Health in Palestine   The Intifada for Independence	Health in Palestine The Occupation's Impact on Health Care Collective Punishment The 1980s The First Intifada Oslo The Post-Oslo Period The Second Intifada The Occupation's Impact on Health Care All aspects of the health situation in Palestine have been affected by Israeli occupation. The 1967 war marked the beginning of the Israeli occupation of the territories and its illegal annexation of Jerusalem. Prior to the Israeli occupation, the West Bank was under the auspices of the Jordanian government and the Gaza Strip under that of Egypt. During the occupation, the Israeli administration did much to undermine health care within the Occupied Territories. Much of this was due to neglect in the form of underfunding. For example, in 1975, the Israeli health budget for the entire West Bank was equivalent to only 60% of the typical budget for one 260-bed hospital in Israel. Between 1967 and 1984 the number of hospital beds in the Occupied Territories actually decreased while the population doubled. The Israelis also took active measures to cripple health institutions in Palestine. They heavily taxed health establishments, closed professional unions, and hampered the ability of health practitioners to perform their jobs in needed areas. Israeli authorities also denied Palestinian health institutions permits to expand existing facilities, or build new ones. As a result, much of the Palestinian public health care infrastructure suffered. Palestinians were forced to become dependent on the Israeli system, which was controlled by the military authority and often used as a political tool to maintain control and order in the Territories. With the public sphere under Israeli control, Palestinians could turn only to the private sector. Unfortunately, the private sector geared itself towards a biomedical, curative approach, and concentrated almost entirely on the larger urban areas of the Territories. Many rural and isolated communities lacked services of any kind, and treatment in general did not take other, non-medical factors into account when addressing health issues. Faced with continued military law, Palestinians in the Occupied Territories were forced to become increasingly self-reliant. Volunteer organizations therefore became an important means of rebuilding a Palestinian infrastructure that had been actively dismantled through Israeli policies. They provided services that were either non-existent or severely maligned under the Israeli law. Collective Punishment While crippling Palestine's health infrastructure, the Israeli governmental policies continued to create health emergencies throughout Palestine. For example, the Israeli government often imposes strict closures and curfews, preventing residents from leaving their homes, even to receive health care. If people manage to get to hospitals and clinics, they often find them severely understaffed, as most of the employees living outside of the curfew area are denied permission to reach their workplace. Facilities are also under-supplied, as new stocks of medicines and supplies cannot pass through military blockades. The Jordan Valley offers another example of health crises caused by the Israeli occupation. The Jordan Valley is one of the poorest in Palestine. The little water that it has comes from aqueducts that are often open to debris and pollution. Also, because it shares a border with Jordan, Israel authorities consider the valley a security zone, and Israeli forces maintain a large military presence there. In some of the villages, the Israeli government has forbidden Palestinians from constructing permanent houses, thus exposing them to the harsh climate of the valley. In other areas, Israel denied Palestinians permits to provide piped water to villages, and access to the national electricity grid. The 1980s During the mid-1980s, the Israeli authority began aggressively suppressing the rising structure of services provided by Palestinian non-governmental organizations. The effects of the occupation and the continuous destruction of Palestinian services began to take their toll. In 1985, the infant mortality rate in Israel was 14 per 1,000 live births, 60 per 1,000 in Syria, and 55 per 1,000 in Jordan. That same year in the West Bank and Gaza, under what was supposed to be the same Israeli system, Palestinian infant mortality was 70 per 1,000 live births. Low physician-to-population ratio (8 per 10,000 in the Occupied Territories compared to 28 per 10,000 in Israel during 1986) contributed to the high mortality rate. The lack of physicians was accentuated by the fact that services provided were mostly biomedical in nature, and did not address the many social and political factors affecting the health of Palestinians. The establishment of an effective, independent Palestinian health care system was essential-one that could not only address the needs of the people, but also resist the pressures and injustices of the occupation. UPMRC and other Palestinian development organizations provided the social, economic and