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A Special Issue Vol. 19, Number 3 Fall 1989 HEALTH / PAC BULLETIN Health Policy Advisory Center An Epidemic of Violence e Medical Rights Abuses in the West Bank and Gaza Strip Health Policy Advisory Advisory Advisory Advisory Center Center Center Center ince its inception in 1968, the Health Policy Advisory S Center known - as Health / PAC - has served as a unique progressive voice for changing consciousness on domestic and international health priorities. Through the Health / PAC Bulletin and the books Prognosis Negative and The American Health Empire, and in its outreach to a national network of grassroots activist groups, Health / PAC con- tinues to challenge a " medical- medical- industrial complex " which has yet to provide decent, affordable care. A Special Isave Vol. 19, Number 3 Fall 1989 j HEALTH / PAC BULLETIN Health Policy Advisory Ceglur An Epidemic ' of Violence Medical Rights Abuses in the West Bank and Gaza Strip Design Sheila Kwiatek, FlowerGrafix Front Cover Palestinian woman in Balata Camp, West Bank, whose hand was broken by Israeli soldiers. Bill Biggart, Impact Visuals. Back Cover Beita resident, shot in the head by an Israeli settler, dead on arrival at hospital. Neal Cassidy, Impact Visuals. IN THIS ISSUE MEDICAL RIGHTS ABUSES IN THE WEST BANK AND GAZA STRIP Why We Went to Israel Jonathan Fine of Physicians for Human Rights explains why the organization has been monitoring medical abuses in the West Bank and Gaza Strip during the intifada....cossssssesseseeessesesssccsesisessenisienecesestitesseistssessssesste 4 The Casualties of Conflict Excerpts from the Physicians for Human Rights'fact finding - report on medical care and human rights violations in the Israeli occupied territories wc... 7 ... And the Violence Continues Continues Physicians for Human Rights member H. Jack Geiger reflects on the importance of medical rights efforts in Israel and around the world veces 16 The Israeli Government Responds The Israeli government dismisses " The Casualties of Conflict " oe. 18 Despite Our Differences: Israeli and Palestinian Physicians Organize Ruhama Marton, an Israeli physician, describes the efforts of an organization of Israeli and Palestinian doctors to halt medical abuses veces 21 Health Care Under Occupation Moustafa Barghouthi of the Union of Palestinian Medical Relief Committees describes how Palestinian health care workers are providing care under the occupation woocessecsesssssssesessesseesssssseseenseesensstsssessesseeerssersatsssesssseesaiessessnsansennssetes 24 The Israeli Palestinian - Conflict Gail Pressberg of the Foundation for Middle East Peace provides the historical context of the decades - old conflict between Israelis and Palestinians 1.0.0.0... 27 Vital Signs Two labor reporters tell of their unions'struggle over health care .e.sssseeescssee 33 Health Policy Advisory Center 17 Murray Street New York, New York 10007 212 267-8890 / Health / PAC Bulletin Volume 19, Number 3 Fall 1989 Board of Editors Tony Bale, Robert Brand, Robb Burlage, Anjean Carter, Robert Cohen, Celestine Fulchon, Sally Guttmacher, Feygele Jacobs, Louanne Kennedy, David Kotelchuck, Ronda Kotelchuck, Arthur Levin, Cheryl Merzel, Regina Neal, Tammy Pittman, Hila Richardson, Pam Sass, Herbert Semmel, Hal Strelnick, Ann Umemoto, Richard Younge. Executive Editor Joe Gordon Assistant Editor Caren Teitelbaum Staff Editor Ellen Bilofsky 1989 Health / PAC. The Health / PAC Bulletin (ISSN 0017-9051) is published quarterly in the spring, summer, fall, and winter. Second Class postage paid at New York, N.Y. Postmaster: Send address changes to Health / PAC Bulletin, 17 Murray St., New York, N.Y. 10007. The Health / PAC Bulletin is distributed to bookstores by Carrier Pigeon, 40 Plympton St., Boston, MA 02118. Articles in the Bulletin are indexed in the Health Planning and Administration data base of the National Library of Medicine and on the Alternative Press Index. Microforms of the Bulletin are available from University Microfilms International, 300 Zeeb Road, Dept. T.R., Ann Arbor, MI 48106. i MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR, AND SUBSCRIPTION ORDERS should be addressed to Health / PAC, 17 Murray St., New York, New York, 10007. Subscriptions are by $ 35 membership for individuals. Institutional subscriptions are $ 45. 2 Health / PAC Bulletin Fall 1989 Breaking the Cycle of Violence The violence that engulfs the people of Israel and T the Palestinians living under Israeli occupation is all the more tragic because it fuels a cycle of anger and distrust. Each new death or injury further blocks the way to peace and health for both peoples. In February of 1988, the U.S. organization Physicians for Human Rights (PHR) sent four of its members on a fact finding - mission to gauge the health and medical consequences of the Israeli Defense Force's efforts to con- trol the unrest in the West Bank and Gaza Strip. The group's findings revealed a disturbing pattern of abuse by the members of the defense forces. Their report makes clear that the health and medical rights of men, women, and children are being grossly violated. The violations take two forms: excessive use of force, which results in death or injury, and interfering with the sick and injured's access to medical care. To focus attention on these violations, and to help speed their end, we offer major excerpts from PHR's report, " The Casualties of Conflict. " Physicians for Human Rights is a national organization of physicians committed to documenting and stopping human rights abuses worldwide. We are grateful to the organization for allowing us to condense its report and especially to its executive director, Jonathan Fine, for helping us contact the other physicians and peace advocates who gener- ously contributed articles to this special issue. To provide balance, we also include excerpts from the Israeli government's official rejoinder to the " Casualties of Conflict. " In an effort to broaden the government's response, in late July I wrote to the Minister of External Affairs at Israel's Ministry of Health in Jerusalem asking the government for an article clarifying and expanding on its position regarding the issues raised in the report. I later made a separate request for a written response from the health ministry through the Consulate General's office in New York. As of early November, the ministry had not replied. In the final articles, we hear from three writers who are working to bring peace to the region. Ruhama Marton, an Israeli physician, writes about the mutual efforts of Palestinian and Israeli doctors to safeguard human rights amidst the violence. Moustafa Barghouthi, a Palestinian physician, reports on the organizational work of Pales- tinian health professionals who, while providing health services in the face of occupation, are also working to rebuild a national Palestinian identity. Gail Pressberg, the director of the Foundation for Middle East Peace, a non- profit, educational organization, concludes the discus- sions by examining the roots of the violence and advocating one widely discussed approach for ending the conflict. Readers wanting to learn more about human rights abuses in the West Bank and Gaza Strip may be inter- ested in recent factfinding reports issued by the Lawyers. Committee for Human Rights and Amnesty Interna- tional. These organizations, like PHR, play a crucial role in exposing government violations and bringing interna- tional pressure to bear on human rights offenders. As always, health advocates are critical allies in such efforts. -Joe Gordon, Executive Editor X ray - of the head of a Palestinian teenager shows six rubber bullets embedded within the face and neck. The widespread use of rubber bul- lets by Israeli soldiers has seriously injured many people during the intifada. Rights Human for Physicans Fall 1989 Health / PAC Bulletin 3 The CasuALTIES OF CONFLICT Why We Went to Israel Jonathan Fine, Physicians for Human Rights rom the onset of the intifada in December 1987 F until the present, the Israel Defense Force has met organized peaceful protests, stone throwing, and intermittent firebombing by Palestinian youths with the use of live ammunition and other lethal and sublethal weaponry, the intentional beating of many hundreds, the imprisonment of thousands without trial or even the filing of charges, the demolition of homes as a form of collective punishment, forced exile of com- munal leaders, the suspension of educational opportu- nity for most youths, and the perpetuation of many forms of economic, social, and political discrimination. While stones, rocks, and firebombs must be condemned as crude weapons which may cause disabling and even lethal injuries, the disproportionately harsh methods of the IDF have resulted in far greater morbidity and death: to date, more than 500 have died and over 30,000 have been wounded. As the executive director of Physicians for Human Rights (PHR), I visited Israel and the occupied territories in January 1989 to see the health consequences of this conflict through both Israeli and Palestinian eyes. PHR, a national, non profit - organization of health professionals, had sent two prior missions to Israel. Our organization's goal is to focus attention on the health effects of human rights abuses and to bring medical, psychiatric, and public health skills to prevent human rights violations wherever they occur. Since its founding in 1986, PHR has undertaken 22 overseas missions to 11 countries. These include Chile, Czechoslovakia, Kenya, Malaysia, Panama, Paraguay, the Republic of Korea, Turkey (concerning the use of poison gas by Iraq), and the Soviet Union, as well as Israel. In February 1988, PHR sent four physicians to report on the medical consequences of the police and military actions in the West Bank and the Gaza Strip. The mission resulted in our report, " The Casualties of Conflict. " The findings of the PHR team received a great deal of atten- tion internationally. To our knowledge, our mission was the first by a U.S. based - national human rights organiza- tion to Israel's occupied territories since the beginning of the occupation in 1969. In August 1988, PHR sent Dr. Robert Kirschner, - Jonathan Fine, a physician, is executive director of Physicians for Human Rights in Somerville, Massachusetts. _ Israeli soldiers soldiers assist assist a 28- year - old Israeli army reserve soldier shot in the head twice at close range in Bethlehem, West Bank. 4 Health / PAC Bulletin Fall 1989 Cristine Grunnet / Reuters 651-12 THE HE CASUALTIES OF Conflict Deputy Medical Examiner of Cook County, Illinois, to investigate the deaths of two Palestinians in detention and to meet with the chief forensic pathologist of Israel, Dr. Maurice Rogev. However, on that occasion Dr. Rogev refused to see Dr. Kirschner " on higher orders, " and no second autopsies were allowed. Since that time, PHR has revisited the occupied territories to conduct a series of forensic investigations at the request of the families of the deceased and the West Bank human rights organization Law in the Service of Man (Haq Al -). On these occasions, for the first time since the occupation began in 1967, the Israeli authorities allowed independent forensic examina- tions. PHR has also conducted an initial study of the health services and conditions of imprisonment of the thousands of Palestinian detainees. (A report of the prison health mission is to be published by PHR in fall 1989). Why so much attention to Israel? There are many egre- gious offenders worldwide. In fact, during the period of the intifada, many more have been killed in other coun- tries. Virtual genocide has occurred in Somalia, Sri Lanka, and Iraq. The honest answer is that many of us were outraged by the deliberate policy of administering beatings to break the bones of Palestinian detainees, announced by Defense Minister Rabin in January 1988. The brutality struck home. Some of us are Jews; all of us are Americans. Israel, for many of us, has been not only an ally, but part of our Rubber bullets collected in Shatti refugee camp, Gaza, June 1988. extended family. Though we never spoke of it at the time, I think many of us felt a special responsibility to docu- ment these abuses for the world community. Within the organization, we had a brisk debate. Over- whelmingly, PHR board members approved of this initia- tive. Since, a few individuals have criticized our efforts as well as those initiatives of other human rights monitoring groups as " picking on Israel. " It is interesting, however, that no one has ever questioned this organization's motives for sending two missions each to Czechoslo- vakia, Kenya, and the USSR or six to Chile. Once the first mission to Israel was completed, we found ourselves rewarded, not only by Arab Americans - , whom we came to know and respect, but by many other Americans who shared our sense of restless conscience about not speaking out. Remarkably, we found that not one of over 1,400 members and supporters of PHR throughout the United States resigned to protest our actions. PHR is also involved in monitoring human rights abuses in the Arab and Moslem world. We have reported on Iraqi use of poison gas against the Kurds and Syrian imprisonment of scores of health workers, and we are currently investigating the imprisonment and torture of Egyptian opposition figures. We intend to continue moni- toring human rights abuses in both Arab countries and Israel as long as we may be useful. OE Visuals Impact /Reinhard Rick The E CASUALTIES OF CONFLICT The Casualties of Conflict Medical Care and Human Rights in the West Bank and Gaza Strip The following excerpts are from " The Casualties of Conflict: Medical Care and Human Rights in the West Bank and Gaza Strip, Report of a Medical Fact Finding Mission by Physicians for Human Rights, " published in March 1988. This condensa- tion of the 49 page - document is reprinted with the permission of Physicians for Human Rights. The photographs that accom- pany the text, as it is presented here, are not part of the original report. " The Casualties of Conflict " is the work of H. Jack Geiger, MD, Arthur C. Logan Professor of Community Medicine of the City University of New York Medical School; Jennifer Leaning, MD, Attending Physician, Brigham and Women's Hospital, Harvard Medical School; Leon A. Shapiro, MD, Associate Clinical Professor of Psychiatry, Harvard Medical School, Mas- sachusetts Medical Center; and Bennett Simon, MD, Associate Clinical Professor of Psychiatry, Harvard Medical School, Cam- bridge Hospital. The complete report is available from PHR, as are reports of subsequent missions, including reports on human rights viola- tions