The impact of occupation and siege on health

The impact of occupation and siege on health and human rights in the OPT Alice Rothchild Lori Rudolph Marya Farah Peter Cook

Focus on Gaza Presented by Alice Rothchild, MD Obstetrician/Gynecologist Author and Filmmaker Jewish Voice for Peace

“ 3. The Occupying Power shall afford civilian medical personnel in occupied territories every assistance to enable them to perform, to the best of their ability, their humanitarian functions. . ” The First Additional Protocol of the Geneva Conventions, Article 15

Health care in the West Bank and Gaza (“fragmented and incoherent” Lancet) Population of >4. 75 million people Ministry of Health United Nations Relief and Works Agency (care for refugees, approx. 2. 2 million people) Nongovernmental organizations (NGOs) Private providers Role of Israeli government

Who is in charge? Health outcomes worse than in Israel 1948 -1967: Egypt & Jordan 1967 -1981 Israeli military control: public health, minimal investment 1981 -1993 Israeli Civil Administration, referrals to Israel, growth of NGOs

1993 Oslo Accords, PA “in charge” But under Israeli military control, no control over water, freedom of movement, import of meds, specialty training Complex permitting and authorization system Fragmented failing system, worse after 2000, Second Intifada, Separation Wall, attacks on medical personnel & infrastructure Aida Camp, Bethlehem

1948 UNRWA REFUGEE CAMPS Multigenerational trauma

Continued challenges to health care system Tightening of all restrictions Psychological and & environmental trauma Medical complicity in torture of prisoners Policy of “dedevelopment” Repeated assaults (Gaza-2009, 2012, 2014) Factional violence & discord Northern Gaza 2015

The Lancet 2009: The Lancet Palestinian Lancet published a Health Alliance (LPHA) established Series of five reports Major pushback about health in the 2015 occupied Palestinian 700 medical prof. territory, 37 Concerned international Academics researchers, of whom Group 19 were based in the OPT

Focus on Gaza: War in 2014 Shejaia- “sterilized area” 2015 Khan Yunis 2015

Post 2014 Gaza Invasion Killed: Israel 74, 66 soldiers, 4 civilians, 1 unknown, 500 injured, 100 civilians Killed: Gaza: 2131, 279 armed resistance, 1500 civilians (257 women, 500 children, 370 unknown) 10 -12, 000 injured, >110, 000 homeless, 450, 000 no water, 220 schools damaged, 18, 000 houses destroyed, 40, 000 damaged, 1000 children with permanent disabilities, >1500 orphaned, 370, 000 children in need of direct psychological support for consequences of trauma and war 20, 000 tons of explosives dropped on a strip of land 6 x 26 miles in 7 weeks 10 tons max shot from the Strip into Israel

2014 UN: $1. 4 billion in direct and indirect damages and $1. 7 billion in economic losses.

Major challenges-Gaza Diabetes & hypertension Childhood food insecurity PTSD & depression Lack of potable water Rising birth defects Siege, restrictions (permit for collaboration) Rift Hamas & Fatah Hamas & IDF violence Khan Yunis 2015

Current challenges - Gaza Explosive remnants of war Lack of international funding Unpaid MOH salaries Lack of essential drugs and medical supplies Delays in surgery and dx outside of Gaza Shejaia 2015

Erez – Gaza exit/entry Gaza: IDF/COGAT (Coordinator of Government Activities in the Territories (or COGAT ) Imagine ¾ of a mile on stretcher, in pain, sick with cancer, child without a parent

What is different in 2017? Restrictive siege continues Food insecurity Severe land restrictions Hamas/Fatah dysfunction Some rebuilding, severe shortages of material continues Erratic electricity 3 -12 hrs per day 95% of water not drinkable Severe shortages of medicine & equipment Cement!

Human rights worker 2017 The most vulnerable have basic services, food, water filters, some psychological interventions and assistance to children, but people are basically hanging on and unable to be independent. 18, 000 homes are still flattened 55, 000 people are waiting for their homes to be rebuilt “Our problem is politics, but it presents as a humanitarian crisis. ”

Gaza Community Mental Health Program: training and service Dr. Yasser Abu-Jamei, executive director “I feel crazy, but I come to work every day. We have 1. 9 million crazy people. ” 2015 51 days of intense fear, insecurity, death, staff mobilized High level of trauma, political, environmental catastrophe, no coping strategies, no hope, continuous PTSD: frequent relapses 2017 Lost 28 family members “I cannot offer patient something I cannot have for myself. ”

The Gaza Community Mental Health Program Deir al Balah Community Center Dr. Amal Bashir, only female psychiatrist Art therapy for PTSD, 34 6 -14 yo, 24 cured

The Gaza Community Mental Health Program Deir al Balah Community Center- 300 drawings

The Gaza Community Mental Health Program Deir al Balah Community Center

So you killed my child, you think you are strong?

