In August 2019, the World Health Organisation (WHO) reported that between 30 March 2018 and 31 July 2019, 315 Palestinians (including 62 children) had been killed during the ‘Great March of Return’ civilian protests in Gaza that demand realisation of the right of return and an end to the closure imposed on Gaza. In addition, Israeli forces’ use of excessive force, including live ammunition, against civilian protesters not posing a direct and imminent threat to life or serious injury, has caused thousands of injuries, many being very serious. 7,381 Palestinians have suffered gunshot wounds, of which 6,437 (87%) presented limb wounds, according to the WHO report.
This blog will focus on the grave ramifications of the related policy decision made in April 2018 by the Israeli government which prevents anyone involved in the ‘Great March of Return’ protests from travelling outside of Gaza for medical treatment, unless their situation is “life-threatening”. The policy has profound consequences for a significant number of seriously injured Palestinians who are denied access to adequate healthcare when it is urgently and critically required.
Large number of injuries during the ‘Return Protests’ require specialised treatment that, if unmet, results in drastically increased risk of amputations
The staggering number of gunshot wounds (25% of the total casualties) suffered during the first year of the protests has had especially serious consequences, with 187 people made permanently disabled as a result of gunshot injuries. The major cause of permanent disability to patients was amputation, with 148 amputations, including 30 to children, reported in the aforementioned WHO report published last month.
For many who have suffered gunshot wounds, avoiding amputation requires travel to access health services outside of Gaza. Approximately 1,209- 1,746 of patients who suffered gunshot wounds will need some form of specialised treatment. The WHO warns “that without this treatment being made available in Gaza, the number of amputations may drastically increase in 2019”. This dire warning was echoed by Jamie McGoldrick, the UN Humanitarian Coordinator for the occupied Palestinian territory (oPt), on 8 May this year:
“We are running against the clock for some of these cases and osteomyelitis – bone infection – will be a crisis, and the need is to treat that, prevent that, otherwise we will have amputations…. [T]he technical abilities of doctors on the ground to carry out treatment required for the 1,700 (injured demonstrators) just doesn’t exist.”
UN OCHA reported in March this year that the mass influx of casualties during the ‘Great March of Return’ civilian protests has overwhelmed Gaza’s fragile healthcare system, adversely affecting the capacity and quality of healthcare. According to B’Tselem, “Given the failing healthcare system in Gaza, injured protesters cannot receive the medical attention they need and must seek vital treatment abroad.”
This is the context that must be understood when considering the ramifications of the policy introduced by the government of Israeli in April 2018 to bar injured Gazan protesters’ access to medical care. B’Tselem has provided data on the substantial impact of Israel’s decision to bar wounded Gazan protesters’ access to medical care as a general rule: only 85 (17%) of applications were approved from the start of the demonstrations through to January 2019, while 408 (83%) were rejected either through denial or delay. As previously reported in a recent LPHR Child Rights Bulletin, Save the Children has highlighted WHO data showing that, “80% of children injured at the protests who applied to leave Gaza to receive emergency medical treatment in Israel over the last year have had their permits rejected or delayed”.
This policy has led to injured Palestinians, including children, having to have leg amputations. One example of this is the case of a 16-year old, AQ, who had a double leg amputation in May this year, in order to save his life after running out of options and beginning to show signs of blood poisoning. He had applied for permission to travel abroad for medical reasons, however this had not been approved, and the decision to amputate both legs came about due to a worsening of his condition.
The severity and complex nature of the protesters’ injuries is underscored by a report just last week from Doctors Without Borders (MSF), who reported that it is dealing with the enormous problem of treating patients who have developed bone infections from their gunshot wounds: more than 1,000 people are suffering from severe bone infections according to MSF. One of the challenges being faced by doctors treating infected patients is that many of the infections are resistant to antibiotics. Gaza now has its first hospital laboratory to analyse bone samples in order to identify the infection and prescribe the correct medication – an integral part of the treatment process – following a recent upgrade supported largely by MSF, who report that the closure of Gaza has made “medical treatment even more difficult.”
The broader context of routine denial and delay of medical travel permits for patients living under occupation
Israel’s policy of preventing Palestinians injured during the Gaza protests from accessing critically needed healthcare outside Gaza takes place within the wider context of a permit system that routinely denies and delays exit from Gaza for patients.
