently approve a second psychiatric examination by a psychiatrist who does not work in a governmental institute. I attached a copy of a picture that Shaban had drawn—a picture of a couple, a rooster and a hen, that he had drawn on a small piece of paper. He would kiss them, feed them and he called them by male and female names. On July 18, 1990, I received a reply from Dr. Itshak Sever, the officer in charge of health. He permitted a second examination by a psychiatrist from Afula Hospital; an examination by a psychiatrist from PHR-IL was not permitted.

In order to present a more complete picture of the socio-political situation at the time, it is important to note that this was right after an Israeli Jew named Ami Popper murdered seven Palestinian workers. Popper was examined by five psychiatrists and later demanded to be examined by three more psychiatrists, doctors that “he trusted.” His request was granted. Shaban’s case was not treated in a similar fashion. PHR-IL published the case in the newspaper. The journalist contacted Avni, who, when referring to me, said: “Her request is political. As opposed to her, I am not a political personality, but rather a specialist in legal psychiatry and an Arabic speaker.”

One can answer Avni simply by quoting Stephen Mitchell: “Is not the posture of not taking sides itself a partisan position, a side one is taking?” The problem is not whether one takes sides, since everyone takes sides all the time. The problem is when a person does not see that he is taking sides. The question is only to what extent are we aware of the fact that we, psychiatrists, like everyone else, are subjective and political. We must view, as J. Greenberg says, “the psychiatrist’s participation as inevitably subjective.” Yet, when one takes the side of the establishment, there is a tendency to blindness.

The patient’s political “crimes” as spelled out by the prosecution—and not his mental state—often determine the psychiatric diagnosis. Rather than diagnosing the prisoner, the psychiatrist, willingly or unwillingly, tries him. As O. Renik argues, the psychiatrist’s understanding of the patient is a result, if but a partial result, of the totality of the psychiatrist’s subjectivity. The prisoner is regarded as a terrorist, an enemy, a person endangering the state of Israel, its citizens and its soldiers, rather than as a person who has lost his sanity. While the psychiatrist cannot escape his or her subjectivity, as Renik points out, in my opinion psychiatrists do not need to flee from such subjectivity—they need to be aware of it as much as possible.

One should keep in mind that the term illness itself—not only one’s political persuasion—is more than a mere description of fact. Illness is subjective and emotionally charged. As K.W.M. Fulford has stated, illness is a fact plus an added value. Our own judgment will always accompany us when dealing with disease or illness. For instance, “influenza” is not as charged as AIDS is. This is also true, of course, when confronted with schizophrenia, which is charged with negative values and judgments. This helps explain why members of higher classes are less likely to be diagnosed as schizophrenia than those of lower classes. The psychiatric community has known for several years, following the publication of various articles and studies carried out in the Western world, that people who belong to the low end of the social scale for reasons of race, color, gender, economy, or education are more likely to be diagnosed as having mental illnesses such as schizophrenia than people who are higher up on the social scale.

According to these findings Avni should have diagnosed Ali Shaban as mentally ill, not only because of his illness, but also because of his low standing on the social hierarchy: he was a poor villager, from a national and religious minority. Yet, in Shaban’s case, the diagnosis was in stark contrast to the common trend shown in the studies: Shaban, a mentally ill youth, was transformed into an imposter, for political-social-cultural reasons. In this case, which is just one of many, the psychiatrist’s tribalism (racism, vengeance, and fear) leads him to introduce a level of sophistication: a mentally ill Palestinian terrorist will be diagnosed as an imposter, so that his illness will not protect him from being incarcerated. The objective is clear: the patient/prisoner will not be freed from a military prison and admitted to a psychiatric hospital, and he will continue to be considered a national threat.

Before continuing, I would like to briefly recount what happened to Shaban. The psychiatrist at Afula Hospital did not wish to diagnose the psychotic youth, and asked that the diagnosis be done at a psychiatric hospital. Since no Israeli hospital agreed to examine him, he was released, following pressure from PHR-IL. More than a decade after his arrest, Shaban spends most of his days in the streets as the village fool. He is not a student; he does not work. Shaban has become a chronic, untreated psychotic. That is Avni’s “imposter.”

I have described Shaban’s case in some detail not because it is exceptional. On the contrary, I know of several similar cases, and, I presume, there are many more that I am unaware of. This was simply the first of a series of cases that I dealt with. Avni’s claim about who is political and who is not is certainly not unique. Many people work, think, and speak like this, including members of the medical establishment. If you don’t question the government, if you agree with the establishment, you are seen as being objective, as being apolitical. But if you object to crimes perpetrated by the government, you are taking a political stance. Making the blind spot visible is accordingly considered one-sided, extremist, and un-collegial.

The knowledge that all humans are “tainted” with political views will enable us to begin engaging in an intra-psychiatric discussion and will increase our self-awareness while carrying out our work. Advancement in this direction will enable psychiatry to support human rights, and will enhance a more pluralistic and conscious discourse. Lack of openness, on the other hand, will necessarily lead to the violation of human rights and to the perverse use of psychiatric power.

IV. The IMA’s Ethics Committee and Prisoner’s Rights

An article, published in the Israeli daily newspaper Hadashot on March 5, 1993, which was based almost entirely on an interview with me, presented the cases of three Palestinian prisoners who were undoubtedly chronic schizophrenics. The article cited bizarre diagnoses attributed to these patients by Israeli psychiatrists like “anxiety as a result of conditions of incarceration” and “an imposter.”

“Anxiety due to conditions of incarceration” seems to mean anxiety as a result of conditions of imprisonment. This apparently logical combination of words requires an explanation, particularly since there is no such diagnosis in psychiatric textbooks. Ostensibly, anxiety due to conditions of incarceration is a normal phenomenon experienced by every prisoner. However, when written by Israeli psychiatrists about Palestinian prisoners who are mentally ill, it eliminates these prisoners’ right to madness; they are subsequently sent, as if completely sane, directly to a military court and frequently to prison for lengthy periods of time.

This combination of words—anxiety due to conditions of incarceration—derides psychiatry, the prisoner, and schizophrenia. Almost every person experiences anxiety—actually fear—when subjected to incarceration. But it is a mistake to call such fear anxiety. The physical and mental conditions that are at times called “fear” and at times “anxiety” are not identical. According to classical psychiatric terminology, the difference between fear and anxiety is that fear has a cause that is visible, while anxiety, including all of the physical aspects of it which are identical to fear, lacks any visible cause.

Could the term “anxiety due to conditions of incarceration” have been written innocently? I do not think so. In classical psychiatry, “anxiety” is a phenomenon that belongs to the world of neuroses and not to mental illnesses—psychoses. So a prisoner suffering from “anxiety due to conditions of incarceration” is most likely neurotic and surely not psychotic. If he is not psychotic, he is fit to stand trial, because only the psychotic is considered to be unfit. Accordingly, the diagnosis “anxiety due to conditions of incarceration,” is employed to prevent a mentally ill person from not being tried or sent to prison. The mentally ill prisoner’s basic right is thus violated. Ironically, many of these prisoners, despite being diagnosed as non-psychotic, are usually given anti-psychotic drugs in prison.

Since “suffers from anxiety as a result of conditions of incarceration” is not a diagnosis, I consider it to be a description of a condition. The problem is that this description is offered as a diagnosis. But what is worse is that this description, disguised to look like a diagnosis, was given to a psychotic person, who was consequently not diagnosed as psychotic.

What does the doctor mean when he says “imposter?” “Imposter” is a well-known psychiatric diagnosis. This diagnosis, when correct, is appropriate in cases where the patient reveals signs of clear consciousness, sophistication, design, and awareness of location, time, and reality. None of these signs appear when the patient is in a psychotic state. Therefore, when a psychotic person is misdiagnosed as an imposter, there is a reversal of roles: most imposters act or play a part when they wish to receive compensation or improve their living conditions in some other way. In this case, it is the psychiatrist who wishes to gain something. What does he wish to gain? He wants to make the authorities happy by not letting a “dangerous” Palestinian “terrorist” evade prison. Another possibility is that the psychiatrist wants to remain true to his blind spot, and not to bother himself with difficult questions. The rhetorical question asked by the journalist at Hadashot hit the nail on the head: “What is a psychiatrist supposed to do when asked to treat a terrorist who is also mentally ill? In the case of Mahsan Mahlal, he was found to be sane, incarcerated for eight years, but given anti-schizophrenia drugs. Psychiatrists also take security into consideration.”

Following the publication of my interview in Hadashot, two of the seven psychiatrists mentioned in the article filed a suit with the IMA’s Ethics Committee. After two years of hearings, the disciplinary court, appointed by the IMA’s Ethics Committee, decided that I should apologize in writing for mentioning the doctors’ names in the article. My apology was to appear in the IMA’s official newsletter. The IMA’s Ethics Committee refused to deal with the moral issues that I raised, which were the basis of the newspaper article, namely, that Jewish-Israeli psychiatrists who examined Palestinian prisoners were providing improper diagnoses time and time again, and therefore, in my opinion, this was not simply an error on their part—it was intentional.

In my “apology,” I discussed the principle and moral significance of the way Jewish-Israeli psychiatrists have systematically related to Palestinians who are mentally ill as imposters and manipulative. As a result, I argued, mentally ill Palestinians are incarcerated in solitary confinement. While serving their full sentence, which is imposed upon them by a military court, this kind of confinement frequently leads them to wipe the cell walls with their own excrement and to hit their heads against the walls. Adding insult to injury, they are not only incarcerated despite their mental illness, they are also forced to suffer the torments of solitary confinement. The “apology” letter I wrote contained a request that the IMA’s Ethics Committee act to remedy this situation. The letter was never published, and the IMA’s Ethics Committee never convened to discuss my request.

The fact that Israel’s supreme medical authority (IMA) has never discussed these issues is a reflection of the socio-political needs of many individual psychiatrists as well as of the organization that unites them. That is, the Israeli-Zionist socio-political need to see Palestinians as the enemy, as terrorists, and as dangerous, may be considered to be part of the hegemonic worldview. This worldview is so powerful that it does not permit a mentally ill Palestinian any means of deviating from this preordained image, not even deviation by way of insanity, of madness. Both junior and senior psychiatrists have diagnosed mentally ill Palestinians as imposters, as prisoners suffering from anxiety due to conditions of incarceration, as manipulative, as not mentally ill; the psychiatrist can be a director of a hospital ward or a district physician, a new immigrant or a Sabras, from northern Israel, the center or the south. They are integral members of their community. Surely, not all of these psychiatrists have had bad intentions or were professionally ignorant. Indeed, they do not intend to violate human rights, particularly not the rights of patients. Rather, their objective is to ensure that Palestinians, as a unified body, remain the enemy, which helps keep Zionist Israeli society glued together as a group with a common ideology and goal. The presence of the enemy is essential for maintaining the link and the interconnection between the patriotic Zionist discourse and the action deriving from this discourse—occupation, oppression, arrests and torture.

If these claims seem at first glance to be unconnected to psychiatry, it would behoove us to look again. The Zionist/Palestinian binary opposition is an integral part of the subjective individual experience of Jewish Israelis, and in many ways helps shape their identity. Jewish Israelis also derive their identity from the social group to which they belong and choose to belong, and the social group, in turn, derives its identity through, among other things, its opposition to other groups. The individual identity determines, inter alia, the way in which psychiatrists encounter their patient. As W. W. Meissner suggests, “It becomes for all practical purposes impossible for the psychiatrist’s values not to impinge on the analytic process, and this would include both technical and personal values…[V]alue judgments seem to seep into the therapeutic process throughout every available pore.”

V. Collaboration of the Israeli Medical Establishment in Solitary Confinement and Segregation

For years the Israeli prison system (including prisons under the control of the police, prison services, military and secret services) have used solitary confinement and segregation as a common way of dealing with “problematic prisoners.” The official reasons for holding a prisoner in solitary confinement or segregation include state security, protection of the prisoner, protection from the prisoner, and punishment. However, the prison authorities use solitary confinement and segregation not only for these “protective” purposes, but also as a policing and disciplinary mechanism. This latter use is absolutely prohibited according to Israeli law.

People usually do not die from solitary confinement—they simply become insane. (Ed. note: For a further discussion of this issue, see “Torture,” pps. XXXXXXX.)–In the last decade, extensive studies have examined the psychopathological effects of solitary confinement. The findings of the different studies are uniform: solitary confinement creates profound psychotic reactions, such as hallucinations, body-image distortions, feelings of suffocation, thought disorder, loss of memory, difficulty in concentrating, acute confusional states and subsequent partial amnesia, obsessions, disorientation as to time and space, fear, panic, paranoid states, fear of impending death, depression, hopelessness, apathy, and self-inflicted injuries. People who have been held in solitary confinement have reported continuing symptoms after their release from this form of confinement. They often suffer from dependence, impaired memory and concentration, and confusion. Research has shown that these long-term effects generally do not subside over time as one would expect, but are actually intensified if they are not exteriorized and treated.

