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Emergencies on Hold
Entry of Palestinian Ambulances into East Jerusalem

“Palestinian ambulances are absolutely prohibited from entering the compounds

of Israeli hospitals.¢
(Yoni Feldman, Coordination of Government Activities in the Territories, Oct. 23, 2005)

August 2007

Written by: Miri Weingarten

Research: Ibrahim Habib
Editing: Hadas Ziv
English translation: Shaul Vardi
Graphic design: David Moskovitz
Print: Shemesh Press
Cover Photo: Ja’far Ishtayeh
Photographs: Ibrahim Habib

Special thanks are due to the workers of Izariyah Municipality, PRCS staff and PMRS
staff, for their assistance in preparing this report.

The report was made possible through the generosity of:

Christian Aid. Secretariat Muassasat - Strengthening Human Rights and Good
Governance. European Union. The Rich Foundation. EED - Evangelischer
Entwicklungsdienst. The Samuel Sebba Charitable Trust. Diakonia. Private donors

*This document has been produced with the financial assistance of the European Union. The
contents of this document are the sole responsibility of Physicians for Human Rights Israel, and
can under no circumstances be regarded as reflecting the position of the European Commission
Contents

Introduction

The Need to Enter East Jerusalem

Difficulties in Entering East Jerusalem Prior to the Agreements between Magen David
Adom and the PRCS
A. The Impact of the Separation Wall
B. Policy of the Army and the Civil Administration

The Agreements between Magen David Adom and the PRCS

The Situation on the Ground following the Signing of the Memorandum

A. Analysis of the Cases
B. Red Crescent Ambulances in East Jerusalem
C. The Policy of the Health Coordinator
D. Army Checkpoint Policy
E. The "Back-to-Back" Procedure and its Consequences

Position of the Security Establishment

Discussion and Conclusion

Demands

Appendices
Introduction

According to Israeli army procedures, Palestinian ambulances should be permitted to move

freely, with the exception of security checks, to all destinations including the State of Israel. This
provision was established in the ”Procedure for Processing a Resident of the Judea and Samaria
Area Arriving at a Checkpoint in an Urgent Medical Emergency Situation”, as drafted during the
course of the proceedings in Supreme Court petition HCJ 9109/06, Physicians for Human Rights
- Israel v. Minister of Defense et al. (see Appendix A). According to this Procedure, patients in
an urgent medical condition are to be permitted to pass through checkpoints even if they do
not hold a permit to enter Israel.

In practice, Israel does not permit Palestinian ambulances to reach Israeli hospitals, or even to
reach Palestinian hospitals in East Jerusalem, without prior coordination, even if they are carrying
patients in an urgent medical condition. A series of directives contradicting the above-mentioned
Procedure require that a Palestinian patient be transferred from a Palestinian ambulance to an
Israeli ambulance at the checkpoints at the entrances to East Jerusalem in order to be taken
to the Palestinian hospitals in the city. Even transfer by this method (known as back-to-back)
is often denied, since it requires prior coordination - something that is impossible in the case
of an emergency. In many cases, therefore, ambulances return to the West Bank without
transferring the patient to Jerusalem. At best, the ambulances are detained at the checkpoint
for an extended period.

Following the acceptance of Magen David Adom (MDA)1 and the Palestine Red Crescent Society
(PRCS) into the Federation of the Red Cross and Red Crescent Societies and the signing of a
Memorandum of Understanding (see Appendix B) between the two organisations, Magen David
Adom undertook to act to promote freedom of movement of Red Crescent ambulances within
the Occupied Territories, including East Jerusalem. Negotiations between the two organizations
and the Israeli security establishment produced an arrangement defining six PRCS ambulances
that are permitted to pass through the checkpoints around East Jerusalem with minimum security
checks, provided that the medical crew are included in an agreed list, and that the patient or
injured person who is being transferred meets a defined list of medical conditions.

1 Hebrew: ’Red Star of David’, the Israeli evacuation service. Until 2006 MDA was not admitted to the International Federation
of the Red Cross and Red Crescent due to disagreements regarding the official recognition of its emblem.

¥
However, the hope that this arrangement would lead to an improvement in the field proved
mistaken after it emerged that in 80 percent of cases the ”authorized” ambulances are not
permitted to cross the checkpoints. Moreover, even when back-to-back transfer is authorized
as an alternative to entry, in most cases the patient is not moved to a Magen David Adom
ambulance but to ambulances belonging to the Red Crescent’s Maternity Hospital in East
Jerusalem (which bear Israeli license plates). Since this is a Palestinian organization, the transfer
process entails further delays, both in terms of prior coordination with the Civil Administration
(up to six hours’ delay) and at the checkpoints (delays of up to ninety minutes)2.

According to figures provided by Red Crescent staff3, the result is that most patients in emergency
medical conditions needing to reach Jerusalem for treatment now prefer to come in a private
vehicle rather than in an ambulance, in the hope that it will be easier for them to cross the
checkpoint in such a vehicle. Such a reality denudes the term ”emergency evacuation” of any
meaning and effectively nullifies the function of the ambulance, which is supposed to facilitate
the transfer of a patient to hospital by comparison to other vehicles.

This report focuses on the entry of ambulances into East Jerusalem for two reasons:
1) In the case of transfer by ambulance, the patient is accompanied by medical staff who
have reached a clear medical decision that the patient requires urgent treatment at hospitals
in Jerusalem.
2) The agreement between Magen David Adom and PRCS was supposed to ensure the free
operation of the Palestinian Red Crescent Society in accordance with the rules of the Fourth
Geneva Convention within the territories occupied in 1967, which include East Jerusalem.

Although this report focuses solely on ambulances, PHR-Israel also demands that patients
arriving at checkpoints by other means be permitted to enter speedily.

It is also important to note that the isolation of East Jerusalem and the restriction of entry into
the city to urgent medical emergencies cause significant damage to the quality and availability
of medical care for the residents of the Occupied Palestinian Territory (oPt), and particularly the
West Bank4.

2 These details were given to PHR-Israel staff in a conversation with Imran Shawish, director of the Emergency Center at the
Palestinian Red Crescent Maternity Hospital in East Jerusalem.
3 At a meeting between PHR-Israel and Imran Shawish, director of the Emergency Center at the Palestinian Red Crescent
Maternity Hospital in East Jerusalem, on May 13, 2007.
4 On this aspect, see the report by PHR-Israel: A Wall in its Midst: The Separation Barrier and its Impact on the Right to Health
and on Palestinian Hospitals in East Jerusalem, December 2005.

µ
The Need to Enter East Jerusalem

The Palestinian hospitals in East Jerusalem are considered the most advanced in the oPt. The
main hospitals, Maqassed, Augusta Victoria, the Red Crescent Maternity Hospital, St. Joseph’s
Surgical Hospital and St. John’s Eye Hospital, provide diverse and advanced medical services,
including emergency medicine, for a population of tens of thousands of Palestinians throughout
the oPt. Services that are available only at these hospitals include neonatal intensive care,
radiotherapy, pediatric dialysis, open heart surgery, complex bypass operations, and care for
high-risk maternity patients5.

Medical referrals to East Jerusalem by the Palestinian Ministry of Health: The Ministry of
Health in the Palestinian Authority refers Palestinian patients requiring medical treatments that
are not available in the West Bank or Gaza Strip to medical centers in Jordan, Egypt, East
Jerusalem, Israel, and other countries, and undertakes to cover the costs.

According to the most recent figures of the Palestinian Ministry of Health6, in 2005 and 2006
some 80 patients were referred to hospitals in East Jerusalem each week. In addition, the
Palestinian Authority refers approximately 30 patients a week to East Jerusalem through the
Health Office in `Izariyah, which is situated within the urban bloc of East Jerusalem but outside
the municipal boundaries and outside the Separation Wall. In total, approximately 440 patients
a month are referred from the West Bank to East Jerusalem for the purpose of medical treatment.

Since February 17, 2007, when the workers in the Palestinian governmental health system went
on strike to protest delays in their salaries7, the number of referrals to East Jerusalem has
increased by 120 percent.

