Palestine: the assault on health and other war crimes

By Derek Summerfield, honorary senior lecturer

Institute of Psychiatry, London derek.summerfield@slam.nhs.uk 

Palestine: the assault on health and other war crimes
Summerfield BMJ.2004; 329: 924

PERSONAL VIEWS

Does the death of an Arab weigh the same as that of a US or Israeli citizen? The Israeli army, with utter impunity, has killed more unarmed Palestinian civilians since September 2000 than the number of people who died on September 11, 2001. In conducting 238 extrajudicial executions the army has also killed 186 bystanders (including 26 women and 39 children). Two thirds of the 621 children (two thirds under 15 years) killed at checkpoints, in the street, on the way to school, in their homes, died from small arms fire, directed in over half of cases to the head, neck and chest—the sniper's wound. Clearly, soldiers are routinely authorised to shoot to kill children in situations of minimal or no threat. These statistics attract far less publicity than suicide bombings, atrocious though these are too.

Amnesty International has called for an investigation into the killing of Asma al-Mughayr (16 years) and her brother Ahmad (13 years) on the roof terrace of their home in Rafah on 18 May, each with a single bullet to the head. Asma had been taking clothes off the drying line and Ahmad feeding pigeons. Amnesty noted that the firing appeared to have come from the top floor of a nearby house, which had been taken over by Israeli soldiers shortly before. Amnesty suspects that this is not "caught in crossfire," this is murder.

Israeli military reoccupation of the West Bank and Gaza—a system of military checkpoints splitting towns and villages into ghettos, curfews, closures, raids, mass demolition and destruction of houses (more than 60 000), and land expropriations—has made ordinary life impossible for everyone, and is driving Palestinian society and its institutions towards destitution. Moreover, Israel has been constructing a grotesque barrier that, when completed, will total over 400 miles—four times longer than the Berlin Wall. Extending up to 15 miles into Palestinian territory, the real purpose of the wall is permanently to lock more than 50 illegal Israeli settlements into Israel proper. This is expansive, aggressive colonisation, in defiance of the International Court of Justice in The Hague and the United Nations General Assembly resolution of last July.

Last year a UN rapporteur concluded that Gaza and the West Bank were "on the brink of a humanitarian catastrophe." The World Bank estimates that 60% of the population are subsisting at poverty level (£1.12; $2; 1.6 per day), a tripling in only three years. Half a million people are now completely dependent upon food aid, and Amnesty International has expressed concern that the Israeli army has been hampering distribution in Gaza. Over half of all households are eating only one meal per day. A study by Johns Hopkins and Al Quds universities found that 20% of children under 5 years old were anaemic, 9.3% were acutely malnourished, and a further 13.2% chronically malnourished. The doctors I met on a professional visit in March pointed to a rising prevalence of anaemia in pregnant women and low birthweight babies.

The coherence of the Palestinian health system is being destroyed. The wall will isolate 97 primary health clinics and 11 hospitals from the populations they serve. Qalqilya hospital, which primarily serves refugees, has seen a 40% fall in follow up appointments because patients cannot enter the city. There have been at least 87 documented cases (including 30 children) in which denial of access to medical treatment has led directly to deaths, including those of babies born while women were held up at checkpoints. The checkpoint at the entrance to some villages closes at 7 pm and not even ambulances can pass after this time. As a recent example, a man in a now fenced in village near Qalqilya approached the gate with his seriously ill daughter in his arms, and begged the soldiers on duty to let him pass so that he could take her to hospital. The soldiers refused, and a Palestinian doctor summoned from the other side was also refused access to the child. The doctor was obliged to attempt a physical examination, and to give the girl an injection, through the wire.

The wall will isolate 97 primary health clinics and 11 hospitals from the population they serve Credit: LARRY TOWELL

There are consistent reports of ambulances containing gravely ill people being hit by gunfire, or detained at checkpoints while drivers and paramedics are interrogated, searched, threatened, humiliated, and assaulted. Wounded men are abducted from ambulances at checkpoints and sent directly to prison. Clearly marked clinics are fired on, and doctors and other health workers shot dead on duty.

Physicians for Human Rights (Israel) have lambasted the Israeli Medical Association (IMA) for its silence in the face of these systematic violations of the Fourth Geneva Convention, which guarantees the right to health care and the protection of health professionals as they do their duty. Remarkably, IMA president Dr Y Blachar is currently chairperson of the council of the World Medical Association (WMA), the official international watchdog on medical ethics. A supine BMA appears in collusion with this farce at the WMA. Others are silenced by a fear of being labelled "anti-semitic," a term used in a morally corrupt way by the pro-Israel lobby in order to silence. How are we to affect this shocking situation, one which to this South African-born doctor has gone further than the excesses of the apartheid era.

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Palestine: the state of despair

Letter to the BMJ by Dr Ismail Jalili, FRCS, DO, FRCOphth
Consultant Ophthalmologist, UK.

Summerfield's article ¹ on Palestine adds to the previously
documented health crisis in this population ^2-5 and demonstrates the
scale of this human tragedy. Indiscriminate obstruction damages an already vulnerable medical infrastructure resulting in increased morbidity, degraded health, premature deaths, and non-fulfillment of basic human needs ². Repeated invasions cause extensive destruction, food shortages, internal civilian displacement and psychological distress ³. Poor socio-economic, demographic and environmental health conditions lead to over-crowding, affects drinking water sources and play a major role in the occurrence of intestinal parasites and diarrhoea with under 5s at highest risk.

Endemic parasitic infestations were found in 29.8% of women4, 24.1% in
1-4 years old; and 13.7% of diarrhoea admissions with 10.6% mainly in <1
year olds.

