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Right to Health Case Study:
Gaza, Israel and the Right to Health
Statistics and Facts on Health in Gaza
Medical Case Studies
Case Study Series No. 001, Created: July, 2008, Canadians for Justice and Peace in the Middle East
“As an occupying power, Israel has an obligation to ensure the right to health of the population of Gaza, without discrimination.” 1
Gaza, Israel and the Right to Health
What is the Human Right to Health?
According to the Universal Declaration of Human Rights, everyone has the right to a standard of living adequate for the health of himself and his family, including food, clothing, housing, medical care and necessary social services. 2
Who should fulfill this right in Gaza?
Under the Fourth Geneva Convention, as the occupying power, Israel is obligated to protect the rights of Palestinian civilians to health care, education, freedom of movement and the ability to lead normal lives. 3
What is the situation in Gaza?
Since the democratic election of the political party, Hamas, in Gaza in January 2006 and its subsequent takeover of the region in June 2007, Israel has placed a stranglehold on the daily lives of the 1.5 million people living there through an economic blockade and by closing all borders to Gaza. The stark deterioration in quality of life in this area is evident in all facets of basic living, but is perhaps most striking when evaluated in the context of health. The right to health can be analyzed in terms of the right to the basic necessities to be healthy, and the right to appropriate care when necessary; both sides of the story are equally shocking.1
The Right to the Basic Necessities to be Healthy
80% of the population of Gaza (over 1.1 million people) are now dependent on food aid, compared to 63% in 2006. 1 A survey by the World Food Program, FAO and UNRWA found Gazan parents are eating less so they can feed more to their children. 6
Between 25-30% of the population of Gaza no longer has running water.1 Those who can afford it are buying water from private companies.4
30-40 million litres of sewage is dumped in the sea everyday because of the lack of fuel to pump or treat human waste.1
Between June 2007 and September 2007, the mean household income dropped by 22%.1 Due to the border closure, 75% of Gazan factories have shut down.9 75,000 out of 110,000 workers formerly in the private sector are now unemployed.1
In June 2005, there were 3,900 factories employing 35,000 people. As of December 2007, there were only 195 factories employing 1,700 people.1 In September 2000, 24,000 Palestinians crossed out of Gaza to work in Israel, today that number is zero.1 In June 2007, 748 truckloads of exports left Gaza daily, in July 2007, there were none. 1
In May 2008, shortages and power cuts averaged three hours per day.6 The main power plant in Gaza is currently operating on diesel given by the EU as aid.1 The Israeli government is putting limits on how much can be supplied.1 The import of spare parts for repair of the electricity and water service infrastructure is prohibited by the Israeli government. 1
The above is an example of Collective Punishment.
A coalition of UK based organizations states that, “The blockade has effectively dismantled the economy and impoverished the population of Gaza. Israel’s policy affects the civilian population of Gaza indiscriminately and constitutes a collective punishment against ordinary men, women and children. The measures taken are illegal under international humanitarian law.” 1
According to 4th Geneva Convention, Article 33 - No protected person may be punished for an offence he or she has not personally committed. Collective penalties and likewise all measures of intimidation or of terrorism are prohibited.
The Right to Appropriate Care when Necessary
Medications and Equipment
There are no first line pediatric antibiotics available in the Ministry of Health. 4
The majority of diagnostic laboratory equipment of the Ministry is not functioning. 4
19% of the necessary medicines and 31% of vital medical equipment were lacking as of January 2008 according to the WHO. 5
Staff and Basic Operations
Hospitals experience power cuts 8-12 hours a day due to fuel and electricity restrictions.1
Emergency generators are used everyday for which fuel is a struggle to obtain. 6
Food is no longer delivered to patients in hospitals. 4
10% of nurses, doctors and other staff are unable to get to work due to lack of transport.8
In some hospitals, up to 40 percent of staff are absent. 7
Access to Appropriate Care
In late February 2008, 23 of the Ministry’s 56 ambulances and seven of the 40 Red Crescent ambulances ceased operation because of shortage of fuel. 5 The Palestine Red Crescent ambulances face restrictions, and the medical personnel are continually verbally and physically abused by Israeli soldiers. 11
June 2007: Rafah crossing to Egypt closed, no longer accessible to the 400-500 patients/month.