In addition to referrals to East Jerusalem, the Palestinian Ministry of Health also issues an average
of twelve referrals a week to medical centers in Israel. Most of the referrals from the West Bank
are to Hadassah Ein Karem Hospital in West Jerusalem.
Dr. Akram Samhan, the Palestinian Ministry of Health official responsible for referrals, estimates

5 For a detailed discussion of this issue, see PHR-Israel: A Wall in its Midst: The Separation Barrier and its Impact on the Right
to Health and on Palestinian Hospitals in East Jerusalem, December 2005.
6 Details provided for PHR-Israel during a meeting with Dr. Akram Samhan, the Referrals and Financial Undertakings director
in the Palestinian Ministry of Health, May 7, 2007.
7 Following the victory of Hamas in the Palestinian elections of 2006, Israel, followed by the US, the EU and other donor countries,
suspended financial support to the Palestinian Authority, including its public health system. Government health workers were
not paid their salaries for many months.

∂
that in at least 30 percent of cases patients are prevented from reaching the intended hospital
due to problems in securing entry permits.

The Palestine Red Crescent Society (PRCS) provides the majority of emergency evacuation
services in the Occupied Territories. Its operations include an emergency hot line; a head office
in Ramallah; eight regional stations and 23 local stations in the West Bank; six regional stations
and one local station in the Gaza Strip; and 44 emergency evacuation vehicles (ambulances)
available at any time, 24 hours a day. The PRCS centers respond to a total of approximately
240 calls a day8. PRCS ambulances transfer emergency cases as well as patients with limited
mobility who require assistance in traveling to and from medical centers. Patients requiring
emergency or specialist treatment at medical centers in East Jerusalem are transferred by
ambulance from throughout the West Bank and the Gaza Strip to East Jerusalem. Less urgent
cases may include frail and elderly patients, or patients who cannot travel without the medical
staff and equipment provided by ambulances.

8 http://www.palestinercs.org/programs/prcs_emergency_appeal_2006.htm.

∑
Difficulties in Entering East Jerusalem Prior to the
Agreements between Magen David Adom and the PRCS

A. The Impact of the Separation Wall

The completion of large sections of the Separation Wall in the Jerusalem area and the blockage
of key entry routes into East Jerusalem has separated tens of thousands of Palestinians living
in neighborhoods and villages in and around East Jerusalem from the hospitals inside East
Jerusalem. This has impaired access to medical treatment. In these circumstances, it is clearly
vital that ambulances and emergency medical teams in various locations in the West Bank, and
particularly in areas close to East Jerusalem, should have access to the various Palestinian
hospitals situated to the west of the Separation Wall in East Jerusalem. In reality, however, the
task facing ambulances and emergency medical teams seeking to evacuate emergency cases
to the various hospitals became almost impossible. Ambulance crews were blocked at the
entrances to East Jerusalem by Border Guard officers who refused to let them pass and ordered
them to turn back.

B. Policy of the Army and the Civil Administration

The indiscriminate policy adopted by the army and the Civil Administration prevented Palestinian
ambulances, including PRCS ambulances, from reaching hospitals inside Israel, and even from
reaching the Palestinian hospitals in East Jerusalem.
Although the checkpoints surrounding Jerusalem are under the responsibility of the Israeli Police
and manned by Border Guard officers as well as soldiers9, the responsible party on the ground
is the regional military commander, who exerts authority over the checkpoint via the local DCO10.
Directives regarding passage of ambulances are transferred from the Civil Administration at Beit
El11 to the DCOs and via them to the officers at the checkpoints. For this reason, the military
Procedure refers also to Border Guards (see Appendix A, par. 7).

9 The checkpoints within the West Bank and the Gaza Strip, and between them and Israel, have been undergoing a process
of transfer to civilian hands since 2005. For this reason staff at checkpoints may include any combination of the following
authorities: the army (IDF), the police and Border Guards, the Crossings Administration at the Ministry of Defense, or the
Airports Authority. The checkpoints surrounding Jerusalem are under the responsibility of the Israeli police, and therefore the
commanding officer who makes decisions, irrespective of the other staff at the checkpoint, is a Border Guard officer. Further
details on this matter can be found in a report submitted to the Knesset Committee for the Interior and the Environment on
19.6.2006, at the following address: http://212.143.66.228/mmm/data/docs/m01532.doc (Hebrew only).
10 District Coordinating Office, an organ established during the Oslo Accords to coordinate between Palestinians and Israelis
on civilian affairs. In practice, until July 2007, only Israeli DCOs functioned in the West Bank.
11 The Civil Administration, established in 1981, is directly subordinate to the Ministry of Defense and wields authority regarding
freedom of movement of Palestinians in the West Bank. It is located in the Jewish settlement of Beit El near Ramallah. For
more on this and other organs of the occupation see the report by PHR-Israel, A Legacy of Injustice, November 2002.

∏
In many cases Palestinian ambulances carrying patients were forced to turn back, despite the
fact that they were transporting urgent medical emergencies meeting the already stringent
requirements of the army Procedure. In other cases the patient and the attending medical team
were required to arrange and pay for an Israeli ambulance to be called to the checkpoint to take
the patient to a Palestinian hospital situated just a few minutes away. This caused substantial
delays in evacuation, and the transfer of the patient from one ambulance to another also
endangered their health. Gross injustice was caused to patients and to their right to receive
proper medical treatment, including emergency treatment. Moreover, the process of transferring
the patient from a Palestinian ambulance to an Israeli ambulance involved protracted and unwieldy
coordination with the Health Coordinator for the Civil Administration, Ms. Dalia Bessa, causing
delays even before the ambulance’s departure for evacuation, or its arrival at the checkpoint.

PHR-Israel has collected testimony describing numerous cases in which ambulances carrying
patients were forced to turn back or to wait for extended periods of time until authorization was
received to transfer the patient to an Israeli ambulance at the checkpoint (see Section 5 and
Appendix C below for a detailed analysis of these cases).

π
The Agreements between Magen David Adom and the PRCS

On June 22, 2006, the Federation of the Red Cross and Red Crescent Societies approved the
affiliation of Magen David Adom (MDA) as a regular member of the movement. It also decided
to approve the affiliation of the Palestinian Red Crescent Society (PRCS). A Memorandum of
Understanding (MoU) signed in November 2005 between Magen David Adom and the PRCS,
including a definition of the spheres of activity of both organizations, had eased the acceptance
of these organizations into the movement (see Appendix B).

According to the MoU, the sphere of operations of the PRCS includes all the Palestinian territories
occupied in 1967, i.e., the West Bank, including East Jerusalem, and the Gaza Strip. The MoU
also recognizes the applicability of the Fourth Geneva Convention to these territories, since they
are defined as occupied territories. Despite this formal recognition of the Green Line as the
boundary of the activities of the Palestinian organization, the MoU and the attached appendices
emphasize that this does not constitute a political recognition liable to affect the legal status of
the oPt, but merely an administrative arrangement.

In paragraph 6 of the MoU, the two organizations undertake to cooperate in implementing the
MoU through operational arrangements.† An Agreement on Operational Arrangements was
attached as an appendix to the MoU in accordance with this paragraph. In this Agreement,
among other provisions, Magen David Adom undertakes to assist PRCS through lobbying and
advocacy vis a’ vis the Israeli authorities in order to advance the freedom of movement of PRCS
ambulances throughout the Palestinian territory, at the checkpoints, between the West Bank and
the Gaza Strip, and at the border crossings. Magen David Adom further undertakes to lobby
with Israeli authorities to enable PRCS ambulances to be stationed at the Red Crescent Maternity
Hospital in East Jerusalem and to facilitate access to hospitals and medical services in the city.

For a long time the contacts between Magen David Adom and the relevant government ministries
did not lead to the slightest improvement in access to East Jerusalem by Palestinian ambulances,
On March 3, 2006, the security establishment agreed to an arrangement whereby six ambulances.
and 22 staff members from the PRCS would informally, and not as part of the agreement, be
defined as†pre-screened†or ”authorized” to enter East Jerusalem from the West Bank. According
to this unofficial arrangement, the details of the ambulances and crews would be forwarded to
the relevant checkpoints in order to facilitate their passage. Patients transferred in these
ambulances would not be required to obtain an entry permit.