Solitary confinement undermines the equilibrium a human being seeks between the needs and demands that stem from both outer and inner worlds. Some of us need more stimuli, some less. The stimuli might be positive or negative, but it is an absolute need. In a state of sensory deprivation, there is no equilibrium between the internal and the external worlds. In short, humans need information via their senses to keep sane. And one of the most elemental stimuli humans require—in fact it is essential to our existence—is the sense of solidarity, the sense of being accepted by others, the need to hear, talk and touch another human being. Yet, all these essential needs are withheld from solitary detainees. As a consequence, one very dominant sensation that inevitably develops is the loss of any ability to feel. Losing this possibility to feel ultimately risks psychological death. In my opinion, solitary confinement is comparable to lobotomy; only here the process is longer and crueler.

In a petition filed to the High Court of Justice in November 1997, PHR-IL and HaMoked (The Center for Protection of the Individual), sought to cancel the unlimited use of solitary confinement. Following the appeal, the Minister of Internal Security appointed a five member committee, including the prison authority’s legal adviser, to examine the issue. In their report the committee members wrote:

“The findings of researchers in this area are unequivocal and show that segregated incarceration leads to deep psychotic responses such as: Hallucinations (visual and acoustic), distorted bodily views, a choking sensation and a sense of confusion of thought, loss of memory, difficulty in concentrating, obsession, paranoid states, etc. This is in addition to the [unhealthy] physical condition that follows anxiety brought on by segregated incarceration. Clearly, the length of time a prisoner is held in solitary confinement has direct implications on the side effects of being held in isolation, since a person held in a cell for one day cannot be compared to a person held for a period of ten weeks, months or years. There can be no doubt that there is a limit beyond which most people will feel that their isolation has become impossible to bear and will suffer from long-term side effects as a result.”

Following the report’s publication, the Mental Health Division of the Ministry of Health refused to provide psychiatrists who would examine prisoners being held in segregation in order to determine whether their mental capacity had changed as a result of such confinement. The psychiatrists at the Ministry of Health refused to cooperate with prison authorities and to assume responsibility of regularly examining prisoners in solitary confinement. The psychiatric examination could be seen as a form of consent to such a method, and in fact, could amount to collaboration with human rights violations. They were not prepared to become a fig leaf, covering up unacceptable methods of imprisonment. In other words, the Ministry of Health’s psychiatrists refused to become part of a disciplinarian apparatus, because they knew they would have no influence over the apparatus itself.

It is important to underscore just how significant and principled this decision was. When an individual psychiatrist, who is employed by the Ministry of Health, understands that unlimited solitary confinement is an egregious violation of human rights and recognizes the severe damage that might be caused to the prisoner as a result of segregation, frequently it is very difficult for him to fight as an individual against the conditions of imprisonment. But if his professional association backs him up, and if the association remains a full partner in such struggle, the psychiatrist can struggle against the violation.

Frequently, the medical associations have not backed physicians regarding the treatment of Palestinian patients. Consider the case of a female Palestinian political prisoner who was suffering from a severe mental illness. In November 1998, attorney Allegra Pacheco asked PHR-IL to intervene on behalf of the young prisoner who prior to her arrest had been abused by her husband whom she was forced to marry. Before her incarceration she had tried to kill herself. In prison she suffered greatly due to the separation from her three children. She did not adapt to prison life and fought with other political prisoners. As a result of her mental condition and other problems, she was placed in solitary confinement for months on end, sometimes without permission to go out.

Dr. Ze’ev Weiner, a psychiatrist, examined the prisoner on behalf of PHR-IL on November 16, 1999 at the Neve Tirtsa Prison, and diagnosed her as suffering from border-line personality disorder with slips into psychosis, which is different from an outright psychotic disorder. Weiner recommended medical treatment and psychotherapy and stated that isolation should not be resorted to as an alternative to treatment.

Dr. Moshe Birger, Director of the Israeli prisons’ Mental Health Department, agreed with the diagnosis and recommendations. Nonetheless, in his response to PHR-IL he stated that the prison system does not provide psychotherapy for Arabic speakers. Despite his opinion that solitary confinement was both wrong and harmful, he added that the prisoner would continue to be held in solitary confinement since the ultimate decision rested in the hands of the prison authorities. This response underscores that even when a senior physician knows and understands the therapeutic needs of a prisoner, he is forced to accept the dictates of the prison system.

The clear role of the Israeli Psychiatric Association in such cases would have been to support the physician in his dealings with the prison authorities, to provide assistance when he or she demands to put an end to harmful solitary confinement. The Psychiatric Association ought to examine the conditions of mentally ill prisoners and to protect them when their rights are violated. Mentally ill prisoners should be released from solitary or segregated confinement and be sent to psychiatric wards. The only way the Psychiatric Association can meet its obligation to ensure that the mentally ill in prison are treated properly is by stripping the prison authorities of its power to make what are essentially psychiatric decisions. Decisions regarding the nature of treatment, psychiatric hospitalization, etc., should be subject to medical calculations alone and determined by medical authorities.

Birger did the best he could as a doctor and as a private person. Had the Psychiatric Association given him organizational-medical support, he might have released the prisoner so that she could be treated within her community. Alternatively, he could have admitted her to a mental hospital. The doctor, as an individual, needs the support of his professional association when facing such institutions like the prison authorities, because he cannot succeed in fulfilling his professional duty to treat and take care of patients without the association’s assistance. The Israeli Psychiatric Association must become a serious and efficient address for matters of this kind, and I can only hope that raising these issues and discussing them will bring about an increase in awareness of the infringement of the rights of prisoners who are suffering from mental problems, and that such awareness will, in turn, also give rise to remedial action.

One should also note that a doctor will find it very difficult to act in accordance with the Hippocratic ethical code so long as he or she has dual loyalties: on the one hand, to the totalitarian system of police, prison services, military and general security services, and, on the other hand, to the patient. Therefore, PHR-IL recommends that doctors working for the security forces be employed directly by the Ministry of Health. Simultaneously, there should be clear ethical guidelines regarding the doctor’s role, as well as a support network for doctors who have to confront the system.

VI. The IMA’s Failure to fulfill its Ethical Duty against the use of Torture

In 1993, six years before the High Court of Justice prohibited the use of moderate or severe physical pressure in Israel, or, in other words, torture, PHR-IL asked the IMA to confront the problem of physicians participating in torture. (Ed. Note: See “Inside Israeli Jails,” pps. XXXXXXXX.) PHR-IL’s demand was based on the United Nations Convention against Torture (1984) and the Declaration of Tokyo (1975). Both documents indicate that the methods of interrogation employed by the Israeli General Security Services (GSS) constitute torture, and the latter contends that a medical examination conducted before, during or after such interrogations constitutes participation in torture.

Following the logic of these and other international documents, PHR-IL does not accept the claim that doctor participation in torture—i.e., by performing examinations before and during interrogations—is in any way justifiable and rejects the argument that doctors are able to prevent suffering and irreparable damage in such examinations. PHR-IL is of the opinion that a doctor’s recommendation to interrogators not to use a particular method of torture clearly implies permission to use other methods. Through his cooperation, the doctor becomes a safety net for the General Security Services, which can then torture without fear that “on site accidents”—i.e. the death of the tortured person—will occur. In addition, a treatment that is nothing more than merely providing remedies for pain (which is what is done in examinations and treatment during interrogations) and is in essence a stamp of approval for sending the patient back to the place where he was subjected to pain—i.e., the interrogation room—amounts to complicity with torture.

The IMA did not rise to PHR-IL’s challenge, which demanded that it insert the following clauses dealing with human rights into its medical code of ethics:

• A prohibition against the participation of doctors in torture by way of medical examinations before and during torture in GSS interrogations.
• Prohibition against writing false doctor’s letters constituting a cover for the GSS after harm was inflicted on the body or mind.
• The obligation of every doctor who sees a man or a woman who has suffered from abuse, beating, torture, etc., to file a report, similar to the law already existing in Israel regarding the duty to report cases of child abuse.
• Prohibition against active participation of doctors, such as examination and treatment of prisoners in solitary confinement or segregated confinement.
• An examination of the professional-ethical problem concerning the way in which Israeli psychiatrists relate to mentally ill prisoners, drawing conclusions and preparing ethical and professional guidelines.

By failing to accept the challenge, the IMA acted in a manner similar to the Medical Association of South Africa, which during the years of apartheid failed to condemn those who allowed the torture and killing of political prisoners, like Steve Biko. According to PHR-IL, the work of doctors in GSS prisons amounts to complicity in torture and is no more than an ethical rubber stamp, which says torture can be carried out in a “humane” manner, which does not harm the torture victim’s body or mind. Only an absolute prohibition of any participation with the GSS will ensure that doctors do not slide down the slippery slope ultimately leading them to participation in torture.

PHR-IL presented a number of cases where Israeli doctors participated in torture and provided its recommendations to the IMA, but the rights group did not receive a germane response from the IMA until the Israel High Court banned the use of torture in September 1999. For six years, the IMA used manipulative tactics to evade PHR-IL’s demands—to introduce new ethical regulations as well as offering a series of seminars on the topic—to prohibit doctor participation in torture. The IMA imposed an impossible and unfair demand: “Bring us the names of the doctors working with the General Security Services who participate in torture, and we will deal with them.” This demand was impractical, because PHR-IL has no way of knowing all the names of doctors who work for the GSS, and it is unfair because it would punish the messengers, but leave the method intact. Therefore, PHR-IL refused to give the IMA the names of two doctors whose signatures appeared on “fitness for torture” medical forms, which it had obtained. The forms themselves provided evidence that doctors regularly examined prisoners before they were tortured.

VII. Conclusion

As a field, psychiatry has considerable influence in determining social norms. The definition of norms and “the normal” are interconnected, and psychiatry is conceived as both having expertise about the two and as an authority regarding their definition. Thus, psychiatry is at the same time the body that determines society’s norms, and the guardian of those norms. Psychiatry can use its powers to determine norms that respect and accentuate the human rights of all people, patients and prisoners, or it can use its powers in a perverse manner, establishing and maintaining unethical and amoral norms.

Tragically, in Israel physiatrists have frequently chosen to use their power in a perverse way. In order to do so, they have violated an unwritten rule of western psychiatry—the rule which calls upon them to remove the mentally ill from the social sphere. The lunatic, as Michel Foucault described him, is the “other” and society treats him accordingly. He is positioned outside the social order, alone, and marked. Ironically, when the mad person is a mentally ill Palestinian prisoner, this rule does not apply. A mentally ill Palestinian will be pushed by force—of power/knowledge—into the middle of the Israeli social order. He is not removed from the social terrain to a psychiatric hospital, as one would expect, but rather kept in an Israeli prison. A mad Palestinian prisoner is not expelled from the boundaries set by the Israeli systems of power/knowledge, since these systems stipulate that every Palestinian is an enemy. And the enemy is part and parcel of the system, one of its constituting elements; accordingly, mentally ill Palestinians are not expelled from the system as mad people are. Therefore, no Palestinian, not even a madman or an insane person, will be allowed to deviate from the identity that has been attributed to him—i.e., the enemy—for the simple reason that any deviation can threaten the hegemonic worldview. Palestinian village fools are consequently killed by security forces and mentally ill Palestinians are tried and imprisoned as if they were aware of or responsible for their actions or, more accurately, the actions that they have been accused of committing.

Within the power game managed by the state to silence the voices of the “other,” the psychiatrist becomes complicit so long as he or she does not actively resist the prevailing mood. The discussion concerning human rights is, I hope, the beginning of a necessary dialectic process which will open the way for critical thinking. This kind of critical thinking has to be carried out by the doctors themselves, and by the organizations that represent them, not least the Psychiatric Association and the IMA. By way of conclusion, I will briefly discuss the way each group relates to human rights and the rights of patients.

In terms of the individual psychiatrist, the violation of human rights and the rights of a patient frequently takes place when the humanity of the Palestinian prisoner is reduced in such a way that the patient is identified as a “dangerous terrorist.” Accordingly, the Palestinian is not diagnosed as mentally ill and as such he is responsible for his acts; he is not considered unfit to stand trial or unfit for incarceration, but rather he is diagnosed as a manipulative imposter or one who suffers anxiety as a result of his imprisonment. The psychiatrist’s worldview is so entrenched that the Palestinian cannot deviate from this reduction to enemy, even when he is psychotic and mentally ill.

Not unlike the majority of Israeli society, psychiatrists often forget their professional obligations when these appear to be in conflict or in contradiction with its obligations towards the state of Israel. Professionalism is undermined due to a type of patriotism, the psychiatrist’s embodiment of a vague ideology known as “Zionism.” The Israeli socio-political need to make all Palestinians identical cannot permit any deviation. Therefore, an insane Palestinian is denied his right to madness, the very same madness that is supposed to eject him from the discourse that describes him as a “dangerous enemy.” To cite once again the words of the journalist from Hadashot: “What is a psychiatrist supposed to do when asked to treat a terrorist who is also mentally ill?” I believe the answer is obvious: one should treat him as a mentally ill patient. Conversely, one should not treat him as the representative of a boundary beyond which there is nothing but fear and hate and therefore as someone who needs to be distanced and punished—one should not disregard his humanity, that is, the fact that he is an individual in and of himself.

