Friday, July 9, 2010

The Impact of Israel's Apartheid Wall on Health

Video + WHO/OCHA update report dated July 7, 2010
Palestinian healthcare paralysed by separation wall:

"AlJazeeraEnglish | July 09, 2010

Palestinians in the West Bank are not allowed into Israel for treatment unless they have a permit.

The process of getting one is lengthy and complex. With males often denied permits on security grounds.

The UN office for the Coordination of Humanitarian Affairs and the World Health Organisation has issued a report expressing grave concern about Palestinians' access to healthcare due to the barrier.

Nisreen El-Shamayleh reports from the West bank on the healthcare implications of the wall.

The Impact of the Barrier on Health - WHO/OCHA update (7 July 2010):

Office for the Coordination of Humanitarian Affairs (OCHA)
World Health Organization (WHO)
7 July 2010

July 2010
Six Years After the International Court of Justice Advisory Opinion on the Barrier
The Impact of the Barrier on Health

Because of the extensive humanitarian impact of the Barrier, OCHA has been monitoring and reporting on affected Palestinian communities in the West Bank, including East Jerusalem, since 2003. The current update summarises the main findings of this research, while outlining developments since the last Barrier report, issued on the occasion of the fifth anniversary of the ICJ opinion in July 2009. This year, in conjunction with the World Health Organization (WHO), the update will focus on the impact of the Barrier on health, in particular patient and staff access to the specialized medical facilities only available in East Jerusalem.

The Barrier: Background and Current Status of Construction

In summer 2002, following a campaign of suicide bombings by Palestinian militants, the Government of Israel approved construction of a Barrier to prevent suicide bombers from entering Israel. The Barrier’s total length is 707 km, more than twice the length of the 1949 Armistice Line (Green Line) between the West Bank and Israel.1 Approximately 61.4% of the 707-kilometre-long Barrier is complete; a further 8.4% is under construction and 30.1% is planned but not yet constructed.2 When completed, the majority of the route, approximately 85%, will run inside the West Bank, including East Jerusalem, rather than along the Green Line.

The total area located between the Barrier and the Green Line amounts to 9.4% of the West Bank, including East Jerusalem and No Man’s land (See map: West Bank Barrier Route Projections). The protection of Israeli settlements, including areas planned for their future expansion, constituted the major factor for the deviation of the Barrier’s route from the Green Line.3 The area left on the western side of the Barrier includes 80 of the 149 settlements and over 85 percent of the total settler population in the West Bank (including East Jerusalem).

Since the last OCHA Barrier report, construction of new sections has almost completely halted as a result of a number of financial constraints, concerns raised by the international community and lack of demand by Israeli society.4 Most of the recent construction involved re-routings ordered by the Israeli High Court of Justice (HCJ). In addition, new construction has taken place in the north of East Jerusalem and in the northwest of Bethlehem governorate.

It was the route of the Barrier, rather than the structure itself, which was the subject of the International Court of Justice (ICJ) advisory opinion in 2004. (See box on page 4). The intrusive route, together with its associated permit and gate regime, is the main cause of the humanitarian impact on Palestinians. The majority of the area between the Barrier and the Green Line has been designated a ‘closed military area’ or ‘Seam Zone’, where Palestinians have been obliged to obtain ‘visitor’ permits to access their farming land and water resources. Access is channelled through a particular gate designated on the permit. Restricted allocation of these visitor permits and the limited number and opening times of the Barrier gates have severely curtailed agricultural practice and undermined rural livelihoods.

In addition, approximately 7,800 Palestinians reside in the closed area between the Barrier and the Green Line. Those aged 16 and above require permanent resident permits from the Israeli authorities to continue to live in their homes.5 Residents have to pass through Barrier checkpoints to reach workplaces and essential services, and to maintain family and social relations on the ‘Palestinian’ side of the Barrier. Few health and education services are available in the closed area: restricted access to health services is the main focus of this update. The Barrier has also adversely affected the access of the entire population to urban areas, in particular East Jerusalem, whose six non-government hospitals are the main providers of routine, emergency, secondary and tertiary care for Palestinian from the West Bank and Gaza Strip.

Area Affected

The Barrier’s total length is 707 km, more than twice the length of the 1949 Armistice Line (Green Line) between the West Bank and Israel.

The total area located between the Barrier and the Green Line is 9.4% of the West Bank, including East Jerusalem and No Man's Land.

When completed, approximately 15% of the Barrier will be constructed on the Green Line or in Israel with 85% inside the West Bank.

Populations Affected

If the Barrier is completed based on the current route: Approximately 33,000 Palestinians holding West Bank ID cards in 36 communities will be located between the Barrier and the Green Line.