±∞
At the same time, an Emergency Center was established at the Red Crescent Maternity Hospital
in East Jerusalem and equipped with two ambulances bearing Israeli license plates. These
ambulances are permitted to collect patients requiring evacuation from areas within the city
limits of Jerusalem but outside the Separation Wall, such as Kafr `Aqab. These ambulances are
also permitted to go to any of the checkpoints around Jerusalem in order to collect patients from
Palestinian ambulances using the ”back-to-back” method.

±±
The Situation on the Ground following the Signing of the Memorandum

The death of Radi Alwahash at the Tunnels Checkpoint,

June 29, 2007
Friday, June 29, 2007, approximately 21:00 hours: The Red Crescent station in
Bethlehem receives a call reporting that a man has been seriously injured in
a traffic accident in the village of Za`atarah. Mohammed Abu `Ajamiyah, the
liaison officer at the station and a professional paramedic, immediately sends
a crew to the site of the accident.
21:10: The Red Crescent crew reaches the site and reports to the station that
an Israeli military ambulance has also arrived on the scene and is providing
the injured man with assistance.
21:30 (approximately): A Magen David Adom ambulance arrives on the scene.
The two Israeli crews state their opinion that the injured man is in a very serious
condition due to massive bleeding in his head, and that he must be transferred
immediately to Hadassah Ein Karem Hospital in Jerusalem. The Magen David
Adom Crew attempts to call a helicopter for evacuation, but is told such a
process would take half an hour. The Magen David Adom crew decides to
evacuate the injured man to hospital, as the fastest possible evacuation.
The Red Crescent crew reports these developments to the Red Crescent
station, and the liaison officer asks them to remain on the scene until the
injured man is evacuated to hospital in Jerusalem by Magen David Adom.
After a short while, the Health Coordinator for the Civil Administration, Ms.
Dalia Bessa, telephones the Red Crescent station in Bethlehem and demands
to know why the injured man was not evacuated by the Red Crescent. The
liaison officer explains that the decision was made by Magen David Adom, and
that the injured man requires urgent specialist care. He also suggests that Ms.
Bassa contact the crews on the scene and request that the patient be transferred
to the Red Crescent.
21:46: The Magen David Adom crew leaves the scene of the incident with the
injured man.
22:00 (approximately): Dalia Bessa again telephones the station, shouting at
the liaison officer and claiming that she will appoint a committee of inquiry to
investigate why the Red Crescent workers refused to evacuate the injured

±≤
 man. Despite the explanations offered by the liaison officer, she says, ”My dear
Abu `Ajamiyah, the injured man is prevented from entering Israel on security
grounds, and he is a resident of the Territories, that is the [West] Bank, and he
cannot enter a hospital in Israel”. After the liaison officer replies that the case
is being handled by Magen David Adom, and that Ms. Bessa will be responsible
for whatever happens to the injured man, she adds, ”My dear Abu `Ajamiyah,
my name is Dalia Bessa and I’m not afraid of you or of bigger people than you”.
She claims that she has already instructed Magen David Adom not to transfer
the injured man to Jerusalem. She orders the liaison officer to send a Red
Crescent ambulance to collect him.
22:02: The liaison officer sends a Red Crescent crew to the Tunnels Checkpoint
south of Jerusalem, through which the ambulance was supposed to transport
the injured man.
22:10: The Red Crescent crew arrives at the checkpoint, investigates the
situation, and reports that the injured man is in critical condition and that
Magen David Adom are treating him on the spot to the best of their ability. The
Border Guard policemen at the checkpoint make it clear to the crew that the
man is not permitted to enter Israel. The crew make it clear to the policemen
that the man is critically wounded and cannot be transferred to another
ambulance, and that he must be transferred urgently to the trauma ward at
Hadassah Ein Karem Hospital. This does not change the position of the
checkpoint commander.
22:25 (approximately): The injured man, Radi Alwahash, dies in the Magen
David Adom ambulance. A military physician signs the death certificate, citing
the cause of death as multiple trauma.
23:05: The body is transferred to the Red Crescent ambulance and then to Beit
Jalla Hospital in the West Bank12.

12 Testimony was collected on July 2, 2007 by B’Tselem staff members Najib Abu Raqiyah and Karim Jubran, and includes
testimonies from Mohammed Abu `Ajamiyah, the liaison officer on the evening in question at the PRCS offices in Bethlehem,
as well as from Mohammed Abu Rian, a paramedic in the Red Crescent team that was sent to the Tunnels Checkpoint. The
testimony is also based on the report of the Magen David Adom paramedic and the death certificate signed by Alexander
Goldman, a military physician.

±≥
During 2005-2007, PHR-Israel has received numerous reports of cases in which an ambulance
arriving at one of the checkpoints around Jerusalem has been required to turn back, to transfer
the patient to an Israeli ambulance by the back-to-back method, and/or to wait for protracted
periods of time. The full list of cases is presented at the end of this report in Appendix C. It
should be noted that this list is not a representative statistical summary of all cases of ambulance
transfers, or even a representative sample, but rather a selection of cases that were referred to
our offices over the years.

A. Analysis of the cases

A review of a selection of cases reported over the past two and a half years shows that the
Procedure for Processing a Resident of the Judea and Samaria Area Arriving at a Checkpoint
in an Urgent Medical Situation has continued to be violated on a systematic basis throughout
this period by the Civil Administration and the military authorities. The authorities also fail to
respect the arrangement regarding the ”authorized” ambulances. Border Guard troops and other
forces responsible for passage through the checkpoints and along the Separation Wall are not
only unaware of the procedure but have received instructions that directly contradict it.

Our analysis will relate to the differences

i. Between the period prior to the agreement between Magen David Adom and the PRCS
and the period thereafter;
ii. Between the behavior of the army toward the ambulances included in the agreements and
the behavior toward ambulances not included.

In 2005, prior to the signing of the Memorandum of Understanding between Magen David Adom
and PRCS, ambulances from various organizations in the West Bank evacuated patients to
hospitals in East Jerusalem. In all cases, however, the army imposed strict restrictions on
ambulances wishing to enter the city, and most of the ambulances were turned back.

In 2006, it is very clear that the principles of the MoU were not implemented. In most cases,
PRCS ambulances did not enjoy any advantage over other ambulances and the forces at the
checkpoints demanded that an ambulance bearing an Israeli license plate be called to the
checkpoint for a back-to-back procedure, entailing lengthy delays both due to the need for prior
coordination and to the procedure itself. This policy had a negative impact on the ability of the
PRCS to undertake emergency evacuation to Jerusalem.

In mid-2006, after the decision to adopt the arrangement with the PRCS relating to the ”authorized”
ambulances, and after it emerged that no change had occurred in the approach adopted by the
army toward Palestinian ambulances, the Palestinian organization PMRS (Palestinian Medical

±¥
Relief Society), a non-governmental organization whose activities include the operation of
ambulances, decided to halt its efforts to transfer patients from the West Bank to Jerusalem
and to refer patients to the PRCS on any matter relating to emergency evacuation to Jerusalem13.
This decision reflected the organization’s sense of responsibility toward its clients and the risks
involved in such delays. It should be noted that this decision increased the workload and
responsibility borne by the PRCS, and made the implementation of the agreements signed
between PRCS and Magen David Adom all the more crucial.

The cases recorded during 2007 enable a comparison between four types of suppliers: Suppliers
other than the PRCS; PRCS ambulances that are not ”authorized” in accordance with the
unofficial arrangement introduced in March 2006; ”authorized” PRCS ambulances; and Red
Crescent ambulances stationed in Jerusalem and bearing an Israeli license plate.

It should first be noted that in all cases, delays occurred that are unacceptable in medical terms.
The sole distinction made in practice by the health coordinator Dalia Bessa and the officers at
the checkpoints is between ambulances with Israeli license plates and ambulances with Palestinian
license plates. The fact that an ambulance belongs to the PRCS, or even to the group of
”authorized” ambulances, in no way guarantees different treatment from that afforded to any
other supplier. At best, such ambulances are permitted to transfer patients by the back-to-back
method to an ambulance with an Israeli license plate. At worst, the ambulance turns back without
evacuating the patient.