health infrastructure for the Occupied Territories during the 80's. During this period, they were able to confront a strong Israeli campaign against organized Palestinian development. The First Intifada During the mid-1980s, a slow and steady movement in opposition to the occupation began taking shape throughout the Gaza Strip and the West Bank. The collective frustration of twenty years of Israeli occupation reached its peak on December 9, 1987, when an auto accident between an Israeli truck and two Palestinian vans sparked a national uprising, the Intifada (Arabic for "shaking off"). The Palestinian people took to the streets in demonstrations, strikes and riots and became symbols of resistance to years of oppression and occupation. Israelis responded to the uprising with brutal military force. In the first year alone, conservative estimates list 389 documented deaths and over 20,000 casualties, all sustained as the direct result of army violence. The majority of those killed, injured and disabled were between the ages of 15 and 25 years. The Israeli army also imposed punitive curfews on refugee camps and villages, blocking residents'-old and young, sick and wounded-access to health care. The wounded were mistreated, vehicles transporting them were obstructed, medical personnel were assaulted as they delivered life-saving services, the army raided health facilities, and the injured were arrested in hospitals. Children suffered tear gas inhalation. Many villages were placed under siege and curfew by the Israeli army. Soldiers entered villages, harassed villagers, detained youth, and imposed collective punishment measures by destroying water tanks, cutting electricity, and blocking food distribution. Having suffered considerable neglect under the military administration, and with staff not possessing the freedom necessary for effective action, the Palestinian healthcare system was overwhelmed by the events. Medical directors of hospitals were issued military orders prohibiting them from treating the wounded without charging them for the services provided, and requiring them to provide the military with a list of names of all injured admitted to hospitals. For this reason, the large majority of the injured were reluctant to seek care in hospitals because of the high possibility of a later arrest by the army, with the injury as evidence of guilt. Curfews would render entire villages under "house arrest," with residents unable to leave their homes except for a few hours daily to buy necessities. Often roadblocks would be set up by Israeli soldiers to keep Palestinians in the villages or alternatively by Palestinians to keep Israeli soldiers out of the villages. Medical teams would have to leave the safety of their vans and walk several kilometers, carrying heavy equipment and supplies, with a constant threat of facing Israeli soldiers. In villages, open buildings would serve as sites for ad hoc medical clinics. Medical volunteers would use any available corner or room to set up various stations-pediatric, dental, and a minor surgical department-to meet the needs of that particular village. Health volunteers would then provide essential first aid information to the local community members so that they could provide basic first aid treatment when outside medical help was not available. Israeli soldiers limited the number of doctors per site to one doctor. Health conditions of the Intifada reached their lowest point during the Gulf Crisis, which began on January 16, 1991. The war lasted 44 days, during which the entire population of the West Bank and Gaza Strip was placed under a strict 24-hour curfew. Such restrictions severely limited the access of the population to health and medical care facilities, and resulted in unnecessary deaths. Furthermore, wageworkers were unable to go to work and hence unable to earn an income to buy necessary food and medicine for their families. Restrictions continued after the war. West Bank residents were not allowed to enter Jerusalem without obtaining a permit from the Israeli authorities. Furthermore, residents of the West Bank and Gaza were prohibited from traveling to and from the other's territory without a permit, exacerbating the problem of patient referral and information exchange between the two areas. Jerusalem was and continues to be the main center for crucial hospital and diagnostic facilities. Israel maintained its policy of services favoring the Jewish population in Jerusalem while simultaneously denying residents from the West Bank and the Gaza Strip free passage into Jerusalem. This situation continues today. Oslo With the end of the Gulf War, numerous initiatives were offered to breach the Palestinian/Israeli divide and bring peace to the region. The most substantive of these initial talks, known as the Madrid Process, involved multi-lateral talks with Israel and several Arab states. As the Madrid talks continued, however, the complexities of the issues and the public nature of the negotiations took their toll. The talks stopped completely after Israel forcibly removed