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The small village Umm a-Rihan, home to some 360 residents, has found itself part of the same fenced off enclave that features the main "district city," Bartaa Sharkiyya, whose population is 3,500. The Palestinian Authority Health Ministry clinic at Bartaa can serve residents of Umm a-Rihan; but there is no paved road between these two localities.

Before the fence's construction, whenever residents from Umm a-Rihan needed urgent medical care, or wanted to consult a doctor, they went to a different clinic, north of their village, which can be reached via a paved road. The fence now obstructs access to this second clinic; and so residents from Umm a-Rihan travel on difficult dirt roads to get to Bartaa.

For pregnant women, the infirm elderly, those injured in accidents, and other patients this route is hardly a sound option, in medical terms; but it also happens to be the only way to go. On the other hand, the fence now separates residents of villages like Dhaher al Aabed and Akkab from the Bartaa clinic; before the wall's construction, they received medical care at the Bartaa facility.

The Bartaa clinic is open 8 A.M. to 2:30 P.M. A nurse from the village, and a doctor who comes from a different enclave created by the fence in the Tul Karm region, staff the clinic. The doctor must negotiate with Israeli soldiers at the northeast gate of his village, Nazlat Issa; then he has to travel across a road filled with temporary army roadblocks; finally, he must negotiate with another group of soldiers to get through a gate and enter the Bartaa enclave. It is impossible to gage precisely the extent to which the delays, and the frustration and anger which accumulate after the daily travel ordeal, influence his work.

All told, some 4,700 people live in the Bartaa area. The government clinic (the only one of its kind in the region) has a pharmacy and also offers counseling on health awareness. But medical specialists do not come to the clinic; it does not offer laboratory tests; nor does it offer family planning. Patients who are referred to advanced medical tests or treatment routines must cross through the separation fence barrier, and head east, to Jenin or Tul Karm. When care-seekers do make it through, it is only after interminable, nerve-racking delays. What holds true for villages within the Bartaa enclave, or those adjacent to it, is also true for residents of other enclaves that have been created, or which are to be created, by the construction of the separation fence.

The Health, Development, Information, and Policy Institute (HDIP), a non-governmental body, reviewed the present and future implications of the separation fence, in terms of health and access to medical services. The institute published the review's finding's last week. Summarizing these conclusions, HDIP director Mustafa Barghouti said that the "Apartheid Wall" (in his words) has destroyed the "normal coherence" of the Palestinian health system. This system was developed according to models devised by the World Health Organization: medical centers which provide basic care are distributed around a number of localities, and they are supported by a carefully planned referral system - patients are referred to larger clinics, which provide specialist medical services, and also to hospitals.

Most of the local clinics are government-run; some are operated by the UN Relief and Works Agency; others are run by non-government health networks.

Badly disrupted

This referral system has run aground. It has been badly disrupted by checkpoints and barriers set up by the Israel Defense Forces during the past three years on the West Bank; these roadblocks sever local Palestinian communities from large West Bank cities. According to data compiled in December 2003 by OCHA, the UN's Office for the Coordination of Humanitarian Affairs, there have been 734 roadblocks of various types - 63 manned checkpoints, 456 ditches which obstruct the passage of vehicles, and also concrete walls and other encumbrances. Now, the preexisting damage done to the Palestinian health system has been aggravated by the establishment of the separation fence.

At the conclusion of the fence's first stage of construction, 26 clinics found themselves fenced off, in enclaves. Local residents, who are now cut-off from large medical centers that provide specialized care, find themselves more dependent on the local clinics. Conversely, this dependence on the local facilities accentuates the absence of expert physicians and specialized medical services. When construction of the fence is completed, the number of these isolated clinics will reach 71, the HDIP figures show. The problem will triple in scope.

