Press release from MAP
10 February 2017
Medical Aid for Palestinians (MAP) and Physicians for Human Rights – Israel (PHRI) have today co-launched the first in a series of briefings exploring how Israel’s occupation affects the health and dignity of Palestinians.
This first volume exposes how barriers to freedom of movement imposed by Israel are preventing some Palestinian patients from being able to access centres of vital care. These barriers include the bureaucratic control of movement imposed by Israel’s permit regime, and physical barriers of the network of checkpoints which control access into and out of Gaza, the west Bank and East Jerusalem.
With many medical specialties such as radiotherapy and heart surgery only available in Palestinian hospitals in East Jerusalem, it is vital that patients and their companions are able to travel there unimpeded. This is especially true for patients in Gaza, where the health sector has been severely damaged by almost a decade of blockade, separation from the West Bank, and repeated conflict.
In 2016, the rate of approvals for permits to leave Gaza for treatment outside the territory dropped to its lowest level in seven years, with a third of patients delayed or denied by the Israeli authorities over the year.
“The very idea that a fence, a wall, a security guard, a bureaucrat could stand between you and such life-saving services should fill us all with a shared sense of dread.”
Robert Piper, UN Coordinator for Humanitarian Aid and Development Activities
In January this year, a 17-year-old boy from Gaza died after Israeli authorities refused him a permit to travel out of Gaza for treatment for a congenital heart defect. The same month also saw protests in Gaza from female cancer patients who had been refused permission to travel for vital treatment.
Free movement of patients and medical personnel is vital to the effectiveness of care. Ambulance and permit delays can lead to missed appointments and interrupted treatments, endangering the health and lives of patients.
International law stipulates that, as the Occupying Power, Israel has a duty to ensure adequate access to medical treatment for the population under its control. It is vital that governments like the UK place pressure on the Government of Israel to remove obstacles to the right to movement which undermine healthcare.
MAP Briefing paper
The medical administration of the occupied Palestinian territory is divided into three regions: Gaza, the West Bank and East Jerusalem. Consequently, the Palestinian health system also spans these three regions, each having different challenges and limitations on resources and expertise as a result of fifty years of occupation, meaning that referrals between regions are frequent and essential. However, the passage of Palestinian residents between and within these regions is controlled by Israel and there is no free passage between regions and medical institutions.
Palestinian residents who need medical care outside of their region of residence require an exit permit from the Government of Israel. This is primarily an issue for residents of the West Bank and Gaza, who are often referred for treatment in East Jerusalem, where the most advanced Palestinian hospitals are located. Residents of Gaza are also often referred to hospitals in the West Bank, for which they need a permit from the Israeli authorities.
On a yearly basis, tens of thousands of patients are referred for treatment outside the Palestinian healthcare system when the medical treatment they require is unavailable in the Palestinian territory. In these cases, the cost of treatment is covered by the Palestinian Ministry of Health.
In 2015, approximately 87,000 patients received such referrals. Of these, some 52,000 – over half – needed an Israeli permit in order to access treatment. Obtaining Israeli permits is a process that is, as stated by the World Health Organisation (WHO), “neither transparent nor timely”. Security services frequently deny travel permits without explanation, citing ‘security reasons’.
There have also been cases where patients from entire geographical areas were denied exit permits, in what the UN has said may amount to collective punishment, or where permits were denied as a result of political events or Israeli holidays. According to WHO, in 2014-15 more than 110,000 Ministry of Health and private patients applied through Palestinian coordination offices for Israeli-issued health access permits, 18% from Gaza and 82% from the West Bank. Relatively similar numbers of patient companions – first-degree relatives who accompany patients to treatment and support them on their journeys – also apply for permits.
Israel’s permit regime
Whether patients are travelling to an East Jerusalem hospital from a hospital elsewhere in the West Bank or from Gaza they will require a permit from the Israeli authorities. In all cases this can be a time-consuming process fraught with delays and arbitrary denials for certain age groups.
However, the permit regime is particularly problematic for Palestinians from Gaza. The health system in Gaza has been severely impacted by a decade of blockade and repeated conflict. Shortages of medical equipment and medications are frequent, and doctors are often prevented from being able to exit Gaza for training, leaving them unable to keep up to date with advances in medical practice . As a result, patients are frequently required to seek treatment in other areas of the occupied Palestinian territory (West Bank or East Jerusalem) or abroad, especially for more specialised surgeries and care.
Yet exiting Gaza is a lengthy, unpredictable process. Applications must be submitted at least 10 days before the hospital appointment, accompanied by medical documentation. If approved, patients are only informed the night before their travel. The waiting time, however, can extend to weeks, and even months. These delays can mean that patients will lose their appointments, and in several recorded instances, such inability to access treatment has resulted in death. The Israeli authorities have also taken advantage of patients seeking exit permits to undertake interrogations for the purpose of gathering information about communities in Gaza, as a prerequisite before requests are considered.
As noted by WHO, “delays are often the result of patients and companions being called to appear for a security interview by security officials as a condition for a permit”.
In 2015, Israeli television station Channel 10 aired a conversation with Lior Lotan, the Prime Minister’s representative for prisoners and missing persons. During that conversation, Lo-tan said the following: “When people, relatives of Hamas big boys, senior people! … When they wanted to enter Israel for medical treatment in Israel, we told them: ‘No, bring us information on Abera’”.
WHO documented 327 incidents of patients being questioned by security officials while seeking to travel for treatment in 2015. Additionally, on more than one occasion in 2016 patient accompaniers have been arrested at the crossing, leaving the patient, sometimes a young child, to wait alone at the checkpoint until a relative can be contacted to take them back to Gaza.
This systematic exploitation of a patient’s need for treatment as a way of gathering information is a clear violation of the patient’s right to access treatment. Physicians for Human Rights – Israel (PHRI) has found that people aged 18-45 experience the most delays and denials.
This is possibly as a result of arbitrary restrictions imposed by Israeli authorities on this age group based on security considerations, and can inevitably have a harmful impact on the health of patients in this age range. Similarly, patient companions are not permitted to be younger than 55, thereby preventing the majority of parents of younger children from accompanying them to hospital appointments and preventing patients from free choice of accompanier.
According to the Palestinian Central Bureau of Statistics, only 6% of the population in Gaza is over age 55. With the current permit regime, political considerations are often given precedence over medical need. In February 2014, the Israeli District Liaison and Coordination Office in Gaza began refusing to accept any stationery, including that of the ministries of the Palestinian Authority, which included the “State of Palestine” logo, thereby leading to a large increase in requests for help with refusals.
Similarly, a 2015 directive by the Coordination of Government Activities in the Territories (COGAT) stated that when deciding on access there must be a distinction between patients requiring lifesaving treatment, and those who could benefit from a drastic improvement in their quality of life, including those living with severe orthopaedic pain.
Such a restriction is contrary to medical ethics and the right to health. For patients in Gaza, accessing vital care in other parts of the occupied Palestinian territory or abroad is therefore fraught with delays or denials. The proportion of patients receiving a permit in time for treatment has steadily declined, from 93% in 2012 to 78% in 2015 and an average of 64% in 2016. WHO has also found that more than half of denied patients did not know why they had been refused a permit