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Crimes Against Humanity- An Investigation into the Destruction of Palestines

Healthcare System

Jenelle Vargas
May 8, 2015

The West Bank and Gaza Strip remain under full Israeli control and have
sustained heavy bombing campaigns and military assaults in recent years, particularly
Gaza. There are many health implications of these attacks, many of which are indirect
causes of conflict. Health implications of the conflict include increased morbidity and
morality associated with increased infectious and chronic diseases, malnutrition and
mental health.

With the mass immigration and settlement of Zionist Jews from Europe, Palestine
erupted in civil conflict in 1947. By 1948, neighboring Arab countries invaded and the
Palestine War broke out. The State of Israel was created and over 800,000 Palestinian
Arabs were forcibly expelled from their homes. Many fled to surrounding countries or the
West Bank and Gaza Strip territories, which were under Jordanian and Egyptian control
respectively. During the June 1967 War, Israel invaded and occupied the Palestinian
territories of the West Bank and Gaza Strip. Israel remains in full control of these
territories today. Israel militarily occupies both areas and has enforced a crippling siege
on the Gaza Strip since 2007.1
Due to military occupation and siege of Palestine, Palestinians in the West Bank
and Gaza have struggled to survive. Israel has employed torture, home demolitions,
political assassinations, and military operations, as well as water, land, and energy

In 2006, Hamas won the Palestinian national elections, to which Israel responded
by putting Gaza under military siege, blocking medical supplies, food, construction
equipment, and other necessary materials. Israel has frequently raided the strip with
military forces and carried out air campaigns, most notably in 2006, 2007-2008, 2012,
and 2014. Due to these frequent military incursions and the crippling siege on the Gaza
Strip by the State of Israel, the situation in the strip has become a dire humanitarian,
economic and public health catastrophe. After multiple Israeli assaults and enduring 8
years of the blockade, Gazas health system and medical infrastructure is in chaos.

The medical and humanitarian crisis cannot be changed unless the conflict
ends. Attempts by the United Nations to persuade Israel to halt its aggression have
proved futile. Negotiations and ceasefires were initiated between the two countries in
2014, with Israel consistently breaking the terms of the negotiations. UN leaders have
condemned Israel for committing crimes against humanity, especially after Israel had
consistently targeted civilian schools and hospitals in recent assaults. A peace process
began in the early 1990s with the Oslo Accords, with Israel ultimately never following
through on commitments made. The United Nations has held multiple meetings and
resolutions calling on Israel to stop the attacks, none of which have been followed. Israel
began to boycott the United Nations in a state of rebellion as the UN has repeatedly
called attention to its war crimes and human rights abuses.
Efforts have been led by the World Health Organization (WHO) to properly
assess medical care needs in Gaza and West Bank. They have provided funding for

medical care, and past efforts proved successful in decreasing mortality rates from 25.5 to
20.6 per 100,000 live births in 2012. Infant morality rates have consistently been higher
in Gaza (23 per 100,000 live births) as compared to West Bank (18.8 per 100,000 live
births).2 The surveillance data for infant mortality rates may no longer be true, since
conflict has increased since 2012. WHO estimates that the conflict has caused 50.8% of
deaths in children under 5.2
WHO has consistently monitored malnutrition and rates of anemia, however these
numbers have not drastically increased as a result of their efforts, and the number of
children suffering from malnutrition may be increasing. The rate of anemia in children
under 5 has consistently been 50%.2 Over fifty organization have been involved in
proving nutrition services to Palestinian children.
Other medical efforts initiated by WHO include increasing facilities for pregnant
women and delivery. These efforts have decreased mortality associated with
childbirth. Efforts to improve overall health care by WHO have not proven successful
since medical facilities are lacking in Gaza. There efforts to increase pharmaceuticals
drugs has also had a minimal impact since Israel blockades medical aid and resources.
WHO has not been successful in procuring medical devices. They have set a goal to
increase the number of medical equipment for the country, as well as spare parts and
personnel to service the equipment. Medical equipment is expensive to buy and to
maintain. WHO has petitioned Israel to increase medical care for those Palestinians in
Gaza.2 These pleas have been ignored by Israel.
WHO has aimed to increase medical care in the country by working with other
governments and non-governmental organizations (NGOs). They have partnered with

