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Trends and Data for 2012
When in need of medical care outside their residence area, Palestinian patients residing in the West Bank and Gaza Strip must apply for a movement permit from Israeli army authorities in order to access medical care in Israel or other countries. Patients' escorts are also required to obtain a permit. Since, November 2011, the approval rate for medical exit requests from the Gaza has increased in comparison to previous periods; however, over the first half of 2012, 288 patients were denied timely medical care; 247 were “delayed” (i.e. they did not receive timely replies to their permit applications) and another 41 were "denied" permits.
Applications of Gaza Patients to Cross Erez Checkpoint
Comparison between the first half of 2011 and 20121
January to June 2011
Approved Delayed + Denied Delayed Denied
January to June 2012
Men aged 18-40 were especially likely to face permit denial or delay by Israeli army authorities; as so, also the majority of patients and their escorts who approached PHR for assistance for obtaining a permit following delay or denial were adult men from this age bracket (64% from the West Bank and 55% from the Gaza Strip). Among those delayed, there were also children whose access to medical care was limited. According to data compiled by the World Health Organization (WHO), between January and June 2012, 48 children from Gaza were not granted permits in time to get necessary medical treatments outside the Strip. In many cases, parents, mainly fathers, were prevented from accompanying their children for treatment and instead required to apply for a different escort, delaying access to children’s care. During the first half of 2012, PHR documented and represented cases of 39 children from the West Bank and the Gaza Strip whose medical exit permits were delayed. The coordination authorities often responded to PHR's appeals by asking that the families replace the child’s escort; PHR therefore assumes that most of these children were denied permits merely because the coordination authorities were unwilling to grant their escort-parent a permit.
Processing of the World Health Organization' data presented at the monthly report on referral of patients from the Gaza Strip, June
On 22 January 2012, Hanin Abu Jalalah, 16 years old, passed away. She suffered from cystic fibrosis, a serious, chronic medical condition, for which she was treated in Egypt and later referred to Almakassad Hospital in East Jerusalem. Since her father’s application for a permit to escort her was rejected, it was Hanin’s mother – herself ill with diabetes and high blood pressure – that had to escort her. Hanin’s father requested once again to escort Hanin so his wife could remain at home, but this request was also rejected. Given the inability of Hanin’s mother to keep accompanying her daughter, and the inability of her father to obtain a permit and replace his wife, both Hanin and her mother returned to the Gaza Strip. Hanin was taken to Shifa Hospital. Hanin’s condition deteriorated and she needed urgent transfer to Israel. With the confirmation of the medical referral to Hadassah Hospital, Hanin's father submitted an urgent appeal on 29 December 2011 for Hanin to get a permit and for him to escort her; he was again denied and the family was instructed to apply with a different escort, despite the urgency. The family had no one to ask to escort the girl for the long period she would require care. PHR applied again to the Gaza District Command Office (DCO), which promised to re-examine the case. PHR also appealed to Member of Knesset Dr. Ahmad Tibi and to an Israeli reporter; both requested a response from the IDF. Surprisingly, within two hours, the Gaza DCO informed PHR that Hanin’s father would be allowed to escort her. Due to the delay, however, the hospital had already changed the date for Hanin's intake. Following further advocacy by PHR, the hospital agreed to advance Hanin’s intake to Friday, the day she finally reached the hospital with her father. As she continued to be hospitalized, Hanin’s medical condition turned out to be more complicated than assumed, and according to her father, after entering a coma for two weeks, she sadly passed away on 22 January 2012. PHR notes that the increase in the percentage of patients approved for medical exit permits from the Gaza Strip was accompanied by an increase in the number of patients called for interrogation by the Israel Security Agency (ISA) during the same period. While 84 patients from Gaza were called for interrogation during the first half of 2011, during the first half of 2012, 106 patients were called for such interrogations; almost 40% among them were women, a high and especially worrisome figure.2
Troubled Journey to Medical Care
Kamil Altaramsi is a 24-year-old resident of Gaza suffering from a rare disease (Acromegaly) in which the hands, feet and skull continue growing disproportionately due to the production of excess growth hormones by the anterior pituitary gland. PHR' volunteer doctor wrote in her review of Kamil's medical records: "If the disease is not treated, there is increased likelihood of morbidity in the cardiovascular, cerebrovascular, and/ or the pulmonary system, with a 30% reduction in life expectancy. Given that therapeutic measures do not exist in Gaza, the patient should be allowed to reach a center where it can be treated urgently". Kamil was told by the Civil Affairs Committee that his application to exit Gaza for an urgent medical treatment at Almakassed Hospital in East Jerusalem was approved. Upon arriving at Erez Crossing, Kamil was arrested and transferred to Shikma Prison. He reported that he was held there for the entire day without food, water or medical treatment, and was released in the evening to return to Gaza because he was found to be “medically unqualified for imprisonment.”
