A Wall in the Heart: Physicians for Human Rights Report

A Wall in the Heart

 

The Separation Barrier and its Impact on the Right to Health and on  Palestinian Hospitals in East Jerusalem

 

Written by Ibrahim Habib

Researched by Hadas Ziv and Ibrahim Habib

Edited by Hadas Ziv

English translation by Tamar Bash

Graphics and print by Gafrourei Dafdefet

Maps provided by OCHA, the United Nations Office for the Coordination of Humanitarian Affairs and by Health Inforum

Photographs:  Niv Kahlili and Ibrahim Habib

Thank you to our donors

A special thank you to Hagar Goren

ISBN

Contents

Forward, Dr. Omar M. Abdul Shafi

Introduction

The Separation Barrier in Jerusalem

            The City Gates: Checkpoints between the West Bank and Jerusalem

            The Barrier and the Law

The Barrier and the Right to Health:  Jerusalem as a Medical Center

            Palestinian Hospitals in East Jerusalem

            The Target Population

            Dying Slowly:  The Barrier's Impact on Hospitals in East Jerusalem

Suffocating Jerusalem: Summary

Appendices

Forward 

The detrimental effects of the separation barrier are countless whether they are social, economical, educational, political or otherwise, but they are most pronounced in the part engulfing East Jerusalem.  The Palestinian population of the West Bank is being systematically cut off from East Jerusalem and, by the same token, East Jerusalem is being deprived of its lifeline i.e. the continuous flow of people and merchandise through it.

Physicians for Human Rights (PHR), ever so diligent in pursuing human rights issues, have organized numerous activities to try and bring about public awareness of this atrocious measure being applied under the pretext of Israeli security.

In the following, professionally researched and compiled, report, PHR is concentrating on the impact of the separation barrier on the health sector in Jerusalem.  This aspect is not to be taken lightly since Jerusalem is not only the centre of Palestinian spiritual life, but also where the most advanced Palestinian medical facilities are located.  The adverse effects of the separation barrier, on the health sector, have just started to show in three main aspects.  The first is the faltering number of patients managing to reach East Jerusalem hospitals, since many patients have to wait for varying periods of time to be granted permits to enter Jerusalem and, many a time, alone without a companion.  The second is the difficulty in getting permits for Palestinian personnel (West Bank and Gaza residents) employed by East Jerusalem health care providers.  Those permits are sometimes given according to a certain quota that often doesn't fulfill the needs of those institutions, moreover, the permits are rendered void whenever a new closure is imposed and new permits have to be issued all over again.  The third is the financial suffocation of East Jerusalem hospitals by the lowered occupancy rates and the ensuing huge financial losses.  Depriving the hospitals of their West Bank and Gaza patients has caused them to fall under the mercy of the Israeli Kupot Holim (health care organizations) that are imposing harsh contracts on them knowing that the hospitals have no other alternative e.g. in Diagnosis Related Groups (DRG) it is normal for an Arab hospital to be paid 33% while a similar Israeli hospital is paid no less than 70 – 80% of the DRG.

This report is raising issues that need to be addressed if we are to avert the approaching calamity.

The separation barrier is doing both the Palestinians and Israeli's a great injustice for which the future generations will pay dearly. By preventing people from getting in contact and dealing with one another, the perception of the human potential on the other side ceases to exist, fueling, therefore, more hatred and violence.

Dr. Omar M. Abdul Shafi, FRCS Glasg.

Director of the Austrian-Arab Community Clinic, Old Sity-Jerusalem.

        

Introduction

This report addresses the impact of the separation barrier[1] being constructed in Jerusalem on Palestinian hospitals in East Jerusalem.  The report discusses how the barrier affects access to the city's hospitals by the Palestinian population in the Gaza Strip, the West Bank and communities adjacent to Jerusalem. It also addresses the difficulties experienced by these hospitals as a result of being cut off from the communities they serve.  Whether by intentional policy or as a by-product of separation, the barrier threatens these hospitals' continued existence.

Over the years, a status quo was maintained by which East Jerusalem enjoyed special standing, and its relationship with the rest of the Occupied Territories was preserved. More blatantly here than anywhere else in the West Bank, separation resembles surgery to disengage Siamese twins.  A large Palestinian population has been annexed de facto to the State of Israel and forcibly disconnected from its natural community in the West Bank.  Similarly, a broad community who depended upon Jerusalem as its economic and social center and for health care and educational services is no longer able to gain access to the city.

 

This report discusses the various populations that are affected by forced separation. While we focus on access to health care, we are aware that what we describe in this realm is true for other aspects of life as well. In the first part of the report we briefly survey the barrier and its legal status. We then address the various groups of people whom it impacts, each on a different scale. We demonstrate how the barrier cuts off Jerusalem residents who have residency status in Israel from the city and from their kupat holim (health maintenance organization, or HMO) facilities, and how Israel shirks its responsibilities toward them. We also show how Palestinian spouses in "mixed" families (one spouse Palestinian, one spouse Palestinian with Israeli residency/citizenship status) become prisoners in their homes, unable to get medical treatment, as well as how Palestinians residing in other parts of the Occupied Territories are no longer able to reach Jerusalem hospitals, even when the care they need is unavailable in the West Bank and the Gaza Strip.

 

Finally, the policy of closure, of which the barrier is the most extreme representation, will decide the fate of East Jerusalem as the center for Palestinian healthcare. Beyond the barrier's obvious effect on access to quality health care, these hospitals have also been a symbol of Palestinian presence in the city, especially after the closing of the Orient House, and witness to its centrality for Palestinians. Israel will tolerate, albeit with obvious discontent, Palestinian Jerusalemites as individuals.  However, it will not accept them as a national entity, certainly not in its capital city. The barrier, which determines – unilaterally and without being disrupted -- the de facto boundaries of annexation, is establishing the city's character for the foreseeable future. By this perspective, the suffocating of hospitals is part of a well-planned strategy of separation.

 

As stated, this report is not intended to address the entirety of the barrier's detrimental effects, which include overcrowding in Palestinian neighborhoods west of the barrier and exacerbated poverty resulting from cutting off economic ties, despite the obvious bearing these factors have on the capacity to realize one's right to health.[2] In this report, rather, we have decided to focus on the barrier's critical impact on freedom of movement, and consequently, on access to health care services, and its implications for Palestinian hospitals.

 

The Separation Barrier in Jerusalem

 

(For a detailed description of the barrier, see Appendix 1)

On July 18, 2001, the Israeli cabinet approved a plan to construct a separation barrier between Israel and the West Bank. This decision was made in the wake of an attack on a nightclub on the Tel Aviv promenade on July 2 that claimed tens of victims; the attack was carried out by a Palestinian suicide bomber who entered Israel from the West Bank. Later that year, the Ministerial Committee on Security Affairs decided to construct a wall around the city of Jerusalem as well following the December 1, 2001 suicide bombing in central Jerusalem's Ben Yehuda pedestrian mall. Known as "Enveloping Jerusalem", the declared objective of this wall was to prevent entry of Palestinians from the Palestinian Authority's jurisdiction into the city.

It was decided that generally the Jerusalem barrier would be built on the city's municipal limits[3].  In the summer of 2002, the state had already begun building sections of the separation barrier around Jerusalem in the first implementation phase of the separation plan. On September 11, 2002, the Israeli cabinet approved the "Enveloping Jerusalem" plan, e.g., surrounding the city with fences/walls from the south, east and north[4].  The cabinet determined the current route of "Enveloping Jerusalem" on February 20, 2005.

The Jerusalem barrier is approximately 90 kilometers long[5].  In built-up urban areas, separation has been achieved via a concrete wall; in rural areas an electronic fence has been erected. Most of the Jerusalem barrier's route has already been completed, with the exception of places where there is debate over the route including areas where a ruling is expected from the High Court of Justice.  

The building of the "Enveloping Jerusalem" barrier has not yet been completed.  In some areas, the barrier has been, or is intended to be, built adjacent to Jerusalem's municipal boundary, and elsewhere strays from it, either leaving neighborhoods that are within Jerusalem's jurisdiction outside of the barrier, or annexing settlements that are not within the city's jurisdiction. For example, the neighborhoods of Kafr 'Aqab, north of Qalandia and the Sho'efat refugee camp, east of Jerusalem, are within Jerusalem's municipal jurisdiction but have been cut off from the city[6], while the Ma'aleh Edumim, Pisgat Ze'ev and Giv'at Ze'ev settlements have been annexed to it via the barrier.

The City Gates:  Checkpoints between the West Bank and Jerusalem

When arguments are made regarding the barrier's destructive impact on the quality of life of residents of Jerusalem and the periphery dependent on the city, the crossings are often raised as a magic solution to the problem. Past experience shows that the security forces' checkpoints, sophisticated as they may be, cannot be, and are not intended to be, a real solution to the problem of freedom of movement in general, and specifically for crossing of patients, ambulances and medical staff[7]. 

In any case, at the time of this writing, construction of checkpoints intended to allow passage between the city and the West Bank, has not been completed.  For now, the Palestinian population continues to endure the difficulties involved in crossing improvised checkpoints and temporary gates along the barrier, until the "modern" checkpoints the military has "promised" are constructed. These checkpoints will not be constructed before a great deal of additional Palestinian land is seized in order to build pathways, parking lots and terminals.

The location of the checkpoints is very important, as is the quality of services they provide, especially for emergency transfer of patients. The Palestinian population is wary of Israeli promises regarding the expected "quality of services" in view of past and present experience with the Israeli military and border police at existing checkpoints.  Violence by soldiers towards residents, overcrowding at checkpoints and arbitrariness of decisions, have all seriously infringed on Palestinians' quality of life, and have even cost human life when access to urgent medical treatment has been denied.

