DENIED

# D EN IED # D E NI E D HARASSMENT OF PALESTINIAN PATIENTS APPLYING FOR EXIT PERMITS June 2015 Written by: Mahmoud Abo Arisheh Research: Mor Efrat, Mahmoud Abo Arisheh Editing: Reut Katz Translation: Lahad Zazar Design: David Moscovitz Photographs: Activestills, Anas Hamra Special thanks: PHR team: Nadav Even Horev, Hussam Issa, Hadas Ziv, Ran Goldstein, Assaf Kinzer Bardugo, Lital Grossman. Members of the PHR-Israel board of directors: Dr. Galit Artom, Dr. Harel Arzi. Palestinian human rights organizations: Al Mezan Center for Human Rights, Gaza Community Mental Health Programme, A-Damir Organization-Gaza. “We would like to inform you that after considering the request, the competent authorities have decided to turn it down for security reasons which cannot, naturally, be divulged”. Gaza DCL TABLE OF CONTENTS 5 Summary 8 Background: freedom of movement and the right to health in the occupied territories 11 Key data 19 Abusive ISA interrogations 23 Patients who died awaiting treatment 26 Bureaucracy at the service of the occupation 29 Conclusions and recommendations 32 Appendices Summary In pursuing its work to fulil the right to health of the Palestinian residents in the occupied territories, Physicians for Human RightsIsrael (PHR-Israel) monitors the way in which Israeli policy is adversely affecting their health, in times of conlict as well as in routine. During the attack on the Gaza Strip in July-August, PHR-Israel documented attacks on ambulances, targeting of medical teams and facilities, and instances where the evacuation of injured people was delayed. A semblance of “calm” prevails ordinarily, but it is only illusory: In reality, Israeli control over the Palestinians only takes on a different form, one that is daily and even transparent, yet no less painful and deadly. In this report, we shall look at some of the mechanisms routinely in place to achieve control, one that can largely explain the bouts of ighting that erupt between Israel and Gaza every year or two. One of the key mechanisms employed by Israel to keep the Palestinians in check is the obligation to obtain an exit permit in order to travel between the West Bank and the Gaza Strip, East Jerusalem and Israel — even when doing so to get vital medical care. Each year, approximately 200,000 Palestinians from Gaza and the West Bank seek approval from the 5 Israeli authorities to travel for medical needs. The present report sets out the technical and substantial failures in the conduct of the Israeli coordination and liaison authorities as regards the freedom of movement of Palestinian patients and their companions, including their being required to report for security interrogations by the ISA (the Israeli Security Agency, Shabak) as a prerequisite for being let out for medical treatment; their being delayed in checkpoints en route to treatment; as well as rejection of applications for exit permits, which prevents the applicants from getting needed medical treatment and often leads the a deterioration in their condition and even premature death. Roughly 20% of applications made annually for a medical exit permit are rejected. Some of these cases are brought before PHR-Israel, which challenges the decisions of the Israeli authorities in order to get them to issue exit permits for the applicants. In 2014, the Occupied Palestinian Territory Department of PHR-Israel received 306 requests, of which 246 concerned denied or delayed applications for permits (while the rest were related to follow-ups on previously-rejected requests, information queries and other matters). In 47.5% of cases (117 requests), the decision to deny applications were overturned following PHRIsrael’s intervention. This means that half the rejections were found to be unjustiiable even by the security standards laid down by Israel itself, since the ISA went back on its decision and issued a permit as per PHR-Israel’s request. Of the total number of requests, 300 came from patients, 246 male and 54 female; six others were from foreign medical practitioners seeking entry into Gaza. Over two thirds of the requests (214) came from the Gaza Strip, slightly less than a third (87) from the West Bank, and one from East Jerusalem, in addition to ive received from abroad. Some 56% of requests were from adults aged 18-45; about 25% concerned transit for children under 14; about 17% were from adults older than 45; and a small number of requests (2%) were made on behalf of minors above the age of 14. Approximately 38% (117) of all requests had to do with refusal to issue an exit permit, while some 42% (129) were occasioned by a long delay in providing answers. In addition, 23 requests came from cancer patients; eight from patients suffering from cardiovascular diseases; 24 from eye patients; 10 from patients with back problems, in addition to 23 requests from patients suffering from other orthopedic conditions. Other requests had to do with neurology (12), urology (11) and other diseases. PHR-Israel represents applicants whose application for an exit permit was turned down, by re-applying to the authorities, clarifying the patient’s medical condition and emphasizing the signiicance of the 6 treatment required by means of opinions from volunteer physicians; in certain cases, legal means are resorted to. In addition to patients and their companions, PHR-Israel provides assistance in obtaining exit permits for medical teams as well. As part of its advocacy activity in 2014, PHR-Israel was able to make the coordination and liaison authorities adopt two new and important procedures. One was that the District Coordination and Liaison Ofice (DCL) at Erez Checkpoint would handle patient applications from displaced Palestinians who had left the Territories in 1967 and returned later, which had previously not been received at all; the other was to allow Palestinian fathers entry into Israel in order to be present when their partners delivered their babies. These changes in procedure are important, certainly making life easier for some of the applicants in dealing with the bureaucracy of the Israeli authorities, yet a much broader change is called for, which must include the elimination of all restrictions on the right to health of the residents of the occupied territories. One simply cannot accept a reality where individuals are denied access to the medical treatment they need due to political considerations. Israel’s use of practices limiting or preventing access to medical services as a tool to oppress the Palestinians must cease. In this report, we shall sum up a year of activity involving the monitoring, accompanying and representation of applicants seeking free movement for medical purposes, and analyze the trends in the policies implemented by the Israeli authorities with regard to the granting of such permits. The report constitutes a kind of qualitative research about the problems and obstacles plaguing those who apply for a permit and describes the arbitrary way in which Israel limits the right of Palestinian residents to receive medical care, even when it is potentially life-saving. 