Oversight and Transparency in

the Israeli Penal System

July, 2008

Research and Writing: Anat Litvin

Niv Michaeli
Gila Zelikovitz

Editing: Hadas Ziv

Translation from Hebrew: Charles S. Kamen

English Editing: Miri Weingarten

1
Contents
Introduction 3

Mechanisms for dealing with prisoners'1 complaints,

and systemic faults in these mechanisms in Israel 7
Prisoner petitions 7
Petitions to the Prison Director and to the Prisons' Commissioner 9
Petitions to the Israeli Police/National Unit for Investigating Prison Staff (NUIPS) 10
Petitions to the Ombudsman in the Ministry of Public Security 11
Petitions to the Ombudsman in the Office of the State Comptroller 13
Petitions to Official Visitors 13
The Ministry of Health Ombudsman 13
Appeals to Physicians for Human Rights-Israel 16

Prison Service External Oversight Mechanisms:

Theory vs. Practice 18
External oversight of the Israel Prison Service (IPS) 18
Problems with external oversight of IPS 19
Transparency regarding health 23

Efforts by Physicians for Human Rights-Israel to

ensure external oversight over implementation of the
Right to Health behind prison bars. 27

The costs of concealment 32

Failures in the Israel Prison Service Health System - Systemic failures 33
Failures in the Prison Service Health System - individual cases 40

It could be different – Transparency in other countries 43

Recommendations 50

Responses 52

1
The term prisoner is used in this context to denote persons held by the Israel Prison Service. When
not quoting Israeli legislation, the more general term "inmate" is employed.

2
Introduction

The common opinion of human rights organizations, as well as that of many

organizations throughout the world responsible for jails and prisons, is that the most
effective way of ensuring inmates' rights, appropriate conditions of incarceration and
access to medical treatment involves increased transparency of jails and prisons,
oversight by external authorities and availability to inmates of effective mechanisms
for complaining about prison conditions.

The idea of external oversight has become a reality in many European countries.
The Council of Europe has adopted the European Convention for the Prevention of
Torture (ECPT), and has created a body that oversees European prisons. The
Convention has established the European Committee for the Prevention of Torture
(CPT), which conducts unannounced visits to all prison facilities in member states of
the European Union.

When the United Nations adopted the Optional Protocol to the Convention Against
Torture (OPCAT), the idea of external oversight received international recognition.
The innovative nature of the Optional Protocol, which went into effect on 22 July
2006, is expressed by its dual system of visits, in which both an international body
and state-level control mechanisms are involved in oversight of prison administration.
International oversight is conducted by the Sub-committee on the Prevention of
Torture (SPT) of the United Nations. In addition, each European Union member state
obligates itself to create one or more oversight bodies that will operate as National
Preventive Mechansims (NPMs).

European Union member states have a certain degree of freedom regarding the
nature and the structure of their oversight mechanisms so long as their mandate, the
tools at their disposal and their areas of responsibility meet the criteria specified by
the Optional Protocol. Independence and freedom of action are critical in this respect,
and member states must ensure that national oversight bodies enjoy this freedom
and independence. National oversight committee members and staff must be free
both personally and organizationally from any dependence on government
institutions. They must also be financially independent.2

2
From the report of the International Association for the Prevention of Torture (APT):
"Visiting places of detention – What role for physicians and other health professionals?”
http://www.apt.ch/component/option,com_docman/task,cat_view/gid,121/I
temid,59/lang,en/

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The Israel Prison Service (IPS) operates away from the public eye, without
appropriate external oversight, particularly with respect to inmates' access to medical
services and to the quality of these services. This situation is even more serious in
view of the fact that inmates have no external body with authority vis-à-vis the IPS to
which they can address their complaints.

The IPS medical services are under the authority of the IPS and of the Ministry of
Public Security, two bodies whose principal concern is security and which have no
special competence in medical and health matters. The Ministry of Health has no
authority over IPS medical services or its physicians3 (with the exception of the IPS
mental health services, whose physicians are under the authority of the Ministry of
Health, not the IPS, even though the IPS mental health center – MHC - and the
conditions of incarceration of those held there, are the responsibility of the IPS itself).
IPS physicians are not members of the Israel Medical Association (IMA), and the IMA
Ethics Board claims that it is unable to oversee them, even when they violate
principles of medical ethics.

The prison system, by its very nature, confronts its medical personnel with problems
of dual loyalty, i.e., explicit or implicit obligations both to the patient and to the
organization, which hamper the ability of medical personnel to act on the basis of
independent clinical judgment, make unbiased treatment decisions, be completely
loyal to the patient and provide the best possible care. IPS physicians are completely
subordinate to the institution that employs them, have insufficient contact with the
medical system outside the prisons and are subject to insufficient oversight by
external medical bodies. The fact that these physicians depend on the IPS for their
livelihood makes it difficult for them to maintain their professional judgment in the
face of "systemic constraints." IPS physicians work with a difficult population, both in
terms of the kinds of medical problems they present as well as in their response to
treatment; they feel alienated and sometimes even hostile toward the patients, some
of whom may actually endanger the physicians. All these factors present obstacles to
the physicians' ability to provide the best care, equal to that provided to persons
outside prison, and to which inmates are legally entitled.

3
Knesset – Research and Information Center: Background paper to a hearing dealing with the Israel
Prison Service Medical Center, 27.5.2002
The response of Dr. Isaac Berlovitz, Acting Deputy Director General, Ministry of Health, to Ms. Hadas
Ziv, Physicians for Human Rights, 24.2.2002

4
The case of Ahmad al Tamimi
Ahmad al Tamimi is a Palestinian inmate serving life-imprisonment since November
1993. He is married with three children.

For the past approximately six years he has suffered from renal failure, for which
condition he receives hemodialysis, and is hospitalized in the IPS medical center
(IPSMC).

Six years ago a family member offered to donate a kidney to al Tamimi, who applied
to the IPS in order to undergo tests to determine whether he was an appropriate
transplant candidate. It should be noted that the procedure for Israelis (who are
insured under the Israeli National Health Insurance Law) who wish to evaluate organ
matching for a transplant from a living donor, takes a few weeks at the most. Al
Tamimi's procedure began in May 2002, and the first stage was completed around
July 2003 (when Physicians for Human Rights-Israel received confirmation from the
IPS that it had completed the tests). A further delay in the transplant process
occurred because the IPS did nothing to further the tests of the organ match between
donor and recipient, even though it had received the necessary information regarding
the donor.

In 2005, IPS Chief Medical Officer (CMO) Dr. Alex Adler announced that the
operation would cost $90,000, and that the donor would have to cover the cost.
PHR-Israel protested, claiming that, according to the response of the IPS itself to
previous petitions, it had committed itself to providing all inmates with medical care
equal to that included under the range of services offered free of charge to Israeli
citizens by the Israeli National Health Insurance healthcare provider "Klalit", and
stating that organ transplants from living donors are included in this range of
services.

The IPS CMO claimed that the treatment was neither urgent nor life-saving, and
since there was no obstacle to the inmate continuing to undergo dialysis, a transplant
was unnecessary.

It is known that a transplant significantly increases the life expectancy of persons

suffering from renal failure, and it certainly improves their quality of life. A PHR-Israel
volunteer, the director of the NePHR-Israel ology Department at a major medical
center, wrote, "…The life expectancy of patients aged 40-44 undergoing
hemodialysis is approximately 8 years, as opposed to 23 years after a transplant.

5
Moreover, the earlier the transplant is carried out, the greater the improvement in life
expectancy."

After PHR-Israel appealed to the Israeli High Court of Justice in October 2005,
requesting that it order the IPS to cover the cost of the transplant, it took 24 months
for a ruling to be handed down, according to which the IPS must pay for the
transplant. Part of the delay was due to the refusal of the transplant center at the
Rabin Medical Center to provide test results and data about the donor and the
recipient, and the hospital released the information only after PHR-Israel contacted
the press. The IPS, for its part, made no effort at any stage of the process to
facilitate the transplant. Instead, the IPS preferred to argue about funding
preparatory tests for the donor, despite the fact that it had undertaken to fund all the
tests required to determine whether the donor and the recipient were able to undergo
a transplant, before discussing funding the transplant itself.

In PHR-Israel 's opinion, this situation could not have come about had medical
services in the IPS been provided under the Israeli National Health Insurance Law,
and were IPS physicians and the services they provide not under the authority of the
IPS and the Ministry of Public Security, but rather under some other body – for
example, the Ministry of Health.

In our view, had al Tamimi been able to apply directly to a body external to the IPS in
order to complain about the delays in the tests and in access to the High Court of
Justice, about the failure of the prison to provide an appropriate diet, about delays in
carrying out dialysis treatments, etc., the medical procedures would have been
carried out more efficiently, and would have saved the patient and his family much
suffering, if not actually lengthened his life.

This report will describe the IPS oversight systems, and the mechanisms by which
inmates may submit complaints. We will present examples of failures within the IPS
medical system that could have been prevented by an appropriate system of
oversight, and will present examples of prison systems in other countries that operate
differently from the Israeli system, and thereby better protect inmates' rights.

6
Mechanisms for dealing with inmates'
complaints, and systemic faults in these
mechanisms in Israel

The bodies to which inmates can apply in order to complain about the conditions of
their incarceration and the medical services they receive are detailed in the Israel
Prison Service directives, the IPS Commission Ordinance, the Prisons Ordinance
and the State Comptroller Law. The chief mechanisms that allow inmates to complain
to external bodies, according to these laws and regulations, are reviewed below.

IPS Commission Ordinance number 04.37.00 – Prisoners' complaints, specifies a

number of mechanisms through which inmates may submit complaints about the
conditions of their incarceration:

Prisoners' petitions
Mechanism: According to the Ordinance, every inmate is entitled to petition the
District Court with regard to any matter concerning his arrest or imprisonment. The
petition must be submitted in six copies, which the inmate must give to the director of
the prison ward. The director of the prison ward must provide the inmate with signed
confirmation that he received the petition, and transmit it without delay to the Deputy
Prison Director. A copy of the petition must be transmitted within 48 hours from the
prison to the Clerk of Court.

The material transmitted to the court should include the original version of the
inmate's petition, a form containing information on the inmate from the "Tzohar"
system (the IPS central computerized information system), an affidavit for
confirmation of the petition signed by the inmate in the presence of the Deputy Prison
Director, and a request for waiver of the court fee if the inmate so desires.

Paragraph 10 of the Ordinance specifies that, concurrent with transmitting the

petition to the court, the prison ward director must undertake an initial inquiry in an
attempt to resolve the problem referred to in the petition. If the problem has not been
resolved, the inmate will be interviewed by the Deputy Prison Director, who will try to
resolve the problem within the prison framework. If a solution is found, the Deputy
Director will notify the District Petitions Officer, who will notify the court via the State's

7
Attorney's office. If no solution is found, the Deputy Prison Director must respond
within 14 days to all the claims raised in the petition, and attach all relevant
documents.

Paragraph 12 stipulates (contradicting, to some degree, Paragraph 10): "A member

of the [Israel Prison] Service shall do nothing that is likely to prevent, delay or
interfere with the submission of a petition to the court, its transmission or the
treatment it receives. No pressure whatever may be exerted on the inmate, directly or
indirectly, to withdraw his petition."

