Question of Palestine home
World Health Organization (WHO)
16 May 2013
Health conditions in the occupied Palestinian
territory, including east Jerusalem, and in the
occupied Syrian Golan
At the request of the Permanent Observer of Palestine to the United Nations and Other International Organizations at Geneva, the Director-General has the honour to transmit the attached report to the Sixty-sixth World Health Assembly (see Annex).
The State of Palestine
Ministry of Health
A REPORT ON THE HEALTH CONDITIONS
IN THE OCCUPIED PALESTINIAN TERRITORY
Sixty-sixth World Health Assembly
1. The Palestinian health situation faces many challenges under the oppressive Israeli occupation of Palestinian land, which deprives the Palestinian citizens of their rights and violates all international treaties, conventions and charters that guarantee the rights of all segments of the Palestinian people. This report contains details about the health reality in Palestine, its indicators and determinants, and the effects of occupation and settlement practices on the health of the Palestinian people, and the ability of the health system to satisfy the needs of the citizens. It concludes by calling upon the international community and the World Health Assembly to do all what can be done to safeguard the rights of the Palestinian citizens.
2. In 2012, the population of the occupied Palestinian territories was estimated to be 4 293 313, including 396 710 in occupied Jerusalem. The population distribution was 61.7% in the West Bank and 38.3% in the Gaza Strip. Population distribution according to sex reveals that men accounted for 50.8% of the population and women 49.2%
Crude birth and death rates
3. Data from the Palestinian Central Bureau of Statistics indicate that in 2012, the crude birth rate was 32.7 per 1000 population and the crude death rate was 3.9 per 1000 population.
4. The Palestinian society is still young. In 2012, children under five years of age accounted for 14.7% of the total population living in the Palestinian territories; 40.2% were in the age group (0–14 years) and 2.9% were in the age group 65 years and above.
Delivery of health services
5. Over the past two years, the Ministry of Health has endeavoured to improve the quality of the health services provided to the citizens and has prepared an ambitious plan to reform and develop the health sector (2011-2013). Despite the actions of the Israeli occupation and despite the lack of financial resources, but also thanks to the insistence of the Ministry of Health on implementing the plan to develop and reform the health system and thanks to the response of many donor states and United Nations organizations active in the health sector, the Ministry of Health is achieving great successes, among the most important of which being the rehabilitation, development and equipping of health facilities and the implementation of ambitious programmes to train health cadres. The main obstacle to the implementation of the strategic national plan to reform and develop the health sector (2011-2013) is the blockade imposed on the Gaza Strip and the abnormal political situation there.
6. Below is an overview of the Palestinian health system and the main services provided to the citizens, together with the main health indicators for 2011. The emphasis is placed on the health situation in the Gaza Strip that is witnessing a marked deterioration and that is at risk of collapsing unless the blockade is ended and the political situation in the Strip returns to its normal state, especially through the return of the Strip to the central administration of the Palestinian National Authority.
THE PALESTINIAN HEALTH SYSTEM
Primary health care
7. Primary health care is delivered by different providers of health services from the Ministry of Health, nongovernmental organizations, UNRWA, the military health services and the Palestinian Red Crescent. In this regard, the central administration of primary health care at the Ministry of Health plays a distinguished role. The network of health care centres has been extended throughout the national governorates, from 454 centres in 1994 to 748 in 2011 – an increase of 64.8% compared with 1994. Government-run centres represent 61.2% of all centres operating in the area of primary health care, of which UNRWA supervises 8.2% whereas nongovernmental organizations supervise 30.6%. In the West Bank, in 2011, the number of visits to primary health care centres administered by the Ministry of Health totalled 2 418 121 for consultations with physicians, which corresponds to a rate of one visit per citizen in the West Bank, whereas there were 1 893 791 visits to nurses in the primary care centres.
8. The proportion of Palestinian women of reproductive age (i.e. 15–49 years) is 48.8% of the total number of women in Palestine. The mortality rate recorded at the national level was 38 per 100 000 live births in 2009, 32 per 100 000 live births in 2010 and 28 per 100 000 live births in 2011. The Ministry of Health has set up a high-level national committee to monitor the recording and reporting of maternal mortality. Due to the current political situation in the Gaza Strip, reporting of these rates is extremely poor. The reported rates do not always reflect reality.
Total fertility rate
9. According to the Palestinian Central Statistical Office, the total fertility rate among women of reproductive age (15–49 years) was 4.1 at the national level in 2011 (4.9 in the Gaza Strip and 3.8 in the West Bank).
10. The annual health report 2011 prepared by the Palestinian Centre for Information in the Ministry of Health showed that most births in Palestine occur in hospitals or in maternity homes (98.5%), and that hospitals administered by the Ministry of Health play a pivotal role in this respect (50.6%). This confirms that most Palestinian women prefer to give birth in a hospital setting, and especially hospitals administered by the Ministry of Health, in view of the good services they offer, and because most of the Palestinian population benefits from the health insurance system covering childbirth. Government hospitals therefore represent generally the most appropriate choice.
