The Ultimate Barrier: Impact of the Wall on the Palestinian health care system – Medecins du Monde report, summar/Non-UN document

The Ultimate Barrier:Impact of the Wall on the Palestinian health care system

By: Medecins du Monde

S U M M A R Y

I- EXECUTIVE SUMMARY

II- INTRODUCTION

1. History of MDM in the occupied Palestinian territories

2. Our work to limit the health impact of the Wall

3. Speak out against the negative impacts of the Wall on people’s health

III- METHODOLOGY 

IV- CONTEXT

V- IMPACT OF THE WALL ON ACCESS TO HEALTH CARE

1- Access problems for patient and their effects on primary health care

·  Access to hospitals 

·  Access to specialists

·  Increased burden on primary healthcare centers

2- Reduced and denied access for medical staff

3- Populations at risk

· Children 

· Pregnant women

· Chronically ill and physically disabled patients

· The specific case of enclaves and the seam zone

VI- SOCIO-ECONOMIC CONSEQUENCES 

1. Increasing poverty and difficulty to pay for healthcare

2. Confiscation and reduced access to land and water sources 3- House demolition

3. House demolition 

4.  Difficulty of access to education

VII- PSYCHOLOGICAL CONSEQUENCES

      1- Breaking of family links

      2- Mental health problems

· Children

· Youth 

· Men 

· Women

VIII- CONCLUSION

IX- MDM’S POSITION ON THE WALL

1. The legal texts 

2. Our position 

3. Our demands 

X- ANNEXES

1. Glossary of Wall related terms

2. The Wall in numbers 9 

3. Activities of MDM in the occupied Palestinian territories 

     NOTES

I- EXECUTIVE SUMMARY

Since June 2002, the construction of the Wall has steadily added another layer of obstacles isolating, fragmenting and thus deteriorating the Palestinian health care system.

In order to address some of the health impacts of the Wall, Médecins du Monde (MDM)- France started the Wallresponse program in May 2004. The organization has supported emergency medical transport services in Aizaria (East Jerusalem), Women and Children mobile health clinics in 11 villages in the West Bank, and monitors the health impact of the Wall, in close collaboration with local partners.

In conjunction with our medical activities, MDM has decided to bear witness to the obstacles created by the Wall in accessing medical care. To accomplish this task, MDM collected 83 testimonies from people living in the West Bank and Jerusalem from July to October 2004. The testimonies focused on how the Wall has impacted individual lives. Once they had been compiled, they were enriched by our medical expertise in the field. MDM does not only take into consideration the “physical” Wall but also the whole set of already existing barriers such as checkpoints, earth mounds and roadblocks which are de facto associated with it.

This report “gives voice” to patients and medical staff who face daily difficulties due to the Wall. Their testimonies illustrate the following:

· How the Palestinian health care system is placed at risk by the problems of access faced by both patients 

· and medical staff. 

· How the Wall impedes people’s access to their livelihoods, resulting in economic difficulties to pay for 

· health care 

· The psychological consequences resulting from the division of families, increased tension and isolation. 

The Wall appears as the final and most visible part of a network of barriers, both physical and administrative, which restrict Palestinians right to life and freedom of movement in the occupied Palestinian territories. Since it does not follow the Green Line and encroaches into the West Bank, the tracing of the Wall is both disproportionate, in its health impact, and illegal. It violates both International Human Rights Law and International Humanitarian Law.

We therefore call on the Israeli authorities:

· To guarantee the free access of the Palestinians and humanitarian and health workers to their medical 

· facilities and to primary water sources 

· To ensure the respect and the protection of the rights of Palestinians, according to International Humanitarian 

· Law. 

· To take all necessary measures to respect and implement the advisory opinion of the International Court of 

Justice (ICJ) of July 9th, 2004, which condemns the Wall.

We call on the international community:

· To ensure that Israel respects and implements this advisory opinion 

· To ensure that Israel and the Palestinian Authority respect their obligations under International Human 

Rights and Humanitarian Law.

We also call on the Israeli authorities and the Palestinian Authority to prevent attacks on civilians and ensure their protection on both sides.

II- INTRODUCTION

1- History of MDM in the occupied Palestinian territories

Médecins du Monde (MDM)-France is a international solidarity association, which depends on the volunteer commitment of its members, who are medical professionals, in order to assist the health needs of the most vulnerable populations both in France and in 52 countries around the world. Based on 25 years of medical experience, it bears witness to the obstacles in accessing medical care and denounces the violations of human rights.

MDM has been working in the occupied Palestinian territories since 1995, carrying out medical initiatives for the Palestinian population. MDM has set itself the objective of limiting the medical and health impact of restrictions on access to health care for the Palestinian population and of bearing witness to violations of the right to health.

At present MDM works in Gaza and Nablus as well as in the villages affected by the Wall1. In addition to dealing with crisis situations, the association conducts training programs for ambulance and medical staff, primary health care, mental health care, mother-child protection and disaster medicine programs, always in close collaboration with local partners.

2- Our work to limit the health impact of the Wall

Since June 2002, the construction of the Wall has steadily added another layer of obstacles isolating, fragmenting and thus deteriorating the Palestinian healthcare system. By encroaching into the West Bank, the Wall and associated barriers disrupt access to primary healthcare centers, medical specialists, hospitals and referral centers for both patients and health care staff. In May 2004, MDM started the Wall Response Program in order to address some of the health impacts of the Wall.2

– Emergency medical transport services in Aizaria (East Jerusalem)

Before the Wall was built, the 40,000 people who live just east of Jerusalem in the towns and villages of Aizaria, Abu Dis, Sawahra, and Sheikh Saad had no public ambulance service and no hospitals. In case of emergency, ambulances would come from Jerusalem. If an ambulance was not necessary, people could easily travel the short distance to Jerusalem to receive medical services. Since the Wall has been built, access to Jerusalem hospitals is very difficult, sometimes impossible, for these people and the ambulances. In response, MDM and the Palestine Red Crescent Society (PRCS) have partnered together to provide emergency medical transport services and community first aid training in these communities in order to handle at least the most urgent cases.

– Women and Children Mobile Health Clinics in the West Bank

With ongoing construction of the Wall and an increasing number of other barriers of the Israeli occupation, many rural and remote communities in the West Bank are no longer able to access the health services that they regularly need. From May to December 2004, MDM, Merlin and the Health Work Committees (HWC) teamed up to provide women and child preventive health services in 11 different villages in the West Bank. The program focused on poor villages with few health care options and whose access will continue to worsen with construction of the Wall. In the North, we worked in Araboneh, Deir Abu Deif, Sanur, Tyassir, Ein el Beida and Bardala. In the South, we worked in Husan, Jaba’a, Wadi Fukin, Battir and Al Walaja.

The program benefited 8,000 women and 5,000 children under the age of 5 years. It focused on activities such as cancer screenings for women, medical and growth evaluations of children, nutritional assessments and counseling for families, personalized health education sessions in the home, and home visits for patients who required special attention. In addition to supporting clinical care for patients, MDM responded to some specific needs such as training nurses and providing medicines and laboratory equipment.

– Health monitoring

In addition to its medical activities, MDM has set up tools to monitor the health impact of the Wall on the Palestinian population. In areas affected by the Wall, MDM collects and analyses data in order to verify if the health needs are covered and if not to respond to them with the collaboration of its local partners.

3- Speak out against the negative effects of the Wall on people’s health

In November 2003, MDM published a report3 highlighting the difficulties faced by both patients and healthcare workers in accessing health care facilities in a safe and timely manner. In this framework, we have decided in conjunction with our medical activities, to bear witness to the obstacles created by the Wall in accessing medical care.

Collecting testimonies in the field is the medium we have chosen to express the difficulties or the denial of access to health services for Palestinians in the West Bank and Jerusalem. The idea behind the testimony collection is to “give voice” to the people who have no voice and who are faced with the Wall and a multitude of associated barriers in order to reach hospitals, primary healthcare centers or clinics. The objective is not merely a documentation of the daily difficulties faced by Palestinians due to the Wall. It is also a way of letting their voices be heard, in order to eventually bring about a change in their access to healthcare in the future.

III- METHODOLOGY

In an attempt to illustrate the impact of the Wall on health, extensive field work was conducted in the West Bank and Jerusalem. As a result, 83 testimonies were collected from July to mid October 2004.

A testimony grid was created, focusing on two categories: specific incidents of prevented or denied access to healthcare and the general impact of the Wall. The interviews were conducted through open questions in Arabic and were later translated into English.

The testimony collection in the field was made possible by a network of local contacts. MDM’s local partners, HWC and PRCS both played valuable roles in the identification and actual testimony collection. A series of presentations of the testimony collection and its objective was made to the medical teams in their clinics. Nongovernmental organizations (NGO) working in areas where MDM is not present were also very helpful. For example, Première Urgence, a French NGO working in Azzun, helped us identify the Bedouins living in enclaves whom we interviewed.

Several target groups were initially identified based on the medical impact of the Wall such as patients, people with chronic diseases, pregnant women, physically disabled children and medical teams. Then these targets were expanded to include other categories affected by the Wall such as school students, medical students, youth and people living in enclaves. The focus of the testimonies was on the medical impact and also took into account psychological and social impacts of the Wall.

In order to preserve the rights and privacy of the people interviewed, and in keeping with the principles of international law and MDM policy, anonymity was safeguarded in several ways:

– Interviews were conducted in a secluded location, face to face, without the presence of anyone outside of the interviewer and interviewee unless the person requested it.

– A consent form was signed voluntarily by each interviewee who agreed to have their testimony published by MDM. These forms are kept in a locked file at MDM headquarters in Paris.

– A code system was developed in order to protect the identity and place of residence of the persons who were interviewed.

The field work initially focused on collecting testimonies in areas where the Wall was already built and especially in its “physical aspect” (8 meters in Qalqilya in the north). As the field work progressed, MDM extended the collection of testimonies to areas where the Wall had not yet been built, but Wall construction was planned.

The definition of the Wall extended from the “physical” cement or electronic Wall to include other barriers such as checkpoints, earth mounds and roadblocks which are associated with the Wall or its impending construction.