with the Norwegian Public Health Institute and the Norway Government to provide
increased surveillance for health care issues, training health care professionals, increasing
medical infrastructure and funding. Missions have been targeted at specific healthcare
issues including tobacco use, tuberculosis, HIV/AIDS, mental health.2
Despite the United Nations Resolutions, and the World Health Organizations
attempts to increased funding and medical resources, the humanitarian situation in
Palestine, particularly in Gaza remains in crisis.

Current research methods into the conflict in Gaza aim to answer the following
questions; is there a human rights violation, how is the conflict affects morbidity and
mortality in Palestine, and what changes can be implemented to decrease morbidity and
mortality associated with the attacks.
Following an attack in July 2014, Physicians for Human Rights-Israel (PHRIsrael) campaigned a mission in Gaza to determine the morbidity and mortality data for
the conflict. Their goals were to determine the types of injuries that had resulted from
Israels attacks on Gaza, the damage to healthcare and infrastructure, evacuation patterns
for those diseased and the emotional impact on individuals affected.3
PHR-Israel chose to send eight medical professionals, not associated with Israel
or Palestine to gather evidence and data unbiased. Four individuals sent on the mission
were experts in the field of pathology and forensic medicine. The other four were experts
in emergency medicine. Visits to Gaza were conducted between August 19 and

November 12 of 2014. The three visits consisted of meetings with medical professionals
in the area and interviews with hospitalized patients, their family members. Some
autopsies were also performed on those presumed to have died in direct or indirect
relation to the conflict.3 Autopsies were difficult to procure due to religious reasons of
family members. This barrier was overcome by promising to keep genitals and other
sacred areas covered throughout the procedure.
The World Health Organization (WHO) has performed surveillance studies in
Gaza and West Bank for health data and statistics. The Sixty-fourth World Health
Assembly (WHA) issued a resolution to partake in a fact-finding report in Palestine. The
purpose of the report was to determine morbidity and mortality data, lacking medical
resources and need for funding. WHO has since worked closely with the Palestine
Ministry of Health to gather surveillance data, while also providing funding for
healthcare. Surveillance studies performed by the WHO focus on poverty indicators,
infant mortality, deaths associated with childbirth and other leading causes of
death. Their research studies focus on looking at health inequalities between Gaza, West
Bank and Israel and health determinants in Palestine.2

Throughout the history of the world, conflicts have caused massive destruction of
human lives, however actual attacks do not cause the majority of deaths. Usually
diseases are indirect impacts of conflict, which continue to persist for years after the
conclusion of conflict have the greatest impact on morbidity and mortality.4 Major issues
that have continued to arise due to conflict include increased infectious diseases, decline

of healthcare infrastructure, and limits on healthcare supplies. More recently, the

psychological effects on war and conflict are being studied, most prominently, Post
Traumatic Stress Disorder (PTSD). Decreased access to sanitized water and nutrition
exacerbate the effects of infectious and chronic disease, perpetuating the cycle of high
morbidity and mortality. Increased violence against women is another cause for concern
for the global health community.4
Political studies performed by the United Nations have declared that Israel has
committed crimes against humanity and have not followed resolutions aimed to decrease
conflict in Palestine. In 2014, the UN denounced Israel for its attacks. Crimes against
humanity include purposely targeting innocent civilians, especially children, schools and
hospitals. Israel has performed all of these acts.
Medical research has produced the same results as political research. The
research study conducted by PHR-Israel found that attacks on Gaza were directed at nonmilitary sources including civilians, destroying 18,000 homes, hospitals and schools. In
one single attack on July 8, 2014, 11,000 individuals were wounded, with 70% of those
consisting of civilians.3 However, the majority of conflict related deaths are not
accounted for in attacks alone.
Medical care in Palestinian territories is lacking due to decreased spending, lack
of hospitals, infrastructure, supplies and personnel. The Palestinian medical system was
at one point run by the Israeli government, who spent an equivalent of of resources in
Gaza as compared to Israel.5 Until 1994, the healthcare system was transferred to the
Palestinian Ministry of Health, who received funding for its medical institution from
income taxes. However, unemployment has reached such a high number from the Israeli