Most of these local clinics lack laboratories. While most have pharmacies, these are generally open only in the morning. Not all of the clinics immunize small children. Many of the small localities in which the clinics are located are not connected to the electricity network. Electricity is supplied to such villages by generators; the generators do not run all day long. On occasion, fuel to run the generators doesn't make it to a clinic, owing to roadblocks and the fence. So the clinics cannot store serums used in immunization. The roadblocks and closed gates in the fence frequently prevent the timely immunization of infants. Clinics in northern areas of the West Bank are not equipped to deal with diabetes patients; and pediatricians, gynecologists and other specialists are nowhere to be found in the Qalqilyah region. South of Ramallah and in East Jerusalem, the separation fence will impede the access of 17,510 handicapped persons to specialized care, the HDIP report shows.

Field workers from the UN Relief and Works Agency report that due to obstructed access to maternity wards in hospitals in Jenin and Nablus, there has been in Bartaa (much to local women's chagrin) a trend of renewed reliance on midwives; there is no prospect of expert medical care being given in times of emergency to pregnant women, or to other types of patients. In most of the isolated clinics, the HDIP report shows, there are no family planning services; nor are means of birth control distributed. In other words, the fence harms, and will continue to harm, efforts made by Palestinian social-health organizations to encourage men and women to think carefully about the number of children they want to have.

In a survey conducted among 890 households in October 2003 by the Palestinian Central Bureau of Statistics, respondents rated the main obstacles which impede their access to medical services. Some 41.6 percent of respondents (73.7 percent west of the fence; 38.6 percent east of it) cited the distance from large medical centers; 42.6 percent (76.4 percent west of the fence as opposed to 39.4 percent east of it) referred to problems faced by medical teams in their attempts to reach the clinics; and 59.6 percent (69.3 percent west; 58.8 percent east) alluded to their inability to pay for medical services.

Roadblock of fear

The establishment of hundreds of checkpoints and barriers on the West Bank has lengthened distances to local or major medical centers for all. The constant encounter with soldiers (who ride in jeeps, tanks or armored personnel carriers on roads) has created a new sort of roadblock - a roadblock of fear. The internal closure enforced by the IDF has impaired the earning power of communities at large, and of each family; it has became harder for individuals and families to meet the rising costs of journeys to medical centers, and of medical treatment. People neglect medical problems, and seek treatment only when their ailments worsen. These dynamics are more extreme in the cases of those who live near the separation fence - so conclude many medical workers, including members of the Medical Relief Committees, a network of clinics (some of them mobile) which operates round-the-clock on the West Bank and Gaza Strip; Dr. Mustafa Barghouti is one of the Committees' directors.

Barghouti proposes that local clinics in "fence localities" be upgraded, meaning that their existing medical equipment would be improved, their physical facilities would be renovated, their operating hours would be extended, etc. In Barghouti's proposal, more emphasis would be given to training of health professionals, so that they would be less dependent upon physicians.

Upgrading of isolated clinics is a logical, urgent matter, from both humanitarian and medical standpoints. Such upgrading would not be logical economically, however. The rapidly disintegrating Palestinian Authority cannot shoulder such an economic burden. In all likelihood, the costs will once again be transferred to donor nations; most have expressed verbal criticism of the separation fence, yet their opposition has not, to date, brought about any change in the fence's route. It is reasonable to assume that the donor nations, and the humanitarian organizations which operate within them, will feel a sense of responsibility, and grasp that there is a need to intervene so as to alleviate somewhat the health crisis caused by the fence. Indeed, the donor nations might act in accord with Dr. Barghouti's recommendations. Yet the sort of upgrading which is proposed represents a form of international and Palestinian accommodation to realities created by the fence - as if Israel builds the destructive fence, and the international and Palestinian communities try to do something to fix the damage.

Barghouti is aware of this trap. He is also a political activist: he has served as a leader of the People's Party (formerly the Communist Party), and today he helps lead the "National Initiative," a political-social mobilization of forces designed to create a third power element in Palestinian society, between the Palestinian Authority and Hamas. Presenting findings of the HDIP study last week to journalists and diplomats, he called on the international community to step up the struggle against the fence. But on a day when he met with delegates of the international community he was informed that the European Union, like the U.S., opposes the discussion of the fence at the International Court of Justice in the Hague.