Family planning programmes
11. Family planning programmes are a major priority for health service providers in general and for the Ministry of Health in particular. The number of primary health care centres offering such services has increased to 187 in the course of 2011 in different governorates. There are currently 167 such centres in the West Bank and 20 centres in the Gaza Strip.
12. In 2011, a total of 81 159 women visited family planning centres (13 738 in the Gaza Strip and 67 421 in the West Bank). Contraceptive pills were the most common birth-control method among women making their first visit to such services, amounting to 68.5% in 2011 against 31.4% in 2010, whereas the use of intrauterine devices decreased from 36.6% in 2010 to 11.5% in 2011. The use of diaphragms amounted to 17% over the two years 2010 and 2011.
Radiographic breast examinations
13. In 2011, the Ministry of Health provided radiographic examination of breast services through primary health care in the different governorates in the West Bank. The number of examined women was 6746, of which 4252 cases were found to be normal, that is 63% of the examined cases; the remainder were followed up for further examinations.
14. The Ministry of Health owns and operates 54 dental clinics at primary health care centres, including 30 in the West Bank and 24 in the Gaza Strip. There are several hundred such clinics in the private and nongovernmental sectors. In 2011, the Ministry of Health recorded a total of 191 743 visits to dental clinics (21.4% in the West Bank and 78.6% in the Gaza Strip).
Laboratories and blood banks
15. The number of Ministry of Health laboratories reached 203 in 2011, with a 2.5% increase compared with 2010 and a 5.7% increase compared with 2009, including four central laboratories, two in the West Bank and two in the Gaza Strip. There were 23 hospital laboratories (12 in the West Bank and 11 in the Gaza Strip) and 176 laboratories located at primary health care centres (138 in the West Bank and 38 in the Gaza Strip). In 2011, a total of 8 427 832 laboratory tests were carried out at Ministry of Health laboratories, of which 33.7% were carried out in primary health care laboratories and 66.3% in the Ministry’s hospital laboratories.
16. Seven hundred and sixty-three technicians and professionals were employed at the Ministry of Health laboratories, including 357, or 46.8%, in the West Bank and with the remaining number in the Gaza Strip. The total number of blood donors was 42 406, of whom 30.7% were voluntary donors, while 69.3% donated blood to a relative or friend. Laboratory tests for blood-borne diseases are carried out on all units of donated blood prior to transfusion.
17. The Ministry of Health is considered the major provider of secondary care services (hospitals) in Palestine. It owns and administers 3372 beds (1404 in the West Bank and 1968 in the Gaza Strip) in 25 hospitals in all governorates (12 in the West Bank and 13 in the Gaza Strip) out of a total of 81 hospitals operating in Palestine with a total capacity of 5996 beds. Fifty-one of these hospitals, with 3215 beds, are in the West Bank; and the rest are in the governorates of the Gaza Strip. In addition to hospitals administered by the Ministry of Health, there are 34 hospitals owned by community-based organizations and 20 privately-owned hospitals, all of which are in the West Bank. UNRWA owns a single hospital in Qalqilya governorate with 63 beds.
18. The Ministry of Health’s services cover almost all specializations, including general and specialized surgery, internal medicine, paediatrics, psychiatry and others. Rehabilitation and physiotherapy are provided by nongovernmental hospitals, which also offer other services such as outpatient and emergency treatment. Dialysis is provided by 15 units distributed among governmentadministered hospitals. These units performed 133 656 dialysis interventions in 2011. The main services offered by government hospitals include diagnostics such as radiology. In 2011, Palestinian government hospitals produced a total of 1 015 271 radiological images. Other important services in this area include laboratory tests.
HEALTH INDICATORS, 2011
Population and demography
The determinants of health
19. There is no doubt that the determinants of health in Palestine have not improved over the past years. Poverty and unemployment rates in Palestine, and especially in the Gaza Strip, have considerably worsened owing to the continued suffocating Israeli blockade. Moreover, demographic indicators such as high fertility rate, high population growth rate and epidemiological changes as reflected in the prevalence of chronic diseases still constitute formidable challenges facing the Palestinian health system. The presence of the Israeli occupation forces, however, is the greatest challenge facing the health sector, as well as the daily acts of violence perpetrated by the occupying army and the hordes of Jewish settlers against Palestinians, in addition to the continued presence of hundreds of military barriers, the apartheid wall and the isolation of the Palestinian territories from each other and from the rest of the world through the closing of the crossings and borders.
20. Israel, as an occupation power, continues its aggression against Palestinian civilians and against children who protest peacefully against the occupation army and settlers’ acts aimed at seizing their land and destroying their crops which are their main source of income, especially olive trees. Settlers continue their almost daily aggression on olive groves, burning or uprooting olive trees.
21. Recently, the Israeli occupation army has been using dogs to terrify and attack peaceful protesters thus causing many injuries.
22. Israel also uses different methods to assassinate those who resist occupation, such as in Gaza where individuals are assassinated by aerial bombardment, whereas in the West Bank and Jerusalem, assassination is carried out by firing directly on peaceful protesters.
