TWN Info Service on Health Issues (Mar18/02)
23 March 2018
Third World Network

United Nations: Israel in profound breach of the right to health in OPT
Published in SUNS #8647 dated 22 March 2018

Geneva, 21 Mar (Kanaga Raja) - Israel has been in profound breach of the right to health in the Occupied Palestinian Territory (OPT), a United Nations human rights expert has said.

While Israel, as the occupying power, has specific and significant obligations under international law to ensure the health and welfare of the Palestinian population under its control, its "avaricious" occupation has had a highly disruptive impact upon health care and the broader social determinants for health for the Palestinians.

This is the conclusion in a report by the Special Rapporteur on the situation of human rights in the Palestinian territories occupied since 1967, Mr Michael Lynk, to the thirty-seventh session of the Human Rights Council, currently taking place here.

The report, which focused in particular on right to health in the Occupied Palestinian Territory, was presented by the Special Rapporteur during the interactive dialogue held at the Council on Monday (19 March).

Six other reports on the situation of human rights in Palestine and other occupied Arab territories were presented at the Council on Tuesday (20 March).

In his report to the Council on Monday, the Special Rapporteur said Israel's avaricious occupation - measured by the expanding settlement enterprise, the annexation of territory, the confiscation of private and public lands, the pillaging of resources, the publicly-stated ambitions for permanent control over all or part of the Territory, and the fragmentation of the lands left for the Palestinians - has had a highly disruptive impact upon health care and the broader social determinants for health for the Palestinians.

While the Palestinian Authority (which governs in parts of the West Bank) and the authority in Gaza have some agency over the state of health care in the Occupied Palestinian Territory, Israel's conduct of the occupation bears the ultimate responsibility, says the report.

The rights expert noted that Palestinian, Israeli and international human rights organizations have persuasively demonstrated both the inequities in the health and social conditions in the Occupied Palestinian Territory and their substantive relationship to Israel's occupation.

"That leaves to the rest of us the obligation to act decisively and effectively," he said.

The rights expert cited several recent examples that he said raise serious concerns about the fulfilment of the right to health in the Occupied Palestinian Territory.

In recent years, civil society organizations and international agencies have extensively documented the significant and chronic challenges to health care and wellbeing related to the occupation of the Palestinian territory.

Among the examples cited by the rights expert are a four-year-old girl in Gaza suffering from heart failure dying following the denial of permission by Israeli authorities for her to return to East Jerusalem for pediatric cardiology treatment that is unavailable in Gaza.

Access to safe and sufficient drinking water in the Occupied Palestinian Territory is severely compromised by the discriminatory access to hydro-sources in the West Bank, and by the depleted and contaminated water aquifers in Gaza.

The principal Palestinian hospital in East Jerusalem is raided repeatedly by heavily-armed Israeli soldiers and police who fire stun grenades and sponge rounds, resulting in mayhem and fear among patients and staff.

Significant stocks of essential drugs are exhausted in Gaza hospitals and are unable to be replaced, even as emergency services in local hospitals are reduced because of political decisions to cut electricity supplies to the territory.

The Special Rapporteur emphasised that the right to health is one of the most fundamental and widely recognized of human rights.

"The right touches upon everything that we do as humans, and its robust promotion is one of the most effective tools available to reduce the scourges of social and economic inequalities, gender disparities, discrimination and poverty."

Reflecting the indivisibility and interdependence of all human rights, the right to health is indispensably linked to the realization of other recognized rights, including the rights to water, housing, food, work, education, life and human dignity.

The rights expert said for protected peoples living under occupation, their right to health is also guaranteed by international humanitarian law and the laws of occupation.

In particular, the Geneva Convention relative to the Protection of Civilians in Time of War of 12 August 1949 (the Fourth Geneva Convention), together with the Additional Protocols and customary international law, places the overall responsibility for civilian access to health care in an occupied territory upon the occupying power.

According to the report, among the extensive responsibilities assumed by the occupying power for the civilian population are: protection and respect for the wounded, sick and infirmed; the protection of civilian hospitals and their personnel; the assurance that the medical supplies for the population are adequate; the maintenance of the medical and hospital establishment and services, public health and hygiene of the territory; and the facilitation of medical personnel of all categories to fulfill their duties.

