Health Under Occupation: Constraints on access to healthcare in the Palestinian Territories

A continuous wave of wars has plagued the Palestinian people both physically and mentally. Gaza’s hospitals and homes are still in shambles a year after the latest offensive.  But apart from death tolls, relief efforts must also place emphasis on the enduring mechanisms of the Israeli Occupation and how they affect the healthcare chain of supply and demand. The glaring restriction on mobility that is the hallmark of the Occupation prevents medical students from traveling abroad to specialize and patients from accessing points of care. The political power vacuum borne out of the rift between Hamas and Fatah to fill the void of an independent nation has left the PA weak and unable to devote resources to the healthcare system. The Occupation is the chief structural barrier to the access of quality healthcare for Palestinians—it has exacerbated existing inequities in the population and has given rise to a host of issues unique to the devastating political reality.

Even when there is no incursion happening, the Occupation is inherently suffocating. Healthcare is not just measured in mortality statistics or disease prevalence. National health systems are highly influenced by the political climate surrounding them, and as Norwegian physician and activist Mads Gilbert puts it, “Medicine and politics are Siamese twins.” If political arguments are not working as fast as they should to end the Occupation – perhaps the healthcare argument—the human argument—will have better luck.

Access – The Pivotal “Intermediate” Outcome

Some egalitarian liberals believe that society has a particular obligation with regard to healthcare—as opposed to a different camp that asserts that the best way to respect moral capacity is to distribute income fairly and let individuals purchase the healthcare they want. But is it the role of the state to provide a blanket of basic healthcare services, or is it the individual’s actual health status that needs to be considered? Do we judge rights by the availability of clinics or by life expectancy? In “Getting Health Reform Right,” a text written by Harvard School of Public Health Professors Marc Roberts, William Hsiao, Peter Berman, and Michael Reich elucidate “the disagreement over whether the government should be responsible for an agreed level of health status or for access to health care, [which] has important implications for the relationship between the state and the individual.” The case of Occupied Palestine transcends the normative issues of public health that are entangled among individual behaviors and socio-economic strata within the society itself. Palestinians are embedded within a political framework in which they are physically unable to get to places of care, or care is physically shut off from them as a result of military occupation and the social, structural, and economic consequences that come with it.

Roberts et al call access an “intermediate performance characteristic” of a health system because they are not themselves ultimate objectives. But access is the primary limiting factor to health system performance and health status in the Occupied Palestinian Territories. While access to healthcare is by no means the only failing health metric plaguing the Palestinians today, it is the Occupation specifically that is precluding this access. There is a direct link between political process and an inequitable access to health care that has made it impossible for a cohesive health system to exist in a way that can be effectively utilized.

Access can simply refer to whether services are offered in a specific area (physical availability), or to how easy it is for citizens to get care (effective availability). Access can also correlate to utilization. In the case of Palestine, low usage of health services reflects barriers to care. Effective availability is influenced by what services are offered where, at what prices and on what terms. It is an intermediate performance characteristic that is “both a consequence of policy and a cause of performance.” In the case of Palestine, access is a rigid fork in the system that cannot be improved without the removal of the Occupation.

Mechanisms at the National Level

Although an independent Palestinian Ministry of Health was established as a result of the Oslo Accords in 1993, the Palestinian Authority’s (PA) internal budget did not result in a parallel distribution of power. The medical system on the ground is dependent to a great extent upon Israel—directly with respect to tax transfers and influence over the budget, as well as policies that indirectly handicap operations. Israeli authorities still control border-crossings and consequently the volume and type of imports/exports, along with the provision of basic infrastructure and commodities—like building permits, water, and sanitation.

As a result, there are a multitude of providers of different levels of care to various factions of the population across the region—there is no harmonized or integrated Palestinian health care system. The territorial segregation of the Palestinian regions has led to the absence of a cohesive health information system and lack of rigor in data collection has also limited the capacity of the system to assess performance. Disunity among the Ministry of Health, UNRWA, NGOs, and the private sector has only exacerbated gaps in access and inequities among access to quality care.

