Israeli Approvals for Medical Entry in the Shadow of Terror Attacks at the Erez Crossing

* For several years, the Rapporteur to the UN Commission on Human Rights (now the UN Human Rights Council) and human rights groups have criticized the Israeli government and health care system for denying access to Gazans seeking to receive permits for care in hospitals in Israel, the PA and Jordan.

Yet the data shows that the number of patients receiving permits for referrals to hospitals in Israel - or the PA or Jordan - increased by 45 percent from 4,932 in 2006 to 7,176 in 2007, and continued to increase in the first six months of 2008. These trends occurred despite a decline in entry approval rates, mostly because of security reasons.

* The facts are that Israel has provided ever increasing numbers of approvals of permits since the Hamas takeover of Gaza, despite increasing rocket attacks on Israel's civilian population, including mortar and terror attacks directed at the Erez crossing used by patients.

* At the same time, there have been at least 20 incidents where Palestinians used medical missions to attempt terror attacks.

* The premise that guides medical ethics is that there should not be even one death from delay, but sometimes the delays were related to problems of availability of beds, and at other times to security concerns. There were cases in which patients' deaths or complications were attributable to delays. But in other cases, deaths and complications were attributable to efforts to transfer to Israel critically ill or near terminal patients from Gaza whose care was deemed as bothersome or too costly.

* The longer term solution to the problem of delays associated with referrals is to promote medical capacity-building in Gaza's hospital and health care systems so that patients should not have to travel elsewhere for critical care.

* The mandate of the Rapporteur to the UN Commission on Human Rights has so far been restricted to reporting only on violations of human rights to life, safety, and access to health care of members of one national group, Palestinians, but not members of another group, Israelis. The result is a selective concern with the human rights of one that ignores assaults on the human rights of the other.

Background

Since the Six-Day War in 1967, Gazans have been coming to Israel for medical treatment and for training in many Israeli hospitals, including Hadassah in Jerusalem, Ashkelon, Tel Hashomer, Beersheva, and others. With implementation of the Oslo accords in 1994, the Palestinian Authority reduced access for training and referrals for care as it sought to increase reliance on its own health care system, but in recent years, there has been a tendency towards increased patient referrals to Israeli hospitals.1 Even so, for several years, human rights groups - notably Physicians for Human Rights-Israel (PHR-I), the UN Commission on Human Rights (now the UN Human Rights Council), and World Health Organization (WHO) agencies - have criticized the Israeli government and health care system for denying access to Gazans seeking to receive permits for care in hospitals in Israel.2,3

To examine the validity of these criticisms and their context, we tracked trends (January 2006 to June 2008) for approved permits and reported deaths in individual patients. In parallel, we tracked trends during the same period for rocket, missile, and terror attacks targeting the Erez crossing, through which Gazans enter Israel.

Methods

Our data came from WHO, PHR-I, the Israel Defense Forces (IDF) medical liaison office with Gaza in the office of the Coordinator of Government Activities in the Territories (COGAT), and the Israel Security Agency (ISA, formerly the General Security Service - Shabak).

We prepared two parallel timelines. One tracked the number of approved permits, based on data from COGAT and verified by WHO (through December 2007). The other timeline tracked Kassam rocket and other attacks from Gaza directed against Israeli civilian populations, notably in Sderot and Ashkelon, based on sources tracking terror attacks on Israel.4

The Palestinian Authority decides whether Gazan patients receiving approval for medical care in Israeli hospitals are treated there, or in Palestinian hospitals in eastern Jerusalem or the West Bank, or in Jordan. The decision as to where to refer is heavily influenced by the fact that the cost of care is substantially higher in Israeli hospitals and the PA covers these costs.

We also reviewed relevant PHR-I and ISA documents on patients denied access to medical care in Israel and deaths, as well as on terrorists disguised as patients.

Trends in Approvals for Patient Referrals

The data showed that patients receiving permits for referrals to hospitals in Israel - or the PA or Jordan - increased by 45 percent from 4,932 in 2006 to 7,176 in 2007, and (...)