After June 2007: Number of requests to exit through Erez (into Israel) doubled. 12
According to the World Health Organisation, the proportion of patients given permits to exit Gaza for medical care decreased from 89.3% in January 2007 to 64.3% in December 2007. Even those given permits, were often denied at the crossing. 1
June 2007: Only patients considered in “life-threatening condition” could exit Gaza. This did not include those with impending loss of sight or limbs.12
September 2007: Even life threatening cases could be denied. 12
January 2008: Israel’s High Court of Justice declared that the occupation had ended so Israel had little responsibility for the residents.12
Case Studies – WHO Report of Five Patients who Died Waiting in Gaza2
In May 2005, 34-year-old Mona Nofal was found to have rectal cancer. There were no appropriate facilities to perform the surgery in Gaza, so Mona jumped the appropriate hoops to have a surgery scheduled in October in Egypt. Unfortunately, at the last second, due to the delay in surgery, it was found to have spread to her kidneys and abdomen, requiring chemotherapy and radiation first. In November, her surgery was finally performed, and in January 2006, Mona returned home to Gaza only to find that one of the three main chemo drugs needed was not available. She chose to just take the two. Between August 2006- January 2007, Mona goes back and forth and receives five cycles of chemotherapy. In June 2007, the Rafah border to Egypt was closed. Mona was due to return for another run of chemotherapy, but was not allowed to cross, and had to apply for a permit to go to Israel. She arrived in Israel on July 25, after having gone 2 and a half months without treatment due to various roadblocks. At this stage, Mona was found to have a recurrence with spread to the liver and lung. She was discharged in August with an appointment for two weeks. The day after discharge, she re-applied for a permit to make her next appointment, but her request was kept under processing for a month. She was, in the mean time, hospitalized multiple times in Gaza. Mona managed to get a permit and appointment for September 10, was hospitalized in Israel for 10 days, and given the second dose of chemotherapy delayed by a month. She was told to return in 2 weeks, and was able to get another permit by October 10th. Applying for her fourth treatment cycle in early November, the Israelis were refusing to coordinate with the new Palestinian health coordinator and Mona, therefore, missed an appointment, was now permanently hospitalized in Gaza, reapplied when they were accepting on November 13th. Since her appointment was for November 10th, her permit was denied. She reapplied again, her fourth cycle of treatment now having been delayed 2 weeks. 34-year-old Mona Nofal died waiting on November 24th, 2007, leaving behind a husband and seven children.
Amir El Yazji
Amir El Yazji was a nine-year-old boy, who woke up feeling sick on November 5th, 2007. He was diagnosed as having meningoencephalitis and was given antibiotics which did not work in Gaza’s pediatric hospital. He deteriorated over the next 5-6 days, and needed a CT scan, but the CT scanner was out of order due to the blockade on parts needed for repair. On November 10th, the CT scanner was fixed, but now, the doctors at Gaza felt he should be transferred to Israel for more appropriate care. On November 14th, Amir’s father put in the papers to the Referral Abroad Department who then tried to contact the health coordinator for an urgent permit. Due to shuffling of coordinators and Israel’s refusal to work with certain people, Amir’s father went through three different coordinators to present his son’s case. He then, along with the health coordinator, over the next few days, made hundreds of phone calls and sent faxes, with no response from the Israeli side. By this point, Amir was unconscious in the ICU in Gaza. Finally on November 18th, the permit was approved and Amir was to arrive in a Palestinian ambulance and be transferred to an Israeli ambulance at the border. Five different potential medical teams to accompany Amir were rejected, although they had all delivered patients before. Finally, a team passed the security check. Unfortunately, by this time, it was close to 5:00pm when the Erez border closed, and the border police, though contacted, refused to extend the border by an hour for this special case. The next morning, November 19th, 2007, Amir’s father arrived at 7:30am to the health coordinator’s office to call the Israeli side, but before he could make this call, he was informed at 7:45am that his son had died.