The majority of Palestinians with East Jerusalem ID cards will reside between the Barrier and the Green Line. However, Palestinian communities inside the current municipal boundary, Kafr Aqab and Shu'fat Camp, are separated from East Jerusalem
by the Barrier.

Approximately 126,000 Palestinians will be surrounded by the Barrier on three sides. These comprise 31 communities; the Biddya and Biddu areas, and the city of Qalqilya.

Approximately 28.000 Palestinians in 9 communities in the Az Zawiya and Bir Nabala Enclaves will be surrounded on four sides by the Barrier, with a tunnel or road connection to the rest of the West Bank.

Barrier Route

Cartography and Barrier Themes: OCHA-oPt IMU Map July 2010
Base data: MoPIC (2000) updates OCHA (2010)
Barrier data: OCHA Field work, Shaul Arieli(Councel for Peace and Security), ARIJ, JRC
For comments contact
Tel. +972 (02) 582-9962

The International Court of Justice Advisory Opinion
On 9 July 2004, the International Court of Justice (ICJ), the principal judicial organ of the United Nations, issued an advisory opinion on the Legal Consequences of the Construction of a Wall in the Occupied Palestinian Territory. The opinion recognised that Israel ‘has the right, and indeed the duty, to respond in order to protect the life of its citizens [but] the measures taken are bound nonetheless to remain in conformity with applicable international law.’6

The ICJ stated that the sections of the Barrier route which ran inside the West Bank, including East Jerusalem, together with the associated gate and permit regime, violated Israel’s obligations under international law. The ICJ called on Israel to cease construction of the Barrier ‘including in and around East Jerusalem’; dismantle the sections already completed; and ‘repeal or render ineffective forthwith all legislative and regulatory acts relating thereto.’7

The ICJ also called on Israel to ‘make reparations’ for the ‘requisition and destruction of homes, businesses and agricultural holdings’ and ‘to return the land, orchards, olive groves, and other immovable property seized.’8 The Court also obligated member states not to recognize the illegal situation created by the Barrier and to ensure Israel’s compliance with international law. Although this is a non-binding advisory legal opinion on 20 July 2004, the General Assembly overwhelmingly approved Resolution ES-10/15 which demanded that Israel comply with the ICJ opinion.

Restricting Access to Land and Livelihoods

In the northern West Bank, since October 2003, Palestinians have been obliged to obtain ‘visitor’ permits to access their farming land between the Barrier and the Green Line, which was declared a ‘closed military area’ or ‘Seam Zone’. To obtain a permit, applicants must satisfy the security considerations necessary for all Israeli-issued permits and submit documents to prove a ‘connection to the land.’9 Entry is channelled through an official access point, usually a gate, designated on the permit: currently there are 57 Barrier gates which open on a daily, seasonal or seasonal-weekly basis. The majority of the gates only open during the olive harvest season and usually only for a limited period during the day: as ‘visitors’, farmers are not permitted to stay on their land over night and must return at the last gate opening time during the late afternoon or early evening.

Although additional permits are issued to farming families during the olive harvest and the gate opening times are generally extended, this is insufficient to allow farmers to carry out essential year-round agricultural activities, such as ploughing, pruning, fertilizing, and pest and weed management. UN monitoring in the northern West Bank has revealed that the combination of the restricted allocation of ‘visitor’ permits and the limited number and opening times of the Barrier gates have severely curtailed agricultural practice and undermined rural livelihoods. Data submitted by the Israeli State Attorney to the HCJ indicated that the number of permits issued to Palestinians farmers to access the ‘Seam Zone’ in the northern West Bank between 2006 and mid-2009 sharply decreased.10

In January 2009, the ‘closed area’ designation was extended to the Ramallah, Hebron and parts of the Salfit, Bethlehem and Jerusalem governorates. Previously, farmers were only required to register with the Israeli authorities and show their ID cards at the relevant gate (the ‘prior coordination’ system): now Palestinians needing to access these areas have gradually been required to apply for ‘visitor’ permits. In the Hebron district, 470 farmers applied for permits to access their land through the Khirbet Al Dier gate during the 2009 olive harvest, of which 370 were granted. By contrast, during the 2008 olive harvest, under the ‘prior coordination’ system, an estimated 1,500 farmers accessed their olive groves through the same gate.

The sharp decrease in the number of applicants is partly attributable to the poor harvest in 2009, but also due to the onerous demands of the permit system. In the Ramallah governorate most farmers have refused to apply for permits. As a result, six of the ten Barrier gates and checkpoints now requiring permits have remained virtually deserted. A similar situation has evolved in those areas of the Jerusalem governorate where the ‘Seam Zone’ regime has been implemented. Out of 15 crossing access points (12 gates and three Barrier checkpoints) five require
permits. During the 2009 olive harvest, only seven farmers were granted permits to cross through these gates while the majority of farmers refused to apply.