23. The blockade imposed on the Gaza Strip since 2005, combined with tightening restrictions on the movement of individuals and goods through all crossings and borders controlled by Israel, hinders economic growth and exacerbates unemployment and poverty and has thus a negative effect on health. Maternal and child health services have deteriorated and deliveries at home have increased. This was accompanied with more high-risk pregnancies and deaths among mothers and newborn babies, and reduced the ability of the Ministry of Health to achieve the Millennium Development Goals.
24. According to estimates, the health services provided to nearly 40% of those suffering from chronic diseases in the Gaza Strip have deteriorated significantly which has led to the worsening of their health conditions. Also the ever-increasing transfers for treatment abroad at the expense of the National Palestinian Authority overburdens the Ministry of Health budget and the Palestinian citizen himself who must endure untold hardships in getting the necessary authorizations to exit the Gaza Strip, in addition to the travel and accommodation expenses incurred by the patients and those accompanying them abroad.
25. The concern of the Palestinian National Authority, through the Ministry of Health, for promoting the health of Palestinian citizens as a basic right, and its efforts to provide integrated health services to Palestinian citizens in response to economic, demographic and epidemiological changes has markedly improved health indicators, thus giving national health services an edge over the services provided by some neighbouring countries, taking into account the differences in rates of health expenditure. This is evidence of the resilience of the Palestinian health sector and its ability to cope with these challenges and to achieve concrete results towards the Millennium Development Goals.
The economic situation
26. In 2011, the unemployment rate reached 28.7% in the Gaza Strip compared with 17.3% in the West Bank, and the poverty rate according to consumption patterns reached 38% in the Gaza Strip and 18.3% in the West Bank. Also 23% of the population in the Gaza Strip and 8.8% in the West Bank suffer from abject poverty as a result of measures taken by Israel and the blockade imposed on the Gaza Strip in particular, and on the Palestinian people in general. The continuation of the occupation and the measures taken against the Palestinian people constitute a major obstacle that prevents patients from paying for treatment costs, thereby adding to the burdens that the Ministry of Health has to bear.
Health conditions of Palestinian prisoners in Israeli jails
27. In 2013, the number of Palestinian prisoners in Israeli prisons rose to 4750, of whom 82.5% are from the West Bank, 9.6% from the Gaza Strip and 0.9% from Jerusalem and the 48. The prisoners include 186 under administrative detention without charge or trial, 12 women, the longest serving of whom being Lina al-Jarbouni, from the year 48 territories, who has been detained for 11 years, 198 children not older than 18 years of age, 25 of whom are under 16 years of age, in addition to 12 deputies, 3 former ministers and tens of teachers and Palestinian political, academic and professional leaders. Arrests and detentions of Palestinian citizens, including children, are carried out on a daily basis without specific charges. These prisoners are subjected to all manner of torture and ill treatment such as nude inspection which represent a stark insult to human dignity and a clear sexual assault. The administrative detention, which ranges from days to months and years, violates the simplest international norms and laws. Despite the fact that many of the prisoners and those on administrative detention went on a hunger strike for periods extending up to seven months in order to realize their just demands, such as in the case of the captive from Jerusalem, Samer Alissawi, whose hunger strike is considered one of the longest in history. This puts his life and the life of other similar prisoners at risk, the Israeli occupation forces still continue their oppressive practice of administrative detention of tens of peaceful Palestinians without putting them on trial or releasing them.
28. There are about 1400 ill Palestinian prisoners inside Israeli prisons; they suffer from very difficult health conditions and diseases (diseases of the heart and lungs, cancer, stomach and intestine, nerves, diabetes, high blood pressure, arteries and veins, eyes, chest, liver, amnesia, glands and kidneys). There are also cases of detention involving individuals with motor disabilities, hemiplegia and psychological and mental diseases. Medical negligence inside the prison has led to serious consequences for their health as a result of the difficult detention conditions, ill treatment and malnutrition. Eight prisoners are permanently housed in the so-called “Alramlah hospital”, some of them unable to move because the prison administration ignores their plight and does not provide them with the necessary health care and treatment. Five hundred and thirty-two prisoners have been sentenced to one or more life prison terms, with consequences for their and their families’ physical and mental health.
29. It is worth noting that, up to the end of 2012, and according to data from the Ministry of Prisoners’ Affairs, the occupation forces had detained approximately 800 000 citizens since 1967, including approximately 15 000 women and tens of thousands of children. Just like men and children, Palestinian female prisoners are subjected to beating, insults and offensive and degrading treatment. When they are moved, they are not told their destination; during an interrogation, they are terrorized, threatened, treated cruelly and their dignity is violated. All this has a negative effect on the mental, physical, family and reproductive health of the female prisoners after they leave prison, and other destructive consequences.
30. Data from the Ministry of Prisoners’ Affairs also show that 204 prisoners have been killed after detention since 1967, including 71 detainees killed as a result of torture, 53 detainees as a result of medical negligence, 74 as a result of homicide and direct liquidation after detention and 7 prisoners were killed as a result of being shot directly by soldiers and guards while inside the prisons.