Problems with the implementation of the mechanism: Inmates who wish to

submit a court petition face a number of obstacles:

1. Language. Petitions must be submitted in Hebrew, and not all inmates are fluent
in Hebrew. Palestinian inmates are the main victims of this obstacle, but Israeli
inmates of Russian, Ethiopian or other origin also have difficulty submitting a
written petition, either because they are illiterate in Hebrew or because
formulating a petition is impossible for them.
2. Multiple copies of the petition. According to what inmates have told us, the prison
does not provide them with carbon paper, or allow them to use a photocopy
machine, in order to prepare six copies of the petition as required by the
commission ordinance. Having to write six separate copies of the same petition
can thus present an additional obstacle to utilizing this tool.
3. Transmitting the petition via the prison ward director and the Deputy Prison
Director. Most petitions submitted by inmates naturally refer to the actions of the
prison staff. The fact that the prison ward director and the Deputy Prison Director
can read the petition creates a danger of sanctions being imposed on the person
submitting it. Inmates who have contacted Physicians for Human Rights-Israel
report that such sanctions are in fact applied, or that pressure involving threats of
various sanctions is placed on those submitting petitions in order that they
withdraw them.
Commission regulations relating to the submission of prisoners' petitions
contain a contradiction between what Paragraph 10 of the Ordinance specifies,
that the prison ward director and the Deputy Prison Director are required to try to
resolve the issues raised in the petition within the prison framework by meeting
with the inmate, and what is specified in Paragraph 12, which prohibits staff from
interfering in any way with the submission of a petition or from pressuring the

8
 petitioner to withdraw his/her petition. Efforts to resolve the petitioner's complaint
within the prison framework provide the prison ward director and the Deputy
Prison Director with many opportunities to exert impermissible pressure on the
petitioner, and it may be inferred from Paragraph 10 that exerting such pressure
is desirable.
4. A large number of prisoners' petitions, preventing timely response. This obstacle
arises mainly in cases requiring immediate attention. An urgent petition is to be
submitted directly to the on-duty judge, a route that is not open to inmates who
are unable to contact the judge.
5. Procedural delays. The fact that the State Attorney does not respond to petitions
prior to the court hearing lengthens the judicial process and delays the decision
of the court.
6. Legal representation. Most of the inmates submitting prisoner petitions are not
represented by counsel. They can't afford an attorney, and the court must
approve representation by the Public Defender's Office, which is not often
granted to these petitions. The problem is particularly serious in the case of
inmates whose Hebrew is poor or who suffer from psychological problems.
7. Pressure to withdraw a petition. Inmates in different prisons reported to us that
after submitting their petition they were approached by prison staff members who
attempted to dissuade them from continuing the procedure. Sometimes these
approaches were accompanied by threats of various sanctions, and at other
times the inmate was promised benefits and a solution to the problems that had
led him to petition the court. In some cases, inmates reported a deterioration in
the conditions of their incarceration followard the submission of a petition - for
example, transfer to a ward or a prison considered to be less desirable.

Petitions to the Prison Director and to the IPS

Commissioner

Mechanism: The complaint must be submitted in writing, specifying the full name
of the inmate and signed by him, to the prison ward director or the shift commander.
An oral complaint may be submitted in an interview with the Prison Director. The
Commander's response must be given to the inmate within seven days of receiving
the complaint. If the Prison Director concludes that the complaint is unjustified, and
involved a premeditated, baseless accusation directed against a member of the
prison staff, he will transfer it to the legal advisor to determine whether it is possible
to initiate legal proceedings against the inmate.

9
If an inmate does not receive a response to his complaint, if the response was
unsatisfactory or if the complaint was directed against the Prison Director himself, the
inmate is permitted to submit his complaint to the IPS Commissioner. The Prison
Director is the person responsible for transmitting the inmate's complaint to the
Commissioner, without delay, accompanied by his own comments if he so wishes.
Inmates' complaints addressed to the Commissioner are dealt with by the officer in
charge of complaints and appeals from the public in the Commissioner's office.

Problems with the implementation of the mechanism: The same difficulties

previously noted regarding the requirement that the complaint be submitted in writing,
also apply here. Although it is possible to complain orally to the Prison Director in the
course of an interview with him, an appeal to the IPS Commissioner is possible only
in writing. The fact that the Commissioner can transfer the inmate's complaint to the
legal advisor, in order to decide whether to institute legal proceedings against him if
he finds that the complaint is unjustified or was a premeditated, baseless accusation
against a member of the prison staff, also represents an implied threat against the
inmate who wishes to complain. The fact that it is the Prison Director who transmits
complaints to the Commissioner can also deter inmates from addressing complaints
to him.

Petitions to the Israel Police/National Unit for Investigating

Prison Staff (NUIPS)
Mechanism: Paragraph 58 of the Criminal Code (combined version) 1982, states:
"Any person may complain to the police regarding a crime that has been committed."
Thus, inmates are also allowed to complain to the police. If a complaint is directed at
a member of the prison staff it will be transmitted to the NUIPS (National Unit for
Investigating Prison Staff).

Problems with the implementation of the mechanism: An appeal to the

NUIPS can be made by phone, fax or post. The first two methods are unavailable to
Palestinian inmates; the second is also unavailable to other inmates.

Petitions to the NUIPS often refer to violence by prison staff against inmates. Dealing
with such complaints requires obtaining statements from witnesses as quickly as
possible, as well as physical evidence of violence on the inmate's person. Contacting

10
the NUIPS by post makes it difficult to collect evidence quickly enough to document
the incident and investigate it adequately.

Moreover, as is the case with complaints to other bodies, the fact that the inmate
must give to a member of the prison staff an envelope addressed to the NUIPS can
be an obstacle to submitting the complaint.

Petitions to the Ombudsman in the Ministry of Public

Security
Mechanism: The function that deals with inmates' complaints is the Prisoners'
Complaints Officer (PCO). The complaint is submitted in writing to the Prison Director
via the prison ward director or the shift commander, and includes the inmate's full
name and his signature.

In addition, every prison should have a receptacle located near the office of the
Prison Director or the Prisoners' Officer, on which is clearly written in Hebrew, Arabic
and Russian: "Complaints by prisoners to the Comptroller of the Ministry of Public
Security and the Ombudsman." Complaints are put in the box after being inserted
into a white envelope provided to inmates upon request by the prison ward director.
He is also the person to whom the inmate gives the envelope containing the
complaint, and he inserts it into the box. The prison ward director is supposed to
document this in a log designated for this purpose. The prisoner may ask to insert the
envelope in the box himself, and must be allowed to do unless security
considerations prevent it.

Every prison ward should have a bulletin board with an announcement in Hebrew,
Arabic and Russian announcing the right of every inmate to complain, and specifying
the manner of doing so.

The PCO may be petitioned by telephone, and if he finds that the case warrants
immediate intervention he can hold an inquiry and decide on appropriate action.

The PCO can request a meeting with the inmate complainant, or a member of the
prison staff, in coordination with the Prison Director. The PCO has no investigative
authority, nor is he allowed to interrogate inmates or prison staff.

The PCO transmits the complaint to the Ombudsman according to what is specified
in Commission Ordinance 04.37.00. The Ombudsman responds to the PCO.

11
When inquiry into the complaint has been concluded, the PCO sends his response to
the inmate complainant, with a copy to the Ombudsman.

Problems with the implementation of the mechanism: According to Prison

Service regulations, inmates may appeal to the prisoners' ombudsman in the office of
the Comptroller of the Ministry of Public Security. The fact that one person in the
Ministry of Public Security is supposed to deal with potential complaints from more
than 20,000 IPS inmates is not reasonable. A single person cannot carry out the task
of ensuring the rights of all IPS inmates held in prisons throughout Israel and the
occupied Palestinian territory (i.e., Ofer Prison, located beyond the 1967 border).
Evidence for this lies in the fact that between July and December, 2007, PHR-Israel
forwarded to the Ombudsman 45 appeals for assistance that we had received from
inmates. Immediately after we began sending complaints, the PCO informed us that
he was unable to respond in writing to each appeal, but that he would examine all the
complaints we sent to him. In response to further questions, we were informed by
Attorney Liat Shalem, director of the ombudsman's office in the Ministry of Public
Security, that the office does not, as a rule, deal with complaints copies of which are
transmitted to it solely for informational purposes, but only with complaints addressed
to it directly. Attorney Shalem added, however, that a review of the appeals we sent
which they succeeded in locating indicates that in most cases the PCO did ascertain
that the Director of the Prison Medical Services was dealing with our appeals.

Notwithstanding the fact that, according to the Commission Ordinance, it is possible

to complain to the ombudsman by telephone, and if he finds a case that justifies his
immediate intervention he can inquire and deal with it accordingly, this alternative is
closed to Palestinian inmates, who comprise more than half the inmate population in
IPS installations. Palestinian inmates are forbidden to use the telephone, regardless
of whom they are calling, whether a relative in the oPt or the Israeli ombudsman.

Inmates also report that some prisons don't have boxes in which envelopes may be
placed. Complaints regarding the lack of boxes were received from the following
prisons: Rimonim, Ashmoret, the IPS medical center and Nitzan. Other inmates were
unaware of the procedure when asked about it. The location of the complaints box
near the office of the Prison Director or of the Prisoner's Officer could also constitute
an obstacle to its use. Inmates are imprisoned in wards, and a prisoner going to the
office of the Prison Director or of the Prisoner's Officer must be accompanied by a
member of the prison staff, who can pressure someone intending to complain not to
do so.

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Palestinian inmates are unable to telephone the Ombudsman because, as noted
above, they are not permitted to make telephone calls.

Petitions to the Ombudsman in the Office of the State

Comptroller

Mechanism: The State Comptroller's office possesses, by law, investigative

authority over every government institution (State Comptroller Law 1958 [combined
version]). The State Comptroller is therefore authorized to investigate and examine
the operation of the IPS and the behavior of its employees, as well as to receive
complaints from inmates. Prisoners submit complaints to the Ombudsman using the
same system of white envelopes described earlier.

Problems with the implementation of the mechanism: Here as well, use of

white envelopes inserted into the complaint box is problematic, as already described.

Moreover, the State Comptroller addresses the activities of government institutions

and examines whether they accord with the law and good administrative practice.
The Comptroller does not view his role as one that involves investigating the
behavior of individual members of an organization, or specific shortcomings in the
treatment of an individual inmate, despite the fact that these can provide an
indication of how the IPS as a whole operates. For this reason, the State
Comptroller's office is not an appropriate address to receive and deal with inmates'
complaints.

Petitions to Official Visitors

Inmates are able to petition Official Vistors, as specified in Commission Regulation

03.04.00. We will discuss this mechanism more fully in Part II: Official Visitors.

The Ministry of Health Ombudsman

Mechanism: This mechanism does not appear in the Commission Regulations, but
represents an additional address to which inmates can turn. The Ombudsman for the
Ministry of Health, who deals with complaints connected to medical services, may
also receive complaints from inmates. They are rightfully considered to be members
of the public, despite the fact that the IPS medical service is not under the authority

13
of the Ministry of Health. As far as PHR-Israel is aware, appeals to the Ministry of
Health Ombudsman are to be made by fax or by mail.

Problems with the implementation of the mechanism: The vast majority of

inmates turning to us were not aware they could appeal to the Ministry of Health
Ombudsman. PHR-Israel learned, in dealing with inmate complaints, that even if one
does reach the Ombudsman, difficulties arise in how it is dealt with, and how long it
takes to do so.

Since mid-2007, we have forwarded every inmate complaint concerning

medical treatment received by PHR-Israel to Dr. Alex Adler, the IPS Chief Medical
Officer (CMO), to Mr.Hasharon Michael, the Ministry of Public Security Ombudsman,
and to Prof. Shimon Glick, the Ministry of Health Ombudsman. On 21.4.08, we
analyzed the responses of the Ministry of Health Ombudsman to PHR-Israel. During
the period under consideration we forwarded 59 complaints to Prof. Glick. Regarding
25 of them, we received the following reply: "I confirm receiving your letter that
arrived at our office on [the date the letter was received]. We have begun to examine
the complaint, and will notify you of our findings when we have finished. I should like
to inform you that sometimes, of course, the process may take a long time." We
received a final reply regarding 13 out of the 25 complaints, after their investigation
had been completed. We have not yet received a response regarding the other 12,
some of which have already been in Prof. Glick's possession for a number of months,
and even for half a year. In any case, Prof. Glick's initial response took between two
and three months to arrive, and a final reply came after at least six months. In total,
Prof. Glick replied to 29 out of the 59 complaints we forwarded to him, and provided a
final answer only to 17 of them. Thirty complaints received no reply at all.

The Ombudsman's replies to us indicate that in many cases his examination

is limited to presenting the complaint to the IPS Chief Medical Officer and obtaining
his response. We confirmed this in a telephone conversation with Prof. Glick's
secretary. She told us that Prof. Glick examines the complaints reaching him
regarding medical treatment of inmates in conjunction with the IPS Chief Medical
Officer, so that there was no point in our sending complaints to the Ministry of Health
Ombudsman. We were recommended to forward them directly to the IPS CMO –
since he is the one who in any case responds to questions connected to his
activities, and to the functioning of medical personnel under his direction. Of the 17
complaints to which we received a final reply, the Ministry of Health Ombudsman

14
accepted the response of the IPS CMO without carrying out any further investigation.
In only two cases was any further investigation undertaken, such as an examination
of the medical record.