Fatima Abdel Al
Fatima Abdel Al, 66 years old, mother of nine, fractured her hip on September 24th, 2007. She was told that there was only one hospital in all of Gaza that had the bone cement needed to do this operation. The health workers unfortunately had gone on strike and so only life-threatening cases were being accepted, which did not include her. Fatima received an appointment for October 7th, but arriving that day at Nasser Hospital, found the bone cement had run out just a few days prior. The surgery was performed without the cement, and Fatima was sent home. On October 14th, Fatima was readmitted as her wound seemed infected, and did not respond to treatment. Two weeks later, Fatima was significantly worse, and was referred for urgent care outside of Gaza. The earliest referral date to Jerusalem was November 7th, and the permit was approved on November 6th. On that day, having prepared at 6am to leave in the ambulance, Fatima and her family awaited the first phone call from the crossing which arrived to them at 10am. At this time, information regarding the nurse accompanying Fatima was extracted. There was no return phone call that day, so the permit to cross expired. Restarting the process the next day, it was found that the next date available in the hospital was now November 24th. All other Israeli hospitals said they had “no vacancy.” Applying for the new permit, they were now told that they were applying too early, and must wait until a few days before the required date. Between November 7th and 10th, Fatima fought for her life, and passed away on November 11th due to uncontrolled septicemia.
Bassam Hararah, 36 years old, felt flu like symptoms on March 2nd, 2007. Investigations found that he was in the end stages of kidney failure and was prescribed hemodialysis for his kidneys. Two weeks later, Bassam decided he wanted to pay for care in Egypt and for a second opinion. He found no difference in the diagnosis there, and was told to prepare for transplant. Bassam was scheduled for the transplant in June in Egypt. Due to the takeover of Gaza in June by Hamas, and the subsequent closure of the Rafah crossing to Egypt, Bassam could not cross and had to start applying to go to Israel. Due to the constant restructuring of the permit system, Bassam’s brother had to restart the application five times, By early September, Bassam managed to get approval from the Palestinian Referral Abroad Department but was denied by Israel for “security reasons”. The family was informed that they must wait a month before they could reapply. In the meantime, Bassam’s condition was deteriorating, but after a month, they reapplied and were rejected once more. Bassam deteriorated and was permanently in need of medications that were not available in Gaza. On November 3rd, Bassam died. He left behind a wife and six children, ranging from 4 months to 8 years old. His family could not find cement to cover his grave, as there was none in Gaza.
Mahmoud Abu Taha
Mahmoud Abu Taha, 22 years old, started having abdominal pains in September 2007. He was told he had a parasite, but a few days later, got significantly worse. Mahmoud got an urgent surgery in Nasser hospital in Gaza and was told he had abdominal cancer. He therefore had to be referred to Israel for further treatment, and so Mahmoud’s family started the process. It took the Referral Abroad Department four days, despite this being an urgent case, to issue a document. A few days later, on October 17th, the permit was received, and Mahmoud was to be transferred. They reached the crossing and were told that Mahmoud’s 65 year old father, Kamal, must walk across while Mahmoud goes through in the ambulance. When the ambulance reached the other side, they were turned away and sent back to Gaza. The reapplication was restarted, and the next day, October 18th, the health coordinator applied for an urgent permit and was told that Mahmoud’s uncle was not allowed in Israel. His cousin then applied, who was also rejected. On October 20th, the nurse meant to accompany Mahmoud was rejected. On October 22nd, the ambulance driver was rejected. In the meantime, Mahmoud’s cancer had spread all over his intestines. On October 28th, Mahmoud was finally approved to pass. Within an hour, Mahmoud was at the crossing and transferred to an Israeli ambulance. Mahmoud’s family awaited his arrival at the Israeli hospital but never found him. On October 29th, Mahmoud passed away and his body was brought back to Gaza two days later.