SHORTAGE OF FOOD SUPPLIES
31. The continuation of the blockade of the Gaza Strip has led to a continued and acute shortage of essential materials, foodstuffs, energy supplies and other vital necessities. This situation has resulted in the emergence of chronic nutritional diseases, including stunting or excessive underweight; 10.6 out of every 100 children under five are chronically or acutely undersized. According to the data of the Palestinian Central statistical office in 2012, and as the nutritional monitoring of the Ministry of Health indicates, the prevalence of anaemia in the Gaza Strip is high among children and women, and the prevalence of anaemia has reached 57% among children aged 9–12 months, being 68.1% in the Gaza Strip and 48.9% in the West Bank, and 36% among schoolchildren aged 6–18 years. Also, data indicate that 1.7% of school students are underweight (2.1% in the West Bank and 1.6% in the Gaza Strip), 2.6% of school students in Palestine suffer from stunting and 7.3% of school students suffer from wasting (7.7% in the Gaza Strip and 7.3% in the West Bank). The level of anaemia among pregnant women in Palestine is 27.8%, and it reaches 36.8% in the Gaza Strip.
32. Lack of access to food and high food prices due to the continuing military barriers, restrictions on movement and confiscation of land in the West Bank have resulted in high levels of unemployment and limited purchasing power among a large segment of the population, which in turn has led to the occurrence of malnutrition-related diseases in the West Bank and also in the Gaza Strip, although to a lesser extent.
SHORTAGE OF FUEL AND ELECTRICITY IN THE GAZA STRIP
33. The electricity supply to the Gaza Strip comes from three sources: 40% from the local power station using industrial fuel arriving to the Gaza Strip via Israel; 50% from the direct electricity supply from Israel and 10% from the Egyptian electricity network. Thus, Israel has total control over the electricity supply required for city lighting and for everyday activities to function. Since 2007, most families and health institutions in the Gaza Strip suffer from power cuts for eight to 12 hours a day or more. On 7 February 2008, on the instructions of the Israeli defence ministry, the Israeli electricity company reduced the supply of electricity to the Gaza Strip by 0.5 megawatt per week. The reduction in electricity and energy puts immense pressure on the already crumbling electricity network in the Gaza Strip, affecting the infrastructure for drinking-water and the sewage system, and disrupting the provision of health care for civilians in the Gaza Strip.
34. Figures documented by the Palestinian Centre for Human Rights indicate that the Gaza Strip’s supplies of fuel and combustibles have been reduced by more than 50% since the decision taken on 25 October 2007 by the Israeli authorities to reduce imports, and that the supplies of petrol, diesel and gas for domestic use have declined by 60% - 73%.
35. The acute shortage of electricity that Gaza has experienced over the past few years has led to the disruption of basic services and the undermining of living conditions that were already precarious. Since February 2012, the situation has further deteriorated following the sharp decrease in the quantity of fuel brought to Gaza from Egypt, in an unofficial way, through the tunnels, and which was used to operate the Gaza power station.
36. The shortage of fuel required to operate the Gaza power station, as well as the regulation of the electricity supply from Israel are continuing at the same rate, leading to many health, social, and economic consequences, notably the following:
1. Impact of shortage of fuel and electricity on the health situation in the Gaza Strip
• The interruption of electric current has affected human rights in the Gaza Strip; 1.7 million civilians living in the Gaza Strip suffer because of long interruptions of the electric current, a situation exacerbated by an acute shortage of fuel supplies.
• The interruption of electric current affects the right to health of the Palestinians in view of its extremely serious impact on health services. Many health services face the threat of being discontinued because of the daily interruption of electricity for long hours combined with the shortage of daily supplies of diesel fuel needed to operate electric generators in hospitals and primary care centres, and which vary from 8000 to 10 000 litres daily.
• Medical services, including rapid intervention services in emergency cases to save lives, are at risk of collapsing because of the imminent exhaustion of the fuel reserves used to operate standby generators and ambulances. The vacillation in the provision of electric power has caused sensitive medical equipment to malfunction and medical services to be interrupted. In the context of setting priorities, the main one among which being emergency surgery, hospitals were forced to postpone other elective surgery which, although not life threatening, has negative impacts on the patients and injured when postponed.
• The stoppage of many surgical operations – only those of an urgent and critical nature take place.
• The shutting-down of a number of oxygen-generating stations, which need high levels of power that cannot be supplied by small generators.
• X-ray units run at 50% capacity.
• The increased suffering of kidney failure patients owing to disruption and stoppage of dialysis units because of power outages.
• The halting of central air-conditioning systems in hospitals is adversely affecting the performance of duties, especially in enclosed areas such as operating theatres and intensive care units, particularly for newborn infants.
• The compromised validity and viability of blood and plasma supplies, which can be damaged when power outages last more than two hours.
• Many diseases affect the young and the old due to the intense heat in summer. Electricity is available for no more than 8 hours a day, and this leads to the spread of diseases affecting children, such as skin allergy which causes scratching and the inability to sleep due to pain. Moreover, the failure to cope with intense heat causes the blood pressure of patients to rise and the sugar level of diabetes patients also to rise. Also, some diseases react to heat such as rheumatoid arthritis and rheumatism which affect older people in Gaza, and many other diseases.
• Many surgical operations of different types are performed daily. Such cases will need a moderate temperature at home to help with the healing process and avoid any complications after the operation. This requires that there be electricity to operate fans and air-conditioners.