in detention camps and prisons in the West Bank and Gaza Strip. PHR is located at 58 Day Street, Suite 202, Somerville, MA 02144, (617) 623-1930. Authors'Note: The Historical and Political Background Almost all serious violations of human rights occur in the context of conflict: national, political, social, economic, cultural, ethnic or racial. Whether the conflict involves hostile or competing groups within a single society or conflict between two societies or nations, any investiga- tion of human rights violations must be read in the light of the relevant history of conflict and the broader context in which violations occur. That attempt should neither compromise the investigators'nonpartisan status nor dilute their findings, but it is an obligation of their work. These general observations apply to the Israeli - Pales- tinian conflict, and were very much a part of the planning and the conduct of this mission. Both the Board of Physi- cians for Human Rights and the four physicians who travelled to Israel, the West Bank and the Gaza Strip from February 4 to 12, 1988, were profoundly aware that the current Palestinian " uprising " and the Israeli response to it were but the latest episodes in a half - cen- tury of almost continuous violence, bloodshed, terrorism and counter insurgency - , including three full fledged - wars, violations of every sort, and prolonged occupation. We were reminded constantly, both before our departure, in the field and on our return, of that history and its relation- ship to the attitudes, the behaviors and the events that were the focus of our concern. It is not possible, in this brief preface, to describe all the complex forces and perceptions which are at work in the current conflict. Any attempt to do so would inevitably result in a balance sheet, the accuracy and fairness of which might be bitterly contested by one side or the other and which might ultimately serve only to distract atten- tion from the principal focus of this report. Nevertheless, during our mission and in extensive discussions during the preparation of this report, we were repeatedly made aware of the importance of these competing viewpoints and urged to describe them as an essential aspect of the context in which human rights problems are occurring. Among the Israelis, we found perceptions of a nation and a people beleaguered and profoundly vulnerable, vastly outnumbered and confronted by hostile neighbors committed to their destruction, refused recognition by much of the world and surviving only through its own military strength and determination in the face of contin- uing terrorist assaults. Some of those perceptions are based on a long and harsh reality: more than 40 years of history which are real to every Israeli, and are the prism through which the Palestinian uprising is inevitably seen, although the interpretation of the current hostilities and the definition of an appropriate response varies widely. It is the reason the uprising is viewed by many (though cer- tainly not all) Israelis as a profound threat to national security, simply another stage in the continuing attempt to destroy their country, despite the obvious disparity in military power in the West Bank and Gaza Strip. In this view, the central lessons of the last five decades are that stones are merely the precursors of rockets, force is a nec- essary response, and a policy of intimidation and subju- gation is not merely justifiable but essential. For others, the uprising represents dangerous claims by an enemy to a land they believe, on religious grounds, to be their own. There is also a large and politically active segment of the Israeli population which draws different lessons from the decades of bloodshed, and urges negotiation over issues of land and peace. For this group too, however, national Fall 1989 Health / PAC Bulletin 7 HE CASUALTIES OF CONFLICT security and the maintenance of military strength are focus on the protection of basic rights, is that the proper essential concerns. understanding and explanation of violations does not Among the Palestinians, we heard similarly fierce and proprietary feelings of lands, villages, homes citi- elso s-t constitute their justification. Most things, we know, can be explained; but some things, we believe, must never be or threatened. There was an acute awareness of a large explained away. These include the medical and psycho- population in refugee status, some for as long as 40 years, logical dimensions of human rights violations which are and a parallel awareness of bloodshed extending through several generations and touching almost every family. A growing nationalism on the West Bank and Gaza Strip, a the central concern of our report. Introduction: The Conduct of the Mission strongly felt denial of a basic right of the Palestinian From February 4 to February 12, 1988, our delegation of people to self determination - , and a decision to take their four physicians from Physicians for Human Rights (PHR) fate into their own hands, seem to be fueled by a pow- undertook a fact finding - mission to investigate the med- erful sense of need for political recognition and of effec- ical consequences of civil disturbances and police and 1 tive abandonment by other Arab nations. Terrorism is military actions in Jerusalem, the West Bank and the Gaza overwhelmingly defined as Israeli Strip. state terrorism, and their own vio- The major part of our visit was lence as justifiable attempts at liber- ation. But the central perception, as it was presented to us repeatedly, is of an indefinitely prolonged and intolerable occupation marked by chronic degradation and brutaliza- tion, systematic injustice, an abso- Mediterranean Sea Tripoli LEB Beirut Sidon Nabat Tyre taken up with visiting hospitals, emergency rooms, blood banks, clinics and homes in the refugee camps, Arab villages, towns and cities in the West Bank and the Gaza Strip. Much of that time was spent seeing, examining or inter- lute denial of their own equal status as humans, and an inex- Haifa ISRAEL viewing patients and attempting to assess what we knew best, doctors orable attempt to destroy their community and identity through the confiscation of land, arrests, @ Port Said Tel - Aviv Jaffa Je Gaza at work with patients and the human rights aspects of medical care. In the course of four days of arbitrary detention, collective pun- such field work, we examined and ishment, economic subjugation and discrimination, and the use of mili- tary force. oth sides, in short, believe - NEGEV DESERT interviewed 103 patients, most of them injured within the preceding 24 hours. We spoke at length with officials and staff of the United Nations that what is at stake is B communal and national survival. That belief over- of Sue whelmingly influences the actions and responses of Palestinians and Israelis alike, and pro- vides the context in which human rights problems are occurring. We are aware of other limitations and potential biases in a human rights mission of this sort. The report of an Relief Works Agency (UNRWA) and the leaders of the Union of Palestinian Medical Relief Commit- tees, and made briefer contacts with the International Committee of the Red Cross and the Palestinian Red Crescent. We interviewed the chief Israeli health officer of the Civil Administration, a branch of the Ministry of Defense, in the West Bank, and met with staff physicians, nurses, administrators and other investigation lasting barely more than one week can pre- personnel of the hospitals operated by the Israeli Civil sent a single snapshot in time, inevitably incomplete Administration in Ramallah, Hebron and Gaza City. We despite our best efforts to be both comprehensive and fair. spoke sometimes at length and sometimes briefly with Nevertheless, if it is the product of careful investigation representatives of a broad spectrum of Israeli opinion, and documentation, as we believe this report to be, and if both within the government and private citizens. We it has been compared with the findings of other nonpar- tisan and experienced observers, and examined for con- talked informally to a few Israeli physicians, some mental health professionals, and at length with Israeli Defense sistency with events both antecedent and subsequent - as Force psychologists commissioned by the army to survey we have attempted to do - it can have real value. The overriding insistence of human rights advocates and report on the effects on soldiers of the present distur- bances and the IDF's methods of response. We also spoke must be that there are no circumstances in which the per- with both Palestinian and Israeli lawyers and human sistent, widespread and major violations of human rights rights advocates on issues of human rights violations described in this report are acceptable. The belief that ini- involving injury, medical care and treatment, and met tiated this investigation, with full recognition of the his- with Israeli and Palestinian university professors. torical and political context but with a single minded - We have attempted, finally, to distinguish carefully 8 Health / PAC Bulletin Fall 1989 THE E CASUALTIES OF CONFLICT between the things we witnessed directly, those that we those with more severe injuries. Those with simpler did not observe but believe to be reliably reported, those on which no final determination was possible, and those which we believe are sources of error or have been incor- injuries remained in their camps or villages or had been discharged from emergency rooms after first - aid treat- ment. Among the patients we examined in the camps, 80 rectly reported. We understand that, in the intensely polit- ical climate of Israeli Palestinian - tension and the continually evolving flow of events, no report can be " final, " but the final responsibility for the present report is, of course, entirely our own. The Medical Consequences of " Force, Might, Beatings " Our team spent three 18 hour - days in the West Bank and one day in Gaza City examining people who had been injured in the uprisings, inter- viewing physicians and medical staff, observing medical care, lis- tening to histories and reviewing medical records, X rays - and other documents. We visited the emer- percent of the injuries due to beatings were confined to the arms and hands. In the hospitals, beating injuries included the lower extremities and other sites as well. As a result of beatings, patients incurred either fractures of limbs, soft tissue contusions - deep bruises, lacerations and scrapes, often with bleeding into the muscles - or both. The contusions occurred on the limbs, the upper back and posterior shoulders. In Gaza, each individual patient had been beaten more extensively and a number :. of patients had also been beaten on the head. Among the 62 patients who were beaten there were 67 serious beating injuries. Of the 67, 40 were in the upper extremities, 18 in the lower extremities, and 9 in gency rooms and inpatient units of Mokassed Islamic Charitable Hos- other sites on the body. From gunshot wounds, patients pital in East Jerusalem and three #.. sustained either open comminuted hospitals operated by the Israeli fractures of one or more major occupying authorities: the hospitals bones of the leg, in which the bone at Ramallah and Hebron in the i - is splintered or crushed, with an West Bank and Shifa Hospital in external wound through which Gaza City. We also spent several bone may protrude, or complex hours in the emergency room of internal injuries from bullets Hadassah Hospital at Ein Kerem in entering the abdomen or lower West Jerusalem. back. Of the 26 gun shot - wounds We saw patients and staff at the we saw, 2 were in the upper UNWRA clinics at Jalazone, Kal- (- extremities, 12 in the lower extrem- andia and al Am'ari refugee ities, 8 in the abdomen, flank or camps, and patients of the Union of Judy Janda Impact / Visuals Palestinian Medical Relief Commit- pelvis, and 4 in the head, neck or chest. Eight of the gunshot wounds tees at Jabalia refugee camp. We also Dr. Rustom Nammari, Director of Al had resulted in serious neurological went into homes within the UNRWA Mokassed Hospital in East Jerusalem, deficits. camps and examined injured people who had not sought formal medical care for fear of political reprisal, or were shows X rays - illustrating damage Those hit with rubber bullets rather done to bones by different types of than live ammunition displayed lacer- ammunition used by the Israeli Army. ations, abrasions and contusions of the recovering from injuries incurred ear- face, upper body, arms and legs, and lier in demonstrations or in Israeli army detention centers. some had serious eye injuries. Tear gas injuries we witnessed 24 hours or more after f the total of 103 patients we examined directly, three had severe burns due to a household fire and 100 had injuries related to the uprisings. Of these, 72 had been injured within the previous 24 hours and 28 had injuries which had been sustained during the previous two months of the uprisings. Whenever possible, we reviewed medical charts, operative notes, and X rays -. The majority of the patients we saw were young men ages 15-25, but the list included some children, some pregnant women and some older women. The injuries fell into one of four categories: those inflicted from beatings, from gunshot wounds, from tear gas, or from rubber bullets. Since our survey was predom- inantly hospital - based, our sample is biased towards the time of exposure were limited to those caused by shrapnel from tear gas grenades: lacerations, contusions, or fractures of facial bones or, in one case, a direct blow to the face at short range from a tear gas cannister fired from a rifle. The Systematic Patterns of Injury. Early on, we began to realize that we were seeing a strikingly uniform pattern of injuries, an impression that was later confirmed by a review of all 100 uprising - related cases. One pattern pre- vailed in the West Bank, another even more severe one in Gaza. Three cases from the West Bank will illustrate this pattern: (1) In the emergency room of Ramallah Hospital, we saw three of four members of one extended family who said they had been attacked in their home at noon, Fall 1989 Health / PAC Bulletin 9 Visuals Impact / Bigart Bill Palestinian demonstration tear gassed. Balata when 12 soldiers broke into their refugee camp, West Bank. provoked nor are resisting third floor - apartment overlooking the scene of stone throwing - and accused them of arrest. A highly effective way to break the metacarpal bones is throwing stones from their balcony. The family head, a 32- year - old shopkeeper, told us he had been sitting in his to force a victim to place his