In addition, there is no doubt that the security forces will likely construct the minimal number of checkpoints necessary, so as to achieve maximum control over the entry of Palestinians from the West Bank into Jerusalem. Limiting the number of checkpoints that allow crossing significantly harms the Palestinian populations' basic rights: schoolchildren, workers and patients will have to walk or drive a longer distance than usual in order to get to the checkpoints.

The location and number of checkpoints along the Jerusalem barrier have not yet been determined.  The largest among them will replace the Qalandia checkpoint[8] in the north, and is intended for the passage of up to some 4,200 people per hour.

The Barrier and the Law

Jerusalem in the Oslo Accords

The September 1993 Declaration of Principles explicitly states that the issue of Jerusalem is to be included in the permanent status negotiations.[9] It also states that the outcome of the permanent status negotiations should not be prejudiced or preempted by agreements reached for the interim period.  The 1995 Interim Agreement emphasizes that the Palestinian Council's jurisdiction does not include issues left to the permanent status negotiations, including Jerusalem.

Clearly, leaving the issue of Jerusalem for the permanent status negotiations obligates both sides not to take unilateral steps that may change the status quo in Jerusalem. Building the barrier, like any action that brings about changes in the existing situation in Jerusalem (i.e., massive building, policies aimed at changing the demographic balance, separation of Jerusalem from the West Bank) therefore constitutes a breach of the Agreement.  

The Roadmap 

The Roadmap repeats what was stated in every previous negotiation:  the issue of Jerusalem is to be deferred to the permanent status negotiations, as is the case with the issues of refugees and settlements. It recognizes the need for Palestinian institutions in Jerusalem, and emphasizes that the Israeli government is to re-open the Palestinian Chamber of Commerce and other closed Palestinian institutions in East Jerusalem, based on a commitment that these institutions will operate strictly in accordance with prior agreements between the parties.

The Roadmap also states that the parties will reach a permanent status agreement ending the occupation that began in 1967, which will include an agreed, just, fair, and realistic solution to the refugee issue as well as a negotiated resolution on the status of Jerusalem that takes into account the political and religious concerns of both sides, protects the religious interests of Jews, Christians, and Muslims worldwide, and fulfills the vision of two states: Israel and a sovereign, independent, democratic and viable Palestine, living side-by-side in peace and security.  As in previous agreements, deferring the discussion on the status of Jerusalem requires that neither side take any unilateral action that could change the existing reality in Jerusalem.

The Legal Struggle

On June 30, 2004, the High Court of Justice ruled that thirty kilometers of the barrier's forty-kilometer route west of Jerusalem were illegal. The petitioners, residents of the Palestinian villages Bidu and Beit Suriq, joined by a group of Israelis from neighboring Mevasseret Zion, argued that the barrier's route was determined by political, rather than security, considerations. The petitioners protested the harsh violation of Palestinian residents' rights to health care, education and livelihood, caused by their being cut off from adjacent cities and from their agricultural lands.

The High Court of Justice instructed the state to halt construction of the barrier in the area, and to come up with an alternate route that balances security needs with the rights of the Palestinian population.  The High Court justices, headed by Supreme Court President Aharon Barak, determined that a "measured" route must be chosen, one that achieves a balance between security considerations and the needs of the Palestinian population, even if this means that a lesser level of security is attained as compared with another possible route.[10]

This ruling, regardless of whether it was handed down in the shadow of concerns about the opinion set to be given the following week by the International Court in Hague, was nonetheless the first time the Israeli court system invalidated the barrier's route and compelled the state to take the needs of the Palestinian population into account, and not employ political considerations in planning of the route.  However, these standards were not maintained a few months later, when the justices of the Israeli High Court discussed the considerations for determining the barrier's route in the a-Ram/Dahiat al-Barid area of northern Jerusalem.

The International Court of Justice in the Hague: On July 9, 2004, the International Court in the Hague issued an advisory opinion on the legality of the barrier. The opinion included the following points:

In article 143:  The construction of the barrier constitutes a violation by Israel of various international obligations incumbent upon it.

In article 145:  Israel must cease the construction of the wall immediately, demolish the portions of the wall that have been constructed, and make reparations to the Palestinian residents of the West Bank and East Jerusalem who have suffered damage because of the wall.  Israel is also obligated, under the Fourth Geneva Convention and international humanitarian law, to prosecute persons responsible for the planning and construction of the wall, which are prima facie illegal actions.

In article 159:  The court believes that all states are under an obligation not to recognize the construction of the wall, not to render assistance in maintaining the situation created by such construction, and to ensure Israel's compliance with international law.[11]

The UN General Assembly was convened on July 20, 2004, following the advisory opinion by the International Court, and voted to demand that Israel heed the legal obligations stated in the advisory opinion.  The Assembly also requested the UN Secretary-General to submit a document detailing the damages caused to the Palestinian population as a result of the wall's construction.  To date, no such document has been submitted by the Secretary-General.[12] 

On August 19, 2004, the Israeli High Court of Justice instructed the state to submit its response to the International High Court's opinion within one month. The state's response was not officially given until six months later, on February 23, 2005. In it, the state claimed that Israel is not legally bound by the Hague decision, just as other countries are not. Israel also argued that the information brought before the Hague tribunal was incomplete and inaccurate, and that from the outset, Israel opposed raising the issue of the wall's legality before the International Court. The state further argued that the Hague opinion constitutes no more than legal advice to the UN General Assembly, and that it is not a binding court ruling or judgment.[13]

Indeed, despite the UN resolutions calling upon Israel to respect international law, and contrary to the International Court's opinion, construction of the wall continued uninterrupted on the ground.  The exceptions were the areas in which the High Court of Justice ordered that construction be halted for a limited time, as well as a minor alteration of the barrier's route around the villages northwest of Jerusalem.

The "Jerusalem Petition": As noted, the Israeli High Court's June 30, 2004 decision regarding the barrier's route west of Jerusalem established a certain standard, by which the needs of Palestinian residents were to be taken into account, and political considerations were to be avoided in determining the barrier's route.  On the face of it, this standard obligated the state in the future as well. However, in the June 2005 High Court of Justice petition regarding the barrier's route near a-Ram in northern Jerusalem, the issue received completely different treatment.  In this case, the State Attorney's office informed the court that the barrier in the Jerusalem area had political, not only security, significance, citing the political implications involved in moving the barrier adjacent to the Jewish neighborhoods, while leaving Palestinian residents of East Jerusalem on the other side: "…the political consideration is a relevant consideration regarding the route that runs within Israel."[14] It appears that the High Court accepted the state's contention that in regard to East Jerusalem, the route is considered to run within Israel, that is, within its area of sovereignty.  Justice Barak clarifies: "Talking about East Jerusalem as occupied territory is not valid as far as we are concerned." Barak adds that "the question whether the fence has political significance is very important for the fence constructed in the areas of Judea and Samaria, but is not relevant to a fence within Israel. The state says, in fact: there is a municipal boundary and it is our right as a state to construct a fence on our boundary, the state's boundary."[15] In this state of affairs, it is clear that the Israeli system has no constraints that can prevent or even mitigate the serious damage the barrier causes by disconnecting Jerusalem from the West Bank.

 A number of international organizations headed by Amnesty International called upon Israel to halt the construction of the barrier in the Occupied Territories and to respect international law. The organization also asked the international community to ensure that Israel fulfill its obligations to the Palestinian people according to the Fourth Geneva Convention. Amnesty's February 2, 2004 press release asserted that the barrier violated international law and caused serious human rights violations.  It also stated that by building the barrier, Israel prevented the Palestinian population's access to basic services such as health care services, food, education and jobs. Amnesty recognized Israel's right to protect its citizens by building a wall on the Green Line, but not in the Occupied Territories.  It was further stated that there was no justification in international law to provide protection to settlers, whose very existence in the Occupied Territories is considered a violation of international law, at the expense of the Palestinian population.[16]

 John Dugard, Special UN Commissioner's Rapporteur on the Situation of Human Rights in the Occupied Territories, stated in his September 8, 2003 report:  "Like the settlements it seeks to protect, the Wall is manifestly intended to create facts on the ground. It may lack an act of annexation, as occurred in the case of East Jerusalem and the Golan Heights. But its effect is the same: annexation.[17]" Dugard repeated this statement a year later: "Now Israel is seizing East Jerusalem by constructing a Wall around Greater Jerusalem to enclose settlements and Palestinian parts of East Jerusalem.  Some 60,000 Palestinians, living in the outer suburbs of Jerusalem, on the West Bank side of the Wall, will be denied access to schools, hospitals and employment.  Families will be divided by the wall."[18]  

 

The Barrier and the Right to Health: Jerusalem as a Medical Center

 

Palestinian Hospitals in East Jerusalem

The Palestinian hospitals in East Jerusalem are considered the most progressive in the Occupied Territories. For decades, they have been serving a Palestinian population from all of the West Bank and the Gaza Strip for difficult and complex cases or medical specialties unavailable locally.  Due to its geographic proximity to the southern and northern West Bank, Jerusalem naturally developed as an important center of Palestinian life in this respect as well. Under the status quo that has been maintained for the most part since annexation, Israel has allowed these hospitals to operate as an almost autonomous system.