In parallel to these testimonies, MDM also incorporated some medical data collected on our programs with the help of our medical partners. Additional medical information was gathered from other organizations which have also been working on the Wall issue. To date, figures showing an increase in the number of deaths or incidence of diseases between the periods “before” and “after” the Wall are rarely available. The impact of the Wall with respect to health is viewed in the broader context of the reduction of access. In assessing the impact of the Wall on health, it is indeed difficult to separate the effect of the Wall on access issues, from the larger deterioration of living conditions and freedom of movement since the second Intifada. Moreover, some long term effects on health for chronic disease patients for example will only be seen in a few years. Therefore the data used in this report focuses on the health care system more than on health as such.

IV- CONTEXT

In June 2002, the Israeli government began construction of a Wall in the northern West Bank of the occupied Palestinian territories. The Israeli government presented the Wall as a temporary structure to separate the West Bank from Israel in order to protect its citizens from attacks by Palestinians, particularly suicide bombers.

The citizens Israel referred to are more than 200,000 Israeli settlers who live inside the West Bank, within the pre-1967 borders.

The planned route of the Wall will span 622 km when completed, 185 km has already been constructed and a further 70 km is currently under construction5. The constructed Wall consists of a system of 8-9 meter high concrete-slab segments, fences, ditches, razor-wire, groomed trace sand, electronic monitoring system, patrol roads and a no-go buffer zone. It is estimated to cost approximately US$ 4.7 million/kilometer.6 Eighty five per cent7 of the planned route of the Wall does not follow the 1967 Green Line and encroaches into the West Bank, looping around 56 settlements in order to keep them contiguous with Israel. When complete,

the Wall will be approximately twice as long as the Green Line. As a comparison, it is twice as long as the Israeli coastline8. 11,5% of the West Bank land area (the equivalent of 63,120 hectares) will be in the seam zone (between the Wall and the Green Line9). Approximately 93,000 Palestinians10 will reside in these areas in a series of enclaves entirely surrounded by the Wall and other restrictions.

By confining communities behind the Wall, between the Green Line and the Wall or completely surrounding them into enclaves, the Wall deprives Palestinians of adequate access to the basic services such as water and education, as well as sources of income such as agriculture and other forms of employment. The Wall has steadily added another layer of obstacles isolating, fragmenting and therefore weakening the already fragile Palestinian healthcare system. It disrupts access to hospitals, primary health centers, medical specialists, referral centers, laboratory, complementary medical tests, pharmacists and rehabilitation centers for both patients and health care staff.

The Wall appears as the final and most visible part of a network of barriers, both physical and administrative, which impede movement inside the occupied Palestinian territories. Over 700 barriers11 (fixed and flying checkpoints, trenches, electric and barbed wire fences, closed gates, earthen mounds, roadblocks, curfews, closures, bypass roads) already restrict movement inside the West Bank. Israel restricts Palestinian travel on sections of roads throughout the territory. The movement of Palestinian people and goods are also regulated according to a complicated and arbitrary system of permits12, by which Israel allows some Palestinians access to Jerusalem, other cities within the West Bank and into the seam zone13 between the Wall and the Green Line. All these Walls fragment and divide people’s lives and their right to physical and mental health care.

V- IMPACT OF THE WALL ON ACCESS TO HEALTH CARE

According to the World Health Organization (WHO), the health care system is divided into 3 levels:

– Primary health care which « refers to a span or an assembly of first-contact health care services directly accessible to the public »14

– Secondary health care, which encompasses « specialized ambulatory medical services and commonplace hospital care ». Patients are referred from primary health care.15

– Tertiary care, which refers to medical and related services of high complexity and usually high cost16.

Patients are referred from secondary care for diagnoses and treatment as these services are not available in primary and secondary care centers. Tertiary care is generally only available at national or international referral centers.17 Access is vital at each of these levels.

Since the construction of the Wall started in June 2002, regular access to hospitals, private doctors, specialists, laboratory services and other secondary and tertiary health care has been disrupted for 200,000 Palestinians.18 When the Wall is completed, 32.7% of all West Bank villages19 will be denied free and open access to their health care system. Both patients and medical staff face difficulties regarding access to health care services.

1- Access problems for patients and their effect on primary health care

Patients both in the West Bank and Jerusalem are facing increased difficulties to access healthcare services in hospitals and primary health care centers.

Reduced access to healthcare can affect health in different ways. It endangers the health of people who require immediate care. By discouraging them, it leads them to delay the medical consultation or to self prescribe medication, which can exacerbate their health status thus potentially increasing recovery time and cost. Finally, restricted movement impedes access to preventive health, which is an essential tool in terms of quality and cost of the population’s health.

– Access to hospitals

The prolonged waiting times or closures at gates and checkpoints associated with the Wall have extended the delays for ambulances to reach the patient and then the hospital in case of emergency.

For example, in the community of Aizaria, prior to construction of the Wall in 2002, approximately 87% of patients20 who required hospital admission went to Jerusalem area hospitals, primarily Al-Maqassad and Augusta Victoria hospitals. A majority of these cases traveled to hospital via taxi or private car, others traveled by ambulance in case of emergency. The average transport time was 15 minutes by car or taxi, and 5 minutes by ambulance.

In 2004, only about 39% of the patients who require hospitalization and who use the PRCS ambulance in Aizaria can gain access to Jerusalem area hospitals, primarily for deliveries and for scheduled surgery cases with a pre-arranged permit21. The vast majority of these cases are now transported to hospitals in Bethlehem, Jericho, Ramallah, Hebron, and Nablus. The average transport time by ambulance from the Aizaria and Abu Dis area to Jerusalem has increased to 1 hour and 52 minutes since the Wall has been built as opposed to 5- 10 minutes prior to the construction of the Wall.

In case of a medical emergency, time is vital. The delay between receiving a call and the time when medical teams start looking after a patient must be minimized in order to increase the chances of survival for the patient.

In severe cases such as asthma crisis, allergic reaction or heart attack, the first hour, also defined as the “golden hour” by emergency specialists, is crucial to provide immediate emergency health care to avoid potential death. Any delay, especially over one hour, jeopardizes the chances of survival for those patients.

The PRCS Emergency Medical Technicians (EMT) working at the ambulance station in Aizaria, face access difficulties daily. In certain cases the need arises for coordination22 with the Israeli military authorities through MDM to obtain the authorization for the ambulance to access Jerusalem hospitals. These attempts are not always rewarded. According to Israeli civil administration orders, ambulances are not subject to the permit system, nevertheless the decision to allow an ambulance to cross a military checkpoint often depends solely on the soldier’s subjective determination of the gravity of the medical emergency. This testimony of a PRCS EMT from the Aizaria Ambulance station illustrates this difficulty:

“After the explosion (in the Rehavia section of west Jerusalem on 22 February 2004), the soldiers have refused to let us transport two of our patients to hospitals in Jerusalem. One patient was an old man with cancer. The other patient had to go to the hospital for dialysis, but the soldier refused to let us pass. He said: “the patient is breathing, his eyes are open, and he does not need to go to the hospital”

All the EMTs MDM interviewed referred to their feelings of helplessness, of their inability to fulfill their duty and their frustration on these endless delays.

– Access to specialists

Most Palestinian health care specialists are based in Jerusalem and some of them are only found there. Patients referred to these specialists often face difficulty obtaining the necessary permits to enter Jerusalem, thus denying them from receiving the required care. A doctor of internal medicine in Beit Sahour (south of Jerusalem) talks about this problem:

“In the past, I used to refer patients with heart attacks, catherization or abdominal operations to Jerusalem; also we have no coronary care unit in the area so we have to refer the patients there. We have been cut off from Jerusalem; this is a problem especially for the referral of patients. It is very difficult for the patients to get permits to go to Jerusalem for treatment so they have to jump over Wall or earth mounds.”

Heavily equipped and specialized units are a basic requirement for treating patients. Several

specialists MDM spoke with told us that they feel unable to do their work correctly, especially since their patients have access difficulties.

The delays affect the quality of the services offered and could even lead to fatalities in case of heart attack monitoring for example. A neurologist in Beit Sahour said:

“Before [the Wall was built], when I received an emergency call I was able to refer the patient from Bethlehem or Ramallah to a hospital in Jerusalem and I would meet the patient there.

Today a referral can only be done by phone, one doctor to another. Even if it’s a very urgent case my hands are tied, I can’t do much”.

For patients who require specialists’ care, it has therefore become more difficult to have regular access and follow up. The time and effort spent waiting at the gate, passing checkpoint or climbing the Wall impedes them from reaching specialists safely or at all. These patients, already particularly vulnerable, are faced with stress and making efforts which put them at risk and prove extremely difficult to avoid. People who suffer from a bad health condition such as severe heart disease or advanced stage of cancer are unable to make these efforts.

Elderly people who commonly suffer from arthritis, face difficulties walking and are often too weak to pass over a Wall or a trench. Therefore, they will probably postpone their visit to the doctor.

For patients who require specialists’ care, it has therefore become more difficult to have regular access and follow up. The time and effort spent waiting at the gate, passing checkpoint or climbing the Wall impedes them from reaching specialists safely or at all. These patients, already particularly vulnerable, are faced with stress and making efforts which put them at risk and prove extremely difficult to avoid. People who suffer from a bad health condition such as severe heart disease or advanced stage of cancer are unable to make these efforts.

Elderly people who commonly suffer from arthritis, face difficulties walking and are often too weak to pass over a Wall or a trench. Therefore, they will probably postpone their visit to the doctor.

– Increased burden on primary health care centers

Primary health care is the core of the healthcare system offered to the population. Damaging this level of healthcare puts the whole healthcare system at risk. In addition to cutting patients off from primary health care centers, the construction of the Wall has increased the burden placed on these centers. This burden is attributed to the fact that as people are denied travel permits to reach referral services, they must return to the primary health clinic for this advanced care. Primary health care centers MDM supported in the North and the South of the West Bank face such problems.