palm against a wall or table and then to hit the back of the hand with club or rifle butt. pajamas eating soup when the soldiers broke in and A highly effective way to break the radius in midshaft is " began to beat up the whole family. " He sustained two to forcibly extend the subject's arm, outstretched with mid shaft - fractures of the bones in the back of his right thumb side up, and then strike the forearm from above, hand between knuckles and wrist (the metacarpal bones). hitting downward with considerable force perpendicular One younger relative, about 20 years old, sustained a mid shaft - fracture of his right radius, the larger of the two to the long axis of the bone. We noted also that almost all of these hand and arm fractures occurred on the domi- bones in the lower arm, located on the thumb side of the arm. Another relative, about 15 years old, incurred deep nant side on the right in right handers - , on the left in left- handers. bruises of his upper shoulders, both upper arms, and both forearms. The fourth relative had left the emergency room without being registered. (2) At the UNRWA refugee camp at Kalandia, we examined a 50 year - old. We also noted the significant absence of certain kinds of injuries. We saw no fractures of the collarbones or at the MCP joints the (knuckles), and only one fracture of the ulna (the other bone of the forearm). Almost all of the man with deep bruises on his back and shoulders and a mid shaft - fracture of his right radius. (3) At Mokassed Hospital in Jerusalem, we saw an 18 year - - old youth from the West Bank who had multiple mid shaft - fractures of the metacarpal bones in his left hand and a mid shaft - frac- ture of the left radius. He was left handed - . soft tissue - injuries, the deep bruises with rupture of small blood vessels and swelling, were on the upper back and shoulders and the backs of the arms and legs; we saw no soft tissue - injuries to the chest, the abdomen or the lower back, sites where damage to internal organs can be lethal. In the West Bank, we saw relatively few people who had been hit on the head. Such injuries, in a much more t is important to understand, in non medical - terms, random pattern, would have been expected in free- the significance of this pattern. None of these frac- swinging melees, in people resisting arrest or actively tures, in a pattern that we saw over and over again, attacking others. are of the kind that usually occur when swinging a What does all of this suggest, and why is it important? fist, warding off a blow with upraised arm, or otherwise It suggests a deliberate policy of systematic beating resisting arrest. They are precisely consistent with designed to disable and not to kill, to inflict maximum widespread press accounts and photographs, television damage while reducing the risk of death. It might be easy images and eyewitness reports of deliberate assaults by to regard this as a welcome manifestation of restraint; to soldiers and police, including assaults on people who are us, looking at the flow of patients with similar wounds, it not involved in demonstrations and who have neither seemed more a planned and purposeful form of brutal- 10 Health / PAC Bulletin Fall 1989 THE CASUALTIES OF CONFLICT ization, indiscriminate in choice of victim but precise in choice of injury, adhered to quite consistently at least during the time of our visit to the West Bank. In Gaza, both the extent and the severity of the beat- ings seemed worse. Indeed, the word " beating " does not properly convey the literal pounding and mauling with clubs and other weapons required to produce the injuries we saw. In Shifa Hospital, we saw a 40 year - - old man, admitted 24 hours earlier, who had been beaten by sol- diers and brought to the emergency room semi conscious - , without an appreciable blood pressure. He had fractures in all four limbs: shaft mid - fractures of both bones in his left forearm and one bone in his right forearm, fractures of multiple metacarpal bones in both hands, and fractures of both bones in his right lower leg and both bones in his left lower leg. He also had received 12 scalp lacerations, each 3 to 5 centimeters in length. An examination of his back revealed a continuous area of swollen, bruised and blood- infiltrated tissue extending from the bottom of his shoulder blades to the hips, and from right side to left. We found clinical evidence of right rib fractures and we sus- pected a punctured lung; air had leaked into the soft tis- sues and under his skin from an area around his right collarbone, extending up into his neck and lower face. There was a centimeter 10 - long vertical bruise on his breastbone. Both legs also had deep puncture wounds. We were shown a broken club, found with his body, around which coils of quarter - inch copper wire had been wrapped, and periodically snipped off to leave sharp pro- truding points. Several of the most seriously injured patients we saw had been brought to hospitals from army detention cen- ters, where their injuries had reportedly occurred. On two occasions, young Palestinian men described to us their experiences in such detention centers. They reported pro- longed sleep deprivation; being forced to stand outside in the rain for 72 hours; being denied access to bathrooms except for one 10 second - period, timed by guards, every 24 hours; beatings; hooding and blindfolding; and denial of access to medical care. That assumption is unlikely, for the intensity of violence and confrontations surely waxed and waned during that time. There were quiet periods and flare - ups, and while shootings were less restrained in December, widespread beatings did not begin until January. On the other hand, our observations constituted only a fraction of the sites Visuals Impact /Csidy Neal The Numbers: Estimates and Extrapolations. During our three days of observation on the West Bank, we examined 53 cases of newly injured people who were hospitalized or being treated in clinics, for an average of 18 per day. In addition, during our visits to clinics in the refugee camps, we saw approximately 2 cases a day in the West Bank of people who had been moderately injured (contusions, one foot fracture) who had not made contact with the formal medical system. For Gaza, the comparable figures we observed were 15 cases who had sought treatment and / or been admitted, and 2 cases who remained in the camps without formal medical attention. If we were to assume that these same injury rates had occurred at these same sites on each of the 60 days of the uprising, then - at these sites alone - there would have been 1,200 newly injured cases in the West Bank and 1,020 such cases in Gaza since the start of the uprising, for a total of 2,220 cases of significant injury in the two areas. Removing section of intestine of Palestinian man shot by plastic bullet. Al Ittihad - Hospital, Nablus, West Bank, November 1988. that contributed to the overall incidence of injury each day throughout the Occupied Territories. There are approximately 20 hospitals in the West Bank and Gaza Strip, and 28 refugee camps, each with a clinic - a total of nearly 50 sites where people might be brought for treat- ment of injuries. Our team's observations, on each of our four days in the field, covered only 4 percent of that total. If we make the conservative assumption that we were seeing not 4 percent but 15 percent of the total injury cases (because our visits included large hospitals that were referral sites from other areas), we can arrive at a total injury figure for the two month - uprising well in excess of 10,000 cases. Fall 1989 Health / PAC Bulletin 11 THE CASUALTIES OF CONFLICT hese figures, we must emphasize, are crude T guesses, made simply to establish a range. The basic point is that in just four days we ourselves examined and interviewed 100 cases of uprising- related injury, 72 of them new. Such a volume casts doubt on the comprehensiveness of the 60 day - total of 250 injured as reported by the Israeli civil administration. Such a volume also makes credible an estimate of overall incidence that finds casualties numbered in thousands, rather than hundreds. The precise numbers of people who have been and are continuing to be injured may never be known, given the multiple sites of violence and the difficulties always inherent in tracking chaotic con- flicts. But in our view, even the lowest numbers - far higher, we believe, than most people have recognized as the con- sequence of army and police actions justify the term we have used to describe what has been taking place in the Occupied Terri- tories since December: an epidemic of violence. n the midst of a very busy morning at the Mokassed Hospital emergency room, with more than 20 wounded patients arriving in the space of a few hours, the emergency room choked with victims and medical personnel and all five operating rooms in use for patients with gunshot wounds and head injuries, we were told that the hospital's one ambulance had been hijacked by police as it tried to reach the scene of a violent confrontation in East Jerusalem. The ambulance driver later reported to us in detail: police had approached the ambulance with guns drawn, ordered two physicians, an aide and the driver out, and held them at gunpoint. Six policemen entered the ambulance and drove it into the Arab neighborhood, behind the lines of the demonstra- wy tion. Two members of our team drove directly to the offices of the International Committee of the Red of Cross to file a complaint. The mes- sage was relayed from the Red Cross to a military liaison officer. After 45 minutes, the ambulance was returned to its team and the Violations of Medical Human Rights ND RIFLE GR crew was ordered to go back to the hospital, still without picking up Denial, Delay and Disruption of Medical Care. At every hospital, any wounded. Other Palestinian witnesses told clinic, physician's office and UNRWA facility our team visited, us that Israeli soldiers repeatedly barred ambulances, doctors and we were told with special urgency health teams from their work in of repeated instances in which refugee camps and villages when Israeli soldiers and police had there were no demonstrations, par- refused entry to ambulances, ticularly in communities that had physicians and other health been placed under curfew. At Jala- workers trying to reach the victims zone camp near Ramallah on of beatings and shootings. These February 5, our team, accompanied reports were precise and specific. by three Palestinian physicians, They named camps, clinics, sites, _ ' Rick Reinhard Reinhard / Guardian dates and hours, and they were made to us by senior physicians and U.S. supplied - tear gas cannisters and UN administrators. grenades collected in Shatti refugee sought entry. We were stopped at gunpoint at a checkpoint at the camp gate, on a hilltop overlooking the community. Below us, we could see the The consequence - which we wit- nessed directly - was that seriously camp, Gaza. community and the UNRWA health clinic; it was absolutely quiet. We injured people had to be brought to medical care, often with delays of up to 4 hours, in private cars, in the backs of panel trucks, sometimes simply carried in the arms of family or companions. Two instances were cited in which patients had bled to death; we found them believable. We saw patients brought by car to Mokassed Hospital in Jerusalem and Hebron Hospital with serious vascular injuries and chest wounds. Some of these injured might have survived had there been access to a modern, multi- waited alongside the highway for the UNRWA medical van to arrive, joined their team of nurse midwives - and nurses, and again approached the gate. The soldiers refused entry. The UNRWA team protested that this was the sixth day in a row in which medical access had been denied. Pressed for a reason, a soldier said, " if the clinic is opened, there will be excitement, people will mill around, there will be trouble. " Uncomfortably, he added: " Of course, if anyone is sick, we'll let them out. " The UNRWA center trauma care system served by an emergency ambulance and transportation network. Instead, there occurred marked delays in bringing people to sites of care, in part because almost all patients were brought by private cars or vans, and in part because improvised, cir- cuitous routes were used in order to avoid army road- blocks, checkpoints and other potential dangers of arrest. team pointed out that such patients had no transportation to doctor or hospital, and no money to pay for care. While we talked, a woman labored up the hill from the camp carrying an obviously ill and feverish five- or six year - - old child whose foot was wrapped in a dirty bandage; as she pleaded with a soldier, the child was visibly cold and shivering. We abandoned the attempt to enter, picked up 12 Health / PAC Bulletin Fall 1989 The CasuaLTIES OF CONFLICT child and mother, and drove them to Ramallah Hospital. As we left, one of the soldiers - to whom some of us had identified ourselves as Americans, physicians and Jews complained about what he called distorted televi- sion coverage of the Army's behavior and said, " Look, I don't like being here either. " Violations of Medical Sanctuary: Assaults on Hospitals, Clinics and Physicians. The Chief of Staff and four other senior physicians at Mokassed Hospital told us that on December 26 soldiers fired teargas cannisters into the hos- pital's front courtyard. The cannisters landed and exploded near the air conditioning intake units. Teargas was sucked into the neonatal intensive care unit, the delivery rooms and the maternity ward, and hospital staff had to race to turn off the air conditioning, open windows and check the infants for respiratory difficulty. On January 16, at 7 p.m., they said, four male nurses on their way to work were stopped at the main hospital gate where patrols of soldiers and police are frequently stationed - and beaten. On January 28, four Israeli soldiers carrying clubs and rifles dashed into the hospital's main lobby, reportedly in pursuit of two boys who had been throwing stones, and carrying - their weapons entered the maternity area and the neonatal unit, which are located on the first floor. Entry to the neonatal unit routinely requires the wearing of sterile gowns and masks. The soldiers were stopped from going further only after a physician barred their way. UNRWA field directors and Pales- tinian physicians on different occa- sions in Gaza City described an incident in which a Palestinian physician had opened his residence door at night - a violation of curfew orders - to admit a woman with a sick child. Soldiers subsequently dragged the doctor from his home, beat him