occupation that income taxes could no longer support the growing financial needs. An
estimated 30,000 have lost their jobs as a direct result of the conflict in Gaza since 2013.6
Unemployment is documented to be at 38.5% as of the last quarter of 2013 and food
insecurity at 57% of households, with 80% of households receiving aid.7 For this reason,
the healthcare system has dramatically took downturn. Beginning in July 2014, the
nations largest hospital Al-Shifa had to shut down major operations, performing only
emergency surgeries in an attempt to reduce spending.7
Currently, military blockades prevent teams from life-saving medical supplies
into the country. Contributing to an already failed medical system, hospital bombings
have reduced infrastructure for medical care, and medical personnel have been targeted
by violent bombings and attacks. Due to budget cuts, the few medical personnel that still
reside in the country are striking due to low pay.5 Some staff members had not been paid
salaries for months, and others receive only half of their annual pay.7 The health disparity
between Israel and Gaza in evident in the fact that Israel contains 1.6 as many medical
doctors than in Palestine.5
Not only are medical supplies not allowed to be brought into the country,
individuals in dire need of medical care that cannot be provided in the country are denied
access to evacuate to neighboring countries for care.3 According to WHO, necessary
infrastructure for providing medical care is lacking in Palestine. WHO has asked Israel
to allow Palestinians, particularly those residing in Gaza who need medical attention to
be transferred to better facilities in West Bank and Israel. In 2012, Israel denied 10% of
those requests,2 and that number has dramatically risen since then.

One of the biggest determinants for morbidity and mortality is access to clean

water. Access to clean water is necessary to prevent spread of infectious disease and for
survival. Over 90% of water in Palestine is unusable,7 with 90-95% of aquifer water
being contaminated.5 There are numerous reasons that Palestinians are lacking adequate
water. Some of these reasons are due to lack of fuel running power plants and watersewage treatment plants and as a direct result of bombings on these facilities.
Attacks on the electrical infrastructure has caused damage to water-treatment
plants, and infrastructure damage was also caused by direct attacks to plants. The
Municipality of Gaza suffered an attack to its electrical system, which caused power
outages which results in faulty pumps. The faulty pumps prevented sewage from
entering the plant and seeping into seas instead, with some seepage causing sewage
flooding in cities.7 The smell from sewage is atrocious, but the deadly effects of
contamination have led to increases diarrheal infectious diseases.
Other causes for lack of power include blockades on fuel sources. Israeli
blockades of fuel has caused an energy crisis. Lack of fuel led to the shut-down of one
power plant for 46 days.7 As previously mentioned, one effect of a lack of fuel is causing
water-sewage systems to be shut down. Another deleterious effect of the energy crisis is
increased accidents due to use of generators and open fires in homes. Lack of energy has
led to shutdown of hospital facilities, over 300 machines to be left out of order, and only
one MRI available in the country, located in one hospital.7
Along with directly destroying water-treatment facilities, water wells have also
been damaged, further reducing the small amount of usable water. Water resources are
being diverted to Israelis, with individual access to water at 246 liters per day. Estimates

show that the typical Palestinian has access to 73 liters of water per day, which is much
less than the WHO recommended daily amount of 100 liters per day.5 Israel imparts
blockades of the Jordan river and aquifer, allowing water to be accessed for only 6-8
hours a day, every four days.7 Israel also has control over construction permits and denies
construction of water facilities.5 Since Israel has claimed that they own all of the
Palestinian land, they prohibit landowners from building water wells on their own land.