– In the West of Bethlehem, the inhabitants of Battir, Husan, Wadi Fukin, Jaba’a and Al Walaja face an uncertain future, as they will doubly suffer the consequences of the planned Wall. Firstly, they will be walled into isolated enclaves. Secondly, their access to medical centers and hospitals will be blocked by another Wall around the city of Bethlehem. It will be nearly impossible for anyone with a health emergency such as a heart attack, severe appendicitis, or a pregnant woman in the midst of a complicated delivery to reach the hospital on time.

The Wall will reduce these villagers’ chances to access the whole scope of technical specialized care that is only available in a larger urban center. The burden placed on the primary health care staff in these enclaves will be excessive as they are forced to cope with a wider and more severe range of illnesses – and are forced to manage with decreased access to medicines and supplies. The number of poor delivery outcomes for mothers and babies and the amount of illness and death for chronically-ill patients will rise, as a woman’s health doctor, working in a village near Bethlehem, explains:

“If they close all these villages with the Wall, the situation of patients will be much more difficult. It will be impossible to take a patient out of the area to go to the hospital. We only do primary health care here.

During previous closures, we have often used one room of the clinic to do the delivery. But it only works well for safe delivery. What if the woman starts bleeding or needs a caesarian? There is no specialist or equipment here. We don’t have monitors or x rays. There is not enough material for very seriously sick patients. The Wall will increase the complication of diseases. What happens if I diagnose some disease but I am not able to give medication or refer to a hospital? ”.

– In the North Jordan Valley, the Wall has just been completed less than 1 km from the villages of Ein el Beida and nearby Bardala. The Wall, in the form of fences, barbed wire, and a ditch, is one of many obstacles that

isolate these villages from access to healthcare services. These villages are often placed under closure23, which means they are not allowed to enter Israel. Additionally, Route 90, the only road that links Ein el Beida and Bardala to area hospitals is intermittently closed, leaving the residents completely cut-off from emergency medical care.

A Women’s Health doctor in a village in the North Jordan Valley tells us the reality she already faces in her daily work:

“Being a doctor is becoming very stressful. I get tired and nervous from the journey (from Tubas to the clinic through the Tayassir checkpoint) . The biggest problem for me is to not be able to refer patients for tests such as blood tests and blood sugar levels during pregnancy.

Sometimes, I feel that I am doing the maximum for the patients but some circumstances are out of my hands”.

Laboratory equipment has become a basic requirement nowadays in order to offer treatment to patients. A doctor is hardly able to work without it.

2- Reduced and denied access for medical staff

The Wall obstructs health workers, medicine and medical supplies from reaching the vulnerable communities. Certain medical supplies, such as inhalers for asthmatic patients, need to be delivered immediately. Others such as vaccines, blood sacks and disinfectant for reusable instruments require specific care in terms of transport.

According to the Health, Development, Information and Policy Institute (HDIP), 26 primary health care clinics have been isolated by the Wall from the rest of the Palestinian healthcare system24. Up to 52% of the doctors working in these clinics all over the West Bank are delayed or denied access in reaching their work place25. In other areas where the Wall is only planned, a variety of barriers also regularly impede access for medical staff.

This is the case for the medical teams working in the North Jordan Valley, as we were told by a HWC health program coordinator:

“We are often delayed at Tayassir checkpoint (in the North Jordan Valley). Even if the medical teams in the ambulance show the soldiers their cards, they don’t care. Our medical cards mean nothing to them. I find that I have less time to do my work because sometimes we are delayed reaching the clinic, yet the number of patients has increased, this delay affects the quality of service provided for the patients.”

Physical attacks, shooting and/or the use of tear gas as well as physical and or verbal harassment against medical teams are frequent occurrences that disrupt them in the performance of their duty. As it is illustrated in the following testimony of a general practitioner in Battir, west of Bethlehem:

“On September 20th 2004 in the morning, I was coming to work to Battir, together with another nurse. At the checkpoint, the soldiers did not let us pass. We showed them our medical cards but they did not care. They told us we had to go home. We climbed on the hill nearby and they shot tear gas at us. We ran and after a while we eventually managed to take a car to Battir. As Palestinians, we are used to it. It is our daily life.”

Harassment of medical staff is part of their everyday reality. Yet it is even more delicate regarding the female staff torn between their commitment to their work and their commitment to their traditions. This was the dilemma faced by a female PRCS EMT from Tulkarem at an Israeli checkpoint:

“Many times at checkpoints I have been forced to take my head scarf off or lift my clothes up. Once there was a military closure and the soldiers demanded that I take my head scarf off. There were at least 30 soldiers around me and they had their guns pointed at me. It was very scary and humiliating.

All the people in the street around me were looking at me. Finally I was obliged to lift up the PRCS vest off my back and reveal my stomach to the soldiers.”

3- Populations at risk

Several vulnerable groups within the Palestinian society are specifically being put at risk with the ongoing construction of the Wall. Among them, we have identified children, pregnant women, chronically ill and physically disabled patients.

– Children

A few of the health risks affecting children can be summarized in three main points: vaccination, malnutrition and anemia, birth malformations.

➣ Vaccination

Due to the Wall, 133, 000 children26 under the age of five may not be able to obtain all the necessary vaccines on time or possibly at all27. Delays associated with travel obstructions such as the Wall and other barriers are bound to affect the “cold chain” that is required to preserve vaccines during transport.

A pharmacist working in the Salfit area (near Nablus) told us about his already difficult experience transporting vaccinations and medication all over the West Bank.

“I use an ice box to transport medications such as insulin and other vaccinations. I usually fill it with blocks of ice to keep the medication at the correct temperature. Usually I keep them between 2 and 8 degrees, because over 8 degrees they get spoiled. But the medication is kept cold in the ice box for maximum 3 hours. The delay can affect the temperature of the medication and spoil them. I spend hours at checkpoints, sometimes the soldiers send me back so I have to go over the earth mounds with the boxes of medication, sometimes I reach the clinics with broken vials. This puts me under great pressure especially when I have to take all the boxes of medication out of the car until they check them one by one and then I have to put them all back in again, this creates a delay in delivery to the clinics.”

This is a common difficulty also faced by other medical staff in the West bank, as we were told by a Women Health doctor working in a village near Bethlehem:

“Recently, we had to vaccinate again all the children against measles. Last year, there had already been a vaccination campaign organized by the Ministry of Health. But the boxes were opened many times by soldiers at checkpoints. Measles vaccines are very sensitive to heat and sun. So we had to do all the vaccines again in June and July this year. The Wall will have a direct impact on vaccines because there will be a gate which only opens on certain hours.”

Although more than 90%28 of children under five received measles vaccination in 2003, less than two thirds have acquired the level of immunity needed for protection against the disease29. It is most probably the result of the problem of access of medical material and vaccine. Any kind of barrier, such as the Wall, which impedes access to medical material, is bound to put at risk a large scale vaccination campaign.

➣ Poor nutrition leading to chronic malnutrition

Nutrition is an important part of health. The Wall, as it separates families from their land, makes access to water more difficult. It worsens the economic situation and can lead to insufficient nutrition, especially among children who are more sensitive to it.

According to UNICEF30, 37.9% of Palestinian children aged six to 59 months are anemic (22.5% of mild anemia, 15.3% of moderate anemia and 0.2% of severe anemia), 3.5% of these children are underweight, 2.5% experience wasting while nine per cent experience stunting.

Poor nutrition makes people weaker31 and less resistant to illnesses. Mothers who are in a fragile state will also deliver more fragile babies. Those babies will become adults who are more prone to be affected by illness and among them there will be weak mothers. This “vicious circle” leads to more health problems for the whole community and is difficult to break.

➣ Birth malformation

Genetic diseases are the leading cause of death among newborn babies. The higher number of consanguineousmarriages and marriages between close cousins in the Arab region is the main cause of genetic disorders32.

We can expect more birth malformation in enclaves and due to closures. 11% of all new children, (approximately 10 children per month) who register in MDM/HWC clinics have congenital malformations such as hernias, foot abnormalities, speech or hearing problems, heart defects or vision problems. A majority of these cases must be referred to a larger health center for specialized follow up and care.

Children born with congenital malformation, even if they are correctly diagnosed at birth, need continuous and specialized medical care. This specialized care can only be found in Jerusalem where access is perpetually an issue for a large number of patients.

For example, the Saint John Ophthalmic hospital based in Jerusalem provides ophthalmic services to the Palestinian population in Jerusalem, the West Bank and the Gaza strip. Access to essential treatment, surgery and follow up are increasingly difficult due to the Wall.

This is the case of a young mother living in Abu Dis who is no longer able to take her 4 year old son for follow up treatment for an eye condition he has suffered from since birth. She said:

“I am supposed to go to the St John eye hospital once a month to have his eyes checked but I can barely make it once every 6 months. Even before the Wall was put up I faced difficulties reaching the hospital for his check up. I used to take the back roads and I have a West Bank I.D so the taxi driver refuse to take me because they are afraid of being stopped. Now the situation is worse because I have to jump over the Wall with my son to get to the hospital.”

Families have also difficulty accessing the referral services that they need because of poverty.

This is the case of 25% of the families in our clinics. With ongoing construction of the Wall and further curfews and closures, we anticipate that this figure will at least double in the near future. In enclaved villages, we anticipate an increase in congenital malformations due to close marriages and the limited choice of potentials spouses since movement in and out is severely restricted.

– Pregnant women

At the beginning of the Wall construction, the Palestinian Ministry of Health estimated that

117,600 pregnant women, including 17,640 high-risk pregnant women33, may not be able to access antenatal care, hospital delivery services and postnatal care.

This projection was reinforced by our figures. In October 2003, 28.7%34 of women in MDM/ HWC clinics have been prevented from going to hospital for delivery by closures and curfews. Among a small sample of women in Battir and Husan villages near Bethlehem who have recently given birth, this has increased to 30.9% between June and October 2004. It  is primarily attributed to access difficulties posed by ongoing closures, checkpoint difficulties and Wall preparation and construction. This percentage is expected to increase once active construction of the Bethlehem village enclaves begins.

