Table of Contents
Ruchama Marton
Looking Back at the June 1967 War, 133-146, Edited by Haim Gordon. Praeger, London, 1999.
Israel's nondevelopment 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.
In order to illuminate my interpretation of the interests that determine Israeli and Palestinian policy toward medical care, the following discussion of the politics of medicine in the Occupied Territories is divided into two parts: the period before the Oslo Accords in 1993, and the period following these agreements.
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 (PHR)Israel was founded in 1988 as a response to the Intifada. From the beginning, we at PHR 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 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 highstandard 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'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 5060 percent, while in private hospitals there was a critical shortage of beds.
We at PHR are interested in comparing the medical services available to the citizens of Israel with those available to Palestinians in the Occupied Territories. In 1990, PHR 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 TulKarema 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 10.1: 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 | + | |
| Longterm 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 twentyfive 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 $1823 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 decisionmaking 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 yearsI 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'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 Shiffa Hospital in the Gaza Strip there was a military outpost on the roof of a new wing. The outpost was occupied twentyfour 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, Shiffa 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 abovementioned 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 sixmonth 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 400page 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 runningcosts, 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 formulated an elevenpoint 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 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'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 elevenpoint proposal, PHR 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 were based on our claim that Israel has a responsibility for the neglected infrastructure. For instance, PHR 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 sedimented in the present.
In June1995, a year after the transfer of the health institutions to the Palestinian Authority, fifteen children from Gaza were dying from heart defects. PHR 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 oh 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 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.
On September 13,1993, the day on which the Oslo agreement was signed in Washington, DC, I was in Gaza. I traveled in a Gazan taxi and asked the driver what he thought would happen now. He answered, "The Rais [leader] will take care of our children's education, will build sewers and roads in the city, and the main thing is that he will give us good medicine in Gaza." The driver didn't speak about stamps or a flag or the number of guards and mirrors to be placed at the border-crossing stations—those subjects that took up most of the 400 pages of the Oslo Accords. The driver didn't know that in the Oslo agreements itself very little was written about health, and nothing was offered. I wonder what that driver would say today.