The psychiatrist must be conscious of the interests he is serving: the patient’s interests or those of the institution and system for which he works. The psychiatrist must first be aware of his own social, political and cultural background. If these components are part of his blind spot, he will be unconscious of his identification with the authorities even while this identification dictates the way in which he relates, professionally to a Palestinian patient. It will not allow him to see that he is violating human rights or being disloyal to basic medical values. In the complex reality in which the Jewish-Israeli psychiatrist operates, he needs an ethical support system no less than a professional support system. Without external ethical support, a psychiatrist who makes the ethical decision might find himself in an extremely difficult position, acting as if he were a Don Quixote and paying a great price for it, with a high chance that his struggle will not bear fruit.

An important and crucial role which the Psychiatric Association should take on involves the provision of courses on human rights and, more specifically, on the rights of the patient. A discussion of human rights’ relation to psychiatry is, in my view, a crucial step in altering the prevailing theoretical worldview which holds that psychiatrists are supposed to be objective and neutral as well as apolitical. It may lead to a broader understanding of ourselves as psychiatrists and as humans. This understanding includes the social, political, cultural relations that help constitute our own personal identities.

The Israel Psychiatric Association can and must be the body that leads the transition from a worldview whose time has passed, both theoretically and socio-politically; that is, it must lead psychiatry from a view that conceives the psychiatrist to be a neutral subject and the patient as an object, to a self-awareness amongst psychiatrists that their own subjectivity is constituted by the political, cultural and social power relations circulating in society and that their patients are also subjects who are constituted in a similar fashion. This view will enable psychiatrists to become aware of human rights in general as well as the specific rights of prisoners and the mentally ill.

The Psychiatric Association is part of the third group, the Israeli Medical Association, which is located at the top of the pyramid. What is the IMA’s position regarding human rights? At a political-government level, human rights are frequently infringed upon in the name of upholding the state’s security, and the IMA does not use its power to remedy this situation. The IMA has a tendency to toe the line drawn by the Israeli government when health and medicine related human rights are violated, particularly when the person abused is a Palestinian. The ways in which the security forces act towards the mentally ill help create the position which, unfortunately, the medical establishment adopts.

One final example may prove revealing. A chronically mentally ill Palestinian named Rejwan was held in administrative detention for two years. When he was brought before a military judge in order to extend his detention, the judge sensed that his mental state justified a psychiatric examination. Rejwan was accordingly taken to Be’er Yakov Hospital and examined by a psychiatrist who found that he was schizophrenic and thus unfit to stand trial. The military judge decided, therefore, not to try him. (Ed. Note: See “Inside Israeli Jails,” pps. XXXXXXX.) At this stage, the Major General of the Southern Command of the Israel Defense Forces, Matan Vilnai, intervened and overturned the previous decisions—both medical and judicial—and ruled, by virtue of his power (in January 1992) that Rejwan would be sentenced to a further six months of administrative detention.

This case exemplifies how the higher echelons of the Israeli security forces demarcate the borders of professional fairness and medical ethics for many psychiatrists. Within totalitarian systems there is the common phenomenon of “obeying orders.” Namely, members of the higher echelons dictate the way things ought to be (not always in writing), and their subordinates obey their orders. If the general in charge puts a mentally ill Palestinian in administrative detention (after he had already been imprisoned for two years without trial), and ignores a judicial decision and a psychiatric diagnosis which say that this person should not be incarcerated, then most psychiatrists who are “obeying orders” will ignore their own professional obligations and abdicate their ethical responsibility.

As an individual, the psychiatrist usually cannot fight such blatant violations of human and patient’s rights. The individual psychiatrist needs the assistance of his professional association—i.e. the Israel Psychiatric Association—and of the umbrella organization, the IMA. The IMA must use its powers, both professional and ethical, in order to remedy the situation and protect the patient’s rights. If it does not do so, then it is using its immense powers in a perverse manner. If the government’s rights-abusive policies are not challenged at the individual level and/or at the organizational level, the rights-abusive worldview will ultimately determine the society’s social practices, and thus cause psychiatrists to “forget” their professional knowledge and obligations.

The medical establishment, including the IMA’s Ethics Committee, is unwilling to challenge in any way whatsoever the security forces. Moreover, the IMA identifies with the security forces’ values, which overshadows professional and ethical questions. I do not know what the positions of individual doctors are; however, I can say that most doctors do not have the opportunity to participate in earnest and in-depth discussions about human rights, at least not in an organized fashion. No courses on human rights are offered at any of the Israeli medical schools. The IMA, which has the power to initiate such courses and hold discussions of this type as well as to introduce regulations that would assist doctors who undergo difficult experiences, does not rise to the occasion even when rights groups challenge it to do just that.

The IMA’s obligation is, inter alia, to protect doctors from committing war crimes and violating international law. If it does not introduce ethical regulations as well as training and education courses, it fails to fulfill its obligations towards doctors. In the absence of any real discussion about these issues and the constant provision of ethical and professional support for all doctors who provide medical services to the security forces, then how can we expect individual doctors to challenge the existing system?

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HUMAN RIGHTS AND PSYCHIATRY IN VIOLENT POLITICAL CONFLICT

[Presentation at conference at Ben-Gurion University, Tel Aviv, Israel, June 2005]

Introduction

The psychiatric establishment is an agent of social supervision, discipline, and control, due, inter alia, to the part it plays in determining societal norms. Society has turned psychiatry into an authority with quasi-judicial powers, which has the ability: (1) to determine a person’s fitness to stand trial; (2) to determine whether an individual’s behavior is dangerous or not; (3) to enforce confinement in mental health institutions; and (4) to set and evaluate various skills, including the intelligence of individuals. At the same time, psychiatry produces the rules informing its own position of power, a power that is both judicial and executive. These different social roles provide the psychiatric establishment—both as a whole, as well as individual psychiatrists—with extremely significant powers that extend well beyond the professional medical definition of diagnosis and treatment of mental illnesses and disease.

Importantly, human rights are historically connected with the advent of psychiatry. The French physician Philippe Pinel was responsible for the release of mentally ill inmates from French jails.² The role of understanding mental illness, distinguishing it from criminal activity, and protecting the rights of the mentally ill, is today still part of psychiatry’s function. Society has compelled psychiatry to be the field that determines fitness to stand trial and fitness for imprisonment, and this responsibility gives rise to an additional duty: namely, upholding the rights of prisoners—the mentally ill in particular, and detainees in general. Human rights and their protection are therefore an integral and substantial component of psychiatry. The awareness or lack thereof of this function dictates, to a considerable extent, the use psychiatry makes of its own power.

The question of where psychiatry situates itself in relation to the state and the individual is a socio-political question that depends on the degree to which it is aware of its role as a protector of human rights. Simultaneously, though, psychiatry’s location in the social landscape also stems from and is subject to the theoretical position which it adopts. According to classical theory, which has informed psychiatry from its inception, the intrapersonal is the principle dimension of the therapeutic relationship. During the last few decades of the 20th century, however, theoretical developments have stressed the significance of the interpersonal dimension. From the perspective of classical psychiatry, which assumes that everything takes place within the personal field, the socio-political dimension—i.e., the super-personal—is considered outside the borders of psychiatry and therefore is not included within the boundaries of its discourse. Obviously, this theoretical position, which ignores the socio-political dimension, is, in itself, political. As we will see the inclusion of the super-personal dimension within the psychiatric discourse is crucial for both increasing awareness of and in providing the necessary theoretical tools for dealing with human rights.

The theoretical term used here to conceptualize the super-personal dimension is intersubjectivity.³ The intersubjective relationship between the patient and the psychiatrist provides room not only for the individual or personal dimension, but also for both parties’ socio-political background. It enables the psychiatrist to broaden his or her spectrum when looking-inward—allowing an in-depth examination of the system of motives, emotions, fears and prejudices informing the psychiatrist—as well as his or her rapport with the patient. This paper will underscore some of the dangers resulting from the exclusion of the super-personal dimension from psychiatry, particularly those that entail the violation of human rights. I shall examine how psychiatry employs its immense force, asking whether it uses it in order to protect human rights, the rights of the mentally ill and of prisoners, or whether it uses its power perversely by toeing the establishment’s line, while disregarding the rights of the individual. Using Israel as a case study, in the following pages I'll explore some practical and theoretical aspects of these questions.

The Diagnostic Relationship in Prison—A Theoretical Perspective

In classical psychiatric language, the psychiatrist is the “subject.” The psychiatrist brings to the diagnostic or remedial relationship his own view of reality, whether consciously or not.⁴ This view of reality constitutes a large portion of the power and knowledge used in understanding the patient, the “object.” In far too many cases, this causes the personality of the object, the prisoner, to be reduced so as to accord to the needs of the psychiatrist. The subject (the psychiatrist), in a blindness that serves parts of his subjectivity, sees only a part of the object (the patient), yet considers it to be the whole. The object is nothing more than a “criminal,” an “Arab,” a “terrorist,” a “woman,” a “mother.” This view eliminates the object’s individuality and transforms him into nothing more than the representative of a group with stereotypical characteristics, which stem from the psychiatrist’s prejudices.

When therapeutic theory and practice provide room for two subjects—one being the classical subject or psychiatrist, and the other the patient as subject (replacing the classical object)—this is much more than mere semantics. In such instances, the patient and psychiatrist are both treated as subjects, each of whom has his own view of reality, including his own personal, social, political, and cultural background. Relating to the patient as a subject, with all of the factors characterizing a subject, is the best antidote to the distorted view psychiatrists often have of their patients.

A “continual deconstruction and analysis of counter-transference,” according to Stephen Mitchell, “is a powerful, very influential form of announcing the psychiatrist’s values and concerns.”⁵ When the psychiatrist is not at all interested in developing self-awareness regarding the values and concerns he brings to the relationship, then Mitchell’s helpful advice will have no effect. The opposite is the case: Instead of looking inward, into his own personal, social, cultural and political world, or in Mitchell’s language, his concerns, the psychiatrist will make a critical decision, preferring, as it were, outsight to insight.

Outsight is a system of ideas including points of view that come from the outside. In the aggressive political game that the Israeli state is playing to silence and oppress the other, there is a constant danger that the psychiatrist will maintain a blind spot regarding his complicity in this process. This blind spot enables the psychiatrist to ignore his professional-ethical obligation as a physician whose role is to protect the rights of the patient, the prisoner, the “other”—any person whom the social order knowingly silences. As a result of his blind spots, the psychiatrist acts as an agent for the authorities, the powers that engender his blind spots do not enable him even to see that he is uncritically accepting the government’s worldview and system of ideas. This specific blindness allows him, in turn, to consider himself apolitical, while any person who does not identify with the government’s worldview, or who objects to it, is considered to be acting according to “political motives,” which counter the purity of the psychiatric profession.

As is well known, psychiatrists have identified with government power throughout history. In Nazi Germany, the Soviet Union, Argentina, Chile as well as other countries, psychiatry was employed as a tool by the authorities. It is both theoretically and practically important that the Israeli psychiatrist recognize the fact that he is positioned on the aggressive and powerful side within a concrete socio-cultural-political reality: healthy versus ill, Israeli versus Palestinian, free versus imprisoned, white collar versus convicted criminal—and frequently, wealthy and educated versus poor and uneducated—and (although changes have taken place over time and there has been some progress) man versus woman.

Psychiatry as Determiner of Fitness to Stand Trial

In Israel, psychiatrists are responsible for diagnosing and assessing people who are about to be tried, in order to determine their ability to stand trial. This responsibility raises important questions, since psychiatry’s boundaries are not always clear. There are the questions concerning the prisoner’s responsibility, will, and ability to understand the difference between right and wrong, as well as whether he is dangerous to the public and/or to himself and what the motives or reasons for his actions were. The motivations for the act ascribed to the patients, not only derive from the mental-personal field and therefore cannot be accounted for by simply invoking mental theory. Motivations are always informed also by the socio-political and cultural spheres, and the borders between them are neither sharp nor clear. In this respect, as with other issues, the psychiatrist’s counter-transference is of considerable significance.

One should bear in mind that mentally ill prisoners are a minority within a minority, and they often suffer from very severe violations of human rights. When mentally ill prisoners are members of a different cultural and national group than that of their psychiatrist, the difference becomes a decisive factor in the diagnosis and treatment. This raises the question concerning the psychiatrist’s personal stance when his patient is from a different culture or nationality: What is the psychiatrist’s position when the patient is a Palestinian—not only a foreigner, but the enemy? Is the psychiatrist aware of his subjective position, which perceives his patient as a “terrorist,” i.e., as a real threat to society’s security? Such a view might be so encompassing as to conceal all other parts of the patient’s humanity. The specific role ascribed to Israeli psychiatry, to protect “public security,” can obscure the boundaries between the psychiatrist’s professional judgment and his political beliefs, and this may occur without sufficient self-awareness.

Palestinian mental illness can therefore fall within the blind spot of the Jewish-Israeli psychiatrist—unseen and undiagnosed. The patient’s (potential) threat to the public is visible, but as opposed to other cases—in which non-Palestinian prisoners are diagnosed—the origin of the threat is political, not mental illness. The crucial question here is the extent to which the Jewish-Israeli psychiatrist is at all aware of his own blindness. In psychiatric language one might say that insofar as the psychiatrist’s counter-transference does not undergo processing and is not raised to the level of consciousness, he is unaware of his motivations.