Emergency Medical Care Unavailable for Farmers in the ‘Seam Zone’

The Barrier gate opening times pose potential health risks for the thousands of farmers who enter their land in the ‘Seam Zone’ on a daily or seasonal basis. The majority of gates open for brief periods, two to three times daily: only two Barrier gates out of 13 open continuously throughout the day. As the gates are locked and unstaffed by soldiers between these short opening times, a widespread anxiety among farmers is that in the event of a work accident, snake bite or pesticide inhalation, they are unable to leave the ‘Seam Zone.’ Unless they succeed in attracting the attention of the military patrol which controls the gates (or communicate through the Humanitarian Hotline to the DCL - Israeli District Coordination Liaison Office) they are stuck until the next opening time, without access to first aid or emergency care. Restrictions on vehicles passing through the Barrier gates means that an injured person needs to be transported by horse, mule or tractor to the gates, which often necessitates a long detour over rugged terrain. The farmers’ anxiety is compounded by the realization that access restrictions to the ‘Seam
Zone’ also prevent the entry of health professionals and ambulances from assisting those in need of medical care.11

Closed Area Communities: Restricting Access to Health and Other Vital Services

The designation of the ‘Seam Zone’ in the northern West Bank in 2003 affected some 10,000 Palestinians residing in the closed area, with those aged 16 and above required to apply for ‘permanent resident’ permits to continue to live in their own homes.12 As most services and livelihoods are located on the ‘Palestinian’ side of the Barrier, children, patients and workers have to pass through Barrier checkpoints to reach hospitals and health centres, schools and workplaces. Relatives and service providers living outside the ‘closed areas’ must obtain ‘visitor’ permits to access these communities.

Demonstrations Against the Barrier
Protests against the Barrier have continued in a number of Palestinian communities, in particular the weekly demonstrations in the villages of Bil’in and Nil’in in the Ramallah governorate and al Ma’sara in Bethlehem. Such protests often evolve into violent confrontations with Israeli forces and account, on average, for approximatly 20 percent of the injuries recorded in the West Bank, in the period 1 July 2009 - 30 June 2010. In the past year, the Israeli authorities have intensified their campaign against these protests, employing night raids to detain organizers and prominent activists and under-cover units to arrest protestors during the weekly demonstrations. In February 2010, the Israeli military declared the area between the Barrier and the built-up area of Bil’in and Ni’lin closed military areas on Fridays, from 8 am until 8 pm, for a period of six months; the orders place non-residents who enter the area without permission from the Israeli military at risk of arrest.

Re-routings of the Barrier during the last year have reconnected a number of ‘Seam Zone’ communities to the remainder of the West Bank. In the Qalqiliya governorate, following a HCJ ruling of September 2005, the Israeli authorities completed the rerouting of a section of the Barrier around the settlement of Alfe Menashe, ‘releasing’ three communities (pop. 800) from the ‘Seam Zone’. However, vital agricultural land from these communities, as well as two Bedouin communities (pop. 400), remain isolated within the Alfe Menashe enclave.13

In an additional easing to a ‘Seam Zone’ community, the checkpoint controlling access between Azzun ‘Atma (population 2,000) in the Qalqiliya governorate and the rest of the West Bank was transformed in March 2010 into a partial checkpoint, allowing largely unrestricted access to the village.14 Previously, for more than six years, the checkpoint was closed from 22:00 to 06:00, effectively confining the entire community during night hours. This proved especially problematic for expectant mothers in labour, as the only medical facility available was a basic primary health care clinic which operates for two hours a day, twice a week.15

In total, despite the expansion of the ‘Seam Zone’ further south, the number of people living in the closed areas behind the Barrier decreased from approximately 10,000 to 7,800. 16 However, those communities still in the ‘Seam Zone’ continue to suffer restricted access to services, in particular, health. The requirement for ‘visitor permits’ to enter the ‘Seam Zone’ generally prevents doctors from providing house calls, ambulances from collecting patients and mobile teams providing health services. The Barta’a enclave, the largest such community, with 5,600 inhabitants, was visited twice a week by a mobile health team from UNRWA: however, since September 2007, UNRWA has been unable to access Barta’a and the programmes have been suspended.17

In Barta’a, a doctor and a midwife are on duty four and five days a week respectively during working hours. However, the main access point for the community, the Barta’a checkpoint, closes at night between 2200 and 0530 hours.18 Emergency medical care during these night hours requires coordination with the Israeli authorities, leading to serious delays (see case study below). As a precautionary measure, pregnant women often leave this community one month before delivery to avoid complications.