7 Background: Freedom of movement and the right to health in the occupied territories The right to health of the Palestinians residents living in the West Bank and the Gaza Strip is under constant threat. Mired in a state of chronic crisis for many years, the Palestinian public health system is unable to cater for all of the inhabitants’ needs. One of the main reasons for this is Israel’s control of the occupied territories and the restrictions it imposes on the freedom of movement of patients, ambulances and medical teams.1 The Palestinian territories are divided into three major regions: the Gaza Strip, the West Bank and East Jerusalem. Israel has the power to allow or prohibit the passage of Palestinian residents between and within these three regions as it sees it. Consequently, the Palestinian health system also spans these three regions—that is, each one of the three has hospitals, clinics, patients and medical staff—but there is no free passage between regions and medical institutions. Israel’s control of movement and passage between the regions, coupled with its 1 For detailed analysis of the effects of Israeli control on the right to health of Palestinians in the West Bank and the Gaza Strip, see Mor Efrat, Divide & Conquer: Inequality in Health, Physicians for Human Rights-Israel, January 2015. 8 illegal annexation of East Jerusalem, has created a situation where the Palestinian Ministry of Health is unable to manage the three areas as a single unit. Palestinian residents requiring medical care in an institution located outside their region of residence need an exit permit from Israel in order to get there. This is most often the case when residents of Gaza and the West Bank are referred for treatment in East Jerusalem, home to six of the most advanced Palestinian hospitals. In many other cases, patients from Gaza are referred for treatment in the West Bank, for which they also need a permit to travel through Israel. Furthermore, each year the Palestinian Ministry of Health refers tens of thousands of patients outside the Palestinian public health system when the medical treatment they require is unavailable within the latter and in the region in which they live, be it in the West Bank or in the Gaza Strip. Referral means that the medical treatment is covered by the Ministry of Health within the framework of the private Palestinian health system, or in one of the neighboring countries — Jordan, Egypt or Israel. In 2013, approximately 61,500 patients received such referrals. Of these, some 37,500 needed an Israeli permit in order to carry out their referral.2 In order to receive a permit, an application together with medical documents has to be submitted to the Israeli coordination and liaison authorities, which are authorized to approve or deny it. PHR-Israel works to change decisions of Israeli authorities where a request for free movement for medical purposes is denied or where the answer is delayed to such an extent as to cause the patient to miss the medical appointment. PHR-Israel handles about 300 such requests each year, which represent only part of the Palestinian patients from Gaza and the West Bank who suffer from failures in the conduct of the coordination and liaison authorities working under the Coordinator of Government Activities in the Territories (COGAT). These failures hinder the right of the Palestinian residents to health, and sometimes even their right to life and dignity. Furthermore, the fact that PHR-Israel is able, in many cases, to bring about a change in the army’s decisions and have a previously-denied application for an exit permit approved following review indicates that the rejection had been unnecessary and unjustiied to start with. 2 World Health Organization, Right to Health: Crossing barriers to access health in the Occupied Palestinian Territory, 2013. 9 In this report, we analyze the requests received by PHR-Israel in 2014 from Palestinian patients whose applications for an exit permit had been turned down by the coordination and liaison authorities. Our aim is to show how the failures in the conduct of the coordination and liaison authorities — as well as the policy they serve — result in serious violations of human rights, primarily the right to health. 10 Key data In 2014, the Occupied Palestinian Territory Department of PHR-Israel received 306 requests, mostly from Palestinian residents in need of obtaining an exit permit from Israel in order to access medical treatment. A relatively smaller number of requests came from relatives who wanted to accompany or visit patients, and from medical practitioners who needed help obtaining an exit permit on their way to work or studies. Requests from patients were primarily received after their applications were rejected or delayed by Israeli authorities, despite having attached thereto, as required, referrals and the documents attesting to the Palestinian Ministry of Health’s commitment to pay for their treatment. In the course of the year, PHR-Israel recorded two cases of patients who died after being denied passage for medical treatments. Also recorded were two abusive ISA interrogations that patients were forced to attend as a condition for having their application for a permit considered, during which their rights were grossly violated. These cases shall be presented later on in the report. 11 Numb er of Reques ts 50 40 30 20 10 0 12/14 11/14 10/14 9/14 8/14 7/14 6/14 5/14 4/14 3/14 2/14 1/14 Dat e o f R equ est s Figure 1: Number of requests, by month, 2014 Gender of the Applicants Most requests are from men Of the 300 requests received from patients, 246 came from men and 54 from women. This igure is a likely relection of Israeli policy, which places tougher movement restrictions on men than on women. Male Female Medical staff Figure 2: Gender of Applicants More women applied for permits after the attack From the start of the year to the irst month after the attack on Gaza (JulyAugust 2014), women did not account for more than 20% of all requests put in with PHR-Israel. Starting in October, a sharp increase was observed in 12 the rate of female requests, ranging between 30%-40% of all petitioners during this time period. This change may be attributed to distress in the Gaza Strip’s health system, exacerbated following the attack, in such a way that limited even further the medical services available in the Strip and compelled more women to seek medical care outside the Strip. Applicants’ region of residence Most requests came from the Gaza Strip More than two thirds of requests (214) came from the Gaza Strip, whereas less than a third (86) came from the West Bank. In addition, ive requests came in from abroad and one from East Jerusalem. These numbers relect a trend that has been ongoing for a number of years, whereby the number of requests reaching PHR-Israel every year from the Gaza Strip far exceeds those coming from the West Bank.3 This has been the case despite the greater number of residents in the West Bank iling applications for exit permits on medical grounds than in the Strip, and despite the rate of applicants receiving a permit being also higher in Gaza than in the West Bank. R eg i o n o f Re s i de nce West Bank Gaza Strip Other Figure 3: Requests by region of residence Age of applicants Young adults are the most delayed age group throughout the year Roughly 56% of requests were received from adults aged 18-45; about 25% requests had to do with transit for children aged under 14; approximately 17% of requests came from adults older than 45, while only a small number 3 The reasons underlying this trend will be studied in the future by the PHR-Israel team. 13 of them (2%) were related to minors over the age of 14. The fact that most requests pertaining to delays or rejections of applications for permits came from adults aged 18 to 45, a group of the population usually considered healthy and less in need of medical services, suggests that the rate of refusals and delays encountered by this group is high in relation to