over 400 activists to Lebanon, and resumed at only a sputtering pace afterwards. It slowly became apparent that there was another set of covert negotiations taking place. In 1993, news of the Oslo negotiations became public. The Oslo I Agreement gave the Palestinians full social and security control over Jericho and 60% of the Gaza Strip. At Oslo II, the same status was conferred to the other major cities of the West Bank. Although the occupation did not end, there now existed a central authority to represent the Palestinian people and to provide infrastructure and civil affairs management for the population. This Palestinian Authority (PA) offered a Palestinian alternative to the Israeli military rule. The PA's creation affected all areas of Palestinian life, including health. In December of 1994, the Ministry of Health (MoH) took over the national health infrastructure. The PA's creation also had tremendous implications for the NGO community, as responsibility for Palestinian infrastructure shifted. Some of the services previously offered by the non-government sector fell under the auspices of the PA. Furthermore, many of the international donors who supported the non-governmental institutions shifted their aid to the newly formed government. As a result, many NGO's were forced to shut down, and many others merged with the PA rather than maintaining their independence. Because the government assumed new responsibilities in the health and education sectors, between 1993 and 1998, over 70 percent of non-governmental primary health clinics and 1,000 kindergartens were shut down in the West Bank and Gaza Strip. While the creation of the Palestinian Authority provided some means of Palestinian self-rule, the occupation of the West Bank and Gaza Strip continued. Although it is considered under full Palestinian control, forty percent of the Gaza Strip remains under Israeli settlements and military installations. The West Bank territory was partitioned into three separate categories, apart from the Israeli-held settlements and annexed East Jerusalem. In areas labeled "C," Israel maintains full security and civil control. This constitutes the vast majority-more than sixty percent-of territory in the West Bank. In areas marked "B," Israel maintains security control and the PA is responsible for civil control. Area A, presently 18% of the West Bank under full PA control, covered only the major cities of the West Bank and Gaza until the Wye Memorandum of 1998. Even after full PA control extended to many Palestinian villages (formerly Area B), Palestinian-ruled areas remain unlinked to one another and the PA does not have control over security, border crossing, water or major roads. The resulting effect has created several isolated Palestinian bantustans within an Israeli backdrop. The Post-Oslo Period After the euphoria of Oslo, the Post-Oslo period came as a sharp reality check for the Palestinian people. During this time, the Palestinian Authority was developing and people were adjusting to life under a semi-autonomous Palestinian government. However, many issues that were supposed to be resolved with Oslo and the formation of the Palestinian Authority have remained. Most importantly, the Palestinian people still lack an independent state and remain under Israeli occupation. Jerusalem, the capital of Palestine, remains cut off from the other Palestinian Territories while Israel continues its policy of Judaizing the city through revoking Palestinians' identity cards, demolishing houses, erecting and expanding settlements, and placing government structures in the illegally annexed sections of East Jerusalem. Settlement building activity, one of the greatest confounding factors to a lasting and just peace, increased tremendously during this time. Since the signing of the Oslo Accords in 1993, 52 new "outposts" have been established in the West Bank alone. Thus settlements have increased by sixty percent in both size and population since Oslo. Settlements, which are illegal under international law, significantly alter the map of the area, and permanently affect the composition of the future state of Palestine. Palestinian lands are confiscated for the settlements themselves and for the intricate network of by-pass roads connecting the settlements throughout the West Bank and Gaza. Palestinian residents are not allowed to use these roads, which frequently bisect Palestinian areas, in effect segmenting the West Bank and Gaza Strip into small, isolated bantustans. On the ground, this makes medical coordination between these areas increasingly difficult. Separation between the West Bank, Gaza Strip, and Jerusalem continued to be a major problem as well. While this frustrates policy coordination, it also poses health problems as access to the specialized services within Jerusalem remains cut off to many people, particularly during periods of closure. The Post-Oslo period was a difficult time as Palestinians tried to build a state like no other in the world, one in which they had control over only 18% of their land in isolated, non-territorially