To sum up: In 88% of the cases in which a final reply was received from the
Ministry of Health Ombudsman, the matter was resolved on the basis of the IPS
reply. Approximately 50% of the cases we forwarded to the Ministry of Health
Ombudsman received no reply at all. The procedure whereby inmate complaints
forwarded to the Ministry of Health Ombudsman are examined only in conjunction
with the IPS CMO, is flawed. The CMO has a clear interest in presenting the IPS
medical service as faultless. The length of time required to examine the complaints
makes the Ministry of Health Ombudsman an ineffective instrument for dealing with
inmate complaints about medical treatment. Such complaints, by their nature, often
require immediate attention, as in the following case:

On 30.10.07, PHR-Israel was contacted by an inmate who had been in touch with us
on previous occasions because he suffers from a number of chronic health problems.
He is on a medications regime and his pulmonary function must be regularly tested.
Failure to provide him with medicine, or to carry out the pulmonary tests, endangers
his health and may also be life-threatening. The inmate told us that he was
scheduled to be examined in the pulmonary clinic at the Rabin Medical Center on
23.10.07, but was informed by the prison medic on the evening preceding the
examination that he would not be going for the test because the referral was lost.
The inmate informed PHR-Israel that a new date had been set, to 21.11.07. In order
to insure that the inmate underwent the test, which was crucial to maintaining his
health, we reported the incident to the IPS CMO, with a copy to the Ministry of Health
Ombudsman.

At the beginning of November, the Ministry of Health Ombudsman responded that

the matter was being examined.

08.11.07 We received a reply from the IPS CMO, informing us that the prison clinic
was unaware of tests scheduled for that inmate on any of the dates referred to, and
that his condition was good and stable.

21.11.07 We received Prof. Glick's reply, stating that he accepts Dr. Adler's response
and considers the matter resolved.

15
03.12.07 The inmate contacted PHR-Israel and informed us that he wasn't taken to
the second appointment either.

23.12.07 In response to a request from PHR-Israel, the hospital sent us confirmation

of the two appointments reported by the inmate, on 23.10.07 and 21.11.07. We
transmitted the confirmation to the IPS CMO on the same day. We requested that he
ensure that the inmate undergo the necessary tests, and also requested to know the
date of the scheduled test. We sent a copy of our letter to the Ministry of Health
Ombudsman.

26.12.07 In his reply, the IPS CMO refused to address our request, claiming that "the
IPS is not set up in a manner that permits it to respond regarding individual cases of
tests or treatment of inmates and to provide regular [emphasis in the original]
updates regarding their condition." [IPS CMO to PHR-Israel chairman, 26.12.07]

02.01.08 PHR-Israel wrote to the Ministry of Health Ombudsman, claiming that the
behavior of the IPS was unreasonable. In our letter, we requested that the
Ombudsman continue to deal with the case.

03.01.08 We received a reply from the Ombudsman (letter dated 1.1.08), referring to
our letter demanding that the inmate undergo the necessary tests (PHR-Israel letter
dated 23.12.07). The Ombudsman informed us that the matter was still under
examination.

17.03.08 In a conversation with the Ombudsman's secretary, we were told that the
matter was still under examination. To date, we have still received no reply.

Appeals to Physicians for Human Rights-Israel

Human rights organizations and prisoner organizations also receive appeals from
inmates. This report will focus on appeals received by PHR-Israel, and the difficulties
we face in resolving the issues they raise.

How does the complaint reach PHR-Israel? Every year PHR-Israel receives about
400 complaints from inmates or from members of their families. We also receive
requests for assistance from other organizations involved in issues relating to prison
inmates.

16
Inmates imprisoned because of criminal activities, migrant workers and asylum
seekers who are incarcerated contact PHR-Israel directly by telephone. Palestinian
inmates defined by the prison system as "security" prisoners are not permitted to use
the telephone, and are limited in the number of letters they may send and receive:
two letters and four postcards per month.4 Their complaints reach PHR-Israel via
family members who visit them, via attorneys and via other released prisoners.

Obstacles faced by PHR-Israel in dealing with complaints: The fact that

complaints of Palestinian inmates reach PHR-Israel at second or third hand (via
attorneys or family members) makes it extremely difficult to deal with these cases.
Impressions may be affected by concern for the inmate's health, and they may be
erroneous because the visitor is not aware of serious problems that are not
immediately apparent on the surface during the course of a visit (symptoms that
appear on parts of the body hidden by clothing, psychological difficulties, etc.).

When we try to deal with the complaint vis-à-vis IPS authorities, the medical staff of
the relevant prison is not permitted to be in direct contact with us, but only via the IPS
Chief Medical Officer (CMO), Dr. Alex Adler. Naturally, the quality of the information
we receive is poor, since the CMO is not directly familiar with the details of the case.
Moreover, the information we receive is scanty, and the CMO refuses to address the
recommendations of PHR-Israel physicians who review those inmates' medical
records, or even those made in the wake of PHR-Israel physician visits to a particular
inmate.

Even more serious is the fact that inmates contacting PHR-Israel report that in the
wake of PHR-Israel appealing to the IPS CMO on their behalf, they may be subject to
reprisals by prison staff and/or prison clinic staff, who may also pressure them to stop
complaining to external organizations.

To sum up, whether due to problems of accessibility or because they are part of the
institutional structure they are charged with overseeing, the mechanisms described
above are inadequate to insure the human rights of inmates and the adequacy of
their conditions of imprisonment. Moreover, they do not operate transparently, nor
are they intended to. In the following section we will examine whether external
oversight systems in Israel are able to fulfill this function in an adequate and
appropriate manner.

4
It should be noted that the postal service in the West Bank and Gaza functions poorly, so Palestinian
inmates have trouble contacting family members by mail.

17
Prison Service External Oversight Mechanisms:
Theory vs. Practice

External oversight of the Israel Prison Service (IPS)

The role of persons appointed as official visitors to prisons is described in the

Prisons Ordinance and the IPS Commission Ordinance.

Prisons Ordinance5: According to this ordinance, the Minister of Police should

appoint official visitors to the prisons. The appointment may be to a particular prison,
to part of it, to certain types of prison, or a general appointment. The function of
official visitors to all prisons can also be carried out by Supreme Court justices and
by the Attorney General.6 District Court and Magistrate Court judges have authority
as official visitors over prisons in their jurisdictional area.7 The official visitor may at
any time enter a prison that he is authorized to visit and investigate the conditions
existing there, the treatment of inmates, the proper functioning of the prison and
whether all these aspects are consistent with legal and other directives. The visitor
may also enter any section of the prison and talk to any inmate.8

The same regulations specify how an inmate may appeal to an official visitor. Such
an appeal must be made via the Prison Director as a request for an interview with the
official visitor. The Director will transmit the request to the official visitor,
accompanied by the Director’s comments. The visitor is not obligated to grant the
request. If he does, he may conduct the interview without the Prison Director, or any
other person, being present.9

The official visitor is subject to a number of limitations. Although the Prison Director
and other members of the prison staff must provide upon request any information he
needs to fulfill his function, information from security files will be given only to visitors
who are Supreme Court justices.10 Moreover, the Minister of Police may at any time
forbid the official visitor from visiting for reasons of prison security and the security of

5
Prisons Ordinance, B: Official visitors
6
Ibid, Par. 72
7
Ibid
8
Ibid, Par. 72a
9
Ibid, Pars. 72b-72c
10
Ibid, Par. 72d

18
the inmates.11 The Minister of Police will explain to the official visitor why he was
prevented from visiting the prison, if the visitor requests him to do so.

IPS Commission Ordinance: According to IPS Commission Ordinance 03.04.00

– Official visitors to Prisons, the Minister of Public Security appoints official visitors to
Israeli prisons. Supreme Court justices and District Court judges serve as official
visitors ex officio. The other official visitors appointed by the Minister are:

1. Employees of the Ministry of Justice and other government ministries, according

to a list prepared by the Ministry of Justice.
2. Members of the Criminology Council that is affiliated with the Ministers of Justice
and Public Security.
3. Representatives of the Bar Association, according to a list prepared by the Bar
Association.
4. Employees of public bodies who have requested that their representatives be
authorized to serve as official visitors and the Minister has found it appropriate to
so authorize them.
5. Any person the Minister decides to appoint as an official visitor.

Paragraph 6a of the regulation specifies that "an official visitor may at any time enter
a prison he is authorized to visit in order to fulfill his function, but will refrain, insofar
as possible, from visiting at night, except in unusual circumstances and after prior
coordination."

Additional visitors: Two bodies external to the IPS and the Ministry of Public
Security that regularly visit prisons are the Public Defender's Office and the Bar
Association. Both bodies publish reports following their visits. In addition,
representatives of the ICRC – who are not defined by law as official visitors – visit
Palestinian inmates, migrant workers and asylum seekers.

Problems with external oversight of IPS

PHR-Israel has no information about some categories of visitors specified in the

Prisons Ordinance and the IPS Commission Ordinance, not about the frequency of
their visits, the quality of their visits or whether their results are made public. With
respect to others, PHR-Israel has only partial information. This fact is enough to raise

11
Ibid, Par. 72f

19
doubts about the effectiveness of the organizations that conduct visits, since their
visits and recommendations should have been made public and visible.

The International Committee of the Red Cross (ICRC) – a limited

mechanism: This is an external mechanism that operates by virtue of international
conventions whose goals are limited. Conclusions and recommendations from ICRC
visits are transmitted only to the IPS and to the Israeli government. Therefore, these
visits are limited in their ability to employ transparency as a tool for changing and
improving conditions of incarceration and for protecting inmates’ rights.

The Ministry of Public Security – infrequent, not transparent: Attorney

Nava Maimon, senior assistant to the IPS legal advisor, writes in a letter dated
20.2.08 regarding the implementation of the Yisraeli Committee recommendations
(see below: Transparency regarding health), par. 11, "…The Ministry of Public
Security conducts oversight activity from time to time [by means of] the
Ombudsman's office. The last such activity was conducted in November, 2005."
[emphasis added] In other words, two years and three months before the letter was
written. This response indicates that the Ministry of Public Security conducts prison
oversight visits about once every three years, which is clearly inadequate. To our
knowledge, reports of these visits are not made public. When, in the past, PHR-Israel
requested a copy of the report prepared by the Ombudsman of the Ministry of Public
Security dealing with health services in the IPS and the police, the Ministry's Director
General made various excuses in refusing to give us a copy.

Committee of the Bar Association: Despite PHR-Israel's requests to the

representative of the Bar Association responsible for oversight visits to IPS
installations, we have been unable to obtain copies of reports of visits by the Bar
Association's representatives in recent years.

The Public Defender's Office – not frequent enough; unable to enforce

implementation of its recommendations12: Between 2002 and 2006,
representatives of the Public Defender's Office conducted some 40 prison visits, in
18 of the 25 existing prisons.

According to reports in our possession of these visits, during the six years there were
6 prisons that were never visited, 5 were visited twice, 2 were visited three times, 2

12
Based on Summary of the Public Defender's Office's visits to prisons during 2002-2006

20
were visited four times (of these, two of the visits were in the same year), and 3
prisons were visited four times (of these, two of the visits were in the same year).

Deficiencies in prisons were found in all basic living conditions, such as

accommodation, nutrition, medical care, hygiene, etc., as well as in conditions
relating to prisoner welfare and provision of essential human needs: relations
between prison staff and inmates, including violence and degradation, family visits,
meetings with attorneys, employment, etc.

Some of the deficiencies are due to inadequate infrastructure, and to the number and
quality of structures used for incarcerating inmates, which do not meet minimal prison
standards. There is no doubt that substantial resources as well as systemic solutions
are required in order to bring about a significant improvement in inmate living
conditions. Even if the funds are allocated, solutions will not be immediate. Some of
the deficiencies are certainly remediable immediately in the existing prisons, though
the reports indicate that even with respect to those prisons that were visited
repeatedly, in which the same deficiencies were noted each time, in only a few cases
was any improvement observed.

It is not possible to evaluate the effect of prison visits by representatives of the Public
Defender's Office in cases where only one or two visits were made at intervals of two
or three years. It is possible to determine what improvements, if any, were made in
six prisons visited 3 to 5 times over five years.

