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Palestinian health care - a letter in the Lancet
Sir--As occupying power, Israel is required by the Fourth Geneva Convention to that ensure the health-care needs of the Palestine population are met. Rachelle Fishman's Nov 22 news item (p 1527)1 dismisses evidence that the draconian Israeli closures policy imposed on the West Bank, East Jerusalem, and Gaza compromise medical care. Two member groups of the International Federation of Health and Human Rights Organisation, having completed an assessment of health-care delivery in the Occupied Territories, reached a different conclusion--that the closures violate medical neutrality and transgress international law.

In 1993, the Israeli government imposed a permanent blockage between Gaza and the West Bank, and East Jerusalem, which prevented free access of Palestinians to their only national tertiary-referral hospitals. Further, in the past 2 years, Israel have responded to terrorist attacks by imposing intermittent "internal closures", of disputed security value, on the whole Palestinian population. Sometimes known as sieges, super-closures imprison residents from six major West Bank towns within town limits and prohibit citizens from the environs and from the remainder of the West Bank from entering, for weeks at a time. Patients who live outside town cannot access hospitals without permission from checkpoint soldiers who lack medical knowledge, and many health employees cannot reach work. A survey in March, 1996, found that 38% of the health workers were unable to reach work and five of ten hospitals had a 50% or greater reduction in emergency cases.2 We interviewed doctors who had smuggled themselves into the village of Asira, after it had been under total closure over 2 weeks, so that they could treat patients, including children, whose medical conditions had deteriorated because they were denied access to appropriate services in nearby Nablus.

Tertiary health-care services for citizens of Gaza are, of necessity, Israeli because after 26 years of Israeli control no accessible tertiary Palestinian service exists, and must be relayed through a referral doctor acceptable to the Palestinian Authority and to Israel. The bureaucracy can hinder good medical practice, to the extent that Physicians for Human Rights (Israel) has frequently had to intervene to ensure Gazaans receive appropriate medical care. Medical training and education is also disrupted--every Gazaan doctor has to return to Gaza during a closure on pain of severe penalty. We had to repeatedly fax Erez checkpoint before a permit was issued to allow a West Bank doctor to present her paper on learning disability to an international conference in Gaza and another Palestinian physician, of international standing, was refused a permit.

Repeated obstructions to the coordinated functioning of a national-health service promotes premature deaths, increase morbidity, and damage the medical infrastructure. The Israeli authorities' disregard for Palestinian health care, evident during their stewardship of the health system during 1967-94, continues to influence their security policy and will, ultimately, have been responsible for an incalculable number of deaths.3

*Peter Hall, Robert Giel

*Physicians for Human Rights (UK), University Department of Forensic Medicine, Royal Infirmary, Dundee DD1 9ND, UK; and Johannes Wier Foundation, PO Box 1551, Amersfoort, Netherlands

1 Fishman RHB. War of words continues over Palestinian health care. Lancet 1997; 350: 1527.

2 Health care under siege: the February 1996 closure of the occupied territories. Health and development information project. hdip@hdip.org. 1996.

3 Giacaman R. Health conditions and services in the West Bank and Gaza Strip. Geneva: United Nations, 1994.



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