with clubs, propped him on the hood of an army jeep and drove down the street until he fell off. A subsequent protest strike by Shifa Hospital staff resulted in an apology from the area military commander, but no identification or punishment of the soldiers and officer involved. The Psychological Impact of Violence Effects on the Hearts and Minds of Palestinians and Israelis. We believe that the prolonged violence in the Occupied Territories will have serious consequences for both Israelis and Palestinians. We observed young men and boys actually throwing stones, and we talked to many who had been beaten. The beatings were clearly not limited to the stone throwers. The effect of the beatings seemed to us to be the very opposite of what the Israeli authorities, according to their own public statements, intended. Young men have been made more angry and defiant and unified around their sense of outrage. We wit- nessed such a unification at a blood bank where dozens of young men were scrambling for a place in line to donate blood. Over 100 units were donated in a few hours, in a community that traditionally has been most reluctant to donate blood. Many elements in the community see these men as " heroes. " But the violence derails their lives and the normal timetable of adolescent development, already dis- torted by profound feelings of futurelessness, by the Les Stone Impact / Visuals Mother and son in hospital in Nablus, West Bank, caring for second son. Both brothers were wounded by rubber bullets in clashes with Israeli soldiers. prospect of menial employment or unemployment, even for the highly educated, and by a sense of loss of national identity. In the uprisings, adolescents are becoming leaders in action before they acquire adult wisdom and judgement. The prolonged violence and closing of schools massively interferes with necessary education and job training. These young men are not being prepared for life as functioning adults: the schooling they are getting is for a life of violence. In addition, we know that violence and the sense of a heroic battle can produce a kind of " high " for teenagers. It will be difficult for many of them to come down from the high and settle into the prolonged and Fall 1989 Health / PAC Bulletin 13 Reutrs / Holander Jim Palestinian youths amidst burning tires hurl stones at Israeli soldiers in the Aroub refugee camp. undramatic day day - to - work of schooling or apprentice- ship, especially since they feel that in their protests they are now doing their community's most crucial work and carrying out its most central purpose. The Palestinian adults we saw who have been beaten, including many older men and some women, seemed ini- tially stunned, helpless, depressed, and bewildered, espe- cially in instances where soldiers have broken into their homes in nighttime raids, smashed furniture and terror- ized their children. The other adults around them were outraged that their kin or neighbors have been beaten and their homes invaded. They believe that the soldiers are carrying out the intention of the government. And the evident failure of the Israeli government to punish the perpetrators of the beatings, the repeated denials that uncontrolled violence is occurring or the assertion that it represents only a few " aberrations, " strengthen this con- viction. he question of effects of the uprisings and vio- lence on the Israeli public is much more difficult to determine. Given the brief span of our visit and despite our attempt to talk to people i gov- ernment, in the Defense Ministry and across the full spec- trum of political opinion, there is little about which we feel competent to conclude. The political situation within Israel seems, indeed, so complex as to defy generalization in any case. The uprisings are causing fear among Israelis, threatening a comfortable sense of domination of Pales- tinians that has been the bulwark of many Israelis, awakening echoes of terrorist assaults in others, and increasing the ambivalence about the future of the West Bank and Gaza in many. We noticed a tendency for all discussions to shift immediately to the difficulties or impossibility of a long range - and permanent political solution. This shift struck us as a way of not dealing with the problem of the violence that is occurring now. The army's response to the uprisings is producing reactions in the Israeli public that range from moral anguish L the Zionist mother of three children who said, on learning that soldiers had buried four young Palestinians alive with a bulldozer, " How can I go on living here? What do I have in common with the people who did that? " - to what struck us as moral blindness: an Israeli settler who earnestly explained to us, with absolute conviction, that the beatings and fractures were not the work of the army but were inflicted by sadistic PLO agents in the camps each day just before television cameras arrived. The Effects on Small Children. When parents are unable to protect their small children, and children are repeatedly exposed to scenes of beatings and bloodshed, the conse- quences may be profound and long term -. On one level, children try to adapt: in the villages, we saw five year- - 14 Health / PAC Bulletin Fall 1989 THE E CASUALTIES OF CONFLICT world are shaped, defining it as a very dangerous place and one that is divided, furthermore, into good (my " tribe ") and evil (the " others "). These can be lifelong effects, distorting the perceptions of a whole generation, with consequences not only for their lives but for the political future and the lives of a next generation as well. Hl An Arab child watches as an Israeli soldier patrols the Old City of Jerusalem. Reutrs /Holander Jim Palestinian boy throws stone at Israeli soldiers during a women's demonstration in Ramallah, West Bank. olds playing with their collections of rubber bullets and shell casings, and older children, their hands protected with pieces of paper, gleefully carrying expended tear - gas cannisters. In a refugee camp, we noticed a two year - - old carefully clutching an onion wherever she went. Asked why, her mother explained: " It's for protection when she goes outside, she thinks it helps when there's tear gas. " Thousands of small children are at risk of chronic anxiety and irritability, childhood depression, sleeplessness and Reutrs /Holander nightmares, and disturbances of maturation. We heard reliable reports (and the press and television screens have repeatedly carried the images) of 8, 9 and 10- year - old children being clubbed, shot with rubber bullets Jim and teargassed. For each such case, hundreds of others must have been terrorized. In a very real sense, for these children, today's blood and tears are the least of the con- sequences. When children perceive that their parents are powerless against violence and that they themselves are therefore vulnerable, fundamental attitudes toward the Fall 1989 Health / PAC Bulletin 15 The E CASUALTIES OF CONFLICT ..And the Violence Violence Continues H. Jack Geiger ighteen months have E passed since the first Physicians for Human Rights mission to the West Bank and Gaza Strip documented what we called " an epidemic of violence. " When that mission's findings were made public, they made front page - headlines around the world. I have before me now a half- dozen clippings from the New York Times, the total of its West Bank and Gaza coverage for the past week. Three of them describe the fatal shooting or wounding of a total of seven Palestinians in intifada - related incidents. Two mention the killing of Palestinians as suspected collaborators by other Palestinians. One reports a court- ordered suspended sentence for an Israeli settler who shot to death a schoolgirl in the Gaza Strip after his car was stoned. The last described pardons granted after six months to three soldiers convicted of beating to death a Palestinian in custody for trying to prevent the arrest of his 15 year- - old son. Jim Hollander / Reuters None of the clippings is more than three inches long. All of them were tucked away on inside pages. After almost two years, such violence is no longer news, and human rights are not even mentioned. The total of Palestinian deaths is now near 600; the wounded are counted in the tens of thousands. Familiarity breeds indif- ference; evil is merely banal; there are other, better stories to make headlines. What has been lost is crucial: the sense of outrage at the abuse of human life. H. Jack Geiger is a professor of community medicine at the City University of New York Medical School and national vice- president of Physicians for Human Rights. Israeli soldier takes aim as women throw rocks during a demonstration in Burin, West Bank. It would be easy to conclude that our effort, and subse- quent human rights missions and reports by PHR and other groups, had failed. But that would be profoundly wrong, for the continuing violations are only part of the story of the past year. On the other side of the ledger, and potentially much more important in the long run, are these developments: * A group of Israeli physicians conducted their own. investigation, confirmed our findings, and published their results. 16 Health / PAC Bulletin Fall 1989 The CasuALTIES OF CONFLICT * A second, larger group has joined with Palestinian physicians an action without precedent - to form a permanent, active medical human rights organization continuously monitoring the West Bank and Gaza Strip, documenting and protesting violations and publishing their findings. Physicians in Egypt and other Middle Eastern nations have asked for help in forming their own medical human rights groups to document and oppose viola- tions in their own countries. Even where oppression is believed to be most fierce and open investigation is impossible, as in Syria, reports to Amnesty International, the Human Rights Watch Committees, PHR and other groups continue to be smuggled out. It is the process, not today's headline, that counts in the long run. The first lesson of our initial mission and the events, good and bad, that followed is that the defense of human rights is a long probably - ceaseless - task. The second lesson is that violations of human rights occur in every society, not just the Middle East. The third is that every society produces protesters and defenders of basic rights and that, increasingly, health workers are among them. We have only to look at our own history -- the civil rights movement in the United States - for examples of all three. Or at South Africa. Or China. There is in this a curious and important parallel to the more conventional jobs of health workers. The task is never done, but doing it can be a life's work. Palestinian woman mourning the destruc- / Guardin tion of her home in Bani Suheila, Gaza Strip, by the Israel Defense Force as an act of collective punishment for her family. Tordai Fall 1989 Health / PAC Bulletin 17 The CasuALTIES OF CONFLICT The Israeli Government Responds The Israeli government issued an 11 page - response to the Physicians for Human Rights'report, " Casualties of Conflict, " in May 1988 with a detailed and sometimes point point - by - refutation written by Dr. Yoram Lass, Director General of the Israeli Ministry of Health. Excerpts from that response are pre- sented here. I. General The Physicians for Human Rights PHR () group under- took a self imposed - task of assessing in eight days the many complexities of our area.... It is clear that they ignored information provided to them, and avoided seeking meetings with government health personnel, both Israeli and Arab alike. ..They..They have not explained how the agenda of their visit was determined. Who decided what to see, when to see, whom to see? Did the agenda, and its control, influence the conclusions?... For instance, the term " injuries related to the uprisings, " used in various forms as a base for statistics, is never defined. The report does not systematically distinguish what has been seen from what has been told, by the patients for example. While in regular medical practice history taken from the patient is a routine part of the medical evalua- tion, what was evaluated here is often the non medical - PHR undertook a self- imposed task of assessing in eight days the many complexities of our area. circumstances. One should remember that the population of informants has been involved in a systematic campaign of violent disturbances aimed in a very real sense at the Western media. The possible bias introduced into the reports should be noted and explicitly analyzed.... The report is especially strong when it describes the systematic nature of the injuries observed. The report is much less convincing when it seems to derive, with very little analysis, the cause, plan and purpose of the observed effects. Direct medical observations are mixed in the same breath with second hand media reports, and Medical observations are mixed with second hand media reports and with answers to questions that can not be decided by a medical opinion. with answers to questions that can not, in principle be decided by a medical opinion. (For example, what are the possible systematic differences between the conditions in which the authors have accumulated their expertise in emergency medicine, and mass riots? Mass violent distur- bances are not necessarily free swinging - melees.) II. Tenor of the PHR Report The report is biased and devoid of professional objec- tivity and perspective. It accepts unconfirmed, hearsay observations described in sensational fashion. It largely relies on anecdotal reports, without significant profes- sional or medical judgment as to veracity, credibility or special pleading. The report dismisses information provided by the Chief Medical Officer in Judaea and Samaria and makes no ref- erence to other Israeli or Arab senior staff of the govern- ment health services. Moreover, the authors made no effort to meet with anyone in the Ministry of Health. As a result, the authors have emerged from their brief visit with an incomplete and unprofessional view of the health services situation to make severe criticisms based on this misinformation. 