The Gaza Community Mental Health Program Deir al Balah Community Center

The Gaza Community Mental Health Program Deir al Balah Community Center

The Gaza Community Mental Health Program Deir al Balah Community Center

2017 GCMHP child therapy continues

GCMHP new building -2017 Psych evaluation and therapy Telephone hot line Outreach to schools, mediation programs, counseling Education for school counselors Training programs for psych and medical students Post graduate research and diploma program Human rights work

Aisha Association for Woman and Child Protection (north): 2015, 2017 Intersections between war, patriarchy, psychological illness, domestic violence and the cultures that make this all possible “What Israel did in this war, they turned a child into a soldier and women became unafraid of anything. ”

El Wafa Rehabilitation Hospital 2014 Before After

El Wafa Rehabilitation Hospital Inside after bombing 30 yo modern facility: comprehensive rehab Repeatedly bombed Appealed internationally 8 international “human shields” Nighttime emergency evacuation, no electricity, lights, patients carried in sheets Almost total loss, 19 clinics destroyed

El Wafa Rehabilitation Hospital Share with elderly care home, Zahar City, all donations, 20% of staff lost their homes Dr. Basman Alashi, director drone attack

El Wafa Rehabilitation Hospital Hamad al Reify, 10 yo, missile to C 2, most of family killed

El Wafa Rehabilitation Hospital Dr. Basman: “Another part of the tragedy, of the siege: killing the victim is part of the crime but also forbidding the victim to say we are victims and are human beings. This is a human feeling. ” “Gaza is fine. What you see from the outside, it looks devastated. But if you live among the Gazans, you won’t leave. I choose not to return to America [where he lived for a number of years]. We are human. I am born here. You don’t have a choice where you will be born, but I have a choice for whom I am. ”

Breast cancer surgeon May 2016 Al Ahil Hospital Gaza - Philippa Whitford Lack of critical meds, including chemotherapy, interruption of treatment dues to lack of drugs. Radio isotopes used in bone scans or for guided biopsy of axillary lymph nodes are forbidden entry into Gaza despite having no potentially dangerous application. Gaza’s surgeons are prevented from travelling out to attend conferences or further develop their skills, freezing surgical practice many years behind the rest of the world. A Harvard Medical School study has shown that five-year survival rates for breast cancer patients are as low as 30 -40%, compared with around 85% in England. https: //www. theguardian. com/commen tisfree/2016/may/18/breast-cancergaza-women-struggling-vital-treatment

Gaza consequences continue unabated Radiotherapy completely unavailable. Need permit from Israel to travel to hospitals in East Jerusalem. Application is time-consuming, patients must cover the cost of their own transport and accommodation. 2/16 World Health Organisation, > 28% of those applying for permits to travel out for treatment were either denied or received no response to their applications. Vast majority of women having full mastectomies and lymph node dissection, which would be deemed unnecessary in the UK or US

Gaza “When you are living in hell, and someone turns up the heat a little, it doesn't change much. You're still in hell. ” Rajaie Batniji, Searching for Dignity, The Lancet Volume 380, No. 9840, p 466– 467, 4 August 2012 Khan Yunis 2015

Human Rights Watch (banned from Israel) Jan. Oct. 2016 I/P Palestinians killed 11 & injured 131 Israelis Israeli security killed 94 & injured 3, 403 Palestinians PA & Hamas, multiple human rights violations, 4 executions in Gaza 20 rockets from Gaza: PCHR: 87 incidents of Israeli shellings, shooting, incursions, detentions in August 2016

What is the role of a clinician or solidarity activist or a humanitarian worker in a conflict situation? • • Heal the patient Heal the society Bear witness, see the human face Use listening and diagnostic skills to increase understanding • Use lens of health care and human rights to investigate and report on difficult areas of conflict: apartheid, torture, ethnic cleansing

Banksy: Wall in Gaza City