The case study presented at the beginning of this chapter is particularly illustrative of the
arbitrariness of Israeli policy, as the evacuation was conducted by an Israeli MDA ambulance,
to which ’security prohibitions’ do not apply, and the casualty was unconscious, making his
’security prohibition’ rather peculiar. In this case, the passage of the ambulance was prohibited
regardless of either the medical condition of the patient, or even the identity of the
ambulance.

In view of this policy, the PRCS decided to discontinue the practice of coordinating the passage
of ambulances from the West Bank to Jerusalem in advance with the Civil Administration. The
organization has explained that such coordination does nothing to prevent delays at the
checkpoints, and merely adds further delays before the ambulance departs. Today, coordination
is conducted partially, according to the decision of the shift officers at the PRCS stations, and
sometimes through the ICRC.

13 Information provided in a conversation with Dr. Mohammad Skafi, a senior PMRS physician and the coordinator of the
organization’s mobile clinics in the Jerusalem and Ramallah districts, September 10, 2006.

±µ
B. Ambulances stationed at the Red Crescent Maternity Hospital
in East Jerusalem:
The two ambulances stationed at the emergency center of the Red Crescent Maternity Hospital
in East Jerusalem, which bear Israeli license plates, receive 160 evacuation calls a month, and
they certainly enjoy better treatment than other ambulances. As stated above, they are permitted
to exit and enter Jerusalem so long as they collect patients from the Jerusalem region, and in
other cases they perform back-to-back transfers from Palestinian ambulances. Jerusalem Red
Crescent ambulances conduct the vast majority of such transfers in comparison to Magen David
Adom, who perform back-to-back transfers in a minority of cases. This is due partly to the large
discrepancy in costs between the two organizations, and to the delays caused by internal Magen
David Adom procedures, which require coordinated accompaniment by the army for any
ambulance before traveling to East Jerusalem. An unknown number of transfers are conducted
by private suppliers of ambulance services, according to arrangements with Ms. Dalia Bessa,
the Health Coordinator for the Civil Administration14. According to figures provided by the Civil
Administration15, 900 cases in which Palestinian patients were evacuated to Israel were recorded
in the first half of 2007 (i.e., an average of 150 transfers per month). Of these, 610 entered by
the back-to-back method by transfer to an ambulance with Israeli number plates, and 290 were
allowed to enter ”without prior coordination”. An additional 51 cases were prohibited from
entering in any way. However, the Civil Administration does not state the identity of the service
providers or whether the ambulances ”permitted to enter East Jerusalem” had evacuated patients
from the Jerusalem region or from other parts of the West Bank.

The arrangement with the Red Crescent ambulances in Jerusalem is inadequate for three
main reasons:
i. Back-to-back transfer at the checkpoint requires prior coordination with the Health
Coordinator Dalia Bessa prior to the authorization of the transfer, causing delays of between
one and six hours.
ii. Significant delays (up to ninety minutes) still occur at the checkpoints despite prior
coordination.
iii. Physical transfer by the back-to-back method delays the process still further and, in some
cases, endangers the patient.

14 These details were provided at a meeting between PHR-Israel and Imran Shawish, director of the Emergency Center at the
Palestine Red Crescent Maternity Hospital in East Jerusalem, on May 13, 2007.
15 In a letter from the military West Bank Legal Advisor to Ibrahim Habib of PHR-Israel, dated 16.7.2007.

±∂
 C. The Policy of the Health Coordinator and Her Function in Coordinating
the Passage of Ambulances
According to the instructions issued by Ms. Dalia Bessa, the Health Coordinator appointed by
the Civil Administration for the West Bank and East Jerusalem, PRCS ambulance crews from
throughout the West Bank must coordinate in advance the departure of ambulances destined
for East Jerusalem. It should be noted that this coordination must take place with the Health
Coordinator herself; in urgent cases, this leads to serious problems and grave delays.

Red Crescent ambulances stationed in East Jerusalem, like Palestinian ambulances throughout
the West Bank and Gaza Strip, are not free to act on the basis of autonomous medical judgments,
but must engage in exhausting preliminary coordination. Before authorizing the transfer of a
patient from the West Bank to East Jerusalem, Ms. Bessa demands provision of the following
details in advance: Full details of the ambulance and its crew; name, identity card number, age,
medical condition and current status of the patient; name, identity card number, and age of the
person accompanying the patient; and full details of the hospital to which the patient is to be
transferred, including department, the specific name of the physician, and the time for which a
consultation is scheduled. The Red Crescent emergency center in East Jerusalem ascertains
all these details and verifies them with the hospital before contacting the Health Coordinator. It
should be noted that in emergency evacuation the patient is referred to the emergency room;
accordingly, most of the requested details are meaningless.
Photo: S. G.

The office responsible for issuing the relevant authorization is the

office of the Health Coordinator for the Civil Administration, which
works in coordination with a ”Humanitarian Hotline” staffed by army
soldiers. However, only the Health Coordinator Dalia Bessa herself
is authorized to make decisions on these matters. It goes without
saying that a single individual cannot be available 24 hours a day
as required. Moreover, Ms. Bessa has no medical training and,
accordingly, is not qualified to make crucial decisions relating to the

Dalia Bessa,
urgency of medical cases. Even if she were a specialist in emergency
Health Coordinator
for the Civil Administration.
medicine, the authority regarding the urgency and gravity of a case
rests with the attending physician alone. For our purposes, the medical
crew in the ambulance is the only source qualified to decide on access to health services. A
person present alongside the patient and familiar with their condition clearly enjoys an advantage
and senior authority over officials sitting in a distant office, even if these officials consult with a
physician, in view of the far-reaching consequences of the decision not to permit a patient
to enter.

±∑
It is thus apparent that the structure and personnel of the office of the Health Coordinator are
inappropriate given the kinds of decisions it is required to make. In addition, however, we have
received testimony suggesting that the coordinator changes her procedures and attitude toward
the emergency center and the PRCS ambulances in an arbitrary manner that some consider
vindictive and capricious. One of the staff members at the Red Crescent emergency center in
Jerusalem states that it is impossible to predict in advance how Ms. Bessa will respond:

”If it’s a good day, she immediately authorizes back-to-back. If she doesn’t feel like it, she says, ”Tell
Maqassed [Hospital] to call me”. Apart from that, sometimes they answer the phone there and
sometimes they don’t. We have two mobile phone numbers for her and two Bezeq [landline] numbers,
but sometimes it’s still very hard or even impossible to reach her. The delay at the checkpoint can
be up to an hour and a half, but the delay because of Dalia can be from one to six hours. You can
never plan or know in advance how it will go ≠ it is completely unpredictable. Emergencies are also
coordinated with her, we call her on her mobile in the middle of the night. It’s impossible to base the
whole system on one person. There is no 24 hour call center. They work in the office until 2 or 3
o’clock, and that’s not adequate”.

Moreover, between March 8-14, 2007, Ms. Bessa decided not to answer any calls from the
PRCS center in Jerusalem for an entire week, after the center refused her request to transport
a dead body within the West Bank (the Good Standard Practice regulations observed by the
ICRC prohibit the transfer of bodies in the organization’s ambulances).
The case described at the opening of this chapter also shows Ms. Bessa’s style and tactics to
be far from compliant with standard medical practice or with medical ethics. A complaint was
issued to the Defense Ministry and the Health Ministry following the case on July 9, 2007,
demanding that disciplinary measures be taken against her, that her removal from her position
be considered, and that the function of the Health Coordinator be reconsidered. No reply has
been received to date.

In light of the above, it would seem that one of the main obstacles facing ambulances seeking
to evacuate emergency cases to Jerusalem is the structure of the Office of the Health Coordinator
in the Civil Administration, its mode of operation, and its personnel. All these factors combine
to produce delays of up to six hours in the coordination of transfer before the ambulance has
even departed. It should be added that over the years PHR-Israel has been unsuccessful in its
efforts to secure written procedures or other documents relating to freedom of movement and
the granting of authorizations by this office.