When Kamal (Mahmoud’s father) had walked across the checkpoint, he arrived thinking his son had safely made it to Israel. He was then made to completely undress and taken to an interrogation area where he was accused of planning a terrorist attack in Israel. Six hours later, Kamal was transferred to Ashkelon prison where he spent the night in solitary confinement. He was taken to court, and stayed in captivity for 10 more days. After the tenth day, on October 29th, Kamal was brought into the interrogation room and told his son had died, so he could leave.
Other WHO health data on Gaza
The WHO reported that from October 1st, 2007 to March 2nd, 2008, i.e. 5 months, 32 patients died due to inability to access their right to health.
In April, 2008, UNICEF shows that 50% of kids under five have anaemia, many kids stunted, and lack Vitamin A, Vitamin D and iodine. 10
Almost 80% of children failed Grade 4-9 in September 2007. 1
Studies how that up to 40% of kids suffer from anxiety and 34% from anxiety. Other symptoms seen include hyperactivity, lack of motivation, depression and bedwetting. 4
One patient with kidney failure died in August 2007 after a medical item (Subclavian catheter G # 20) that is needed for kidney dialysis was not available.4
A 21 year-old leukemia patient died after the drug Cisplatinum was no longer available in the MoH, and after denial of a permit to cross Erez for treatment in Israel. 4
In May 2008, a group called “Physicians for Human Rights-Israel” submitted a petition to the Israel High Court of Justice on behalf of thirteen patients with life threatening conditions who had been denied permits. Several of these patients had traveled to Israel before for treatments and therefore had no reason to be suspicious. The 13 patients range in age from a 27 year old with breast cancer to a 67 year old who needs cardiac surgery. 13
Why Not Just Provide More Humanitarian Aid?
Doctors Without Borders/Médecins Sans Frontières’ (MSF) finds its medical activities in the Gaza Strip are being seriously hindered by the lack of fuel.7 The UN Relief and Works Agency for Palestinian refugees has had to interrupt delivery on two occasions due to lack of fuel.9 The International Committee of the Red Cross states that solving the problems is far beyond the ability of humanitarian organizations.8
Over 1 million dollars worth of UNICEF supplies including pumps/accessories for water/sewage treatment, computers, photocopiers for schools were barred.10 Due to the tightening of the blockade, the previous 250 trucks of aid entering Gaza with supplies daily has been whittled down to 45 trucks a day, if that. The Christian Aid’s director stated that humanitarian aid can help stave off total collapse but it will not provide a long-term solution. 1
The United Nations has launched the largest-ever humanitarian appeal, at $462 million for 2008 for the Palestinians. This is the third largest request after Sudan and Congo. International governments have also pledged an unprecedented US$7 billion for the Palestinians over the next three years.1
What do the experts believe is the solution?
