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Rapporti sulla situazione sanitaria


Medicine Under Attack

Critical Damage Inflicted on Medical Services in the

Occupied Territories:

An Interim Report

April 4, 2002




In recent months, critical damage has been caused to medical services in the Occupied Territories. Infringements of human rights in the field of medicine have occurred throughout Israel’s occupation of the Territories, and particularly since the outbreak of hostilities in September 2000. However, after Israeli security forces entered the Palestinian cities (Jenin and Tulkarem at the beginning of March, and again recently), we have reached an unprecedented low in terms of disrespect for human life and gross violation of medical neutrality. Before Israel entered the Palestinian cities, the infringements were mainly the result of the policy of imposing internal closures, manned checkpoints and physical roadblocks in the Territories. This led to delays in the passage of sick people, women in labor and medical personnel at the checkpoints; in some cases, passage was completely impossible. Fatalities caused in these conditions reflected the high price paid for this policy. The responses of the IDF and the security forces to complaints against this policy showed that the authorities failed to respond seriously to issues in the medical sphere, despite their repeated promises to “clarify the procedures” ensuring the passage of sick persons and medical personnel.


After the IDF invaded the Palestinian cities, infringements became even worse, leading to the almost total paralysis of medical services. Several grave incidents in which medical personnel came under fire reflected the deteriorating situation. On March 4, 2002, a Red Crescent ambulance carrying three crew members and a physician set out for Jenin refugee camp with the goal of evacuating injured persons. The departure of the ambulance was coordinated with the Red Cross and the Israeli Civil Administration. Despite the coordination, the security forces opened fire on the ambulance, which exploded. Dr. Khalil Suleiman was trapped in the ambulance and burned to death. The other occupants of the vehicle were able to jump out, thus saving their lives. All three sustained serious burns. There was no-one in the ambulance other than the medical personnel. The announcement of the IDF Spokesperson that the explosion was caused by hidden explosives was contradicted by a later announcement by the IDF Spokesperson claiming that the explosion had been caused by an oxygen tank. A few days later, on March 8, 2002, the securities forces opened fire on an UNRWA ambulance in the Tulkarem area. As the result of the firing, the driver Kamal Muhammed Salem was killed and two crew members were injured. At the same time, a Red Crescent ambulance also came under fire; the driver Ibrahim Muhammed Sa’ada was killed and two crew members were injured. In both cases, the departure of the ambulances had been coordinated in advance.


“[I feel] betrayed by the behavior of the IDF, which has willfully and brutally trampled on the rules of the Geneva Convention… I was shocked by the fear I saw in the eyes of the ambulances drivers. It is sad.” The Head of the Red Cross Delegation to the Occupied Territories and Israel, René Kosiernick (Ha’aretz, March 20, 2002), when asked to speak of what happened to the [Palestinian] crew members hit by the IDF, stated that they had been murdered.


The apologies offered by the security forces are shameful, and place the blame on the alleged use of ambulances to carry wanted persons and ammunition. No evidence has been offered for this sweeping allegation. The single case publicized by the security forces cannot be taken as the rule; this incident was condemned by the Palestine Red Crescent Society (see the attached statement).


The Invasion of Ramallah and Other Palestinian Cities

In recent weeks, following the invasion of Palestinian cities, PHR-Israel has received dozens of complaints reflecting grave injury to medical services: ambulances, hospitals, medical personnel, the evacuation of the injured, the transfer of the sick and the provision of food. Existing infringements, such as delaying and preventing the passage of sick persons and medical personnel, were exacerbated still further and new infringements were seen, including shooting at medical personnel and shelling hospitals. Below we present the principal infringements in the medical sphere, with reference to the international conventions providing protection against such infringements. The cases reported below are only examples – dozens more cases have been reported to PHR-Israel and processed by the staff members over the past week.


Destruction of Civilian Life

Since the Israeli security forces took control of the cities, the infrastructure of the Palestinian Authority has been completely paralyzed. This situation prevented the operation of civilian mechanisms vital for everyday life. Such conditions have always typified armed conflict and occupation and are addressed in international law:

Art. 43. The authority of the legitimate power having in fact passed into the hands of the occupant, the latter shall take all the measures in his power to restore, and ensure, as far as possible, public order and safety, while respecting, unless absolutely prevented, the laws in force in the country. (Convention (IV) respecting the Laws and Customs of War on Land and its annex: Regulations concerning the Laws and Customs of War on Land. The Hague, 18 October 1907, ANNEX TO THE CONVENTION : Regulations respecting the laws and customs of war on land #Section III : Military authority over the territory of the hostile state.)