 In Hasharon prison, which was visited three times, in 2002, in 2004 and in 2005,
and in which terrible conditions, verging on the inhuman, were reported in all
areas of life, including violence and degrading behavior by prison staff, no
improvement was reported. The same was true of Ma'asiyahu prison, which was
visited in the same years with no improvement reported.
 Damon prison was visited four times: in 2002, twice in 2004, and in 2006. One of
the serious problems reported after these visits, was violence by prison staff. The
Public Defender was in contact with the Attorney General and tracked the
hearings regarding cases that were opened. Even though no indictments were
issued, the visitors in 2006 received the impression that "routine violence by
prison staff no longer exists in Damon prison."
 In Shitta prison (Shatta) there were five visits: in 2002, twice in 2003, in 2005 and
in 2006. The reports cited systematic, serious and extremely worrisome violence
by prison staff against inmates, nor was any improvement noted during visits in

21
 these years. The report for 2006 noted a reduction in the number of complaints
about the quality and availability of medical treatment compared to 2005.
Neither in Shatta nor in Damon prison were any other improvements reported.
 Ashmoret prison was visited five times: in 2002, twice in 2004, in 2005 and in
2006. All visits reported very poor living conditions in all areas, but noted a
number of improvements. In 2005, a significant improvement was noted in the
relations between inmates and prison staff. An additional room had been set
aside for meetings with attorneys, conditions in the solitary confinement cells had
been improved and there was a decline in the number of complaints about
medical care.
 The IPS Medical Center was visited four times: twice in 2004, in 2005 and in
2006. The first visit in 2004 reported, among other things, very poor hygienic and
sanitary conditions, which are unacceptable in a prison intended to serve as a
medical institution. The second visit that year reported a significant improvement
in the level of hygiene and sanitation, and improvement continued in 2005 and in
2006. It should be recalled that on 22.12.04, the High Court of Justice (HCJ) had
issued a decision in the appeal of Physicians for Human Rights-Israel (HCJ
3274/02, submitted 18.4.02). In its decision, the HCJ accepted the
recommendations of the Yisraeli Committee regarding medical care in prisons,
and it can be assumed that this decision also contributed to the improvements.

The visits and reports of the Public Defender's Office seem to have some effect on
correcting certain deficiencies in prisons, but the improvements are only a drop in the
bucket of shortcomings described in the Public Defender's Office reports. The visits
are undoubtedly an important and necessary tool for overseeing what goes on in
prisons, but their effectiveness depends on their being conducted more frequently,
and in all prisons. Even if we take budgetary constraints into consideration, as well as
existing infrastructure deficiencies, oversight and follow-up of the implementation of
recommendations will lead to improvement in many areas where they can be applied,
even under existing limitations.

Overall, the frequency of visits by all the organizations mentioned above is

inadequate, and their reports do not sufficiently influence what happens behind
prison walls. Thus, for example, repeated reports by different visitors to Damon
prison about violence against inmates by prison staff did not lead to changes in the
situation for a very long period of time. After the Prison Director had been replaced –

22
whether because of, or unconnected to, the many reports – the number of complaints
by inmates about violence declined.

We note that a decline in the number of complaints is not a sufficiently valid index of
improvement in conditions of incarceration, in this case violence by prison staff.
Moreover, viewing inmate complaints as a valid index could lead to prison staff
threatening inmates and punishing them to prevent them from complaining.

Transparency regarding health

Official visitors to prisons do not include medical personnel, except when they are
from the Ministry of Health (see below), so their attention to problems of access to
healthcare is limited.

The Public Defender's Office: The delegation from the Public Defender's Office
does not include medical personnel (as is true of most of the delegations from
organizations conducting visits), so the only way they can evaluate the healthcare
provided is by hearing inmate complaints, but they completely lack the professional
tools to investigate such complaints. This weakness is particularly noticeable in the
various reports issued by them.

 2002: The report contains no reference to problems of healthcare access.

 2003: The report refers only to Shatta prison and notes "a deterioration in
conditions of incarceration with respect to medical care, compared to the
situation existing in 2002" (as noted above, the 2002 report made no
mention of medical care). Inmates complained about the quality of
medical care, that their needs were ignored and that necessary treatment
was delayed.
 2004: The report discusses four prisons: Hasharon, Ashmoret, Giv'on
and IPS Medical Center in the Physical and Mental Center (PMC). The
problems described relate primarily to the quality and availability of
medical care. Inmates in Hasharon prison complained mainly about
delays in obtaining dental care, female inmates complained about not
having been examined by a gynecologist since arriving at the prison, and
that the eight-month-old baby of one prisoner was taken only once to a
Mother-Child Healthcare Center (“Tipat Halav”).
 2005: The report refers to various problems connected to the quality and
availability of health care in eight prisons: Shatta, Ohalei Keidar, PMC,

23
 Nafkha, Ashmoret, Hasharon, Carmel and Meggido. The authors
conclude: "The staff of the Public Defender's Office do not possess
the professional tools to evaluate [emphasis added] whether the
waiting period is in fact unreasonable. Nevertheless, the number of such
complaints raises concerns about a possible situation in which various
medical problems are not receiving timely treatment, a situation that
should not be viewed with indifference. In light of this, in our view, the
issue should be addressed comprehensively."
 2006: The report notes various unspecified problems regarding the
quality and availability of healthcare, with reference to five prisons:
Shatta, Damon, Eshel, Ashmoret and Ayalon. The Public Defender's
Office had the impression that conditions had significantly improved this
year compared to last. Special note was made of Ashmoret and Shatta, in
which the number of complaints was significantly reduced.
 The IPS Medical Center was visited twice by the Public Defender's Office
in 2002. Many deficiencies were found during the first visit, primarily
having to do with physical conditions and hygiene, such as: stench, poor
ventilation, dirt, shortage of cleaning staff, difficulty accessing toilet
facilities by patients in wheelchairs, lack of emergency call buttons, and
more. Significant improvement was noted in the second visit with respect
to hygiene and cleanliness, but the other problems had not been solved.

The reports indicate that the only tool employed by the Public Defender's Office to
examine the quality and accessibility of prison healthcare is inmate complaints. In
fact, the sole criterion applied in 2006 to determine that the medical situation had
improved was a decline in the number of complaints. No attention is paid to the
conditions or the quality of the clinics, medical equipment, quality of entries in
medical records, quality of the medical staff, staffing requirements, available
medicines, patients’ diet and more.

Visitors from the Public Defender's Office are aware of the importance of access to
healthcare as well as the fact that they lack appropriate tools to evaluate such
access. They therefore write in their 2006 report: "It is, of course, unnecessary to
emphasize the importance of medical care, especially for a population that has no
control over the treatment it receives or the opportunity to obtain additional or
supplemental care. The staff of the Public Defender's Office lacks medical expertise,
and its official visitors possess no tools appropriate to examining individually the

24
validity of each complaint presented to them. The complaints, therefore, have been
noted and included in the detailed report on each prison, so that professionals may
examine their substance."

Despite the fact that none of the external organizations visiting prisons include one
that is capable of professionally examining medical conditions, and despite general
agreement that healthcare lies at the core of prisoner rights, the request of PHR-
Israel to include its medical team in the visits of the Public Defender's Office was
denied.

Ministry of Health: The Ministry of Health conducts regular oversight visits to the
IPS Medical Center, but since IPS medical services are not under its authority, but
under that of the Ministry of Public Security, the IPS has no obligation to follow
recommendations made by the Ministry of Health in the wake of such visits, and they
remain at the level of recommendations. For a discussion of the problematic nature
of the Ministry of Health's authority, see the discussion below of the Yisraeli
Committee.

The Israel Medical Association (IMA): Although this organization could provide
professional medical oversight, it lacks the status of official prison visitor. Moreover,
the Ethics Board of the IMA announced on a number of occasions that it is unable to
oversee the work of IPS medical staff.

During 2001, one of the inmates at the IPS Medical Center was required to shine the
shoes of Dr. Shmuel Beck, the director the IPS Medical Center at the time.
Physicians for Human Rights-Israel submitted a complaint about the incident to,
among other bodies, the IMA Ethics Board. In his reply, Prof. Avinoam Rekhes, chair
of the Ethics Board, wrote, "the Ethics Board lacks the tools required to undertake an
investigation of the facts involved in the type of matter about which you are
complaining."

During 2007, PHR-Israel transmitted to the IMA a complaint about treatment provided
to a Palestinian inmate who, in the month prior to his arrest, had undergone spinal
surgery. PHR-Israel's investigation found that IPS physicians who examined the
prisoner prior to his transfer to the General Security Service (GSS, Shin Bet) for
interrogation failed to call attention to his medical condition or to ensure his safety
and his health during the period they were responsible for him. A complaint about the
physicians' behavior was transmitted to the IMA. Dr. Yoram Blachar, the IMA chair,

25
replied: "Unfortunately, after investigation by the Israel Medical Association, it
appears that the physicians allegedly involved in this case are not members of the
Medical Association and the IMA Ethics Board therefore has neither the ability nor
the authority to investigate the case." Details of the case will be presented later in
this report.

26
Efforts by Physicians for Human Rights-Israel to
ensure external oversight over implementation
of the right to health behind prison walls

Requests to permit representatives of Physicians for Human Rights to

enter the prisons: PHR-Israel applied a number of times to various bodies,
requesting that its physicians take part in official visits. All our requests were denied.

In January, 1997, PHR-Israel first contacted the IPS Commissioner requesting

permission for its representatives to visit the IPS Medical Center. The request was
submitted after numerous complaints from ill inmates had reached the PHR-Israel
office, raising serious questions about the possibility of blatant violation of inmate
rights, both regarding the quality of medical care given to them and regarding the
conditions of their incarceration. Following a long correspondence with the IPS
Commissioner (Lieutenant General Amos Azani, and, later, Lieutenant General Orit
Adato), and with the Minister of Public Security, Prof. Shlomo Ben Ami, we were
finally told that our request that PHR-Israel physicians visit the IPS Medical Center
had been denied. The reasons, as listed in the letter dated 5.9.1999, from Mr. Micha
Pinto, chief of staff and advisor to the Minister of Public Security, to Ms. Hila Dayan,
intervention coordinator, Physicians for Human Rights-Israel, are as follows:
"1. A voluntary organization has no legal standing that would require it to be
permitted entry to a prison.
2. IPS inmates receive continual, faithful and professional care by IPS physicians
and by civilians.
3. There is no current IPS inmate whose continued incarceration endangers his life.

After its request was denied, PHR-Israel decided to send an attorney, who by law is
allowed entry, to the IPS Medical Center, to meet with inmates who had complained
and obtain affidavits from them. We decided to focus on the IPS Medical Center,
rather than on other IPS prisons, both because of the large number of complaints
and because the IPS Medical Center is, essentially, a medical facility, even if –
according to the IPS – not an official one.

The attorney visits uncovered serious problems in the conditions of incarceration in

the IPS Medical Center, and in the medical treatment received by the inmates. The
picture shown by the visits was of a medical facility operating with no independent
external supervision or oversight. We found that supervision by the Ministry of Health

27
– when it occurred at all – did not occur as a matter of obligation. We found cases of
inappropriate medical care; delay of treatment and of surgery; disparaging behavior
toward, and inhuman treatment of inmates by medical personnel and prison staff;
gross interference of non-medical personnel in medical care and its availability;
shameful sanitary conditions in facilities unworthy of human habitation, much less
one that presents itself as a hospital facility; shortcomings in transferring patients to
external hospitals; neglect of patients needing custodial care or rehabilitation for
whom the IPS Medical Center, in our opinion, is not the appropriate facility; threats
against inmates who complained and even a number of deaths which, according to
inmates, were but the tip of the iceberg.

Our efforts were summarized in a report13 that was submitted to the relevant
authorities. The response of the Ministry of Health was: "Indeed, as the report states
– the Ministry of Health has no supervisory authority in prison installations." [Letter
dated 24.2.02 from Dr. Yitzhak Berlovitz, then Acting Deputy Director, Ministry of
Health, to Ms. Hadas Ziv, Project Director, PHR-Israel]. The IPS Chief Medical
Officer (CMO), for his part, claimed in response to the report [Letter dated 26.2.02
from Dr. Alex Adler, Deputy Commander, Chief of Medical Services, IPS, to Ms.
Hadas Ziv, Project Director, PHR-Israel] that the IPS is subject to external
supervision and oversight by the State Comptroller's Office, by the Ministry of Public
Security Comptroller, by official visitors – and that, in addition, the IPS is supervised
more closely than any other government ministry by means of its unique mechanism
that allows petitions from inmates. Moreover, according to the IPS CMO, the Ministry
of Health District Medical Officer, the District Nurse and the District Pharmacist
conduct an annual review of the IPS Medical Center, and are satisfied. The IPS CMO
denied all PHR-Israel's claims regarding problems in the conditions of incarceration
and medical care of the inmates.