the number of applications it puts in with the DCLs. This is probably due to the policy adopted by the Israeli authorities of imposing sweeping restrictions on this age group based on arbitrary security considerations. As a result of this policy, individuals with concrete — at times critical — medical needs might not get the response they need due to a sweeping security prohibition imposed upon them due to their age and gender, regardless of their personal security record. This, then, constitutes a form of collective punishment in violation of human rights and the rules of international law. A g e g r o up Boy/Girl (-14) Minor (15-17) Adult (18-45) Elderly (+45) Figure 4: Age of applicants Reasons for addressing PHR-Israel As previously mentioned, the great majority of requests coming in (246 of 306) were due to delays in answering applications on the part of the Israeli authorities or refusal to allow transit for patients. Delayrelated requests accounted for 42% (129) of all freedom-of-movement requests, whereas rejection-related requests accounted for 38% (117). In fact, there is not much difference between the two, since patients whose application for a permit is delayed rather than denied also lose their scheduled appointment as a result, and are therefore deprived of receiving medical treatment in reality. The remaining requests (60) were made for the purpose of obtaining information and explanations, 14 following up on previously-rejected applications and other matters. Eighty per cent of requests (246) came from patients and 12% from people wanting to escort patients (37). The rest came in from relatives who wished to visit patients (13), from medical staff (6) and others (4). R ea so n f o r r e q ue s t Other Rejection Delay Figure 5: Reasons for approaching PHR-Israel According to data from the World Health Organization (WHO),4 the total number of male and female patients whose applications were denied or delayed in 2013 was about 50,000. In the West Bank, 17% of the applications were denied and 3.5% delayed, totaling 20.5% of all applications, namely 48,449 applicants. In the Gaza Strip, 88.7% of applications were approved, 0.3% denied and 11% delayed, totaling 11.3% of applications denied or delayed, representing 1,546 applicants. Distribution of applicants’ medical problems In 2014, PHR-Israel received 23 requests from cancer patients and 8 from cardiovascular patients. This goes to show that even applications from patients with life-threatening diseases are delayed and denied. Eye diseases and orthopedic problems are not deemed serious medical conditions Further to a trend observed in recent years, this year too saw a large number of requests coming in from patients suffering from eye diseases (24) and orthopedic problems (33), ten of which had back problems. These data indicate that Israel is still pursuing its policy5 of not taking eye 4 World Health Organization, Right to Health: Crossing barriers to access health in the Occupied Palestinian Territory, 2013. On the triage of patients by the Israeli authorities, see: “Who Gets to Go? In Violation of Medical Ethics and the Law: Israel’s Distinction between Gaza Patients in Need of Medical Care”, June 2010. http://www.phr.org.il/uploaded/Microsoft%20 Word%20-%20PP%20-%20Hebrew.pdf 5 15 diseases and orthopedic problems — even those putting patients at risk for blindness or disability — as serious medical conditions warranting the grant of an exit permit for medical purposes. This kind of policy ignores the great distress of those aflicted by these problems without having the treatment they need available to them in their region of residence. The inability of the Palestinian healthcare system to address problems in these ields is also apparent from WHO data, according to which some 7% of medical referrals provided by the Palestinian Ministry of Health for medical treatments outside the public health system are in the ield of ophthalmology (eye medicine), whereas about 3% are in the ield of orthopedics. Following are excerpts from two opinions written by PHR-Israel volunteer physicians on two cases of patients whose applications for exit permits for the purpose of getting medical treatment were denied: A.A., aged 48, from Jabalia “Given the anamnesis, the physical examination and the imaging, the picture corresponds to disease of the cervical spine, manifest in bulging discs exerting pressure on the middle cervical spine and causing partial spastic paralysis in four limbs and sphincter-control disorder. I recommend urgent treatment by means of surgical intervention to remove the bulging discs and free the cervical spine, thus preventing serious, irreversible complications and mainly quadriplegia”. (Dr Raik Massalha, neurologist) N.A., aged 28, Khan Yunis “The above indings correspond to a ruptured anterior cruciate ligament, and in this situation, considering the applicant’s age, surgical treatment for reconstructing the ACL is recommended. Failing such surgical treatment, he will continue to experience pain and swelling alternatively, possibly also a sense of instability in the knee when walking. In addition, he will be exposed to the risk of accelerated degenerative changes in the knee. In order to prevent the disability and suffering that can be prevented surgically, he should be allowed out of the Gaza Strip to get the treatment he needs”. (Dr Harel Arzi, specialist orthopedist) 16 In addition, there were scores of requests from patients in the ields of neurology (12) and urology (11). A number of requests were also received in matters of pregnancy and birth (4), otolaryngology (6), infectious and chronic diseases (5) as well as other diseases. PHR-Israel intervention on behalf of applicants from the occupied territories High success rate in changing the decisions of the coordination and liaison authorities As mentioned, of the 306 requests received in the course of 2014, 247 were due to delayed or denied applications for exit permits put in by Palestinian patients. PHR-Israel appealed to the coordination and liaison authorities with regard to these patients, demanding that they go back on their decisions and approve their passage. Following our interventions, backed by opinions from volunteer physicians, 117 applications (47.5%) were approved after review, and the patients were granted exit permits. This high rate of success in changing the decisions of the Israeli authorities raises the suspicion that the decisions had been arbitrary and irrelevant to begin with. One of the requests received by PHR-Israel concerned a six year old girl from the Gaza Strip named Ritaj (pseudonym). Suffering from problems in the nervous system, Ritaj was invited for surgery at St. Joseph hospital in East Jerusalem at the end of October. Ritaj’s family put in an application to coordinate her transfer to Jerusalem, but was answered by the DCL that the application was “being processed”, even after the date of the scheduled operation had already passed. Upon receiving the request in November 2014, a PHR-Israel representative iled a complaint with the Erez DCL concerning the delayed handling of the request; this had the effect of accelerating things, and the patient was given an exit permit. This is one routine incident among many serving to illustrate how the applications of patients who clearly pose no security threat to the State of Israel might also be delayed without cause. There were also many cases where PHR-Israel’s intervention failed to change the position of the Israeli authorities and assist patients, who were left