Due to a number of unsanitary conditions, infectious diseases run rampant in

Palestine. One major contributor to infectious diseases is contaminated water

sources. Some diarrheal diseases that are spread by lack of clean water include bacterial
diseases such as E. coli, Shigella, Campylobacter, and Salmonella (typhoid fever). Viral
infections are caused by norovirus, rotavirus, Hepatitis A and E. Parasitic diseases such
as giardia and cryptosporidium are also spread by contaminated water, as are amoebas.4
Bacterial and viral diseases have historically caused a massive number of deaths due to
diarrhea. A compounding issue with bacterial infections is the lack of antibiotics to treat
infections. Oral hydration therapy is typically given to children upon onset of diarrheal
symptoms.4 This treatment reduces the mortality associated with diarrheal infections,
however, these life-saving treatments are also scarce.
Chronic respiratory infections are one of the leading causes of mortality in
Palestine. These affects are compounded by debris from bombings of buildings. Those
who were forced from their homes may have travelled to refugee camps, were those
living in close quarters are more likely to pass respiratory infections along to others,
making chronic respiratory diseases worse.4

Other infectious diseases are preventable by immunization programs, but are

common due to lack of vaccinations. These include Hepatitis B, human papilloma virus
(HPV), chickenpox, pneumonia and rotavirus.5
Lack of nutrition can lead to increased morbidity and mortality due to infectious
diseases. Many global studies prove that the burden of disease is increased, especially in
undernourished children. Fifty-seven percent of those living in Gaza lack proper
nutrition.7 Anemia is one disease that is directly related to undernourishment. Two
different studies in Palestine show that anemia is prevalent among children under
five. One study reported that anemia is present in 59.7% of preschool aged children6 and
in 72.8% of children under the age of 2.8 Stunting is estimated to be prevalent in almost
32% of children, wasting in 34% and underweight in 32%.7 High rates of anemia are
partly due to malnutrition of mothers, who receive little antenatal care and calories.
Almost 40% of women of receiving care during pregnancy were determined to have
anemia.2 Anemia in mothers is shown to impact development of children for their lives.
Some studies have estimated that children that are born to anemia mothers may never
recover later in life. These children are also more prone to infectious diseases, especially
communicable respiratory illnesses.4

Mental health is a new area of research that has shown to have profound impacts
on survivors of conflict. An estimated 68.9% of adolescents exposed to conflict in Gaza
developed post-traumatic stress disorder (PTSD), 40.0% depression, and 94.9% severe
anxiety.9 Staff in mental hospitals are under qualified, if they have any training at all, and
only a small portion of the Gaza Ministry of Healths budget goes towards mental health
due to a lack of resources. There is only one mental hospital in Gaza. Related surveys of

human insecurity found a major increase in the number and severity of mental health
cases in Gaza following the 2007-2008 military assault, which was boosted by gunfire,
home demolitions, displacement, imprisonment, and indirect effects of the siege as well.
Noise impacts of bombings and gunfire also contribute to increased stress, leading to
chronic diseases.
The situation is more egregious in the fact that Israeli citizens on the other side of
the blockade enjoy exponentially better health care, life expectancy, and quality of life
than their Gazan counterparts. This is evident in the comparative rates of infant mortality,
maternal death, cases of infectious diseases, number of medical professionals, and water
consumption.2,4,6 According to report released January 2015 by Physicians for Human
Rights, Israels control of the strip has caused massive disruptions to Gazas healthcare

The solution that would cause the biggest change in the healthcare of Palestine is
eliminating the conflict in Palestine, particularly in Gaza by eliminated attacks by Israel.
This needs to be done by increasing pressure by the United Nations and other financiallyimpactful countries. Countries such as the United States need to stop supporting Israel
financially. Taxes from the American people are given to military defense systems used
to attack Gaza.
Increased media attention can bring light to the situation where citizens of highincome countries, such as the United States demand that their government pull funding
for Israels military.