Israel froze the transfer of tax funds in December 2014, which further debilitated the Palestinian Authority’s severe financial crisis. Yet budget allocations to security services in 2014 amounted to as much as thirty-five percent of the public budget. The PA maintains that this allocation is essential for internal security, to protect against Israeli incursions, and to gain support for its costly and lengthy political project in the form of negotiations with Israel. Security services come at the severe cost of the healthcare and education sectors. The heightened security unrest at all times as a result of ongoing tensions between Israel and Palestine and the continued military presence of Israeli Occupation in daily life in the West Bank make it unlikely that the PA will reallocate the budget.

It is important to recognize, however, that political disarray within Palestinian governance, specifically the lack of unity between Fatah and Hamas, is also responsible for the lack of coordination and access to health services. Just a few weeks ago, Gaza’s only power plant was forced to temporarily shut down due to disputes between Hamas and the PA over fuel tax. Before 2007, the MOH coordinated the healthcare sector and provided guidelines for operation. But after Hamas (now deemed an ‘extremist’ organization) came to power, many international donors were unwilling or legally unable to collaborate. Suspicion of Hamas collaboration with jihadist attacks in Sinai after the oust of Morsi have pushed Egypt to further increase restrictions on the border at Rafah Crossing (which has been continuously closed since October), delaying many patients from Gaza in need of care at the only border that is not controlled by Israel. Patients can be referred to more advance rehabilitation centers in the West Bank, Turkey, or Germany, but referrals for those in the lower social strata are dependent on getting paperwork and financial commitment from Fatah-led Ministry of Health in Ramallah.

Mobility

The most glaring restriction to healthcare and to life in Palestine is freedom of movement. Approximately 96 fixed military checkpoints dot the West Bank—not including the hundreds of deliberate road obstructions (dirt embankments, concrete blocks, iron gate , trenches), and the fact that there is 60.92 kilometers of West Bank road that Israel has classified for the sole use of Israeli settlers. 200,000 Palestinians request permission from Israel for medical-related travel each year, and 40,000 are denied. People deciding to leave Gaza are called in by Shin Bet security services and many forgo treatment out of fear that Hamas will accuse them of collaboration with Israel. According to reports by Physicians for Human Rights-Israel, the scope of medical personnel permitted to work in East Jerusalem is not enough to cater to the population. The departure of patients from Gaza is conditional on security questioning, and there are limitations on the freedom of movement of patients, medical professionals, and ambulances between Gaza and the West Bank, and East Jerusalem.

Physician Dani Filc, author of “Circles of Exclusion: The Politics of Health Care in Israel,” noted that “health care has been structured as an instrument that reinforces the ongoing Occupation.” The Separation Wall itself, the hallmark of the Occupation delineating Israeli land from Palestinian, is itself a barrier to access. It has barred communication and interaction between people, creating an unquantifiable psychological and traumatic effect. The Wall has isolated Palestinian regions, preventing them from accessing any existing facilities. The 6 NGO-managed facilities in East Jerusalem that are the central providers of primary, secondary, and tertiary care for the majority of the population in the West Bank are essentially out of reach for most Palestinians due to permit restrictions. The rural areas in particular face devastating circumstances with regards to access. In Area C of the West Bank, which is under full Israeli control, over 180,000 Palestinians, many herding/Bedouin communities, suffer unequal access to healthcare due to restrictions of the PA in being allowed permission to build any health facilities. Bedouins have lived on Israeli land for centuries, but the Israeli state does not recognize the Bedouin ownership claims of areas in the Negev and pressures rural residents to move to the cities by cutting off their electricity, water, and sewage. The ongoing political campaign of increasing settlements in the West Bank and the continued occupation of Palestinian cities have resulted in significant barring of access to healthcare.