contiguous bantustans with no control over borders, security or water. The issue of water is particularly sensitive, as it is a 'final status topic,' which means that until final negotiations are settled, Israel maintains absolute control over the water resources in the West Bank, including in Area "A." Israel continued to stall on promised accords such as troop withdrawals, and settlements expanded unabated, altering the landscape of Palestine. Full military occupation continued in the majority of Palestinian lands, and land confiscations, house demolitions, systematic violence and other punishment measures such as closures and curfews continued and worsened. The population also became poorer as the GDP decreased by about one-third from 1993 - 2000. The Palestinian people became quickly disillusioned and began to despair of ever achieving a just solution to their situation through the Oslo Accords. The Intifada for Independence The current crisis has once again created a situation in which many people are blocked from receiving health services. Thirty-four years of military occupation and seven years of an ineffectual peace process, topped by the provocative visit of former defense minister Ariel Sharon to the Haram Al-Sharif in Jerusalem triggered the Intifada in late September 2000. Sharon, who was responsible for massacres of Palestinians in Lebanon, arrived at the Muslim sanctuary with 1,500 heavily armed Israeli security forces. The next day, these forces responded to Palestinian protests against Sharon's visit with excessive force, firing tear gas, rubber-coated metal bullets and live ammunition at worshipers and protestors. Around 200 civilians were injured and six killed. Demonstrations and clashes erupted throughout the West Bank and Gaza Strip in direct response to the killings in Jerusalem, and Palestine entered into a state of emergency as Israeli aggression against civilians intensified. The Israeli army continues to escalate its deadly use of force, attacking men, women and children with tear gas, rubber-coated metal bullets, explosive high-velocity ammunition, anti-tank missiles, tank shells and attacks from helicopter gunships and F-16s. Israel's policies during the Intifada have led to devastation and disruption in all areas of Palestinian life. From 29 September 2000 until 22 April 2002, 1,482 Palestinians were killed, and more than 20,000 injured. Approximately 2,000 of those injured will be left permanently disabled-500 of whom are children according to an analysis by the Ministry of Health. In conjunction with its excessive use of force against civilian demonstrators, the Israeli government has systematically destroyed houses, industrial plants and orchards. Furthermore, it has imposed various collective punishment measures that have served to choke the physical, mental, political, economic and social life of Palestine. The Israeli government has imposed arbitrary curfews preventing Palestinians from leaving their homes. It has also imposed a strict internal and external border closure, which has severely restricted mobility between the West Bank and the Gaza Strip and between the cities and villages throughout the Occupied Territories. Palestine is now effectively made up of 220 discontinuous geographical entities. Israeli closure policies have led to an unemployment rate reaching 48%, and an estimated 50% of households lost more than half of their usual income since the beginning of the Intifada. By April 2001, more than two-thirds of Palestinians in the West Bank and Gaza were living below the poverty line, subsisting on less than $2 a day. [1] Many families have become unable to afford their basic living needs including food supplies, medication and other health care needs. The current Intifada has resulted in serious economic hardship that will have severe long-term effects, especially for the most marginalized groups including women, children, the elderly and the handicapped. Palestinians in the West Bank and Gaza Strip have suffered from numerous direct and indirect health consequences of the Israeli attacks and collective punishment measures. Obviously the direct health difficulties Palestinians face include the deaths and injuries that occur on a daily basis from Israeli aggression. However, Israel's policies of collective punishment also have severe health consequences. Closures prevent Palestinians from accessing primary health services, and approximately 70% of the population is cut off from hospital care for weeks and months on end. Closures also prevent medical staff from reaching clinics, especially those located in the isolated, rural areas which are most affected by the closures. Sometimes doctors and community health workers cannot pass through particular Israeli military checkpoints for days or weeks, even when they show identification that clearly marks them as medical personnel. Ambulances are also often denied passage. 1. Impact of the Israeli Measures on the Economic Conditions of Palestinian Households." Palestinian Central Bureau of Statistics. April, 2001.