±∏
D. Army Policy toward Palestinian Ambulances at the Checkpoints
In addition to the delays in coordination, the checkpoints that surround Jerusalem to the north,
east, and south constitute a further obstacle to Palestinian ambulances seeking access to the
city. As noted above, if the ambulance bears Palestinian license plates, the officers at the
checkpoint simply refuse to let it pass. In the case of a Red Crescent ambulance bearing Israeli
license plates, a delay of approximately fifteen minutes is usually encountered at the checkpoints
to the north and east of the city ≠ A-Za`im, Mt. of Olives, Hizma, and Kalandiyah. This delay for
a security inspection may be justified. By contrast, at the southern checkpoints ≠ and, in particular,
the ”Minharot” (Tunnels) Checkpoint ≠ the minimum delay is 20 minutes, and in most cases
ambulances are delayed for between 30 and 90 minutes ≠ clearly an extremely dangerous delay
in the case of emergency evacuation16.

E. The ”Back-to-Back” Procedure and its Consequences

As explained above, when the military decides to permit a patient to enter Jerusalem, it usually
requires that s/he be transferred from a Palestinian ambulance to an ambulance bearing an Israeli
license plate. This method is already employed for the transfer of merchandise between Israel
and the West Bank or Gaza Strip.

Professor Yoel Donchin, Anesthesiologist and Head of the Patient Safety Unit at the Department
of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Hospital, Jerusalem,
prepared a professional opinion relating to the potential damage that may be caused by transferring
patients from one ambulance to another by the back-to-back method. He determines that ”the
transfer of injured persons and patients in an ambulance includes a stage of treatment and the
preparation of the injured person for transfer. Removing a patient from [a stretcher or ambulance]
and transferring him/her to another represents not only a disruption of the continuity of treatment
but also an unnecessary bother and a tangible danger. Undoubtedly, a person suffering from a
hipbone or cervical spine injury will suffer damage due to the moving and transfer from one
vehicle to another”. (see the opinion in Appendix D).

16 Figures provided by Imran Shawish, director of the emergency center at the PRCS Maternity Hospital in East Jerusalem.

±π
The army is also aware of the danger of the back-to-back method. During a lecture at the College
of Administration in Rishon LeZion on April 6, 2006, Lieutenant Ofer Meital, head of the International
Organizations Desk in the Civil Administration for the Judea and Samaria Area confirmed these
concerns regarding the back-to-back procedure, noting that the transfer of a patient in a serious
condition from one ambulance to another is dangerous. Nevertheless, the army continues in
practice to require the use of this procedure on a routine basis.

In conclusion, the
statistics clearly
show that the
”authorization” of
ambulances did not
in practice remove
the need for prior
coordination.
Accordingly, no
visible improvement
can be noted in
terms of access to
Jerusalem by these
ambulances or
others. The
”authorized”
ambulances are still
Back to back transfer at Tunnels Checkpoint, July 2007.
required to transfer
patients to Israeli
ambulances by the back-to-back method; moreover, the authorization of these ambulances
does not solve the problem of transferring patients in extremely urgent cases, when by definition
it is impossible to ensure that the patient will be brought to the checkpoint in the ”right” ambulance.
In many cases, even transfer by the back-to-back method is not permitted at the checkpoint,
and the ambulances turn back without evacuating the patient17. As mentioned above, the PRCS
now refuses as a matter of principle to coordinate in advance the arrival of ambulances at the
checkpoints due to the failings of the coordination mechanism. The PRCS demands that its
ambulances be permitted free passage in cases defined as emergencies by definition.

17 According to Imran Shawish, director of the emergency center at the PRCS Maternity Hospital in East Jerusalem, at a meeting
with PHR-Israel staff members on May 13, 2007. According to the Civil Administration s own records, cited above, since the
’

beginning of 2007, ambulances have been turned back twice a week on average.

≤∞
Position of the Security Establishment

On September 27, 2005, PHR-Israel contacted Major-General Yosef Mishlav, Coordinator of

Government Actions in the Territories, warning of failings in the implementation of the military
Procedure and in the passage of ambulances from the West Bank to East Jerusalem. Subsequently
(on October 16, 2005), Dr. Yoram Blachar, chairperson of the Israel Medical Association, also
alerted the authorities to the phenomenon of the denial of ambulance access to hospitals in
Jerusalem. The reply received from the Office of the Coordinator of Government Actions in the
Territories, dated October 23, 2005, shows that the Procedure declared before the Supreme
Court is not respected, and that ”Palestinian ambulances are absolutely prohibited from
entering the compounds of Israeli hospitals”. The letter also noted that ”the passage of a
Palestinian patient in an ambulance must be implemented by the back-to-back method,
in accordance with procedures”, and that only in extremely exceptional cases will the soldiers
at the checkpoint permit a Palestinian ambulance to cross on the basis of humanitarian
considerations. It should be noted that the request by PHR-Israel to receive a copy of the
procedures mentioned in the letter has not met with a response to date (see Appendix E).

On April 25, 2006, Attorney Yohanna Lerman, representing PHR-Israel, contacted the Coordinator
of Government Actions in the Territories and requested that action be taken to ensure the
implementation of the Procedure for Processing a Resident of the Judea and Samaria Area
Arriving at a Checkpoint in an Urgent Medical Situation at all the checkpoints along the Separation
Wall; enable the passage of Palestinian ambulances carrying patients in an medical emergency
condition to Palestinian hospitals in East Jerusalem; and abolish the above-mentioned back-
to-back procedure.

On May 14, 2006, the security establishment sent an initial response stating that the entry of
Palestinian ambulances is prohibited due to the instructions of the Ministry of Health (which were
not detailed in the response), and due to the security risk involved. The letter stated only that
in particularly exceptional and humanitarian cases the passage of a Palestinian ambulance may
be permitted. On June 6, 2006, a further response was sent claiming that the said Procedure
was not intended to regulate the passage of medical emergency cases, but solely of ”urgent”
medical emergency cases. The response also clearly implies that the general rule is that Palestinian
ambulances are prohibited from entering East Jerusalem; exceptions to this rule will be possible
only in extremely special humanitarian cases. In addition, however, the response alluded to a

≤±
future new procedure that would regulate the passage of specific ambulances that would receive
prior security clearance, in the hope that such a procedure would resolve the problem.

Regarding ”urgent” medical emergency cases, Professor Yoel Donchin, Anesthesiologist

and Head of the Patient Safety Unit at the Department of Anesthesiology and Critical
Care Medicine, Hadassah Hebrew University Hospital, Jerusalem, states in his attached
professional opinion that there are many medical cases which, while not constituting
”extremely urgent emergencies”, are nevertheless situations requiring rapid medical
intervention without which the patient s condition is liable to deteriorate in a matter of
’

minutes, causing irreversible damage and death. (See Appendix D).

After PHR-Israel learned that the arrangement regarding the ”authorized” ambulances was not
being implemented in practice, it submitted a complaint to the security establishment. On August
6, 2006, we were informed that, as part of the new procedure, patients with an entry permit to
Israel would be permitted to enter in an authorized Palestinian ambulance, with prior coordination.
We were also informed that this new procedure would not replace the previous coordination
procedure for the entry of patients into Israel. The new procedure was intended to provide a
response for cases in which the patient faced immediate mortal danger or was liable to suffer
irreversible damage, and in which the back-to-back procedure constituted a medical risk. Even
in accordance with this new procedure, however, a permit and prior coordination would be
required to enter Israel, and patients would not be permitted to enter without completion of this
authorization and coordination process.