Art. 18. Civilian hospitals organized to give care to the wounded and sick, the infirm and maternity cases, may in no circumstances be the object of attack but shall at all times be respected and protected by the Parties to the conflict.

Art. 19. … The fact that sick or wounded members of the armed forces are nursed in these hospitals, or the presence of small arms and ammunition taken from such combatants which have not yet been handed to the proper service, shall not be considered to be acts harmful to the enemy.


In reality, however, hospitals have become the targets of various forms of attack, reflecting a perspective that denies any special protection to medical institutions. Tanks have been deployed alongside a large number of medical institutions, including Red Crescent stations, the government hospital in Ramallah, the Medical Relief center in Nablus and others. Sick persons are denied free access to these medical centers and the departure of ambulances is prevented.


On March 31, 2002, at 10 pm, security forces accompanied by dogs undertook a search of the Arab Care center. We were informed that the medical staff, physicians and nurses were taken into one room and their hands tied behind their backs. Staff were prevented from making telephone contact with anyone outside the hospital. One of the members of the medical staff managed to call a member of the staff of PHR-Israel, Salah Haj Yahya, and to provide these details, which were confirmed by a representative of the Red Cross to whom I spoke. We were later informed that a magnetic disk had been taking containing the personal and medical details of all patients hospitalized at the hospital.


On the night of April 3-4, the government hospital in Jenin was shelled and surrounded by tanks. The supply of oxygen, water and electricity has been disrupted and the north-facing windows shattered. At 9:30 pm on April 4, Dr. Nader Rashayed informed us from inside the hospital that the staff and patients were crowded on the internal staircase of the hospital, sheltering from the continuous shelling and firing. The 35 patients at the hospital were joined by 14 injured persons.


On April 4 at approximately midday, the Israeli security forces entered the Red Crescent maternity hospital in El-Bireh. Some twenty five soldiers entered the building, and roughly the same number stood in the courof the hospital. The soldiers gathered together all the workers and patients in the hospital, including women who had given birth and nborn babies aged between 3 and 10 hours. The soldiers subsequently demanded that the director of the hospital, Dr. Auda Abu Nahla and another staff member accompany them as they searched the hospital rooms. When unable to open doors, the soldiers broke them down with large metal bars. The soldiers also entered the surgical theaters, the treatment rooms for premature babies and the delivery rooms.


At a later stage, all those present in the hospital were concentrated in the entrance area close to the information desk and a process of humiliation began. Some of the soldiers photographed themselves with the group, while they laughed among themselves. About seven of those present, including the director of the hospital, were asked to stand to one side. Their eyes were bound and their hands tied behind their backs, after the soldiers removed their robes and their Red Crescent emblems. Dr. Abu Nahla and a cleaning worker named Haled were then released. The remaining Palestinians were taken to an armored troop carrier and the soldiers left the hospital, after some two hours.


Injury to Medical Personnel and the Operation of Ambulances

Medical personnel, particularly those staffing ambulances, inevitably find themselves moving through cities at the same time as the IDF " either in response to urgent calls to evacuate the injured, or in response to “routine” but no less vital calls: births, cardiac arrests and so on. It is therefore inevitable that ambulances will come into contact with the Israeli security forces. The numerous cases of attacks on these staff reflect a lack of attention and the absence of clear policy protecting medical staff in the course of their work. Here, too, international law explicitly states (in the Fourth Geneva Convention) that:

Art. 20. Persons regularly and solely engaged in the operation and administration of civilian hospitals, including the personnel engaged in the search for, removal and transporting of and caring for wounded and sick civilians, the infirm and maternity cases shall be respected and protected.


The World Medical Association has also discussed this matter and explicitly determined that:


“The members of medical and auxiliary professions must be granted the protection needed to carry out their professional activities freely. The assistance necessary should be given to them in fulfilling their responsibilities. Free passage should be granted whenever their assistance is required. They should be afforded complete professional independence.” (Regulation in Time of Armed Conflict, WMA 1956, 1957, 1983 “Rules governing the care of sick and wounded particularly in time of conflict”).


Ambulance crews coordinate their departure to collect sick persons, deliver food and care for the injured with the Israeli security forces, through the offices of the Red Cross. This coordination is time consuming and effectively prevents any possibility of effective and prompt evacuation. Not only does coordination cause delays, but even after these delays ambulances are still stopped, either at roadblocks or by tanks, and are prevented from progressing for many hours and even days. The ambulance crews are treated in a humiliating and violent manner, and each response to a call for help takes place in an atmosphere of terror.