Given the difficulty of this experience, Kamil didn’t dare make a new appointment, despite his declining health condition. Only following PHR’s intervention did he obtain a new date for treatment and submit a permit application. This time, however, the Palestinian Civil Affairs Committee refused to submit a new request to the Gaza DCO on Kamil’s behalf. In March 2012, PHR submitted a request directly to the Gaza DCO, demanding to urgently allow Kamil’s exit for medical treatment, and to ensure he would not be arrested or otherwise harassed. In April, Kamil was examined in Gaza by a PHR volunteer physician during a Mobile Clinic delegation to the Gaza Strip. PHR sent the physician’s expert opinion, together with another permit request, to the Israeli DCO, as well as complained to the ISA about the practice of "honey trap"; misleading patients by calling them to Erez checkpoint ostensibly in order to grant them a permit but arresting them instead. After these efforts proved unsuccessful, PHR petitioned the court on Kamil’s behalf. The Attorney General’s office issued a preliminary response saying our petition should be rejected because – among other things – the treatment in question was not urgent or life-saving. In addition the reply insisted that treatment could be obtained in hospitals outside of Israel (Israel views entry to East Jerusalem as entry to Israel itself). The response also claimed that Kamil is an "active militant terrorist," a claim that is particularly hard to understand in light of the fact that Kamil was released from detention due to the severity of his medical condition, and has also been confined to his house for a long time due to this condition. At the court hearing that was held on his case in July 2012, PHR' petition was rejected based on the information presented by the state.
Among those who approached PHR for assistance during the first half of 2012, 25 patients from Gaza reported that they had been called for an interrogation as a condition to process their applications to exit the Strip. Sometimes, PHR was directly informed by the Gaza DCO that an interrogation was set for the patient, and that his application would only be processed following the outcomes of the interrogation and with the end of the security clearance process.3 These interrogations not only endanger the lives of patients who might be suspected of "cooperating" with Israeli security forces, but also might deter other patients from applying for exit permits through Erez at all. In July 2012 alone, two patients and one escort from Gaza were arrested under such circumstances4. Among them was Rawhi Qarqaz (testimony below), a patient whose case PHR has processed since he first faced difficulty acquiring an exit permit for medical care in East Jerusalem.
Thirteen Days of Trauma
In 2009, Rahwi Qarqaz (age 42) fractured his right shoulder and suffered a breakage in the cartilage of his left knee due to a motorbike accident. Since then, he underwent several surgeries, most recently in April 2010 after his knee ruptured. On the 15 July 2012, Rahwi was arrested at the Erez checkpoint after applying for a permit to enter Israel and seek further treatment. He was subsequently detained for 13 days. “Even after surgeries in Gaza and an additional surgery in Egypt, I still suffered from pains in my leg. I was told that I required a specialized treatment; however this service was not available in any of the hospitals in Gaza. I therefore asked my doctor for a recommendation for referral to a hospital in Israel, and in May I started the process of obtaining a medical referral. The process took too long, and my health kept deteriorating. I had to wait until July before I could finally get my referral and an appointment to Almakassed hospital in East Jerusalem.”