The Position of the Israeli Supreme Court

In the past the Supreme Court has expressed its opinion in numerous rulings regarding Israel s ’

commitment to permit the passage of ambulances and emergency medical staff to hospitals:
”...Our combat forces must observe humanitarian rules relating to the treatment of injured persons,
patients, and bodies. The exploitative use that has been made of medical staff in hospitals and
of ambulances requires the IDF to act to prevent such actions, but it does not, in itself, permit
the sweeping violation of the humanitarian rules. Indeed, this is also the declarative position of
the state. This position is mandated not only in accordance with international law, on which the
Appellants base their case, but also from the values of the State of Israel as a Jewish and
democratic state” (HCJ 2936/02, PHR-Israel v Commander of IDF Forces in the West Bank,
Piskei Din 56(3) 4).

≤≤
Discussion and Conclusion

The army s Procedure relating to urgent medical emergencies clearly states that, in the case
’

of a patient in an urgent medical emergency condition, there is no need for a prior permit in
order to cross the checkpoint. If the commander of the checkpoint gains the impression, whether
by himself or with the assistance of a medical authority, that the case is indeed an urgent medical
emergency, he is to permit passage without need for a prior permit. Accordingly, the current
demand of the security establishment for prior coordination and the receipt of a permit to enter
Israel in the case of patients in an urgent medical emergency condition constitutes a violation
of the procedure and leads to delays in the evacuation of patients. The outcome of this situation
is injury to human life and health.

Throughout the period during which PHR-Israel has engaged in correspondence and discussion
of this matter with the security establishment, no significant improvement has been recorded,
despite our warnings regarding the current situation whereby the Health Coordinator, on the
one hand, and the officer at the checkpoint, on the other, are defined as the final arbiters,
permitting or denying the passage of ambulances at the checkpoint. Refusal to permit passage
is particularly grave since the above-mentioned arbiters lack the necessary medical knowledge
to consider the ramifications of their decisions. Moreover, many such decisions are taken in
contradiction of the clear demand by a Palestinian medical team that the patient be evacuated.
Prior coordination and the total dependence on the Health Coordinator, Ms. Dalia Bassa, are
also unacceptable. Even if Ms. Bessa were a medical authority, her intervention would be
completely improper, since priority must be given to the opinion of the attending medical team
on the ground. As stated in Prof. Donchin s letter,
’

”The experience of the team treating the patient (medics, paramedics and doctors) during the stage
before arrival at the hospital is the most important factor in the provision of appropriate care. Only
they can sense and diagnose the need for speedy transfer to the emergency room. Only they can
assess ”who will live and who will die”.

Giving persons who cannot distinguish between medical levels of severity the power to conduct this
medical classification causes serious medical damage and limits the possibility of saving lives, which
is the reason for the establishment of emergency services and their ability to activate a siren and a
flashing light during their journeys, in order to enable them to reach their destination speedily”.
(Appendix D)

≤≥
The dependence of a vital system of this nature on the presence and decision of a single
individual who cannot possibly be available 24 hours a day is unprofessional, negligent, and a
danger to human life.

The State of Israel has signed international conventions regulating the obligation of the occupying
power to ensure medical treatment and aid for the local population. Accordingly, it must ensure
the passage of ambulances and emergency medical staff at checkpoints without delay and
hindrance in order to permit them to reach hospitals for the purpose of medical treatment. The
sweeping denial of passage, without ensuring an immediate and proper alternative to the
passage of the ambulance, effectively constitutes a gross violation of the obligation to respect
the right to life and physical integrity of protected civilians, and is improper since it constitutes
a collective measure taken against all Palestinian civilians.

The admirable intentions reflected in the Memorandum of Understanding signed by Magen

David Adom and PRCS have not had the slightest impact on reality on the ground. The main
reason for this is the interference by security authorities in decisions that should be of a purely
medical nature. This injury to the professional independence of medical teams, and particularly
emergency teams, is contrary to the guidelines established by the World Medical Association18.

It is no coincidence that the friction and the numerous contradictions in Israeli policy described
in this report occur in East Jerusalem and along its boundaries. The policy of the security
establishment faithfully reflects the ambivalence of Israeli governments, who are unwilling, on
the one hand, to contain the Palestinian population accessing services in East Jerusalem, yet
are unable completely to exclude it. This pattern of simultaneous exclusion and containment
can be likened to a situation in which Israel holds the reins attached to the necks of the Palestinian
residents and institutions in the city, tightening and relaxing, pulling and pushing, accepting and
rejecting, containing for its own use and excluding for the purpose of its own self-definition19.

As for the aspiration to achieve separation, one could say, with Edward Said, that ”...In the area
between Ramallah to the north and Bethlehem to the south, eight hundred thousand Israelis
and Palestinians live on top of each other and cannot be separated”20.

18 See The World Medical Association Regulations in Times of Armed Conflict, Par. 12: http://www.wma.net/e/policy/a20.htm.
19 This definition paraphrases a characterization presented in an article by Benny Nurieli, ”Arab Jews in the Ghetto in Lod,
1950-1959”, Theory and Criticism 26 (2005), 29.
20 Edward Said, ”What Can Be the Meaning of Separation?” Al-Ahram, November 11-17, 1999.

≤¥
Demands

PHR-Israel wishes to present the following demands to the security establishment, including the
Civil Administration and the army, from the command level to the persons staffing the checkpoints:
1. Passage into East Jerusalem: Palestinian ambulances should be permitted rapid passage into
East Jerusalem without the need for prior coordination.
2. Searching: If the army or police insist on examining each case on its own merits when an
ambulance reaches the checkpoint, the military procedures do not justify any delay in passage
beyond a physical search in order to inspect the interior of the ambulance; this must be undertaken
with maximum speed and the ambulance must be prioritized over other vehicles.
3. ”Back-to-back”: In any case, the back-to-back method is not to be permitted due to the
delays it entails without any medical justification, and due to the medical risk as described above.
4. Passage into Israel: A person referred for medical treatment in Israel at the discretion of the
referring physician is to be permitted passage in accordance with exactly the same principles
as described above with regard to East Jerusalem.
5. The Health Coordinator: In view of the grave testimonies collected by our office regarding the
functioning of the Health Coordinator, we request that:
A) The specific accusations regarding her behavior and decision-making process be
examined. According to the findings, personal accountability should be demanded of the
bearer of this function.
B) The necessity of the Health Coordinator to decision-making regarding entry into
Jerusalem for medical purposes be re-examined. The concentration of such extensive
and fateful decision-making powers in the hands of a single individual who lacks appropriate
medical training should be questioned; as a servant of the security forces, that individual
cannot defend the health rights of Palestinian residents. Only an independent body
committed to the patient, i.e., the attendant physician, can and should consider the need
for passage into Jerusalem.

≤µ
Appendix A: ”Procedure for Processing a Resident of the Judea and Samaria Area Arriving
at a Checkpoint in an Urgent Medical Emergency Situation”
[Translation from the Hebrew original by PHR-Israel]:

1. This procedure regulates cases in which a person arrives at a checkpoint in the

Judea and Samaria Area in an urgent medical emergency situation, and asks to
pass the checkpoint in order to reach a medical institution at which he can receive
medical treatment, in Israel or in the Area, during calm, closure or internal closure.
2. As a general rule, the checkpoint commander shall permit the passage of the
person at the checkpoint (including entry into Israel) for the purpose of obtaining
medical treatment, even if that person does not have the requisite permit, if the
case is an urgent medical emergency situation. An urgent medical emergency
situation shall be, for example: a situation in which a woman about to give birth
arrives at the checkpoint; a situation in which a case of severe bleeding arrives at
the checkpoint; a case in which a severe burns case arrives at the checkpoint, etc.
3. The discretion regarding the question as to whether the case is an urgent medical
emergency situation rests with the commander of the checkpoint. As far as time
limitations permit, the checkpoint commander shall consult a medical source.
4. In the event of doubt as to whether the case is an urgent medical emergency
situation, the balance of doubt shall be in the resident s favor.
’

5. A soldier at the checkpoint who encounters an urgent medical case shall

immediately forward processing of the case to the checkpoint commander.
6. The checkpoint commander shall consider the possibility of accompanying the
resident who is in an urgent medical emergency situation using a vehicle in the
possession of our forces, and shall consider the possibility of transferring the
resident to a vehicle or ambulance of our forces to take him to his destination.
7. This procedure shall be repeated to all IDF and Border Guard soldiers at the
checkpoints.