The difficulty of access to adequate care or follow up for pregnant women has already led to the reliance on more “traditional” deliveries performed by midwives. As it was explained by a women health doctor in Jaba’a, near Bethlehem:

“When women in Jaba’a need to go to the hospital for delivery, they go to Hebron but they have to walk 4 to 5 km to Surif and then take a taxi, or go to Bethlehem, but there are frequent closures which make it impossible for them to access. Therefore the deliveries are sometimes made at home by a midwife. I know two or three women who had their babies delivered at home by midwives who usually perform animal deliveries. ”

Midwives are usually known in the village community but despite having years of experience they lack any basic medical training. As a young mother from Araboneh stated:

” I am afraid of being delivered by a midwife because I had a very bad experience 2 years ago when my daughter was born, I nearly bled to death. So I would rather take the risk and go to Jenin.”

In the case of high risk pregnancies women and unborn children face a real threat of severe illness or death. High-risk factors can have serious consequences during pregnancy and delivery for both mother and child. The most frequently occurring risk factors are: previous caesarian section, high multiparity (5 or more previous births), the age of the birth mother (16 years or younger or 38 years or older) and anemia. The risk of premature labor is increased when the mother is pregnant with more than one child (e.g. twins or triplets). Prenatal tests are performed in order to determine if the baby has a serious health problem (e.g. heart defect). If a health problem is detected, the mother may require additional tests and treatment in order to ensure a safe pregnancy and healthy delivery. Pregnancy in itself can create complications resulting in a high-risk; these include, but are not limited to gestational diabetes and hemorrhages. Finally, many women who suffer from chronic illnesses require special attention as they progress through their pregnancy.

In the past five months, HWC clinics in partnership with MDM have identified 263 pregnant women who have at least one high risk factor for a poor delivery outcome for the mother and baby. These women represent 16% of all antenatal visits who are seen in HWC/MDM clinics. There is a looming crisis if the Wall prevents these women from reaching the hospital in time to deliver their babies. Premature birth, low birth weight and congenital malformations cause more than half of all infant deaths in the occupied Palestinian territories. According to the 2003 Ministry of Health (MOH) annual report, conditions in the prenatal period are the third leading cause of death for women in their reproductive years. Without access to hospitals, the already high number of infant and maternal deaths is likely to increase.

A patient from Husan confided:

“I was three months pregnant in February 2004. I went to see my gynecologist in Bethlehem. The doctor did several tests including an ultrasound. She told me that there was no feotal heart beat, the baby was dead. I went home. At 2 am I woke up in pain, I was bleeding and I felt something come out of me. The road to Beit Jala was closed but my husband and I managed to walk over the earth mound. Another ambulance was waiting for us on the other side. All through the journey from the town to the hospital in Bethlehem I was bleeding”.

– Chronically ill and physically disabled patients

The Wall limits or prevents access to essential medical services such as doctor visits and medications for nearly 10,00035 persons with chronic diseases such as diabetes and high blood pressure. When the Wall is completed, up to 39,85036 chronically-ill patients and 17,640 disabled patients may not be able to access essential specialized health care because of the Wall.

Access to sophisticated medical interventions such as dialysis for kidney failure and chemotherapy for cancer patients is vital to their survival. Patients requiring these procedures must be at the hospital at regular intervals scheduled by the treating physician.

Delays or denial of access to hospital facilities may result in death.

The Augusta Victoria hospital is the only Palestinian hospital with the resources to provide

dialysis treatment. Patients from the West Bank need a “medical permit”37 in order to access any hospital in Jerusalem.

Obtaining a permit can be a long and arduous process even with all of the necessary medical documentation. Furthermore, once a permit is issued, it is usually valid for a limited period and still does not guarantee passage at checkpoints. The “security” situation is frequently used as justification by the Israeli military to suspend or cancel permits before their expiration date.

A doctor of internal medicine in Beit Sahour told us the case for this patient suffering from a kidney infection:

“This week, I had a patient who had polio as a child and wears a brace on his leg in order to walk. He had a kidney infection and it took him three weeks to get to Augusta Victoria hospital in Jerusalem to get a biopsy done. Each time he applied for a permit even with the medical documents he was refused the permit. So he had to get to Aizaria and jump three times over the Wall at the gate.”

Access to Jerusalem is dependant on the soldiers at the checkpoints who lack medical knowledge. Because of this, chronically ill patients find themselves having to justify their condition and providing proof of illness. This is the case for a 64 year old dialysis patient from Abu Dis:

“I go to Augusta Victoria hospital 3 times a week. The treatment lasts for 4 hours. I have to be there at 7 am in order to be hooked up by the machine. Three days ago, I was very tired. I could not walk and I had to jump over the Wall. I had pain all over. Before the Wall was built, I used to be able to reach the hospital in 10 minutes in my private car. I can’t do that anymore. Even when I get a permit, the soldiers sometimes send me home. I show them the puncture marks on my arm so they believe me, but it doesn’t help. In this case, I take the back roads, this way is longer, I got through the mountains, I have to walk far but I can’t afford to miss the dialysis. If my treatment is delayed, I reach the hospital with 4- 5 kg of water. I have severe water retention.”

4- The specific case of enclaves and the seam zone

In certain areas, the construction of the Wall has created extreme situations. Some people live in enclaves encircled by the Wall, like the Azzun Atma enclave near Qalqilya. Others live in closed areas, also defined as the “seam zone”, which are situated between the Wall and the Green Line, like the area of South Hebron.

A network of 55 gates38 and a “permit system”39, established in October 2003, currently regulate and control access to these areas. Palestinians without a permit are denied the right to work their lands which have been annexed or confiscated to the west of the Wall.

Patients living in an enclave, can only access medical care in larger neighboring cities by passing through a gate guarded by soldiers. The hours that the gates are scheduled to be open are not always reliable, which results in delays in reaching hospitals for scheduled appointments. If an ambulance is called to respond to a medical emergency in these enclaves, they will first need to get authorization from the soldiers to pass through the gate. This is illustrated by the following testimony of a young woman living in an enclave situated near Qalqiliyia:

“My aunt had a stroke in May, the soldiers at the gate saw her situation and let us through. She stayed in the hospital for 2 days. (I went back home), it is very difficult for us to get out now that they have put the gate. If there were no Wall around us and no gate at the entrance of the town, we could take her to Qalqiliya for treatment.”

In the seam zone and in enclaves, the percentage of people who cannot access primary health clinics, medical centers, and hospitals as needed, totals 80.7%40. This situation is rendered more difficult by the fact that medical staff coming from outside the seam zone and the enclaves, face difficulties trying to enter. Medical staff is required to have a permit to go in and out and coordination41 with the Israeli army.

The father of a 10 year old child suffered the consequences of the above mentioned situation, when his daughter suddenly fell ill. The child’s 45 year old, uncle from Ras Al Tira, near Qalqiliya told the story:

“One year ago, my niece was seriously ill. She had very high temperature. At that time the Wall had just been built. It was a fence, without a gate and it was not electrified. That is why an army patrol was permanently present at the site of the gate. My brother took his daughter to the gate to take her to the neighboring town of Habla were there is a doctor. As he reached there, the soldiers stopped him and told him that the gate was closed. He tried to explain the situation but they did not care. Finally he told them “if you won’t let me through at least let me call a doctor to come and check on her.” When the doctor came one hour later to the gate, they did not let him pass. He passed a box of medication through the fence.”

In the enclaves in the West bank, such as Azzun Atma, near Qalqiliyia, Palestinians must apply for permits to leave the enclave and travel to other towns in the West Bank. The situation of the Bedouins in this enclave, is additionally complicated since their current place of residence (Azzun Atma) is different than that specified in

their identity card (I.D) which is Hebron. Therefore, it makes it very difficult for them to obtain permits to leave the enclave. If they take the risk to leave the enclave without a permit, they will never be able to return.

The difficulty to obtain permits prevents access to medical facilities and therefore to medical treatment. This is the case of the 35 year old young Bedouin woman, living in the Azzun Atma enclave:

“We can’t come and go as we wish. It is difficult for us to get medical care. My mother suffers from arthritis, but I can’t take her to a doctor, we have no permits and the roads are long. Even if she gets out without a permit she can’t come back through the gate without one, so she has to take a long detour, it is a very long way and she can’t walk. She needs to do some tests and an x-ray but we can’t do them. There is no ambulance service here, before we used to go to Habla, but now there is no way out for us.”

VI- SOCIO-ECONONOMIC CONSEQUENCES

According to the World Health Organization (WHO), health is defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”42 As a medical humanitarian association, MDM has a global approach to health which not only focuses on access to healthcare but also encompasses access to work, education and housing. All of these factors have a more or less direct influence on people’s health.

The Wall and its associated barriers impact more than just access to healthcare, these barriers also reinforce unemployment and poverty, which are already widespread in the occupied Palestinian territories with 40% unemployment43 in the West Bank and Gaza and 2/3 of the population living under the poverty line44. Per capita, Palestinian income remains 35% lower than its pre-intifada level45. Confiscation of land and property, house demolition and difficulty of access to education are among the socio economic consequences of the Wall. These factors all contribute to the difficulty of paying for healthcare and therefore an increased risk of deterioration of people’s health.

1- Increasing poverty and difficulty to pay for health care

The majority of men living in areas surrounded by the Wall depended on Israel for their livelihood. The fact that this economic opportunity no longer exists has plunged these families into poverty.

Thousands of Palestinian households are now being cut off from employment opportunities, social services, trade and commerce. This is the situation a 45 year old man from Ras Al Tira, near Qalqiliya explained: “80% of the men in the town used to work in Israel, nowadays; they can’t get permits so there is a high rate of unemployment. They try to get into Israel without permits because there is no work in the village itself, we have no industry of any kind, but some people have animals or olive trees as their only source of income. Most of the land of the village has been swallowed up by the Wall”.

The economy in the Wall affected areas has suffered enormously because of the restrictions on the movement of people and goods. The movement of West Bank I.D holders depends on the deliverance of a permit46 by the Israeli civil administration situated at the various District Civil Liaison offices47. As security considerations have the potential to affect the movement of Palestinians in any area, they often lead to the cancellation of permits. It prevents people who used to work in Israel from accessing their work place.