Israel, as the occupying power, has specific and significant obligations under international law to ensure the health and welfare of the Palestinian population under its control.

As a state party to the International Covenant on Economic, Social and Cultural Rights and as an occupying power, Israel is required to observe international human rights law throughout the occupied Palestinian territory.

And as a state party to the Geneva Conventions of 1949 and as the occupying power, Israel is bound under international treaty and customary law to scrupulously apply the Fourth Geneva Convention and the other obligations of international humanitarian law.

Mr Lynk said that the unprecedented length and character of Israel's fifty-year acquisitive occupation - driven by the logic of demographic engineering and territorial annexation, both de jure and de facto - has badly fragmented the Palestinian territory.

The consequence has been the political separation and geographic isolation of the West Bank, East Jerusalem and Gaza from one another, significantly impinging upon the Palestinians' internal freedom of movement.

"This fragmentation likewise splinters the delivery of Palestinian health services and deforms the social determinants of health throughout the occupied Palestinian territory."

In the West Bank, health care is primarily delivered by the Palestinian Authority and the United Nations Relief and Works Agency (UNRWA), while in Gaza, the governing authority and UNRWA are the principle providers of health services.


According to the report by the Special Rapporteur, the health and humanitarian crisis in Gaza has become acute, bordering on a human calamity.

Gaza has suffered grievously through three destructive wars in 2008-09, 2012 and 2014. Israel has imposed a comprehensive blockade on Gaza's land, sea and air frontiers since 2007, which amounts to a form of collective punishment prohibited by international law.

"This blockade comprehensively controls and restricts the movement of people and goods in and out of Gaza, resulting in economic suffocation, faltering reconstruction efforts, social and familial isolation from the outside world and a dire impact upon the territory's already-anaemic living and health standards."

Mr Lynk said that the 12-year-old political schism between the Palestinian Authority and the authority governing Gaza has further compounded this misery.

The two million people living in Gaza rely upon a health care system that UN health officials have said is on the edge of collapse.

According to the WHO, an estimated 206 (40 per cent) of the 516 listed essential medicines in its basic health basket were completely out of stock by the end of January 2018, and another 43 per cent of essential drugs had less than a month's supply remaining.

This included drugs required for treating cancer and auto-immune diseases, performing dialysis and conducting cardiac angiographies.

As well, serious shortages of essential medical disposables - such as syringes, line tubes, filters for dialysis and dressing materials - had also been reported.

The crippling electricity shortages in Gaza have forced many hospitals to shut wards and ration essential services such as operating theatres, emergency departments, diagnostic services, general medical wards, instrument sterilization and the treatment of chronic illnesses.

At the beginning of 2018, three hospitals had temporarily closed, along with thirteen primary healthcare clinics, affecting healthcare delivery to more than 300,000 people.

For the hospitals that remain open, bed occupancy rates are reported to be above 90 per cent. By December 2017, the waiting time for elective surgery stood at 52 weeks, well beyond the operative threshold of 24 weeks.

Compounding the problem of treatment services has been the inability of Gaza hospitals to obtain Israeli permission to import replacement parts for vital diagnostic imaging equipment, putting them out of service for months and even years.

According to the Special Rapporteur, this dilapidated and failing Gaza health care sector is overwhelmingly a human-made crisis.

He said one consequence of this acute crisis has been the compelling need to refer larger numbers of patients with serious or chronic health conditions to medical facilities outside of Gaza for treatment that they should be able to, but cannot, receive in the territory.

The Special Rapporteur said: "Israel administers a byzantine and opaque exit permit system imposed upon those patients who require specialized treatment in East Jerusalem (the location of the most advanced medical facilities within the Occupied Palestinian Territory), the rest of the West Bank, or abroad".

Patients with complex disorders who are unable to be adequately treated in Gaza include: cancer patients requiring surgery, chemotherapy and/or radiotherapy; pediatric patients with metabolic disorders or congenital defects; heart patients requiring open-heart surgery or with post-operative complications; eye patients in need of specialized surgery or cornea transplants; bone-disease patients requiring hip or knee joint surgery; neuro-surgical patients; patients requiring MRI (magnetic resonance imaging) scans; and patients with blood diseases.