without an exit permit. Some of them converted the medical referral to Egyptian hospitals. While this frees them from depending on Israel for permits to leave Gaza Strip through Erez Checkpoint, the Rafah Crossing between the Gaza Strip and Egypt is also closed most days 17 of the year. Moreover, the public healthcare system in Egypt is not as good as that of Israel, Jordan, the West Bank and East Jerusalem. Other patients whose applications had been denied decided to give up on the referral and live with their disease. In two cases, after the authorities’ refusal to issue exit permits, and after exhausting the usual procedures, PHR-Israel appealed the decision in court, but legal action also failed to resolve the matter. In another case, the court accepted the appeal and overturned the authorities’ decision. In the case in question, Aiman (pseudonym), aged 37, resident of the West Bank, tried, from early October 2014, to obtain an exit permit in order to accompany his wife, a resident of Jaffa, for his son’s birth which was due in November. However, because he had previously stayed in Israel without authorization, he was deined by the authorities as “prohibited on criminal grounds” and his applications were denied. PHRIsrael intervened on his behalf, appealing the decision to the Israeli Civil Administration, but no reply was forthcoming. In the meantime, on 25 October 2014, the baby was born without his father being present at his birth, and PHR-Israel approached the Civil Administration again to request permission for the father to visit his son and support his wife. In the absence of any answers to these appeals, PHR-Israel took the matter to court with two demands: The irst was to have an exit permit issued to Aiman so as to allow him to visit his wife and son; the second was a principled demand to change the procedures so that Palestinian men would be allowed entry into Israel to escort women who were about to give birth. In February 2015, ive months after the initial request was submitted, the permit was granted and Aiman visited his family. In addition, the procedures were changed so as to allow fathers to accompany their partners during delivery.6 6 For the article published in Haaretz newspaper on the subject of the changed procedure governing the escorting of women about to give birth, see: http://www.haaretz.co.il/magazine/tozeret/.premium-1.2600076 18 Abusive ISA interrogations Since 2007, PHR-Israel has been documenting a particularly troublesome practice employed by the Israeli security services, whereby Palestinian patients applying for an exit permit on medical grounds are required to show up for ISA questioning at Erez Checkpoint as a prerequisite for considering their application. During interrogation, the patients are requested to provide information and/or become collaborators with Israel. In 2008, PHR-Israel issued a report on the subject, entitled “Conditional Medicine”,7 based on 30 testimonies by patients who had undergone such questioning. Over the course of the years since, more and more testimonies kept coming our way, indicating that this abusive policy of extorting patients by the ISA persists. According to the WHO, the number of patients called in for questioning has stood at around 200 per annum in recent years.8 Thus, in 2013, 199 Gazan patients were summoned for questioning, among them 170 men and 29 women (data for 2014 have yet to be released). 7 8 See: Ran Yaron, “Conditional Medicine”, Physicians for Human Rights, 2008. World Health Organization, Right to Health: Crossing barriers to access health in the Occupied Palestinian Territory, 2013 19 During 2014, PHR-Israel recorded 15 cases (5% of all requests) of Palestinian patients being summoned for ISA interrogation as a prerequisite for considering their permit application. Two such interrogations were particularly abusive, involving crude violations of patient rights. Collaboration with Israel as a condition for going out for medical treatment Rami Abu Jama’, a 31 year old resident of the Gaza Strip suffering from severe ear problems, applied for an exit permit in order to be treated at Al-Mezan hospital in Hebron. In February 2014, Rami received a inancial commitment and a referral for treatment from the Palestinian Ministry of Health, and had an appointment scheduled at the hospital. Accordingly, he submitted a number of requests to the Palestinian Civil Committee—the body responsible for receiving the applications from the Palestinian residents and forwarding them to the Gaza DCL — for the purpose of obtaining an exit permit. For many long weeks, Rami awaited an answer on his request, but was only told by the Civil Committee that the application was “being handled”, and this even after his hospital appointment had long elapsed. Rami scheduled other dates for treatment but missed those as well, as his request had not yet been approved. All that time his ears continued to give him a hard time, with a purulent infection in his left ear, and a putrefying hole in his right ear. Rami Abu Jama’ In June 2014, Rami was summoned for questioning by the ISA at Erez Checkpoint, to which he presented himself in due time. After being 20 interrogated, he recounted some dificult experiences he went through: Before going into questioning, the DCL people stripped him of his clothes and emptied his medication boxes, which made him experience a poignant sense of humiliation. Waiting for him in the interrogation room were three interrogators who sat facing him while he remained standing up without being offered to sit down. According to his account, the meeting included harsh words and accusations thrown at him, such as: “You’re a liar”, “Your friends are Hamas people”, etc. During the interrogation, Rami was asked questions pertaining to security issues, such as whether he had seen a military parade in the past, and what type of weapons the warriors were carrying. One of the investigators said to him: “You need to serve the State of Israel so that it serves you”, then opened the door and said: “Go to the hospital, but provided you help us and supply information”. Rami repeatedly replied that he had no information to give, and that he was an innocent civilian without any security record who just wanted to go out for medical care. The ISA investigators chose to take this answer as a refusal to collaborate with them and informed him that they would change his personal record to show two illegal entries into Israel, which would change his status to “denied on security grounds”, precluding him from receiving exit permits in the future. PHR-Israel approached the Gaza DCL on multiple occasions regarding this patient, appealing the decision to deny his application. The appeals were rejected. Rectal weapons search The patient, a 32 year old resident of the Gaza Strip, suffers from a ruptured cartilage in his right leg. According to the medical reports, he requires complex knee surgery, which is not feasible within the means available in the Gaza Strip. In January 2014, H.T. was referred by the Palestinian Ministry of Health for treatment at A-Najah hospital in Nablus. He was scheduled for an appointment at the hospital in May, when his application was not approved he re-scheduled for a later date in the same month. The patient iled a number of applications with the Palestinian Civil Committee for obtaining an exit permit, following which the Committee informed him that he would be summoned for questioning by the ISA. According to H.T.’s account, he arrived for questioning at Erez Checkpoint on 18 June 