Disregarding the Super-Personal Dimension

Stephen Mitchell said: “Is not the posture of not taking sides itself a partisan position, a side one is taking?”⁶ The problem is not whether one takes sides, since everyone takes sides all the time. The problem is when a person does not see that he is taking sides. The question is only to what extent are we aware of the fact that we, psychiatrists, like everyone else, are subjective and political. We must view, as J. Greenberg says, “the psychiatrist’s participation as inevitably subjective.”⁷ Yet, when one takes the side of the establishment, there is a tendency to blindness.

In a case of 17 years old Palestinian from the west bank, which is just one of many, the psychiatrist’s tribalism (racism, vengeance, and fear) leads him to introduce a level of sophistication: a mentally ill Palestinian prisoner will be diagnosed as an imposter, so that his illness will not protect him from being incarcerated. The objective is clear: the patient/prisoner will not be freed from a military prison and admitted to a psychiatric hospital, and he will continue to be considered a national threat.

I can only say that the knowledge that all humans are “tainted” with political views will enable us to begin engaging in an intra-psychiatric discussion and will increase our self-awareness while carrying out our work.

The IMA’s Ethics Committee and Prisoner’s Rights

An article, published in the Israeli daily newspaper Hadashot on March 5, 1993, which was based almost entirely on an interview with me, presented the cases of three Palestinian prisoners who were undoubtedly chronic schizophrenics. The article cited bizarre diagnoses attributed to these patients by Israeli psychiatrists like “anxiety as a result of conditions of incarceration” and “an imposter.”

“Anxiety due to conditions of incarceration” seems to mean anxiety as a result of conditions of imprisonment. This apparently logical combination of words requires an explanation, particularly since there is no such diagnosis in psychiatric textbooks. Ostensibly, anxiety due to conditions of incarceration is a normal phenomenon experienced by every prisoner. However, when written by Israeli psychiatrists about Palestinian prisoners who are mentally ill, it eliminates these prisoners’ right to madness; they are subsequently sent, as if completely sane, directly to a military court and frequently to prison for lengthy periods of time.

Could the term “anxiety due to conditions of incarceration” have been written innocently? I do not think so. In classical psychiatry, “anxiety” is a phenomenon that belongs to the world of neuroses and not to mental illnesses—psychoses. So a prisoner suffering from “anxiety due to conditions of incarceration” is most likely neurotic and surely not psychotic. If he is not psychotic, he is fit to stand trial, because only the psychotic is considered to be unfit. The mentally ill prisoner’s basic right is thus violated. Ironically, many of these prisoners, despite being diagnosed as non-psychotic, are usually given anti-psychotic drugs in prison.

What does the doctor mean when he says “imposter”? This diagnosis, when correct, is appropriate in cases where the patient reveals signs of clear consciousness, sophistication, design, and awareness of location, time, and reality. None of these signs appear when the patient is in a psychotic state. Therefore, when a psychotic person is misdiagnosed as an imposter, there is a reversal of roles: most imposters act or play a part when they wish to receive compensation or improve their living conditions in some other way. In this case, it is the psychiatrist who wishes to gain something. What does he wish to gain? He wants to make the authorities happy by not letting a “dangerous” Palestinian “terrorist” evade prison. Another possibility is that the psychiatrist wants to remain true to his blind spot, and not to bother himself with difficult questions. The rhetorical question asked by the journalist at Hadashot hit the nail on the head: “What is a psychiatrist supposed to do when asked to treat a terrorist who is also mentally ill? In the case of Mahsan Mahlal,⁸ he was found to be sane, incarcerated for eight years, but given anti-schizophrenia drugs. Psychiatrists also take security into consideration.”

The fact that Israel’s supreme medical authority (IMA) has never discussed these issues is a reflection of the socio-political needs of many individual psychiatrists as well as of the organization that unites them. That is, the Israeli-Zionist socio-political need to see Palestinians as the enemy, as terrorists, and as dangerous, may be considered to be part of the hegemonic worldview. This worldview does not permit a mentally ill Palestinian any means of deviating from this preordained image, not even deviation by way of insanity, of madness.

Surely, not all of these psychiatrists have had bad intentions or were professionally ignorant. Indeed, they do not intend to violate human rights, particularly not the rights of patients. Rather, their objective is to ensure that Palestinians, as a unified body, remain the enemy, which helps keep Zionist Israeli society glued together as a group with a common ideology and goal. The presence of the enemy is essential for maintaining the link and the interconnection between the patriotic Zionist discourse and the action deriving from this discourse—occupation, oppression, arrests and torture.

If these claims seem at first glance to be unconnected to psychiatry, it would behoove us to look again. The Zionist/Palestinian binary opposition is an integral part of the subjective individual experience of Jewish Israelis, and in many ways helps shape their identity. The individual identity determines, inter alia, the way in which psychiatrists encounter their patient. As W. W. Meissner suggests, “It becomes for all practical purposes impossible for the psychiatrist’s values not to impinge on the analytic process, and this would include both technical and personal values…[V]alue judgments seem to seep into the therapeutic process throughout every available pore.”⁹

Conclusion

As a field, psychiatry has considerable influence in determining social norms. The definition of norms and “the normal” are interconnected, and psychiatry is conceived as both having expertise about the two and as an authority regarding their definition. Thus, psychiatry is at the same time the body that determines society’s norms, and the guardian of those norms. Psychiatry can use its powers to determine norms that respect and accentuate the human rights of all people, patients and prisoners, or it can use its powers in a perverse manner, establishing and maintaining unethical and amoral norms.

Tragically, in Israel physiatrists have frequently chosen to use their power in a perverse way. A mad Palestinian prisoner is not expelled from the boundaries set by the Israeli systems of power/knowledge, since these systems stipulate that every Palestinian is an enemy. And the enemy is part and parcel of the system, one of its constituting elements. Therefore, no Palestinian, not even a madman or an insane person, will be allowed to deviate from the identity that has been attributed to him—i.e., the enemy—for the simple reason that any deviation can threaten the hegemonic worldview. Mentally ill Palestinians are tried and imprisoned as if they were aware of or responsible for their actions or, more accurately, the actions that they have been accused of committing.

Within the power game managed by the state to silence the voices of the “other,” the psychiatrist becomes complicit so long as he or she does not actively resist the prevailing mood. The discussion concerning human rights has to be carried out by the doctors themselves, and by the organizations that represent them, not least the Psychiatric Association and the IMA. By way of conclusion, I will briefly discuss the way each group relates to human rights and the rights of patients.

Not unlike the majority of Israeli society, psychiatrists often forget their professional obligations when these appear to be in conflict or in contradiction with its obligations towards the state of Israel. The psychiatrist must be conscious of the interests he/she is serving: the patient’s interests or those of the institution and system for which he/she works. The psychiatrist must first be aware of his/her own social, political and cultural background. If these components are part of his/her blind spot, he will be unconscious of his identification with the authorities even while this identification dictates the way in which he relates professionally to a Palestinian patient. It will not allow him to see that he is violating human rights or being disloyal to basic medical values. In the complex reality in which the Jewish-Israeli psychiatrist operates, he needs an ethical support system no less than a professional support system. Without external ethical support, a psychiatrist who makes the ethical decision might find himself in an extremely difficult position, acting as if he were a Don Quixote and with a high chance that his struggle will not bear fruit.

The Israel Psychiatric Association can and must be the body that leads the transition from a worldview whose time has passed, both theoretically and socio-politically; that is, it must lead psychiatry from a view that conceives the psychiatrist to be a neutral subject and the patient as an object, to a self-awareness amongst psychiatrists that their own subjectivity is constituted by the political, cultural and social power relations circulating in society and that their patients are also subjects who are constituted in a similar fashion. This view will enable psychiatrists to become aware of human rights in general as well as the specific rights of prisoners and the mentally ill.

The Psychiatric Association is part of the third group, the Israeli Medical Association, which is located at the top of the pyramid. What is the IMA’s position regarding human rights? The IMA has a tendency to toe the line drawn by the Israeli government when health and medicine related human rights are violated, particularly when the person abused is a Palestinian. The ways in which the security forces act towards the mentally ill help create the position which, unfortunately, the medical establishment adopts.

One final example may prove revealing. A chronically mentally ill Palestinian, named Rejwan.¹⁰ was held in administrative detention for two years. When he was brought before a military judge in order to extend his detention, the judge sensed that his mental state justified a psychiatric examination. Rejwan was accordingly taken to Be’er Yakov Hospital and examined by a psychiatrist who found that he was schizophrenic and thus unfit to stand trial. The military judge decided, therefore, not to try him. At this stage, the Major General of the Southern Command of the Israel Defense Forces, Matan Vilnai, intervened and overturned the previous decisions—both medical and judicial—and ruled, by virtue of his power (in January 1992) that Rejwan would be sentenced to a further six months of administrative detention.

This case exemplifies how the higher echelons of the Israeli security forces demarcate the borders of professional fairness and medical ethics for many psychiatrists. Within totalitarian systems there is the common phenomenon of “obeying orders.” Namely, members of the higher echelons dictate the way things ought to be (not always in writing), and their subordinates obey their orders. If the general in charge puts a mentally ill Palestinian in administrative detention (after he had already been imprisoned for two years without trial), and ignores a judicial decision and a psychiatric diagnosis which say that this person should not be incarcerated, then most psychiatrists who are “obeying orders” will ignore their own professional obligations and abdicate their ethical responsibility.

As an individual, the psychiatrist usually cannot fight such blatant violations of human and patient’s rights. The individual psychiatrist needs the assistance of his professional association—i.e. the Israel Psychiatric Association—and of the umbrella organization, the IMA. The IMA must use its powers, both professional and ethical, in order to remedy the situation and protect the patient’s rights.

The IMA’s obligation is, inter alia, to protect doctors from committing war crimes and violating international law. If it does not introduce ethical regulations as well as training and education courses, it fails to fulfill its obligations towards doctors. In the absence of any real discussion about these issues and the constant provision of ethical and professional support for all doctors who provide medical services to the security forces, then how can we expect individual doctors to challenge the existing system?

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RESTRICTIONS ON FREEDOM OF MOVEMENT FOR MEDICAL STAFF AND STUDENTS IN THE OCCUPIED PALESTINIAN TERRITORY: UNDERMINING HEALTHCARE IN EAST JERUSALEM, THE WEST BANK AND GAZA STRIP

[Bangkok, Thailand, January 2011]

Introduction

When we hear about limitations on access to adequate healthcare for Palestinians in East Jerusalem, the West Bank and Gaza Strip, the focus is often on the tragic and dramatic cases of patients being stopped at checkpoints and not reaching medical treatment in time to save their lives.

We know of the many patients from Gaza Strip denied permits to leave for treatment in Israel or abroad, who cannot receive the treatment they need because of the poor state of the healthcare infrastructure in Gaza Strip.

In this paper, however, the focus will be on the less dramatic but systematic damage caused to the entire Palestinian healthcare infrastructure by the restrictions healthcare students and employees face under the 43-year-old Israeli occupation. In particular, the two case studies examined in this paper will illustrate the difficulties hospital staff from the West Bank have in reaching their places of work in East Jerusalem, and the denial of permits to medical students from the West Bank to complete training in East Jerusalem. Amongst many examples of other difficulties created for the Palestinian healthcare system, aspects of the Israeli occupation such as these are integral to the denial of basic rights to healthcare experienced by Palestinians.

Background

The situation regarding healthcare facilities in East Jerusalem reflects the broader effects of Israeli occupation in East Jerusalem and the West Bank, whereby the two areas are becoming increasingly separated and populations in both areas suffer as a result. The construction of checkpoints at city entrances at the end of 2000, and of the separation barrier through and around certain areas of the city, as well as the harsh permit system imposed on Palestinians which prevent them from moving between different regions of the West bank, have caused a significant decrease in the number of patients who are able to get to hospitals in the city. These hospitals are becoming facilities for East Jerusalem Palestinians only, the same hospitals that used to be the main medical facilities for the entire West bank and Gaza Strip. Israeli health maintenance organizations (HMOs) do not refer Jews to these hospitals, and Jews do not go to them. This development fits in well with the increasing segregation and inequality in the area of healthcare, since the best Palestinian hospitals are half empty and therefore experiencing severe economic difficulties and the population remains with no proper medical care.

Access for staff

Hospitals in East Jerusalem have always relied on employees who are residents of the West Bank or Gaza Strip – 70% of their staff members were residents of these areas as of 2005. This number has been gradually decreasing in the last few years. Since the early 1990s restrictions have been placed by Israel on the movement of medical personnel into East Jerusalem. In 1996 Israel established quotas of the numbers of staff from the West Bank which East Jerusalem hospitals could employ and who would receive permits to travel to work, exploiting these hospitals’ dependence on staff from the West Bank and Gaza Strip as a mechanism of oppression and control. Permits are regularly denied to employees in the name of security, final decisions being made by the General Security Services (GSS, or 'Shabak'). Furthermore, medical staff is frequently denied passage even when they do have a permit, at the discretion of Israeli soldiers at the checkpoints. Hospitals mostly avoid challenging these decisions due to the weak position they are in vis-à-vis the Israeli authorities. They constantly have to replace staff that is denied permits, thus losing time and money and impeding the hospitals' functioning. Upon completion of sections of the separation barrier, many hospital employees without entry permits left their workplaces in Jerusalem altogether, having to make do with jobs available locally in the West Bank, because of the great difficulty and the daily risk involved in reaching their workplaces in the city. The barrier and the almost-total separation it imposes on the hospitals from the population they are supposed to serve thus pose a real threat to the very existence of these hospitals.