In 1994, upon acquiring responsibility for the area of health, the Palestinian Authority (PA) began developing the government hospitals in the West Bank and Gaza Strip. With international assistance, private medical centers and medical centers run by NGOs and charitable organizations have also continued to exist and develop in the Occupied Territories. Nevertheless, despite the importance of the medical centers located in Gaza, Ramallah and Nablus, the hospitals in Jerusalem are still considered the most advanced of all Palestinian medical facilities, and tens of thousands of patients are referred to them every year from all over the Occupied Territories. The Israeli policies of closure, sieges, and limiting of movement by permit have all seriously impeded patients' access to hospitals in Jerusalem, harming both patients and hospitals.

Mukassed Hospital on the Mount of Olives, with 220 hospital beds, is the largest and most skilled hospital in the Occupied Territories. A teaching hospital, it operates in cooperation and coordination with the medical school at al-Quds University in Abu-Dis. Mukassed, and houses an advanced surgery unit with capabilities for laparoscopy, neurosurgery and open-heart surgery.  The hospital also has internal, intensive care, pediatric, maternity, neonatal intensive care, genetics and pathology units. 

Augusta Victoria Hospital is the second largest in terms of the scope of its services.  It is the primary hospital serving the Palestinian refugee population in the Occupied Territories. The services provided at Augusta Victoria include a surgical unit, and internal, pediatrics, nephrology and oncology departments.  It is the only hospital in the Territories that provides certain procedures, such as radiation therapy for cancer patients and pediatric dialysis.

Saint John's Hospital is the only public hospital in the Occupied Territories specializing in ophthalmology.  Keeping abreast of the latest developments in the field, the hospital operates in cooperation with The Royal College in England and with the Ophthalmology Department at Hadassah Medical Center in Jerusalem.  

The Red Crescent Hospital is the largest maternity hospital, and includes surgical and neonatal intensive care units. Other maternity hospitals are al-Dajani in the Beit Hanina neighborhood and al-Quds in Kafr 'Aqab. The obstetric departments in Jerusalem are considered the finest in the Occupied Territories. Mukassed and Red Crescent have advanced neonatal intensive care units, and they are the only facilities for high-risk pregnancies in the Jerusalem area for Palestinian patients from the West Bank.   

Additional hospitals in Jerusalem are Princess Basma, the first and most progressive pediatric rehabilitation facility for children with physical and emotional disabilities; al-Ja'abi geriatric hospital; and Saint Joseph's general hospital serving almost exclusively East Jerusalem residents who are insured by Israeli HMOs.

Target Population

About half a million Palestinians live within a 20 kilometer radius of the Old City of Jerusalem. For them, Jerusalem is the hub where all essential services, including health care services, are located. However, Jerusalem is struggling to survive as the most important and progressive medical center for all residents of the Occupied Territories.

The Palestinian population in the Jerusalem metropolitan area:  According to the Palestinian Central Bureau of Statistics, this area has a population of 432,545 people, of whom over 230 thousand hold Israeli identification cards.  67.3% are urban residents, 26.2% live in villages, and 6.5% live in refugee camps, for the most part in Qalandia and Sho'efat[19].

The Palestinian Central Bureau of Statistics makes a distinction between Palestinian neighborhoods and towns of a more urban type (J1), and villages in the periphery (J2), without taking into consideration the limits of jurisdiction of the Jerusalem Municipality as established by Israel.

The urban area (J1) includes the following neighborhoods: Beit Hanina, Sho'efat, Sho'efat refugee camp, 'Isawiyeh, a-Sheikh Jarrah, Wadi el-Joz, a-Sawaneh, a-Tur, the Old City, a-Shayah, Ras el-'Amud, Silwan, a-Thuri, Jabal al-Mukabar, a-Swahara el-'Arbieh, Beit Safafa, Sharafat, Sur Baher and Um Tubeh. 269,900 Palestinians live in these neighborhoods, most of whom hold Israeli identification cards. Nearly all these urban neighborhoods will be on the Israeli side of the barrier.  However, Sho'efat refugee camp (17,000 residents), the adjacent Ras Hamis neighborhood (3,500 residents), and a-Salaam (Peace) neighborhood (about 4,000 residents) in 'Anata, will all be on the other side of the fence, and their residents will be cut off from Jerusalem and its medical facilities.

The rural area (J2) includes the following villages:  Rafat, Kafr 'Aqab, Makhmas, Qalandia refugee camp, Jab'a, Qalandia, a-Ram and Dahiat al-Barid, Bir Naballah, Beit Hanina al-Balad, al-Jib, al-Jedira, Beit Duqo, Beit 'Anan, Beit Ijza, al-Kubiba, Hirbet um al-Lahem, Badu, al-Nabi Samuel, Ketana, Beit Suriq, Beit Iksa, al-Khan al-Ahmar, Hazma, 'Anata, a-Zayam, al-Izariyeh, Abu-Dis, a-Sawarha al-Sharkiyyeh, and Sheikh Sa'ed. 162,645 Palestinians live in these areas, most of whom carry Palestinian identification cards[20]. Some of the villages, such as parts of Izariyeh and Abu-Dis, have already been cut off from Jerusalem and are located on the east side of the barrier.  Others, such as Bir Naballah, al-Jib and Beit Hanina al-Balad, will soon find themselves fenced in within enclaves and cut off from Jerusalem. It should be emphasized that Kafr 'Aqab, with some 18,000 residents holding blue (Israeli) identification cards, included in Jerusalem's municipal area, is on the other side of the barrier. Its residents' passage between their homes and Jerusalem is contingent upon "Kafr 'Aqab" appearing as their official address on their identification cards. Even then, moving through checkpoints depends upon gates being open and the amount of congestion at the checkpoints[21].

The villages of Abu-Dis and Izariyeh, east of Jerusalem, are located some five to ten minutes' drive from Mukassed, Augusta Victoria and Red Crescent hospitals in East Jerusalem.  These villages have four clinics that provide primary care only. One such clinic belongs to the Palestinian Health Ministry and operates until the early afternoon hours (8:00-14:00).  A second clinic is operated by the Mukassed not-for-profit agency during the same hours. Two other clinics, privately run, are open until 22:00.  From ten o'clock at night until eight o'clock in the morning, there are no local medical services available to the residents of either village.

At night, and for emergencies, the only remedy for these villages' 30,000 residents is going to the Palestinian hospitals in East Jerusalem. Now that the barrier in the area is completed, this option is not accessible to these residents. In order to get to medical treatment in Jerusalem, they must submit a request for entry into the city to the Israeli District Coordination Office (DCO) in the settlement of Ma'aleh Edumim. If a permit is ultimately given, the patient must then drive at least 25 minutes on the Ma'aleh Edumim road, cross a-Za'ayam checkpoint, and go through Jerusalem's a-Tur neighborhood to the nearest hospital. When an ambulance is needed to transfer a patient from Abu-Dis or Izariyeh, it takes at least forty minutes from the moment the ambulance is called until the patient reaches the hospital in Jerusalem.

Under these circumstances, village residents prefer to drive to hospitals in Bethlehem, half an hour away by private car.  However, the only road to Bethlehem, via Wadi a-Nar, is blocked by a roadblock located east of Abu-Dis, (the "Container Roadblock"). Whoever wishes to go through needs a special permit (permit for movement under siege) or, alternately, must convince the soldiers at the roadblock of the necessity of immediate passage[22].

Holders of Blue Identification Cards[23] (who have residency status in Israel):  East Jerusalem's Palestinian residents, unlike residents of the rest of the Occupied Territories, were annexed by Israel along with East Jerusalem in 1967, contrary to international law. Subsequently Jerusalem's Palestinians are residents of Israel and therefore entitled, among other things, to medical services from the state through its various health care organizations. The National Health Insurance Law, which applies to all residents of Israel, is supposed to benefit East Jerusalem residents as well.  For the most part the law is implemented, but not without difficulties arising from discrimination against residents of East Jerusalem as compared to other residents of Israel.

The Oslo Accords notwithstanding, Israel does not recognize the Palestinian Authority's responsibility for implementing the right to health in East Jerusalem (as opposed to the rest of the Occupied Territories).  In this "in-between" situation, in which Israel is responsible (regardless of whether as occupier or as "sovereign") for implementing Jerusalem residents' right to health, it is incumbent upon it not only to avoid actively harming residents' health, but also to take positive steps to promote it. The barrier is a blatant violation of this obligation. In the case of Jerusalem residents, Israel is in violation not only of international law but also of its own law.

Access to Primary Care: Over the years, Israeli health care organizations have developed primary care services accessible to its members. For example, out of six primary care clinics in a-Ram, four belong to the Israeli HMOs and serve their member residents (the other two are operated, respectively, by the Palestinian Health Ministry and by the al-Mukassed not-for-profit agency).  Three of the Israeli clinics are staffed by independent physicians who work for the Israeli HMOs, and are located within the town's limits. The largest clinic, operated by the Clalit HMO, in which 750 residents of a-Ram and its environs are members, is now located on the west side of the barrier, while these members live east of it.  When the barrier is completed, these insured will not be able to reach their clinic quickly and simply. They will have to go to the Qalandia checkpoint, cross over to the western side of the barrier and proceed to the clinic[24] In order to overcome this hurdle, the HMO will have to expand its branches east of the barrier, typifying the Kafkaesque situation in which residents are within the system, yet outside of it at the same time.