For virtually all of these patients, time is of the essence, either because of the deteriorating nature of their serious or life-threatening disorders, or because life is at an absolute standstill as long as their chronic and debilitating health conditions remain unresolved.

Since WHO began collecting statistics for medical permit approvals in 2008, 2017 has marked the lowest annual approval rate. In 2012, the approval rate was 92 per cent; it declined to 82 per cent in 2014; and declined further to 62 per cent in 2016.

According to WHO, the approval rate by Israeli authorities for the 25,812 health travel permit applications filed from Gaza in 2017 had tumbled to 52.4 per cent.

While only 2.6 per cent of the applications were formally rejected by Israeli authorities (invariably with no clear reasons provided) in 2017, a large number - 45 per cent - were delayed, with no response provided.

An estimated 11,000 medical appointments were missed in 2017 by patients from Gaza whose travel permit applications were either denied or delayed.

The WHO has documented that 54 patients died in Gaza in 2017 who had applied for a medical travel permit, and who had either been denied permission or who had not received an answer to their application.

"It is not known whether any of the 54 patients would have either recovered or stabilized had permission to travel been granted, but the chances of their health improving were negligible without the opportunity to obtain the care they required outside of Gaza," said the rights expert.

Geographically, he noted, Gaza and Israel are cheek and jowl to each other. Gaza City is only 75 kilometres from Tel Aviv.

"However, there is an extraordinary gap in health outcomes between Gaza and Israel, using some common international measuring sticks."

The Special Rapporteur cited the following statistics provided by WHO: Life expectancy - 73.1 (Gaza) versus 82.1 (Israel); infant mortality rate - 20 per 1000 live births (Gaza) versus 3 (Israel); maternal mortality rate - 31 per 100,000 births (Gaza) versus 2 (Israel); and breast cancer 5-year survival - 65 per cent (Gaza) versus 86 per cent (Israel).

"The right to health is thus severely restricted for the residents of Gaza. Despite the fact that this is occurring in full view of the international community, the Palestinian authorities, and the Government of Israel, little has been done to alleviate the suffering of Gaza's people."

Israel's obligations, as occupying power, to the residents of Gaza remain far from fulfilled, and the international community takes note of the dire situation of Gaza's residents, yet fails to act, the rights expert underlined.


The rights expert also pointed out that recent health studies in the Occupied Palestinian Territory have found that the cumulative threats to human security for its residents have had a significant and adverse impact upon the psychological well-being among the population.

These cumulative threats include traumatic and anxiety-inducing experiences of warfare, home demolitions, imprisonment and beatings, land confiscation and violence arising from demonstrations and settler attacks, as well as the diminished character of life caused by the lack of freedom of movement, food insecurity, the lack of control over water resources, discrimination and statelessness, precarious work and the tottering economy and the mounting poverty rates, all of which serve to erode the social fabric of society in the Occupied Palestinian Territory.

"Above all, the Palestinians lack any collective control over the occupying authority that not only makes virtually all of the decisive political, economic and social decisions which govern their lives, but makes them in a fashion that thwarts their interests and disregards their well-being."

According to a 2013 regional study on mental health, the Occupied Palestinian Territory bore the largest burden of mental disorders among the examined countries in the Eastern Mediterranean region.

A third of patients attending primary health clinics in the West Bank and Gaza were reported to be suffering from mental health issues, a rate that is higher than more politically stable countries.

A recent WHO report has stated that mental health workers in the Occupied Palestinian Territory have found that the most common mental health issues are affective disorders, anxiety, depression, epilepsy, aggression, insomnia, neurosis, schizophrenia, total exhaustion, drug-induced conditions and post-traumatic stress disorder (PTSD).

Another health study has estimated that the expected population prevalence of post-conflict PTSD and major depression would be close to 30 per cent among Palestinians in the West Bank and Gaza.

According to the Special Rapporteur, one significant feature is the relative lack of psychiatric, psychological and counselling services available.

The West Bank, with 2.6 million Palestinians, has only one mental hospital, in Bethlehem, with 180 beds. Gaza, with 2 million people, has only a 40-bed hospital.