Injuries rose sharply, a staggering 32 and 9-fold increases in the first and second Intifidas respectively. Before the Intifida, victims were men, there were no <10's; during the Intifida 9% were women and 12% under 14 years; injury patterns changed with 65% due to firearms or explosives, 19% to beating and 6% to gaseous substances. Among children, most firearm injuries involved the head, including eye injuries and brain damage ⁵.
After the 1967 war, Israel's labour market opened to workers from the Occupied Territories, with jobs in construction, agriculture etc; conditions were poor and exploitation rife6. By 1984, 87,000 Palestinians were employed in Israel - 36% of the total workforce. Since 1991, there has been a sharp decline, with Romanian and Thai workers recruited instead. Girls and young women increasingly risk illiteracy and families are marrying their daughters at younger ages for security ⁶.

Before 1987, the author witnessed the failure to provide treatment for 2
children with retinoblastoma; neglect and bureaucracy led to advanced,
metastasised presentation, causing excruciating pain and agony. They
were failed by a lack of initial treatment but also by denial of
terminal care ⁷, reflecting the neglect of poor and deprived pointed out
by Summerfield's and others ^1,8.

1. Summerfield D. Palestine: the assault on health and other war
crimes. Br Med J 2004;329:924.
2. Quato D. The politics of deteriorating health: the case of
Palestine. Int J Health Serv 2004; 34:341-64.
3. Giacaman R, Husseini A, Gordon NH, Awartani F. Imprints on the
consciousness: the impact on Palestinian civilians of the Israeli Army
invasion of West Bank towns. Eur J Public Health 2004;14286-90.
4. Abu Mourad TA. Palestinian refugee conditions associated with
intestinal parasites and diarrhoea: Nuseirat refugee camp as a case
study. Public Health 2004;118:131-42.
5. Helweg-Larsen K, Abdel-Jabbar Al-Qadi AH, Al-Jabriri J,
Bronnum-Hansen H. Systematic medical data collection of intentional
injuries during armed conflicts: a pilot study conducted in West Bank,
Palestine. Scand J Public Health 2004;32:17-23.
6.Diamond J. Demography of the Arab World. Lecture. ST203, 21.10.02.
7. Jalili IK. Childhood visual impairment in the West Bank and Gaza
Strip. Thesis - in preparation.
8. World Health Organisation. Health conditions of, and assistance to,
the Arab population in the occupied Arab territories, including
Palestine. The 54th World Health Assembly, Agenda item 17, 22 May 2001.

Published on line: http://bmj.bmjjournals.com/cgi/eletters/329/7471/924?ehom#81170

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The present conflict in Iraq signals a contrast of paradoxical proportions. The Iraqi people, their interim government, and their largely US and British occupiers are preparing for landmark elections early in the new year. Yet a ruthlessly violent insurgency is successfully destabilising these arrangements, murdering foreign civilians and Iraqi law enforcement officers in the most brutal ways imaginable, and exploiting the world’s media in doing so. Amid this deep national uncertainty, it is hard to judge what is happening among Iraqis themselves. This week The Lancet publishes the first scientific study of the effects of this war on Iraqi civilians.

In a unique US-Iraqi collaboration, Les Roberts and his colleagues report substantially more deaths in Iraq since the war began than during the period immediately before the conflict. Much of this increased mortality is a consequence of the prevailing climate of violence in the country, and many of the civilian casualties that are described were attributed to the actions of coalition forces. These findings—and the tentative countrywide mortality projections they support— have immediately translatable policy implications for those charged with managing the aftermath of invasion.

The research we publish today was completed under the most testing of circumstances—an ongoing war. And therefore certain limitations were inevitable and need to be acknowledged right away. The number of population clusters chosen for sampling is small; the confidence intervals around the point estimates of mortality are wide; the Falluja cluster has an especially high mortality and so is atypical of the rest of the sample; and there is clearly the potential for recall bias among those interviewed. This remarkable piece of work represents the efforts of a courageous team of scientists. To have included more clusters would have improved the precision of their findings, but at an enormous and unacceptable risk to the team of interviewers who gathered the primary data. Despite these unusual challenges, the central observation—namely, that civilian mortality since the war has risen due to the effects of aerial weaponry—is convincing. This result requires an urgent political and military response if the confidence of ordinary Iraqis in the mostly American-British occupation is to be restored.

Roberts and his colleagues submitted their work to us at the beginning of October. Their paper has been extensively peer-reviewed, revised, edited, and fast-tracked to publication because of its importance to the evolving security situation in Iraq. But these findings also raise questions for those far removed from Iraq—in the governments of the countries responsible for launching a pre-emptive war. In planning this war, the coalition forces—especially those of the US and UK—must have considered the likely effects of their actions for civilians. And these consequences presumably influenced deployments of armed forces, provision of supplies, and investments in building a safe and secure physical and human infrastructure in the post-war setting.

With the admitted benefit of hindsight and from a purely public health perspective, it is clear that whatever planning did take place was grievously in error. The invasion of Iraq, the displacement of a cruel dictator, and the attempt to impose a liberal democracy by force have, by themselves, been insufficient to bring peace and security to the civilian population. Democratic imperialism has led to more deaths not fewer. This political and military failure continues to cause scores of casualties among non-combatants. It is a failure that deserves to be a serious subject for research.

But this report is more than a piece of academic investigation. A vital principle of public health is harm reduction. But harm cannot be diminished by individual members of society alone. The lives of Iraqis are currently being shaped by the policies of the occupying forces and the militant insurgents. For the occupiers, winning the peace now demands a thorough reappraisal of strategy and tactics to prevent further unnecessary human casualties. For the sake of a country in crisis and for a people under daily threat of violence, the evidence that we publish today must change heads as well as pierce hearts.  

www.thelancet.com 
Published online October 29, 2004 http://image.thelancet.com/extras/04cmt384web.pdf