In terms of healthcare, more organizations need to see the conflict as a dire

situation and continue to provide funding and raise awareness of the situation. The
World Health Organization has proven to be the major player in improving the medical
system in Palestine. The Government of Norway has given monetary donations, and the
United States needs to take its financial investments away from Israels military and
towards improving healthcare in Palestine.
Employment is area that needs to be increased in order to decrease poverty in
Palestine, which is one of the major health determinants in Palestine. A contributing
factor to malnutrition is the increasing unemployment rate. Families no longer have the
financial means to buy food.10 Access to water will also give necessary nutrients to
farming so that food production can be increased.
A vaccination program needs to be implemented in all children. Vaccines can
decrease mortality of infectious diseases. Rotavirus, polio and Salmonella are all waterborne diseases that have effective vaccines. Measles is another infectious disease that is
highly contagious and prevalent in low-income countries. This vaccine is very cheap and
easy to administer. Providing these vaccines for undernourished children will decrease
infection rates.
Providing drugs is another relatively cheap method that can reduce mortality rates
of infectious diseases. Although antibiotic resistance is a growing worldwide problem,
these drugs are desperately needed to treat infections.
Other more expensive measures to increase healthcare is to buy medical
equipment, especially those to provide radiology and surgical equipment to provide
surgeries for patients who undergo trauma in violent attacks.

Providing fuel for electric plants and reconstructing the water-sewage systems.
This action alone would minimize diarrheal infectious diseases. Organizations can train
healthcare workers and send them on short-term and long-term mission trips to provide
services in a country where healthcare workers are lacking.
Palestine is in a dire situation under a non-compliant country, Israel. The world
needs to get more involved in this situation politically, and the health community needs
to band together to provide healthcare to this oppressed nation.

1. Tessler M. A History of the Israeli-Palestinian Conflict. 2nd ed. Indiana Series in
Middle East Studies. 2009.
2. Health conditions in the occupied Palestinian territory, including east Jerusalem,
and in the occupied Syrian Golan. World Health Organization. 2012.
Accessed April 18, 2015.
3. Bachmann J., et al. Gaza 2014: Findings of an Independent Medical Fact-Finding
Mission. Physicians for Human Rights. 2015.
Accessed April 18, 2015
4. Epping-Jordan J, Hawkes C, Mensah G, Steyn K, Yach A. Complex Emergencies In:
Merson M, ed. Global Health Diseases, Programs, Systems and Policies. 3rd ed.
Burlington, MA: Jones and Bartlett Learning; 2012:597-601.
5. Efrat M. Divide and Conquer: Inequality in Health. Physicians for Human Rights.
EPORT%20JAN%202015.pdf. Accessed April 18, 2015.
6. Humanitarian Bulletin: Monthly Report. United Nations Office for the Coordination
of Humanitarian Affairs. 2014.
2_19_english.pdf. Accessed April 18, 2015.
7. Gilbert M. Brief Report to UNRWA: The Gaza Health Sector as of June 2014. United
Nations Relief and Works Agency. 2014. Accessed April 18, 2015.
8. El Kishawi R., Soo K. L., Abed Y. A., Manan W. BMC Public Health. 2015. Accessed
April 18, 2015.
9. Michail M, Saymah D, Tait L. An overview of the mental health system in Gaza: as
assessment using the World Health Organizations Assessment Instrument for
Mental Health Systems (WHO)AIMS). International Journal of Mental Health
Systems. 2015;9:4.
217.pdf. Accessed May 8, 2015.

10. Socio-economic and Food Security Survey. United Nations Relief and Works
Agency. 2012. Accessed April 18,