≤∂
Appendix C: Summary of Reports on the Delaying of Ambulances at Checkpoints,
2005-200721
Summary of Reports, 2005
Transfer by suppliers not party to the agreement between Magen David Adom and the PRCS

Date Description Intake Body Origin and Destination Location of Delay Outcome
Jun. 1 Woman in advanced Izariyah To the Red Crescent Delayed at A-Za’im Woman gave birth
2005 state of labor Municipality Matemity Hospital Checkpoint at checkpoint;
baby died.
Nov. 17 Heart patient requiring Palestinian Ramallah Hospital to Delayed at Hizma Request to pass
2005 urgent catheterization Medical Relief Maqassed Hospital Checkpoint for denied; ambulance
following heart attack Society (PMRS) 20 minutes turned back.
Nov. 22 Heart patient requiring PMRS ’Alia’ Hospital in Hebron Delayed at Tunnels Request to pass
2005 urgent catheterization to Maqassed Hospital Checkpoint for denied; ambulance
following heart attack 15 minutes evacuated patient to
Beit Jala after
extensive delay.
Dec. 8 Patient suffering from Izariyah Abu Dis to Maqassed Delayed at A-Za’im Passage permitted
2005 heart attack Municipality Hospital Checkpoint for after PHR-Israel
25 minutes intervened.
Dec. 14 Patient suffering from Izariyah Abu Dis to Maqassed Delayed at A-Za’im Passage denied;
2005 stroke Municipality Hospital Checkpoint for patient transferred
15 minutes to Ramallah.

21 The data in the tables was taken from the following sources: Izariyah Muncipality, PMRS, PRCS and records of individual
casework by PHR-Israel.

≤∑
Summary of Reports, 2006
Transfer by suppliers not party to the agreement between Magen David Adom and the PRCS

Date Description Intake Body Origin and Destination Location of Delay Outcome
Jan. 19 Toddler aged 18 PMRS From Qalqiliya to St. Delayed at Hizma Request to pass
2006 months with eye injury John’s Eye Hospital Checkpoint for denied; patient
15 minutes evacuated to Ramallah.
Mar. 1 Baby aged 20 days Izariyah From Izariyah to Delayed at A-Za’im Passage permitted
2006 suffering from Muncipality Maqassed Hospital Checkpoint for after PHR-Israel
pneumonia 40 minutes intervened; medical
crew required to
deposit their ID cards.

Transfer by PRCS ambulances

Date Description Intake Body Origin and Destination Location of Delay Outcome
Jun. 15 Heart patient requiring PRCS Intensive care at Beit- Delayed at Gilo Soldiers demanded
2006 urgent surgery due to Jala Hospital to Checkpoint that patient be
blockage of cardiac Maqassed Hospital evacuated by private
arteries. car or taxi since his
condition did not
warrant transfer by
ambulance.
Jun. 17 Respiratory PRCS Augusta Victoria Delayed at Ambulance not
2006 tract cancer in a outpatient clinic in Qalandiya permitted to cross;
deteriorating condition Ramallah Hospital to Checkpoint patient waited in
Augusta Victoria serious condition until
Hospital in Jerusalem an MDA ambulance
evacuated him to
hospital.

Jul. 12 Patient with broken PRCS To Maqassed Hospital Delayed at Tunnels Transfer eventually
2006 hip Checkpoint and permitted at Gilo
redirected to Gilo Checkpoint.
Checkpoint. Total
delay: two hours

Jul. 31 Heart patient PRCS Beit Jala Hospital to Delayed at Gilo Officer at checkpoint
2006 carrying entry permit Maqassed Hospital Checkpoint argued that the case
for two hours was not urgent. MDA
ambulance arrived
after two hours and
evacuated patient to
hospital.
Aug. 3 Man injured in road PRCS Jericho area to Delayed at A-Za’im Transferred by back-
2006 accident with Maqassed Hospital Checkpoint for one to-back method to
multiple fractures hour despite prior MDA ambulance
coordination despite risk due to his
fractures.

≤∏
Summary of Reports, 2007
Transfer by ”authorized” PRCS ambulances or by Red Crescent ambulances
with Israeli license plates

Date Description Intake Body Origin and Destination Location of Delay Outcome
Jan. 20 Woman suffering Red Crescent To Augusta Victoria Delayed at Tunnels Transfer permitted,
2007 severe chest pain and Jerusalem, Hospital Checkpoint for patient’s condition
high blood pressure ambulance with one hour and deteriorated
Israeli license 35 minutes, despite due to delay.
plate prior coordination
Jan. 25 Leukemia patient with Red Crescent To Maqassed Hospital Delayed at Tunnels Transfer permitted,
2007 nasal bleeding and Jerusalem, Checkpoint for patient’s condition
unstable pulse ambulance with 35 minutes, despite deteriorated due to
Israeli license prior coordination delay (patient required
plate respiration).
Jan. 27 Heart patient requiring Red Crescent To Maqassed Hospital Delayed at Tunnels Transferred by
2007 open heart surgery Jerusalem, Checkpoint for back-to-back
ambulance with 35 minutes, despite method.
Israeli license prior coordination
plate
Feb. 20 Woman suffering from Red Crescent To Augusta Victoria Delayed at Tunnels Transfer permitted.
2007 cancer of spleen Jerusalem, Hospital Checkpoint for
ambulance with 30 minutes, despite
Israeli license prior coordination
plate

Feb. 20 Leukemia patient Red Crescent To Hadassah Delayed at Tunnels Transfer permitted.
2007 Jerusalem, Ein-Kerem Hospital Checkpoint for
ambulance with 35 minutes, despite
Israeli license prior coordination
plate

Feb. 24 Edema in Red Crescent To Maqassed Hospital Delayed at Tunnels Transfer permitted;
2007 respiratory tract Jerusalem, Checkpoint for patient’s condition
ambulance with 52 minutes, despite deteriorated, suffered
Israeli license prior coordination shortness of breath.
plate
Apr. 19 Woman aged 80 Izariyah To Maqassed Hospital Delayed at A-Za’im Soldiers conditioned
2007 with hip injury Municipality in Checkpoint for 40 permission on transfer
an ”authorized” minutes, despite by private ambulance.
PRCS transfer in an Patient transferred to
ambulance ”authorized” PRCS Israeli ambulance
ambulance writhing in pain after
protracted delay.

≤π
Transfer by suppliers not party to the agreement between Magen David Adom and the PRCS
or by ”non-authorized” PRCS ambulances

Date Description Intake Body Origin and Destination Location of Delay Outcome
Mar. 27 Woman in advanced Izariyah To Maqassed Hospital Delayed at A-Za’im Transferred to Israeli
2007 stage of labor Municipality Checkpoint for ambulance. Amniotic
35 minutes fluid broke in
ambulance. Gave birth
in hospital.
Apr. 26 Acute appendicitis Izariyah To Maqassed Hospital Delayed at A-Za’im Soldiers conditioned
2007 (requiring urgent Municipality Checkpoint for 35 passage on order of
surgery) minutes (significant Israeli ambulance.
delay in an Patient transferred by
appendicitis case). back-to-back method.
Apr. 26 Student injured in riots PRCS Al-Bireh To Maqassed Hospital Delayed at A-Za’im Soldiers conditioned
2007 in Abu Dis, sustained Checkpoint for passage on repeat
internal hemorrhaging 90 minutes coordination with
health coordinator.
Driver and patient
entered without the
remainder of the crew.
Apr. 29 9-month-old baby Izariyah To Maqassed Hospital Delayed at A-Za’im Passage conditioned
2007 with respiratory Municipality Checkpoint for on ordering
problem and fever 30 minutes ambulance from
PRCS Jerusalem.
Baby suffered from
lack of breath due to
delay.