18 Health / PAC Bulletin Fall 1989 THE CASUALTIES OF CONFLICT The report denigrates and politicizes the serious effort of the Israeli authorities and local health personnel to advance health in the areas. This is an irresponsible act, which only serves to hinder the continuing efforts to improve health services. III. Violent Civil Unrest and its Results The PHR group refers to an " epidemic of violence, " but fails to acknowledge the fact that it is the violent rioting taking place which has created the situation in which deaths and injuries are occurring. Over the past four months there has been a situation of civil unrest in the ter- ritories, with rioting on a large scale. Rioters throwing bricks, stones and other dangerous objects, including Molotov cocktails, place the security personnel in serious danger, and disrupted normal life by violence and threats against the local population. The PHR group concedes that the government authority is obliged to maintain law and order. However, by its biased and inflammatory report, the PHR inadvertently may encourage this violent civil unrest. The Israel Defense Force is not organized, equipped and trained for crowd control, since its major purpose is different. But the scale of the riots made the use of the military necessary. The authors choose to trivialize " recent characterization of the uprisings by high Israeli officials... as'a war. " " The authors may ponder this further, especially if they are interested in communicating with Israelis and not just in criticizing them. Israelis view their state's existence as one continuous struggle, in which Arabs have, at various times, used different combinations of tools - full scale wars, terrorist campaigns, economic boycott, propaganda campaigns. Presenting the security concerns of both sides in symmetric language can be highly misleading.... The recent disturbances can be viewed and are, indeed, perceived by many Israelis as just another expression of Arab total unacceptance of the existence of Israel.... PHR fails to acknowledge that it is the violent rioting which has created the situation in which deaths and injuries are occurring. The mass riots in the occupied territories were designed to overwhelm any sort of police response, and to make response by the army necessary.... It is true that on occasion the military authorities have resorted to measures that have caused difficulties within certain communities. These measures are not undertaken lightly, since it is obvious they are often self defeating in the long run, even if effective in the short run. But some- times actions like curfew are necessary in order to restore order. The public peace is fragile, and can take only so much disruption. People who disrupt the public peace widely and systematically should not be surprised if they can not enjoy its benefit. When their doctors can not get through road blocks erected by their children, to whom should they complain? When their doctors can not get through road blocks erected by their children, to whom should they complain? IV. Medical Care of the Injured The report lacks understanding of the process of building up of health services in previously underdevel- oped areas. It fails to acknowledge the continued func- tioning of health services during the period of unrest, both in treatment of injured persons and in carrying on with the regular activities of health care such as immu- nization, prenatal care, and elective surgery. The government and non government - hospitals have continued to function throughout this period, providing dedicated services, without shortages of supplies, equip- ment, drugs or manpower. Injured persons are treated in these hospitals, or are referred to Israeli hospitals on the basis of medical needs. Professional standards of service have improved greatly as a result of the establishment of new specialty departments, and the training programs which have been carried out in recent years. The staff of the local hospitals are Arab physicians, nurses and other health personnel. They have carried out their duties in an exemplary fashion, under considerable strain. For this they deserve the thanks and respect of the local people, the government and anyone truly interested in health and medical care. The PHR authors report on cases in a misleading and unprofessional manner. They include cases which... might possibly be due to other events, such as domestic or polit- ical squabbles, vehicle and work accidents, or criminal acts, such as occur in a population of over 1.3 million per- sons.... The authors'extrapolation of the numbers of injured leads them to exaggerations.... How many patients would be expected to occupy hos- pital beds in a population of 1.5 million? Do these patients represent an inordinately large fraction of this group? How do the figures reported in this report reflect the ambient level of violence in this population? In addition, the " multiple occasion " assumption gener- ates a major error in the total number of casualties.... On the basis of a presumed observation of 4 percent of Fall 1989 Health / PAC Bulletin 19 THE CASUALTIES OF CONFLICT injuries, they assumed that this may have been as much as 15 percent of the trauma cases, and this, however, leaves 85 percent of their reported figures as an extrapola- tion. They arrived at a total trauma figure in excess of 10,000. This means that 8,500 are a result of inaccurate extrapolative measures.... V. Mental Health and Long Term Trauma The report comments on mental distress caused by the recent events in an entirely speculative fashion. In fact, there has been no increase in mental hospital admissions. According to the chief psychiatrist of Judaea Samaria / , There is no evidence of increased mental distress or symptomatology in the local population. there is no evidence of increased mental distress or symp- tomatology in the local population.... There is also no med- ical basis for the sweeping statement about long term damage and rehabilitation. The authors should also con- sider that there are long term stresses on the Israeli popu- lation from the repeated wars, conflict and acts of terrorism. VI. Violent Incidents in Hospitals Reference is made to violent incidents occurring on hos- pital premises. However, these references make no account of the fact that these incidents have been initiated when youths who engaged in violence, throwing stones, Molotov cocktails or other missiles at soldiers have taken refuge in hospitals. This has included threatening of hos- pital staff, throwing stones, Molotov cocktails or other missiles at soldiers from the roofs of hospitals and turning the hospitals into riot zones. Their behavior endangers and disturbs the hospital and its functioning. Regrettably on these occasions, force has had to be used to remove rioters from hospital premises. However, it is more appro- priate to place the responsibility for these events on the rioters than on security personnel who are trying to assure the hospitals'continued functioning. It should also be pointed out that the large numbers of relatives and friends who converge all at once on a hospital for lengthy visits, entering even the surgery room during an opera- tion, cause tremendous difficulties for the hospital. By suddenly overcrowding the hospital wards and inter- fering with efforts to maintain sanitary conditions in the surgical areas, these large groups of people hamper the medical staff from carrying out its duties, and, as a result, security personnel may be called in by the staff to remove the multitude of visitors.... We agree with the report that " the occupying authority has a responsibility for the provision of a medical care infrastructure,... " but are hard pressed to understand the basis for the authors'demand that this should be " at... a level comparable to that enjoyed in Israel proper. " Why not compare the level of health care they enjoy now to that which they had before 1967? The poor health condi- tions which Israel found in the territories in 1967 required extensive efforts and resources to bring the medical ser- vices to proper levels. With all its goodwill and commit- ment to help, Israel's capabilities have not been unlimited. VII. Background Events The PHR report pays lip service to the larger context of the Arab Israel conflict and the historical background of these events.... In short, the report understates the sources and extent of the violence, while exaggerating the extent of injuries resulting from riot control measures.... The report should state and its readers should query - what is the motivation and where is the objectivity of the PHR authors? VIII. The Basic Health Situation This section of the Israeli response presents the improvements in health care that have taken place in Gaza and the West Bank since the Israeli occupation in 1967. These include decline in infant mortality, improvement in immunization coverage, development of primary health care centers, improvement of sanitation, increase in number of practitioners and hospital facilities, and close cooperation between the health systems of Israel and the occupied territories. IX. Prevention of Civil Violence In many parts of the world there are wars, unresolved regional conflicts, and civil unrest which cause great suf- fering and casualties. These are certainly areas that can use preventive medicine. However, it would be more con- structive for physicians to promote peaceful resolution of international conflicts, rather than encourage civilian uprisings and violent civil unrest as means of political action. The organization of Physicians for Human Rights might play a role in supporting health services in Judaea, Samaria and Gaza. For example, the organization may wish to contribute toward building one of the many health projects which have been planned for the area and which await funding.... The Physicians for Human Rights organization might also have some other health service projects which it would like to propose in order to improve health in the territories. OE 220 Health / PAC Bulletin Fall 1989 Despite Our Differences Israeli and Palestinian Physicians Organize RUHAMA MARTON ince the beginning of the intifada in December S. 1987, the Israeli authorities in charge of the occu- pied Palestinian areas of the West Bank and the Gaza Strip have used interference with medical services as a tool of political pressure and as a means of pun- ishing Palestinians, individually and collectively, for the rebellion. The Association of Israeli and Palestinian Physicians for Human Rights was formed in March 1988 to monitor, The Israeli authorities have used interference with medical services as a tool of political pressure and a means of punishment. report, and protest such practices as interfering with Palestinian physicians, systematically delaying medical treatment for prisoners, allowing the armed forces into hospitals, and removing the injured from medical facili- ties for interrogation. We believe that the right to receive appropriate medical treatment is a basic human right. and, in accordance with the Geneva Conventions, should transcend political and national considerations. The organization routinely receives dozens of personal appeals from families of prisoners, doctors, lawyers, and human rights organizations around the world to inter- vene in individual cases. For example, we were contacted by the family of Jamal Sha'at, who was detained in November 1988 for interrogation at the " Ansar II " prison in the Gaza Strip only four days before he was scheduled to undergo kidney surgery. Four months later, a military judge ordered the prison to schedule the operation, but the authorities brought Jamal to the hospital in the after- noon of the appointed date, and he was turned away. Another date was set for late March, at which point the family asked our association to intervene. We immedi- ately sent a telegram to the prison commander, stating that if the detainee was not brought to the hospital on time for surgery, we would embark on a public cam- paign. This time, Jamal was brought to the hospital on time, underwent surgery, and received the medical care he needed. Jamal's case is by no means unique. Such stories were one of the reasons we began to organize nearly two years ago. Origins of the Association In January 1988, when the word intifada was just begin- ning to be heard, a group of Israeli physicians decided to respond to the state of health care in the occupied territo- ries as health professionals - not just by demonstrating and signing petitions, but by doing fieldwork and meeting with Palestinian colleagues to seek cooperation. We organized two delegations of doctors, one to the Shifa hospital in Gaza and one to Al Muqassad hospital in East Jerusalem. As an Israeli physician, this was a unique experience for me. At the beginning of the occupation, I made a vow never to go to the occupied territories, never to shop in the markets, never to take walks in occupied areas. The few times I ventured into the territories were for demon- strations against the occupation. I was certainly never inside a Palestinian hospital. For all the members of our group, this was a new and shocking experience. During our visits, we saw children whose hands were broken as they were trying to protect A volunteer European physician and Palestinian nurse examine a patient in the West Bank as part of a Popular Health Committee mobile medical unit. Visuals Jand /Impact Ruhama Marton, an Israeli pediatrician and psychiatrist, is chairperson of the Association of Israeli and Palestinian Physicians for Human Rights, which can be contacted at P.O. Box 10235, Tel Aviv 61101, Israel. Judy Fall 1989 Health / PAC Bulletin 21 their heads from soldiers'clubs. We saw young men with multiple fractures in their arms from having been held by two soldiers and beaten by a third. We saw the effects of the plastic and rubber bullets fired by the soldiers, and we examined the effects of their massive use of tear gas. We photographed the wounded, recorded their testi- mony, spoke with the doctors, and went home to publi- cize our findings. In March 1988, we held our first joint meeting of Israeli and Palestinian physicians in Tel Aviv. An unprece- dented 100 physicians signed up as members of the new organization. For many, this was their first political activity. The participants formulated a set of principles of action (see sidebar) as the basis for our activity. These principles, while identifying specific targets for investiga- tion and action, emphasized the development of trust and cooperation between Israeli and Palestianian physi- cians working together. The meeting concluded with a resolution in support of the two state - solution - estab- lishing a Palestinian state alongside of Israel. Investigating Interference Since its founding, the Association of Israeli and Palestinian Physicians has had a number of successes in improving the situation of health care workers and the health conditions in the occupied territories. A common form of interfering with health care in the occupied territories is preventing Palestinian physicians from performing their medical duties, either through administrative detention or through harassment such as denying them driving