In addition to decreased access to essential services in Jerusalem, a threat lingers over these residents' heads of complete loss of their rights, including health insurance. Palestinian residents who have been cut off from the city, whether they be residents of Kafr 'Aqab and Sho'efat, originally within Jerusalem's jurisdiction, or Jerusalemites who have "migrated" to adjacent neighborhoods, such as a-Ram[25], are very concerned about their future "residency" status.  The requirement to demonstrate one's "center of life" in Jerusalem[26] which has been fodder for the policy known as "the quiet deportation", may facilitate massive revocation of rights; proving a "life center" becomes more difficult if not impossible, when the state does everything in its power to cut these residents off from Jerusalem and impede their movement in and out of the city. The National Insurance Institute insists that health insurance be revoked from those Jerusalem residents whose "center of life" is not in Jerusalem.[27] Documenting these residents' crossing at barrier checkpoints may support the National Insurance Institute's claims that they do not live in Jerusalem itself, and serve as an instrument in the policy intended to revoke their rights.

The new reality that the barrier imposes on residents by cutting them off from their "center of life",  while monitoring of their daily activities is increased, leaves residents with only unfavorable options.  Concern for their freedom of movement and their rights in Jerusalem, and a lack of clear Israeli policy regarding the way in which they will be allowed to enter and exit the city through the barrier, has caused many to choose to migrate to neighborhoods on the west side of the barrier.

Thousands of residents of a-Ram, Kafr 'Aqab and other neighborhoods that have been placed outside the barrier, have already left these areas and rented homes in Palestinian neighborhoods on the west side of the barrier.  Buildings and even entire streets in a-Ram have been emptied out. On the other hand, housing shortages and rising housing prices are seen in Palestinian neighborhoods that are on the "right" side of the barrier, such as Beit Hanina, Sho'efat, a-Tur and Issawiyeh.

The Sharon administration's decision #3873 of July 10, 2005 (Appendix 4) established that by September 1, 2005 -- the estimated time of completion of the Jerusalem barrier's construction -- government ministries involved with the barrier's construction, in cooperation with the Jerusalem Municipality, will have prepared a program for providing essential services to residents of Palestinian neighborhoods that are within the Jerusalem Municipality's jurisdiction, but separated from it by the barrier. The services are to be provided by community management organizations to be established by the Jerusalem Municipality in these neighborhoods. In that same decision, various government ministries, including the Ministry of Health, Ministry of Education, Ministry of Social Affairs (via the National Insurance Institute) and the Ministry of the Interior, were instructed to complete preparations for providing the necessary services for Jerusalem residents who are located on the other side of the barrier by September 1, 2005. At the time of this writing, none of these ministries has announced any plans to fulfill the government's decision.[28]

Regardless of whether or not they hold blue identification cards, all residents of the Jerusalem metropolitan area are tied to Jerusalem, their "center of life", where they receive health-related services, among other things. Since the construction of checkpoints at city entrances at the end of 2000, and more so since the separation barrier has been built in the north and south of the city, there has been a significant decrease in the number of patients who are able to get to hospitals in the city.  Many patients, particularly residents of the villages surrounding Jerusalem, who frequented Jerusalem for medical services, especially for secondary and tertiary health care services[29], must now seek medical services in Ramallah, Bethlehem, Jericho and Nablus.

Those without Residency Status: In many East Jerusalem families, one spouse is a resident of Israel and the other lacks residency status. Residents of the Occupied Territories who married residents of East Jerusalem and have not yet received status[30], suffer due to construction of the barrier from severe limitations upon their freedom of movement, especially those who submitted a request for family unification and whose request was denied by the Israeli Ministry of the Interior[31]. Theirs is the opposite difficulty: exiting Jerusalem.  Many of the spouses without status live with their Jerusalemite families in the city, without any permit from the authorities.  From Israel's perspective, they are considered to be staying illegally, and any run-in they may have with police or border police may end in their deportation to the West Bank.  Their lives are accompanied by a constant worry about being separated from their families.  As the barrier is being completed, every attempt on their part to visit or get treatment in the West Bank (where they are insured and treatment is less expensive) means taking the risk that going for treatment may turn into a one-way trip, and they may not be permitted to return.

S. H., a 45-year-old resident of the Occupied Territories, is disabled and wheelchair-bound.  He is married to a resident of East Jerusalem and is the father of four, who also have residency status in Israel. The family has been living for years in the Ras al-Amud area.  In 1996, the couple submitted a request for family unification. However, to date S.H. has not received residency status in Israel. Since the barrier has been completed in the Abu-Dis area, he has been unable to leave his house to go to the West Bank, where he used to get his necessary medical services and visit his family. Under Israeli law, S. is in Israel illegally, even at his home in Ras al-Amud.  He cannot leave his home without worrying that he may be caught and not permitted to return to Jerusalem.

Palestinian Residents of the West Bank and Gaza Strip: The numerous checkpoints and the selective policy of issuing entry permits to Jerusalem have cut off the Gaza Strip from the West Bank and certainly from East Jerusalem.[32]  In the case of West Bank residents, some patients may risk entering the city without a permit.  This option is unavailable to residents of the Gaza Strip, which is enclosed within a barrier. The situation is changing in the West Bank as well, and patients who have been able to "sneak" illegally into Jerusalem for medical treatment will no longer be able to do so. When the barrier is completed, an entry permit to the city will be still more essential than in the past, even for patients who live in the Jerusalem area.

Patients from more remote West Bank areas or from the Gaza Strip, whose access to Jerusalem was in no way easy before the construction of the barrier, will find it even more difficult to Jerusalem for medical treatment. A Palestinian patient needing treatment in Jerusalem is first required to produce medical documentation that describes his or her condition, confirms his or her medical appointment at a certain hospital, and states that the needed treatment is not available to the patient elsewhere in the West Bank. Beyond the medical issue, the patient must also prove that he or she has no criminal or security record. Then he or she must wait several days, or weeks, for receipt of the entry permit, if one is granted. Submitting and receiving a request for a permit means waiting long hours at the local Israeli DCO offices[33]. 

Obtaining an entry permit, a grueling effort in itself, does not guarantee that the patient will receive treatment in Jerusalem[34]. Once the permit is obtained, the patient must make his or her way to the city through one of the checkpoints along the barrier.  At the checkpoint, he or she will have to deal with additional delays due to congestion, security checks, and unanticipated events. These delays take precious time on the way to the hospital, and affect all residents, both those moving by permit and those who are guaranteed entrance into the city by power of their residency.

Not only is the permit policy humiliating, but it also causes delays and prevents the Palestinian population from getting medical treatment of reasonable quality within a reasonable time. Patients with a "security past" are barred from entering Jerusalem, as are persons classified by the security forces as "prevented for security reasons".  The reasons for this restriction are often unclear, and often not directly connected with the patient him/herself.

Maryam Mazhar, age 71, a resident of the Deheishe refugee camp adjacent to Bethlehem, suffers from kidney failure and diabetes, which has caused her blindness. Her medical condition requires dialysis three times a week monitored by a nephrologist, a procedure that is unavailable at her local hospital, al-Husseini in Beit Jalla. Maryam submitted several requests to receive an entry permit for Augusta Victoria Hospital in Jerusalem, unsuccessfully. The Israeli authorities classified her as "prevented for security reasons". Maryam claimed that the Israelis have long been trying to pressure her in any way possible to surrender her son who is wanted. Physicians for Human Rights-Israel (PHR-Israel) made several requests for an entry permits on her behalf from the Beit El Civil Administration. These requests were denied as well. Maryam continued to go to Augusta Victoria hospital accompanied by her daughter, without a permit, bypassing checkpoints and parts of the barrier that had already been constructed south of the city by using unacceptable roads. She was not always successful and there were weeks when she was unable to get to the hospital, receiving no treatment at all.  Other weeks, she received only one or two treatments of the three she requires.  The tribulations and missed treatments caused her condition to worsen.  On January 17, 2005, PHR – Israel petitioned the High Court of Justice on Maryam Mazhar's behalf (HCJ 556/05).  On January 19 an arrangement was reached with the Israeli authorities, allowing Maryam to enter Jerusalem with a permit to be renewed every three months.

According to the Civil Administration's data, there has been a sharp increase in the number of entry permits to Jerusalem issued to Palestinian patients from the West Bank: from 8,000 permits in 2002, to 20,000 in 2003, to 45,000 in 2004 (of these, some 10,000 were permits for people accompanying patients).  The procedure for entering Israel, including East Jerusalem, requires that with the exception of minors, every resident of the Occupied Territories have an entry permit. The many checkpoints inside the West Bank, between the West Bank and Israel, at the entrances to Jerusalem, and the closure of Jerusalem by the barrier, lead to many more people having to apply for entry permits at local Civil Administration offices.  The expected number of permits for 2005 is an estimated 60,000[35]. 

Indeed, a simple assessment of the 2002 data indicated a lack of correlation in the past between the number of permits and the number of patients who came from the West Bank to the hospitals:  the total number of patients hospitalized in 2002 in Palestinian hospitals in East Jerusalem was 29,000, not including the tens of thousands who came to outpatient clinics and for one-day treatment. In contrast, the Civil Administration's data shows only 8,000 permits were issued for patients. A similar picture arises regarding 2003, with the Civil Administration reporting 20,000 permits to patients and their accompaniers, while the hospitals report some 30,000 patients hospitalized that year, in addition to 177,500 visits at outpatient clinics at all the Palestinian hospitals in the city.

The large discrepancies raise the heavy suspicion that despite the increase in the number of applicants for permits, there still remains a very large population that is forced or chooses to forego treatment that is dependent upon Israeli approval. These residents face a choice between two bad options: to make do with less progressive medical services at a West Bank facility, or to do without treatment entirely.