The most recent guidelines brought in on November 2, 2008, required Palestinian medical personnel traveling between the West Bank and East Jerusalem to use only the Qalandiya checkpoint in Ramallah, and forbid them to use other checkpoints closer to their homes. The passage via Qalandiya checkpoint adds one hour to two and a half hours to the daily journey of the staff on their way to East Jerusalem hospitals. These employees are also not allowed to use their own cars to cross the checkpoints, so must use local transport and cross on foot. These restrictions caused further delays and seriously disrupted the hospitals’ work. Various parties, including PHR-IL and the Palestinian Medical Relief Society, who were approached by medical personnel affected by the new guidelines, protested these new guidelines. This resulted in a partial lifting of the restrictions – but only allowing physicians to use any checkpoint, and not other medical staff.

Restrictions for medical students

Amongst those affected by the restrictions on movement and the permit policy are Palestinian medical students from Al-Quds University in Abu-Dis (Jerusalem), which lies on the eastern side of the separation wall. During their fifth year of study they are required to complete practical training placements, which are most appropriately carried out in hospitals in East Jerusalem, for example in Makassed, where students are able to do the rounds at hospitals with a fuller range and higher standard of treatment facilities than in West Bank medical facilities. Makassed, with 200 beds, located in the Mount of Olives in Jerusalem, is the only teaching hospital in the occupied Palestinian territory and is considered the leading one professionally. The application process for these placements requires the hospital to send names and ID numbers of students to the West Bank Civil Administration Health Coordinator, who has to approve the applications in coordination with the Israeli GSS ('Shabak'). Those students who receive permits then have to cross checkpoints from the eastern to the western side of the separation barrier, where they are sometimes stopped and required to attend interrogations by the Shabak, their permits taken away until they do so.

PHR-IL is regularly approached by students in these cases. In recent months, for example, a medical student from Ramallah, who started his fifth year of studying medicine at Al Quds University, was granted a permit for six months to work in Makassed hospital. After three months, as he was crossing a checkpoint to get to Makassed, he was stopped by private security personnel, who took away his permit and told him he was denied access, without giving him any reason. He approached the DCO (District Coordinator's Office) in Ramallah about what had happened and they told him that on his file he was requested to attend an interrogation with the Shabak, although he had not been informed of this request until approaching the DCO on his own initiative. A few weeks later he went to this interrogation where he was requested to collaborate with the Israeli authorities in order to get his permit back, which would involve him providing them information about his fellow students, particularly those traveling abroad, and being in daily contact with the Shabak. When he refused to collaborate they threatened to use force against him. He approached PHR-IL, who wrote to the Israeli authorities on his behalf in order to request the reason his permit had been removed. An answer came only two months later, which stated that the permit had been removed for security reasons, and they may reconsider the decision if the student applies again. PHR-IL submitted a petition to the High Court, and subsequently received an answer from the Israeli Ministry of Security that stated that students may apply for permits only once per year and denying the allegation that permits are denied to those who refuse to cooperate with the Shabak. In the meantime this student has been unable to complete his training at Makassed hospital in East Jerusalem.

Similar cases of slow and complicated application processes and arbitrary denials of permits to qualified medical staff are regularly dealt with by PHR-IL, illustrating how the entire system of medical care in the occupied Palestinian territory is being undermined by the occupation's bureaucracy. In the case of Palestinians from Gaza Strip, permits for students or staff are simply not approved any more, meaning that it is impossible to maintain an adequate health system for the residents of Gaza Strip and preventing East Jerusalem hospitals such as Makassed from employing staff from Gaza Strip.

Conclusion

Outcomes of the situation described above include the establishment of many smaller medical centers or hospitals within the West Bank and Gaza Strip, replacing one good centre in East Jerusalem. No one centre is able to provide the highest standards of medical care whilst more and more smaller centers are built and the healthcare infrastructure as a whole increasingly undermined. This wastes money and human resources in an already stretched small budget. Moreover, it is inefficient and unnecessary to establish multiple medical facilities in such a small geographical territory, when one good facility in East Jerusalem could serve the whole population as it did for many years.

The state of healthcare in East Jerusalem, the West Bank and Gaza Strip is ultimately dependent on the political realities of Israel/Palestine and the way in which Israel is implementing “facts on the ground,” in particular the territorial separation of these Palestinian areas. Israel's demand to postpone negotiations on the status of Jerusalem until permanent status negotiations also commits itself not to take unilateral steps that may change the status quo in the city, until such negotiations take place. The kinds of actions that have been described in this paper constitute a violation of this obligation. Human resources for health in the occupied Palestinian territory, therefore, cannot be genuinely strengthened without pressure being put on the Israeli state to change its political actions on the ground, for example the construction of the separation barrier and restrictions placed on movement of Palestinians.

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HUMAN RIGHTS VIOLATION DURING ISRAEL’S ATTACK ON THE GAZA STRIP: DECEMBER 27, 2008 TO JANUARY 19, 2009

[Reprinted from The Journal of Global Public Health, Special Issue: “Conflict and Health in the Middle East,” Vol.6, No. 5 July 2011]

The Situation Prior to the “Cast Lead” Attack on the Gaza Strip

The Gaza Strip is 41 kilometers long, and between 6 and 12 kilometers wide, with a total area of 360 square kilometers, in which a population of approximately 1.5 million Palestinians resides. With a population density of 4,118 persons/sq. km, the Gaza Strip is the sixth densest region in the world. Israel occupied the Gaza Strip, together with the West Bank, the Syrian Golan Heights and Sinai during the 1967 Six Day War. In August 2005, Israel decided unilaterally to withdraw its ground forces from Gaza and dismantle all Israeli settlements there, in what was known as the "disengagement plan."

Even after this “disengagement,” however, Israel continues to rule the lives of Gaza residents in many ways and to control the land crossings. This includes indirect but effective control over the Rafah crossing between the Gaza Strip and Egypt, thus restricting the exit and entry to the Gaza strip of patients, students, family members of Gaza inhabitants, merchants and over professionals. Israel also controls the airspace and territorial waters of the Gaza Strip as well as maintains the Gaza population registry. Because the Palestinian civilian systems in Gaza have been dependent on the State of Israel since 1967, Gaza residents were left without an adequate civilian infrastructure of their own, including a medical and health systems and electric power plants capable of supplying the needs of the entire population.

At the same time, Israel, which continued to control the crossings into Gaza, imposed strict limitations on the movement of people and goods into and out of the Gaza Strip. After the installation of the Hamas government on 25 March 2006 in the wake of Palestinian elections, the Israeli government instituted a policy it called “humanitarian aid,” which imposed harsh restrictions on the movement of goods into and out of the Gaza Strip. This policy became more severe after Hamas captured the Israeli soldier Gilad Shalit in June 2006. A year later, in June 2007, upon the Hamas takeover of the Gaza Strip, Israel tightened these restrictions and imposed an almost total closure, preventing the passage of people and goods into and out of Gaza.

In September 2007, Israel declared the Gaza Strip to be “hostile territory.” One month later, it imposed stringent restrictions, which still continue, regarding the entry into Gaza of diesel and cooking gas, including industrial diesel used for the production of electricity in Gaza’s power plant. The limited inflow of industrial diesel led to interruptions in the daily supply of electricity for 3-5 hours on average – and sometimes for 12 hours a day – in various parts of the Gaza Strip during the year preceding the military operation. The shortage of industrial diesel prevented efforts to create a diesel reserve for the Gaza power plant for use in emergencies. The irregular supply of electricity, like the shortage of diesel for alternative generators, also disrupted the operation of water and sewage pumps throughout the Gaza Strip. In addition, Israeli restrictions on the entry of construction materials, spare parts and equipment became more stringent during the two months prior to the military attack and made it impossible for the Gaza utility companies to carry out necessary repairs, maintenance and upgrading.

Throughout this period, Hamas was sporadically firing rockets indiscriminately into the towns of southern Israel. On December 27, 2008. Israel began a military attack on Gaza known as the “Cast Lead” operation. This attack continued for over three weeks, ending on January 19, 2009.

The State of the Health System in Gaza Prior to the Attack

Even prior to the military operation, Gaza’s health system was buckling under the sealed border regime and struggling to cope in difficult circumstances: the lack of medical knowledge, expertise and experience to deal with complex illness or injury, inadequate medical equipment and staff knowledgeable about its operation, insufficient medical supplies and medicines, and extended electricity blackouts. Thus, the infrastructure of electricity, water and sewage in the Gaza Strip, as well as its medical and health systems were in a state of serious disrepair even before the ‘Cast Lead’ military operation.

Delegations of medical experts, members of PHR-IL or under its auspices, visited Gaza nine times during 2008 and three times during 2009. The delegations worked jointly with the major Gaza hospitals (Shiffah in Gaza, the European hospital in Khan Yunis), advising local physicians and carrying out complicated operations, especially in the fields of orthopedic surgery, neurology and neurosurgery. The delegations also included psychologists. The information gathered during PHR-IL's ongoing connection with Gaza hospitals, as well as that provided by international organizations, in particular the World Health Organization’s monthly reports, indicates that serious shortages exist in medicines, medical equipment and, most notably, in medical skills.

According to the WHO monthly reports, there is a shortage of more than 100 types of medication and more than 100 kinds of medical equipment in Gaza Strip in an average month. The shortages are due both to restrictions imposed by Israel, which prohibits the importation of “dual use” materials, including radioactive isotopes needed for examinations such as bone mapping and radiation treatments, and to shortcomings of the Palestinian Authority, which isn’t always able to pay for the medications.

With regards to equipment, there is an ongoing shortage of sophistical surgical equipment for complex operations, particularly orthopedic and neurosurgery. As of 2009 there were only two CT scanners and one MRI device in Gaza. In addition to the small number of devices relative to the size of the population, frequent interruptions in the supply of electricity and normal wear and tear result in frequent equipment breakdowns. This often leads to the equipment being shut down because Israel prohibits importing spare parts or new equipment into Gaza Strip. As a result, diagnostic capacity is very poor, affecting the entire treatment process.

The most serious shortage, however, is in medical skills. For various reasons, resulting both from Israeli policy but primarily because of tensions between the Palestinian factions, it is almost impossible for physicians to leave Gaza for medical training in the West Bank, Israel, Jordan or abroad. The same is true for medical students wishing to leave to complete the practical part of their training in the Al Maqqassed University Hospital in Jerusalem. As a result, the level of medical knowledge and skill in Gaza is very low, for both diagnosis and treatment. This is particularly true in the case of complicated injuries and illnesses.

Violations of the Right to Health in Gaza during Operation “Cast Lead”

Given the nature of this article and its scope, I will touch only upon a few examples of violations of human rights and international conventions executed by Israel during the 22-day assault on the Gaza Strip. Much fuller and wider documentation of violations can be found in numerous reports that were composed in the aftermath of the attack by local and international human rights organizations, development agencies and UN bodies. Most of the information presented here is based on rigorous field research and collection of primary data by PHR-IL.

Since its establishment (1988), PHR-IL regularly monitors and acts upon violations of human rights in the oPt and in Israel. The organization gathers information through ongoing communication with the medical community – hospital and physicians on the ground – and direct contact with rescue and aid organizations, such as the WHO, the Red Cross and the Red Crescent. PHR-IL also employs caseworkers who are constantly approached by effected residents and patients.

In the 22-day attack, PHR-IL maintained continual contact with Shiffah hospital and with its director, Dr. Hassan Khalaf, who also serves as the Deputy Minister of Health, and the European Hospital and others in order to obtain information about the number of wounded the type of injuries and coordinate transfer of urgent cases and more. PHR-IL also maintained direct and continual contact with staff of the WHO, the Red Cross, the Red Crescent, the Palestine Medical Relief Society and other organizations involved in evacuation of the wounded, medical treatment and the collection and documentation of relevant information.

During the attack, PHR-IL caseworkers who under ordinary circumstances are approached by patients seeking to leave Gaza for medical treatment, received many calls from wounded persons asking to be taken from the field to the hospital; civilians trapped in areas where fighting was underway and unable to get out; medical teams confronting many difficulties, caused primarily by the Israeli army, while attempting to evacuate the wounded; and staff of international organizations who tried to coordinate evacuation of the wounded. In addition, PHR-IL maintained its working relationship with The Palestinian Civil Liaison Committee. The Palestinian committee, under Ramallah’s authority, responsible for coordinating civil and humanitarian matters between Gaza and Israel, served as the main coordinating body in normal times as well as during the attack.

Health personnel under attack

According to the World Health Organization (WHO), 16 health workers in Gaza were killed during the “Cast Lead” attack and 22 injured while on duty. PHR-IL has collected testimonies regarding seven of those killed. Fourteen of the 27 hospitals and 38 primary healthcare clinics in the Strip were damaged by the strike, as well as 29 ambulances that were damaged or destroyed. Twenty-four out of 75 health facilities were closed for part or all of the period of the attack.