We note once again that, since the Ministry of Health lacks legal authority to oversee
the functioning of the IPS Medical Center, the decision whether to implement the
recommendations of Ministry of Health representatives depends solely on the good
will of the IPS, which is not obligated to alter or correct anything in the wake of these
visits. Not only has the IPS refused to adhere to Ministry of Health demands following
these visits, but the oversight reports dealing with medical care of inmates and
medical services remain unpublished, and the public is unaware of them. Moreover, it

13
Ziv, Hadas, Physicians for Human Rights-Israel, "These Worldly Bars – Maltreatment and Neglect
in the IPS Medical Center. " Tel Aviv: March 2002.

28
would be appropriate for the Ministry of Health to oversee the entire range of IPS
medical services, including the operation of all prison clinics.

In the wake of the responses PHR-Israel received to its report, we petitioned the
Israeli High Court of Justice (HCJ 3274/02: Physicians for Human Rights-Israel and
others vs. the Minister of Public Security and others (IPS Medical Center petition),
asked that the IPS Medical Center as it currently operates be closed for a
predetermined period of time during which arrangements will be made for it to
operate in accordance with the law. We also demanded that the reports regarding
medical care of inmates and the IPS medical services be made public.

The High Court of Justice (HCJ) ordered the appointment of an expert committee to
examine the claims raised in the petition regarding the functioning of IPS medical
services and inmate care. The Yisraeli Committee, headed by Prof. Avi Yisraeli, then
Director of the Department of Medical Administration and Economics, Hadassah
Medical Center, Jerusalem, which was appointed in response to the Court's order,
included physicians from the Ministry of Health, Asaf Harofeh Hospital, Sheba
Medical Center, Physicians for Human Rights-Israel and the IPS. We note here that
the Court denied our request to apply the National Health Insurance Law to inmates,
which would have resulted in a system-wide improvement in access to healthcare
and lead to equality in their status with that of other residents of Israel.

The Yisraeli Committee

The committee's recommendations dealt with a number of topics, among them the
issue of supervision and oversight of IPS medical services, oversight by the Ministry
of Public Security, and the Ministry of Public Security Ombudsman for Inmate
Complaints Regarding Medical Issues:

A. Supervision and oversight

Addressing the problem of dual loyalty of IPS medical staff, the committee
recommended strengthening supervisory and oversight mechanisms, and creating
two new positions for this purpose. The new positions would, on the one hand, be
unconnected to the IPS, and would, on the other, be part of the institutional hierarchy
at the Ministerial level, so that those conducting the oversight would have the
authority and the ability to intervene in order to bring about desired outcomes, while
preserving their professional connection to the Ministry of Health. The oversight
should be conducted by trained professionals, respected authorities in the field of
health, having knowledge and experience regarding organizations like the IPS.

29
The committee recommended that the issue of hierarchy be reexamined in the future,
following the implementation of its recommendations and their application in practice.

B. Oversight in the Ministry of Public Security

The committee determined that there is a need for external oversight in addition to
existing oversight mechanisms. It recommended that the Ministry of Public Security
be given the authority and responsibility for overseeing IPS medical services.
This oversight would deal on a permanent basis with the planning and control of
prison medical services. It would be conducted, in part, by means of regular visits,
as well as unannounced visits, to prison medical facilities, as frequently as, and in
whatever form, deemed necessary. It would be possible, and even recommended, to
include in these visits additional professionals, such as Ministry of Health staff,
representatives of District Health Offices, medical specialists from other disciplines,
etc., according to the issues under examination from time to time. The visits should
include, among other things, examination of facilities, of medical records, equipment,
conversations with and examination of inmates, according to the decision of those
conducting the visits and the topics addressed.

Upon its request, the oversight body will receive regular reports from the IPS. It will
receive reports about unusual incidents relating to inmates' health and their medical
care, as it determines. The goal of the oversight is to track on an ongoing basis the
quality of care and service provided by the IPS medical department, in order to bring
about continual improvement. When deficiencies are found, the oversight will insure
that the IPS medical services act to correct them and prevent their recurrence.
The committee was of the opinion that the oversight should be directed by a
physician and a nurse, and that there should be a professional connection between
them and the Ministry of Health.

C. Ombudsman for Inmate Complaints Regarding Medical Issues in the

Ministry of Public Security
The committee recommended appointing an Ombudsman for Inmate Complaints
Regarding Medical Issues in the Ministry of Public Security. The position should be
held by a respected senior physician, a specialist, with administrative experience.
The appointment would be made with the approval of the Minister of Public Security
and the Minister of Health.

30
The Ombudsman would act in cases where inmates have difficulty for any reason in
exercising their rights. Complaints would, therefore, have to be dealt with frequently
and immediately. The procedure would include investigating the facts of the case,
arriving at findings, determining what deficiencies must be rectified and justifying the
conclusions. In his investigation of individual complaints, the Ombudsman will act to
protect the individual inmate and to insure he receives appropriate medical care.
Each investigation will also pay attention to the overall medical care inmates receive,
in order to identify systemic problems in prison medical services. The Ombudsman
will be assisted by the Ministry of Public Security oversight staff referred to above.

The existence of the Ombudsman of Inmate Complaints Regarding Medical Issues

must be publicized, as well as the procedures by which inmates and others may
freely access him. The IPS may place no limitations whatsoever on such access.

Given that the courts frequently address the issue of prison medical services, the
committee suggests that petitions and their outcomes be brought to the attention of
the Ombudsman of Inmate Complaints, so that he can track trends and recurring
problems in order to propose possible solutions to them.

The Ombudsman will publish an annual report regarding appeals and findings, and
will follow up the implementation of his recommendations. The existence of the
oversight mechanism and the position of the Ombudsman will strengthen the trust of
the inmates and of the public in the medical services provided in prisons.

The Israel Medical Association (IMA), which had joined the petition regarding the IPS
Medical Center as a friend of the court, also believed that IPS medical services
should be under the authority of the Ministry of Health, whose function would be that
of external oversight. The IMA's attitude regarding the appointment of an
Ombudsman of Inmate Complaints Regarding Medical Issues was that the solution
proposed by the Yisraeli Committee and by the Government in the course of the
Yisraeli Committee’s discussions, that the Ministry of Health Comptroller would also
serve as the Ombudsman of Inmate Complaints, was not an appropriate oversight
mechanism for protecting inmate rights.

According to the IMA, a separate, independent, external body is required to deal with
day-to-day issues in order to protect all the rights of sick inmates. The IMA believes
that inmate complaints and the manner they were dealt with should be publicized.

31
The cost of concealment

The failure of the legal and governmental systems to institutionalize transparency

with regard to conditions of incarceration in general, and access to health in
particular, takes its toll on the human rights of the inmates and on their health. Many
will return to the community for some length of time, and the consequences of
neglecting their medical needs will impose a heavy burden on them, on society and
on the health budget. Oversight mechanisms staffed by persons having professional
competence in medical matters and in human rights issues could rectify or prevent a
number of system failures. The accounts of individual inmates that follow show the
personal price paid by people who are hidden behind prison walls.

Failures in the Prison Service Health System - Systemic

failures
Violence and torture:
There is no doubt that one of the most serious failures regarding the preservation of
inmate rights in Israel has been, and remains, protecting Palestinian inmates from
violence and torture. Torture was carried out for years behind a screen of denials and
lies. In 1999 the Israeli High Court of Justice finally handed down a decision
regarding interrogation methods employed by the General Security Service (GSS,
shin bet, recently renamed the ‘Israel Security Agency’ or ISA): violent shaking,
forcing the interrogee to squat on the tips of his toes for varying lengths of time, the
"shabekh" – seating the person being tortured on a low stool with his hands cuffed
behind his back, his head covered by a sack while deafening music plays in the
background, and preventing him from sleeping. The first three methods were
forbidden as violating reasonable interrogation procedures, and the Court decided
that the GSS lacks authority to employ them. Prevention of sleep was prohibited if its
only purpose was to exert pressure on the interrogee, but permitted if it was a "side
effect" of an intensive interrogation.

All the hearings leading up to the decision exposed the system that existed behind
prison walls in which interrogations were conducted using these illegitimate
techniques with the knowledge of medical personnel. Thus, for example, the
government stated explicitly that, as one of the safety mechanisms during
interrogations, physicians are present in the facility 24 hours a day (Par. 7 of the

32
statement): "We also wish to add that, since about a year ago, physicians are
present 24 hours a day in all active GSS interrogation facilities. The purpose is to
permit immediate skilled medical care in every case that requires medical care or
examination. This fact is also relevant, of course, when weighing the danger that the
interrogee will suffer a medical injury due to the use of the above means."

It follows, therefore, that the physicians served as a safety net for the torture
apparatus. Human rights organizations, including PHR-Israel, argued for years that
these interrogation methods constituted torture. Finally, after a long delay, they were
defined by the High Court of Justice as unreasonable interrogation methods, and
their use was prohibited. We believe that the very fact that torture is employed, and
that medical personnel have been involved for many years, was made possible in
large measure because of the lack of transparency in the organizations conducting
the interrogations – the fact that human rights activists and delegations of
independent physicians were unable to enter the interrogation and incarceration
facilities made it easier to conceal what was going on there, and to delay the High
Court hearings for years.

Various reports,14 supported by depositions, indicate that torture is again being used.
As in the past, it is justified by repeated references to "ticking bombs." There is no
denying that the atmosphere existing today in the country may make physicians more
willing to ignore torture and even take part in it through "supervision" – examining the
prisoner prior to, during and after interrogation under torture. Such supervision is an
important tool – a sort of fig leaf – that allows others in the system to continue with
this prohibited behavior. Although medical ethics explicitly prohibit the involvement of
physicians in torture, the widespread public dehumanization of Palestinian inmates
as well as the dominant nature of the security discourse results in medical personnel
agreeing to participate – even if only by tacit consent – in torture. Moreover, medical
staff often operate in a quasi-military system which places a premium on obedience
that reduces their independence and their ability to act according to their best
medical judgment. We have no doubt that those medical personnel require external
support – legal, judicial, professional, medical-ethical – to help them act according to
the ethical and professional codes they have sworn to uphold.

14
Center for the Protection of the Individual and B'Tselem, "Totally forbidden: Torture and abuse of
Palestinian prisoners by Israeli security forces," May, 2007; Public Committee Against Torture,
"Ticking bombs – Testimony by victims of torture in Israel," May, 2007; Public Committee Against
Torture, "Family treatment," March, 2008.

33
The Tokyo Declaration of the World Medical Association [1975], in a translated
version as approved and adopted by the Israel Medical Association, states, inter alia,
that15:

 No physician shall participate in any activity involving torture, cruelty or

degrading treatment of another person, regardless of that person's actions,
the charge against him or his beliefs.
 No physician shall provide medical authorization for torture, nor shall he
provide medical information, equipment or medicine for such purpose.
 A physician who examines a prisoner or inmate who may be subject to
interrogation or torture will take particular care to preserve the confidentiality
of the medical information provided him, and shall not use it for the purpose of
interrogation or torture.
 A physician who witnesses an interrogation or torture shall report this to the
appropriate authority.
 No physician shall be present at a location where interrogation or torture is
conducted.

The fact that prisoners are again testifying and complaining about torture, and that
there is still no external oversight – certainly not public oversight – on what occurs at
those interrogation sites, raises the suspicion that many years will again be required
to expose the reality of torture and do away with it.

The case of A.N., arrested on 8.2.07: Information on his arrest and medical
condition – suffered from a herniated disc, and underwent surgery on his back in
December 2006 – reached PHR-Israel on 13.2.07. Since we had been told that he
was being interrogated by the Genera Security Service (GSS) in Kishon detention
facility, and we feared that the interrogation methods would injure his health, we
appealed the same day to Dr. Alex Adler, IPS Chief Medical Officer, and to the
person in charge of the Kishon clinic. A letter from his doctor accompanied the
appeal. We followed up the appeal with a telephone call to the Kishon clinic, in which
we warned them to pay special attention to his medical condition.