Refugees:  For the Palestinian refugee population, particularly residents of Qalandia and Sho'efat refugee camps, Jerusalem is almost the sole medical center. UNRWA operates two primary care clinics in Qalandia and Sho'efat, but the main UNRWA clinic is in the Old City and serves refugees from the Jerusalem environs and from the West Bank.  Over a three-month period in 2005 (August through October), 19,095 family doctor visits were recorded at the Old City UNRWA clinic, as were more than 5,000 visits with a pediatrician and 1,802 visits with a dentist. Sixty percent of patients came from the Jerusalem vicinity. When the barrier is completed, these patients' entry into the city will be impossible without special permits[36].

The barrier's most deleterious effect is preventing access of refugees to secondary and tertiary health care at Palestinian hospitals in East Jerusalem. Over a period of close to a year (January 1, 2003 to November 11, 2003), UNRWA referred 6,255 West Bank refugees for secondary and tertiary care at Jerusalem hospitals.  Of these, 2,605 were referred to Augusta Victoria; 2,811 to Saint John's; and 839 to Mukassed[37]. 

Even before completion of the barrier, getting from Sho'efat or Qalandia refugee camps to medical treatment in Jerusalem could take two hours. The road is filled with roadblocks, walking sections that are not fit for the task, and even physical obstacles that one must climb over.  Many patients, especially children and the elderly, are unable to withstand these trying conditions.  Therefore, UNWRA has long been referring patients to alternative hospitals in the West Bank.

 

Emergency Transfer:  Passage of Ambulances from the West Bank to Jerusalem

Patients needing to get from the West Bank to an East Jerusalem hospital via ambulance are not guaranteed quick and trouble-free passage through the checkpoint, even in an emergency. Sometimes the ambulance carrying a patient is ordered to turn back, despite the emergency situation. The primary reason for this is that the decision-making power is in the hands of the soldiers at the checkpoint, rather than with the medical team in the ambulance, who are familiar with the patient and are caring for him or her. In certain cases, the patient is allowed to go through, but without the ambulance that brought him or her.  In these cases, the patient must pay for an Israeli ambulance to be called to the checkpoint and to take him or her to the hospital in Jerusalem[38].

Five-year old Izariyeh resident Muhammad Saleh Hamadin suffered from respiratory problems for which he was treated at Mukassed Hospital.  On August 18, 2005, Muhammad was feeling poorly, and the local physician recommended he be transferred to Mukassed right away. Accompanied by his father, Muhammad was taken in a Palestinian ambulance.  At a-Zayam checkpoint, after a half-hour's delay, the soldiers refused to let him through, claiming that the ambulance's entry into Israel had not been coordinated, despite the boy's distress and the fact that the Mukassed medical team was familiar with his case and medical history.  The ambulance's crew was forced to drive to a hospital in Jericho, half an hour's drive away, where Muhammad was treated.

In the afternoon hours on August 19, 2005, a Palestinian ambulance from Izariyeh,  carrying a nine-year old girl with a head injury caused by a fall, arrived at a-Zayam checkpoint. The ambulance crew requested the soldiers' permission to take the girl to Mukassed Hospital due to her serious condition.  The soldiers refused to allow the ambulance to go through, although the girl was clearly bleeding and the ambulance crew unable to stabilize her condition. After standing at the checkpoint for twenty minutes, the crew gave up and drove to a hospital in Jericho.  The refusal to let the child through the checkpoint caused her to receive treatment an hour after her fall.

In HCJ 9109/96 Physicians for Human Rights-Israel vs. the Minister of Defense, the State guaranteed patients' passage through the checkpoint including into Israel, regardless of whether he or she holds a permit. Health Coordinator Dalia Basa now requires prior coordination, as soon as the ambulance leaves for Jerusalem. PHR-Israel receives many complaints about ambulances being denied access to Jerusalem even in emergencies, including being told by the soldiers to seek treatment at West Bank hospitals or to transfer patients to Israeli ambulances in "back to back" procedures. 

Obstetrics:  Pre-Natal Care and Emergency Transfer for Birth

During 2003, the number of live births in Jerusalem's Palestinian metropolitan area was 2,381.  Of these, 2,132 births occurred in hospitals and 249 outside of hospitals (in private clinics or at home). Among hospital births, 652 were at Palestinian government hospitals in Ramallah and Bethlehem, and 1,480 at non-governmental hospitals in East Jerusalem, primarily Mokassed and Red Crescent[39]. These figures do not include births of Jerusalem residents who carry Israeli documents and who have Israeli social security rights.

These numbers demonstrate the extent to which Palestinian mothers from the Jerusalem area depend on East Jerusalem hospitals. Palestinian women prefer to give birth in Jerusalem because of its proximity to their villages and because its hospitals have higher medical standards than most of the government hospitals in the West Bank.

Blocking access to medical centers, first via checkpoints at the entrances to the city and now by the barrier, makes it very difficult for pregnant Palestinian women to access health care, starting with pre-natal visits. Before every regular pre-natal visit in Jerusalem, at the Red Crescent or UNRWA clinics in the Old City, a pregnant woman must go through a bureaucratic sequence: requesting a permit, each time anew; producing medical and other documentation to justify the visit; and waiting at the entrance to the DCO, a procedure that involves a great deal of inconvenience, suffering and humiliation.

Requesting a permit is nearly impossible when it comes to the birth itself.  A woman in labor is usually unable to submit an urgent request for a permit, especially since the DCO offices are closed to the public in the evening and night, as are (to Palestinians) most of the checkpoints on the way to the city.  If she does obtain an entry permit, her journey will be longer than usual, involving passage though checkpoints along the barrier. Transport in an ambulance is not an effective solution either. Ambulance service is not available in every village or neighborhood, and in any case the ambulance driver needs to show an entry permit into Jerusalem before responding to the call (see above). A woman from the town of a-Ram, for example, a ten-minute drive to the hospitals in East Jerusalem, is not allowed to enter the city without a permit.  She must go to a hospital in Ramallah or Jericho, about a half an hour away assuming there are no delays at the checkpoints. Jerusalemites must get to Qalandia checkpoint and from there to the hospital, about a half-hour's drive if there are no delays at the checkpoint. 

Mothers-to-be who are residents of Israel, thus covered by national health insurance and registered with social security, are also adversely affected by the barrier. These women are entitled to coverage of hospital expenses at any of the hospitals in East Jerusalem, as well as to a maternity grant from the National Insurance Institute. As described above in the case of other residents with blue identification cards, these women are also concerned that their residence east of the wall not only impedes their crossing for treatment at Jerusalem hospitals, but may also lead to revocation of their rights by the National Insurance Institute[40].

'A. is a resident of a village east of Ramallah. With fertility treatments, she became pregnant with quintuplets. Considered a high-risk pregnancy, all of her prenatal care was provided at Mukassed hospital in Jerusalem.  The PA provided her with a payment voucher for pre-natal care and delivery at Mukassed, the only hospital equipped to treat her.  On September 5, 2005, 'A. went for a checkup at a Ramallah Medical Center because she was in pain. The medical staff established that she had gone into labor, and called a Union of Palestinian Medical Relief Committee ambulance to take her to Mukassed immediately.  The ambulance, with a physician inside, left Ramallah without a problem after being inspected at two checkpoints.  At Hizma Checkpoint, the soldiers argued between them whether or not to allow the woman through. Some agreed to do so, based on medical documents and an examination by a female soldier confirming that the woman was indeed pregnant. However, one of the soldiers refused to let her through, saying, "As far as I'm concerned she can give birth in Jenin or Nablus.  No patient goes through here." The physician attempted in vain to explain that this was a high-risk pregnancy for which only Mukassed was equipped.  She asked to speak with the officer in command but was told that there was none available. One of the soldiers told the driver, "Don't listen to him [to the soldier preventing the passage], just close the door and drive." The driver feared that going ahead would cause the soldier to shoot at him, and instead called Health Coordinator Dalia Basa. Ms. Basa asked to speak with the soldier, but he refused to speak with her. Subsequently, Ms. Basa instructed the driver to go back to Ramallah, asserting that the ambulance's entry had not been coordinated with her.  The physician insisted that the woman be transferred to Mukassed right away. Ms. Basa then called an Israeli ambulance to get to the checkpoint and transfer the woman.  Only after delays did the soldier allow a "back to back" transfer. 'A. gave birth immediately upon arriving at the hospital.  The delay at the checkpoint: approximately one hour[41].  

Dying Slowly: The Barrier's Impact on Hospitals in East Jerusalem[42]

When patients' access to hospitals is blocked, delayed, or rife with obstacles, they are the first ones harmed, by lack of appropriate treatment. The decline in Palestinian patients' access to hospitals in East Jerusalem also has damaging implications on the hospitals themselves. The barrier and the almost-total separation it imposes on the hospitals from the population they are supposed to serve pose a real threat to the very existence of these hospitals.

East Jerusalem's nine hospitals comprise a total of 524 hospital beds, which constitute 11.2% of the total beds in the Occupied Territories[43].  Of these beds, 450 are in non-governmental hospitals and the remaining 74 are in the city's private hospitals[44]. In 2002, a total of 344,172 patients from the West Bank and Gaza Strip visited outpatient clinics in Jerusalem's Palestinian hospitals.  In 2003, this figure declined by half: only 177,500 patients from the West Bank and Gaza Strip visited East Jerusalem's outpatient clinics.  Of these visits to clinics, 22,937 were for OB/GYN; 13,196 for physiotherapy; 34,638 for ophthalmology; 7,694 for orthopedics; 4,440 for mouth and jaw; and 4,142 for EEG[45].