Emergency medical evacuation impeded

Access to wounded and dead was impeded by ongoing gunfire. Ambulance operators, MoH, (Minister of Health) PRCS, Civil Defense and UHWC United Health Workers Committees all reported areas (pocket zones) they could not reach at all. Even coordinated sorties (exits) were attacked. International Committee of the Red Cross (ICRC) coordinated with the Israeli army, but they were also attacked repeatedly. Wait time for requests by the ICRC (International Committee of Red Cross) for coordination and actual evacuation ranged from hours to days. After the injury of one of its workers during the fighting, the ICRC suspended evacuation from areas outside Gaza City. Other ambulance teams evacuated without coordination in some places and suspended evacuation in other areas, especially “pocket zones.” explain In many cases ambulances that set out for evacuation duties, with or without pre-coordination, were fired at by Israeli helicopters or tanks.

Medical system stretched to breaking point; healthcare for the civilian population restricted

About 5,300 residents of Gaza Strip were wounded in the attack. Many of the patients had multiple injuries necessitating ICU beds, ventilation, expert surgical teams and operating theaters. Only nine foreign surgeons were in Gaza during the attack and the severe shortage of beds, equipment and expert teams as well as closure of the crossings meant that the wounded were treated inadequately and belatedly. For the sick, access to healthcare was severely restricted. Specific concerns were about the chronically ill patients. It is estimated that, during the period of the Israeli attack, 40% of them were forced to interrupt their treatment. These concerns are exacerbated by the virtual halt of referrals of ordinary patients outside Gaza Strip as life-threatening injuries had a higher priority in an overwhelmed system. Elective surgery and non-urgent routine medical interventions were delayed or suspended during the crisis.

Referrals to care outside Gaza prevented

Between the 2nd and the 19th of January not a single Palestinian patient was allowed to leave Gaza via the Erez crossing (the main crossing to Israel) except for three members of the Abu Al-Aysh family (relatives of a prominent gynecologist who is well-known in Israel) who were injured during prime-time Israeli Television coverage on January 16, 2009. In addition to the injured, three of Izz Al-Deen Abu Al-Aysh's daughters were killed as a result of the two shells that hit the house. They were evacuated in Israeli ambulances and helicopters to Israeli hospitals. In the course of the attack 608 patients, mostly wounded persons were evacuated from Gaza via the Rafah crossing, mainly to Egyptian hospitals, but also to Saudi Arabia, Jordan, Morocco, Turkey and Belgium. The need for referrals of regular patients, excluding the wounded, to external medical centers was estimated at 800-1000 patients per month.

Distribution of medical supplies and food jeopardized

Israeli attacks were reported against both ICRC-led convoys of medical supplies and UNRWA food convoys. Several international workers were injured by Israeli attacks, leading to temporary suspension of their activities. As a result, several regions in the north and center of the Gaza Strip were cut off from access to food and medicines.

Atypical attacks against civilians

Reports were received regarding killing of unarmed civilians at short range and of the use of anti-personnel arms in densely populated civilian areas. An independent fact-finding mission invited by PHR-IL and Palestinian Medical Relief Society has examined some of the evidence for this and the other violations described and released its conclusions in April 2009.

Case study I: Muhammad Shurrab and his sons

At about 13:00 on 16 January 2009 Muhammad Shurrab, 64, set out in his car with his sons Qassab, 27, and Ibrahim, 17, during the humanitarian pause in fire in Khan Younis. He was allowed to pass a military checkpoint. Suddenly, he was hit by gunfire from soldiers who had taken over an apartment near the road. His son Qassab was hit directly and died immediately. His son Ibrahim was hit and lost a lot of blood. The father himself was also injured in the arm, but not badly. The father said his son Ibrahim shouted with pain and he wanted to called an ambulance, but the soldiers yelled at him, “You son of a bitch, shut your mobile or we'll shoot you.” Ibrahim was thus not able to make a call, but his father later made contact with the Palestine Red Crescent Society, the International Committee of the Red Cross, another son who was living in the US and other organizations.

Hours went by but an ambulance never came. Muhammad’s son Ibrahim died of loss of blood at 00:30, about 12 hours after the shooting. PHR-IL was contacted late at night and called Muhammad after Ibrahim was already dead. PHR-IL then contacted various representatives of the Israeli army and the ICRC. Their first response was that “there is a problem with coordinating ambulances at night.” Tom Mehager, PHR-IL's caseworker, insisted that they must immediately coordinate evacuation, but he was told that there would be no ambulance before dawn. Local and international evacuation services told PHR-IL that the case was known and that a request had been sent to the army.

At about 02:30 the army told PHR-IL that an ambulance had been sent the previous afternoon but it had not found the injured people. PHR-IL repeated its demand to evacuate immediately, but with no result.

At about 04:00 PHR-IL demanded an explanation for the refusal to authorize evacuation. The army said that there was an explanation but refused to give it. All night Tom Mehager of PHR-IL spoke to the father, Muhammad. Muhammad cried over his sons' bodies, which lay outside his car. He said he could see the soldiers and tanks a few meters away. PHR-IL's experience has shown that the army has refused to evacuate wounded people itself during this operation, and the father feared them very much; thus, the caseworker did not suggest that he try to approach them. The car had also been damaged by the shooting and was not able to be driven. Beyond his distressed condition, the father bled from his arm and complained he was cold all night.

At 06:00 Tom Mehager contacted members of the Israeli parliament and Israeli press. Israeli Internet news websites Walla and YNet contacted the army but were told the case was “under consideration.”

At 07:00 PHR-IL contacted international ambulance services asking them to intervene again for evacuation.

At 07:30 PHR-IL was told that evacuation had been authorized for 12:00. At 10:30 PHR-IL was told that ambulances had set out to evacuate.

At 12:00 Muhammad and the bodies of his two dead sons were evacuated, almost 24 hours after being wounded.

In parallel, PHR-IL was contacted by another of Muhammad's sons in the US, asking to hear about the condition of his father and two brothers. PHR-IL was obliged to tell him the bitter news of the death of both his brothers. On 16 January 2009, at 5.32 PM (USA time), Amro Shurrab wrote:

“My father's car was bombed today, he was in it with two of my brothers, my older brother, 27, was killed while my dad, 64, and my little brother, 17, have been bleeding for over 14 hours and Israeli troops blocking ambulances access. They are in front of supermarket Abu Zidane El-Najjar, El-Fukhary, Khan Younis, Gaza Strip. Please contact any media outlets, your congressmen, senators, any international organizations and try to get them help."

Case Study II: the Al-Aeidi Family

On 3 January 2009 the Al-Aeidi family house was partly destroyed by missile fire. Twenty-eight family members (including fifteen children), among them six injured, were trapped in an isolated area southeast of Gaza City halfway between Netzarim junction and the Karni crossing. Despite press coverage and pressure from the ICRC, only on 9 January 2009, following a petition by PHR-IL to the Israeli High Court, were eight family members (two injured) allowed to leave on foot. On 10 January 2009, the remaining family members, some injured, walked to Gaza City on foot.

Case Study III:

1 December 2009: Five ambulances of PMRS, UHWC and MoH coordinated with ICRC to evacuate the wounded from Jabalya City after a missile strike. After entering the building, a second missile was shot by an F16 plane, destroying it. Dr. Issa Saleh, 32, was killed – a direct hit to his head. Paramedics Ahmad Abu AlFul and Abd ElMajed Abu ElAish were lightly injured, as well as many other civilians. The crew evacuated some of the injured to Kamal Adwan hospital, then returned, but shelling was renewed from aircraft and tanks, even as they were leaving the building with the injured people.

As human rights were greatly impeded by Israel in the “Cast Lead” operation, organizations such as PHR-IL played the imperative role of defending human rights and documenting grave violations. Intervention was necessary even in order to get an ambulance to do its duty and even when evacuation was finally approved it was done as a huge favor, not as a respectful right. Only via humiliation and belittling, begging and many refusals, if one is lucky he/she would be able to fulfill a basic human right. This power game is characteristic to everyday life in the oPt.

Disrespect for human rights during operation “Cast Lead” was unprecedented, yet to a large extent it followed the same pattern of Israeli control in oPt at large, which is characterized by an arbitrary attitude towards the Palestinian population. In the reality of the oPt, one cannot trust any regulation, any order, any agreement or even any routine. Every situation can change with no predictability. For example, the humanitarian pause declared by the Israeli army (in the Shurab case) was violated with no warning, by firing at the family’s car. This is not exception; on the contrary, this is a common situation in the oPt, not only in times of open violent conflict. This uncertainty thus defines and characterizes a large part of the work of PHR-IL that makes interventions and goes through the same exhausting procedure, vis-a-vis the army, to allow the sick and wounded to cross the West Bank checkpoints or Gaza crossings.

The direct outcome of this uncertainty in the lives of Palestinians is the impossibility to make plans, to have a sense of future. Not having the capacity of planning shatters the human wellbeing and threatens personal integrity. A sense of personal certainty is based on perceiving connections between one’s actions and one’s life. When the sense of safety is broken it gives way to a painful sense of uncertainty which is a psychological disturbance that might end up in despair and/or depression.

With regards to PHR-IL’s staff, it is important to examine the complexities and trauma that is undergone by the staff. Take, for instance, the young man Tom Mehager, who spent the dreadful night on 17 January with Muhamad Shurab, feeling as if he himself was there, in the field, with the crying father and his two dead sons. Tom felt the pain, the helplessness, the frustration, the fear, the anger, the time that went by so slowly, the poignant feeling of being abandoned, and the shame and guilt of being part of the Israeli collective. It is not the Shurabs’ trauma alone. The secondary trauma of Tom, like many of the staff, is there and need to be taken into account in order to give Tom and others the needed support.

The unpredictability of Israeli actions poses a major threat to public health. It jeopardizes the ability of medical crews, hospitals and aid agencies to react effectively to serious situations and provide adequate treatment to patients and injured and is a critical obstacle for the defense of human rights. The fact that, throughout the attack, medical workers had no way of knowing which announcements and agreements by the Israeli Army could be trusted and which would be simply ignored, made their work almost impossible.

In addition, most of the medical organizations found it very difficult to intervene on policy level. While not all medical organizations conceive their role as surpassing mere health care delivery, even those which do get involved with public health issues in the wider sense risk being dismissed as exceeding their mandate or as politically biased. Brought together, the difficulties in securing good quality health care on the one hand, and the complexities of working efficiently on public health on the other, create a huge implementation gap in the realm of health rights in all oPt and particularly in Gaza.
PHR-IL's hands-on approach is one way to address this gap, given that it combines clinical work with campaigning and advocacy that derives from actual, particular cases. PHR-IL’s volunteer medical professionals provide limited medical care free of charge to persons whose access to healthcare is impaired, in the West Bank, as a mark of solidarity and an instrument of protest. At the same time, PHR-IL’s staff works to effect long-term policy change through data collection, individual case work, legal and public action, local and international advocacy, and education and mobilization of the Israeli medical community toward monitoring human rights and opposing torture and ill treatment. Thus PHR-IL strategically utilizes the privileged position of health workers regarding access to the field and collection of data. Moreover, the accuracy of testimonies PHR-IL collects and exposes and the first hand evidence it collects support the effectiveness of advocacy efforts.

PHR-IL acknowledges the fact that "health" should be addressed on both the clinical and the political level. It uses a very wide definition of health and accessibility to health resources and healthy environment as a working definition, while emphasizing the terms in which restrained treatment turns in effect into denied treatment. PHR-IL identified Israel's restrictions on the health system and supporting infrastructure in the Gaza Strip as a clear threat to public health, as well as to individual health and safety that derives from political conditions and which should be addressed on both levels – clinical and political.

This association between Israel's policy and public health in Gaza may seem natural to the international eye that isn't immersed in the Israeli public discourse. Yet in Israel today it is highly controversial. Most of the Israeli public supported the military attack and remained silent throughout the attack, among them most of the Israeli health workers and, most notably, the Israeli Medical Association (IMA). Only following PHR-IL's appeals did IMA call for a humanitarian aid to the wounded, but did not voice any criticism as to the targeting of clinics and ambulances in Gaza or blocking of ambulances and thus preventing swift and adequate evacuation of the wounded.

Physicians know that when a crisis sets in, the Hippocratic Oath and medical ethics obligates them to treat the sick and injured, regardless of race and nationality. But this oath extends beyond humanitarian aid. Medical professionals must ensure that the proper medical infrastructure exists to treat those affected during times of crises. The medical community must guarantee that ambulances, hospitals, and clinics are up and running and that those will never be targeted during military operations. Medical ethics does not end with humanitarian aid; at a bare minimum, it includes the principles outlined in the Geneva Convention. Physicians who do not realize that they must be proactive and not just reactive in times of crisis forget the golden rule of the Hippocratic Oath, "First Do No Harm." Dwelling among an occupying nation, this is the professional commitment that Israeli health workers all too often overlook.

