One of the more pervasive theories in political science suggests
that, in order to understand what makes a political system tick, it
is crucial to examine its institutions. According to this version,
institutions not only have a major impact on the political arena,
but they also reflect the interactions and power relations taking
place within it. The Palestinian health-care system, one of the
five civil institutions transferred to the Palestinian Authority
(PA) in June 1994, is no exception.
The plight of the Palestinian health institution today reflects, on
the one hand, the effort of the fledgling government to face the
legacy of occupation and, on the other, Israel's wanton neglect of
the Palestinian population. Not only were the conditions in which
the health institution was transferred to the Palestinians
appalling, but the Palestinians were unable to uphold and nourish
this institution. Hence the existing crisis facing the health
Twenty-Seven Years of Health under Occupation -
Health conditions in the West Bank and Gaza Strip have improved in
a number of areas since 1967. Israel facilitated a comprehensive
immunization program for Palestinian infants. Training seminars in
Israeli medical centers were provided for Palestinian doctors and
certain medical facilities were expanded. Yet, although infant
mortality has been reduced from approximately 100/1,000 to
38/1,000, it is still much higher that Israel's 9.9/1,000. Life
expectancy has risen in the territories by about 10 years, but the
average Israeli lives 14 years longer.
Comparison with Israeli medicine reveals a flagrant discrimination
between Israel's investment in the health of its citizens and those
living under its military occupation. In 1992, governmental
expenditure per capita on health care was $500 in Israel, and
$18-20 in the occupied territories. There is a vast differential in
per-capita funding. For example, Civil Administration (military
government) hospitals provided 1,477 beds in 1992, roughly equal to
the number of beds available 25 years earlier, although the
population had more that doubled. The ratio of hospital beds are
1.1. per 1,000 in the West Bank and the Gaza Strip, and 6.1 per
1,000 in Israel.
Israel's unwillingness to develop the Palestinian health
institutions was in violation of a number of international
conventions. Most notable of these is the Fourth Geneva Convention
(1949), which stipulates that the adequacy of health-care services
must be determined by the extent to which the real medical needs of
a population are being met. Article 56 states that the occupying
power "has the duty of ensuring and maintaining the medical and
hospital establishments and services, public health and hygiene in
the occupied territories." Numerous studies have testified that
Israel has failed to maintain the medical facilities in the West
Bank and Gaza Strip in proper functioning condition.
In June 1995, a year after the transfer of the health institutions
to the PA, 15 children from Gaza were dying from heart defects.
Physicians for Human Rights-Israel (PHR) wrote: "Surgery can save
their lives, but nowhere in the Gaza Strip is there a single
pediatric cardiologist capable of handling these cases; nor is
there a scanner or catherization room. The only echocardiology
machine available is outdated to the extent that it has not been
used in Israel for over 20 years. An operation that can save these
children's lives costs $12,000 in Israel. The cost of a similar
operation in Cairo is $3,000; but even this sum is too great for
the Palestinian Ministry of Health to meet." How, the physicians
asked, "did Gaza reach a state in which only five out of the 300
infants born annually with heart defects are operated on?"
Severe lack of expertise and equipment extends to other fields,
such as oncology and hematology, pediatric neurology and
neurosurgery, metabolic diseases and rehabilitation. Children
suffering from a disorder related to one of these fields need to be
transferred to hospitals outside of the West Bank and Gaza Strip in
order to receive adequate medical care. One should note that the
dilapidated condition of the pediatric institutions is a
microscopic example that accurately represents the overall
infrastructure of the Palestinian health institution, and
underscores life-and-death Palestinian dependency on Israeli
medicine. It is revealing to examine how the Israeli and
Palestinian authorities addressed this legacy of the
The Israeli and Palestinian authorities should have taken into
account the Palestinian dependence upon Israeli medical services,
and ensured the referral of patients who cannot be treated in
Palestinian hospitals to medical institutions which can treat them.
Second, the negotiators should have laid the grounds for Israeli
and Palestinian cooperation in the development of an independent
Palestinian medical infrastructure.
Surprisingly, neither of these areas of responsibilities were
adequately addressed in the Interim Agreement which was signed in
October of 1995. In the Article dealing with health, it is
stipulated that Palestinians will assume responsibility for the
vaccination of the population. The Palestinians will also cover the
cost of all treatment of Palestinian patients in Israeli medical
institutions. The Israelis will assure "safe passage" of patients
in and out of he West Bank and Gaza Strip. The two sides concluded
by agreeing that a joint committee should be established to
facilitate coordination and cooperation on health and medical
issues. Three pages, out of the 400-page agreement, were dedicated
to the health of the population.
The infrastructure of the health system was not mentioned in the
agreement. Only later did the Palestinian Ministry of Health and
the World Bank Education and Health Rehabilitation Project assess
the situation and determine that in order to develop effective
institutions, the health sector needs $48.8 million ($21.8 million
in Gaza and $27 million in the West Bank). This, of course, did not
include the estimated recurring costs of $66.2 million per year (at
the 1995 rate). The actual health expenditure for 1996 was much
higher: $107 million for running costs, while the actual health
revenues (e.g., health insurance premiums) was a mere $44 million;
this incurred a deficit of over $62 million. It is important to
note that in 1996 alone, almost $15 million were paid to Israeli
hospitals for treatment of Palestinian patients who could not be
treated in local facilities.
