Post the war in 1967, Israel annexed East Jerusalem and applied Israeli law to its residents, in opposition to international law. Over the past 50 years, Israel’s occupation of Palestine has resulted in severe restrictions on Palestinian development, freedom of movement, autonomy, and safety. Repeated military attacks and the psychological stress of living under occupation has resulted in a record number of people suffering from mental health problems and chronic diseases. These living conditions have far-reaching consequences for Palestinians, and in particular their right to health.
Despite having specific duties and obligations under international law to the Palestinian people in Occupied Palestinian Territories, Israel has not undertaken to protect Palestinian’s right to health. The right to health for people living under occupation is guaranteed by both International humanitarian law and the laws of occupation. The Fourth Geneva Convention emphasises the obligations of an occupying power towards its residents in relation to health, while international protocols place the burden of responsibility to provide health care for civilians under occupation upon the occupying power. This includes the provision of medical services, protecting freedom of movement, protecting hospitals, maintaining medical supplies, ensuring that health facilities are not attacked and providing services to the residents of the occupied territory at the same level as the citizens of the occupying power. However with respect to Palestine, a number of barriers to accessing health services exist, many of which have been exacerbated by the ongoing conflict.
BARRIERS TO ACCESSING THE RIGHT TO HEALTH
Barriers to accessing health are not just limited to physical access, but extend to other critical factors such as availability of services, quality and appropriateness of care. From shortage of medicines and medical equipment to restriction of movement within Palestinian territories to lack of healthcare infrastructure to bombing of hospitals, Palestinians are denied access to the most basic aspects of the right to health every single day.
ACCESS TO TRAVEL PERMITS FOR PATIENTS AND COMPANIONS
The functioning of the Palestinian health care system is severely disrupted by the political division and geographic isolation of Gaza, the West Bank and East Jerusalem. For example, movement of patients requiring advanced and subspecialty treatment from Gaza and the West Bank to East Jerusalem hospitals is dependent upon obtaining Israeli-issued travel permits to move between jurisdictions.
The exit permit process implemented by Israel is opaque and complicated. Processing time can extend over weeks or months and patients are not notified until a day before their scheduled appointment and travel. Permits can be refused by the Israeli authorities without any explanation and are sometimes refused to all patients from a geographic area due to political conflict or Israeli holidays.
The Israeli security service has also made interrogations a condition of permit requests. Over 755 patients were called for interrogation in 2016, of which 59 patients were elderly (over 60 years) and 17 were children (under 18 years).
The World Health Organisation (WHO) data shows that the approval rates on medical permits have been gradually declining from 92% in 2012, to 62% in 2016. The lowest approval rate of just 52.4% was recorded in 2017, with 45% delayed without response and 2.6% of the applications rejected without providing any reason. Over 54 patients in Gaza died in 2017 either waiting for a response or after being denied permission.
This level of uncertainty places stress on vulnerable patients requiring specialised medical treatment in East Jerusalem or abroad, and means the receiving hospitals have to schedule medical procedures at short notice. Unrestricted access is a critical for patients with complex conditions such as cancer, congenital defects, heart conditions requiring surgery or transplant cases. Delays in issuing permits or refusal of permit can be life-threatening.
These difficulties are compounded by restrictions on who a patient can travel with. Patient companions need to be older than 55 years, and only one companion is allowed per patient. This is a significant problem for parents below 55 years of age with young children, who are prevented from travelling with their children for treatment. This also causes issues for people with disabilities and the elderly who may require young companions to accompany them. With only 6% of people living in Gaza being above the age of 55, finding a known and reliable companion is difficult. The approval rate for companions is even lower than patient-approval rates, with only 53% of applications approved in 2016.