Other permits are issued for medical reasons. They are subject to a medical investigation in parallel to a security investigation48. The deteriorating Palestinian economy has affected the patients’ ability to pay for treatments, medicines, especially for expensive treatments, as a doctor of internal medicine in the Beit Sahour area explained us:

“Some patients ask me to give them less tests to do, or to reduce the expense of the tests that we have to do. Some lab tests are expensive especially if people don’t have health insurance.”

Most of the medical teams we interviewed said they are often faced with patients who cannot afford all the medication they need, thus they are forced to make a choice between what is essential and what is not. This situation is illustrated in the testimony of a pharmacist in Salfit.

“The other day, an old woman came up to me in the pharmacy. She had a prescription for 3 medications, the total of 9 NIS. She told me “I have no money to pay for these”. I felt bad for her and gave her the money. I often deal with patients who are too poor to buy the medication they need. Sometimes people come up to me in the pharmacy and ask if I can give them half of the medication prescribed by the doctor. They ask “Which one is the most important? I can’t afford both.” A nurse who also distributes medication at the PRCS clinic in Salfit added:

“Give us half or a quarter of the medication you prescribed”. It’s a sentence I hear practically every day from all my patients. I do what I can for them. People have to compromise on their health because they have no money.

Patients also face the difficulty in paying for public transportation to access health care services, as an EMT from Aizaria told us:

«The soldiers at the checkpoint prevented us from passing and told us to get an ambulance with a Jerusalem license plate, because I drive a West bank ambulance. I called a private ambulance in Jerusalem so they could pick up the patient. They arrived quickly and they took 350 NIS (80 USD) from the patient for a 5 minute trip to the hospital. In certain cases I have been forced to call the Israeli ambulance (Magen David) and in that case the patient is forced to pay a lot of money (650 NIS – 150 USD). »

The price of a ride by an Israeli ambulance represents itself 33 % of the medium monthly income in the West

Bank, estimated to 1929 NIS (439 USD).49

2- Confiscation and reduced access to land and water sources

The construction of the Wall has already resulted in the confiscation and leveling of privately owned land, the up-rooting of trees and the destruction of water pipes.50 25 000 hectares51 have been confiscated due to the construction of the Wall and a total of 63,120 hectares, representing 11,5% of the West Bank will be confiscated by the time the construction of the Wall is completed. Land confiscation orders are delivered to the inhabitants of the areas on the projected route of the Wall by order of the commander of the Israeli army in that zone. According to calculations based on the Israel Defense Force plan of June 2004, 15,586 hectares of land will be in the area between the Green Line and the Wall when construction is completed. The annexation of the West Bank’s most fertile land hinders agricultural productivity, which has become the main source of revenue for people in the occupied Palestinian territories. As an engineer from Salfit told us:

“The confiscation of land to build the Wall has reduced the agricultural land people depend on for a living since most people have turned to the land because they can’t enter Israel to work The uprooting of trees has environmental consequences since it increases air pollution from the settlements and affects the wildlife.”

The good quality and accessibility of water is an important parameter for the standard of living of communities and has a direct effect on people’s health. The building of the Wall has lead to the confiscation of a substantial number of natural springs, and wells.

According to the Palestinian Environmental NGO network (PENGON), 50 wells have already been annexed from neighboring communities by the Wall and are therefore no longer accessible.52 It is difficult to access clean drinking water, even if this is not the case, people are forced to drink polluted water. By annexing the West Bank’s water resources such as the natural springs, the Wall will have grave long term implications for the environment. Another engineer from Salfit explained:

“Ein Al Matwi (a natural spring) , which is 5 km from here will be included in the Wall when it is built, thus cutting Salfit off from one of its natural water sources. Salfit and the nearby villages will lose 20% of its natural water supply as a result.” In Salfit, the liquid, gas, and solid wastes left by the 17 settlements from the district are causing pollution to the environment, agriculture and water. The industrial waste is often discharged into Palestinian land without treatment.

The untreated wastewater can contain many pollutants especially heavy metals.53 It increases the risk of intoxication and epidemics such as hepatitis A or infectious diarrheas.

The (re)building of water distribution or evacuation of used water infrastructures represents an important cost for communities54. As does the maintenance of pumping stations, purification and waste evacuation infrastructures which needs qualified personnel.

3- House demolition

“Four months ago we received a demolition order, regarding the new building situated opposite our house. They told us that it is in a C zone (Israel) and therefore we have no right to build there. This is strange since this house we are living in is not contested, it is in B zone (Palestinian authority). The problem is we have no land registration forms for the land or the houses. They told us we need to get a detailed architectural map of the house as well as a surveyor’s map of the land and existing structures. This is very expensive. My mother in law can’t sleep at night, she worries about the house, it’s all we have, and it’s the fruit of all our efforts”.

As it is the case for this family in the village of Araboneh, when the Israeli authorities claim that homes in the West Bank are built on land that is situated between zone A and zone C55, they issue house demolition orders to the owners, who desperately seek legal council to stop the demolition of their home. According to the Israeli Committee against House Demolition, about 4000 houses have been demolished in the occupied Palestinian territories during the second Intifada. Among them, 200 have been demolished due to the construction of the Wall.

Sometimes, homeowners in the West Bank are taken by surprise and are helpless to stop the demolition of their house. In the village of Walaja, Israeli authorities claim that there are houses in the town that were built in zone A but others were built in zone C and are therefore at risk of demolition. A 51 year old doctor, who lives there, told us about the day his house was demolished:

“I started building this house in Walaja for myself and my family in June 2003. The house was nearly finished. I had never received an evacuation order or an order to stop construction. Although I visited the site of the new house every day, I never saw a paper or any other indication that the house might be demolished. On 21 June 2004, 2 bulldozers with at least 25 border police, 6 mounted police, 4 special forces arrived in the village. Part of the bulldozers and part of the soldiers destroyed a stocking area in Walaja and the others destroyed my house, without prior notice. In 20 minutes, they destroyed 20 years of work. It has caused mental and psychological damage to my kids. They want to force us to live somewhere else so that they take our land. Destroying a person’s house is destroying a part of oneself.”

Families who have had their homes demolished suffer from considerable emotional duress and often experience high levels of depression and stress-related illnesses.

Other families living close to the Wall or some settlements are pressured to leave. That is what an 80 year old man who also lives in Walaja near the Har Gilo settlement told us:

“ I have been living in this house for more than 35 years. A month and a half ago, officials from the army and the police came to see me. They offered to buy my house, for whatever amount I wanted. They told me that when the 4 meter electrified fence is built, I won’t be able to get out. This gate will be open only when they want. If they decide to put the road I will either live or die on my land. I have nowhere else to go”.

The threat of house demolition and the impossibility to move away from certain areas which are close to the Wall gradually forces some populations to migrate.56

4- Difficulty of access to education

The father of an 11 year old child explains how the Wall in Aizaria has affected the access of his son to his school in Jerusalem:

“My son used to be able to reach his school in 3 minutes from our home by bus. The distance from our home to my son’s school is 1, 5 Km. Nowadays, it takes him about 45 minutes to an hour. Sometimes there are 2 checkpoints on the way to school, one at the entrance of the town and one at Zaim. Since they built the Wall he is forced to take a longer detour of 22 Km. He gets upset because sometimes he misses his lessons; and he has even missed a few exams”.

The Wall has cut some children and teachers from their school. The longer and uncertain traveling distances, often obstructed with barriers or checkpoints to reach school or university result in the loss of routine and of one to two education hours. It is a source of great psychological stress.

The testimony of this fifth year dentistry student illustrates these daily difficulties:

“ I needed a permit to get out of Kalandia checkpoint (between Ramallah and Jerusalem) . Sometimes even with the permit they would send me back, So I had to walk through the mountains and the hills to get to university. When I still lived in Ramallah, I had to leave 3 hours before the lecture to arrive on time, because my classes start at 8 am, I rarely got there on time.”

Access to school is especially difficult for physically disabled children, as their difficulties of movement have increased with the construction of the Wall and other barriers. This is the case for a physically disabled child we met in Walaja, who was born with spina bifida, a congenital birth malformation. The access of the village has been cut of the nearest town Beit Jala and from his school in Bethlehem. Getting him to school every day is physically challenging as his mother explained:

“In order to get my son to school we walk a distance of 0.5 km, then we reached the first earth mound, and I leave his wheel chair behind and carry him on my back. I then cross another earth mound with him on my back. My son weighs 30 kg so it is a considerable weight especially in the winter when he gets completely soaked. When I have reached the end of the third earth mound I place him in the taxi waiting to take him to school.”

VII- PSYCHOLOGICAL CONSEQUENCES

1- Breaking of family links

The Palestinian society maintains its cohesion through the strengthening of family ties. A family orientated society implies that the family is the center around which each member’s life revolves. The Palestinian society’s cohesion has become more fragile in the last few years. The construction of Wall has added another layer to this trend.

In neighborhoods around Jerusalem that have been surrounded by the Wall, a new kind of problem is emerging: couples who have different identity cards. They still live on the Jerusalem side, which makes one of them illegal in their own houses. The West bank I.D holder who is illegally found with his family on the Israeli side of the Wall can face a multitude of sanctions, such as being sent back to the West Bank and the obligation to sign a “ commitment” not to enter Israel illegally. Once a person has signed this document, he will be fined if he is found inside Israel again. The Jerusalem I.D holder will lose the I.D if he/she decides to follow their spouse and live in the West Bank. Nowadays, many families mainly in the Aizaria and Abu Dis area, due to the proximity to Jerusalem, face the dilemma of choosing between their spouse, who is a West Bank I.D holder and their Jerusalem I.D card. A 36 year old woman who is currently living in this situation told us about her everyday reality:

“ When there is total closure, my husband’s permit becomes invalid so he stays at home. Can you imagine that after 7 o’clock, he is living illegally with me and the kids in the house. My husband already started thinking to move out of the house. So me as a Jerusalemite, I have to stay in the house in order to protect my residenceship according to the Israeli regulations and my husband will move inside Abu Dis and so we are going to be separated from each other. The other night, we started even discussing the issue of children, that the children might stay with him for three nights and that they will stay with me for fours nights.”

