This report, "A False Dawn", makes three contributions to an understanding of the right to physical and mental health in the West Bank and Gaza Strip:
Firstly, it provides an account of a collaborative investigation carried out in the area in October 1997 by two independent European medical health and human rights organisations into the effectiveness of current heath care delivery, set within the context of the health legacy the Palestinian Authority inherited, and the role of health workers and professional bodies in relation to violations of human rights and ethical codes.
Secondly, the report compares the investigators' findings with internationally recognised standards including codes of conduct for medical professionals such as the Declarations of Geneva and Tokyo, as well as with international human rights and humanitarian law.
Thirdly, the report presents recommendations to relevant professional, political and human rights organisations worldwide.
THE RESEARCHERS The investigation was conducted by the Johannes Wier Foundation and Physicians for Human Rights (UK), affiliates of the International Federation of Health and Human Rights Organisations (IFHHRO). The six member Anglo-Dutch team comprised a chief nurse, two psychiatrists, a general practitioner, a physician and an international human rights lawyer.
THE METHODOLOGY Having researched existing literature on the subject, the investigators travelled throughout the Gaza Strip and West Bank, including Jerusalem, interviewing, documenting, and collating the views of representatives of organisations and individuals involved in past and current Palestinian health care delivery, from both Palestine and Israel. The research technique employed observations and interviews rather than surveys and questionnaires. This qualitative method of collecting the experiences, views and accounts of the people involved, enabled the investigators to develop concepts that aided understanding of health in the complex political context within which it is set.
THE RESPONSIBILITY FOR HEALTH CARE Throughout the 27 years leading up to the peace process which followed the 1993 Oslo Accords, the Israeli government, as Occupying Power from 1967, was legally responsible under the Fourth Geneva Convention for providing a health service that met the health needs of the Palestinian people. Since 1994 the responsibility for primary, secondary and tertiary care in all areas except East Jerusalem has been assumed by the new Palestinian Authority, although some aspects remain under Israeli control.
THE LEGACY OF THE OCCUPATION The Israeli occupation has left the Palestinian health system under-developed and under-resourced in direct contravention of Israel's obligations under the Fourth Geneva Convention and the Hague Regulations. This legacy continues to adversely impact the health of the Palestinian population because every adult Palestinian’s accumulated health status as well as the condition of the present health infrastructure is to a significant extent the product of the last quarter century’s maladministration.
Although a comparison between the health care delivery system of 1992 with that of 1967 shows considerable improvement, the system contrasts poorly with those in neighbouring countries and, notably, with that of Israel. A study in the early 1990's demonstrated that, using obstructive measures and regulations, the Israeli military administration introduced distortion, irregularity and inequity into the distribution of health services and facilities in the West Bank. These policies perpetuated a dependence on the Israeli medical services and other non-Palestinian agencies, and the Israeli administration admits there was never any long term strategic aim to achieve Palestinian self reliance in health care.
THE OSLO ACCORDS The provisions for health within the Oslo Accords were limited and failed to address Palestinian health needs. Hand over arrangements for the transfer of responsibility of health care provision for 2.5 million Palestinians were limited to a perfunctory 1.3 pages of the Oslo Accord – half of which were dedicated to arrangements for Palestinian Authority payment for future medical care of Palestinians in Israeli hospitals or informing the Israeli authorities of Israeli citizens hospitalised in Palestinian facilities. The conveyance was further hampered by the Palestinian Authority's preoccupation with contemporary macro-political issues and by Israeli imposed travel restrictions preventing free movement between the West Bank and Gaza. Importantly, many of the senior managers in the new Ministry of Health were not only without experience of the Palestinian Health care system but also of health care itself.
THE PROBLEM OF HEALTH CARE ACCESS The topographical fragmentation of the Palestinian community brought about by the Occupation and the Oslo Accords, has left the Palestinian people living within a complex mix of Israeli occupation and Palestinian autonomy. Gaza and East Jerusalem are isolated from the West Bank which itself has become a jumble of areas of variable Palestinian responsibility juxtaposed with Israeli settlements. Inevitably, such a situation has damaged health care provision; with access to health care, the movement of patients and the provision of services all obstructed.
Israel is implementing a number of policies aimed at a de facto deportation of Palestinians from Jerusalem, thus depriving thousands of people of their right to health care. Further, as most of the Palestinian tertiary care services are located in East Jerusalem, they have been virtually cut off from the Palestinian population. Arranging alternative tertiary care facilities in Israel or further abroad is expensive, complicated to arrange and difficult to reach. For instance a Gazaan citizen’s access to tertiary services, of necessity almost always in Israel, must be relayed through a referral doctor acceptable to the Palestinian Authority and to Israel. The bureaucracy involved in this interchange can prevent prompt treatment – to the extent that Physicians for Human Rights Israel has frequently had to intervene to ensure Gazaans receive appropriate medical care.
THE CONSTRAINTS ON HEALTH CARE TRAINING There are huge training needs within the new health service, yet insufficient training opportunities. What training is available, is hampered by difficulties in organisation within a fragmented service and by restrictions on movement, including international travel. For example, every Gazaan doctor has to return to Gaza during an Israeli closure on pain of severe penalty. The research team observed the IFHHRO having to repeatedly fax Erez checkpoint before a permit was issued allowing a West Bank doctor to present her own paper on learning disability to an international conference in Gaza, while another Palestinian presenter – of international standing – was refused permission.