In mid-February 1996, Amira Hass of the Israeli newspaper Ha'aretz
reported that out of an estimated 188,000 children under the age of
five who are living in the Gaza Strip are in need of urgent
treatment for malnutrition. In 1995, 41.6 percent of the families
living in the Gaza Strip had to sell appliances in order to buy
food; 53.8 percent took out loans in order to buy food and only
five percent of the population had savings accounts.
Already in 1994, PHR proposed that "Permission to enter Israel
should be granted to patients on the basis of a recommendation by
the Palestinian Ministry of Health, without need of a permit of any
sort from the Israeli authorities, including the General Security
Service." Despite PHR's warnings, the bureaucratic red tape and the
closure, which is the direct outcome of the existing detachment
policy, have had fatal consequences for Palestinian patients.
Gideon Levy from Ha'aretz reports that, during March and the first
weeks of April 1996, at least nine patients died due to closure,
five of them children.
PHR also wrote that: "Israel should supply permits to allow the
regular passage of West Bank and Gaza Strip residents who are
members of the medical staff working in medical institutions in
East Jerusalem." This proposal took into consideration that the
largest and most modern Palestinian medical institutions are
located in East Jerusalem, including Makassed, Augusta Victoria and
St. John's hospitals. Some 60 percent of the employees of these
institutions (1,000 workers), which provide medical attention for
the population of the West Bank and Gaza Strip, are not residents
of East Jerusalem and need entry permits in order to reach the
hospital. As of February 1997, no policy had been established to
ensure the free movement of medical personnel at all times, and it
is still common for the operation of these hospitals to be is
hindered due to restriction of movement for the staff.
As time went by, the conditions in the Gaza Strip and the West Bank
worsened. In an Al-Quds interview (29/12/96), the Palestinian
Minister of Health, Dr. Riad Za'anun, asserted that all referrals
of Palestinian patients to Israeli hospitals had been stopped.
Patients, he said, will be referred to hospitals in Amman and
Cairo, since in these medical centers the cost for medical
treatment is on average 70 percent less than the rate charged by
Israeli hospitals. Such budget consideration directly affect
patients. Imagine, for example, traveling 12 hours on a bus from
Gaza to Cairo in order to receive radiation treatment; imagine the
return trip after the treatment. Israel's attitude towards the
Palestinian health crisis indicates that it pays no heed to the
historical context of the occupation and its consequent
responsibilities - as if the present is not founded on the past.
According to PHR, there is no communication between the Palestinian
and Israeli health ministries, and the joint committee which was
supposed to facilitate coordination and cooperation on health and
medical issues has been inactive for months.
The crisis facing the health-care institutions is but an example of
the consequence of an Israel's policy which turns a blind eye to
history. This denial has been integrated into the Interim
Agreement, which, to a large extent, will condition the future
relations between the two peoples.
It is also clear that Israel's policy enforces a punitive strategy
directed towards the future - one which strangles the Palestinian
population economically. One can safely claim that Israel's policy
denies not only the right of the Palestinian population to adequate
health care, but also to livelihood, and in the final analysis, to
self-determination. This latter claim is based on the simple truth
which Plato recognized over 2,000 years ago; namely, that the
ability to sustain oneself physically is a necessary condition for
realizing political freedom. People living without a guarantee of
basic health care are essentially handicapped in their
participation in the development of their society. Again and again,
one encounters citizens in different countries demanding that their
government assume responsibility for health care. The 1992
presidential campaign in the USA and the current debate about
Medicare is an indication of this trend. The establishment of a
national health plan in Israel in 1994 is another example. Health
care is perceived as one of the basic rights which must be ensured
to every citizen by his or her government.
After so many years of neglect, Israel ought now to ensure that all
Palestinian patients who cannot receive proper care in the West
Bank or the Gaza Strip will be treated within Israel, until a
comprehensive Palestinian medical infrastructure is established.
Simultaneously, Israel must cooperate with the Palestinian Ministry
of Health in building an independent Palestinian medical
infrastructure. A first realistic step would be the opening up of
the Israeli medical schools and hospitals to Palestinians who wish
to study and specialize in different medical fields. Financing full
training for Palestinian doctors, nurses, and technicians is not
beyond Israel's means.
The predicament of the Palestinian population is surely not only
Israel's responsibility in a field like health. It is also the
responsibility of the Palestinian Authority itself. The USA, the
European Community, and the World Bank, to name a few, also have
major roles to play before the Palestinian people can build a
healthy economy as an essential stage in the full realization of
their natural aspirations. As for Israel, bearing in mind the
legacy of the occupation, it has a special moral responsibility for
Barghouti, Mustafa. Palestinian Health: Toward a Healthy
Development Strategy in the West Bank and Gaza Strip. Jerusalem:
Union of Palestinian Medical Relief Committees, 1993.
Barghouti, Mustafa and Ibrahim Daibes. Infrastructure and Health
Services in the West Bank: Guidelines for Health-Care Planning.
Ramallah: The Health Development Information Project, in
Cooperation with the World Health Organization, 1993.
Health in Judea, Samaria and Gaza: 1967-1994. Jerusalem: The
Ministry of Health, 1994.
Mazali, Rela, Nogah Ofer and Neve Gordon. Annual Report -- 1992:
Focus on the Occupied Territories' Health-Care System. Tel Aviv:
Physicians for Human Rights, 1993.
The World Bank, Developing the Occupied Territories: An Investment
Washington D.C.: The World Bank, 1993.