If the Barrier is completed as planned, approximately 33,000 West Bank Palestinians will reside between the Barrier and the Green Line, in addition to the majority of the Palestinian residents of East Jerusalem. The greater part of these are in the Bethlehem governorate, where nine rural communities of approximately 22,000 residents will be cut off from the urban centre by the route of the Barrier around the Gush Etzion settlement bloc. Some health facilities are available within these communities: level 1 clinics in Al Jaba’a and Husan, level 2 in Fukin and level 3 in Nahhalin and Batir.19 Al Walaja however - which will be completely surrounded by the Barrier and separated from these other communities - is only served by a mobile medical team every two weeks. Specialized medical care for all of these communities is located in Bethlehem, to which access will be restricted.

‘I Deal Almost Daily With Cases of Sick People.’
The Israeli Barrier cuts Barta’a off from the rest of the West Bank. The nearest hospital is in Jenin, accessible only through a checkpoint. Abu Rami, a member of the village council, is responsible for the coordination with the Israeli authorities. His own mother died at the checkpoint.

‘I deal almost daily with cases of sick people who need to cross the checkpoint. Anyone who cannot walk needs special coordination with the Israelis as well as anyone who has to cross during the night when the checkpoint is closed. Expectant mothers leave the village weeks before the expected date of birth, just to make sure that they will be able to reach the hospital in time. With the Barrier and the checkpoint, what was a 15 minutes drive to or from Jenin now takes about one hour.

I deal with the crossings as part of my job, but it has also affected me personally. I remember the day that my mother died, as if it was yesterday. She was old and had health problems for some time, but during the day her condition deteriorated. I called the Israeli authorities to get permission for the ambulance from Jenin to come and pick up my mother. The ambulance arrived at the checkpoint three kilometres outside our village within 15, 20 minutes. But the security guards at the checkpoint searched the ambulance and then ordered it to turn back. Why? I don’t know. They were probably just in a bad mood.

During that time I repeatedly called my Israeli interlocutors to get permission for the ambulance to cross – to no success. When I realized that, I asked for permission to drive my mother to Jenin in my own car. This was granted. However, just after we had crossed the checkpoint, my mother passed away. When we turned around to go home, the guards insisted on searching the car with my dead mother in the back. It felt like they were making fun of us, because we had not been out of view of the checkpoint.

My mother was old and I knew she would probably die. But the feeling of helplessness was terrible. I am the person responsible for medical coordination in Barta’a so I know the procedure and I have all the telephone numbers. Nevertheless, I could not even save my own mother.’

Access to East Jerusalem Hospitals Vital for the Health of Palestinians

East Jerusalem, with its six hospitals, is the main provider of specialized care to the population of the oPt. The hospitals have 624 beds, 12.4 percent of the total available in the oPt20 and provide a range of specialized treatment unavailable elsewhere in the West Bank and Gaza Strip: dialysis and oncology at Augusta Victoria hospital; open-heart surgery at Maqassed Hospital; neurosurgery at St. Joseph Hospital; neonatal intensive care at the Red Crescent and Maqassed Hospital, eye surgery at St. John Hospital and rehabilitation for handicapped children at Princess Basma Hospital. Restrictions in access to East Jerusalem for the vast majority of the Palestinian population started before the construction of the Barrier. In 1993, Israel introduced a permit regime which obliges any Palestinian who does not have residency rights in East Jerusalem or Israeli citizenship to apply for a permit to access Jerusalem. This also applies for medical cases who must apply for a permit through a complicated and time-consuming process. The patient’s physician submits a request to the Referral Abroad Department (RAD) of the Palestinian Ministry of Health which determines the eligibility of the patient and the hospital required. The patient then sets up an appointment with the hospital following which, the RAD or the hospital sends a request to the Israeli Civil Administration to issue a permit for the period of the appointment or operation.21

In addition to the stress involved in waiting for the permit to be issued (or denied), permits can be granted for shorter periods than the treatment requires, particularly if multiple consultations or operations are necessary. Males aged between 15 and 30 often have their requests for permits turned down on the grounds of security. In many cases, it is also difficult for parents of sick children or for family members to obtain permits to escort patients to Jerusalem. Permits are also invalid during periods of general closure: between April 2009 and the end of March 2010 the Israeli authorities imposed a general closure on the West Bank for a total of 50 days due to Israeli holidays and ‘security alerts.’

Before the construction of the Barrier, permit requirements were enforced at checkpoints and with random spot checks. However, access to Jerusalem from the West Bank was still possible without a valid permit, in particular on foot. Since 2007, with the completion of much of the Barrier in the Jerusalem area, the possibilities for those without permits to access the city for medical care are significantly reduced: for those with permits, access is channelled though designated Barrier checkpoints only. West Bank residents are only allowed to use three out of the 14 checkpoints: Qalandiya, Gilo and Zaytoun. The checking procedures are arduous and queues can be long, in particular during rush hour.

The limited access to East Jerusalem affects the health system in terms of access for patients to medical care; access for emergency medical services; and access of medical staff and students to their places of work and training.