SHORTAGE OF MEDICAL SUPPLIES
Since 2007, Israel has imposed a blockade on Gaza, not just restricting the movement of people, but also the importation and exportation of goods. This has resulted in economic suffocation and isolation of Gaza from the rest of the world, directly impacting the living conditions in the region and subsequently, the health standards of its residents. By early 2018 40% of the most basic and essential medicines were completely out of stock and another 43% of essential medicines had less than four weeks of supply left. Israel has repeatedly denied permits to the hospitals in Gaza to import vital diagnostic equipment or even replacement parts for the existing equipment. Such equipment shortages extend even to the most basic medical equipment, such as vital laboratory supplies and disposable medical equipment.
Access to health services for cancer patients is even more dire. Radiation therapy and radioisotopes for medical diagnostics does not exist in the region due to the ban placed by Israel on the importation of medical isotopes. Cancer diagnoses are often made in the final stage of the disease due to the lack of adequate resources for early diagnosis and treatment. Even if diagnosed early, surgeries for tumour removal and other complicated surgeries are extremely difficult due to the crippling shortage of electricity. This is mainly due to Israel’s policies that prevent maintenance of services required for health promotion, like maintenance of water reservoirs and importation of fuel for electricity. Consequently, three hospitals and 13 health care facilities have closed in 2018 affecting access to health care for over 300,000 Palestinians in the region.
ACCESS TO AMBULANCES
Hospitals with advanced treatment facilities are all concentrated in East Jerusalem, meaning most patients are referred there for diagnosis, complex surgeries, and critical care. Patients from other areas, particularly West Bank need to be transferred to these hospitals in ambulances to access appropriate medical care. This involves a process called ‘back-to-back’ transfer, where the patient is transferred from the Palestinian registered ambulance to an Israeli registered ambulance at a check point before entering East Jerusalem. 68% of non-emergency patients and 41% of emergency patients underwent back-to-back transfer at checkpoints in 2016 and 2017. The average delay caused by such transfers is 27 minutes for emergency cases, which is a significant amount of time for patients in a critical condition. It can take up to hours for non-emergency cases. This is not merely inhumane but in extreme breach of The International Humanitarian Law and the laws of occupation.
SAFETY OF HEALTH CARE FACILITIES
Violence directed at health care facilities include bombings by Israel military forces and drones. Despite providing the Israeli military with the Geographic Information Service (GIS) coordinates of all health care facilities to prevent attacks, an increase in attacks on hospitals and other health care facilities have been documented. 147 hospitals and health care facilities were either damaged or destroyed by successive military attacks between 2008 and 2014. Further, 80 ambulances were destroyed, and 145 health workers were injured or killed in Gaza alone. This is in breach of the Fourth Geneva Convention that requires health workers, hospitals and ambulances to be protected at all times.
Israel exercises full civil and military control of ‘Area C’ in the West Bank, where a mere 1.4% of building applications were approved between 2010 and 2014. As a result, not a single hospital or primary health care facility is present for over 300,000 Palestinians residing in Area C. Consequently, 23% of people in Area C have no access to health care at all and 50% of people live over 30 kilometres away from the closest clinic. On the other hand, illegal Israeli settlements in the West Bank have excellent access to health care with modern health facilities available within the settlement area. It is no surprise why Israel’s treatment of Palestinians has been regularly and repeatedly recognised by the United Nations Special Rapporteurs as evidence of an Apartheid system.
As the WHO rightly stated, “Without health, other rights have little meaning”. The WHO has always maintained that Israel is in extreme breach in relation to Palestinian people’s basic right to health. In addition, Israel is also guilty of apartheid, systematic oppression, and racial discrimination of Palestinian people. Its avaricious occupation which spans over half a century has impacted not just the health of the Palestinian people, but also their right to access basic healthcare. The structural inequality between the people who control the power and those without power, who are forced to face the consequences of these rapacious decisions has uprooted the very idea of human rights. Israel’s policies over Palestinian people would not be possible without international support; for that reason, the oppression of Palestinian people and the apartheid system will certainly continue until Israel and its allies display an organised international conscience. Until then, Palestinian people may just have to wait.