permits. Under Israeli policy, indi- viduals can be detained for up to six months without The Palestinian physicians who meet with us are in constant danger of arrest, interrogation, and detention. trial or charge, an order that may be renewed indefi- nitely. One of our first actions, therefore, was a demon- stration in front of the Ministry of Defense in Tel Aviv in May 1988, protesting the administrative detention of Dr. Zacharia Ibrahim Al Airah - , chairman of the medical association in Gaza. In June, five doctors and nurses trav- eling in a van were arrested in the West Bank. After our ASSOCIATION OF Israel and Palestinian PHYSICIANS PRINCIPLES OF ACTION Preface role vWeres,al Iy sverrasaellyi d asa ebnefdin giP daneflieenesddt wi inthpiinar nwi itPhinanl ceethsiitcpailn ltihaee nfsr apm.ehw yorskii Pcmhyispaicnirsan,os avvndii ethwne ggouiu drel tipnoerso efndpeesarvoira oocnf au-nli - htuimcaen lwiifte ha ntdh hee apluthr.p ose of maintaining and makWionrgk ienvge rfyo rp olsisfieb laend ehfefaolrtth tion siutpsp obrrto ahdeusmta ns ernisgeh tisn.c lTuhdiess sartireisv.i ng must not not be limited by national national, ethnic or racial bound- Being a physician and practicing medicine in an area of conflict such as Israel and the occupied territories one wrietsht rtahien tc haanldl einng et hper ifnacciep loefs osfi ganpipfliycianngt tehxetseer nmaolr aplr epsrseusreenst.s without The Association of Israeli and Palestinian Physicians tahtet eanmdp tresc oPgnailteisont ipnhyisainc iatnos . eisntdaivbildiuaslh Thciosn tenadcetav oarn dna tcioonoaple rhaast iaso ni debnettiwtieeesn i tIss rpraeemlisie teahche m emrbeer,c ion galnl iitts iasopenct s.o f both the and of The conflict between our two people evokes powerful emo- building betwe n trust and tairoen s difficult and, in relating to each other, often raises questions which solved. We eton dapepraovacohr c otntoi nue and which building may have to remain unre- coopera- tion while taking into consideration the difference us. Specific Objectives 1. To hold meetings in an ongoing fashion between Israeli physicians fories, as medical and Palestinian delegations physicians to hospitals of the and oc upied clinics, ter - and as personal encounters between physicians. 2. To the study health the care cur ent system problems in the of oc upied the structure ter itories and function such as of: and budgets quality, personel personel of medications, the state, and of hospital medical care suplies, suplies the; quantity to raise ahweaarlentehs abnyd d ifsaecmiilnaittiangt ianndg htelhpe imoprrgovaen iinzfaotrmiaotniosn ainifdo rmfartoiomn othfe ,v hoolludinntge currse natb prroeasd .h eaalntdh croenfperreensceens tcaatrei vseysst eom,f 3. Tinoju reidn icnclluudidngi,n: gin trmusoionni dteloayrs ind oefl paroyvisdi,ng raremepd oprrovti,di nga fnordce s pmredoictale msedti caul ninetot thrieactmaenlt hopspriataclst tio,c aensd ,th e removing the injured from medical facilities for interro gation. 4. To investigate complaints about avoidable deaths and bodily injuries in the occupied territories, and to seek to pre- vent such occurrences. according 5. To ensure the protection Palestinian of Palestinian Palestinian physicians from from arbi- arbi- and trary physical arrest, administrative harm. detention, dismissal, harassment, 6. To organize, to need and feasibility, medical vol- unteer work in clinics and hospitals in the occupied territo- ries. 7. To hold scienitni ftihce -o cmceudpiiceadl tmeerertiitnogrsi eisn ddeeaalliinngg wciotohp ersautbijoenc twsi tohf physicians relevance to both sides. 8. To create and maintain contacts with human rights groups with similar goals throughout the world. 22 Health / PAC Bulletin Fall 1989 intervention, all were released the same night. Through our activity on this issue, the policy of detaining medical staff was actually halted for a period of seven months - up until May 1989. As of this writing, four physicians are under admin- istrative detention. In June 1988, we went to the Gaza Strip to investigate the state of medical care there, in par- ticular, the effects of tear gas used in confined areas. Our report, released to the press and to Amnesty International, appears to have had an effect. The use of tear gas has dropped drasti- cally, and the reports of miscarriages, infant mor- tality, and deaths of elderly people as a result of tear gas inhalation have nearly ceased. Another widely publicized report resulted from our trip to the Ittihad Al - hospital in Nablus to investigate the army's use of plastic bullets. We have currently completed a comprehen- sive report on the state of health services in the Gaza Strip and plan a similar study on the West Bank. We travel to all the hospitals in the area and examine the hospitalization conditions, medical equipment, amount and quality of med- ications, budgets, number of medical staff, and physicians'complaints about disturbance of their work by the army or Civil Administration. Compiling such reports is not a simple matter. The frequent imposition of curfews on the occu- pied territories and designating them as " closed military areas " prevent us from visiting hospitals and meeting with our Palestinian colleagues there. New army regulations allow even a low- ranking officer to close off an area. Thus, we may arrive at a checkpost after hours of travel, only to find that we are forbidden to continue. The Palestinian physicians who meet with us are in constant danger of arrest, interrogation, and detention. Victims of army brutality may refuse to be named or photographed for fear of being arrested from their hospital beds. We have documented other incidents of bodily injury, including cases of women beaten in the Gaza Strip and of people injured in tear gas attacks. We concentrated special efforts on publi- cizing the case of children in the Nablus area who were severely burned by certain unidenti- fied objects. Faced with an outpouring of public concern, officials initially denied responsibility and the army refused to investigate. However, the media recently announced that four of these children will be compen- sated for their injuries. The objects that caused the burns apparently turned out to be missile decoys used by the air force. A Just Peace Obviously, as long as the occupation and violent repression continue, striving for a better health system, more humane treatment of prisoners, and respect for human rights are only one aspect of the struggle for a just peace for both the Palestinian and Israeli peoples. We believe that although many of our ultimate goals cannot Visuals / Jand Impact Judy Palestinian youth injured during the intifada. Al Mokassed Hospital, East Jerusalem. be achieved as long as this situation prevails, we are making our contribution as physicians and as human beings to peace and the preservation of life. We are espe- cially proud to have succeeded in creating both profes- sional and personal relationships of cooperation and understanding between Israeli and Palestinian physi- cians. We hope to continue our efforts, adhering to the ethical principles of our profession, unlimited by national, ethnic, or racial boundaries. 0) Fall 1989 Health / PAC Bulletin 23 Guardin / Reinhard Rick Health Care Under Occupation MOUSTAFA BARGHOUTHI he Union of Palestinian Medical Relief T Committees (UPMRC) is a movement of health professionals in the Israeli occupied - West Bank and Gaza Strip. These Palestinian health workers are striving both to provide health services to the population and to create independent Palestinian health institutions. UPMRC views this effort as an integral part of the Palestinian struggle for national liberation. Begun in 1979, by 1988 the organization numbered among its members approximately 350 physicians - one - third of the physicians in the entire country - as well as nurses, village health workers, technicians, and pharmacists working to create an alternative model for health devel- opment in occupied Palestine. Organizing under Occupation At the time UPMRC was founded, Palestinians were suffering the effects of two shattering experiences. The first was the creation of the state of Israel in 1948, which Moustafa Barghouthi is a Palestinian physician and member of the Union of Palestinian Medical Relief Committees, P.O. Box 51028, East Jerusalem, Via Israel. Dr. Moustafa Barghouthi of the Union of Palestinian Medical Relief Committees exam- ines a stroke patient in a Jordan Valley vil- lage on a mobile clinic visit. dismembered Palestinian society and dispersed hun- dreds of thousands of refugees all over the world. The second was the occupation of the West Bank and Gaza Strip in 1967. Israeli military rule has been aimed at possessing the land without its people, by destroying the infrastructure necessary for rebuilding Palestinian society in the future and reducing Palestinians to dependence on Israel for all services including health care. The survival of the Palestinian community under occupation has become Health care delivery quickly became an important arena for political struggle. linked to the people's ability to organize at the commu- nity level and to meet their own basic needs, despite the harsh Israeli policies. In this context, health care delivery quickly became an important arena for political struggle. UPMRC was founded primarily by young, progres- sive, urban - based professionals as part of a new health movement that emerged in the 1970's. These activists had links to the increasingly active organizations, such as women's committees and trade unions, emerging in the towns, villages, and refugee camps of the West Bank and Gaza Strip. Although the Palestinian medical establish- ment shares our perception that the development of 24 Health / PAC Bulletin Fall 1989 health care services in the occupied territories is a vital part of the struggle against Israeli rule, UPMRC differs from the health establishment both in its strong commu- nity orientation and its new social consciousness. In contrast to purely curative, urban - based medicine focusing on mechanical solutions to health problems, UPMRC is a health - and not just medical movement - . The organization advocates reaching people in remote rural areas and refugee camps and poor urban communi- ties with basic curative services, without artificially sepa- rating those services from preventive activities. It emphasizes health education and the participation of individuals in solving their own health problems. Moreover, its membership reflects the interests of the most oppressed and exploited groups in the society. Most of those volunteering their services as health profes- sionals come from poor peasant or refugee backgrounds. Although they were catapulted to middle - class and pro- fessional status through educational opportunity, they have remained at the bottom of the medical establish- ment's ladder, retaining a community - based conscious- ness that the medical establishment has not been able to coopt. A Question of Balance Palestinians in the West Bank and Gaza face unique health care conditions because our country is in a transi- tional state. We suffer from the diseases both of underde- velopment and of industrialized nations. As the Medical Relief Committees evolved, the organizers needed to provide the proper balance of activities in its work, while Palestinian physician teaches first aid class to girls in El Khadr, West Bank. remaining sufficiently flexible to adapt to the rapid and unexpected changes of the political and social situation. For example, at the beginning, our primary focus was providing curative medical services through mobile clinics. Only later did we introduce preventive services, gradually and without interrupting the services already offered. Even so, we sometimes moved faster in imple- UPMRC is a health - and not just medical movement -. menting preventive health activities than the level of dia- logue and trust we had established with the population would allow. Through these experiments and failures, we began to learn the right balance among the different strands of providing medical care. Responding to the Emergency When the uprising began on December 9, 1987, we were not prepared for the health and medical needs it brought with it. The number of casualties was simply overwhelming. We estimate that 40,000 were injured in a period of one year. Tens of villages and refugee camps were raided and placed under a state of siege and extended curfew, leaving them cut off from medical and other care for extended periods. Consequently, we often had to respond to calls for emergency mobile clinic care in all sorts of locations all at the same time. In 1988, we labored through 700 mobile clinic visits, in contrast to 350 in 1987. We Neal Cassidy / Impact Visuals - attended to the medical needs of 80,500 people, compared to 47,000 in 1987. In the first year of the uprising alone, we gave emergency medical care to approximately 2,600 injured people who needed to be hospi- talized but could not be for fear of arrest. And what's more, we had to face these monumental emergency needs with the vol- untary labor of our health pro- fessionals, working after hours. and on their days off. Even with the new volunteers who joined our ranks during this time, we were still unable to respond adequately to calls for medical assistance. To be able to concentrate our energy on the emergency situation without losing the ongoing health devel- opment activities we had already built, we needed to develop new programs to meet the newly emerging needs. campaign to type the blood of the population of the West Bank. Those tested were given cards denoting the results, and we collected the names and addresses of potential blood donors who could be contacted whenever needed. So far, 24,000 people have been registered, with the infor- mation easily accessible on personal computer to any hospital that needs them. This project has saved many lives, both those who have been injured by army vio- lence and those with ordinary medical problems. Visuals Visuals Visuals Visuals Visuals Impact Impact Impact Impact Impact / Impact Janda Janda Janda Janda Judy Judy Judy Judy Popular Committee Mobile Medical Unit dentist treats woman in the West Bank. Among the emergency programs we created, three stand out. The first was an outgrowth of our realization, even at the onset of the uprising, that it was impossible for us to send physicians and nurses to every village and locale in the country that needed emergency medical assistance. As an alternative measure, we had to train We decided to turn the population population into a roving roving blood bank. Normalizing the Emergency By spring of 1988 it was becoming clear that the uprising was destined to continue for some time to come, and we needed to locate a new equilibrium between emergency and developmental work. It was especially important to rechannel some of our energy back to med- ical and health development because of a 50 percent reduction taken in the budget for health services, coming on top of the medical and health care complications cre- ated by the repeated states of siege and extended curfews afflicting some communities. With our third special project, the roaming primary care, physiotherapy, and rehabilitation program, initiated in January 1989, we began to expand emergency medical care to include other basic health care needs. Physiotherapy and rehabilitation were the first services to be introduced because of the needs of those injured in the uprising. However, the health needs of the popula- tion are more numerous and varied than they were before the uprising, for a number of reasons: 1. A rise in the birth rate and the reduction of maternal and child health services as a result of the cut in the Israeli military health services budget. 