Read more on ISA interrogations at PHR's report "Holding health to ransom," 2008. Here For details on these three cases, see PHR's update from July 2012. Here
Rahwi was called to attend a security interview with the ISA before they would allow him to enter into Israel: “I arrived at Erez around noon, they searched me and an Israeli officer asked me what the purpose of my visit was. I showed him all my medical reports but I was taken to an investigation room. The officer told me that they did not care about my documents and that they had been waiting for me for a long time. They then accused me of manufacturing and storing rockets in my home.” Rahwi was subsequently blindfolded and taken to a prison in Ashkelon: “They put me in a solitary confinement cell and I was questioned all day and all night with only one or two hours of break. I was tied to a chair that was fixed to the ground, my hands were tied to the back of the chair and my feet were tied to the legs of the chair. They did not harm me physically, but they swore at me and verbally insulted me. The number of investigators in the room varied between one and five and people would come and go at any given time.” During the investigation, several charges were raised against Rahwi: “For the first four days they asked me about my house and also about the steel factory that my brother owns. In 2010, my house caught fire, I stored diesel for my generator and the machines for my brother’s factory at that time but I still don’t know what started the fire. They said that the fire was caused by some of the rockets I was in the process of making and they also claimed that my brother and I had manufactured between 900 and 1000 rockets. I told them that, even if it had been a fire caused by rockets, it would not only have affected my house, but the entire neighborhood.” After four days, Rahwi was transferred to the Be’er Sheva central prison, where he spent the next three days with other prisoners: “They sent other prisoners, who pretended to be Hamas activists, to come and talk to me in order to try to get me to admit to crimes I hadn’t committed. One of them, an old man about 60 years old, got angry and argued with me when I refused to confess to the charges. He even tried to coerce me by using physical force. Another prisoner came with a notebook and was recording what I was saying. He lied to me by saying that my brother had said that the charges were true and that I should also confess.” Rahwi was then taken back to Ashkelon prison for what he describes as the “worst days of his detention.” In Ashkelon he was interrogated day and night: “I was interrogated from 9am to 4:30pm on Sunday and then given a 30 minute break. I could tell the time by looking at the investigator’s watch. At 5:00 pm, the interrogation resumed and I was interviewed until 5:30am on Tuesday. During this time I was not allowed any breaks. They would give me different names of people and then demand that I give them information about these persons. They were specifically interested in three persons whom I didn't know at all. They also showed me a map of my neighborhood and asked what I knew about my neighbors. I was psychologically traumatized by all the questioning but they would not let me go, even when I told them that I didn’t know what they were asking for.” On 2 August, around 11:30, Rahwi was finally released: “They told me that I had not been helpful and that I could only go if I agreed to give them information about my neighbors and other people in the future. They told me that they might call me for this purpose.” Rahwi is grateful to be reunited with his family, but to date he still has not received any treatment for his leg. He limps and requires a crutch for support: “The entire episode was extremely hard for my wife and my three children. They went through a lot and all they could do was to call lawyers, the ICRC, and other organizations in order to try to get me released. My own mental state was also greatly affected by the endless questioning. Right now, I am just taking the medication I was given by my doctor after I returned. Hopefully, I will be able to go for an operation in Egypt in September, but for now, I will just wait.”
Even though his interrogators promised him to consider his application to enter into Israel, following the torture and the degrading treatment he suffered, Mr. Qarqaz did not try to submit a new application. Even if he receives a referral to Egypt instead of East Jerusalem, he is not sure that he will be able to cover the expenses of the travel.5
The total number of patients from the West Bank called for interrogation is not known. According to a fact sheet released by the WHO, almost one in five patients and their escorts from the West Bank are not granted permits, and 32,678 out of the 175,228 patients and escorts who applied for health access permits during the 2011 were denied or delayed.6 A new survey during the first quarter of 2012 showed that the most common reason for denial was “security,” and it is estimated that more than 40% of those who were not allowed to exit the West Bank for medical care were denied for alleged security concerns.7 In general, patients from the West Bank who approached PHR during the first half of 2012 were more likely to be denied (rather than delayed) than those from Gaza. 73% of the West Bank patients who approached PHR for assistance were denied while 61% of Gaza patients were denied and the rest delayed. However, it's important to note here that the mentioned above data gathered by the WHO on medical permit applications by Gaza residents includes only patients, without their escorts; If these statistics were to include both patients and their escorts, the rate of individuals whose applications are denied or delayed would likely be comparable to that of the West Bank.