• The interruption of the electric current has serious repercussions on the right to safe and sufficient food. Such interruptions affect poultry, livestock and fisheries because of their detrimental effects on the different phases of rearing, production and consumption. This seriously affects food security, and hence public health.
• The use of dangerous traditional means of energy and light production (such as wax, firewood, petrol lamps) by families, especially during the night hours and in winter, has led to cases of asphyxia and the death of tens of individuals, and even of entire families.
2. Impact of shortage of fuel and electricity on drinking-water and sewage systems in the Gaza Strip
37. There are 180 water and sanitation facilities in the Gaza Strip, including 140 wells, 37 water pumping stations and sanitation plants and three sewage treatment plants, all of which require regular maintenance, spare parts and technical equipment not available in local markets owing to the Israeli blockade and closure. The Water Authority secured only 50% of its fuel needs, resulting in the irregular supply of drinking-water on a permanent basis. Also, the stoppage of sewage treatment plants causes large quantities of untreated sewage water to be discharged into the sea, thereby polluting sea water, fish and beaches. The sea shores of the Gaza Strip are badly polluted, because untreated sewage water is pumped into the sea, thus exacerbating the environmental crisis and continuously damaging public health. Some 76 134 families, 12.2% of the total, still have no access to safe drinking-water. The cuts in power to the Gaza Strip hinder the operation of water pumps, domestic refrigerators and health centres, since water is pumped for only two to three hours a day.
Transfers for treatment abroad, the Israeli restrictions, the financial crisis and its repercussions
38. The peculiarity of the political situation that Palestine is experiencing, the continuous Israeli aggression against the Palestinian people and its institutions, the destruction of its infrastructure and the effects of this on the health conditions have led to the inability of the Palestinian health system to provide the required services, be it in the West Bank or the Gaza Strip. Accordingly, demand has increased for treatment outside the Ministry of Health institutions, and especially in the private sector and hospitals in east Jerusalem, Egypt and Israel.
39. It is worth mentioning that the total number of transfers to buy services outside the Ministry of Health facilities in both the West Bank and the Gaza Strip in 2012 amounted to 56 076, which represents a decrease by 0.7% compared with 2011, when there were 56 468 transfers, and an increase of 5.8% compared with 2010, when there were a total of 53 025 transfers to buy services outside the Ministry of Health facilities.
40. The total cost of all transfers in 2012 was 604 417 285 shekels (i.e. approximately US$ 151 104 321), which represents an increase of 3% compared with 2011, when the cost of transfers amounted to 472 456 181 shekels (or the equivalent of US$ 121 695 302). The high value of these transfers overburdens the Palestinian Government budget in light of the severe financial crisis and affects the capacity of the government to provide high quality health services to other citizens.
41. Obtaining an authorization to leave for treatment outside the Gaza Strip or the West Bank, and especially to Jerusalem hospitals, involves great suffering. A great portion of cases are not given authorization by the Israeli authorities for reasons justified as security-related; the issuance of other authorizations is delayed. Many have suffered as a result of their treatment being delayed or refused, or for waiting for an authorization until the last minute, which has led to the deterioration of their health condition and to many deaths that could have been avoided among Palestinians. Often, the Israeli authorities interrogate patients when they cross the military barriers, or interrogate those accompanying them in the case of children. Two hundred and six patients aged 18-40 years were subjected to interrogations in 2012 in order to obtain an authorization. Data show that approximately 222 188 requests for authorization were submitted to the Israeli authorities in 2012 from patients in the West Bank and those accompanying them for treatment in Jerusalem hospitals; 177 051 were approved (79.9% approved, 17.6% refused, 2.7% received no answer). From the Gaza Strip, 9329 requests were submitted; 8628 were approved and the rest refused.
42. There are also restrictions on the movement of ambulances transporting patients to Jerusalem hospitals. In 2011, only 5% of Palestinian Red Crescent ambulances in the West Bank were allowed to enter Jerusalem, 95% had to drop off patients at the barrier to be transferred to ambulances with Israeli licence plates (back-to-back). In 2012, only 9% of Palestinian ambulances were allowed to enter Jerusalem. The situation is not any better concerning the movement of medical teams working in Jerusalem hospitals and carrying Palestinian identity cards. There are about 1053 staff, including physicians and health workers, from the West Bank and the Gaza Strip who work in east Jerusalem hospitals and who require for their movement provisional authorizations indicating how and where they should move. It is also possible that an authorization be issued once but then refused many times for the same employee, which causes their work to be disturbed and affects the follow-up of patients and their health status. There are 21 employees who are banned on security grounds.
43. In the same context, mention must be made of the large debt incurred by the Palestinian Ministry of Health which has increased in an unprecedented manner due to the economic blockade imposed on the Palestinian people and to donors not honouring their financial pledges, as is the case in other institutions of the State of Palestine. The accumulated debt up to the end of 2012 amounted to 565 545 659 shekels (i.e. approximately US$ 141 386 415).
