The Social and Political Determinants of Health Care: i.e. Don’t get Sick While Palestinian – Alice Rothchild in Palestine and Israel, part 3

June 13, 2014, East Jerusalem

So this is my current understanding of a fragment of Palestinian health care, (take a deep breath and suspend any concepts you may harbor regarding the right to health):

A Palestinian family calls an ambulance in East Jerusalem, the call goes to the Magen David Adom, (Israeli ambulance service which is by the way, bound by international agreements).  If the MDA determines that this is a “high risk” neighborhood, they demand a police escort and will not enter the area until the police arrive. The (Palestinian) Red Crescent ambulance (they are not allowed to use Palestinian in their title in East Jerusalem and are also tracked by GPS) can also be called directly but that is a different not-so-well known number. If the police do not come, then the Red Crescent is called, but if the situation is determined to be too dangerous, depending on the location, the Palestinian Medical Relief Society ambulance is called.

Rothchild T02025But PMRS ambulances are based in Al Bireh on the West Bank and must pass through check points and inspections and cannot reliably enter East Jerusalem. Palestinian ambulance drivers must have permits to drive the ambulance and personal permits to enter East Jerusalem; the permits last six months and they are often given with dates that do not entirely overlap, so there are months when the drivers are unable to work.  Palestinians in need of critical care from the West Bank face huge barriers, often have to walk (OK imagine chest pain, leg fracture, bleeding wound, emaciated and weak from cancer, and walking) across checkpoints or be transferred by gurney between two back-to-back ambulances at a checkpoint. (I have seen this with vegetable produce, it can ruin a shipment of tomatoes, but human beings?) A Palestinian living in East Jerusalem is covered under Israeli insurance which does not pay for the Red Crescent ambulance which is often the only one that is able to come, thus the ailing patient (should he or she survive) is also out 150 shekels for the crime of being sick while Palestinian in a racist society.

Ambulances get to Jewish Israelis in an average of seven minutes.

In the case of a motor vehicle accident in the West Bank, ambulance pick up is determined by the identity of each victim; Magen David transports the Jews (i.e. settlers), Palestinian Red Crescent transports the Christian and Muslim Palestinians. (The unaffiliated I suppose are clearly out of luck.) But if the doctor determines that the Palestinian needs high level care that is only offered in East Jerusalem, the patient is transported to Kalandia checkpoint where a “humanitarian line” is intermittently open, there are huge traffic jams, and an East Jerusalem ambulance is supposed to meet the patient there for a back-to-back transfer, if appropriate permits are obtained which are ultimately determined by the Shin Bet, the Israeli General Security Services.

These medical decisions are reportedly made by the Israeli health coordinator, Dalia Basa, an Iraqi Jew who speaks some Arabic, who has worked in the West Bank since the 1970s, and holds immense power around issues of patient permits. There is another COGAT (Coordinator of Government Activities in the Territories) which is by the way, under the Ministry of Defense, for the Erez checkpoint in Gaza.  The barriers to obtaining permits also include lack of phone availability, inadequate communication with Israeli hospitals, broken FAX machines, the moods of young Israeli Defense Force soldiers or privately hired security (sometimes referred to as thugs) at checkpoints who are the ultimate arbiters of passage and who sometimes do security checks (even on ambulances and UN cars which is illegal) and sometimes don’t.  I am told that these 18 to 21-year-olds with large guns and no medical knowledge decide if a case is medically “severe”: Is there blood? Burns? Is the woman in labor or just “fat”? The sister of a friend, in labor with a real pregnancy, when faced with the obstacles at the checkpoint to Jerusalem, just gave up, turned around, and delivered in Ramallah rather than face the risk of a dangerous checkpoint delivery.

Forgive me if I sound angry. It is stunning what one can learn just listening to health care providers and administrators chatting over a cup of thick Arabic coffee in an office in East Jerusalem.  There are so many injustices, some imposed by occupation, racism, fear, and some by internal dysfunction.  There is a growing drug problem in East Jerusalem (think poverty, hopelessness, no police protection or functional court system, dealers running out of an Israeli crime network), currently mostly young men on heroin and three small NGOs working on drug rehabilitation. Abu Dis, (a neighborhood of East Jerusalem divided by the separation wall), just developed its first forensic center and one is now just developing in Ramallah, so solving crimes is still a bit of a mystery.

Jerusalemites pay the same taxes as West Jerusalemites and get minimal to no municipal services.  There is not enough garbage collection, rare playgrounds, and until two months ago, Palestinians did not even have addresses! There are now apartment numbers and street names, but they are not the names that people have used for years and everyone has a post office box anyway. In Beit Hanina, a neighborhood in East Jerusalem, the water supply is connected to Ramallah but the sewer is connected to the Israeli system.  Recently residents were hit with a bill for seven years of sewer service charges. The municipality charges an occupancy tax (Arnona) which is based on the size of the houses.  Arab houses tend to be bigger, house large extended families; Jewish Israeli houses tend to be smaller, more urban. As a consequence Arab families have been penalized with greater taxes since 1967.  As one public health worker noted, “This causes hypertension.” I wonder if this qualifies as torture by sheer constant aggravation.

The Association for Civil Rights in Israel recently documented the absence of mental health clinics in East Jerusalem, there was also a petition about the inadequate number of post offices in East Jerusalem. These deficiencies do not happen by accident. One woman involved in health advocacy noted, as Jerusalem, (and Israel as well with its expanding ultra-Orthodox population and steady flight of the alienated and disenchanted), grows more traditional, more tribal and family based, both for Jews and Palestinians, patriarchy grows stronger and women pay the price. There is a “de-modernizing influence,” a constriction of the space in which women can breathe, grow, and explore. When civil law does not adequately protect the population, people turn to social family law. I see so many ramifications to these distressing trends, from the health of the individual to the health of the overall society.

And in case you forgot:

Geneva Convention IV, Article 56

The occupying power has the duty of ensuring and maintaining with the cooperation of national and local authorities, the medical and hospital establishments and services, public health and hygiene in the occupied territory… Medical personnel of all categories shall be allowed to carry out their duties.”

International Human Rights Law

“The Right to Health is composed of four essential, inter-related elements (1) Availability; (2) Accessibility, both physical and financial; (3) Acceptability; and (4) Quality.

CESCR, General Comment No. 14

Where do we begin?

Alice Rothchild MD, is Assistant Professor at Harvard Medical School. She serves on the steering committee for American Jews for a Just Peace- Boston, and has worked with medical delegations to Israel and the Occupied Territories with the AJJP Health and Human Rights Project. She is the author of Broken Promises, Broken Dreams: Stories of Jewish and Palestinian Trauma and Resilience (Pluto, 2007; 2010) and director of the 2013 documentary Voices Across the Divide.

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