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WORKING TOGETHER IN SOLIDARITY: ADVANCEMENT OF PUBLIC HEALTH AND HUMAN RIGHTS IN ISRAEL AND THE OPT

[Address to the American Public Health Association, Washington, D.C., October/November 2011]

Since 1967 Israel has occupied the Palestinian territories of the West Bank, Gaza Strip and east Jerusalem. A World Health Organization (WHO) report delivered in May 2011 states that due to the occupation, “the Palestinian health-care system continues to face many challenges [including] restriction of movement and access to health services.” The Palestinian system is not equipped to fully serve its population and the effective control that Israel exercises over the oPt (occupied Palestinian territory) makes improvements practically impossible. Palestinians must apply for permits for travel and/or pass military checkpoints to access appropriate health care. Sometimes passage is not granted despite urgent medical need. The majority of Palestinian health care is in East Jerusalem – an area annexed by Israel and accessible only with an Israeli permit for non-Jerusalemites. In Gaza, instability of supply of medications and electricity due to the blockade undermine the day to day functioning of the health care system.

The occupation has resulted in an unacceptable restriction of the right to health for Palestinians.

From its inception, PHR-IL has worked to achieve its goals through cooperation and solidarity with the Palestinian community. As Palestinians are not able to move freely, our doctors and staff enter the oPt. PHR-IL has worked for many years in partnership with the non-governmental organization Palestinian Medical Relief Society (PMRS), the largest primary healthcare provider in the West Bank. PHR-IL and PMRS have created a unique line of mutual respect and communication between our two organizations and between doctors and patients.

The Cooperation of PHR-IL and PMRS

The co-work of PHR-IL and PMRS covers many aspects. It begins with protest and solidarity. We provide health care to many thousands of Palestinians. We play a role in the professional development of Palestinian medical professionals. We distribute information on human rights abuses in order to create public awareness and influence policy makers. Through our publications we give first hand information to our colleagues around the world.

Access to health care: the Mobile Clinic

For almost 24 years PHR-IL has operated mobile clinics in partnership with PMRS. Once a week, the clinic travels to a village in the West Bank. In 2010, we held 56 clinics, which gave treatment and medication to 9,190 individuals. This includes 1,622 children and was achieved with the help of 636 medical staff who volunteer their time with the PHR-IL mobile clinics. In the first half of 2011 41 clinics were held treating upwards of 7,600 patients. Staff members include doctors, nurses, optometrists and pharmacists as well as translators.

General and specialist clinics

Thirty three of the clinics last year and 24 clinics in 2011 were general in nature. Among other things, patients are treated for vascular, gynecological and eye and ear-nose-throat problems.

Palestinian and Israeli pharmacists distribute medication at these clinics.

Specialist clinics take place in larger towns and address a lack of specialized health care. Eleven were held in 2010, and seven in the first half of 2011. Israeli and Palestinian specialists work in the areas of pediatrics, cardiology, gynecology, orthopedics and diabetes.

From time to time our clinics are held in a particular town as a “solidarity” visit. For example, on the 4th June 2011 the clinic visited Madama village near Nablus to show solidarity on the 44th anniversary of the occupation. Inhabitants of Madama, as in most Palestinian villages, suffer from aggressive acts by settlers such as injuries or even killings, uprooting of trees, prevention of children going to school, stopping farmers from cultivating their fields and orchards and so on.

When it is possible PHR-IL sends a medical delegation to Gaza. Permits must be obtained and may be withdrawn at any time. Regular clinics cannot be maintained. When a delegation can pass through to Gaza Strip, they visit hospitals such as Shiffah in Gaza City and the European Hospital in Khan Younis to perform surgeries.

Women’s Clinics

2010 was the third year of operation of the Women’s Clinics (see Section 3, “Women,” ppp. xxxxxx) , which are run by women for women. Access to health in the oPt is particularly restricted for women. For example, a lack of sufficient pre- and post-natal care has resulted in large numbers of women suffering from comparatively high maternal death, anemia during pregnancy, and a high rate of perinatal infant mortality. These clinics cannot solve these deep problems, but they do create a forum for women to seek medical care from other women. Women can attend this clinic for issues that they would not feel comfortable bringing to the general clinic.

The Women’s Clinics aim to empower women to claim their rights in general and to access to health in particular. Educational health lectures are held at the beginning of the clinic to provide information on women’s health issues. Palestinian women are involved in the organization of the day, unlike during the general clinics.

Nine such clinics were held in 2010, and five in the first half of 2011. In 2010, 809 female patients received medical services and follow-up. By August of 2011 the figure was already at 590. By selecting women’s health issues as worthy of special attention, the clinic promotes the health of Palestinian women as a source of strength and status.

Surgery Days

In the oPt there is a lack of qualified surgeons due to the severe restrictions on Palestinian doctors wishing to go to Israel or abroad to pursue education. The surgery days allow Palestinians access to surgical care without going through the weighty bureaucratic requirements for treatment overseas or in Israel.

Three surgery days were held at Tulkarem hospital last year. Eighteen patients received pro-bono surgical procedures including cyst removal, scar correction, hernia surgery and corrective ear surgery. A further 56 people received surgical consultations free of charge.

Two surgery days were held in early 2011, at Rafidia hospital in Nablus and at Tulkarem. Four surgeries and nine consultations were completed.

The surgery days create a valuable forum for doctors to work and learn together. Palestinian doctors do the preparatory work for the surgeries before the day of the clinic, and assist at surgeries to learn up-to-date techniques from their Israeli counterparts. This provides Palestinian doctors with skills for their future work.

Hearing Aid Project

This project is an example of American cooperation with Israelis and Palestinians. During two special clinics lasting three days each in April and May 2011, 1088 Palestinian adults and children were assessed for and fitted with hearing aids. This project was a result of agreement between PHR-IL, the Starkey Hearing Foundation (from the USA), Sheba Medical Center in Israel and the American Friends of Sheba Medical Center. Hearing aids are not funded by the Palestinian public health system and hearing problems are widespread. PHR-IL arranged the travel and safety of the team in coordination with the Palestinian Authority. The Starkey Hearing Foundation donated hearing aids and PHR-IL physicians and specialists from the Sheba Medical Center carried out the fittings.

Training – Medical Conferences

The occupation restricts the movement of Palestinian health professionals wishing to expand their medical training. In response, PHR-IL has organized medical conferences with the Palestinian Medical Association. In 2010 two training days were held in the West Bank, with over 100 Palestinian physicians in attendance at each. Topics included:

• Neo-natal health and fertility treatments
• Neurology
• Cardiology and blood pressure
• Rheumatology
• Swine Flu and vaccinations
• Parkinson’s disease

An additional three meetings for physicians were held in the first half on 2011. Attendance ranged between 120 and 150 participants and topics such as cardiology, colon and rectal disease were presented.

In April this year a nursing conference was held with the council of nurses in the West Bank. The conference was mediated by Palestinian nurse Aiman Aniya from Rafidia hospital in Nablus. More than 150 nurses attended from West Bank hospitals.

These conferences go some way to fulfilling the significant need for physicians and nurses to maintain their training and stay abreast of current developments in medicine. Their response has been very positive.

Advocacy

PHR-IL and PMRS work together to bring human rights abuses to light. This is a key to alerting Israelis and internationals to the truth of the situation in the occupied Territory, advocating for policy change and more specifically for an end to the occupation.

After the Israeli military moved into the oPt in Operation Defensive Shield in March and April of 2002, PHR-IL wrote an interim report detailing and condemning the violent treatment of citizens and health care professionals and the contraventions of international humanitarian law committed by the Israeli army. During this period ambulances and hospitals were attacked and medical staff killed by the Israeli army. Palestinian Medical Relief staff were trapped in the middle of this warfare and reported to PHR-IL about their direct experiences. The PMRS and Red Crescent ambulance stations in Nablus were surrounded and their access to those needing urgent medical care was completely cut off by tanks and soldiers. The Israeli Medical Association and the Ministry of Health, the major Israeli professional medical bodies, did not respond to these abuses. PHR-IL's voice was alone in denouncing the wrongs done by the military.

PMRS and PHR-IL acted after the next major assault, Operation Cast Lead in 2008-2009 in Gaza Strip, to commission an independent fact-finding mission of independent experts to Gaza. The mission reported the testimonies of 44 civilians and medical staff that had come under attack. It revealed the illegal actions of the Israeli army in preventing the safe passage of ambulances and doctors.

The report stated that:
"…Besides the large-scale, largely impersonal destruction that the team witnessed and heard of, it was especially distressing to hear of individual cases in which soldiers had been within seeing, hearing and speaking distance of their victims for significant stretches of time, but despite the opportunity for 'humanization', had denied wounded people access to lifesaving medical care, or even shot at civilians at short range…"

It is a principal concern of PHR-IL and PMRS that these facts are revealed and publicized within Israel and internationally. By speaking out against such violence we fight the occupation, the cause of the abuse of rights in the oPt.

Conclusion

We, Israelis and Palestinians, are creating a subversive way of addressing the occupation. For Israelis, it is subversive because it opposes the military approach and the 'no partner' idea which is the consensus in our society. For Palestinians, it is subversive because it involves working with Israelis in spite of the anti-normalization stance. Working with PHR-IL is an exception to this stance based on the notion that we are clearly opposed to the occupation, therefore our co-working is not conceived as ‘collaborating’ with Israel.

The work of PHR-IL and PMRS in the Mobile Clinic, training days and advocacy is important in itself and as an example of the possibilities of Israeli-Palestinian cooperation and communication. It illustrates an alternative way to the enmity-military approach, a way that we have been traveling together for 24 years and that will continue to grow.

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HEALTH CARE AND THE PALESTINIAN BID FOR STATEHOOD

[Reprinted from The Lancet, Vol. 378, issue 9800, 15 October 2011]

Everything one can say about the health-care system in Palestine was summed up by the physician and political leader Haidar Abdel-Shafi in the wake of the Oslo Agreement in September, 1993. He said: “We cannot take care of health and education as long as we live under occupation.”

On Sept 13, 1993, I happened to be in Gaza city. A taxi driver told me: “My expectations from the Agreement are very few. I would like to have a better health care system, better education for my children and much better roads in the Gaza Strip.” Maybe he didn't ask for too much, but these things were impossible to achieve because of the reallocation of responsibility between the State of Israel and the newborn Palestinian Authority, which took place without a parallel redistribution of power.

The costly responsibility for civil needs such as health care and education was shifted to the Palestinians. Yet Israel maintained full power over the borders, movement on the roads, access to water, access to health services, taxes, and the import and export of goods. The Palestinians could not even guarantee their health teams and patients free movement to medical centers, hospitals, and clinics. This new form of occupation was actually worse, since the new “balance” saddled the Palestinians with material costs while providing them with only the illusion of power.

Coming back to Tel Aviv in 1993, Neve Gordon and I urgently wrote an 11-point document demanding two main things from Israel: (1) immediate concern by the Israeli medical institutions for the welfare of individual patients until an adequate Palestinian service had been developed, and (2) cooperation between Israel and the Palestinian Authority in the development of an independent medical and health infrastructure. Both sides and the negotiators practically ignored our proposal.

The reason I'm mentioning this sad history is that now, as the Palestinian Authority waits to hear whether the UN Security Council will back its bid for full membership, the situation is much the same. Israel has used health and medicine as an instrument of control and oppression of the Palestinian people and leadership in the occupied Palestinian territory throughout the years since 1967. We at Physicians for Human Rights-Israel conceive this situation as a disease for which the cure is the total removal of control by Israel over the Palestinians. There is no way that a future Palestinian state, if there ever is one, can handle the health-care system (or any other socioeconomic system) if the Israeli occupation and control continues.

Haider could see it much before most people could. This is why he refused to take part in the negotiations after Madrid and even more so after the White House hand-shaking in September, 1993. Maybe now leaders will see it too. The Israeli policy makers have the inherent obligation of mending all the wrongs inflicted by them during the 44 years of occupation. This is the way the heavy responsibility of building a health-care system will be borne by those who have the power to do it.

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NON-POLITICAL HUMANITARIAN AID BETRAYS THE HIPPOCRATIC OATH

[“Caring for Civilian Populations in Situations of Conflict, 140th APHA Annual Meeting, San Francisco, October 31, 2012]

This presentation addresses Israel's central role in the de-development of the occupied Palestinian territory (oPt) and in particular of Gaza Strip, in two connected fields of health and economy.

Various parties, including governments, international organizations and local human rights organizations, frequently utilize concepts from the field of humanitarian aid. Yet the very act of focusing on specific crisis situations and humanitarian reactions shifts the public discourse away from the cause of the crisis: Israeli policies that prevent development in the oPt; away from the ramifications of successive Israeli policies on some four million residents of the occupied Palestinian territory.

Humanitarian discourse in the service of preventing sustainable development: The Gaza Strip as a test case

The emphasis on humanitarian discourse contributes to an approach whereby Israel, despite being the ruling power, is not obligated to provide for civil development for residents of the oPt. This injury to the residents of the oPt is usually perceived as a minor wrong, an excuse, stemming from Israel’s security needs. Hence any particular privilege this population may enjoy is perceived as a humanitarian gesture, and not as the actualization of a basic right.

In September 2007 Israel declared the Gaza Strip a hostile entity. The restrictions included a prohibition on exports, restrictions on the exit of persons, and on entry of goods beyond the “humanitarian minimum,” including diesel fuel and cooking gas. This brought about a severe crisis in the supply of electricity to Gaza. Since then, we have seen a growing inflexibility in the crossings policy involving the movement of people and goods, as well as a decline in the functioning of the health system in Gaza.

