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 system.

Twenty-Seven Years of Health under Occupation - Background

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 occupation.

Palestinian Dependence

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.

Punitive Strategy

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 the future.

References

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 in Peace.
Washington D.C.: The World Bank, 1993.