2014 at 08:00. At 12:30, after waiting for four and a half hours, he was taken in for questioning, which lasted another four hours, after which he was released home. 21 Prior to entering the Erez Checkpoint area, H.T. was searched electronically by means of a special system installed on site. He was then asked to take off all his clothes, including his underwear, and two “security oficers” in civilian clothes searched his body manually. One of them inserted his inger into H.T.’s rectum, and when the patient resisted and asked him what he was doing, he was told that he was making sure that he had no weapon in his body. The patient reported a “torture-like ordeal, and humiliation that was hard to describe”. After the search, H.T. was taken for a long tour through the underground section of the Checkpoint, which caused him exhaustion and pain from the tear in the cartilage aflicting him, which was the reason he was referred to surgery. The walk through long underground corridors made him anxious, thinking that they might be taking him to a deserted area in order to torture him. During questioning, H.T. was asked about his personal inances and presented with information regarding all his family members. The investigators showed him pictures of strangers and asked him if he knew them. At the end of the meeting, he was told that there was basically no problem and that he could schedule a new appointment and leave for the treatment, but since then he was given several appointments that he was not cleared to leave Gaza for. One of the applications that H.T. iled in recent months was met with a positive response and he was granted a permit, but when he arrived at Erez Checkpoint, the soldiers took away his permit, and he was sent back to the Gaza Strip. To date, H.T. has not yet undergone the surgery he needs. 22 Patients who died awaiting treatment In this part, we will present two cases of Palestinian patients, one of them a resident of the West Bank and the other a resident of the Gaza Strip, whose passage to East Jerusalem for the purpose of receiving medical treatment was delayed for many weeks; they ended up dying before making it to treatment. Displaced woman dies after being denied access to medical treatment Fatma abu Zarqa, a 77 year old displaced Palestinian woman living in the Gaza Strip, previously had breast cancer and underwent surgery to remove the tumor in 2012. A routine monthly checkup found that the disease had struck again, this time around the mouth and gums. In November 2013, the patient was referred by the Palestinian Authority for chemotherapy at the Augusta Victoria hospital in East Jerusalem. Her relatives tried time and again to apply on her behalf for an exit permit so that she might access treatment, but their applications were denied on the spot based on a rule applied in the Gaza DCL, under which displaced Palestinians who went back to reside inside the Gaza Strip would not be allowed entry into Israel. 23 Fatma was one of about 100,000 Palestinians—around 30% of the Strip’s residents at the time9 — who were forced to leave their homes after the Israeli occupation in 1967. Since the 1990s, especially after the Oslo Accords were signed,10 tens of thousands of displaced Palestinians started returning to the territories, which had become part of the Palestinian Authority. The late Fatma abu Zarqa also went back to the Gaza Strip after her husband’s death and lived there with relatives. As far as the Palestinian authorities were concerned, she was considered a resident of the Gaza Strip for all intents and purposes, complete with identity card from the Palestinian Ministry of Interior and medical insurance; but her status as a resident of the Palestinian territories was not recognized by the Israeli authorities, which is why her requests for exit permits were not even processed. And so, on 7 February 2014, Fatma died of her disease, after being prevented from leaving for East Jerusalem to receive medical treatment which might have extended her life. All of PHR-Israel’s efforts in dealing with the Israeli authorities failed to bring about a change in Fatma’s situation. After her death, PHR-Israel continued to ight the procedure discriminating against the displaced Palestinian residents, which culminated in a decision, on 10 February 2014, to cancel the procedure and accept applications for permits from the displaced, just like the rest of the Palestinian population. Patient dies after many bureaucratic obstacles prevent his access for treatment Fadel abu Hashem, aged 45, resident of Khirbet A-Sarra in the West Bank, Hebron area, suffered from renal failure and was hospitalized for a number of weeks in serious condition. Fadel was referred by the Palestinian Ministry of Health for treatment in Maqassad hospital in East Jerusalem, and was accordingly summoned by the hospital for 25 December 2013. The patient’s family submitted an application for an exit permit to the DCL, but this was turned down on the very day that he was supposed to set out for his treatment, on the grounds of a “security prohibition”, as his family was told. It should be noted that the deceased was an amputee who had lost his arm and also had diabetes, was recognized to have 72% disability, which casts serious doubts over the potential security threat he supposedly posed to the State of Israel. 9 10 Mussa Sahma, “A-siraa’ a-dimografi fi falestin al-muhtallah” [The Demographic Conflict in Occupied Palestine], 1986, pg. 58. See: Palestinian Central Bureau of Statistics, The Residents in the Palestinian Territories 1997-2025, Ramallah, 1999, pg. 23. 24 On 5 January 2014, after receiving the request regarding the patient, PHR-Israel addressed the Civil Administration ombudsman in the West Bank, demanding that they act to issue an exit permit for him. The Civil Administration replied by telephone that the medical opinion attached to Abu Hashem’s application was not detailed enough, and that the patient had to re-apply and produce a detailed medical document. This, in contradiction to the answer previously given to the patient’s family — that the application was denied due to a security prohibition— and despite the fact that his serious condition was well relected in the medical report provided in his regard as well as in the referral of the Palestinian Ministry of Health. This answer was passed on to Fadel’s family. At this stage, his health condition deteriorated, and this fact, coupled with the family’s feelings of despair with the ongoing bureaucratic red tape surrounding the application for the permit, led them to decide against a renewed attempt to ile an application, assuming that it would again be to no avail. Abu Hashem died on Thursday, 15 January 2014, leaving behind him a wife and three children. 25 Bureaucracy at the service of the occupation PHR-Israel has been working for many years vis-à-vis the coordination and liaison authorities subordinated to the Coordinator the Government Activities in the Territories at the Ministry of Defense, with a view to protect the right to health of residents of the occupied Palestinian territories, with an emphasis on access to medical services. As part of this activity, PHR-Israel documents and monitors the way in which arbitrary procedures used by the army structures, as well as ulterior political motives, inluence and adversely affect the residents’ ability to have their medical needs adequately met. Gazan patients paid the price of the UN’s recognition of the State of Palestine Patient applications for an exit permit must include, as per instructions of the Israeli DCL at Erez Checkpoint, a document from the referrals unit at the Palestinian Ministry of Health stating the medical institution to which the patient is being referred and the amount of inance approved to cover the cost of treatment. Since the UN declaration recognizing the State of Palestine in November 2012 — a declaration not recognized by the State of Israel—the government ministries of the Palestinian Authority have changed their stationary to read “State of Palestine”. 