March 30, 2002: Five members of a Red Crescent ambulance crew were arrested by the IDF. The five were arrested while on their way to evacuate a woman in labor from the old quarter of Ramallah (the lower town). The Red Crescent is unaware where the employees are being held. Three of the crew members were seen by a Red Cross representative on March 30, handcuffed and blindfolded in a Ramallah apartment. Since then, however, they have been transferred elsewhere. The ambulance itself was returned to the station by the Red Cross. According to eyewitnesses, this ambulance was stopped by a military convoy and forced to serve as a human shield as the convoy progressed through the streets of Ramallah. The same “use” was made of an ambulance belong to the Palestinian Ministry of Health, whose crew was also arrested.


March 31, 2002: At approximately 8 pm an ambulance from Sheikh Zayed Hospital in Ramallah left for the “Mukta’a” compound with food, medicines and water, after proper coordination. The driver, Sami Hamdan, transferred the supplies to the office of the President of the Palestinian Authority and left the site. While returning to the hospital the ambulance was stopped by tanks a few hundred meters from the building and was not permitted to proceed, despite the fact that the same roadblock had permitted the ambulance to enter the compound. In a conversation with the ambulance driver (at 8:50 pm on March 31), he told me that he had reached a distance of 20 meters from the tanks before they blocked his passage. He left the ambulance with his hands raised and said that he must return to the hospital. The soldiers shouted at him to return via a different route. His efforts to explain that all the other roads were blocked were to no avail. The soldiers fired warning shots in the air in order to force him to retreat. The ambulance was now 500 meters from the tanks and unable to return to the hospital. A further conversation with the driver (at 10:15 am on April 1) revealed that he was still waiting for the Red Cross to coordinate his return to the hospital. In the meantime, he had found shelter for the night with a local family. He was finally released at approximately 3:30 pm, after waiting for some 19 hours.


On April 2, three Red Crescent ambulances departed to evacuate sick and injured persons. The ambulances were stopped by Israeli tanks at 9 am. The crews " including Mr. Younis Al-Khatib, president of the Red Crescent " were ordered to leave the ambulances and to crawl in the rain toward the tanks, a distance of 50 meters. At 7:30 pm the crew was released. Four members of the crew required medical attention. This is not the only case where ambulances have been delayed and their crews “held for interrogation.” This behavior constitutes the use of threats against medical personnel by the security apparatus, which is supposed to provide protection in order that they can carry out their function without fear.


Injury to Sick and Injured Persons and to Pregnant Women

The inability of hospitals and ambulances to provide reasonable medical services for the population constitutes a grave injury to sick persons, including the chronically ill, to women in labor and to injured people, all of whom do not receive treatment within a reasonable period of time. In addition to these infringements, sick people have also been injured directly when their vehicles have come under fire as they attempted to reach hospital. Physical obstacles have delayed or prevented their journey to hospital. All these circumstances are in complete contravention of the protection such persons are afforded under international law:


Art. 16. The wounded and sick, as well as the infirm, and expectant mothers, shall be the object of particular protection and respect.

Art. 17. The Parties to the conflict shall endeavor to conclude local agreements for the removal from besieged or encircled areas, of wounded, sick, infirm, and aged persons, children and maternity cases, and for the passage of ministers of all religions, medical personnel and medical equipment on their way to such areas.


March 31, 2002: At 9:55 pm PHR-Israel received a report from Sheikh Zayed Hospital in Ramallah that injured and killed persons in the center of Ramallah (in the vicinity of Walid Nazer Hospital and the Ramoni and Al-Asira building) are not receiving treatment because ambulances were not allowed to reach the scene. A similar report was received from Dr. Mustafa Barghouti of the Union of Palestinian Medical Relief Committees (UPMRC), and was confirmed by the Red Cross representative in Al-Bireh. The Red Cross representative added that the mechanism for coordination with the Israside had “broken down” during the past few hours, and there was no possibility of coordinating the movement of rescue teams. At 10:15 pm, after I left a message on his pager, Spokesperson of the Civil Administration, Peter Lerner, contacted me and confirmed that there was indeed a “mess.” In contrast, the Assistant to the Government Military Secretary, Mr. Yossi Lahmani, with whom I spoke at 10:50 pm, characterized these facts as “despicable Palestinian lies.” However, the facts were confirmed in a conversation with the Spokesperson for the Coordinator of Operations in the Territories, Ofir Hacham, who blamed the “far from simple situation in the field” for the fact that ambulances were unable to arrive. According to reports, ambulances were eventually permitted to enter the area at about midnight, but were only able to evacuate the dead, since the injured had been taken by the IDF.