Human Rights Watch:
“This [economic] blockade is one of the primary factors behind the dire humanitarian situation in Gaza at present.” 9
Medecins Sans Frontieres:
“Since 2006, MSF has denounced the health and economic effects of this embargo. On several occasions, MSF has expressed its concern regarding the repercussions of this blockade on a population that is already severely affected by years of conflict.” 7
International Committee of the Red Cross:
“The ICRC has already called for political solutions to the ongoing conflict on a number of occasions.” “The ICRC has urged and continues to urge Israel to respect the rules of international humanitarian law. Under international humanitarian law, Israel is responsible for meeting the basic needs of the population, which include food, medical supplies and means of shelter.” 8
Head of the United Nations Relief and Works Agency, Karen Koning Abu Zayd“Gaza is on the threshold of becoming the first territory to be intentionally reduced to a state of abject destitution, with the knowledge, acquiescence and – some would say – encouragement of the international community.” 1
Oxfam UK, Amnesty International, CARE International UK, Christian Aid, Medecins du Monde UK, Save the Children UK and Trocaire:
“The blockade has effectively dismantled the economy and impoverished the population of Gaza. Israel’s policy affects the civilian population of Gaza indiscriminately and constitutes a collective punishment against ordinary men, women and children. The measures taken are illegal under international humanitarian law.” 1
“The situation for 1.5 million Palestinians in the Gaza Strip is worse now than it has ever been since the start of the Israeli military occupation in 1967. The current situation in Gaza is man-made, completely avoidable and, with the necessary political will, can also be reversed.” 1Amnesty International UK Director, Kate Allen"Punishing the entire Gazan population by denying them (these) basic human rights is utterly indefensible. The current situation is man-made and must be reversed." 1
In January 2008, the British government stated that it did not support Israel’s closure of all crossings into Gaza as it prevented the delivery of vital supplies. In February 2008, the government also said that cutting electricity supplies to Gaza risks further deterioration in the humanitarian situation in Gaza without improving the security situation. 1
So what is the Canadian government doing?
People of all political views and backgrounds can agree that health is a human right. This right is
decreed by various instruments of international law and cannot be denied to a civilian population. The situation in Gaza is dire in terms of health access and outcomes, and the recent drastic decline to health access is a direct result of Israel’s blockade. As the occupying power, Israel has the responsibility to ensure the health and well-being of Gaza’s civilian population. Canadians and the Canadian government should join the chorus of human rights organizations calling for this man-made crisis to be brought to an end.
1 “The Gaza Strip: A Humanitarian Implosion” Joint Report: Amnesty International, CARE International UK, CAFOD, Christian Aid, Médecins du Monde UK, Oxfam UK, Save The Children UK and Trócaire, March 2008. See also CJPME’s Factsheet # 41 “Israel’s ongoing status as a military occupant of Gaza.”
2 “Access to Health Services for Palestinian People”, WHO Report, April 2008
3 “Joint Letter to President Bush on the Situation in Gaza”, Human Rights Watch, Gisha, Physicians for Human Rights – Israel, May 2008
4 “Gaza Strip Humanitarian Fact Sheet”. UN Office for the Coordination of Humanitarian Affairs, UNICEF, FAO,
United Nations Relief and Works Agency, WFP, WHO. November 2007
5 “The Gaza Strip - Grave dearth of medical supplies and lifesaving treatments”, B’Tselem: The Israeli Information Centre for Human Rights, May 2008
6 “Gaza Strip Inter-Agency Humanitarian Fact Sheet”, UN Office for Coordination of Humanitarian Affairs, June 2008
7 “Fuel Crisis in Gaza: MSF Is Forced To Scale Back Its Medical Activities”, Medecins Sans Frontieres, April 2008
8 “Gaza is Running Out of Fuel”, International Committee of the Red Cross, April 2008
9 “Israel/Occupied Palestinian Territories (OPT) Events of 2007”, Human Rights Watch, World Report 2008
10 “OPT Humanitarian Action Update” UNICEF April 2008
11 “Violation Report against PRCS Medical Teams”, Palestine Red Crescent, April 2008.
12 “Gaza: Access of Patients to Medical Care”, Physicians for Human Rights – Israel. April 2008.
13 “The Struggle for Patients’ Access Continues”, Physicians for Human Rights – Israel. May 2008.
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rks Agency, Karen Koning Abu Zayd“Gaza is on the threshold of becoming the first territory to be intentionally reduced to a state of abject destitution, with the knowledge, acquiescence and – some would say – encouragement of the international community.” 1
decreed by various instruments of international law and cannot be denied to a civilian population. The situation in Gaza is