Overall, split families are becoming a common phenomenon in the West Bank due to the Wall and other movement restrictions. To avoid the humiliation, waste of time and unpredictability of crossing checkpoints and other related barriers, many people are forced to spend the week or more at the place of work or study. Such temporary living arrangements increase household expenditure on housing and food for the persons staying elsewhere, leaving less for the women and children at home. These arrangements also have implications for the cohesion of the family and of the Palestinian society at large. As it is illustrated in the testimony of a teacher who lives in Abu Dis and teaches at a local high school.

“This Wall has literally cut me off from my sister who lives inside Israel. Before the Wall was built, we could reach her in 15 minutes, there were only 4 kms between us, now there is a concrete Wall between us. Even the Eid (the feast of Ramadan) is not the same, the fun and joy has been taken out of it, every eid my mum cries because my sister and her kids are far from us.”

2- Mental health problems

The breaking of family links, unemployment, difficulty to handle usual roles, the feeling of being isolated and abandoned have a lot of consequences on people’s mental health. A significant deterioration has been noted in emotional, physical and behavioral symptoms in the population affected by the Wall. Feelings of insecurity havealso increased in the areas directly affected by the Wall57. A neurologist from Beit Sahour explains the increase in symptoms of illnesses in his patients, which he believes are related to the construction of the Wall and the uncertainty regarding the future. Especially in relation to the patients he treats in Jerusalem, in areas where the Wall is built.

“There has been a big increase in the number of patients being treated for headaches, migraines, or tension. I also see symptoms such as anxiety, depression, insomnia and a lack of stability. I am a neurologist and I tend to recognize these signs in the patients whom I see.”

For Qalqiliya area residents, depression, suicidal thoughts and feelings of hopelessness are among the psychological impacts created by the Wall. Among those surveyed by the Palestinian Counseling Center, 52% of the persons had thoughts of ending their life while 92% felt no hope for the future. 100% report feeling stressed and 84% said they were angry because of circumstances out of their control.

“ I have noticed in the last few years since the Wall was built, there is an increase in stress related illnesses being manifested by physical pains. When patients can’t reach here Qalqiliyia, it creates a delay in their treatment and in the healing process. The rapport that is established between the patient and me is briskly cut off and the patients feel depressed to lose, even momentarily, the link with the person they perceive as the “healer”. This situation has forced me to do lot more psycho-social work in addition to my work as a physiotherapist. Besides, the patients can’t go and get treatment elsewhere because it costs money, money that they don’t have.

Physiotherapist, Beit Amin, near Qalqiliya

– Children

Children are usually the first and the most affected by the changes occurring around them. The current situation in the West Bank regarding the ongoing construction of the Wall and its adverse effects on their health is no exception. Children living in areas crossed by the Wall are disproportionately prone to exhibit aggressive behavior. (44% in Wall areas compared to 35% in other areas58).

A mother of three explains the psychological stress that her children suffer from in Beit sahour.

“My children used to get scared when they heard the shooting, they were worried, and they couldn’t sleep. They always ask me ”why do we suffer like this?” At night, they would only sleep in my arms, when I was near them. My eldest daughter was suffering from insomnia, lack of concentration, and constant fear, she was even afraid to take the school bus.” When my father in law asked my youngest son what he wanted to be when he grows up, he said “an Israeli soldier”. He asked him why? He said

“so I can ride in a tank and let you through at the checkpoints”.

There is increased conflict at points where Palestinian people are obstructed in their normal activities such as at checkpoints, gates, etc. It is likely that the occupation-related barriers tend to focus or elevate tension. It is thus not surprising that children near these barriers manifest signs of such stress59.

– Youth

Palestinian youth have also been adversely affected by the construction of the Wall. The vast majority of youth, who were interviewed, expressed the feeling of having no future, since the Wall would cut them off from health care services and their family. A 23 year old young man in the town of Battir, south of Bethlehem, explains the frustration he feels:

“The Wall has affected the young people a lot. There is no entertainment or fun in this town or near by. Before I used to go to Ramallah but now one has to leave in the day time and come back before dark and the road is long and the roads are difficult. I feel depressed because there is nothing I can do about it. No one can access Jerusalem anymore without taking big risks. I can’t even imagine the future, there is no Wall around us yet but the situation is already difficult, and we can’t get out. ”

Academic achievement is an important way in which young people can feel empowered and hopeful about their future. The Wall has hindered this possibility by making it difficult for faculty, staff and students to openly access some university facilities such as Al Quds University in Abu Dis.

A 16 year old school student, already feels that his present prospects have been compromised by the construction of the wall and feels that his future will be even more affected..

“ When the gate (an improvised passage in the Wall in Abu Dis) is closed, I always have to think about how I can get to university. The roads are difficult and often very bumpy. How will I get to the university in the future if the roads are closed? My choices have been affected and even cancelled by the Wall ».

– Men

In addition to being the witnesses of increased tension at points of conflict (such as checkpoints and gates), men are more often directly involved in conflicts than women or children. This increases their risk for stressrelated behavior and disorders. Traditionally, the man is the provider, the bread winner and the head of the family. In that sense he must provide for his wife and children in addition to other family members he is responsible for, such as his parents or other relatives. Unemployment due to the restriction of access creates a feeling of guilt and helplessness which exposes them to psychological problems.

A 28 year old woman in the village of Battir, south of Bethlehem told us:

“My husband does not have the permission to go and work in Israel. One or two days a month he manages to get through, leaving the house at 4 in the morning. The rest of the time, he stays at home. It is hard for him. He is always nervous and angry. The money is not enough to feed our children. He feels useless.”

An EMT from Qalqilya told us:

« Life is very difficult in Qalqiliya, my friends envy me because as an EMT I can get out of the town and work in Ramallah. Some young men used to go to university in other towns. Nowadays, they have been psychologically affected by the construction of the Wall. It is like living in a prison, it is the biggest prison in the West Bank. My friends always ask me when they can come and see me, to have some fun or just to get out of Qalqilyia. It is a very depressing atmosphere; my friends always look worried. »

– Women

Unemployment, the inability to work inside Israel and the increase in poverty has lead to a role reversal in the Palestinian society. Women are often the only providers. This situation creates tension within the traditional family structure and leads to great psychological pressure. The testimony of a PRCS nurse in Salfit illustrates this point:

“My husband has been unemployed since before the second intifada, I try not to hurt his feeling or offend him because he is sensitive about the fact that I work and he doesn’t. I had decided that I wanted to move to Salfit but I brought it up with him first, I didn’t want him to feel left out. It is difficult for me to deal with all this pressure all the time; I can’t talk about my work at home for fear of offending my husband.”

Women’s participation in society has also been particularly curtailed by Wall construction. This is illustrated by the following testimony of a health program coordinator in a village near Bethlehem

“ In Battir there is no secondary school for females. They have to go to Husan. When the Wall is completed, the chance for girls here to continue education will be very poor. Families will be afraid to let their daughters go through gates and checkpoints. They will prefer not to continue their education and marry them at 16 or 17 years old. Preferably to a cousin or someone from the same village, in order to avoid being separated in the future. Early and inter marriage will increase, thus increasing congenital and hereditary diseases.”

In Wall-impacted villages where MDM, HWC and Merlin work together to provide women and child preventive health services, statistics show that 49.4% of girls marry by the age of 18 years and 46.9% of women marry their first or second cousin.

Options for girls to continue their education, instead of marrying young, and in choosing marriage partners outside of their close family will only worsen once families are completely isolated into enclaves by the finished Wall. This is the case for a 14 year old student from Battir, near Bethlehem.

“I have no life, now we can’t get out from here; it is even difficult to get to Bethlehem these days. I worry about the future”. One of my friends who is 13 years old got married this summer, now she is pregnant.

I asked her why did you get married?. She told me that her father has no money to educate her, so she got married.”

With the Wall, women will be playing a more important, but also a tougher and more demanding role. As they will be cut from most institutions which work on empowering them, their participation in society and decision making will be strongly curtailed. As HWC health coordinator in the South says:

“ The Wall will increase our burden. Here, women have to be father and mother at the same time. They become the providers when the husband can’t work, nurses when you can’t reach the hospital… With all these responsibilities to cope with, they are exhausted. But still, because of the community, women are not the ones who take the final decision. Instead of thinking of how to empower, women will have to think about how to overcome all these obstacles everyday.”

The difficulties faced by families will lead to an increase in domestic violence, including intra-marital rapes and incest.

VIII- CONCLUSION

The testimonies presented in this report show how the Palestinian health care system is affected by the construction of the Wall. This fragmentation appears in the data published by Palestinian medical actors and the ones collected by MDM. Our medical expertise in the field confirms the deterioration of the Palestinian health care system.

Some effects of the Wall emerge right away. If patients don’t have access to their medical facilities or if medical staff cannot reach the facilities to provide medical services the health care system is bound to deteriorate.

The most vulnerable populations such as children, pregnant women, chronic disease or physically disabled patients are likely to feel their health weaken. The risk is potentially greater in enclaves, where the health care system is more affected by barriers.

The socio economic environment also plays an important role in health. Increasing poverty, difficult access difficulties to fundamental needs such as water and food, housing and education also determine the level of health of the population. The mental health of the population is also affected by the construction of the Wall.

The Palestinian health care system used to have a high level. Despite a severe degradation, it therefore still manages to guarantee more or less an access to health care for Palestinians.

The system benefits from an important support from international institutions as well as Palestinian and foreign NGOs. When deficiencies appear, they tend to be coped with palliative solutions. But these coping mechanisms are not a long term solution. The Wall construction is also a process which takes time contrary to other major crises like natural disasters. This relative slowness permits health workers to mobilize resources at their disposal in order to prevent the collapse of the system.

