The security establishment is worried about the collapse of Gaza’s health system because this will make it more difficult for the Israel Defense Forces to pursue a major military operation there in the event the political leadership orders one. That’s what Yaniv Kubovich wrote last week in his report on a recent security cabinet discussion on the matter. In other words, the very poor performance of the Palestinian health system is one of the things that must be taken into account when deciding whether to attack the besieged Palestinian enclave yet again.
We can learn two other things directly from the report: 1. Most of the casualties in the expected confrontation will be civilians (as was the case in the previous operations, incidentally) who will not be rescued from the combat zones in a timely manner or receive proper medical treatment and 2. The international community (presumably meaning Western countries) will have a hard time supporting another Israeli operation because of the inability to save wounded civilians.
What one can learn between the lines is that both the security and political establishments deny any responsibility of their own for the situation in Gaza in general and that of the Palestinian health system in particular. On the contrary, a political source even said the Palestinian Authority wants Gaza’s health system to collapse.
Indeed, one cannot minimize the serious consequences of the destructive, irresponsible and sectarian competition between Hamas and Fatah. But Israel’s total denial of responsibility for the situation and the connection between Gaza’s economic deterioration and Israel’s closure and isolation of the Strip since 1991 reinforces the suspicion that despite all their updated and precise information, the politicians and military leaders aren’t prepared to change a basic facet of their policy, which views Gaza as a separate entity and autarkic economy.
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The deterioration of Gaza’s health services is also linked to United Nations Relief and Works Agency’s distress after the United States stopped funding it. Ironically it was a years-long political campaign against UNRWA by senior Israeli officials that spoke to the heart of U.S. President Donald Trump’s administration.
Another financial blow is expected soon, and it will directly or indirectly harm the Palestinian health system: Israel has decided to deduct the value of the allowances given to the families of the Palestinian prisoners from the duties it collects at its ports and transfers to the Palestinian Finance Ministry. These tariffs are the lion’s share of the PA’s revenues, and cutting them will harm essential services. PA President Mahmoud Abbas has already blamed the PA’s budget deficit for the cuts he ordered in salaries and allowances for the Gaza residents. The deduction of hundreds of thousands of additional shekels from customs duties will be a reason to cut medical services in Gaza.
Kubovich’s report mentions the 6,000 people wounded by Israeli gunfire who are waiting for urgent operations. As early as last April, Haaretz reported that Palestinian and international medical officials were shocked by the number and severity of the wounds inflicted on the unarmed demonstrators. Information and warnings about the seriousness of the situation were never lacking and were accessible to all. Doctors Without Borders, the World Health Organization, the London-based Medical Aid for Palestinians (MAP), the Tel Aviv-based Physicians for Human Rights (PHR-Israel), and Gisha – the Legal Center for Freedom of Movement, are only some of the organizations that issued regular, worrisome reports, which surely arrived in real time on the desks of the Coordinator of Government Activities in the Territories and the Shin Bet security service.
The decision to use live ammunition rather than non-lethal means to disperse the unarmed demonstrators was the army’s. The soldiers’ orders to shoot masses of demonstrators in the legs at close range, which caused very serious wounds and even disability, came from their commanders.
“Our medical teams note the injuries include an extreme level of destruction to bones and soft tissue, and large exit wounds that can be the size of a fist,” said an April 2018 report by Doctors Without Borders (one of the Dan David Prize winners this year). “These patients will need to have very complex surgical operations and most of them will have disabilities for life.”
But the soldiers continued to wound the unarmed demonstrators this way, even after the reports were published, and after it was explicitly reported that Gaza hospitals were unable to properly treat all the wounded, whose initial treatment came at the expense of ordinary patients, that they were being released prematurely, and that due to a lack of the necessary drugs they were developing infections and gangrene.
It might have been possible to save the legs of some of the wounded – and the lives of other wounded – if they had been allowed to seek treatment outside Gaza, in places where there is no shortage of drugs, anesthetics, needles and electricity. But a political order not to allow them to leave, coupled with a very cumbersome permit mechanism also sabotaged this avenue, which would also have relieved the pressure on Gaza’s operating rooms. Often the delays in granting exit permits for treatment lead to deterioration in the patients’ conditions, putting further stress on Gaza’s health system.
The security establishment (meaning the District Coordinating Office, which is subordinate to the Coordinator of Government Activities in the Territories) and the Shin Bet security service are responsible for the complex procedure for examining requests for exit permits from Gaza, including permits to obtain medical treatment. According to the WHO, in 2018, 25,897 requests were submitted to go through the Erez crossing to seek medical treatment in the West Bank or Israel. Each applicant got a guarantee from the PA that their medical expenses would be covered. But the DCO and the Shin Bet approved only 61 percent of the requests in a timely fashion. Some 31 percent got no response or were addressed too late for the applicants to make their scheduled medical appointments. Eight percent of the requests were refused.