26 On 11 February 2014, oficials from the Gaza DCL informed the Palestinian Civil Committee, responsible for coordination with the Israeli side, that patient applications for exit permits would no longer be accepted, as they include documents carrying the “State of Palestine” logo. This decision led to a drastic increase in the number of requests received at PHR-Israel’s ofices: 33 new requests received in February and 48 in March, almost double the monthly average, which stood at 25 in 2014. This is an abusive decision that is purely politically motivated and indicative of exploiting patients’ plight to serve the government’s political needs. This policy was directly detrimental to scores of Palestinian patients before the Israeli authorities retracted their decision a few weeks later. Referring PHR-Israel representatives to the Palestinian Civil Committee A major, frequently-recurring problem in dealing with the Gaza DCL is their practice to respond to PHR-Israel queries by referring PHR-Israel representatives to the Palestinian Civil Committee, the body in charge of coordinating between Gaza’s residents and the Israeli DCL. The Civil Committee is the entity forwarding patients’ applications to the DCL and the latter’s replies back to the patients. PHR-Israel approaches the DCL only after a negative answer is received to the initial application or an answer is delayed, its intervention constituting in fact a second stage of appeal and renewed application. Referring PHR-Israel representatives back to the Civil Committee only to receive the same answer given to the Committee — as well as rejecting applications without providing the reason for it —actually neutralizes the appeal function and thus limits even further the tools available to Gaza’s residents in trying to obtain permits and access the medical treatment they need. In February-March and September-October, for example, most of PHRIsrael’s appeals to the Gaza DCL, both by telephone and via formal letters, resulted in oral or written referrals of PHR-Israel representatives to check the status of applications with the Palestinian Civil Committee, leaving many patients with no effective response to their applications and no recourse to appeal the decisions made in their respect. PHR-Israel turned to the Gaza DCL several times demanding that they put an end to this conduct, but these requests remained without an adequate response. 27 Inaccessibility of the coordination and liaison authorities In the course of the year, many organizational dificulties arose in working with the coordination and liaison authorities in both the West Bank and the Gaza Strip, foremost the scant availability of ombudsmen on the phone. This was highly detrimental to PHR-Israel’s ability to assist patients, particularly in urgent cases requiring immediate response. Many appeals sent by PHR-Israel to the coordination and liaison authorities remained unanswered, while others were answered very late — sometimes a month late or even more — and this only after sending written reminders and bringing pressure to bear over the phone. Even when an answer was received, it often contained incorrect and irrelevant information. On several occasions, PHR-Israel took up the matter with the parties in charge thereof, including COGAT, in letters detailing the dificulties involved in dealing with the coordination and liaison authorities. Some of our queries were answered with irrelevant letters that ignored the allegations made; others were never answered.11 11 Details can be found in the letters attached as appendices to this report. 28 Conclusions and recommendations The information presented in this report points to the policies restricting the free movement of thousands of Palestinian residents requiring medical treatment outside their region of residence. According to the most recent data from the WHO,12 in 2013 approximately 250,000 Palestinians submitted applications for exit permits to the Israeli authorities in order to access medical treatment or escort a patient, and around 20% of all such applications were denied or delayed. Similar data were recorded in recent years. What this means is that thousands of applications by Palestinian patients are delayed or denied every year by the Israeli authorities, affecting their right to health and their right to life and dignity. In 2014, PHR-Israel handled dozens of requests from such patients, which demonstrate the numerous failures in the conduct of the coordination and liaison authorities, and mainly in the policy that governs their work. Since the occupation of the Palestinian territories in the West Bank, the Gaza Strip and East Jerusalem in 1967, the State of Israel has put in place various mechanisms to control and oppress the Palestinian residents. 12 World Health Organization, Right to Health: Crossing barriers to access health in the Occupied Palestinian Territory, 2013. 29 The coordination and liaison authorities, which impose restrictions on the freedom of movement of residents — among them tens of patients, injured and disabled individuals seeking access to medical care — also act as part of a complex control mechanism which deepens and perpetuates the occupation. Continued Israeli control in the territories inlicts on going suffering on Palestinian residents in all spheres of life and prevents the development of the Palestinian healthcare system as an independent, accessible system. The conduct of the coordination and liaison authorities clearly derives from the government’s policy towards the occupied territories and frequently changes in accordance with the approach that the government decides to take towards the Palestinians. PHR-Israel’s high rate of success (47.5%) in turning around the decisions of the coordination and liaison authorities regarding applicants whose application for a permit had been initially denied suggests that, in many cases, there is no true security justiication behind the patient and escort applications being denied or delayed. A blatant example of the arbitrary mode in which the applications of Palestinian residents are handled and of their medical needs being taken advantage of to achieve political objectives is the sweeping refusal to process applications submitted on referral paper carrying the caption “State of Palestine”. Another abusive policy is the sweeping rejection imposed on some residents on a collective, group basis. Thus, for example, applications from male patients are delayed and denied in much greater numbers compared to women, mainly in the 18-45 age group. This categorical refusal suggests that the Israeli authorities base their decisions on arbitrary and unreasonable security considerations instead of examining each individual application on merit while attributing the proper weighting to the patient’s medical needs and condition. The need for authorizations from security bodies is also abused to put pressure on patients to collaborate with Israel. To this very day, the ISA continues to summon patients for interrogations, and evidence provided