According to Physicians for Human Rights-Israel, every year, an average of 200,000 Palestinians from Gaza and the West Bank are required to seek approval from Israeli authorities for a permit to travel for medical needs. The application process is slow and convoluted. Every year some 40,000 patients, accompanying persons, or visitors, are prevented from leaving Gaza or the West Bank for medical care or to support an ill relative. These include patients who are critically ill, including cancer patients requiring chemotherapy. Denial and delay of permission to travel for medical care is especially serious given the increase in the child mortality rate and the drop in survival rates for some chronic illnesses in Gaza. In December 2017, B’Tselem reported that 21 Gazan residents whose exit applications for medical treatment were denied or refused that year had subsequently died of serious illnesses, including two young girls aged four and five. 16 of these patients died of cancer.
The pervasive denial and delay of travel permits by Israeli authorities for medical cases strongly suggests that Israel is in breach of its obligations under international law to ensure the health and welfare of the Palestinian population under its control, a finding made last year by UN Special Rapporteur on the situation of human rights in the occupied Palestinian Territory, Professor Michael Lynk.
Israel’s Supreme Court has upheld the policy to prevent access to specialist medical treatment for Gaza protests, despite incompatibility with the right to health
Israel’s policy decision to specifically deny, as a general rule, travel permits to injured protesters, is an extreme manifestation of its general travel ban imposed against all Palestinians in Gaza since implementing its closure of Gaza in 2007.
The policy was challenged by Adalah and Al Mezan Centre for Human Rights – on behalf of two severely injured Palestinian protesters from Gaza – before Israel’s Supreme Court in April 2018. Israeli government lawyers told the court the applications of the two injured protesters had been rejected, “given the policy of the Minister of Defense on the issue, whereby, as a rule, entry into Israel shall not be granted to persons injured while taking part in the violent public disturbances organised by Hamas, where the concrete medical circumstances were not deemed to warrant considering a departure from said rule, as the petitioners are not in a life-threatening condition.” B’Tselem then reports that:
“Despite the dire condition of both men, and the urgent treatment it called for, the justices refused to schedule an urgent hearing. The doctors had no choice but to amputate a leg on each patient. Only more than a week after the petition was filed, the High Court ordered the state to allow one of them, Yusef al-Kurunaz, 19, to travel to a hospital in Ramallah, where doctors were able to save his other leg. The justices did state, however, that this was an exceptional case and that they were not taking a stand on Israel’s overall policy toward injured protesters. In doing so, they effectively permitted the state to continue its policy of barring most injured protesters from receiving medical treatment.”
The decision by Israel’s Supreme Court to uphold the policy instituted by Israel’s government was made without apparent reference to Israel’s obligations as an occupying power under international human rights law. It is clear-cut that Israel’s policy to deny medical exit permits for injured protesters in Gaza is incompatible with its legal obligation, as an occupying power, to guarantee access to the right to health under Article 12 of the International Covenant on Economic, Social and Cultural Rights. Additionally, Israel’s denial of permission to travel for medical care to children suggests that it is also in breach of its legal duty under Article 24(1) of the UN Convention on the Rights of the Child, which gives children the right to the enjoyment of the highest attainable standard of health.
It is necessary for the international community to challenge the cruel and inhumane policy implemented by Israel’s government to specifically bar injured Gazan protesters from accessing critical medical treatment outside of Gaza.
LPHR endorses the four specific recommendations made to the government of Israel by the UN independent Commission of Inquiry on the 2018 Gaza Protests (at paragraph 797 of its March 2019 report) to ensure the fulfillment of the right to health of injured persons, including protesters exercising their basic right to freedom of expression and assembly:
(a) Lift the blockade [closure] on Gaza with immediate effect;
(b) Ensure that all those injured at demonstrations are permitted prompt access to hospitals elsewhere in the Occupied Palestinian Territory, in Israel or abroad;
(c) Ensure timely access of medical and all other humanitarian workers to Gaza, including to provide treatment to those injured in the context of demonstrations;
(d) Ensure efficient coordination for entry of medical items and equipment into Gaza, and remove the prohibition of entry applied to items with legitimate protective and medical uses, including carbon fibre components for the treatment of limb injuries.
Maria Skotori and Angelina Nicolaou