Jul. 2 20 year-old man PRCS, Hebron A-Ahli Hospital, Delayed at Tunnels Passage denied;
2007 critically ill due to fluid and Bethlehem Hebron, to Maqassed Checkpoint from patient returned to
in lungs Hospital 14:15 to 16:00, Hebron. Next day
despite prior passage coordinated
coordination with by means of transfer
ICRC and at the checkpoint to a
coordination Red Crescent
attempts by PRCS ambulance from East
Bethlehem Jerusalem.
Jul. 11 Cancer patient in need PRCS, From Beit Jalla Delayed at Tunnels Passage was
2007 of urgent surgery Bethlehem Hospital to St. Checkpoint from conditioned on
Joseph’s Hospital 15:36 to 16:25, transfer at the
despite coordination checkpoint to a Red
with ICRC Crescent ambulance
from East Jerusalem.
Passege enabled only
after intervention on
site by PHR - Israel
worker.

≥∞
Appendix D: Professional Opinion of Professor Yoel Donchin on Medical Emergencies and
Urgent Cases, and on the Method of Transfer of Patients and Injured Persons by Ambulance

TRANSLATION FROM HEBREW

(Wednesday, December 6, 2006)

Att.
Physicians for Human Rights Association

Subject: Definitions of Medical Emergency and Urgency Situations

Extremely urgent emergency situations in medicine are few: blocking of the respiratory tract,
which leads to strangulation and death within minutes; uncontrollable hemorrhage from a large
blood vessel, which leads to shock and death within about five minutes; and emergency
obstetrics situations. An additional situation demanding immediate urgent attention is cardiac
arrest. The shorter the time (measured in minutes) until the beginning of care, the higher the
chances of saving and reviving the patient.

These are extreme emergency situations, which are clear not only to reasonable doctors but
also to the layperson. In such cases immediate intervention is necessary to prevent death.
However, many conditions demand medical intervention without which a speedy deterioration
will occur and death follow within an hour or within hours.
A patient diagnosed with diabetes needs to have the level of sugar in his blood balanced and
frequent injections of insulin. Administering of insulin is accompanied by frequent testing of
blood and urine glucose levels. Prevention of these tests and cessation of access to insulin is
tantamount to a prolonged and painful death sentence. Patients suffering from hypertension
must also receive treatment to balance blood pressure, lacking which a rupture of blood vessels
or cardiac damage will bring to death or disability.
Pregnant women ≠ low mortality rates among women giving birth and newborns in Israel are
a result of follow-up provided to women. Prevention of such follow-up or medical intervention
are tantamount to a death sentence on the mother.

Chronically ill patients who need advanced technologies such as artificial kidneys, plasmapheresis
or frequent blood transfusions ≠ their lives are dependent on the level of their access to care.
They might be able to wait an additional hour in an ambulance, but they cannot withstand long
hours of waiting, without knowing whether at the end of the wait their blood will be filtered as
necessary.

≥±
Transfer of the injured and the sick by ambulance includes a stage of treatment and preparation
of the injured person for transfer. Removing a patient from [a stretcher or ambulance] and
transferring him/her to another represents not only a disruption of the sequence of treatment
but also an unnecessary bother and a tangible danger. Undoubtedly, a person suffering from a
hipbone or cervical spine injury will suffer damage due to moving and transfer from one vehicle
to another.

The time element, as already mentioned, is one of the most important components of the process
of treating the patient.

Persons suffering from chest pain ≠ the longer the time until diagnosis and treatment the higher
the risk of myocardial injury and extension of infarction. The same is true of injury to other internal
organs.

The experience of the team treating the patient (medics, paramedics and doctors) during the
stage before arrival at the hospital is the most important factor in the provision of appropriate
care. Only they can sense and diagnose the need for speedy transfer to the emergency room.
Only they can assess ”who will live and who will die”.

Giving persons who cannot distinguish between medical levels of severity the power to conduct
this medical classification causes serious medical damage and limits the possibility for saving
lives, which is the reason for the establishment of emergency services and their ability to activate
a siren and a flashing light during their journeys, in order to enable them to reach their destination
speedily.

Sincerely,
[signature]
Professor Yoel Donchin
Department of Anesthesiology and Critical Care Medicine,
Hadassah Hebrew University Hospital, Jerusalem
License Number 11769
ID number 008240251
POB 12007, Jerusalem 91120
0505-529423

≥≤
Appendix E: Letter to PHR-Israel from the Public Relations Department of the Operations
Division, Office of the Coordinator of Government Actions in the Territories
dated October 23, 2005

[TRANSLATION FROM HEBREW; bold characters in the original]

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State of Israel
Ministry of Defense

Coordination of Operations in the Territories

Operations Division
Tel 03-6977465
Fax 03-6977689
KL-129960
20 Tishrei
23 October 2005

To
Mr. Ibrahim Habib
Physicians for Human Rights

Subject: Prevention of Entry of Palestinian Ambulances to Hospitals in Israel

≠ Response from the Coordinator of Government Operations in the Territories

1. I hereby confirm receipt of your query dated September 27, 2005. Our response is as follows:
a. As a rule, the entry of vehicles bearing Palestinian license plates into Israel is prohibited,
including ambulances.
b. According to existing regulations, the passage of patients from a Palestinian hospital to an
Israeli Hospital necessitates coordination.
c. The Palestinian Ministry of Health (which is responsible for medical matters in the region of
Judea and Samaria) coordinates the transportation of each patient according to set regulations
and standards.
d. In many cases, the Red Crescent attempts to bypass the regulations by arriving at a
checkpoint without coordination, making shortcuts in its routes via Jerusalem, transporting

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[people] for non-medical needs, transporting [people] who are prohibited from entering Israel,
transporting patients who don t need ambulance transport, reinforcing emergency deployment
’

at the Temple Mount, and more.

e. In such cases the by passing of the coordination regulations is accompanied by provocative
comments on the part of the drivers.
f. Below is our response to the testimony of ambulance drivers mentioned in your query:
i. Event on 5.9.05
The lingering in the abovementioned event from the moment the ambulance was ordered by the
”Hiba” center in Ramallah was a result of bypassing the coordination regulations. This delay
would have been avoided and would have passed in a smoother way had prior coordination
been conducted by the driver or by the medical center. In the event, from the moment of
application to the Health Coordinator, an Israeli ambulance was ordered, which reached the site
within minutes and was even asked by the soldiers at the checkpoint to transfer the woman in
labor to the Israeli ambulance immediately.
ii. Event on 18.8.05
The event is not known to us and no application regarding it reached us.
iii. Event on 19.8.05
The event is not known to us and no application regarding it reached us.
g. We note, that ”Maqassed” Hospital is careful to admit urgent patients transferred from
hospitals in the Judea and Samaria region with prior coordination. In many cases that are
not pre-coordinated, the hospital refuses to admit the patient, and this causes a delay in
provision of medical care.
h. With regard to the procedure drafted following HCJ 9109/96 ≠ ”Procedure for the Handling
of Residents of Judea and Samaria Arriving at a Checkpoint in Urgent Medical Emergency
Condition”:
i. Paragraph 1:- is implemented in its entirety, in any case an urgent patient passes subject to
the regulations. If there is need for an ambulance – an Israeli ambulance is ordered for evacuation.
ii. Paragraph 2:- is implemented in its entirety including all its details.
iii. Paragraph 3:- is implemented in its entirety including all its details.
iv. Paragraph 4:- is implemented in its entirety including all its details.
v. Paragraph 5:- is implemented in its entirety including all its details.
vi. Paragraph 6:- is implemented, but the issue of payment for Israeli ambulances ordered
to evacuate Palestinian patients who cannot pay for the ambulance has not yet been
resolved.
i. In light of the above, all issues detailed in the query are conducted subject to regulations.

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j. Regarding the request to permit entry of Palestinian ambulances to hospitals in Israel:
i. according to the directives of the Israeli Health Ministry and due to existing threats of
terrorist attacks in hospitals in Israel, Palestinian ambulances are absolutely prohibited from
entering the compounds of Israeli hospitals.
ii. In very exceptional cases the soldiers at the checkpoint enable the passage of a Palestinian
ambulance according to humanitarian considerations including the risk involved.
iii. As a rule, the passage of a Palestinian patient must be carried out from back to back, in
accordance with the regulations.

Sincerely,
Yoni Feldman
Ass.Off. Public Relations

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