Healthcare Infrastructure Complicated by Occupation

When evaluating the healthcare system of Palestine, exploring the physical infrastructure makes for a powerful case. A Physicians for Human Rights-Israel report found that there are 0.22 specialists per 1000 people in the Palestine territories, compared to 1.76 in Israel. The crux of the problem revolves around medical education – 10-20% of medical students and graduates are forbidden from entering East Jerusalem for training due to security issues. The medical staff employed at the four major teaching hospitals in East Jerusalem (Al-Makassed, Augusta Victoria, Red Crescent, and St. Joseph) are grossly underpaid and subsequently not obligated to create a robust or defined curriculum – knowledge is stagnant and skills left unrefined. The lack of open resources and high-level medical equipment have deterred foreign medical graduates from returning to Palestine, and the gross lack of scientific research in the OPT juxtaposed against the thriving biotech and pharma scene in Israel has thwarted any major investments into the health sector.

The state of military occupation and dependence of the OPT on Israel also influences the patient referral pathway.  Limited investment by the PA in public services has spurred the development of private medical practices at the expense of the public healthcare system, leaving poor Palestinians often unable to pay for treatment.  In West Bank and Gaza hospitals, Israeli authorities have to approve purchases of technology. Something as standard as a PET-CT scan has yet to be seen in a Palestinian hospital. West Bank doctors have to refer their patients to hospitals in Israel for diagnostic scans. This process begins with a referral from a Palestinian specialist, a wait for approval by the PA health ministry, and then a request to the IDF for permission to enter Israel—which is not always granted. It is important to continue to recognize that getting to the hospital alone is just the tip of the iceberg. The PA spends $248 per capita on healthcare, compared to $2046 in Israel.

Gaza: A Microcosm

Gaza is a microcosm of a natural disaster at the expense of state actions. The most prevalent of health inequities across the Occupied Territories persist within the Strip, one of the most densely populated regions in the world. The majority of the 1.7 million inhabitants resides in refugee camps and has been subject to a protracted state of economic, social and environmental degradation for decades. Since the split from the West Bank and the subsequent blockade imposed by Israel in 2007, however, restrictions on imports, exports, and channels of donor aid have handicapped all arms of infrastructure—impeding health service access and delivery. In the throng of violent conflict, healthcare systems struggle. What sets Gaza apart is the threat of constant war and the constructed isolation that Israel has imposed on it from the rest of Palestine and the rest of the world.

One of the most devastating consequences of the constructed isolation of Gaza is the chronic shortages in medicines and equipment. A WHO investigation earlier this spring reported that nearly 50% of Gaza’s medical equipment is outdated and the average wait for spare parts is approximately 6 months. An average of 25.7% of medicines on the essential drug list (124 of 481 items) and 47% (424 of 902 items) of medical disposables were at zero stock in Ministry of Health facilities. Although UNRWA remains the main provider for primary health services in Gaza, the health ministry in the WB is still responsible for supplying medicines and medical equipment for the ministry-run hospitals and clinics within the GS. The geographical discord across the OPT has hindered transfer of resources, and medicines received are often expired or out of date.

During the assault last summer (which claimed 2,200+ Palestinian lives and destroyed 12,000+ houses) 45 ambulances were attacked, 2 hospitals completely flattened, and 100 healthcare workers injured or killed while on duty. Israeli shelling destroyed Gaza’s only power plant, adding to the electricity shortages across the strip that have been plaguing the strip for years with repeat offensives. The 2014 war spurred an increasing amount of literature is being produced to measure public health indicators in Gaza. Chronic malnutrition is wreaking havoc on an increasing amount of children. A recent UNIECF-Ministry of Health study confirmed that 29% of children under the age of five are stunted due to chronic malnutrition—which inhibits growth but also exacerbates longer-term health problems of nutrient deficiency-iron and Vitamins A/D in particular. Yet any public health expert knows that virtually every chronic health issue in a society is also a disease of poverty. The World Bank estimates that Gaza has the highest rate of unemployment in the world (60% youth). Israel closed down Gaza’s sewage treatment plant to build the Wall, and the only power plant in the Strip was bombed during the offensive last summer. The devastated electricity and water infrastructure – (96% of the fresh water from the underground aquifer is unsafe for human consumption)  put it just outside the periphery for a public health disaster that could include dysentery, measles, hepatitis A, typhoid and cholera.  Only peace can prevent an epidemic. The repeated violent assaults and the eight-year blockade that Israel has imposed in Gaza have created an isolated poverty vacuum that swallows the ability to access quality care.