On April 4, 2002, the Red Crescent station and the ambulance station of UPMRC in Nablus were surrounded, with the result that the movement of ambulances was completely paralyzed. In a conversation with PHR-Israel, Dr. Ghassan Hamdan of UPMRC stated that on attempting to depart in response to an urgent call, soldiers in tanks ordered him to return. The entire staff of UPMRC had taken shelter in the building. He stated that there was no fighting in their vicinity, yet the tanks and guns were still firing. In another conversation at 11 am the next morning, Dr. Muhammed Karaina reported that he was at home, along with a person named Dweikat who had been injured by machine gun fire and was suffering from open fractures and severe bleeding. Dweikat had been injured at 11 pm the previous night, but despite his call for help no ambulance arrived. Dr. Karaina came on foot from Askar refugee camp, but could offer the patient no more than infusions. Another injured person was lying in the street a few meters from his home, but Dr. Karaina was unable to reach him. The man lay bleeding for several hours before he passed away. Dweikat was eventually evacuated by a Red Crescent ambulance on the evening of April 4, approximately one whole day after he sustained his injuries.


Dialysis patients cannot reach hospital. Coordination and numerous contacts are required in order to find solutions. After the passage of ambulances was stopped for two days in Bethlehem, preventing any possibility of reaching hospital, passage of ambulances was finally restored on April 4, albeit with numerous restrictions and protracted coordination. Five patients were able to reach hospital and receive treatment. In Tulkarem, however, not a single dialysis patient has been able to receive treatment. If the movement of ambulances is not rapidly restored, the lives of some 40 patients in an around Jenin will be jeopardized. Pregnant women are also unable to reach hospital: PHR-Israel has already heard of several cases in which women who were scheduled for caesarian sections were unable to reach hospital after entering labor.


The Response of Professional Medical Bodies in Israel

Faced with the gross violation of medical neutrality and critical damage to medical services in the Occupied Territories, medical organizations in Israel have reacted with silence at best and collaboration at worst.

Magen David Adom: Professional Betrayal

Magen David Adom, the Israeli national ambulance company, remained silent in the face of the grave attacks on ambulances, and failed to express solidarity or demand that ambulance crews be protected. Following a protracted propaganda campaign by the Israeli security forces against the Red Crescent, alleging that ambulances are being used to transport weapons and armed activists, Magen David Adom broke its silence by issuing a condemnation of the Red Crescent, which it accused it of the illegal use of ambulances. Magen David Adom accepted all the claims of the IDF (see enclosed announcement). Moreover, after the president of the Palestine Red Crescent was beaten and detained for hours by the security forces, the president of Magen David Adom, Dr. Moshe Malloul, made no effort to express solidarity with his Palestinian counterpart.


PHR-Israel believes that such grave violations of international law and the distress faced by patients and physicians alike in the Occupied Territories demand a forceful, rapid and unequivocal response. PHR-Israel urges Magen David Adom to retract its sweeping allegations against the Palestinian Red Crescent " allegations that jeopardize the work of ambulance crews and even their lives.


The Israel Medical Association: All quiet while the guns roar

Medical crews are gravely injured; physicians are prevented from working safely to help their patients; hospitals are shelled; and medical personnel are killed while performing their duties " yet the Israel Medical Association remains silent. Recently, after numerous calls by PHR-Israel, a forum was convened to discuss the position of the IMA in the face of the attacks on health services in the Territories. After almost two years of conflict, including worsening infringements in the health sphere, the IMA failed to express even once its solidarity with its colleagues. We believe that the IMA should adopt an unequivocal stance; as the representative body of the medical establishment in Israel, this might go some way to correct the deterioration in the behavior of the Israeli security forces toward Palestinian health and rescue services. Given the severity and scope of these incidents, the IMA must act immediately, unequivocally and clearly to condemn injury to hospitals, ambulances, medical personnel and sick persons. To adopt any other position would be to betray the IMA’s mission, and would jeopardize the IMA’s membership of the World Medical Association.



PHR-Israel Demands an Immediate End to Attacks on Medical Institutions and Crews

l Ambulances responding to urgent medical calls should be allowed to move freely.

l Ambulances held by the IDF should be returned and the removal of ambulances from service prevented in the future.

l The Israeli authorities should permit the delivery of medical supplies and ensure that hospitals can respond effectively to the emergency situation. There is no justification for jeopardizing the supply of oxygen for patients.

l Medical personnel, sick persons and women in labor must be permitted to pass through roadblocks.

l Medical personnel, medical institutions and those hospitalized therein should not be attacked.

l Immediate assistance should be provided by all available means to assist the injured and sick.

l The Israeli government must ensure the supply of food to residents under military occupation who are unable to secure provisions due to restrictions on freedom of movement and protracted curfew.


In addition, the authorities should announce the location and condition of all detainees, particularly medical personnel. The absence of medical workers not only raises concern for their well-being, but also gravely impairs the functioning of medical services and constitutes a form of threat against their colleagues.

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