 

Funding

East Jerusalem hospitals rely financially on payments from several referring sources:  The Palestinian Authority, UNRWA, Israeli health care organizations, the National Insurance Institute (for births), payment by private patients and donations from international funds and organizations.

The ongoing closures imposed on the Occupied Territories since the 1991 Gulf War cut the Territories off from East Jerusalem, disrupted operations of Palestinian institutions active in the city at the time, and caused some of them to move to the West Bank, primarily to Ramallah[46]. According to various agreements between Israel and Palestinian representatives, any institution interested in operating in Jerusalem required special permission from the Israeli authorities, while the Israelis pledged to keep the status quo in East Jerusalem. Following these agreements international organizations, principally the World Bank, suspended their support of Palestinian institutions in Jerusalem pending a decision on the political fate of the city[47]. This decision dealt a blow to East Jerusalem hospitals as well, as most of them had been receiving support through donations by international organizations[48].  In addition, the rift between Palestinians and the Gulf countries, due to Palestinian support of Saddam Hussein, cost hospitals the loss of these countries as a significant funding source. Nonetheless, some funding still comes from donations.

Patient referrals by the Palestinian Authority: Residents of the Authority's jurisdiction who are covered by Palestinian health insurance are usually referred for treatment at government hospitals in the West Bank and Gaza Strip. When the required treatment is unavailable at government hospitals, the Palestinian Ministry of Health refers patients to hospitals in Jerusalem, or alternatively, in Jordan, Egypt or Israel. Payment rates are determined in advance by contracts with hospitals[49]; the PA prefers to refer patients to the less expensive facilities.

In 2003, the PA referred 28,866 patients for hospitalization at non-governmental hospitals in East Jerusalem, and was charged for a total of 128,373 hospitalization days (an average of 4.5 hospitalization days per patient)[50].

In January 2005, the Palestinian Ministry of Health and Mokassed hospital agreed that residents of the villages in the Jerusalem area (J2) covered by Palestinian health insurance could be treated at Mokassed by referral from the local government clinic, without having to get a referral from the main Health Bureau in Ramallah. The change was intended to facilitate access by patients living in these areas, and demonstrates these patients' dependence on East Jerusalem hospitals, Mukassed in particular.

Certainly, this move has great political significance for the PA, as it represents its commitment to the struggle for the continued existence of Palestinian institutions in East Jerusalem. The agreement's significance for Mukassed hospital should not be underestimated either, as it provides the hospital with an additional source of revenue (provided that the PA indeed fulfills its obligations and pays for the hospital's services). After hospital management ended its contract with the Clalit HMO (see below), following the significant decrease in financial support from the Gulf countries, the hospital lost its financial stability, reaching losses estimated at tens of millions of NIS. An agreement with the Palestinian Ministry of Health would help, at least in part, to restore financial stability and to maintain medical standards.

Referring patients who are members of Israeli HMOs:  East Jerusalem residents holding blue identification cards have national health insurance and are members of Israeli HMOs. These insured often prefer to receive treatment at Palestinian hospitals in the city, an inclination that has become stronger in years when nationalist sentiment runs high, permeating hospitals as well. Due to loss of income, most of the hospitals found themselves depending upon referrals from Israeli HMOs as their primary source of funding. The Israeli HMOs, in turn, lost no time in taking advantage of the situation. From conversations with some of the Palestinian hospitals, it has been confirmed that none of the Israeli HMOs pay Palestinian hospitals the full hospitalization rate, nor have they, to our knowledge, in the past: up until the end of 2003, the Clalit HMO paid Mokassed 45% of the public rate.  The Meuhedet, Maccabi and Leumit HMOs pay Mokassed between 45-50% of this rate. In 2004, a crisis occurred when the Clalit HMO offered Mokassed 33% of the public rate for its services, up to a ceiling of NIS 300,000, after which they would pay 25% for referrals. The hospital refused, maintaining that this rate would not cover costs and would cause losses. Subsequently, Mokassed's contract with Clalit has not been renewed since the beginning of 2004. As most East Jerusalem residents are members in this HMO, the hospital lost a very important source of income.  Non-renewal of the contract also negatively impacted the insured who can no longer use the hospital's services.

PHR- Israel appealed to the Israeli Minister of Health to use his authority to defend Mokassed hospital vis-a-vis Clalit HMO. The minister responded that he had no authority to obligate a HMO to pay the hospital the full hospitalization rate, but added that he would consider intervening if the hospital appealed directly. However, due to the ambivalent relationship between them, the hospital would not make such a request to the minister (see below). By maintaining this condition, the Ministry of Health sustains the HMOs’ power to control the market. Thus, the HMO can lower its rates for East Jerusalem hospitals to levels that jeopardize service provision and quality[51]. 

In fact,  "The Minister of Health may determine that certain contracts between a HMO and a service provider […] require his approval." (Article 30 of the National Health Insurance Law) The law states in clear language that "regarding contracts between HMOs and service providers […] the HMO will act without discrimination between service providers." (Unofficial translation) We believe, therefore, that the Minister of Health is authorized and even obligated to intervene in the discriminatory arrangement described above.

In contrast to Mokassed, Saint Joseph's and Red Crescent hospitals enjoy relative financial stability, because the population they serve is almost exclusively insured by the Israeli HMOs.  Ninety-five percent of the referrals to Saint Joseph's Hospital come from Israeli HMOs, with whom the hospital has agreed to a reduced rate, thereby weakening other hospitals' bargaining power. Red Crescent Obstetric Hospital maintains its stability for a different reason: as a maternity hospital, most of its hospitalizations are for births, for which it receives payment from the National Insurance Institute – a fixed rate, unlike HMOs payments. According to Israeli Ministry of Health data, its occupancy rate has gone up from 91.7% in 2002, to 115.4% in 2003[52].

Medical Staff 

In addition to cutting off patients, the closure has impaired hospitals' functioning by impeding medical staff's access to their workplaces.

Since their inception, Palestinian hospitals in Jerusalem have relied on employees who are residents of the West Bank and the Gaza Strip; 70% of their employees were residents of these areas. Israel is gradually cutting them off as well.

In 1996, a general curfew was imposed on the Occupied Territories, forcing these hospitals to operate with less than one-third of their staff.  This intolerable situation led to a petition to the High Court of Justice by Mukassed Hospital, PHR-Israel and the Association for Civil Rights in Israel on February 21,1996 (HCJ 2054/96). The petition demanded that Israel issue permits immediately to Palestinian medical personnel and create a policy for keeping medical personnel's entry permits valid during periods of closure.  An agreement was reached by which, for a limited period of time, 250 employees would receive permits; if this number of permits was not increased over a reasonable period of time, the petitioners would be able to court.  A conditional order was also handed down instructing the state to issue a procedure for granting permits to a limited number of medical personnel within 45 days. The closure would remain in effect for the first days of each closure. The hospital's willingness to work understaffed for a few days would allow the state to review the names of medical personnel, and hopefully to approve them, so that after the first few days of each future closure, staff would be able to travel to their place of employment.

Contrary to the spirit of the agreement, Israel showed no willingness to expand the quota for medical personnel after the HCJ case.  On the contrary, Israel made cynical use of the ruling by establishing as a norm, unrelated to any particular closure, quotas for the number of residents of the Occupied Territories that East Jerusalem hospitals could employ.  Israel also refused to grant permits to residents of the Gaza Strip. Hospitals that were paying salaries to employees who were "stuck" in the Strip for months, unable to get to work, gave up hope and finally had to let them go entirely.    

Despite the ruling's accomplishment --allowing hospitals to return to functioning during that specific closure – Israel exploited it by limiting the number of permits for hospital staff. The hospitals' dependence on employees from the Occupied Territories creates a control mechanism for Israel: Civil Administration Health Coordinator Basa "releases" medical staff to reach their workplaces whenever she sees fit, and denies access when she deems appropriate, all in the name of security, with the General Security Service (GSS) making the final decisions. The Civil Administration's permit mechanism facilitates a "carrot and stick" policy; most hospitals avoid fighting for entry permits for staff members that have been classified "prevented for security reasons "[53], so as not to jeopardize the security forces' "goodwill".

When PHR-Israel asks the authorities to explain on what grounds a particular medical employee has been barred from entering the hospital he or she works at in East Jerusalem, the Civil Administration often responds that the hospital must appeal on behalf of its employee, knowing full well that the hospital is in a sensitive situation and prefers to avoid confrontation regarding restrictions placed on one or the other of its employees. Thus, the employee remains alone in the battle for an entry permit, and may lose his or her source of income. Often, the "security" bar is removed from employees represented by PHR-Israel, after we contact the authorities or petition the High Court of Justice. Receipt of the permit, however, is then delayed until a check is done to see whether the employee's hospital has exceeded its quota, and whether an official request has been submitted by the hospital on the employee's behalf. This intentional "red tape" costs the hospital loss of personnel who were trained for their jobs, and impedes its functioning because it must find suitable replacements again and again.