Restricted Access for Patients to Hospitals in East Jerusalem

In 2009, almost half of all patients referred for specialized care by the Palestinian Ministry of Health were to East Jerusalem hospitals (49.6 percent), up from 26 percent in 2006.22 In 2009, over 19,000 patients from the West Bank attended East Jerusalem hospitals for treatment, an average of 365 patients per week. In total, West Bank Palestinians make up for 61.7 percent of all admissions at East Jerusalem hospitals, and patients referred from Gaza another 10 percent.

Vehicles with Palestinian license plates are not allowed to pass the Barrier checkpoints into East Jerusalem – a difficulty for sick or injured people who have problems walking.23 Depending on the number of people queuing, the time to cross the checkpoint can be up to two hours, in particular during rush hours. This is especially stressful for people in poor health or with disabilities. Princess Basma Hospital, which specializes in the rehabilitation of children, cites cases where wheelchairs and crutches cause problems for patients waiting in line, crossing revolving gates, or passing through metal detectors.

The Barrier also impacts the approximately 50,000 Palestinians who have residency rights in East Jerusalem but who reside in neighbourhoods such as Kafr ‘Aqab and Shu’fat Refugee Camp, which are now separated by the Barrier from the city. These Palestinians now also need to cross checkpoints to access health care to which they are entitled as residents of Jerusalem. Although they are not limited to the three checkpoints allocated for West Bank Palestinians, their travelling time to hospitals and clinics in the city has increased. East Jerusalem ambulances can also take substantially longer to reach Kafr’Aqab than before: although Kafr’ Aqab residents can easily access Ramallah hospitals, they prefer the health facilities in East Jerusalem to which they are entitled.

Restricted Access for Emergency Medical Services

Patients requiring emergency treatment available only in Jerusalem are especially affected by the delay in accessing the city through Barrier checkpoints. Permission for emergency cases can be obtained the same day through the Palestine Red Crescent Society (PRCS): this involves coordination with the Israeli District Coordination Office (DCL), the authorizing of a specific checkpoint for the patient to cross, and back-to-back ambulance procedures, as West Bank ambulances are prevented from entering Jerusalem. Even if permission is granted, emergency cases are frequently delayed at the checkpoints. In 2009, the Palestine Red Crescent Society (PRCS) recorded 440 delays and denials of ambulances throughout the oPt, two thirds of which occurred at Barrier checkpoints accessing Jerusalem.24

‘A Hospital Cannot Function With Doctors Alone.’

Salam Kana’an used to drive to the Palestine Red Crescent Society (PRCS) Maternity Hospital in East Jerusalem in just over 15 minutes. Now, she sets out two hours before her shift starts to be on time. As the Nursing Director, she struggles to maintain her staff’s operational schedule due to the Israeli permit regime and delays at checkpoints.

‘We used to have difficulties before the construction of the Barrier, because the permit regime predates it. But since three, four years, when the Barrier became effective in Jerusalem, the situation became worse. Depending on where you live you can only use a certain checkpoint. If the checkpoint is closed or the queues are long, you have a problem. Before the construction of the Barrier, you had alternative routes. But not any more.

There is a bus system for medical staff. But the buses run only for the morning shift. And then, each bus has to be accompanied by a so-called ‘security officer’, someone who holds a Jerusalem ID card. We have only one such person and whenever he is sick or on leave, the whole bus is held up. Most of the time, we then have to join the queue with all the workers and the time you take to pass is incalculable.

About seventy percent of our 57 nurses at the PRCS Maternity Hospital come from the West Bank, and almost every day someone is delayed at the checkpoint or even turned back. A common problem is that the machine at the checkpoint does not recognize your fingerprint. This has happened to every one of us. Just last month, two doctors and a nurse could not come to work because their fingerprints were not recognized.

Doctors have a special stamp in their permit, which allows them facilitated passage at any checkpoint. But a hospital cannot function with doctors alone. For any operation - and in our case, the 250 to 290 births per month - the doctor needs nurses who assist him. In emergencies we cannot bring in additional nurses quickly. To be prepared for emergency cases, we oblige the staff member who is on stand-by to remain at the hospital. This leads to additional costs and impairs the staff member’s private life.’

‘There is no Care Here for Our Daughter at All’
In addition to separating large parts of East Jerusalem and its population from the rest of the West Bank, the Barrier leaves approximately 1,500 West Bank ID card holders on the ‘Jerusalem’ side of the Barrier. On such community is Um Al Asafir: residents face access restrictions to their health and education services on the ‘Palestinian’ side of the Barrier.

Eight and a half year old Ala’ Zawahri is mentally and physically handicapped. Living in a house trapped between Har Homa settlement and the Barrier, her parents have to make an arduous journey to Bethlehem or to Beit Sahur to obtain medical services for their daughter.