These particularities explain to some extent the resistance of the general level of health of the Palestinians despite the severe degradation of their health care system. However, the system is cracking under pressure and some consequences of the Wall have already appeared. They are still difficult to calculate but they are obvious in the field of mental health and within particularly fragile populations.

The suffering Palestinians we meet everyday along the Wall are the warning signs of a possible health catastrophe. Health indicators are taking an alarming turn. Therefore it is imperative to react in order to guarantee health care and prevention.

IX- MDM’S POSITION ON THE WALL

1- The legal texts

The question of the legality of the Wall under international law has been ruled by the International Court of Justice (ICJ) July the 9th 2004. In its advisory opinion60, the Court recalled all the international legal rules and principles applicable to the Wall.

Regarding the UN Charter, the ICJ reaffirmed that “all Members shall refrain in their international relations from the threat or use of force against the territorial integrity or political independence of any state, or in any other manner inconsistent with the Purposes of the United Nations”61. The Court also referred to the resolution 2625 of the UN General Assembly. According to this resolution, the construction of the Wall constitutes a violation of the prohibition on acquisition of territory by force, one of the basic principles of international law and a correlation of the prohibition of the use of force. Furthermore, the ICJ referred to the general principle of law: the right of self-determination of people.

Regarding International Humanitarian Law, the ICJ recalled that the regulations to the 4th Convention of The Hague of 1907 are part of customary international law. Thus, it is applicable to the Wall. Moreover, the 4th Geneva Convention related to the protection of the civilian population applies62in the occupied Palestinian territory.

The construction of the Wall entails confiscation of land and vast destruction of Palestinian civilian property and will create enclaves. This violates the laws governing the conduct of hostilities contained in the Hague regulations of 190763. Furthermore, the construction of the Wall changes and will change the nature of the Occupied Palestinian Territory which also constitutes a violation of International Humanitarian law64. As far as International Human Rights Law is concerned, various principles and rules are relevant. The International Covenant on Civil and Political Rights, the International Covenant on Economic, Social and Cultural Rights and the International Convention on the Rights on the Child are to be respected. The construction of the Wall restricts the freedom of movement of the Palestinians, their right to work, their right to health, their right to education, their right to an adequate standard of living and the right to choose their place of living65.

The construction of the Wall violates International Law, International Humanitarian Law and International Human Rights. It also constitutes grave breaches of International Humanitarian Law.

2- Our position

As a humanitarian medical organization working for civilian populations, MDM states that violations of International Humanitarian Law have disastrous effects on the physical and mental health of the victims of such violations. MDM states that these violations fuel the incomprehension and violence that are the cause of further violations.

– We are deeply concerned with the consequences of the Wall on the Palestinians’ health as a whole. We acknowledge that Israel has the right to take measures to ensure its own the security. However, in deciding to “build a Wall to prevent attacks” within Israel, the authorities selected the most extreme solution to the problem. The Wall, to the degree that it encroaches on occupied land in the West Bank, is both disproportionate in its impact on the local population health and illegal. It also severely infringes the Palestinian’s right to self-determination.

– As it does not follow the Green Line and encroaches into the West Bank, the Wall blocks access to health and education separates Palestinian communities severs social and economic links, leading the population to migrate. The legitimate right of Israel to security on its borders should not justify the construction of a Wall inside the occupied Palestinian territories.

– The Wall is the most visible component of a network of access obstructions that include fixed and flying checkpoints, trenches, electric and barbed wire fences, closed gates, earthen mounds, roadblocks, curfews, closures, bypass roads, and the permit system. While denouncing the Wall, we also firmly denounce all other factors of occupation which restrict Palestinians right to life and freedom of movement in the occupied Palestinian territories.

– The tracing of the Wall entails serious violations of both International Human Rights Law and International Humanitarian Law.

According to the 4th Geneva Convention of 1949, Israel, as an occupying power, has to ensure, respect and protect the fundamental rights of the Palestinians. Due to the tracing of the Wall Palestinians are forced to move from their land. Thus, they become internal displaced persons. Furthermore, Israel is prohibited under international humanitarian law from transferring members of its own population into the occupied Palestinian territories. As a party to the International Covenant on Civil and Political Rights (ICCPR), Israel is obliged to respect, protect and ensure the rights set out in the treaties to all individuals within its territory or subject to its jurisdiction without any kind of discrimination (right to work, to health, to education, to an adequate standard of living, to food and to family life, right to liberty of movement and freedom to choose its residence…)

3- Our demands

➣ We call on the Israeli authorities :

– To guarantee the free access of the Palestinians and humanitarian / health workers to their medical facilities and to primary water sources

– To ensure the respect and the protection of the rights of Palestinians, according to international humanitarian law

– To take all necessary measures to respect and implement the advisory opinion of the ICJ of July 9th, 2004, which condemns the Wall

➣ We call on the international community

– To ensure that Israel respects and implements the advisory opinion of the ICJ concerning the Wall.

– To ensure that Israel and the Palestinian Authority respect their obligations under international human rights and humanitarian law66

➣ We call on the Israeli authorities and the Palestinian Authority to prevent attacks on civilians and ensure their protection on both sides.

ANNEXES

ANNEX 1: GLOSSARY OF WALL RELATED TERMS

– Seam zone / closed area: areas of the occupied Palestinian territories between the Wall and the Green Line, excluding East Jerusalem.

– Enclave: area of the occupied Palestinian territories encircled by the Wall

– Semi-enclave: area encircled by the Wall with only one access road

– Green Line: 1967 Armistice Line

– Gate: it allows restricted movement through the Wall to Palestinian lands and into Israel. Permits are required for Palestinians in order to pass through a gate. Although each gate has official opening hours, they remain erratic.

– Permit: Palestinians must fill in an application form from the Israeli District Civil Liaison Office (DCL), to get this document in order to enter Israel, the West Bank, Gaza and to cross a gate at the Wall. The passage of ambulances is not subject to this permit system as they need coordination through the health coordinator at the DCL.

Permits for medical needs are subject to a medical investigation in parallel to a security investigation. Even when a permit is granted, its implementation depends on the authority of the health coordinator over the DCL.

– District Civil Liaison Office (DCL): They were created according to the Oslo agreements, which stated that each side (Palestinian and Israeli) would establish and operate these DCL in determined sites in the West Bank and Gaza. In order to deal with any urgent matter arising in the civil affairs field. In reality, security considerations are presented in the agreement as having the potential to affect the movement of Palestinians in any area, and they often lead to the cancellation of permits.

– Bypass roads: roads that enable access to settlements and travel between settlements without having to pass through Palestinian villages.

– Closure: total prohibition on Palestinian residents and goods in the occupied Palestinian territories to enter Israel unless they have a special permit.

– Siege: blocking of the access roads to certain towns and villages or to whole areas by means of staffed check points or concrete blocks, dirt piles or deep trenches.

– Curfew: completely prohibiting people from leaving their homes, it can be a total curfew of the entire town or a partial curfew of a certain part of time for a limited or unlimited duration.

– Coordination: an international humanitarian organization contacts the DCL (according to the geographical zone in question) on behalf of a Palestinian humanitarian organization in order to facilitate passage of ambulances, medical staff and supplies.

– Checkpoint: either a fixed checkpoint: a military barrier at the entrance of major West Bank cities, manned by the Israeli army and/or the border police. It controls the movement of pedestrians and goods; or a flying (temporary) checkpoint, which is placed in a specific location for a specific duration and is manned by the Israeli army and/or the border police.

– Roadblock: a series of 1 meter high concrete blocks used to obstruct vehicle access.

– Earth mound: a mound of rubble, dirt, and/or rocks to obstruct vehicle movement.

– Trench: a ditch used to prevent vehicle access.

ANNEX 2: THE WALL IN NUMBERS

622km: Total length of the Wall when it is constructed67 255 km are completed or under construction.

85% of the plan of the Wall does not follow the Green Line and intrudes into the West Bank. The length of the planned Wall is twice longer as the Green Line.68

11.5% of the West Bank land (excluding East Jerusalem), that is to say 63,120 hectares, will be between the Wall and the Green Line. 69

93,200 Palestinians (63 communities) and 140,200 Israelis (56 Israeli settlements) will reside in these areas.70

200 houses have been demolished due to the construction of the Wall71

25,000 hectares have been confiscated72

124 km of roads are totally prohibited to Palestinians in the West Bank73. 244 km, are partially prohibited, Palestinians being allowed to travel only if they have a special permit. 364 km can be reached only via an intersection where the Israeli army maintains a checkpoint.

More than 700 barriers, other than the Wall, prevent freedom of movement within the West Bank.74

32.7% of all West Bank villages will be denied free and open access to their health care system because of the Wall. This figure will go up to 80.7% in the seam zone and in the enclaves.75

26 primary health care clinics have been isolated by the Wall from the rest of the Palestinian health care system.76

52% of the doctors working in these clinics are delayed from reaching their work place or denied access because of the Wall.77

117,600 pregnant women, including 17,640 high risk pregnant women may not be able to access antenatal care, hospital delivery and postnatal care.78

10,000 chronic disease patients are prevented from accessing essential medical services.79

133,000 children under the age of five may not be able to obtain all the necessary vaccines on time or possibly at all.80

In 2003, 56,755 permits were issued in the West Bank for a population of about 2,313,609 Palestinians81

ANNEX 3: ACTIVITIES OF MDM

IN THE OCCUPIED PALESTINIAN TERRITORIES

– WALL RESPONSE PROGRAM (see I-2)

– GAZA

Since the outbreak of the second Intifada in 2000, the Gaza strip has been the scene of increased violence. The repeated military operations have caused civilian losses, lead to frequent road blocks and prevented access of patients and wounded to medical facilities. MDM, which has been present in Gaza since February 2002, has reacted several times to emergencies by distributing medical kits to doctors living in the areas most exposed to incursions such as Rafah in May 2004. The association has also put in place programs aiming at improving the treatment of medical emergencies by intervening at multiple stages of the emergency process.