In May 2003, PHR-Israel petitioned the High Court of Justice via attorney Andre Rosenthal on behalf of twenty Mukassed Hospital employees (HCJ 4326/03), requesting to remove their security restrictions and allow them access to the hospital. Mukassed Hospital did not join the petition for the reasons described above, although many of the petitioning employees held very important positions at the hospital, some having been employed there for many years. PHR-Israel withdrew its petition after a settlement was reached by which nine employees' restrictions would be removed; as for the others, the court determined that they had to appeal separately, not as a group. Appealing to the court individually would remove their special status as medical staff, and prevent a principle advocacy discussion regarding the status of Jerusalem hospitals. The fact that the hospital does not appeal on behalf of its employees weakens any attempt to bring forth the underlying principle issue to the court. This action also seems to demonstrate the hospital’s reluctance to rely on the Israeli court system. The current allotment for entry permits for medical personnel is 1,100; one thousand of these are for staff of the Palestinian hospitals in East Jerusalem.  This quota is completely used up and even exceeded, due to hospitals' constant demand for more permits[54].  Each hospital has a certain allotment determined by the Civil Administration. In the current situation, tens of medical personnel go to work without a permit, due either to a security bar by the Israeli authorities or because their institution's quota has been used up. Some employees are forced to sleep at their workplace for days, or even months at a time, for fear of being discovered on their way to, or from, work. Upon completion of sections of the barrier south and north of the city, many hospital employees without entry permits left their workplaces in Jerusalem, having to make do with jobs available locally in the West Bank, because of the great difficulty and the daily risk involved in reaching their workplaces in the city.

Dr. 'A. completed his medical studies at al-Quds University in Abu-Dis in 2001, and began a residency at Mukassed Hospital. At the hospital's request, Dr. 'A applied to the Israeli DCO in Hebron, where he resides, for a magnetic card.  Receiving a magnetic card is a prerequisite for obtaining an entry permit into Jerusalem. At the DCO, Dr. 'A was told that in order to get the card, he would have to meet with the GSS representative at the Hebron DCO.  Dr. 'A. arrived several times at the DCO, where soldiers made him wait for hours at the office entrance to meet the representative, to no avail. Dr. 'A repeatedly received the same kind of response:  "The GSS is busy today", or "The GSS doesn't want to meet with you today. Come back another time." PHR-Israel contacted the Civil Administration on Dr. 'A's behalf, requesting that the campaign of humiliation be stopped and that he be allowed to complete his residency.  The Civil Administration responded by summoning him for yet another meeting with the GSS representative at the Hebron DCO. Despite PHR-Israel's opposition to the meeting, 'A. preferred to try this way for the final time.  The script repeated itself:  Dr. 'A. waited all day for the representative, only to be told by one of the soldiers that he must go home because no GSS representative was present at the DCO that day[55].  

Hospitals and the Israeli Ministry of Health

Over the years, a kind of status quo has been maintained: the Israeli Ministry of Health does not finance East Jerusalem hospitals (who do not even make this request of it). In turn, the Ministry makes do with formal monitoring only.  The reality is that the Israeli health care system does not consider these hospitals to be an integral part of it. 

Occasionally, the Civil Administration demands that hospitals apply for work permits for their medical staff. These permits require a license to work in Israel, provided by the Ministry of Labor and Welfare. These licenses, significantly different from entry permits that allow medical staff to enter Jerusalem, require authorization from the Ministry of Health that the licensee is allowed to practice medicine in Israel. Every time PHR-Israel has fought in support of medical staff's special status in the Palestinian health care system, the Civil Administration has retreated from this demand. The threat of new licensing requirements, which has increased in recent years, makes the struggle for maintaining ties between East Jerusalem and the West Bank even more difficult.

The hospitals in East Jerusalem operate under Israeli law, which has been applied to the entire city.  Formally, therefore, these hospitals must meet Israeli licensing requirements. .Traditionally, the Israeli Ministry of Health renewed the temporary working licenses of these hospitals annually. For some of these hospitals, the licensing issues are perceived as a permanent threat, looming over their heads and very existence.

The Ministry of Health has recently begun to demand an individual work permit for each member of hospitals' medical staff.  This issue causes much concern among staff, especially among physicians, most of whom have a Palestinian, not an Israeli, license. This issue has not yet been decided. Hospitals' licensing depends upon staff's meeting these conditions. The Ministry of Health's requirement implements the policy of separation de facto. 

According to this new policy, physicians with blue identification cards (mostly residents from East Jerusalem) must meet Israeli standards for licensing. These standards require a general practitioner who is not a specialist to pass an examination prior to receiving a license to practice medicine in Israel. A physician who is a specialist is forced to leave his or her job to complete a residency period of about six months in an Israeli hospital, regardless of the length of time he or she has actually worked as a specialist. Following this residency, he or she must take the certification examinations. Physicians who did their residencies abroad are also required to take the examination.  At al-Quds obstetric hospital in Kafr Aqab, several physicians have already been fired and are not licensed to work because of this policy. 

On the other hand, physicians, including specialists, who hold Palestinian identification cards may continue to work at the same hospital. These physicians, like their Jerusalemite colleagues, completed studies abroad, and work in their respective fields with a special license that does not require Israeli entrance exams (provided the physicians produce documentation proving their certification abroad). This license is renewed yearly.  

A third category of physicians includes residents of the Occupied Territories who have Palestinian identification cards and who are graduates of the al-Quds medical school in Abu-Dis. They cannot get a special license, nor can they do residency in Israel or take the exams[56].

Under this policy, three different categories of physicians may work in one hospital: those with an Israeli license, those with a special license, and al-Quds graduates who have no license. One might surmise that because Israeli patients are hospitalized there (note that only patients from East Jerusalem are referred to these hospitals), the Ministry of Health has a clear interest in monitoring the hospital's medical standards. Were this not? the case however, why would the Ministry agree to a hybrid situation, in which physicians who have passed examinations and those who have not, work side by side? If the Ministry implements Israeli standards, why does it not finance these hospitals, help them develop, and provide continuing medical education programs for their staff? Again, we seriously question whether Israel's consideration (at least not its only one) is its concern for these hospitals' medical standards, or rather jeopardizing these hospitals' existence in the guise of professionalism or for bureaucratic reasons .

Furthermore, if the barrier is completed, these hospitals will clearly become hospitals for East Jerusalem Palestinians only. Israeli HMOs do not refer Jews to these hospitals, and Jews do not go to them. This development would fit in well with the trend of apartheid in Jerusalem health care, where separate and unequal health care systems have already been created. 

This practice, even more than the previous ones described, exposes the liminal situation of Jerusalem hospitals.  Israel has a clear interest in maintaining this situation, which facilitates Israeli control over the hospitals without obligating it professionally or financially. 

 

Damage Control:  When Patients are not Mobile, the Hospital is Mobile

Different hospitals have developed various survival tactics; all of them have undergone changes in consumer patterns and service provision. Some examples:

Creating unique services:  Augusta Victoria Hospital has recently opened an advanced oncology department, the only one in the Occupied Territories that provides radiation treatments for cancer patients. In addition, the hospital operates a pediatric dialysis unit, also one of its kind in the Territories.  Thus the hospital guarantees that patients will make an effort to get to it, and that the Palestinian Authority will make referrals to it, simply because it is the sole provider of these services.  

Organized transportation: In addition, since September 2004 Augusta Victoria's management has been organizing transportation for patients and medical staff from the West Bank.  This project is called "Health and Hope Cross the Barrier" and its objective is to assist patients and staff by ensuring fast passage at the checkpoints. Other hospitals also prefer to bring in patients by organized transportation. 

This is not an optimal solution that can neutralize the occupation's bureaucracy, as arriving in these transports also requires an entry permit from the Israeli security forces for each Palestinian who wishes to get treatment at a Jerusalem hospital. Nor is organized transportation a solution for patients who need to get to the hospital in an emergency, or for staff summoned urgently to work, especially in the evening or at night. 

Dr. Naim Salameh, a 54-year old Abu-Dis resident, is a senior oncologist and director of the emergency room at Augusta Victoria Hospital.  Dr. Salameh is often summoned to the hospital at night for emergencies. He applied several times to the Civil Administration for an entry permit into Jerusalem by private car.  Before construction of the barrier in the Abu-Dis/Izariyeh area, Dr. Salameh was able to get to the hospital with an individual permit within 10-15 minutes. Now, in absence of direct access from Abu-Dis to Jerusalem he must go through a-Zayam checkpoint, at least twenty minutes' drive to Augusta Victoria. The difficult situation is made impossible at night when he is on call and is summoned to the hospital, because there is no public transportation and it is very hard to find an Israeli cab in Abu-Dis at night. Calling a cab from Jerusalem means doubling the time it would have taken for him to get there on his own. Dr. Salameh's inability to get to the hospital in a reasonable amount of time has cost human lives.

On November 17, 2003, PHR-Israel petitioned the High Court of Justice on Dr. Salameh's behalf, demanding the military authorities allow him to drive to the hospital in his own car (HCJ 10261/2003). Following a few months of negotiations, the petition was canceled, as its prospects were hopeless. Dr. Salameh remains prohibited from driving his own car to work, despite the risk this poses to human lives. 

Moving services to the east side of the barrier: As part of Augusta Victoria Hospital's attempts to ease patients' access, it opened a medical center in Ramallah at the end of December 2004.  The center includes outpatient clinics with most of the specializations that exist in the Jerusalem hospital. The center is operated by the hospital's own staff, and is intended to be an alternative address for patients who are having difficulty getting to the hospital in Jerusalem because of the obstacles on the way. As part of the service it provides, the center makes referrals and arranges transportation for patients who need continued treatment or surgery at the hospital in Jerusalem.

Augusta Victoria's endeavor may be viewed as an attempt to help patients and ease their access to the care they need; it may also be construed as Palestinian submission to the barrier, which serves Israel's interest in cutting East Jerusalem off from the rest of the Occupied Territories and restricting West Bank Palestinians' entry into Jerusalem.  