‘Just last week, we needed to bring Ala’ to the doctor. She cannot speak, but when she cries, we know something is wrong, because usually she is very quiet. When she was little, we could drive to Bethlehem or Beit Sahur in less than 15 minutes. That was before the Barrier was built just outside our home. Now we have to find a taxi driver who actually comes here, to drive us to Gilo checkpoint. We then cross on foot carrying Ala’ in our arms. Then we take another taxi to the clinic or hospital. All together 45 shekels for one way. Most of the time, this takes one to one-and-a-half hours.

Ala’ cannot eat by herself, she cannot even sit up. Most of the time she just lies quietly on her couch. She needs constant care and the doctor says that she will need it all her life. Here, where we live, there is no care for Ala’ at all, no doctor, no mobile clinic. Nobody even supports us in taking care of her. About 100 meters from here, in the Israeli settlement, there is everything. But we are not allowed to go there. We have West Bank ID cards, although we live on the Jerusalem side of the Barrier.

We have repeatedly tried to register Ala’ for health insurance, but without success, despite the Palestinian Authority officials’ awareness of her case. Fifty-three members of our family live here in Um Al Asafir – nobody has health insurance. A friendly doctor in Bethlehem used to treat Ala’ for free. But he died. Now we not only have to pay for transport and medicine, but for doctors’ visits too. All in all, over 500 shekels since last year.

We have six other children. They are older and live with relatives in Beit Sahur in order to go to school and university easily. From the hill outside our house we can see where they stay – but in order to visit their handicapped sister Ala’ they need to make the long journey through the checkpoint.’

Restricted Access to East Jerusalem for Medical Staff and Students

In November 2008, the Israeli authorities implemented new restrictions obliging West Bank staff working at East Jerusalem hospitals to enter Jerusalem through the three designated checkpoints only. Previously, staff were allowed to use any checkpoint, by means of a special stamp on their permits. This concession is now limited to doctors. Hospital employees from the West Bank must cross the checkpoints on foot and use public transport to reach their hospitals, entailing long delays, and periodic refusals, leading to chronic lateness and disruption in the efficient functioning of the hospitals. The provision of special busses has brought some improvement, although problems continue (see case study: ‘A hospital cannot function with doctors alone.’).

The future of the medical system in the oPt depends on the professional level of its medical staff: access for students to specialized training institutions in East Jerusalem is also crucial for the health of the Palestinian population as a whole. The main training institution for medical professionals in the West Bank is al Quds University in Abu Dis, which is now separated from East Jerusalem by the Barrier. About 150 to 160 students in the fourth, fifth and sixth year of studies at Al Quds medical school are eligible for training at East Jerusalem hospitals.

Some 90 percent of them are from the West Bank and need permits to attend training in specialities such as paediatrics, neonatology, surgery, internal medicine, cardiology and other areas: medical training in many of these specialities is not available at the same level elsewhere in the occupied Palestinian territory. In June 2010, Al Quds medical school reported that 11 students could not continue their training in East Jerusalem because the Israeli authorities had refused to renew their permits.25

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.
Preamble to the Constitution of the World Health Organization

Access to health is a key component of the right to health. One of the instruments that stipulate the right to health is the International Covenant on Economic, Social and Cultural Rights (ICESCR).26 Israel ratified the ICECSR in 1991, and is therefore legally bound by all of its provisions. The Committee on Economic, Social and Cultural Rights (CESCR), the body supervising the implementation of the Covenant, has repeatedly stated that Israel’s obligations under the Covenant apply to all territories and populations under its effective control.27

The International Court of Justice confirmed the applicability of the ICESCR to the occupied Palestinian Territory in its Advisory Opinion of July 2004. As the single largest obstacle to Palestinian movement within the West Bank, including to and from East Jerusalem, the Barrier constrains Palestinians from accessing health facilities and health providers from servicing the Palestinian population. The Barrier, with its associated permit and gate/checkpoint regime directly infringes the right to health of the Palestinian population as a whole, as it isolates East Jerusalem from the remainder of the oPt.

The Way Forward

The Barrier, in conjunction with its gate and permit regime, continues to be the single largest obstacle to Palestinian movement within the West Bank, including to and from East Jerusalem. The impact has been particularly severe on rural communities, as the intrusive route cuts through eight of the West Bank’s eleven governorates, isolating the farms, greenhouses, grazing lands and water resources of tens of thousands of Palestinians farmers.28

The extension of the ‘closed area’ and permit regime since January 2009 has further restricted access to agricultural land in the central and southern West Bank.