Just 12 days ago, the High Court of Justice heard a petition by Gisha, PHR-Israel and HaMoked: Center for the Defense of the Individual, demanding that the state amend a procedure from 2017 that sets longer than ever deadlines for responding to exit requests, including requests to seek medical treatment. This procedure, which the organizations call draconian, doubled and tripled the length of time the Israeli authorities could take to process permit requests. Now the authorities can take up to 70 working days to respond (positively or negatively) to requests to leave Gaza for higher education abroad, medical training or commerce in the West Bank; 50 working days to handle requests to visit a sick parent or child, and up to 23 working days (i.e., a month) to respond to a request to seek medical treatment, regardless of the date of the person’s medical appointment. The procedure thus allows security officials to ignore appointments for critical medical treatments or events taking place on specific dates, and to prevent visits to ill relatives.
But Justices Menahem Mazuz, Ofer Grosskopf and Alex Stein refused to hold a hearing on the injustice in principle caused by the long processing times the procedure allows, and demanded a petition dealing with specific cases. “For medical cases, up to 23 days is reasonable,” Stein said, while Mazuz added, “I find it difficult to see how one can be persuaded that 50 or 70 days [for handling a request] is illegal.”
Another petition is pending, filed by PHR-Israel and the Gaza human rights organization Al-Mezan, against the relatively new rule that forbids exit permits to people with relatives in the West Bank.
Due to the growing economic and psychological distress in Gaza, an increasing number of Gaza residents who managed to obtain a permit to visit the West Bank for a few days have simply remained there. They often find work there and send help to their families in Gaza. The security establishment and the political echelon regard them as “illegal aliens,” even though the Oslo Accords stipulate that the Gaza Strip and the West Bank are a single territorial unit.
Over the past two years, the defense establishment has made leaving Gaza for medical treatment conditional on the return to the Strip of relatives who remained in the West Bank. In other words, the defense establishment, which is concerned about the collapse of the Palestinian health system, is making it even more difficult for that health system by forcing it to treat patients with resources it doesn’t have, and forcing its doctors to watch their patients deteriorate because they cannot help them.
“For a long time we’ve been warning that the health services in Gaza are collapsing and it’s clear to all that Gaza could not withstand another war,” PHR-Israel says. “And yet, when we demand that patients be allowed to leave, we are in many cases told that the request is not approved because treatment is available in the hospitals there. Now the defense establishment is finally acknowledging reality.”
Over this past weekend, six volunteer doctors from PHR-Israel performed some 30 complex operations in Gaza hospitals suffering from shortages. These Palestinian doctors are Israeli citizens who hold senior positions at Rambam, Hasharon, Hacarmel and Shaare Zedek medical centers. Three other volunteers from PHR-Israel – a family doctor, a pediatrician and a psychologist – treated hundreds of other patients.
For the past 11 years, volunteers from the organization have been entering the Strip once a month and spending a few days operating and treating patients round the clock. On every visit they bring medical equipment, the tools they need to perform surgery, prostheses for gunshot victims, insulin for diabetics, Clexane for blood thinning and other costly drugs for many patients. This time the group brought around $90,000 worth of drugs and equipment, most of which was donated by Palestinian civil society groups in Israel.
“More than the patients talk about their physical condition, they speak about the psychological and economic difficulty of living as prisoners in the closed Strip,” the delegation coordinator, Salah Haj Yihye, told Haaretz. “The doctors in Gaza are good,” he said, “but they do not have permits to leave the Strip for advanced training, they do not have the necessary equipment, the electricity supply is spotty, and they get only a partial salary. There are doctors who don’t have the money to get to work. They have pressure unlike the pressure in any hospital in the world.” That’s why Gaza needs this help, even though the help is only a drop in the bucket for Gaza’s poverty-stricken society.
The Gaza health system’s financial difficulties cannot be disconnected from the Strip’s poverty, and its poverty cannot be disconnected from its main cause; the denial of freedom of movement to Gaza’s residents. This has led production in Gaza to drop to a minimum. This policy began before Hamas seized power in the Strip, and intensified after the 2005 disengagement, when thousands of laborers were no longer permitted to work in Israel. The rehabilitation of Gaza’s health system will not be possible unless freedom of movement and the ability to earn a decent living are restored to its residents.