Mobile clinic: The management of Saint John's Hospital has reinforced its mobile clinic, in operation in the West Bank since 1982, with a second, similar, clinic. Each of the clinics is staffed by medical personnel with equipment and medication, who go twice a week to remote villages and refugee camps in the West Bank; there they provide free medical treatment to populations whose access to Jerusalem has been blocked because of the barrier and the checkpoints. The mobile clinic also refers patients to hospitals for continued treatment and surgery; some patients are covered by the Palestinian Authority or UNRWA, and others receive care free of charge.

Patients referred by Saint John's mobile clinic's physicians for continued treatment in Jerusalem must request an entry permit into Jerusalem from their local DCO. The original summons from the hospital's mobile clinic makes it difficult for the Israeli authorities to reject the application.

Creating parallel hospitals on the east side of the barrier:  For the past few years, there have been reports of efforts to open a teaching hospital in Abu-Dis, east of Jerusalem.  This initiative is to be funded by the Japanese government, in coordination with, and assisted by, Israel. The new hospital is intended to serve al-Quds University's medical school, thereby offering an alternative to Mokassed Hospital as the only teaching hospital in the Occupied Territories. The new hospital is also meant to serve the Palestinian population east and south of Jerusalem, whose freedom of movement to medical services in Jerusalem has been restricted, especially after the building of the barrier south and east of the city.

While the planned hospital is intended to ease patients' and students' access to medical treatment, it will contribute, in the long term, to disconnecting Jerusalem from the rest of the West Bank. Moreover, creating an alternative hospital to Mokassed may put Mokassed at risk for closure, after its decades-long reputation as the most advanced medical center in the Occupied Territories.

It is not surprising, then, that at the cabinet meeting that decided to provide services to the Palestinian population cut off from the city by the barrier, the government offered hospitals assistance in opening branches beyond the barrier. This "bear hug" is clearly motivated by the interest of complete separation: if there is no flow of patients to the hospitals, the hospitals will cease to operate[57].

 

The Future of Palestinian Medicine: al-Quds University Medical School

In all the years of occupation, Israel has not allowed Palestinian students to study in Israel. Whoever wished to study medicine had to travel outside the area, usually to Eastern European countries.  When the PA was created, one of its goals was to create a future for local medicine.

The Faculty of Medicine was created in 1994, as part of al-Quds University in Abu-Dis. This institution has great significance as the only one that trains physicians in the Occupied Territories. Graduates receive a Palestinian work license to practice medicine, following six years of study and two years' residency at Palestinian hospitals in East Jerusalem, where a wide range of specialization fields is available. The practical studies beginning in the fourth year of studies take place mostly at Mokassed Hospital, as well as at other hospitals in East Jerusalem and elsewhere in the Occupied Territories. The demand for studying at the al-Quds Medical School is constantly on the rise by high school graduates all over the West Bank and Gaza Strip. Four classes have graduated so far, and enrollment is now at 290, including 60% women.

The degree awarded by al-Quds University is not recognized by the World Health Organization, based on the UN regulations that only accept certification by universities in countries recognized by the UN. Subsequently, the al-Quds University Medical School has appealed to other countries, including the US, Canada and Britain, all of whom have agreed to recognize al-Quds certification and open their doors to its graduates for work or residency. Israel does not recognize the al-Quds degree and bars its graduates from doing residencies at, or being employed by, Israeli hospitals. Israel also prevents them from working at Palestinian hospitals in East Jerusalem (see section on medical staff).

Notwithstanding the assistance received from local and international organizations, students face many hardships on the way to the degree, primarily difficulties in access to the Abu-Dis campus and to Mokassed Hospital. Harsh restrictions have been imposed on the students' freedom of movement: according to Civil Administration policy, a Palestinian under age 24 cannot receive a magnetic card, a prerequisite for applying for a permit for passage within the Occupied Territories and/or between the Territories and Jerusalem. Therefore the large majority of Palestinian students, including medical students, could not get these permits. Before September 2000, some traveled to the university via detours, and others chose to live close to the university, avoiding the tiring daily trip, full of uncertainty, to another day of studies. In January 2005, al-Quds Medical School administration was able to reach an agreement with the Civil Administration that medical students would be able to apply for a magnetic card from age 21. Consequently, some of the medical students, residents of the West Bank only, received permits to travel between parts of the West Bank and the Abu-Dis campus, and between the campus and East Jerusalem.

The problem became more acute with the outbreak of the Intifada in September 2000 and the proliferation of checkpoints all over the Occupied Territories, particularly at entrances to East Jerusalem. Students' arrival at East Jerusalem hospitals has become a nearly impossible task:  the eastern section of the barrier being completed around Jerusalem runs only meters from the Abu-Dis campus, separating the medical school, which is on the eastern side of the barrier, from the East Jerusalem Palestinian hospitals on the western side.  Students from the Gaza Strip are in a particularly difficult situation. Their access to Jerusalem was never easy, but since September 2000, Israel does not allow their access to the medical school at all. On July 23, 2002, Israeli forces entered the university, arresting two students from the Gaza Strip and deporting them back to Gaza.

The medical school attempted to partially resolve Gazan students' predicament through the assistance of the Gazan institutions al-Azhar University, al-Shafa Hospital and the European Hospital, which allowed these students to make up practical training. As these are not teaching hospitals, however, this solution constitutes a significant compromise both in terms of the academic standards set by the medical school and of the essential connection between the West Bank and the Gaza Strip. In addition, some of the studies take place via lecturers sent from the West Bank to the Gaza Strip, and some via videoconferencing[58].

These harsh restrictions severely infringe upon Palestinians' opportunity to produce a suitable medical reserve necessary for the creation of an independent, efficient health care system.  Furthermore, up until a few months ago, young people from the Gaza Strip wishing to study at higher education institutions abroad were thwarted by the inflexible Israeli policy barring men ages 16-35 and women up to age 25 from leaving Gaza's borders. This policy prevented hundreds of young people from going abroad to begin or continue their studies, and prohibited young doctors from going for their residencies abroad[59].

PHR-Israel contacted the Coordinator of Government Operations in the Territories protesting the damage done to the education system, particularly to medical studies.  We asserted that these restrictions deprive Palestinian society of the opportunity to plan and build a specialized society able to fulfill its future needs.  It takes no small measure of cynicism on the part of Israel to contend on the one hand that the Palestinian Authority is responsible for malnutrition and for providing health care services in its jurisdiction, while reserving the right on the other hand to restrict development of health care and education services. No response to our complaint has been received.

 

Preventing Palestinian students, particularly Gaza Strip residents, from studying medicine is an ongoing Israeli policy. Throughout all the years of occupation, Israel has not allowed Palestinians to pursue medical studies at Israeli universities. Palestinian young people wishing to do so have had to study abroad, placing a heavy financial burden on their families. Having nothing to do with students' security backgrounds, Israel's arbitrary policy prevents Palestinians from realizing training opportunities, their right to education, their personal futures and the future of the society they wish to serve. Preventing passage from Gaza Strip to the West Bank also contradicts the Oslo Accords, which obligate Israel to preserve the territorial integrity of the two areas[60].  

N. is a 24-year-old Jenin resident, a sixth-year student at al-Quds University's Medical School. Since the beginning of her practical training at Mokassed, N. has been barred from entering Jerusalem on the grounds that she is under the minimum age for a magnetic card and a permit. After removal of the age condition, N. was again denied a permit, this time on security grounds. In December 2004, after all of N.'s efforts, even with the assistance of both the medical school and the hospital, failed, she contacted PHR-Israel requesting our help in getting the restriction removed. PHR-Israel contacted several authorities, including the Jenin DCO, the Civil Administration's Health Coordinator, and the military's Legal Advisor. Only then did it become apparent that a police restriction had been placed on N.'s entry into Jerusalem, because in the past she entered without a permit, and has since been classified as staying in Israel illegally. N.'s sixth and final school year is supposed to begin in mid-September 2005, and the case still awaits resolution.

 

Suffocating Jerusalem:  Summary[61]

The debate on Jerusalem and its status touches upon the most sensitive nerves of the conflict, and is of considerable impact in the international arena. It is particularly astonishing, then, that facts are being established on the ground without interference, by the only player on the field: Israel. From what we have learned about the manner of planning and decision-making regarding the barrier's route, it is clear that the health and welfare of the Palestinian population is not a significant, if at all existent, consideration in the Israeli government's decisions. Unilateral, calculated political maneuvers, which violate many basic human rights of Palestinians and contradict international agreements, are facilitated by the apparent lack of interest or pressure by Israeli society and its legal system, as well as on the part of international groups.

The cutting off of hospitals in East Jerusalem from the rest of the Occupied Territories is a gradual process which can only be perceived as calculated, intended to serve political ends.  Requiring patients who wish to get to hospitals to obtain permits has in turn led to hospitals' dependence on Jerusalemite patients, who are referred through Israeli health maintentance organizations (kupot holim). Hospitals have been required to comply with permits, quotas and licenses for their staff, all in keeping with the times, and serving the needs of the Israelis.

The implications of the closure and the barrier on hospitals are devastating. As far as Israel is concerned, hospitals are not a target in themselves, but rather a symbol of urban life in what is, still, a Palestinian metropolis. Clearly, as we head for possible negotiations, or even without negotiations, Israel is willing to tolerate the presence of "Palestinian residents of East Jerusalem" but not the presence of a Palestinian center declaring itself as such. The connection with the West Bank is, therefore, the initial target for destruction by the barrier.

The survival tactics adopted by the hospitals are just that: good for the short term and for economic survival, as long as Israel does not take di