by these patients suggests that these are abusive and humiliating interrogations intended to make patients provide information, while sometimes presenting the grant of an exit permit for medical treatment as being conditional on agreeing to collaborate. The conduct of the coordination and liaison authorities requires comprehensive examination by the competent authorities, including the State Comptroller. The multiplicity of violations and failures in the functioning of the Gaza and Beit-El DCLs as shown in the present 30 report require immediate examination of the DCLs’ conduct, including their transparency vis-à-vis Palestinian applicants and human rights organizations and other entities working to protect the rights of the residents in the occupied territories. Israel must retract from its abusive policy involving irrelevant political considerations in handling the applications of Palestinian residents — especially when it comes to patients and medical teams — and adopt a civilian policy adapted to civilian needs. The particular situation of residents with medical needs moreover demands fast and eficient processing of their applications—in contrast to the state of affairs presented in the current report — in a way that will prevent unnecessary delaying of patients and infringement upon their rights. The worrying testimonies regarding ISA interrogations yet again lead to the conclusion that immediate action must be taken to eliminate this practice, which abuses patients’ distress to turn them into vessels at the hands of the security system. As the ruling power in the occupied territories, Israel must allow full freedom of movement for patients and medical teams, as part of its responsibility to ensure the Palestinian residents’ right to health. 31 APPENDICES 32 Appendix 1 TER-17-2-Freedom of movement 3 March 2014 TO TO TO TO Major General Yoav Mordechai Coordinator of Activities in the Territories Fax: 03-6975177 Col. Khatib Mansour Head of DCL Gaza Fax: 02-9704703 MK Yael German Minister of Health Fax: 02-6787662 Major General (Res.) Dan Harel Director General, Ministry of Defense Fax: 03-6976218   Dear Sirs, Madam, Extremely Urgent  Re: Difficulties working with the bodies handling our inquiries at Erez DCL 1. As part of our work for more than two decades now, the Physicians for Human Rights (PHR) organization acts to help uphold the right to health of the Gaza Strip’s residents in the face of various players, including the Erez DCL, and more particularly the Humanitarian Center therein. 2. PHR’s activity vis-à-vis the Erez DCL takes place within the context of Israel’s commitment to ensure the right to health of the Strip’s residents, as established also by the High Court of Justice in its ruling that “Israel is required to provide help in order to allow the satisfaction of necessary needs for the local population, which would not be met without her”,1 and that the state’s organs must “discharge the obligations falling upon them by virtue of the International Humanitarian Law”.2 3. This obligation is also finds expression in COGAT’s policy paper dated 5 May 2011 on the subject of “the policy governing the movement of people between the State of Israel and the Gaza Strip”, which was brought before the High Court of Justice.3 This document 1 2 3 HCJ 1169/09 Legal Forum for the Land of Israel v the PM (15.6.09) HCJ 9132/07 Albassiuni v the PM (30.1.08) paragraph 11 HCJ 495/12 Azzat v the Minister of Defense (24.9.12) 33 contained criteria permitting movement into Israel, among them: medical care, medical teams, visiting a patient. 4. The work relations with the Erez DCL are generally in order, and PHR’s interaction with the DCL often proves to be an important and vital part in handling requests. Thus, for example, inquiry by PHR resulted every now and then in new information being revealed regarding applications submitted to the DCL for examination through the Palestinian Civil Committee, following which applications were reviewed and approved. Moreover, in some cases, and following an inquiry directed by ourselves to the DCL, it turned out that a given application by a resident of the Gaza Strip had been approved without the Palestinian Civil Committee having been notified thereof. 5. Despite the long history of working with the DCL, difficulties do arise on occasion that impinge on fundamental human rights, in many cases without good reason or cause. The present letter is written in response to a new hurdle that has been put up these last days by the Gaza DCL, and which is delaying access to medical care for many patients. Our request is that the issue be dealt with immediately, allowing us to resume normal work relationships. A new directive? – Referring PHR inquiries to the Palestinian Civil Committee 6. On 26 February 2014, during a conversation I had with the Head of the Civil Coordination Section at Gaza DCL, Mr Tareq Shanan, the latter emphasized that our queries pertaining to health-related applications were to be addressed to the Palestinian Civil Committee. 7. This is the place to affirm and clarify the obvious: PHR’s activity is meant not to replace— but rather complement—the Palestinian Civil Committee, and to assume roles that the Committee does not or cannot play. This is something you know, and the way things have been going on for two decades, as mentioned. 34 8. Redirecting PHR inquiries to the Civil Committee is unreasonable and irrelevant, and here is why: A. PHR customarily presents Gaza DCL with questions to check out health-related information we receive from Gazan applicants after these had already approached the Palestinian Civil Committee, where the answer (or lack thereof) in their matter implies that your decision regarding their application has led to a violation of their right to health. These cases require our involvement, and it is plain as day that this must be worked out with you. This being the case, it is not clear why we have to talk to the Palestinian Civil Committee as long as the subject of our inquiry is related to your work. B. This is also the place to address your written answers to our inquiries, which almost regularly contain a section anchoring within it the new directive, as follows: “First let us remind you that, in accordance with the work procedures agreed with the Palestinian Authority, all of your inquiries relating to the entry of Palestinians from the Gaza Strip into Israel must be referred to the Palestinian Civil Committee, which constitutes the body in charge of coordinating and prioritizing the appeals of Palestinians residing in the Judea and Samaria region and the Gaza Strip to the Israeli side”. This section is puzzling to us, being irrelevant to our inquiry, as we have already mentioned. Let us say in passing that we have approached the Erez DCL as early as 17 July 2013 to obtain clarifications (see our communication with you from 17.7.13 under the title “Handling requests on our behalf – semi-annual review). To date, no response has been received to this query of ours. 9. The new directive piles unnecessary obstacles to aiding patients: Requiring of us to deal with the Palestinian Civil Committee is tantamount to creating an impasse, as the latter cannot assist us as long as our inquiry pertains to your work. The existence of this kind of failure in the system handling patient requests from the Gaza Strip sometimes 35 leads to tragic results, as you well know, which we shall discuss separately. 