15
Website of the Israel Medical Association, 24.6.2008:
http://www.ima.org.il/imahebnew/T1.asp?p=2&n=7952 (in Hebrew), cf. The World Medical Association
Declaration of Tokyo. Guidelines for Physicians Concerning Torture and other Cruel, Inhuman or Degrading
Treatment or Punishment in Relation to Detention and Imprisonment, http://www.wma.net/e/policy/c18.htm, and
World Medical Association Resolution on the Responsibility of Physicians in the Documentation and
Denunciation of Acts of torture or Cruel or Inhuman or Degrading Treatment, http://www.wma.net/e/policy/t1.htm

34
On 15.2.07, Dr. Adler responded that he had received our appeal and transmitted it
urgently to the director of the Kishon detention facility. Because A.N. was prohibited
from meeting with an attorney during his interrogation, PHR-Israel petitioned the High
Court of Justice on 15.2.07, requesting that (1) the prohibition be lifted, (2) that he be
examined by a physician from PHR-Israel, and (3) that he be incarcerated in a
manner appropriate to his medical condition. On 20.2.07, the Court decided not to lift
the prohibition against meeting with an attorney, nor to allow an examination by a
PHR-Israel physician – apparently the fear of an independent physician concerned
about the inmate's rights is not restricted to the security forces. Nevertheless, the
High Court ordered A.N. to be examined by an orthopedist at Rambam Hospital. It is
important to note that during the court hearing, GSS representatives announced that
since receipt of PHR-Israel's letter on 13.2.07, A.N. had been interrogated while
lying on his back or in any other position that he found comfortable.

On 8.3.07, after the prohibition against meeting with an attorney was lifted, a PHR-
Israel attorney visited him. A.N. told the attorney that [emphasis added]: he had
reported his medical condition to the physician at Ofer detention facility. The
physician had asked him for documentation of his condition and the surgery he had
undergone, but did not act to obtain authorization for A.N. to contact his family. At
Kishon he was again examined by the facility's physician. Again he told the
physician about his medical condition, and that his family possessed the
necessary documentation. He reported that the physician told him that it was not
his [the physician's] concern. After being examined by the physician he was
turned over for interrogation. During the course of the interrogation he was forced to
sit on a chair for four hours without a break, with his left hand tied to the chair. A. told
the interrogator that he was unable to sit for such a long time and that he was
suffering from extreme pain but the interrogator ignored what he said. In the
following days his interrogation continued, and each day he was forced to sit
handcuffed to the chair for a period lasting from 5 to 8 hours. His statement indicates
that on 13.2.07, the day of PHR-Israel's letter, he was transferred, without having
so requested, to the facility physician. By this stage he had difficulty walking
and had to sit on the floor while he was being taken to the vehicle that would bring
him to the clinic. A.N told the physician that he had been interrogated for hours while
seated tied to a chair. The physician told him that under no circumstances
should he sit on a chair, and that doing so endangers his health. He also said
that he would note in his medical record that such treatment was completely
prohibited. Only during his interrogation on 18.2.07 (after a date had been set for

35
the hearing on his petition to the High Court) was A.N asked to bring a mattress from
his cell, and permitted to take any position that was comfortable for him. On the same
day he also received painkillers. On 22.2.07 he was taken to Rambam Hospital to be
examined. On 28.2.07 he was again examined at Rambam at the request of the
hospital physician.16

On 17.4.07, PHR-Israel contacted Prof. Avinoam Rekhes, chairman of the IMA Ethics
Board, Prof. Avi Yisraeli, Director General of the Ministry of Health, and Mr. Rani
Falk, Director General of the Ministry of Public Security, requesting that they locate
the physicians who had examined A.N. in the various jails from the day he was
arrested until he was examined at Rambam Hospital, and investigate whether their
behavior was consistent with the ethical rules obligating them to ensure his safety,
and to examine the connection between the physicians and the interrogators – in
particular, transmission of medical information and ensuring the interrogee's safety.
We also requested to be informed what means are used by the GSS while
interrogating prisoners in the Kishon detention facility, and whether the physicians
are aware of them. This inquiry is necessary because PHR-Israel believes that the
physicians – given the description in the statement of their behavior – are not of the
opinion that their first priority is to ensure the wellbeing of people placed under their
care. PHR-Israel asked that both cases be investigated completely transparently and
that conclusions be drawn with regard to the physicians involved.

The replies we received exposed once again the absence of effective oversight of the
functioning of prison medical staff and the protection of inmate rights. The reply of the
Ombudsman, Prof. Shimon Glick (dated 26.4.07), demonstrated that he again was
satisfied with examining our claims in coordination with Dr. Alex Adler, the IPS Chief
Medical Officer, who failed to respond to most of the issues we raised. The IMA
chair, Dr. Yoram Blachar, warned Dr. Adler (4.5.07) that the IMA prohibits any
involvement of physicians in interrogations and in torture. But, in the wake of an
additional appeal from PHR-Israel, the reply we received (dated 30.1.08) was that
although the IPS physicians in the facilities involved had apparently behaved
improperly in the present case, “since the physicians involved are not members
of the IMA we have neither the ability nor the authority to investigate the
matter.” Dr. Blachar added that the IMA will establish a phone hotline that physicians
may use if they need consultation regarding ethical issues. This welcome initiative

16
The request from the Rambam Hospital's physician is documented in the medical records received by
PHR-Israel .

36
cannot be a substitute for meeting with physicians who do not believe that their own
behavior involves ethical problems.

We therefore contacted the Ministry of Health a second time, requesting that as the
body in charge of health in Israel, it meet with those physicians. We also requested
that the Ministry of Health clarify for us who is the body responsible for ensuring
ethical behavior by physicians employed by the security services, since most of
them are not members of the IMA. And we requested that the Ministry of Health
clearly express its view regarding the participation of physicians in interrogations. To
date, the matter is still under consideration by the Ministry of Health.

IPS transportation arrangements:

Some 1800 inmates are transported every day in IPS vehicles to various destinations
in Israel. Some are taken from one prison to another, some to court hearings at
various judicial levels and some to medical treatment carried out outside the prison in
which the inmate is incarcerated. There is almost no inmate who does not complain
about the extreme discomfort involved in these journeys, in vehicles that the inmates
call "Posta". The inmates' accounts indicate that the difficulties are due both to the
length of the tiring trips and to the harsh conditions of the journey.

Inmates report that they usually have to sit on metal seats that have no backs or
upholstery. The vehicles are divided into compartments with very small openings for
ventilation. Not all vehicles are air-conditioned. Inmates report that when the air
conditioner has operated for a long time, it "freezes" them. Others report that on hot
summer days the air conditioner is not turned on at all, or is not turned on while the
"Posta" is parked at one of the prisons from which it is collecting inmates.

Many inmates testified that during the long and tiring journeys they receive no food or
drink, and suffer from various pains because they are not allowed to use the toilet nor
move around during the trip that can last, according to their reports, for up to 12
hours. The inmates are required to sit with their hands and legs bound, often one
next to the other. Inmates transported for medical care suffer doubly, particularly
those with medical problems that make sitting difficult in any case, such as back
problems or haemorrhoids, whose pain is exacerbated by prolonged sitting.

Complaints about conditions in the transport vehicles have for years been submitted
to the IPS and the Ministry of Public Security by many bodies, including human rights

37
organizations, judges, members of the Israeli parliament (Knesset) and the Public
Defender's Office.

In order to obtain an accurate picture of the conditions of inmate transport,

Physicians for Human Rights-Israel had to distribute questionnaires by mail to
inmates, including Palestinian inmates. Collecting the information took a long time,
during a period when many inmates continued to suffer from the difficult transport
conditions. Some even decided to forgo medical treatment they would have had to
receive outside the prison. Following data collection, PHR-Israel, Adalah: The Legal
Center for the Rights of the Arab Minority in Israel and the University of Haifa Legal
Clinic for Prisoners Rights and Rehabilitation petitioned the High Court of Justice.
We demanded that transport conditions be improved, and that the length of the trips
be significantly shortened. As of today, we are still awaiting the respondents' reply to
the petition.17

The hunger strike in 2004:

During August and September 2004, Palestinian inmates conducted a three-week
hunger strike to protest their conditions of imprisonment. As the strike progressed,
PHR-Israel discovered that the striking prisoners were not receiving medical
treatment appropriate to their situation, were not being examined daily by IPS
physicians, and when they asked prison medics to be examined or receive medical
care, the reply they received was that they should end the hunger strike if they want
to be treated.

Experience elsewhere in the world in the treatment of prisoners engaged in hunger

strikes has led various organizations, including the World Health Organization and
the ICRC, to stress the importance of trust between the hunger striker and his/her
physician. The physician mediates between the striking inmates and the prison
authorities, so it is important that he be independent of, and not subordinate to them.

PHR-Israel contacted the IPS to request that PHR-Israel physicians be permitted to

examine the striking inmates. The IPS response arrived only after the end of the
strike, and stated that "during the course of the strike, the inmates received good,
appropriate medical care, consistent with IPS procedures…Throughout the strike, the

17
HCJ 1482/08: Adalah: The Legal Center for the Rights of the Arab Minority in Israel, Physicians for
Human Rights – Israel, the University of Haifa Legal Clinic for Prisoner Rights and Rehabilitation vs.
the Prison Service and the Ministry of Public Security.

38
condition of the prisoners was good, and their health was never in real or immediate
danger."

During the strike, attorneys representing PHR-Israel visited striking inmates in

various prisons. In some cases, prison staff refused entry to the attorneys without
providing sufficient justification for their refusal.

A mass hunger strike by inmates is an extreme situation which certainly requires

supervision and monitoring by elements outside the prison system, especially
medical personnel. Unfortunately, this did not occur in the present case. Nor are we
aware of any intervention by the Ministry of Health or the Israel Medical Association
during that hunger strike.

Shortage of physicians in Rimonim Prison:

During the last week of June, 2008, inmates in Rimonim Prison complained that they
were unable to see the prison physician despite repeated requests. According to
them, the regular physician had left, and his replacement was not seeing patients
every day, but only during some days of the week. Inmates reported that some
inmates from particular prison wards had been asking to be examined by a physician
for about three weeks.

An inmate contacted PHR-Israel to report that, since recently undergoing a

gastroscopic examination, he had been suffering from stomach pains. His request to
be examined by a physician received no reply for a week.

Family members of another inmate contacted PHR-Israel to complain that for six
days he had not received the medicine he regularly takes for his epilepsy. According
to them, the medics told the inmate that the physician is the only one who can give
him the medicine, but they did not take him to the prison clinic.

PHR-Israel contacted the IPS Chief Medical Officer in this matter but received no
reply. After PHR-Israel contacted the media, the IPS spokeswoman told Israeli Radio
that there is no difficulty whatsoever in being examined by a physician in Rimonim
Prison, and that a physician is at the prison every day.

After a few more days during which complaints continued to reach PHR-Israel about
Rimonim prison inmates' inability to see a physician, and after our letters to IPS
about the matter had received no reply, we telephoned (an unusual step for us) the

39
ombudsman for prisoners in the Ministry of Public Security, who promised to visit
Rimonim Prison.

Failures in the Prison Service Health System – individual

cases
R.G.: In June, 2007 an inmate serving an 18 year sentence for criminal activity
contacted PHR-Israel. He complained that for two years he had suffered shortness of
breath, pain in the area of the lungs, and breathing accompanied by whistling sounds
and rhonchus. He reported that the medication he receives fails to improve his
condition, and that the prison physician does not take his complaints seriously. The
inmate's complaints were transmitted to the IPS Chief Medical Officer (CMO), but,
because R.G. did not provide us with a signed waiver of medical confidentiality, PHR-
Israel was unable to request an update on his case.

In September, 2007 the inmate contacted us again and reported that nothing had
changed since he first contacted us, that he still was still suffering from the same
medical problems, and that whenever he asked to be examined by a physician he
was not permitted to reach the clinic. We again contacted the CMO, this time
submitting a medical information privacy waiver that we had in the interim managed
to give to the inmate and have signed and returned to us.

The IPS CMO replied that all the inmate's requests to visit the clinic were met, and
that his medical condition was good and stable. After receiving this response, PHR-
Israel requested the inmate's medical records. The PHR-Israel physician who
reviewed the file found shortcomings in the treatment given to the inmate, in
particular regarding treatment of his breathing problems. According to the physician,
"it appears that no comprehensive examination was conducted, nor was there a
diagnosis that would permit appropriate, ongoing care."