The impact of Israeli control and restrictions on resources, referrals and training is obstructing the development of an independent Palestinian health infrastructure and constitutes a continuing violation of international humanitarian law and human rights law.
THE FACTORS AFFECTING MENTAL HEALTH The pervasive and dominating effect of occupation and Israeli security actions on the Palestinian population, together with poverty, oppression and hardship, has had an effect on mental health. Symptoms of post traumatic stress, depression and anxiety are increasing. There is a perception that past sufferings have not been acknowledged or brought about a change for the better. There is a prevailing sense that high expectations raised by the Oslo process have not been met and the initial optimism has given way to feelings of loss and frustration.
THE IMPACT OF ISRAEL'S SECURITY MEASURES ON HEALTH The frequent imposition of blanket closures on the pretext of protecting Israeli security constitutes a collective punishment. Such measures are disproportionate and in direct contravention of the Fourth Geneva Convention and the human right to freedom of movement (1). They deprive the Palestinian population of their human right to access to health care and as such have grave consequences for health. Moreover, decisions as to whether patients are permitted to pass checkpoints in order to reach medical services are made by Israeli security personnel without medical training and have resulted in unnecessary deaths. The priority afforded to security concerns over medical considerations at checkpoints endangers lives and undermines the integrity of health care provision.
THE PROBLEM OF HEALTH CARE MANAGEMENT Morbidity and mortality have been affected by a range of other factors. Environmental factors are an important issue, particularly the inadequate quantity and quality of water allocated to Palestinian communities by Israel. Failure to adhere to this elementary public health measure risks the spread of disease as a consequence of difficulties with sewage and waste disposal (2). Hospital building projects in the West Bank have been blocked by the withholding of planning permission by Israel. There are problems with funding, such as a long-standing reliance on international donors, a limited and expensive insurance scheme and the effect of Israeli restrictions on the Palestinian economy. Among health professionals, there are concerns regarding the financial management of the health care system – in particular, there are complaints that health is insufficiently prioritised in budgeting by the Palestinian Authority, and there are reports of corruption.
THE REGIONAL RESPONSE TO MEDICAL ETHICS There is only limited awareness among Palestinian health professionals of relevant codes relating to human rights and humanitarian law and of professional responsibilities in relation to these, although some NGOs are active in promoting awareness. Under the prevailing circumstances, Palestinian and Israeli health workers often face choices which directly or indirectly risk violating medical ethics. The Israeli Medical Association, by failing to speak out against abuses regarding Palestinian health, and to take proactive steps to address allegations that Israeli doctors actively participate in torture, is in breach of its obligation as a member of the World Medical Association to adhere to the World Medical Association Declaration of Geneva.
THE CONCLUSION The Israeli authorities’ disregard of the importance of Palestinian health care, evident during their 1967-1994 stewardship of the health system, remains a feature of their policies, particularly on security, and will ultimately have been responsible for an incalculable number of deaths. The Palestinian health service suffers from insufficient funding and from mismanagement by a Palestinian Authority that assumed responsibility with little previous training or experience of health care management. The negotiations which form the continuing Peace Process provide the opportunity for both Israeli and Palestinian authorities to act on the recommendations of this report in such a way that the Palestinian health care system will meet the internationally recognised standards of human rights law, humanitarian law and the medical community.
 In its concluding observations on Israel’s Article 40 report, the Human Rights Committee noted with regret "the continuing impediments imposed on movement, which affects mostly Palestinians travelling in and between East Jerusalem, the Gaza Strip and the West Bank, and which have grave consequences affecting nearly all areas of Palestinian life". Paragraph 22 [CCPR/C/79/Add.93] 18 August 1998.
(2) In its concluding observations on Israel’s Article 40 report, the Human Rights Committee expressed concern that "Palestinians in the occupied territories who remain under the control of Israeli security forces do not enjoy the same rights and freedoms as Jewish settlers in those territories, in particular in regard to planning and building permits and access to land or water". Paragraph 13 [CCPR/C/79/Add.93] 18 August 1998.
Post script Article 12* of the International Covenant on Economic, Social and Cultural Rights deals with a State’s obligations to maintain the health of its population. Every state signatory is required to make ‘periodic reports’ to the Committee on Economic, Social and Cultural Rights (CESCR) at five year intervals. In November 1998 PHR-UK gave evidence before the CESCR on healthcare in the Occupied Territories on the occasion of Israel’s quinquennial report. Paragraph 18 of the concluding observations of the CESCR deals with the most substantive issue within PHR-UK’s submission “... [the Committee] notes with grave concern the severe consequences of closure on the Palestinian population. Closures have prevented access to health care, first and foremost during medical emergencies, which at times have tragically ended in death at checkpoints and elsewhere”
* Article 12 of the International Covenant on
Economic, Social and Cultural Rights
1. The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.
2. The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for:
(a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child;
(b) The improvement of all aspects of environmental and industrial hygiene;
(c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases;
(d) The creation of conditions which would assure to all medical service and medical attention in the event of sickness.
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