10. Let us note that the fact that you too saw fit to proceed differently in reality before the new directive—inasmuch as it exists—came along suggests that you likewise recognize that the needs on the ground are not adequately and correctly addressed by the new directive or, alternatively, the aforementioned section. 11. We regret to say that our reservations are not reduced to the sole existence of this new directive, and there is in fact a broad set of shortcomings that we would ask to point out in a separate discussion, among them inappropriate expressions uttered by the DCL’s representatives within hearing range of PHR’s staff. 12. In light of the above, and given the urgent circumstances of patients awaiting medical treatment, we would like to ask you to instruct the Gaza DCL to revert to the practice that had existed so far and take care of PHR inquiries. 13. Please treat the matter urgently. MahmoudAbo Abo Arisha Arisheh Mahmoud Coordinator, Freedom of movement and public enquiries Tel: 054-5205088 36 Appendix 2 UNCLASSIFIED 1 STATE OF ISRAEL MINISTRY OF DEFENSE Coordination of Activities in the Territories Coordinator’s Office Public Inquiries Tel.: 03-6977957 Fax: 03-6975177 General 11472 26 March 2014 To: Mr Mahmoud Abo Arisheh Physicians for Human Rights Re: Difficulties working with the bodies handling inquiries at Gaza DCL Your letter dated 3/3/14 1. The District Coordination and Liaison Office for Gaza handles applications for permits received through the Palestinian Civil Committee, the entity responsible for coordinating and prioritizing the transfer of applications from Gaza Strip residents to the Israeli side. Applications submitted directly to the DCL other than through the Civil Committee will only be dealt with in urgent, life-saving humanitarian cases. 2. We wish to point out that the Gaza DCL maintains direct and continuous contact with the Palestinian Civil Committee, and that the process of handling applications is carried out within the framework of an ongoing dialogue with the Committee (including demands made to complete missing documents or other factual inquiries required in order to reach a decision). For every application, a reply is returned to the Civil Committee, whose responsibility it is to reply to the applicants. 3. A resident of Gaza who has not yet received a response to his application has to contact the Civil Committee to find out where his request stands. UNCLASSIFIED 37 UNCLASSIFIED 2 4. The public inquiries call center at the Gaza DCL may be contacted in writing in order to inquire about the handling status of the outstanding application, enclosing a written attestation from the Palestinian Civil Committee regarding the submission of the request to be passed on to the Israeli side, and the DCL will answer the organization accordingly. 5. Sincerely, Elad Rahamim, Captain Public Inquiries Officer COGAT UNCLASSIFIED 38 Appendix 3 7.12.14 Ter-106 TO: Eliran Sasson Public Inquiries Officer Civil Administration Office – Beit El By fax: 02-9977341 Capt. Elad Rahamim Public Inquiries Officer – HQ, Coordinator of Activities in the Territories By fax: 03-6975177 Adinah Harish Public Inquiries Officer Gaza DCL, by email mhavrim@int.gov.il  Re: Difficulties working with the Israeli Civil Administration in the West Bank and the Gaza Strip, plus request for meetings  In what follows, we wish to complain about your very slow response times and about failure to respond to our inquiries concerning patients in need of medical care, and about your nonavailability to take phone calls. In light of this difficulty, we request a meeting to be held with representatives from the West Bank and Gaza DCLs in order to get the working relations back on track. As you know, Physicians for Human Rights has been working for decades to protect the right to health in Israel and the occupied territories, with an emphasis on access to medical treatment where it is located. Each week, we initiate several contacts, some of them are urgent, with the Israeli Civil Administration in the West Bank and Gaza, to inquire about the status of applications submitted by patients seeking entry permits into East Jerusalem or Israel in order to receive medical treatment who have had their application denied or the answer delayed by the Israeli District Coordination and Liaison Offices. 39 On 15 September 2014, we took this matter up with you as regards the conduct of the Civil Administration in the West Bank, but apart from being acknowledged receipt of our communication, we never got an answer. We still come across many failures in the Civil Administration’s conduct as the body in charge of answering our inquiries and those of other players with regard to patients. The Public Inquiry people are hardly available on the telephone, and answering is possible only during limited hours. This kind of conduct becomes all the more problematic in the event of urgent cases requiring your attention. Such an incident took place on Thursday, November 20th, at around 13:00. We were contacted by a woman who was waiting at the Kalandia checkpoint, delayed on her way to give birth. When we called the Civil Administration office in Beit El, we were told that the soldiers from Public Inquiries had left and there was no one there to help us. This answer is unacceptable, unreasonable and all the more infuriating in view of the urgency involved. We demand that you allocate an emergency telephone number for urgent cases and keep it available at all times.  Another problem we encounter is no response to our letters. More often than not, a small number of them are answered, while most are not. We keep sending reminders, by fax, by email and telephone, to which we get a limited and partial response. We demand that all our communications be answered within a reasonable time frame that takes into account the inherent fact that our communications with you revolve around medical issues, which naturally call for quick, and sometimes immediate, action. 40 On top of that, numerous replies received to queries sent to the Civil Administration in Gaza are irrelevant to the actual questions. Thus, for example, on 21 September 2014, we addressed the Gaza DCL by email with regard to a patient who had been refused entry by the DCL. On 13 October 2014, after significant delay, an answer was received from the Gaza DCL that the patient was referred to treatment through the Rafah crossing. Contrary to this answer, we were informed by the patient that he was granted an entry permit through Erez Crossing. In other cases that we approached the Gaza DCL on, their answers stated that they had not received any application; verification with the Civil Committee showed that the latter had indeed forwarded the application to the DCL. All of the above raises concerns that our inquiries—as an organization acting in the interest of public health and having acted for decades, as mentioned, to defend the right to health—are not taken seriously nor handled devotedly as would be expected when it comes to health and medical matters. The long delays in responding, the non-availability of the Israeli Civil Administration, and the faulty handling of patient inquiries directly infringe on the rights of patients to receive adequate healthcare services, which are enshrined in international and Israeli law, and even end up compromising patients’ health and their likelihood of dealing with their disease. We would appreciate your fast response and scheduling of meetings. Sincerely, Mahmoud Abo Arisheh and Mor Efrat Occupied Palestinian Territory Department Physicians for Human Rights – Israel To contact us: 054-5205088, 054-3240201, fax: 03-6873029 41