The inmate contacted us again on 15.11.07 with the same complaints. He had
difficulty speaking, and the rhonchus, whistling and difficulty breathing were audible
over the phone. During the conversation the inmate repeated that his requests to see
the prison doctor were not being met. The PHR-Israel physician who reviewed the
medical record sent an urgent letter to the IPS CMO in which he noted that he had
reviewed the inmate's medical record and would soon forward his comments. He
also noted that, in the wake of the inmate's call to PHR-Israel that same day, he fears
that the inmate may be suffering from shortness of breath. The physician requested

40
the CMO to intervene immediately with the prison physician. He also tried to reach
the IPS CMO by phone, and left messages in his office. His attempts went
unanswered.

Two days later PHR-Israel’s physician forwarded to the CMO his comments on the
medical file. He wrote that, according to the file, it appears that no comprehensive
examination was conducted of the inmate's breathing difficulties, nor was a diagnosis
made that would allow appropriate, ongoing treatment. Other problems of which the
inmate complained suggested the existence of disorders of the urinary tract, kidneys,
brain and heart that, according to the contents of the file, were not investigated in a
manner that would allow confirming or disconfirming the presence of these medical
disorders. The medical record does not explain why such investigations were not
conducted.

After a few days we received the CMO's reply. It stated that the inmate had been
examined by an internist and a pulmonary specialist, that laboratory tests had also
been conducted (no documentation of this appeared in the medical record), and that
he had not suffered attacks of shortness of breath for a long time.

Because the inmate continued to complain of problems in the medical care he was
receiving, a PHR-Israel physician examined him in February, 2008, in the prison
clinic. The physician recommended changing his medication, and the IPS accepted
this recommendation. Since the visit and the change in medication, the inmate no
longer complains about breathing problems.

In addition, we should note that on two occasions the inmate reported over the phone
that he was reprimanded by the clinic staff because he had complained to PHR-Israel
about the treatment he was receiving. He told us that the first time this occurred was
when he went to the clinic and the physician was holding a letter bearing the PHR-
Israel letterhead, which he shoved in the inmate's face and yelled that he won't treat
someone who complains about him. The second time the inmate was again
reprimanded by the physician after PHR-Israel had complained to the IPS CMO. He
also reported that following this incident a medic came over to him and said he knew
the physician had yelled at him, but asked why he really complained to "that stupid
organization." The medic told the inmate that he could always talk to him or to the
physician, and they would help him. The medic suggested that the inmate contact
PHR-Israel and "take care of the complaint." Even during the visit by PHR-Israel’s
physician, the prison physician expressed dissatisfaction that it was occurring, and

41
amazement at the fact that the inmate had even contacted an external body. Since
this is not the only example where IPS staff criticized PHR-Israel's intervention in
matters regarding inmates, we have decided to address this fact as a systemic
problem, which is the reason we are reporting it here.

L.L.: In June, 2007, an inmate imprisoned since 2002 for criminal behavior contacted
PHR-Israel. For many years he had suffered from renal failure. The inmate reported
that a few months earlier he had been examined by a nephrologist, who
recommended tests to determine whether he was an appropriate candidate to be
placed on a waiting list for a kidney transplant. According to the inmate, nothing was
done since the recommendation was made. In response to a letter from PHR-Israel,
the IPS CMO claimed that the inmate was not a transplant candidate because he had
undergone tests and was found inappropriate by the director of the hospital's
transplant unit. The inmate himself did not know anything about this, and PHR-Israel
asked to see his medical records. A review of the file showed that in 2003, a
physician from the transplant center wrote to the prison physician that, because of
the information that the prison physician had provided to the effect that the inmate
was uncooperative regarding his treatment and with prison medical staff, the
transplant center physician had determined that the inmate was not an appropriate
candidate for a kidney transplant. The transplant center physician reached this
conclusion without examining the inmate, and without talking with him or explaining
his decision. Subsequently, a PHR-Israel physician met the inmate in December,
2007, talked with him and determined that no medical obstacle prevented him from
being tested to determine whether he would be an appropriate candidate for a
transplant, and that the decision that he was not an appropriate candidate for such
tests was superficial and incorrect. Following this visit, the IPS notified us in January,
2008, that the inmate had been sent for the necessary tests. To date, the tests have
still not been carried out. The inmate claims that a date was set, and that he was sent
to the hospital, but because prison staff were late in transporting him from the prison,
the hospital wasn't willing to receive him and a new date had to be set. The IPS CMO
was contacted about this matter. PHR-Israel will follow up to determine whether the
tests are conducted, and will consider taking legal action if necessary.

42
It could be different – Transparency in other
countries

India:
In 1919-1920, a committee on prisons was convened by the British government. The
committee recognized the importance of appointing official and non-official prison
visitors as a means of ensuring the existence of independent and unbiased oversight
bodies. The committee operated with the idea that such visits serve the interest of
the government as well as of the public by insuring adherence to laws and
procedures governing the prisons (legislation from 1894), and ensure that violations
of inmate rights, if they occur, will be brought to light, to the attention of the public
and the government, and will be dealt with as rapidly as possible.18 In other words,
the issue of external oversight of jails and prisons arose in India almost 100 years
ago, and since then has been anchored in legislation.

Supervision in India currently comprises two types of visitors, official and non-
official.19 Nine official supervisory bodies include representatives of the police, judges
and supervisors from the Ministry of Health. The non-official visitors are appointed
by law by the parliament of the state in which they operate. The parliament contacts
a judge in the relevant state who, together with the police commanders, submits a list
of names to the prison. The prison selects the number of visitors required by law from
the list of names.

The number of non-official visitors varies according to the size of the prison, and
ranges from two to six. Prisons holding female inmates are required to include at
least two women in the list of visitors.

Non-official visitors are appointed for a period of three years, which may be extended
for three additional years. One of the shortcomings of the Indian system, however, is
that the local parliament is able to cancel a visitor's appointment without providing
any reason.

18
Report from 2006 of the "Commonwealth human rights initiative – CHRI," an Indian human rights
organization that acts to advance human rights as defined in international conventions, including in
prisons.
19
CHRI report on the system of prison visits in India, 2000.
http://www.humanrightsinitiative.org/publications/prisons/prison_visiting_system.pdf

43
The visits of official and non-official visitors are organized by a district supervisor who
heads the visitor committee of which they are members. The committee is required to
meet once each quarter to prepare a program of visits for the coming twelve months
so that each prison will receive an official or a non-official visitor at least once each
month. Non-official visitors have the right to make additional visits to the prison in any
given month, unrelated to the visit organized by the committee, and without prior
notice to the prison director.

The obligations and areas of responsibility of the visitors have been anchored in
decisions of the Indian Supreme Court.20 The visitors are obligated to tour all areas
of the prison, see all the prisoners, attend to all their complaints and form an
impression of the degree to which the laws and regulations are implemented in
practice. The visitor is permitted to view any document or book. The Indian Prisons
Act21, Par. 12(4), requires that every prison contain a log in which the visitors record
their comments, and visitors are responsible for writing comments at the conclusion
of each visit.

Non-official visitors are not to be in contact with inmates who are on a hunger strike
or inmates who should not be visited for medical reasons. The government may
appoint a district court judge who will have the right to visit these inmates. If the
visitor comes across a case that he believes should be reported in a manner that
goes beyond commenting in the prison visitor log, he may contact the state
parliament or a district judge directly. It is important to note that the visitor is
prohibited from issuing instructions to members of the prison staff. The visitor's
comments and the response of the prison director are transmitted by the district court
judge to the district supervisor of visits, who may transmit them to parliament if he
decides to do so. If the general supervisor or the parliament issues any instructions in
the wake of the visit, they will be transmitted to the visitor by the prison director.

The prison director is obligated to inform each visitor, at the time of his first visit to the
prison, of the laws and relevant documents22 that contain information about subjects
on which the visitors should focus, including: condition of the buildings, crowding,
sanitary conditions, food and water. Inmates must be permitted to speak with the
visitors privately, without being overheard by any member of the prison staff.23

20
Sunil Batra vs. Delhi Administration, 1978
21
Prisons Act 1894. http://www.mha.nic.in/pdfs/Prisons_act1894.pdf
22
For example, Madhya Pradesh Jail Manual, Par. 814
23
Sunil Batra vs. Delhi Administration, pp. 521-522

44
An important restriction imposed on the visitors is the prohibition against contacting
the media regarding information in their possession. Moreover, the various Indian
states are not obligated to appoint visitors, but are only allowed to do so. These
restrictions have been widely criticized by human rights organizations, and criticism
has also been leveled against the inadequate attention devoted to medical topics in
the jail Manuals and at the shortage of female visitors. Corrections are clearly
needed in the Indian system, including appropriate training of visitors and better
ensuring that they carry out their obligations, since they don't always take the time to
summarize their visits.

Britain – England, Wales:

Supervision of prisons in Britain is conducted on four levels:24
1. Every prison has a local Independent Monitoring Board made up of community
volunteers.25 The Board is entitled by law to enter the prison at any time, to meet
with any inmate and to review documents. Volunteers must visit the prison at
least 2-3 times per week, and they must ensure that a volunteer is accessible –
by phone, at least – 24 hours a day.
2. "Her Majesty's Inspectorate of Prisons" – is appointed by the Home Secretary
and is not under the authority of the prison service. Its role is to conduct
unannounced inspections and regular inspections of prisons, and to publish
reports that are submitted to the Home Secretary. The Inspector directs staff
members having expertise regarding different inmate communities: men, women,
minors, migrants. Staff members include visitors from various specialties,
including health and drugs.26
3. Prisoner Ombudsman – Also appointed by the Home Secretary, and not under
the authority of the Prison Service. His role is to examine complaints by inmates,
not initiate investigations. The ombudsman office has nine employees.
Applications to the office are made in writing, and they remain confidential. In
general, letters from inmates to oversight bodies and legal authorities, and
responses to them, are defined as confidential, and prison staff are forbidden to
open or delay their transmission and/or receipt. The envelopes are stamped
"Confidential," and are inserted into special boxes placed in each ward.

24
http://www.humanrights.org.lv./upload_file/OPCAT/John%20KissaneENG.doc. A presentation by
John Kissane, Department of Constitutional Affairs
25
http://www.imb.gov.uk The web site of the organization of unofficial visitors.
26
http://inspectorates.homeoffice.gov.uk/hmiprisons/about-us/faqs/ Her Majesty's Inspectorate of
Prisons for England and Wales

45
4. Britain has fully adopted the recommendations of the Optional Protocol to the
Convention Against Torture – OPCAT. Therefore, in addition to the mechanisms
that have already been described, national and international oversight
mechanisms also exist in Britain, as described in the introduction to this report.

Northern Ireland:
Northern Ireland has non-official visitors from the community who visit prisons. Their
authority is defined by "The Prison and Young Offenders Centre Rules (Northern
Ireland) 1995. The Secretary of State appoints between 6 and 20 visitors to each
prison, from various professions.27 They conduct inspections and deal with issues
related to diet, living conditions and violence. Members of the Board of Visitors have
free access to all parts of the prison to which they were appointed as independent
visitors. They may arrive at the prison at any time, and interview any inmate privately,
out of the hearing or view of prison staff. They have what can be described as
reasonable access to documents, but not to those that the prison Governor is
required to keep confidential. Visitors may present any complaint they have to the
Governor, and are required to submit reports to the Home Secretary.

In addition to inspections initiated by the Board, the law also obligates the authorities
to involve Board members, to provide them with information and to report to them if
various events occur. For example, if an inmate dies the Governor must notify the
Board of Visitors.28 He must also notify them if an inmate must be restrained to
prevent him from harming himself, others or property.

Inmates have the right to contact the Board in writing, and their letters must be
transmitted as soon as possible by prison authorities, who are prohibited from seeing
their contents.

Spain29:
A number of bodies oversee prisons in Spain:

27
Northern Ireland Prison Service web site: http://www.niprisonservice.gov.uk/
28
Par. 29(1): The Prison and Young Offenders Centre Rules (Northern Ireland) 1995. "If a prisoner
dies, the governor shall immediately notify the coroner having jurisdiction, the board of visitors and the
Secretary of State."
29
This information was taken from the report of the Inspector of Irish Prisons, on the basis of
information he received in meetings with various representatives of the Spanish prison authority.:
http://www.justice.ie/en/JELR/lstannreport.pdf/Files/lstannreport.pdf, p. 41

46
1. Spain has 771 prisons and 64 thousand inmates.30 The supervisor of prisons is
under the authority of the Department of Justice, which is part of the Ministry of
the Interior, which also includes the Spanish Prison Service. It is an official body
that reports to the coordinator of the Department of Justice. The supervisor
oversees 12 deputy supervisors, each of whom has an office and a secretary.
They may enter prisons at any time with no advance notice, and speak with any
inmate or employee. Each prison visit must last at least four days. A duty
supervisor must also be available by phone 24 hours a day, seven days a week.
2. District Court judges – Madrid has six prisons and three judges attached to them.
Each judge must visit at least two prisons every week.
3. External oversight of prisons is also conducted by members of parliament, the
Attorney General, and a body that serves as the inmate ombudsman.