2. The absence of a health apparatus capable of disease surveillance and control and eradication of infectious dis- eases such as Maltese fever, typhoid, and hepatitis. 3. The rise in psychological and physical problems related to severe stress. 4. The deteriorating health conditions in prisons that have affected the more than 40,000 Palestinians who have been through Israeli prisons since the beginning of the uprising. 5. The deteriorating financial conditions of the popula- tion and its impact on health, particularly in terms of malnutrition and anemia. As this list shows, we must continue to carry out our emergency projects while also maintaining ordinary pri- mary health care services. people in the community in basic first aid. Since launching our first aid training program in December 1988, we have held 1,000 training sessions for about 22,000 people and have distributed 19,000 first aid kits. Through this program we have saved the lives of many wounded individuals who would have died as a result of uncontrolled bleeding or complications following an injury. The second program was introduced as a result of the absence of a national blood bank system. With local pri- vate blood banks failing to provide the supply of blood that was desperately needed, we decided to turn the population into a roving blood bank pool. We began a Faith in the Future Our task is massive and difficult, yet our confidence in the future provides us with energy and hope. Indeed, our faith in the future has grown stronger with the aston- ishing manifestation of self reliance - , dedication, and cre- ativity that all Palestinian health institutions have achieved so far. Our tragic history and our trying present have helped to reinforce our belief that true and compre- hensive development of health care for our people is linked not only to our efforts and activities but also to the attainment of the Palestinian people's natural right to self determination - and equal development with all other nations in the world. Y' 26 Health / PAC Bulletin Fall 1989 The Israeli- Palestinian Conflict GAIL PRESSBERG ow easy it would be if the parameters of the Y'IYsra'eli Palestinian - conflict could be neatly divided between absolute right and absolute wrong. In reality, however, there is more than one view of the truth, more than one interpretation of history, and two peoples in conflict and in pain. The Palestinian Israeli - conflict is a contest between two competing national movements, each having long and legitimate claims to the same land in pre 1948 - Palestine -the land surrounded by Lebanon, Syria, Jordan, and Egypt, which now comprises Israel, the West Bank, and Gaza Strip. Palestinian - Israeli relations have worsened through a history that includes five wars and a vicious cycle of violence, terrorism, and repression, as the Israelis and Palestinians struggle over issues of land, security, the right of national identity, governance and sovereignty, and economic resources. There is more than one view of the truth, more than one interpretation of history, and two peoples in conflict and pain. mouth; if I prefer not Jerusalem among my chief joy. " Each year at the traditional Passover meal, the seder, Jews commemorate the ancient Israelites'exodus from Egypt when they say, " Next year in Jerusalem. " Modern Zionism, founded in the 19th century, became a popular movement in the Jewish community and began to gain international legitimacy after the murder of six million Jews during the Holocaust. The Jewish com- munity supported the need for a state of Israel in which Jews could determine their own affairs. Today, the over- whelming majority of Jews see Zionism as an " affirma- tive action " program for the Jewish people and identify with and support the state of Israel. Palestinians also trace their roots in historic Palestine back more than two thousand years. For more than 1,300 years, Palestine was inhabited by Palestinian Arabs who formed a cohesive group in their own homeland. Modern Palestinian nationalism developed in reaction to Jewish settlement in Palestine since the end of the nine- teenth century. The Palestinian community resisted the presence of an organized Jewish community and the sub- sequent emergence of the state of Israel in 1948. As a result of the 1948 war between Israel and the neighboring Arab states, 750,000 Palestinian Arabs were made home- less. Today, the Palestinian people number 3.8 million, with 1.8 million living under Israeli occupation in the West Palestinian women under curfew in Shatti refugee camp, Gaza, trying to get past soldiers with their supplies. Guardian / Tordai Roots in Palestine Jewish nationalism developed as Zionism in the early nineteenth century. For Zionists, the project to create a Jewish state in historic Palestine was a response to perse- cution and segregation from whatever larger community Jews lived within. As long ago as their exile in Babylon in Biblical times, Jews sang the psalm, " If I forget thee, O Jerusalem, let my right hand forget her cunning. If I do not remember thee let my tongue cleave to the roof of my Gail Pressberg is the Executive Director of the Foundation for Middle East Peace, located in Washington, D.C. Fall 1989 Health / PAC Bulletin 2227 Bank and Gaza Strip, a half million in Israel, and the remaining 1.5 million Palestinians scattered throughout the Arab world, North and South America, and Europe. Since the Palestinians were dispersed, however, Palestine has continued to exist in the collective consciousness of its people. Edward Said, an eminent scholar at Columbia University and a member of the Palestine National Council (the legislative arm of the Palestinian Liberation Organization), describes this collective consciousness and the impetus for Palestinian nationalism: A child born since 1948. 1948... asserts the original connec- tion to lost Palestine as a bit of symbolic evidence that the Palestinians have gone on regardless: He or she would have been born there but for 1948. The disper- sion of Palestinians, the refugee camps, keep alive an image of the world of the old Palestine.i This collective consciousness is immediately obvious to anyone who encounters the Palestinian community. In the refugee camps people live on the streets named after the village from which they fled. In the United States, Palestinians belong to the Ramallah Club, el Bireh Society, or Bethlehem Society, organizations named after their home cities. In this way they keep alive the memory of their homeland. Israeli " women in black " in West Jerusalem protesting their government's policies in the West Bank and Gaza. Signs in Hebrew and Arabic read " End the Occupation. " Roots of the Intifada In the 1967 war in which Israel defeated surrounding Arab countries, Israel wrested control of the West Bank (until then under the control of Jordan) and Gaza Strip Palestinian - Israeli relations have worsened through a history that includes five wars and a vicious cycle of violence, terrorism, and repression. (until then under Egypt's control), and imposed military law in these territories. Abba Eban, the former Foreign Minister of Israel, has described the situation of Palestinians living under occupation this way: It is extraordinary to find so many diaspora Jews indif- ferent to whether or not Israel is to be a land of double jurisdictions, or whether there is a Jewish equality. The Palestinians in the West Bank and Gaza cannot vote or be elected to anything, have no juridical control over the government that rules their lives, have no appeal fiZ oelZ,L oe,Z,L ------ fiZ oelZ,L fiZ oe,Z,L Y Visuals SAL Impact /Courney Andrew against the judgments of military courts, are not free to leave their land with assurance of the right to return, are not immune, as are their Jewish neighbors, from such penalties as expulsion or the blowing up of homes or administrative detention, have no flag to revere, and do not possess the same economic and social conditions as their immediate Jewish neighbors. The deep and pervasive repression against Palestinians by the Israeli military is one of the most significant fac- Young Palestinian women attend school in Jabalya refugee camp, Gaza. tors leading to the Palestinian uprising (intifada) in December 1987. In addition, Palestinians in the West Bank and Gaza concluded that the United States and Israel were hostile to the notion of an international peace conference to resolve the conflict - an idea supported by most Western countries - and that Arab countries were obsessed with their own problems, particularly the Iran- Iraq war. For many Palestinians the Arab summit held in Amman in November 1987 was but another indication that Arab governments placed insufficient emphasis on resolving the Palestine question. As one Palestinian activist in the West Bank told me in December 1987, " It's hard enough for Arab governments to develop a strategy to deal with their own top priorities. When we saw that our situation was moved to a low priority, it was the signal that we'd better rely on ourselves. " As a result of these long term - and more recent frustra- tions, demonstrations finally erupted in the West Bank and Gaza in December 1987. It soon became apparent that the anger over the occupation was deep enough to draw all segments of Palestinian society into either par- ticipating in or supporting the uprising. The Israeli military has sought to quell the intifada by intimidating Palestinians through harsh repression. This strategy has backfired and has only fueled young Palestinians'rage, making them more determined to con- tinue the intifada. Palestinians since the mid 1970's - have undeniably sanctioned the Palestine Liberation Organization as their sole, legitimate representative. The PLO serves as an umbrella political organiza- tion uniting all the signifi- cant Palestinian groups. Attempts by Israel and the United States to bypass the PLO in negotiations simply haven't worked because to Palestinians the organiza- tion represents the symbol and the embodiment of self- determination - whose reality would entail a state of their own, a flag, a pass- port and the preservation of Palestinian identity. Any attempt to bypass the PLO is perceived to be an effort to undermine Palestinian self determination -. While examining the plight of the Palestinians living under occupation, it is important to note that Palestinians have faced extreme difficulties living in Rick Guardian Reinhard / other parts of the Middle East. They are a minority subgroup within most Arab countries and therefore are feared. Living conditions, and indeed survival itself, are extremely precarious for Palestinians in Lebanon, where It is the harsh conditions under which they live in both Israel and Arab countries that drive Palestinians to demand a state of their own. they have been massacred, made homeless, and live under constant threat. Palestinians face surveillance and human rights abuses in Syria, Jordan, and other Arab countries as well. Yet it is the harsh conditions under which they live in both Israel and Arab countries that drive them to demand a state of their own. Fall 1989 Health / PAC Bulletin 2299 Israel's Insecurity Israelis live in a constant state of insecurity. Every bomb that is thrown, every bus overturned on a moun- tainside, and every civilian stabbed is a reminder to the average Israeli that Palestinians are their enemy; and that Israelis live in a constant state of insecurity. enemies are to be both feared and challenged because, in fact, they can do and have done harm - . While the Israeli government has misused their distrust to justify wrongful government actions, the fear that Israelis have of Palestinians and Arabs is real, based upon experience, and cannot be underestimated. Israeli perceptions of Palestinians cloud their ability to hear peace proposals when the PLO makes them. For example, Israeli public opinion polls have consistently shown that a majority of Israelis believe their govern- ment should talk to the PLO if the organization recog- nizes Israel's right to exist, renounces terrorism, and agrees to live at peace with Israel. The PLO's chairman, Yasser Arafat, did just that in a press conference on behalf of the PLO in Geneva in January 1989; yet Israeli public opinion polls taken in mid 1989 - indicate that only 16 percent of the Israeli public believed him. Clearly, the PLO faces a formidable challenge in overcoming fear and suspicion and building Israeli support for its peaceful goals. Israelis need more than reassurance; they need to know in a way that transcends mere words, that Arafat and the PLO truly mean a lasting, comprehensive peace in which the conflict is finally put to an end. Statement of Ownership, Management and Circulation (required by 39 S.S.C. 3685) The Health / PAC Bulletin, publication number 179051, is published four times per year in the spring, summer, fall and winter. Subscriptions are $ 35 per year for individuals, $ 45 for institutions. Mailing address: 17 Murray Street, New York, NY 10007. Owner and Publisher: Health Policy Advisory Center at the same address. Executive Editor: Joe Gordon, at the same address. CIRCULATION Average no. copies each issue during preceding 12 months Actual no. of copies of single issue nearest filing date Total no. copies Paid circulation 1. sales through dealers and carriers 2. mail subscription Total paid circulation Free distribution Copies not distributed Return from news agents Total 2300 210 1600 1810 45 445 0 2300 2300 344 1509 1853 50 397 0 2300 While the security issues are real and urgent for the Israeli public and the