In between Security and Bureaucratic Harassment
Mohammad Awawdeh is a 52 year-old male from Hebron. On 6 January 1992, he was injured while working on a construction site in Ashkelon, an injury from which he still has not fully recovered. He was diagnosed with PTSD, and his physical condition prevents him from returning to work. Mohammad was recognized as the victim of a work accident by the Israeli National Insurance Institute (NII), with 77% disability. Since then, for twenty years, he has regularly been coming to Israel for medical and psychological treatments necessary to care for his injury. In June 2011, Mohammed turned as usual to the DCO requesting an exit permit in order to receive treatment in Israel; this time, however, his request was denied. Only after he re-appealed was he told that the denial was on “security grounds." He was told that if he arranges to be accompanied by a private security company, at his own expense, each time he enters Israel, a permit could be given. The sum needed is high for anyone living on Palestinian wages, let alone for someone who is an unemployed patient. PHR’s appeal to the coordination authorities on Mohammed’s behalf received the same response. In December 2011, PHR submitted a legal petition instructing the State to explain why Mohammed was refused an entry permit to Israel for medical and psychological treatment which he needs and which he had received for many years in Israel.
The testimony was taken by PCHR-Gaza, and modified according to the information collected by PHR. First Published 15 August, "Right to Health: Access to Jerusalem", Key Facts by WHO. Published Online, July 9, 2012. Here "Barriers to the access to health services in the occupied Palestinian territory: a cohort study", The Lancet. Published Online, October
8, 2012. Here
In April, the demand for an escort by a private security company was dropped. The Attorney General’s office relayed to PHR that: “The position of the security forces is that at this time the petitioner’s entry into Israel for medical treatment is not conditional upon being escorted by a security company.” In spite of this reply, Mohammad’s entry to Israel for medical care continued to be denied. He missed many appointments set for him due to various bureaucratic obstacles. After Mohammad received another refusal in June, PHR again requested an explanation. The Civil Administration’s Health Coordinator, Ms. Dalia Bassa, explained that he had been forbidden entry by the ISA. The reason why Mohammad was suddenly deemed a security threat after receiving regular treatment in Israel for so many years is puzzling. According to Mohammad, these delays and permit denials started after he was called by the ISA for a security interrogation and asked to "cooperate," but refused to do so. Mohammad is still waiting to return to his treatment regimen in Israel. Meanwhile he has spent ten thousands of shekels for drugs and injections for which he might not be refunded. PHR is still trying to change the decision in his regard.
Some Palestinian patients face trouble with the Palestinian coordination system, too. Patients asking to leave the strip for treatment on their own expense (self-funded), for example, are reporting increased difficulty getting their permit applications handed by the Palestinian Civil Affairs Committee to the Israeli coordination office at Erez. While PHR has not recorded any case since the beginning of 2012 from the West Bank whereby a patient was prevented from applying for a permit to access self-funded treatment, several patients from Gaza reported to PHR that the Palestinian committee refused to receive their applications and submit it to the Israeli side. The committee even announced last June that such applications won't be received at all unless they are officially sponsored by a known third-party (such as PHR, the Peres Center for Peace, etc.).
Security considerations continue to threaten the health rights of Palestinians residing in the Occupied Territories. Most patients denied permits to access healthcare are denied on “security grounds.” For other patients, the delayed ones, it is often the security clearance process that results in permit delays for them and their escorts. PHR’s appeals to the Israeli military authorities on behalf of delayed patients often receive a reply that the patient’s application is still “under the examination of the security apparatus.” Many of these patients, particularly those from the Gaza Strip, are called for an interrogation at some point as part of the security clearance and as a condition for processing their application. These patients are
forced to endure delays that require them to set new appointments and sometimes even start the entire process of coordinating care all over again; and sometimes withdrawing their application completely. PHR considers any delay or denial of the exit of a patient for medical care as a denial of access to medical services and a violation of the health rights of individuals residing in the Occupied Palestinian Territories. Whether for lifesaving or any other vital treatment, a patient’s access to medical care must not be blocked. Instead each patient, per definition, should be ensured access to health care; in cases whereas the Israeli military insists over its refusal to issue a movement permit, the Israeli military, the coordination authorities and the Israeli Ministry of Health must ensure that the patient will have an alternative to receive the needed medical care and that his life will not be endangered. PHR condemns the reprehensible practice of "honey trap" to arrest and interrogate patients, and calls upon the Israeli military and the ISA to cease the exploitation of Palestinian patients’ need for medical care, the conditioning of access to medical care on "cooperation," and the extortion of intelligence information. These methods expose patients and their families to psychological strain, impede their access to vital treatments, pose life-threatening danger to those in need of urgent medical care, and ultimately constitute a blunt violation of health rights and basic medical ethics.