SHORTAGE OF MEDICINES AND MEDICAL CONSUMABLES
44. The severe financial crisis has been clearly reflected in the inability of the Ministry to buy medicines and medical consumables within the basic list. In the Ministry of Health depots in the West Bank, in 2012, there were about 150 types of medicines that were either unavailable or in insufficient quantities to meet emergency needs, whereas the shortage in the Gaza depots exceeded 250 types. As for the medical consumables, the shortage in the Ministry’s depots in the West Bank reached 120 types, and in Gaza more than 170.
THE ANNEXATION, EXPANSION AND APARTHEID WALL IN THE WEST BANK
AND OCCUPIED JERUSALEM
45. In defiance of the advisory opinion of the International Court of Justice in 2004, the construction of the annexation, expansion and apartheid wall did not stop, nor did its destructive effects on the lives of Palestinians. It continues to divide and isolate communities, destroying their livelihoods and preventing hundreds of thousands of people from travelling normally to their workplaces, families, markets, schools, hospitals and medical centres.
46. In 2002, Israeli occupation forces began building the annexation, expansion and apartheid wall. Upon its completion, the proportion of villages unable to access health facilities in the region will be about 32.7%, rising to 80.7% if the isolated pockets are taken into account as well as the tangential line. After completion, the wall will isolate a total of 71 clinics: 41 clinics having already been totally isolated. Some 450 000 Palestinians will be directly affected, and a further 800 000 indirectly.
47. The establishment of the wall is part of a comprehensive Israeli policy which began with the building of settlements, then barriers, and finally the wall that dismembers the West Bank and turns it into ghettos. The aim of building the wall 35 kilometres deep inside Salfit and Qalqilya – thereby isolating the occupied city of Jerusalem from the West Bank, and expanding the settlements of “Ma’aleh Adumim”, Bethlehem and Hebron – is to create ghettos; there are about 28 ghettos containing 64 Palestinian communities.
48. The report of the Palestinian Centre for Information in Ramallah states that the situation in the occupied city of Jerusalem is dreadful and that the wall, settlements and barriers cause serious health problems and isolate entire communities in Jerusalem, such as the village of Anata and the Shufat refugee camp, from those major facilities that provide them with services in the city of Jerusalem, such as Al-Uyoun, Al-Maqasid and the Red Crescent hospitals. The report also shows that more than 70 000 Palestinians with Jerusalem identity cards are threatened, as Israel’s next move, after constructing the wall, will be to prevent them from reaching Jerusalem, and then to withdraw their health insurance and Jerusalem identity cards on the grounds that they no longer reside in the city.
49. Furthermore, the report shows that there are no advanced health services in the city of Qalqilya; so its 46 000 inhabitants have no choice but to rely on hospitals in other cities, such as Nablus, in a trip that used to take 20 minutes but that now takes three and a half hours because of the barriers and the wall.
50. Also, the segregation wall directly affects even the villages that seem to be remote from the construction site, because of the road network that Palestinians are forbidden to use. For example, Palestinians are unable to reach Ramallah and occupied Jerusalem because of these streets.
51. The wall, the settlements and the Israeli authorization system are destroying the economic and social life of the population in the West Bank, and are responsible for exacerbating poverty and unemployment, with dire health consequences.
BARRIERS, PHYSICAL OBSTACLES AND PROHIBITED STREETS
52. Strict limitations imposed by Israel on the movement of Palestinians in the West Bank are implemented through a network of fixed barriers, unexpected movable barriers, physical obstacles, streets where Palestinians are prohibited from circulating and gates along the segregation wall. These restrictions allow Israel to control and restrict the movement of Palestinians in the West Bank according to its own considerations and interests through the massive violation of the rights of the Palestinians.
53. The continuing checking and inspections by soldiers at one part of the barriers, as well as the degrading treatment and long queues, discourage the Palestinian drivers from even using those streets where the restriction and prohibition do not apply. As a result, the movement of Palestinians has shrunk in part of the main streets of the West Bank, whereas these streets have been available for the almost exclusive use of settlers.
54. In February 2013, the number of fixed barriers erected in the West Bank reached 98, of which 58 were internal barriers erected deep in the West Bank, away from the Green Line. This figure also includes 16 barriers erected in area H2 in Hebron, in which Israeli settlement points exist. Of the total number of internal barriers, 32 are reinforced on a permanent basis.
55. Forty of the fixed barriers are final points of inspection before entering Israel, although most of them are kilometres away from the Green Line, before entering Jerusalem. All these barriers are reinforced on a permanent basis, and are closed to circulation when they are not reinforced. Part of the barriers have been totally or partially privatized. Some of them are reinforced today by armed civilian guards employed by private security companies under the supervision of the Crossings Administration in the Ministry of Defense.
56. Moreover, the army erects hundreds of unexpected movable barriers along the streets of the West Bank. The number of unexpected movable barriers has increased markedly of late. According to a count by the United Nations Office for Humanitarian Affairs, between April 2009 and March 2010, unexpected barriers were erected at a rate of about 310 per month. This is to be compared with a rate of 65 unexpected barriers between September 2008 and March 2009.
57. In part of the barriers, Israel prohibits the crossing of private Palestinian vehicles unless with special authorization. In general, it only allows the movement of public transportation and commercial vehicles.
