Factsheet - Violence against healthcare in Gaza

VIOLENCE AGAINST HEALTHCARE IN GAZA JUNE 2018

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Médecins du Monde France (MdM) has been working in Palestine since 1996, and more particularly in Gaza for over 16 years. A part from its medical work, MDM advocates for access to healthcare services and health-related human rights.

This year, in a period of only eleven weeks (30 March – 11 June), MDM has been witness to violent incidents against healthcare in Gaza, resulting from Israel’s response to the demonstrations taking place along its border. So far it has been reported that 328 health workers were injured, two were killed and 45 ambulances were damaged.

MDM calls all actors to condemn all attacks on healthcare and to act in order to ensure the protection of health workers, patients, humanitarian workers and medical facilities.

“HEALTHCARE SERVICES ARE PARTICULARLY NEEDED DURING CRISES, AND THEREFORE ARE SUBJECT TO SPECIAL PROTECTION.”

MÉDECINS DU MONDE FRANCE (MDM) INTERVENTION IN GAZA MDM is present in Gaza to help counter some of the structural problems the health system suffers as a result of the blockade such as: the lack of drugs, salaries and specialized trainings abroad which hampers its capacity to respond to the population’s needs.

MdM’s programs therefore work towards preparing the national health system at both primary and secondary levels to diverse emergencies, including mass casualties.

Among others, it has trained medical personnel to deal with diverse medical emergencies, as well as patient flux management.

Moreover, MDM has provided first aid drugs and disposables, as well as equipment. The programs have also reinforced and empowered local communities to respond to their immediate health needs, offering Basic Life Support trainings for trainers to community-based volunteers.

Despite MDM’s assistance, in times of emergency the structural problems become more blatant; and when violence against this sector is also associated, the consequences are extremely severe.

PROTECTION OF HEALTHCARE With the intention of reducing the impact of overall violence on the most vulnerable, International Human Rights Law (IHRL) and International Humanitarian Law (IHL) both define the particular need to protect healthcare and ensure access to the right to health(1) In terms of legal bodies applied to Gaza’s particular context, international actors such as the ICRC, the UN, the US and the EU, consider that the fourth Geneva Convention on the protection of the civilian population and occupation is applicable.

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Beyond the Gaza context, both IHRL and IHL extend special protection to healthcare due to its critical need, in particular during crises. They state that personnel engaging in medical tasks, medical units, equipment, and ambulances must be respected and protected in all circumstances. IHL in particular states that any attack on any of the above mentioned protected persons may represent a severe breach of the Convention and could tantamount to war crimes.(2) In May 2016, the United Nations Security Council adopted Resolution 2286 strongly condemning all acts of violence, attacks and threats directed at ill and injured patients, nursing staff, humanitarian workers and medical facilities. Within this framework, the WHO has launched the Surveillance System for Attacks on Health Care (SSA), aiming at producing a standardised data collection system and regular reports identifying trends and patterns of violence.

MDM has also strengthened its advocacy directed to the protection of healthcare through campaigns such as “Targets of the World”, with which it has systematically condemned these kinds of attacks, raised awareness on the severity of the situation and called for action.

As found on the field and despite the abovementioned efforts, including those taken by organisations such as the ICRC, the measures taken by the international community and individual states are still far from ensuring protection and accountability for these kinds of attacks.

(1)

Cf. ICRC, International legal framework for the protection of healthcare during armed conflicts, http://www.icrc.org/en/download/file/19448/health-care-in-danger-workshop-legal-provisions.pdf

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Rome statute of the International Criminal Court, 1998. UN.

Total number of injured health workers (30 March to 11 June 2018)

Since the first weekend, the health sector mobilized and prepared itself for addressing mass casualties. However, the Palestinian health institutions and NGOs were not expecting to become victims themselves of the violent response. After the first couple of weeks, WHO reported a total of 47 healthcare staff plus five ambulances were affected by different incidents in one week.(7) 11 weeks later, two healthcare staff had been killed and 328 others injured, of which 25 with live ammunition, 11 with shrapnel, 18 directly by a gas canister, and 45 ambulances damaged.(8)

256 237 238 245 250

171

33

48

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Figure 1 - *The total number at the end differs from the last date (8 June) because not all organisations provided on-time reports.

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40

38

41

45

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16

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14

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13

13-avr.

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36

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Total Number of Damaged Ambulances (30 March to 11 June 2018)

06-avr.

This year, in what has been called the “Great March of Return” demonstrations, for over 11 weeks, thousands of Palestinians in Gaza exercised their right to protest launching massive rallies at the border with Israel. In these demonstrations, Palestinians have been asking for their rights to be respected, in particular their right to return to their hometowns.(5) The Israeli security forces positioned snipers using live ammunition to dissuade the demonstrators from approaching the fence. Consequently, more than 14’600 people have been injured and 118 civilians killed.(6)

213

30

The occupied Palestinian territories come across as one of the most dangerous places in the world when comparing international trends of violence against healthcare structures, personnel and ambulances. Between 2014 and 2016, the oPt had the second highest number of attacks on healthcare among countries in emergency, after Syria, with 53 attacks representing 9% of all the attacks the WHO registered.(3) In 2017 alone, 93 attacks were registered by the Safeguarding Health in Conflict Coalition, awarding Palestine the unfortunate prize as the second most dangerous place on earth for healthcare.(4)

300 250 200 150 100 50 0

30-mars

2018 GAZA GREAT MARCH OF RETURN

328

350

Figure 2 – The damaged ambulances belong to the Palestinian Red Crescent Society, the government,

PMRS and UHWC.