International Response

The international community has become increasingly involved in the Israel-Palestine conflict, and the issue of healthcare is now in the limelight. There has been a slow shift in international media coverage to take a human rights perspective on the consequences of the political conflict—healthcare being the crux. While UN agencies like UNRWA, UNOCHA, and UNHCR are continuing their extensive work in the region, younger local NGOs such as Physicians for Human Rights-Israel and Breaking the Silence—a group of veteran Israeli Defense Forces (IDF) soldiers committed to releasing testimonies of human rights violations made by Israel—are helping to shift the narrative to reflect the political conflict as a cause and bearer of a deeply humanitarian one. At the beginning of the month, Breaking the Silence published a 240-page report outlining various tactics used by soldiers during the 50-day Gaza war this summer that violate international human rights law. The Palestinians formally joined the International Criminal Court (ICC) in April – a key step towards being able to pursue Israel for alleged war crimes, and a primary investigation has been launched for the first time in history.

The Lancet, one of the leading global medical and public health journals, has also been a key player on the axis of health and politics. In July 2014, at the height of the Gaza incursion, the Lancet published “An Open Letter for the People of Gaza” that accused Israel of war crimes and opened its website to be used to collect over 20,000 email signatures in support. The Lancet also is in partnership with several NGOs in the region as part of the Lancet-Palestinian Health Alliance, a network of health researchers illuminating public health and scientific issues in the Palestinian context. Editor Richard Horton acknowledged the political aims of the Lancet’s involvement by saying “we publish science at the Lancet, but the evidence has to go beyond that to the humanity of the people…We need a deeper and more rigorous investigation of Palestinian health and wellbeing- most specifically its economic, social, and political determinants.” A rebuttal call was recently made a group of several hundred pro-Israeli physicians to boycott the Lancet for its involvement in the political conflict. Mads Gilbert, Norwegian surgeon and the chief signatory of the original letter, has since been blocked by the Israeli government from entering Gaza to perform surgeries after the war last summer.

The ongoing debate over The Lancet’s endorsement of the Palestinian right to freedom from military occupation pecks at the broader issue of the intersection of healthcare, which is often recognized as a universal right, and polarizing political conflict. In the myriad of devastating political conflicts tearing at seams across the globe today, there is never a burden associated with sympathy or solidarity for any innocent civilian victims. Palestine is unique because the war is blamed on the victim. The medical community is being attacked for doing nothing but its duty—to be on the side of peace.

Although the occupied Palestinian territories face many of the same problems regarding health access as developing countries in conflict situations, this represents a particular case, as the barrier to access is a consequence of the state of military occupation interwoven with political and geographic segregation. The political conflict and interactions between Israel, the PA, Hamas, and Fatah have stifled the development of a functioning healthcare system, leaving Palestine continuously reliant on external funding and in a dependent and fragile economy. The armed borders and checkpoints, and the very fact that a Palestinian needs permission to travel for healthcare all serve to further delineate how the political climate of the Occupation is the catalyst and crux for the resulting disarray of healthcare services—not to mention the unending fear and trauma wreaking havoc on the society’s psyche. According to Dr. Akihiro Seita, head of UNRWA (the UN body responsible specifically for the welfare of Palestinian refugees), “A lot of clinics and studies have been shooting up trying to study the mental and psychosocial wellbeing of Palestinians. But the only solution here to mental and psychosocial well-being is peace. Without peace, all we are doing is scratching the surface.” Healthcare and politics are inseparable in the context of Palestine because it is the political situation the people have been forced into that is precisely affecting their ability to lead healthy lives. The healthcare argument is a human argument—one that transcends national boundaries – or in this case, a Wall. Unless the wider political situation is addressed, the barriers to access will persist, and the health of the Palestinian people will never be given the attention it deserves.