There is only one psychiatric training program in the Occupied Palestinian Territory, and, as of May 2016, there was only one psychiatrist, along with approximately 30 psychologists.


"The health and social well-being of children are an apt barometer of the larger well-being of a society," said Mr Lynk.

Recent studies have reported that food insecurity in the Occupied Palestinian Territory has resulted in worrisome levels of child malnutrition.

A 2013 study found disturbing levels of anaemia (26.5 per cent across the Occupied Palestinian Territory, and 30.8 per cent in Gaza), vitamin A deficiency (73 per cent across the Occupied Palestinian Territory) and vitamin D deficiency (60.1 per cent across the OPT, and 64.4 per cent in Gaza) among children ages 6 months to 5 years.

These micronutrient deficiencies are strongly linked to poverty and poor nutrition.

The study also found troubling levels of childhood stunting in the same age cohort: 10.3 per cent across the Occupied Palestinian Territory, and 11 per cent in Gaza. Stunting among young children is a consequence of chronic malnutrition, it is irreversible, and it has adverse life-long effects.

A more recent study, conducted in 2014-5, focused on levels of malnutrition among children and their mothers in the Jordan Valley. This study found that 16 per cent of children under 5 years of age covered by the survey were stunted. Half of all the surveyed children (49.3 per cent) were anaemic.

This study also observed that 87 per cent of the land in the Jordan Valley is under full Israeli military or settler jurisdiction, and Palestinian use of these lands is prohibited.

It noted that these structural barriers associated with the occupation significantly affect the overall health status of the surveyed population.

According to the Special Rapporteur, a focused concern in recent medical literature has been on the mental well- being of children in the Occupied Palestinian Territory.

A 2007 study that examined 3,415 adolescents living in the Ramallah District of the West Bank found a strong correlation between the humiliation induced by conflict conditions and a high number of subjective health complaints.

Chronic exposure to humiliation (defined as the subjective experiences felt by an individual who has been unjustly treated and debased) has been linked to higher levels of insecurity, depression, diminished personal freedom, poorer health, stress and of feeling broken or destroyed among Palestinians in the West Bank.

The aftermath of intense warfare fought among dense civilian neighbourhoods has resulted in a high PTSD rate among children in Gaza, with one study estimating that the prevalence of PTSD among children in Gaza even before the destructive wars of the past decade ranged from 23 per cent to 70 per cent.

After the 2012 war on Gaza, a study found exceptionally high numbers of children (ages 11-17) experiencing personal trauma (88 per cent), and witnessing trauma experienced by others (84 per cent), all of which raised the potential of depression and PTSD.


The Special Rapporteur emphasised that an occupying power has the duty, under international law, to ensure that the right to health - the enjoyment by the protected population of the highest attainable standard of physical and mental health - is fulfilled during the temporary period of occupation, consistent with its reasonable security needs.

While fully respecting its legal obligation not to act covetously towards the territory and resources of the occupied territory, it would actively work to restore and enhance the health care system for the people under its effective control.

It would not obstruct the access by patients and medical staff to hospitals and health clinics, either physically or bureaucratically.

It would strive to create conditions of stability and security, so that the social determinants of health can advance, rather than retard, the flourishing of physical and mental wellbeing.

It would promote equality of access to health care for all, with particular attention paid to the vulnerable and marginalized.

The occupying power would actively work with the health institutions of the protected population to chart a progressive health care strategy for the future that also respected the coming restoration of full sovereignty.

It would not discriminate. It would not torture or mistreat prisoners and detainees. It would not impose collective punishments of any sort.

As a priority, it would provide all the necessary health services and supplies that the medical institutions of the protected population are unable to deliver themselves.

"Measured against these obligations, Israel has been in profound breach of the right to health with respect to the Occupied Palestinian Territory," Mr Lynk said.

The Special Rapporteur called on the Government of Israel to ensure regular and reliable access, at all times, for all Palestinian patients who require specialized health care outside of their jurisdictions, consistent with genuine Israeli security concerns.

The Government of Israel was also called upon by the rights expert to end the conditions which obstruct the free passage of Palestinian ambulances to access and transport patients to health care facilities in an expeditious fashion.