58. Moreover, the Israeli army erects hundreds of unexpected movable barriers along the streets of the West Bank. According to a count by the United Nations Office for Humanitarian Affairs, there were about 256 movable barriers in May 2012, compared to about 340 barriers in March 2012. Between January and September 2011, the United Nations Office for Humanitarian Affairs counted unexpected barriers at a rate of about 495 per month. This is to be compared with a rate of 351 unexpected barriers per month between the years 2009 and 2010, and 65 unexpected barriers between September 2008 and March 2009.
59. In addition to this, Israel has closed the access to part of the main streets in the West Bank through hundreds of physical obstacles, including lumps of earth, concrete cubes, iron gates and conduits. The number of obstacles changes from time to time according to the political and security circumstances. In 2012, tangible obstacles were counted at a rate of 445 per month, compared to a rate of 434 obstacles per month between May and December 2001 and a rate of 519 obstacles in 2010. These obstacles prevent the movement of ambulances in emergency cases. Moreover, they also prevent the movement of pedestrians - such as the elderly, the sick, pregnant women and small children - who cannot surmount them.
60. An additional component in the system of restrictions is the streets where Palestinians are prohibited from travelling. Up to February 2013, Israel had allocated 67 kilometres of West Bank streets to the exclusive or almost exclusive use of Israelis, and in the first place the settlers in the West Bank. Israel prohibits the Palestinians from even crossing part of these streets by cars, in a manner that limits their access to neighbouring streets where the prohibition does not apply. As a result, many Palestinian travellers must leave the cars, cross the street on foot and look for alternate means of transportation on the other side of the street.
61. The prohibited streets policy is not codified in a military decree or any official document except for the prohibition to travel on street 443 which links the coastal area to the north of Jerusalem, and which was codified five years after it had effectively been implemented. It has been partially annulled following a petition submitted to the Higher Justice Tribunal. Another street, linking the Beit Oa intersection and the settlement of Nejohut, was reopened to Palestinian circulation after the decision issued by the Higher Justice Tribunal in October 2009. The Israeli army spokesman has informed the B'Tselem organization that these restrictions are imposed on the basis of “oral orders” transmitted to the soldiers. This feature adds a new dimension of mistrust, and is difficult to monitor or legally challenge.
THE SEGREGATION WALL
62. In addition to the restrictions detailed above, the segregation wall, which was erected deep inside the West Bank, affects the movement of Palestinians. Up to 2012, along the segregation wall, 35 barriers were erected (included in the above-mentioned data on barriers). Up to the end of 2011, the United Nations Office for Humanitarian Affairs counted 60 agricultural gates that allow Palestinians living on either side of the wall to access their land that remained on the other side. The movement at these barriers and gates is conditional on obtaining special authorization and prior coordination with the civil administration. Over the last years, Israel has reduced the number of authorizations allowing access to lands and villages that remained on the western side of the wall and limited the authorizations it has already issued to specific periods.
63. The strength of the restrictions imposed on people seeking to cross the specified barriers and gates in the wall changes from time to time according to the barrier or gate. However, in almost all specified and reinforced barriers and gates in the segregation wall, travellers and pedestrians are asked to show identity cards or passage authorizations, and these are examined according to the passage requirements applicable at the given barrier. Oftentimes, soldiers inspect vehicles and travellers’ luggage.
AGGRESSIONS BY SETTLERS
64. For a long time, Palestinians have suffered, on the one hand, from the Israeli army, and on the other, from the settlers. The settlers act as if they were in a war that goes back a century against the Palestinians to control Palestinian land and resources. 2012 has witnessed a steady increase in settlers’ attacks against Palestinian civilians. Settlers threaten Palestinians, block their roads, throw stones at them, indiscriminately shoot at them, beat their children on their way to school, throw garbage at the mothers of those children, attack older Palestinians with dogs, kidnap shepherds and steal their sheep, and cut and uproot olive trees, the source of income for Palestinians. They make their life miserable day and night. These settlers seize the hills and valleys. Most of the time, they carry out their attacks under the protection of the Israeli army.
AN UNACCEPTABLE POLICY THAT ENTAILS COLLECTIVE PUNISHMENT
65. One of the stated objectives regarding the policy of imposing restrictions on the movement of the Palestinians is to safeguard the settlers’ security. In light of the fact that the settlements themselves are illegal, this constitutes a massive and disproportionate violation of the freedom of movement for the entire population in order to implement and perpetrate a policy that is illegal in the first place. But even if these restrictions were aimed at preventing operations inside Israel itself, the policy would still be illegal, because of its massive and disproportionate nature making it a prohibited collective punishment.
66. All the above mentioned obstacles have direct and indirect consequences on the mental and physical health of Palestinians; they are a flagrant violation of the simplest rights of movement and access to safe and sustainable health services whenever and wherever they are required.
67. Mental health is an integral part of public health; it is closely linked to other factors that influence it such as the increase in social, economic, political and security-related anxieties. The mental health of individuals and communities is clearly linked to poverty indicators, a low education level, arduous living conditions, discrimination on the basis of sex, risks associated with violence and poor physical health, and human rights violations.