Even the release of Gilad Shalit on October 18, 2011 did not bring about meaningful change in Israel’s policies regarding the crossings.

The humanitarian discourse and Israeli policies in the oPt

Since the year 2000, we have seen a growing use of terms taken from the international humanitarian discourse regarding the Palestinian situation in the oPt.

This adherence to the term “humanitarian case” placed the emphasis on local solutions to particular problems, and thereby prevented or delayed thinking about complex and comprehensive solutions. The political philosopher Giorgio Agamben argued that “The humanitarian involvement conceals the rather covert division of labor that exists between the humanitarian organizations and the authorities, whose policies are the cause of the disaster.”¹¹

Likewise, when Israel permits transit at a crossing for trucks carrying basic goods for the residents of Gaza Strip, an action Israel is obligated to allow under international law,^{12 13 14} this action is not perceived as Israel’s obligation but as a voluntary humanitarian act on its part.¹⁵

Humanitarian crisis

A humanitarian crisis is a code name for a severe crisis. For example, an outrageous absence of electricity due to Israel’s refusal to allow fuel into Gaza was termed a “humanitarian crisis” by the Israeli government and press.¹⁶ A severe shortage of medicines and medical supplies is also called a “humanitarian crisis”.

The discussion of possible ways to resolve the crisis (such as allowing limited additional quantities of food or medicines into Gaza) creates a picture of positive acts preventing hardship, and ignores the political reasons that created the crisis in the first place. Continued use of the “humanitarian” discourse deflects attention from an in-depth examination of the situation facing residents of the oPt in terms of economy, health system, and health determinants such as water, nutrition and infrastructure.

“Humanitarian” actions by the Israeli government or by humanitarian organizations leave the residents of Gaza Strip dependent on charity and damage their ability to help themselves and to improve their situation independently in broad civic areas.

Towards an independent Palestinian health system–Obstacles and options

The Palestinian health system and Israel

Under the Oslo Accords, health was among the first areas to be transferred to the aegis of the Palestinian Authority. These agreements also stated that both sides see the West Bank and the Gaza Strip as a single territorial unit which should have enabled continuous free movement, a necessary condition for the existence of a functioning, balanced health system.¹⁷

The Palestinian Health system today serves a population of some four million people, yet is geographically and functionally divided between the Gaza Strip, the West Bank and East Jerusalem.

In addition to its own failures to ensure public services and allow private medicine, the Gazan health system suffers from Israel's restrictions. For example, out of its twelve government hospitals, there is only one that has an MRI machine (in Shiffah Hospital) but the machine has been out of order for over two years and cannot be repaired because Israel prohibits the radioactive materials necessary to repair it from entering Gaza.

Gazan residents in need of advanced medical care depend on exiting to East Jerusalem and the West Bank, which – though not without difficulties – have the most advanced health centers in the Occupied Palestinian Territory. In East Jerusalem there is a Palestinian medical campus that serves the Palestinian population in the oPt at a relatively high level.¹⁸ At this campus there are seven hospitals, including St. John's Eye Hospital, St. Joseph Hospital (French hospital), Augusta-Victoria, Al Makassed and the Red Crescent Hospital.

The health system in Gaza Strip is dependent on Israel in order to operate continuously, and this is directly linked with Israel’s control of the crossings. This control is evident in five main areas:

• Exit for ill residents of Gaza seeking to receive health services outside the Strip.
• Transit for medical teams into and out of the Gaza Strip.
• Transport of medical equipment and medicines into Gaza.
• Strengthening and repairing the medical infrastructure in Gaza – building new clinics and hospitals and rehabilitating infrastructure damaged during Israeli attacks on the Strip.
• Partial Israeli control of those passing through the Rafah crossing.

Currently, nearly twenty years after the signing of the Oslo Accords the Palestinian health system is divided and in disarray, with its budget, patients, medical professionals and medical institutions separated from each other, preventing the system from functioning as an autonomous whole. Despite all the problems arising from the political crisis between Fatah and Hamas, clearly the main cause is Israel’s policy of continued blockade and closure.

Obstacles to developing an independent Palestinian health system:

Israel’s policy of movement restrictions

From the 1990s, Erez crossing was closed to civilians with growing difficulties in the granting of exit permits. For years now, a resident of Gaza seeking to leave the Strip for medical treatment must navigate a series of obstacles,¹⁹ beginning in the Palestinian system. Only after the patient has a referral form, a financial coverage form, and an appointment at a hospital can she/he submit—via the Palestinian Coordination Office—an application to the Israeli military authorities for a permit to enter Israel via Erez crossing. In the best case scenario, it takes between a week and ten days to receive a response. If the date set for a patient’s hospital appointment passes, she/he must repeat the process. At no point can the patient directly address the Israeli authorities to clarify the progress of her/his application.

Since the disengagement in 2005, the Israeli Security Agency is using patients to try to obtain information and intelligence on Gaza Strip, pressuring them to collaborate if they wish to obtain a permit to exit for medical care as documented in a 2008 report by Physicians for Human Rights-Israel.²⁰

In 2010, about 52 percent of requests from men aged 18-40 did not receive timely responses and they lost their hospital appointments. Among all requests submitted, 6 percent were refused exit permits with no explanation whatsoever, representing 646 ill men and women.²¹ These numbers show the impact of political decisions on the ability of patients to exit Gaza Strip for medical care, especially how patients are refused out of Israel’s desire to counter Hamas through pressuring the civilian population, rather than out of strict security concerns.

Obstacles concerning the free movement of Palestinian medical professionals

Palestinian doctors who live in Gaza Strip are not permitted to travel freely from Gaza into Israel or the West Bank or abroad in order to study, train or attend conferences. Like the patients, they must submit special applications and wait a long time to receive permits to exit Gaza Strip. Only a small proportion of medical personnel are allowed to leave for training in Israeli hospitals or abroad.

Obstacles to training medical students

Over the years, medical students from Gaza Strip have studied at East Jerusalem and West Bank universities and completed their internships abroad because Gaza lacks adequate university teaching hospitals. Today, students from Gaza Strip are banned from entering hospitals in East Jerusalem where the complete series of training rotations in all the required specialties is available.

When the Second Intifada began, an across-the-board ban was instituted on student exits for study outside Gaza Strip and those who were in the West Bank were forceably returned.²²

Obstacles concerning medicines, medical supplies and equipment:

Every shipment destined for Gaza Strip is inspected, tested and authorized by Israel, even if donated by external agencies. Together with the economic and political crisis, this creates a shortage in medical supplies.

In 2011, several pharmaceutical companies stopped operating in Palestinian Authority areas due to its economic problems. In September 2011 there was a grave shortage of 36 percent of critical supplies for routine operations at hospitals and clinics in Gaza Strip, comprising 164 different critical medicines. A visit by a PHR-Israel delegation in the winter of 2011 revealed that there were no more analgesic medicines for children.

There is not a single clinic qualified to fit prosthetic devices for amputees.

Conclusion

Dr. Angelo Stefanini, who was the head of the WHO delegation to the OPT, diagnosed the main obstacles to the development of the Palestinian health sector as resulting from

(a) The ongoing political disorder, and the consequent system instability, due to the occupation policies of isolation and segregation;

(b) The high dependence on foreign aid from a multitude of donors, each with its own agenda,

(c) Internal difficulties of the Palestinian leadership, due to both lack of control over the basic resources necessary to run a functioning health system, and domestic divisions, corruption, lack of accountability and transparency.²³

Dr Stefanini concludes that as Palestinians do not have a full-fledged state to protect them this role should fall on the international community.²⁴ The international community is thus under the obligation not to render aid that might maintain the situation created by the occupying power, but rather to ensure Israel’s respect for international humanitarian law, and not to substitute for the responsibility of the occupying power.

PHR-Israel is of this opinion as well, and thus we dedicate much of our resources to identify, expose and struggle against the mechanism of separation and suppression. PHRI's understanding is that:

a. There is no way to differ between the political reality, meaning the occupation, and the development of civil systems. There will be no satisfying and independent health system, as well as other civil systems, under the occupation regime.

b. The co-working of Israelis and Palestinians in the health arena is a way to demonstrate an alternative and subversive attitude to separation and oppression. We work for empowerment of the Palestinian health system by conducting medical conferences and intensive surgical clinic days in which expert surgical teams from Israeli hospitals come to perform a series of operations in hospitals throughout the West Bank for training purposes. We should note that, despite attempts to organize them, similar training days in Gaza Strip are not currently possible, due to the permanent prohibition on Israeli Jewish medical professionals’ entry into Gaza Strip and the bureaucratic aspects controlled by the Shabak and the army.

c. The goal is working for future, long term development in contrary to short term humanitarian aid. The humanitarian aid contributes to the problematic situation, tends to duplicate the problem, not to solve it.

The PHR-IL recommendation to the international community is to move from humanitarian donations that aim to deal with deficiency—subsidizing the Israeli occupation—to strategic development with a long term vision. In other words: without political change there is no chance to solve the crisis since humanitarian aid cannot solve humanitarian crisis. Only political change can.

1. Kol Ha’ir, June 8, 1990
2. Philippe Pinel, Traite medico-philosophique sur l’alienation mentale, Paris, 1801.
3. I employ Jurgen Habermas’s notion of intersubjectivity, who accentuated “the intersubjectivity of mutual understanding” to designate an individual capacity and a social domain. Jurgen Habermas, “A theory of Communicative Competence” in H. P. Dreitzel ed., Recent Sociology, New York: Macmillan, 1970.
4. The masculine gender is used here because prisoners, guards and the psychiatrists involved in these cases are almost always men.
5. S. Mitchell, Influence and Autonomy in Psychoanalysis, London: Hillsdale 1997, p. 189.
6. Mitchell, S. Influence and Autonomy in Psychoanalysis, London: Hillsdale, 1997, p. 183.
7. J. Greenberg, “Psychoanalytic Interaction,” Psychoanalytic Inquiry, Vol. 16, 1996:25-38.
8. The name has been changed in order to protect his privacy.
9. W. W. Meissner, “Values in the psychoanalytic situation,” Psychoanalytic Inquiry, Vol. 3 1983: 577-598.
10. The name has been changed in order to protect his privacy.
11. Agamben, Giorgio, 1998. Homo Sacer. Stanford: Stanford University Press, p. 133.
12. From a joint report by PHR-Israel and Gisha, “Rafah Crossing: Who holds the keys?” March 2009.
13. "The fighting is over and in Israel they are moving toward taking care of Palestinians", Haaretz, 18.1.2009:http://www.haaretz.co.il/news/health/1.1241794 (Hebrew).
14. On the opening of a 24-hour center for urgent cases, operated by the Civil Administration in 2011, although the Civil Administration was always required to be prepared to deal with urgent cases 24 hours a day, see IDF PressRelease:http://dover.idf.il/IDF/News_ Channels/today/2011/05/1703.htm/ (Hebrew).
15. Among the dozens of examples, see e.g. this article: “Israel allows humanitarian aid entry via the Sufa Crossing”, at http://www.ynet.co.il/articles/0,7340,L-3513726,00.html (Hebrew).
16. See "Ynet" report on the "humanitarian crises" due to the lack of electricity:http://www.ynet.co.il/articles/0,7340,L-3269334.00.html (Hebrew). Also, see the UN fact sheet at: http://www.ochaopt.org/documents/ocha_opt_gaza_electricity_crisis_2010_05_17_hebrew.pdf .
17. For the full document, see at: http://www.knesset.gov.il/process/asp/event_frame.asp?id=42 .
18. In this passage we are addressing Jerusalem as a territory separate from the West Bank, solely because from a territorial contiguity standpoint (and concerning all aspects of access to health services), East Jerusalem has been separated from the West Bank by checkpoints and the separation barrier, and Palestinian patients residing in the West Bank require transit permits in order to get to hospitals located in the city.
19. For more on the exit process for Gaza patients seeking medical treatment, see the PHR-Israel web site exhibit entitled “Bumpy Road,” at http://www.phr.org.il/default.asp?PageID=60&ItemID=664.
20. For the whole question of Shabak interrogations of Gaza patients, see the PHR-Israel report on “Conditional healthcare: Extortion of Palestinian patients by the Shabak in interrogations at the Erez crossing,” August 2008.
21. All the data are taken from the WHO annual report published at the end of 2010: “Referral of Patients from Gaza – Data and Commentary for 2010”.
22. As far back as November 25, 2004, PHR-Israel received a written reply from Avi Biton, then Lt. Colonel in the Public Inquiries branch of COGAT, that travel for students between Gaza and the West Bank is prohibited. An appeal in principle regarding students by Gisha was submitted to the High Court in 2007, after imposition of closure on Gaza and the decision on a permanent policy regarding the exit of students from Gaza to the West Bank: http://www.humanrights.org.il/articles/aviv6.doc .
23. Mataria A, Khatib R, Donaldson C, Bossert T, Hunter D, Alsayed F & Moatti J-P. (2009). "The health care system: assessment and reform agenda". The Lancet, 373(9670), 1207-1217.
24. Batniji R, Rabaia Y, Nguyen-Gillham V, Giacaman R, Sarraj E, Punamaki R-L, Saab H & Boyce W. (2009). "Health as human security in the occupied Palestinian territory". The Lancet, 373(9669), 1133-1143.