– Basic Life Support

The refugee population in the Gaza Strip lives in one of the most densely populated areas in the world and is one of the populations most exposed to violence. In order to improve the knowledge and community attitude to first aid, MDM has put in place a program of “training in actions that can save” in partnership with the United Nations Relief and Works Administration (UNRWA). The first phase entailed training trainers in the topics. The trainers will then share their knowledge in the schools. 76 people from the 14 UNRWA medical centers have already benefited from this training in first aid, cardio pulmonary resuscitation, and teaching methods. After a pilot project in a school of Beit Laya, the method will be extended to 600 other students this year.

– Pre-Hospital emergency medical care

In order to improve emergency medical care (including reducing the effect of delay at checkpoints and difficult access to hospitals), MDM has been training EMTs of the Palestine Red Crescent Society (PRCS).The objective is to improve the level of competence and autonomy in providing medical care and resuscitation. 115 EMTs from 6 ambulance stations (Gaza, Jabaliya, Deir Al Balah, Khan Yunis, Rafah and the Airport), as well as theMawassi enclave benefited from this training. The sessions take place approximately once a month, on topics such as hygiene, the use of medical equipment, burns, acute bleeding, etc. MDM has also equipped two ambulances with intensive care equipment and carried out specific training on the use of the semi-automatic defibrillator. In order to perpetuate this training to a larger public, the program is orientated towards the training of 10 trainers in the EMT schools of Khan Yunis and Ramallah.

– Disaster Medicine

In order to facilitate the coordination of medical assistance in case of catastrophe involving a large influx of victims and in partnership with the Ministry of Health, MDM is considering the possibility of creating a Department of Disaster Medicine, to organize the humanitarian and material resources in response to such an emergency. The project includes disaster medicine training of specialized personnel (26 doctors) in order to regulate pre-hospital and hospital medical care.

– Emergency planning and response

In times of crisis, MDM works in collaboration with other health agencies in assessing and responding to health needs. Such situations generally arise in relation to Israeli military action, such as the large-scale incursion into Rafah in May 2004, or the prolonged closure of Beit Hanoun in July-August 2004.

– NABLUS

Since the operation “Defensive Shield” in April 2002, Nablus has been regularly subjected to incursions by the Israeli army. The military operations often last several days, thus preventing the inhabitants and medical personnel from accessing medical facilities. The fragmentation of society and the level of stress confronting the population lead to many psychological problems.

MDM has been operating in the West Bank since 1999 through a mental health program in partnership with local associations. It aims at improving the quality and the access to psychological and psychiatric care, raising awareness of the population on matters of mental health and reinforcing the competence of the network of existing professionals.

MDM participates in putting in place a community mental health service that will be opened in Nablus in 2005, as part of the Ministry of Health’s national mental health plan funded by the World Health Organization (WHO), the French consulate and the Italian cooperation. Our teams will be in charge of training and supervising the medical and the paramedical personnel at the center. It will offer reception, treatment and follow-up for patients in need of psychological and psychiatric care. Training modules are organized in a similar center in Jenin. MDM will also participate in the national program for training physicians about mental health in Gaza and the West Bank.

In order to prepare the opening of the center and provide mental health care to rural people who have limited access due in part to restricted movement, MDM has put in place a mobile psychiatric consultation in a number of villages and eventually in general hospitals in Nablus. A psychologist, a nurse and a social worker visit primary healthcare centers in 11 villages of the district to train the medical teams and make consultations.

A psychiatrist is also be available for consultation. The theater project is composed of 12 social workers and psychologists trained in psycho drama. A play is presented in two schools of Nablus. It allows the children to transcend the difficulties of their daily life by stimulating their imagination and allows the professionals to identify the children with psychological/psychiatric problems.

Men, who have been particularly affected by the conflict due to unemployment and the breakdown of family ties, are often less capable of expressing their distress. MDM has initiated two conferences to raise the subject with local mental health professionals. A literary cafe has been put in place in order to reach out to men in the places where they gather, and allow them through stories to talk about the things that preoccupy them.

MDM also works on destigmatisation of mental health problems. An information campaign has been launched since September 2004 targeting the Nablus population by using pamphlets and local media to raise awareness of the general public.

NOTES

1 In this report, we have chosen the word “Wall”, as it is the one currently used by the International Court of Justice (cf advisory opinion of the International Court of Justice, 9 July 2004). See context section for more details.

2 See other MDM activities in the oPt in Annex 3

3 Access to health care and protection of the medical services in the Occupied and Autonomous Palestinian Territories, Médecins du Monde, November 2003

5 Figures as of September 2004, UN Office for Coordination of Humanitarian Affairs (OCHA) Barrier report, September 2004

6 Israeli Ministry of Defense at www.seamzone.mod.gov.il./Pages/ENG/questions.htm

7 OCHA Barrier report, September 2004

8 The Israeli coast line is 273 km according to the CIA World Fact book, so the Wall is 2.3 times as long

9 OCHA Barrier Report, September 2004

10 Ibid. This figure excludes East Jerusalem

11 Ibid

12 See glossary in annex I

13 Ibid

14 www.euro.who.int/InformationSources/MtgSums/2002/20030506_1

15 WHO and European Observatory on Health Care systems, 2000

16 WHO, 1998a

17 WHO and European Observatory on Health Care systems, 2000

18 HDIP, 2002

19 OCHA and Btselem

20 MDM Wall Assessment, April 2004, MOH 2001 Statistics

21 The permit is delivered by the Israeli District Coordination Liaison (DCL) at Beit Eil (near Ramallah) following the authorization of the Israeli medical coordinator.

22 See glossary in annex I

23 See glossary in annex I

24 Barghouti, Mustafa et al. Heath and segregation: impact of the Israeli separation Wall on access to health care services, Health, Development, Information and Policy institute (HDIP), 2004. There are more than 500 primary health care centers in the West Bank.

25 Ibid

26 Health Status Palestine Annual report 2003, produced by PHIC, July 2004

27 Major vaccines are Hepatitis B, Measles, Polio, Tetanus and Diphtheria

28 Source MOH, UNICEF, WHO

29 UNICEF data provided for the UN Consolidated Appeals Process 2005 documentation.

30 http://www.unicef.org/infobycountry/opt.html

31 The level of anemia of young children in the West Bank approaches 40%. In the Wall-impacted areas where we work, there is a 44.8% anemia prevalence among children 0-5 years. Source MDM/HWC/Merlin

32 Centre for Arab Genomic Studies, http://www.cags.org.ae/news20031208.html

33 Ministry of health 2002 Annual report and the Palestinian Central Bureau of Statistics (PCBS)1997 census

34 Women and child health survey, occupied Palestinian territories, Merlin, July 2004 and MDM-HWC-Merlin data, July, September 2004

35 MDM, MOH, PCBS survey information, 2003

36 Projection of data provided by MOH, PCBS, HDIP, and MDM

37 See glossary in annex

38 See glossary in annex I

39 Ibid

40 MDM and PCBS

41 See glossary in annex I

42 Preamble to World Health Organization Constitution, as adopted by the Health International Conference, New York, 19-22 June 1946, signed on

22 July 1946 by the representatives of 61 states (official acts of the World Health Organization, n°2, p100) and enforced on 7 April 1948. This definition has remained unchanged.

43 UN Economic and Social Council, Question of the violation of Human rights in the Occupied Arab territories, including Palestine, 8

September 2003.

44 Ibid.

45 Source: World Bank assessment, October 2004

46 See glossary in annex I

47 Ibid

48 see part V-1

49 Impact of the Israeli measures on the economic conditions of Palestinian households, PCBS (July-September 2004)

50 see www.stopthewall.org

51 ICJ advisory opinion

52 see www.stopthewall.org

53 study of the health and environment dept of the salfit district of 2004.

54 The average cost for a water distribution infrastructure is 200 USD per inhabitant. It is 350 USD per inhabitant for a network of evacuation

of used water, in Médecine tropicale, Gentilini, Flammarion

55 Since 1995, the West Bank is divided into three areas, each with distinctive borders and rules for administration and security controls:

– Area A: the Palestinian authority has full responsibility for internal security, public order and civil affairs

– Area B: the Palestinian Authority controls all civil authority but security remains under the control of Israel.

– Area C: Israel has full responsibility on security.

56 In July 2004, a total of 1,425 households living in proximity of the Wall reported that they had changed their place of residence, in Impact of the expansion and annexation of the Wall on the socio economic conditions of Palestinian households, PCBS, July 2004

57 90% compared to 75% in other areas, in Source: A study on the Psychological Implications of Israel’s Separation Wall on Palestinians, Palestinian Counseling Center, June 2004

58 Ibid.

59 92% of children interviewed by Save the Children in Qalqiliya District enclaves said that “the Wall made them feel more afraid.” In the words of one child, “This wall is a prison. It was safe living here before we had this wall, but now it is fear and terror,“ in Living Behind Barriers: Palestinian Children Speak Out, Save the Children UK and Sweden, March 2004, p. 10.

60An advisory opinion is only consultative and not binding as such on the requesting bodies.

61 See article 2 § 4 on the UN Charter.

62 Israel considers that the 4th Geneva convention is not applicable to the occupied Palestinian territory.

63 See articles 23, 46 and 52 of the Hague regulations.

64 See article 49§6 of the 4th Geneva Convention.

65 See article 12 § 1 of The International Covenant on Civil and Political Rights. See also the International Covenant on Economic, Social and Cultural Rights and the International Convention of the Rights of the Child.

66 Article 1 common to the 4 Geneva conventions reads as followed “The High Contracting Parties undertake to respect and to ensure respect for the present Convention in all circumstances”.

67 OCHA Barrier report, sept 2004

68 Ibid

69 Ibid

70 Ibid

71 Source: Israeli Committee against House demolition

72 ICJ opinion, 9 July 2004

73 Betselem, August 2004

74 OCHA,

75 OCHA and Betselem

76 Barghouti, Mustafa et al. HDIP report, 2004

77 Ibid

78 MOH 2002 and PCBS 1997

79 MDM, MOH, PCBS Survey information 2003

80 Health status Palestine Annual report 2003, PHIC, July 2004

81 during 2003 up to September 2003, in The bureaucracy of occupation, joint report Machsom Watch and PHR-Israel, May 2004