The intrusive route of the Barrier inside the West Bank including East Jerusalem, together with its associated permit and gate regime, is not only contrary to international law, but is also gravely impacting on Palestinian access to health, in East Jerusalem and the ‘Seam Zone’ communities. In the past year, the Israeli authorities have ‘released’ certain of these communities to the ‘Palestinian side’ of the Barrier. However, these amendments, which are in compliance with decisions issued by the Israeli High Court of Justice rather than the ICJ advisory opinion, leave the re-routed sections of the Barrier within the West Bank rather than along the Green Line or in Israel. In many cases, while restoring the communities’ links to health and education services, they restrict their access to the agricultural land on which their livelihoods and survival depend.

Although Israel has the duty to ensure the safety and security of its citizens in response to attacks by Palestinian militants, this must be in accordance with international law and should not cause long-term detriment to the local Palestinian population. The ICJ advisory opinion called on Israel to cease construction of the Barrier, including in and around East Jerusalem, and to dismantle the sections of the Barrier already completed. In line with the advisory opinion, Israel should stop all Barrier construction and dismantle or re-route the constructed sections to the Green Line. Only then will the Palestinian communities cut off by the Barrier be able to exercise their rights to freedom of movement, work, education, health and an adequate standard of living. This will also ensure that no Palestinian land and water reserves are isolated between the Barrier and the Green Line, preventing rural communities from cultivating land, harvesting crops and grazing animals.

* Although no measures can substitute for the full implementation of the ICJ advisory opinion, the Israeli authorities can initiate interim steps to mitigate the negative effects of the Barrier and its associated permit and checkpoint/gate regime on Palestinians’ right to health:

* Residents of the ‘Seam Zone’, and farmers working their land there, must be allowed to leave the area around the clock and without delay in order to access to medical facilities whenever needed.

* Palestinian medical personnel must be allowed to enter the ‘Seam Zone’ at all times and without delay, in order to provide care to residents and farmers alike.

* The specialized hospitals in East Jerusalem must be accessible to all Palestinians from the West Bank and Gaza Strip. Medical needs must be a priority in the allocation of permits.

* Barrier checkpoints into East Jerusalem should offer facilitated passage for patients and a speedy transfer of patients in ambulances.

* West Bank employees from East Jerusalem hospitals should be allowed to use all Barrier checkpoints.

* Access to specialized training in East Jerusalem hospitals must be ensured for medical students.

UNRWA Barrier Monitoring Unit
In conjunction with the sixth anniversary of the ICJ advisory opinion, UNRWA announces the establishment of a Barrier Monitoring Unit (BMU) with funding from the Swiss Agency for Cooperation and Development. The aim of this unit is to document the humanitarian impact of the Barrier on refugee communities. The unit will inform UNRWA’s programmes and partner organisations in order to support communities affected by the Barrier. The BMU will work closely with OCHA in its advocacy endeavour.