government, ideological issues and political divisions within Israel are also factors in the Israeli government's refusal to negotiate with the PLO. The politics of Israel today reflect a dramatic division within the country over whether Israel should exist as " Greater Israel " (i.e., Israel before the 1967 war plus the occupied territories of the West Bank, Gaza Strip, and Golan Heights) or whether Israel should negotiate a terri- torial compromise with the Palestinians and Arab gov- ernments in order to secure its borders and future. It must be understood that the debate is not between right- wing loyalists and a fringe minority; it is taking place within the establishment of Israeli society and is a major factor in the composition of the current coalition govern- ment consisting of the deeply divided Labor and Likud parties. The Israeli Palestinian - conflict is a contest between two competing national movements, each having long and legitimate claims to the same land. Israel is facing other problems as well that probably cannot be resolved until the conflict with the Palestinians is ended. The most serious is its economic state. Israel's economy is in shambles, in part because of its large defense budget and the need to increase the number of troops in the West Bank and Gaza since the intifada. An indicator of Israel's economic woes is the increase in the rate of unemployment since the intifada (now at 10 per- cent) with an even higher rate (20 percent) in " develop- ment " towns towns - that are traditionally working class. The Ways to Peace The proposal for a two state - solution has gained wide international support because it represents the best pos- sible solution to the conflict. In order for there to be peace, the government of Israel and the Palestine Liberation Organization (the only credible representative for Palestinians) must negotiate a comprehensive peace agreement based on terms that are mutually acceptable. Specific issues on which there will have to be a treaty include security, an end to the occupation, trade, move- ment of goods and people, water, and a transition period that builds confidence between the parties. The Palestinian National Council adopted the two- state solution as the basis of its declaration of indepen- dence in 1988, and Arafat underscored PLO support for this approach at a 1989 speech at the UN General 350 Health / PAC Bulletin Fall 1989 We March Again in Jerusalem You Cannot Stand Aside and Do Nothing. YOU TOO ARE PEACE NOW! 7 ae ee eo! eee = Emil Grunzweig and comrades in Peace Now march: the Fifth Anniversary. 1. Peace Now calls for immediate elections for municipalities and local councils on the West Bank and Gaza. 2. The precondition for elections the cessation of violence on the West Bank and in Gaza, and of terror from outside Israel. 3. The elections should take place within two months. Until that time, Israel should cease expulsions, release those incarcerated during the uprising, and permit the reunification of Palestinian families. 4. Elections should take place under supervision, in order to guarantee full freedom to choose and be chosen. 5. A delegation should be selected from among the chosen candidates. With other representatives from the territories, those chosen should join the Palestinian - Jordanian delegation to negotiate a peace agreement with Israel, which should determine the future of the territories, on the basis of mutual recognition. Assembly earlier this year. Within Israel, the peace move- ment has adopted the two state - solution as the basic demand in its peace program. In Israel, roughly 50 percent of the public voted for political parties that favor some compromise with the Palestinians. Approximately one quarter - of the Knesset as well as a significant number of former Israeli military generals support a two state - solution. The Jaffee Center for Strategic Studies in Tel Aviv, an organization headed by a retired Israeli general, has just written a report called Options for Israel, which says that a two state - solution, while not a remedy to the Palestinian Israeli / problem, is nonetheless the most practical approach. The cautious and renowned defense analyst for Ha'aretz (Israel's " New York Times ") has concluded the same. In addition, the largest mass peace organization in Israel, Peace Now, has adopted the two state - solution as the basic demand in its peace program. Health care advocates who want to see an end to the killing and suffering in Israel and the occupied territories must support the rights of both the Israeli and Palestinian people to live securely within mutually rec- ognized boundaries. To support one side of this conflict against the other only perpetuates the cycle of violence that plagues both peoples. Y' 1. Edward Said, Question of Palestine, New York: New York Times Book Co., 1979. 2. Abba Eban, " Opportunity Squandered, " Jewish Frontiers (November- December 1987). MARCH WITH US! Now Date: Saturday night, February 13, 1988. Time: 7:00 p.m. Place: Wingate Circle (Salame Circle), Jabotinsky Street Peace of | lZL oeCourtesy Ls Peace Now ad published in the December 2, 1988 Jerusalem Post, setting forth its pro- posals for settling the conflict. Fall 1989 Health / PAC Bulletin 31 A Magazine for Health Rights The policies of Ronald Reagan and George Bush have created the greatest health inequities this nation has ever known. We live in the shadow of epidemic hunger, homelessness, and drug addiction. The health care status quo can and must be changed, and the Health / PAC Bulletin is dedicated to making health care the inalienable right of all citizens, regardless of their income, + EMERGENCY Rosenthal Rosenthal Rosenthal Mel illness, race, gender, sexual orientation, abilities, or disabilities. The Bulletin is widely recognized as the only health care journal that routinely exposes the powerful corporate, political, and professional forces which are misallocating the precious resources of the nation's largest industry. If you want to know what you can do to restore health rights to the top of the nation's agenda, then join the thousands of concerned readers who look to the Health / PAC Bulletin for ground breaking - reporting, criticism, and analysis. eee" Yes, I want to receive the Health / PAC Bulletin. i i [Individuals $ 35 Y' Institutions $ 45 Y' 2 years $ 70 Y' Student / low income $ 22.50 | i I want to help Health / PAC support the fight for health rights. Enclosed is my tax deductible i contribution of Y' $ 15 |. $ 25 | $ 50 | Y' 100 $ Y' other | Name ] Address City i State | Charge: i Number i Exp. date Zip. Y'Y'Y' Vi|si a Mastercard I Signature i Send your check to Health / PAC Bulletin, 17 Murray Street, New York, NY 10007 a In this Vital Signs column, Dan North, a veteran labor journalist at Local 1199, and Dave Newman, a shop steward and rank - and - file leader in CWA Local 1101, report on two impor- tant labor struggles in which health care issues are central. Hospital Workers Win In the jubilation that followed the October contract victory in which Local 1199, Drug, Hospital and Health Care Employees Union won major wage increases from New York City's League of Voluntary Hospitals, Mount Sinai Hospital housekeeper Jos Gomez summa- rized the five mont-h lo-n g negotia- tions this way: " If we'd gone out on strike July 1 [when the previous con- tract expired] it would have been bad. But we got together and built the pressure and, little by little, drops of water split the rock. " Gomez's drops of water might have seemed like a downpour at times, with tens of thousands of hos- pital workers marching through the city during the summer; support from John Cardinal O'Connor, Jesse Jackson, David Dinkins, and the majority of New York City's delega- tions to Congress and the state legislature all amplified through extensive media coverage. But Local 1199 won because it stubbornly maintained an innovative three pronged - strategy that eroded and finally broke apart a collective hospital management that initially seemed rock solid. First, rather than immediately seeking a traditional all out - strike, 1199 conducted two one day - strikes in July and a three - day strike in August. This was crucial, because the extent of members'militancy was an unknown quantity when the contract expired. Union members were wary after their disastrous 47- day walkout in 1984 under different leadership. But the tremendous turnout on July 11 for the first one- day strike, rally, and march to the headquarters of the League of Voluntary Hospitals exposed a huge reservoir of members'anger waiting for expression. Second, newspaper ads publicized support by hundreds of political leaders for 1199's position that a fair contract for the union would alle- viate understaffing and ease the city's hospital crisis. Politicians cer- tainly took note when 1199 sus- pended contract activities in early September and devoted an all out - effort to David Dinkins'victorious campaign in the mayoral primary, putting more than 2,000 volunteers into the streets. Third, the union exploited man- agement's disunity, steadily under- mining the hard - line position of hospital management hawks. The first crack appeared with 1199's set- tlement with the Catholic hospitals on July 7. It reached its most dra- matic point in the pre dawn - hours of October 4, as hospitals, under a strike deadline, bolted from the League to line up behind a separate peace forged by Presbyterian and Beth Israel Hospitals. Each of these strategies played its part. And, as members'conscious- ness of their own power was en- hanced by each previous successful action, the union's leadership was able to advance bolder strategies. The big story of 1199's contract vic- tory was the slow, steady trans- formation of an initially wary membership into an active and uni- fied force. -Dan North NYNEX Puts Health Benefits on Hold As the price of medical insurance rises by an estimated 20 percent each year, corporations are increas- ingly seeking to control costs by shifting the burden of health care coverage to their workers. Sixty thousand telephone workers, mem- bers of the Communications Workers of America (CWA) and the International Brotherhood of Electrical Workers, went on strike against NYNEX in early August. Medical insurance is the major issue of the dispute. NYNEX demanded that workers pay an increasing portion of medical insurance premiums each year, up to $ 35 a week. When this cost- shifting is factored into the proposed miniscule wage increase, many workers would actually suffer a wage cut. The company rejected Fall 1989 Health / PAC Bulletin Vital Signs 33 CWA's current proposals to contain medical costs without forcing workers to pay more. NYNEX man- agement doesn't really care about holding down rising medical costs- it simply wants workers to pay more of the bill. A key CWA cost containment - pro- posal calls for establishing a pre- ferred provider organization (PPO), which would offer increased cov- erage with no added cost or out - of- pocket expense. In return, workers would be required to use only selected doctors and hospitals. Clearly, the PPO approach is not a panacea. Workers are concerned that health care providers with whom they have built good relationships over many years may not be part of the new network. We resent the idea of paying additional hundreds of thousands of dollars to continue seeing doctors we know and trust- if we can afford their services at all. Yet, no matter how good our cur- rent medical coverage is, many members, especially single parents, cannot afford to pay doctors up front and wait to be reimbursed by the insurance company. Many workers also lack regular health care pro- viders. By eliminating out pocket - of - expense, a PPO could make it easier for many telephone workers to get medical treatment. Regardless of its effects on dif- ferent groups of workers, the PPO proposal does not address the funda- mental causes of the health care crisis; nor does it offer any solutions. In fact, it may herald a further class division of the health care system, with PPO's and other managed care systems supplying inferior treatment for working - class and poor people, and elite, expensive, " unregulated " doctors providing first - rate medical service to those who can afford to pay for it.Y' -Dave Newman Photgraphy Miler 34 Health / PAC Bulletin Some of the 35,000 members of Local 1199 who marched in July in a one day - strike action, led by Reverend Jesse Jackson (holding flag) and 1199 President Dennis Rivera (to right of Jackson). Fall 1989 LOOKING FOR A FEW GOOD ISSUES? HEALTH / PAC BU Petes Advisory Cen The Hospital Crisis: New York City's hospital system is experiencing a crisis of unprecedented proportions. Policy analysts examine what's unique about the situation. there compared to other cities. across the country. Are there viable, equitable solutions at hand? The authors - drawn from labor, the municipal hospital system, and the consumer movement- explore these issues and the reciprocal relationship between hospital ills and the social ills of the city, the state, and the country. Illustrated by Timothy McCarthy. Minorities and AIDS: This special issue reports on grassroots minority organizations in major U.S. cities engaged in the fight against AIDS. Articles include. an interview with a young Puerto Rican man with ARC, an account of a social worker's efforts to provide care in a hospital AIDS unit, and a review of Randy Shilts's And the Band Played On. Illustrated by Frances Jetter. BEYOND SICK Chy's HEALTH / PAC BULLETIN DARING TO CARE The struggle for health in South Africa HEALTHPACOLLE 1990 Health Rights in South Africa: In " Daring to Care, " Health / PAC reports on health care workers aiding the victims of the Pretoria regime's brutality. South African health professionals relate their organizational struggles to care in a country where the very act of seeking medical assistance can place one's life in jeopardy. Includes government - banned photographs. Send $ 5 for each issue (12 $ for institutional subscribers) with your name, address, the issue (s) desired and your check or money order to: Health / PAC Back Issues 17 Murray Street New York, N.Y. 10007 Visa and MasterCard will be accepted for orders of 15 $ or more. Please be sure to include the full account number and expiration date. Inside: Israeli and Palestinian physicians fight health abuses page 21 Providing health care under occupation page 24 The context of the Palestinian Israeli - conflict page 27 Health Policy Advisory Center 17 Murray Street New York, New York 10007 NOTE TO SUBSCRIBERS: If your mailing label says 8801, your subscription expires with this issue. 2nd Class Postage Paid at New York, N.Y. 1