68. When talking about mental factors, the Palestinian society has its own peculiarity as it is clearly linked to the suffering that the people endure as a result of an occupation that has lasted for several decades and has negatively affected all areas. The occupation has played a major role in increasing the cases of mental disorders as a result of its blatant aggression and repeated invasion of cities and towns in the West Bank and the Gaza Strip, its use of all kinds of deadly and terrorizing weapons, its suffocating blockade of Palestinian cities and towns, especially in the Gaza Strip, the repeated wars on the Gaza Strip resulting in hundreds or even thousands of dead and wounded, and the dislodgment of the population as a result of the destruction of their homes. All this has led to many cases of mental illness, especially among women, children and the elderly. The mental shock of losing a spouse, a breadwinner or a relative has a devastating effect on mental health. A study shows that 47.7% of the wives of martyrs suffer from severe or very severe depression and 79.9% suffer from moderate to very severe anxiety; also, 77.9% of the wives of martyrs suffer from moderate to severe post-traumatic disorders.
69. UNRWA reports show that the rates of cases of psychological shocks and post-conflict disorders in the Gaza Strip increased by more than 100% following the latest Israeli aggression on the Gaza Strip. UNRWA stated that the number of people in Gaza that it is treating from psychological shocks and post-conflict disorders has doubled from November to December 2012, and that 42% of them are under 9 years of age. These latest statistics, gathered from UNRWA health facilities in the coastal sector, support the results of the most recent children’s survey in Gaza carried out by UNICEF, and which concluded that there is a sharp increase in the rates of mental disorders associated with conflicts, and that a vast number of cases are not reported.
70. The survey carried out by UNICEF for the rapid psychological evaluation of children in Gaza also confirms that sleep disorders among children have increased by 91%, whereas 84% of the respondents to the survey seemed in a state of shock or daze and 85% experienced changes in appetite.
71. In conclusion, we confirm that the State of Palestine still believes that peace is the strategic option for both the Palestinian and the Israeli peoples, and that only peace can bring an end to the long Israeli occupation and lead to the establishment of an independent Palestinian State with Jerusalem as its capital. We also confirm the need to take immediate action to stop the unjust blockade of the Gaza Strip and put an end to Israeli barriers, annexation walls and the expansion of settlements, so that the Palestinian people can enjoy their right to health and safe access to good-quality health services.
Palestinian Ministry of Health
• calls on the international community to exert pressure on the Israeli Government to lift the blockade on the Gaza Strip, to prevent the worsening of the humanitarian crisis there, and to take action to fulfil its moral and legal responsibility to protect the basic human rights of civilians in the occupied Palestinian territories;
• calls on the States Parties to the Fourth Geneva Convention to fulfil their obligations under Article 1 of the Convention, whereby the Contracting Parties undertake to respect and to ensure respect for the Convention in all circumstances, and their obligation, as provided for in Article 146, to pursue those accused of grave breaches of the Convention. It should be noted that such breaches are deemed war crimes under Article 147 of the Fourth Geneva Convention and the Additional Protocol thereto, which guarantees the protection of Palestinian civilians in the occupied territories;
• expresses its thanks to donor countries for their support of the Palestinian people in all areas and appeals to them and to international health agencies to extend their political and financial support to implement the health development plan and create the political environment necessary for the implementation of the document on ending the occupation and establishing the state that was presented by the Palestinian Authority. The Palestinian Authority is now working in earnest to create an environment conducive to the implementation of that document;
• requests the international community to exert pressure on Israel to implement forthwith the consultative opinion of the International Court of Justice on the illegality of building the annexation wall deep inside the occupied West Bank territories. It also requests the cessation of house demolitions, the displacement of Jerusalem Palestinians from their homes, the Judaization of Jerusalem and the construction of settlements in Palestinian territories occupied in 1967 which constitute not only a violation of international resolutions, but also a threat to the safety and health of the Palestinian citizens, and in particular to their ability to access health services;
• invites all international human rights bodies, and in particular the International Committee of the Red Cross, to intervene urgently and immediately with the occupation authorities and the Israeli prison administration to require them to provide treatment to sick captives in Israeli jails whose health is deteriorating daily. It calls for the establishment of an international committee composed of medical specialists to review critical cases and treat them immediately and rapidly, and appeals to civil society organizations to exert pressure to save the lives of prisoners, treat those who are sick immediately and release critically ill cases so they can be treated abroad. It also appeals for imprisoned Palestinian women to be allowed to receive prenatal and postnatal treatment and to be allowed to give birth in healthy and humane conditions in the presence of their families; it further demands the immediate release of child prisoners;
• confirms that the blockade is continuing and that crossings are still not fully and permanently open, which means a continuation of the crisis and sufferings that preceded the Israeli aggression in the Gaza Strip at the end of 2008, and that the Ministry of Health needs to rebuild the health facilities destroyed in the aggression, to complete works on other needed medical institutions and to provide them with essential medical equipment;
• requests the strengthening of formal and non-governmental support for the Palestinian health sector as an important stabilizing factor and to guarantee the right of the Palestinian people to have access to health services, as endorsed by international legislation;
• appeals to the international community to intervene immediately to stop the attacks by settlers on Palestinian citizens, to stop the settlement policy and expansion of settlements and to require Israel to evacuate all settlements as they are illegal.
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