1Four routes of the Barrier have been approved by the Israeli cabinet in 2003, 2004, 2005 and 2006. The map of the current route was published on the website of the Ministry of Defense in April 2006. (See www.seamzone. For a comparison of the Barrier routes and revisions see OCHA oPt, ‘Five Years after the International court of Justice Advisory Opinion’, July 2009, pp. 10-11. For more on the background and impact of the Barrier see the UN video documentary, ‘Walled Horizons’, narrated by Pink Floyd founding member, Roger Waters, at: watch?v=rLqd0z2lrRY
2The planned Barrier route is based on the Israeli government map, published in April 2006 and data provided by Shaul Arieli (Council for Peace and Security) in July 2009. The constructed and under construction Barrier route is extracted from aerial photos, ( May 2009), compared to data provided by the Council for Peace and Security, Joint Research Centre, Applied Research Institute Jerusalem and verified by field surveys as of July 2010.
3See Shaul Arieli and Michael Sfard, The Wall of Folly (2008), Chapter 4; B’Tselem and Bimkom, Under the Guise of Security: Routing the Separation Barrier to Enable the Expansion of Israeli Settlements in the West Bank, December 2005.
4According to one journalist, citing an IDF source, the entire Barrier ‘is not slated to be completed until 2020 - in other words, 18 years after the Sharon government decided to put it into action.’ Hanan Greenburg, ‘IDF estimates security fence to be completed in 2020’, Israel News, 2 March 2010. The cost of the entire project is unknown but according to a recent estimate, the Barrier ‘has cost NIS 7 billion thus far. The total cost …once it is completed, will reach NIS 11 billion in the best case scenario.’ Alex Fishman, Efficiency versus Cost, Yedioth Ahronoth, 10 January 2010.
5The exception is the village of ‘Azzun ‘Atma whose residents, although located on the ‘Israeli’ side of the Barrier, were not required to obtain permits to continue living in the village. In March 2009, the IDF installed an inner fence, or secondary Barrier, with two gates along it, cutting off nine houses from the rest of the village and obliging their 75 inhabitants to apply for permanent resident permits.
6ICJ, Legal Consequences of the Construction of a Wall in the Occupied Palestinian Territory, Advisory Opinion of 9 July 2004, para. 141. The full text of the ICJ opinion can be found at: &p2=4&k=5a&case=131&code=mwp&p3=4
7Ibid., para. 163.
8Ibid., paras.152-53. Following the ICJ advisory opinion, the United Nations Register of Damage Caused by the Construction of the Wall in the Occupied Palestinian Territory (UNRoD) was established in accordance with General Assembly resolution A/RES/ES-10/17 of January 2007. UNRoD’s mandate is to serve as a record, in documentary form, of the damage caused to all natural and legal persons concerned as a result of the construction of the Wall by Israel in the Occupied Palestinian Territory, including in and around East Jerusalem.
9This normally requires submission of valid ownership or land taxation documents. In the West Bank, where the majority of land has not been formally registered ownership has passed down to the next generation by traditional methods which do not require formal inheritance documentation. This requirement also runs contrary to traditional farming practices, whereby extended families participate in planting, harvesting and maintaining the land.
10HCJ 639/04, The Association for Civil Rights in Israel vs. IDF Commander of Judea and Samaria, Response from August 2009.
11See OCHA oPt, ‘Five Years after the International Court of Justice Advisory Opinion’, July 2009, p. 36, for the case of a farmer who severed his fingers with a chainsaw while working in the closed are behind the Barrier.
12Israeli citizens and the settlers living in the area, tourists, or persons of Jewish origin are exempt from this regulation.
13The communities ‘released’ are Ras At-Tira, Ad Daba, and Wadi Rasha. Those that remained in the closed area are two vulnerable Bedouin communities, Arab Ar Ramadin, and Arab Abu Farda.
14This development follows the completion of a secondary barrier around the village which isolates nine families from the rest of the village; a checkpoint along this secondary barrier, which closes between 22:00 and 05:00, remains fully staffed.
15See OCHA oPt, ‘Five Years after the International Court of Justice Advisory Opinion’, July 2009, p. 17.
16The extension of the “Seam Zone” designation in February 2009 affected only a limited number of people: a few localities between the Barrier and the municipal boundary of Jerusalem with a total population of approximately 500, and three families (approximately 100 people) in Beit Yattir in southern Hebron. In May 2010, the Israeli authorities refused to renew the permits of twelve members of this community, arguing that their holders reside in the enclave on a seasonal basis, and therefore are not entitled to a ‘permanent resident’ permit.
17WHO, The right to health in the occupied Palestinian territory: West Bank and East Jerusalem, August 2009, p. 6 18. The alternative crossing point, the Tura Checkpoint, also closes at night between 1930 and 0730 hours.
19Level 1 clinics provide mother and child health care, immunization and first aid. Level 2 clinics offer the same services plus general practitioner medical care and in some cases a laboratory. In addition to that a level 3 clinic provides family planning and dental services, specialist medical services, a laboratory and health education.
20Palestinian Ministry of Health, Annual Health Report 2009.
21The procedure for obtaining permits also includes a thorough background check on the applicant’s past records, relatives, friends, political and religious affiliation, carried out by the Israeli Authorities
22Palestinian Ministry of Health, Annual Health Report 2009. Two factors lie behind this trend: the closing of the Rafah border between the Gaza Strip and Egypt in 2007 made referrals to Egyptian hospitals more complicated; and referrals to Israel and Jordan decreased proportionally due to the high cost of treatment there.
23In September 2004, Augusta Victoria Hospital set up a bus system for patients and medical personnel which was soon extended to serve the other five East Jerusalem hospitals. However, this system has been experiencing interruptions. See Case Study: ‘A hospital cannot function with doctors alone.’
24PRCS, Humanitarian Duty Report, 2009, p. 44, 47
25OCHA Humanitarian Monitor, May 2010, p. 7.
26Article 12, lists among other ‘The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for: … The creation of conditions which would assure to all medical service and medical attention in the event of sickness.’
27Concluding Observations in 1998, 2001 and 2003.
28An OCHA/UNRWA survey in 2007 identified 67 communities with an estimated population of 222,000 in the northern West Bank alone, which had land isolated in the closed area between the Barrier and the Green Line. UNOCHA/UNRWA Special Focus: The Barrier Gate and Permit Regime Four Years On: Humanitarian Impact in the Northern West Bank, November 2007. According to the World Bank, ‘some 170,000 dunams of fertile agricultural lands are affected by the Barrier, some 10.2% of the total area cultivated in the West Bank, with an average economic value of $US 38 million - equal to roughly 8% of Palestinian agriculture production.’ The World Bank: The Economic Effects of Restricted Access to land in the West
Bank, October 2008, p. 16.

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