Canada:
Incarceration facilities are known as "correction centers," and their openness to
supervision is an inherent aspect of their operation.

1. The Correctional Investigator serves as an investigator and as inmate

ombudsman. He is appointed by the governor. His function is to respond to
complaints from incarcerated inmates. This investigator has the right to obtain
any document or information and visit any correction center at any time. He
must investigate inmate complaints and attempt, in coordination with correction
center authorities, to solve the problems presented to him. If, in his view, the
complaints have not received appropriate attention, and are not solved by
correction center authorities, he may forward them to the Minister.
2. Citizens' Advisory Committees. A local voluntary organization intended to
increase community involvement in the operation of correction centers and
participate in decision-making about their operation. Committee members are in
contact with inmates and correction center staff in order to increase their links
to the community, to make the public aware of inmate rehabilitation activities,
and to act as a balancing activist element, particularly in times of crisis and
problematic events.

In conclusion: One challenge in the field of public health is to obtain care and
treatment for people who need it most, in particular those who are hardest to reach.

30
Country-by-Country Status National Preventive Mechanisms: APT, Report dated 1 July 2008.
http://www.apt.ch/component/option,com_docman/task,cat_view/gid,49/Itemid,59/lang,en/

47
The reality is that many people suffering from multi-system health disorders in the
field of public health are incarcerated in prisons. Thus, many recommend that they be
treated especially while they are incarcerated, and thus are most easily accessible to
public health workers. The World Health Organization recommends a holistic
approach to prisons – a "Whole-Prison Approach" – that views them as sites in which
inmate and staff health can be improved. This holistic approach addresses
environmental factors that improve health, and not only the medical treatment given
to one inmate or another. The prison, in this view, must work to transform itself into a
site that provides personal security, enables correction and rehabilitation, and
promotes health, based on principles of fairness and respect for human rights.

Among the factors noted in the World Health Organization report as important to the
holistic approach to improving health in prison is involvement of external experts,
such as public health specialists and voluntary organizations.

The Israeli experience:

A positive Israeli example of the involvement of human rights organizations in what
occurs in prisons are the visits of the Hotline For Migrant Workers in incarceration
facilities where migrant workers and asylum seekers are held.

Hotline volunteers regularly – in fact, almost daily – visit the wards in Ma'asiyahu
Prison where migrant workers and asylum seekers are held, as well as visiting
migrant workers and asylum seekers held in Nitzan Jail (which is under the authority
of the IPS), Ketziot Prison, and the Michal Jail that is supervised by the Immigration
Authority.

The stated purpose of the visits, at least during the period when the IPS permitted
them, is not to oversee the activities of the IPS and the conditions of incarceration,
but to deal with the status of the inmates vis-à-vis the Ministry of Interior and the
courts that oversee custody issues. It was not so long ago that representatives of the
Hotline also visited the wards of Ketziot Prison where asylum seekers who had
entered Israel illegally (usually across the border with Egypt) were held. But in
January, 2008, following a petition to the High Court regarding the conditions of
incarceration of asylum seekers in Ketziot Prison (HCJ 212/08, Hotline for Migrant
Workers and others vs. the Israel Prison Service and the Ministry of Interior),
permission for visits by Hotline representatives to the different wards of Ketziot
Prison was rescinded, and they were permitted to meet inmates only in the ward

48
designated for them. The visits are coordinated a few days in advance by providing
the visitor's name and ID number.

Restrictions on the visits by Hotline staff because they criticized the IPS demonstrate
that even when the IPS grants a human rights organization access to its facilities, it
does so in a manner that does not allow criticism, identifying failures and joint efforts
to overcome them. Organizations seeking to examine prison conditions and hear
complaints from inmates will be refused permission to visit the prisons.

After the appointment of Lieutenant General Beni Kaniak as IPS Commissioner,

PHR-Israel representatives met with him in October, 2007. We asked for permission
to visit prisons and examine the conditions of incarceration and medical services, and
to offer workshops to prison medical personnel on issues of health and human rights.
Our request to visit prisons was unequivocally refused. Lieutenant General Kaniak
did agree, however, to our request to conduct workshops. Following the meeting,
PHR-Israel wrote to the IPS Chief Medical Officer (letter dated 12.6.08), requesting to
meet with him in order to arrange the workshops, and called his attention to a course
intended for prison medical personnel, designed by the Norwegian Medical
Association for the World Health Organization, translated into Hebrew by Physicians
for Human Rights-Israel and included on the web site of the Israel Medical
Association.31 To date, we have not yet received a reply.

31
Cf. Medical ethics: "Physicians working in prisons: Human rights and ethical dilemmas"
http://www.ima.org.il/

49
Recommendations

In order to protect the rights guaranteed by law to inmates in IPS facilities, the
following actions should be taken:

1. Appointment of a government oversight body, external to the IPS and the Ministry
of Public Security, that will conduct regular oversight visits and report its findings
to the State Comptroller's Office, the Ministry of Public Security, the Ministry of
Health, the Ministry of Justice, the Knesset Interior and Environmental Quality
Committee and to human rights organizations. The reports should be publicly
available. Members of this body should have free access to every area of IPS
incarceration facilities, the opportunity to speak privately with any inmate and any
member of the prison staff, as well as the ability to review documents relating to
the administration of the facility and the treatment of the inmates.

2. Because of the importance of the right to health among other inmates’ rights, and
the consequences of an inmate's health for the inmate population as a whole as
well as for the community outside the prison walls, an authoritative, professional,
governmental medical body external to the IPS and the Ministry of Public
Security, should be appointed specifically to inspect IPS medical services. This
body should make regular, frequent visits to all incarceration facilities in which the
IPS has responsibility for medical care of inmates. The medical staff members of
this body should have free access to all areas of the facility, be able to speak
privately with any inmate or member of the staff, and be able to review any
document (including those relating to medical care of inmates). The body should
address individual cases in which the medical care received by an inmate was
inadequate, as well as systemic problems in medical care, and other matters
relating to violations of the right to health at the facility. The body should report its
findings to the Ministry of Health, the State Comptroller's Office, the Ministry of
Public Security, the Ministry of Justice, the Knesset Interior and Environmental
Quality Committee and to human rights organizations.

3. Appointment of a prison inspection group composed of representatives of civil

society organizations. Members of such a group should be allowed to make both
regular and unannounced visits to prisons. The group should include experts
from different fields in order that it may evaluate conditions in the various areas of
prison life. Medical specialists would comprise an important component of this

50
 group, so that it would be able to evaluate medical services and the health status
of inmates.

4. Permission to representatives of human rights organizations to meet with

individual inmates who complain that their rights have been violated, including
complaints regarding conditions of incarceration or medical care. Such visits are
particularly important to protect the rights of Palestinian inmates, who are unable
directly to contact organizations or institutions who could assist them when their
rights are violated.

5. Permission for Palestinian inmates to make phone calls. A total ban on phone
calls – particularly in view of the fact that there are no regular visits by family
members, representatives of human rights organizations, etc. – is clearly
disproportionate. The justification given for the ban – security risks – also applies
to criminal offenders who maintain contact with dangerous offenders outside the
prison walls, but security authorities don't consider denying them this basic right.
Its total denial to all Palestinian inmates is nothing other than a form of collective
punishment.

51
Responses
[translated from the Hebrew by PHR-Israel]

Israel Prison Service

- restricted -

Office of the Legal Advisor

21.July 2008
Ref. 68720708

Physicians for Human Rights

Director of Prisoners and Detainees Department – Ms. Anat Litvin
9, Dror St.
Jaffa 68135

Re: Draft of Physicians for Human Rights report on oversight and

transparency in the Israel Prison Service

Regarding the aforementioned communication, our response is as follows:

1. The IPS is a public body operating according to law whose function is to hold
inmates in secure custody. As such, the IPS is responsible for the safety and health
of the inmates in its custody.

2. Like every public body, the IPS is subject to external supervision and control by
the State Comptroller's Office, the Ministry of Public Security Office of the
Comptroller, and official visitors. Moreover, the IPS is supervised by the Ministry of
Health Ombudsman, and in addition, the IPS is under close, continual supervision via
the unique mechanism of "inmate appeals."

3. Physicians for Human Rights is not a recognized "official visitor," despite repeated
requests on your part to be granted this status, or a similar status.

4. Under these circumstances, it is obvious that everything in your report is based on

rumors and suppositions, not on any actual independent field investigation.

5. Although I am under no obligation to do so, let me note that about a year ago the
Minister of Public Security appointed a team to examine the provision of medical care
to all IPS inmates on the part of the Health Maintenance Organizations. The team
included representatives of the IPS, the Ministry of Public Security, the Ministry of
Health and the Ministry of Finance, and it examined all aspects of the matter. The
panel's recommendation, that the Minister accepted, was that medical services
continue to be provided by the IPS.

6. Therefore, we totally reject the contents of the aforementioned report.

/s/ Nava Maimon, Atty.

Senior Assistant to the Legal Advisor

Office of the IPS Legal Advisor

Ramleh Commission, POB 81, Tel. 08-9776252, Fax. 08-9193840

52
 State of Israel

Ministry of Health
Administration of Medical Services
General Medicine Division
22.July, 2008
Ref. 131/38334 – 18 (m)

To
Ms. Anat Litvin
Director of the Prisoners and Detainees Department
Physicians for Human Rights-Israel
9, Dror St.
Jaffa – Tel-Aviv 68135

Dear Ms. Litvin,

Re: Draft of Physicians for Human Rights report on oversight and

transparency in the Israel Prison Service

I confirm receipt of the draft report.

Sincerely,

Dr. Dror Guberman

Director, Community Health Branch

cc.
Prof. Avi Yisraeli, Director General
Dr. Boaz Lev, Deputy Director General
Dr. Hezi Levi, Head of Health Administration
Dr. Michael Dor, Head of the General Medicine Division

53
 Ministry of Public Security
Office of the Director General
30.July 2008
03777308

To
Ms. Anat Litvin
Director of the Prisoners and Detainees Department
Physicians for Human Rights

Re: Transparency and Oversight in Israeli prisons

1. Your communication to Mr. Dani Brinker, Director General of the Ministry of Public
Security, was received in our office on 27.7.2008, and transmitted to the
Ombudsman in the Comptroller's Office, as is done with every appeal from the
public, and that office will respond.

2. For additional information, you may contact the Ombudsman in the Comptroller's
Office.

3. A copy of this letter will be transmitted to Mr. Yitzhak Segev, the Ministry
Comptroller, accompanied by your communication.

Sincerely,

/s/ Eitan Horn

Assistant to the Director General

54
 State of Israel
Ministry of Public Security
- not classified -

Office of the Comptroller

Ombudsman Department

Jerusalem, 31.July 2008

46841/08
Att.
Physicians for Human Rights-Israel (Registered Association)
Director of Prisoners and Detainees Department – Ms. Anat Litvin
9, Dror St.
Jaffa – Tel-Aviv 68135

Dear Madam,

Re: Your letter to the Director General of the Ministry, the Office of the Ministry
Comptroller, and others in the Ministry and in the IPS regarding transparency
and oversight in Israeli prisons

Mr. Yitzhak Segev, the Ministry Comptroller and in charge of public complaints, with
whom you also spoke on the phone about this topic, asked me to confirm receipt of
the aforementioned letter, and notify you that the matter has been transmitted to the
responsible authorities in the IPS for their response. We will inform you when their
response has been received.

Respectfully,

/s/ Liat Shalem, Attorney

Director, Public Complaints Office

cc.
1. Director General, Mr. Dan Brinker
2. Prisons Commissioner, Lieutenant General Beni Kanyak
3. Comptroller, Mr. Yitzhak Segev
4. IPS Chief Medical Officer, Dr. Alex Adler, Brigadier
5. IPS Legal Advisor, Brigadier Hayim Shmulevitz, Attorney
6. Mr. Michael Sharon

55