While the actual figures are already staggering, underreporting has been a major issue.

Bigger organisations such as the Palestinian Red Crescent Society (PRCS), Palestinian Medical Relief Society (PMRS), the Union of Health Workers Committees (UHWC), and some other governmental institutions have shared their reports. However, smaller NGOs and community based organisations, which have equally suffered numerous incidents, have not systematically recorded them, mostly due to the lack of a proper reporting system and other safety policies.

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(3)

World Health Organization (2016), Report on Attacks on Healthcare in Emergencies.

Site: http://www.who.int/hac/techguidance/attacksreport.pdf, p.4 (4)

Safeguarding health in conflict Coalition. “Violence in the front line: Attacks on Health Care in 2017”. IntraHealth International, Johns Hopkins Bloomberg School of Public Health, 2018.

(5)

The Palestinian’s right to return is enshrined in UNGA Resolution 194

(6)

OCHA, Humanitarian snapshot: casualties in the context of demonstrations and hostilities in Gaza | 30 March - 12 June 2018. OCHA-oPt

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WHO, Special Situation Report oPt, Gaza – 6th-9th April 2018.

WHO-Health Cluster http://www.emro.who.int/images/stories/ palestine/documents/WHO-Special-Situation-Report-on-_Gaza-6th_ April_2018.pdf?ua=1 ; Palestinian Ministry of Health, The Most important statistics of current events - 7:00 PM - 13.04.2018, MoH-PHIC.

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WHO, “Situation report – occupied Palestinian territory, Gaza – 4-11 June 2018”, June 2018. http://healthclusteropt.org/admin/file_ manager/uploads/files/shares/Documents/5b1ecdb440bc9.pdf

WHAT MDM HAS DIRECTLY WITNESSED With the help of the Palestinian NGO Network, MDM conducted a series of surveys among the Palestinian health NGOs staff and volunteers aiming at understanding the complex environment in which the attacks happened, but also to identify the challenges in terms of reporting and safety policies.(9) The findings show that 70% of the surveyed NGO healthcare personnel had been direct victims and 9 been indirect victims of an attack where their physical or emotional integrity was threatened or at risk as a result of violence. 97% of the attacks had been caused by tear gas and only one by live ammunition.

Yet, some also got hurt when running away from the gas. Israeli use of tear gas affected several health workers at a time. Five survey-takers stated being victims of tear gas attacks while working inside a medical tent.

ENDLESS SUFFERING FOR HEALTH WORKERS On Friday April 7, Ali10 a 25 years old volunteer at the Palestinian Medical Relief Society in Gaza was working with his colleagues in Khuza’ area in the Khan Younis governorate. He was assisting a big range of different injuries when he became a target.

“After bringing the injured to the medical tent run by the ministry of health, we went back to help others who were close to the fence and wounded. That is when we were surprised by heavy gunfire. I was shot in my legs with a bullet that penetrated both and then settled in someone else’s leg.”

Medics of the PMRS rushed to provide aid to Ali and tied his legs to stop the bleeding. Afterwards, they took him to the same medical tent he brought injured people to, some minutes earlier. His condition was very critical due to heavily dissected and damaged arteries. Ali was then transferred to the European Hospital in Southern Gaza, where he stayed for about 40 days and underwent several surgeries to remove the damaged bones. Despite several interventions, doctors have stated that he requires to be treated abroad. “I have submitted the necessary paperwork to exit Gaza and get treated in Jordan, but since then I have been endlessly waiting.”

Reporting procedures have been a challenge.

After suffering the incident, 67% said they had told their line manager about the incident and only 16% filled up a written report.

This lack of reporting has hampered the general surveillance system, as well as the NGOs capacity to improve safety.

The consequences of these attacks ranged from impeding the staff to work momentarily due to suffocation, to the full suspension of whole teams, as it was the case of the PMRS teams after the killing of their volunteer colleague, Razan Al-Najjar. Tear gas attacks have had different effects on health workers, from mild to some fainting and spasm attacks, reducing their response capacity for the day.

Healthcare staff and patients have also had to evacuate when the incidents targeted the medical tents and tent area, affecting care quality and limiting the response capacity for stabilizing the most serious cases. Moreover, a great number of them expressed systematic psychological stress and fear.

Actors from all the international spectre have expressed their concern on the direct and indirect attacks to healthcare structures, personnel and ambulances. From joint UN agencies statements, to the Secretary General of the UN, to international humanitarian and human rights organizations, the international community has largely called for independent investigations on the incidents.

On 18 March 2018, the Human Rights Council approved an independent international Commission of Inquiry; however, Israel immediately dismissed any possibility for this investigation to take place. Instead, Israel has not proposed any other mechanism that will allow an independent investigation, leaving little hope for accountability.

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For more information on the surveys methodology and results, please refer to MDM’s Violence Against Healthcare in Gaza 2018 Report.

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His name has been changed to protect his identity.

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CONCLUSIONS Attacks on healthcare workers, structures and ambulances should never occur: neither in times of peace, nor in times of war. They represent grave breaches of IHL and IHRL. Between 30 March and 16 June 2018 healthcare workers, volunteers, ambulances and structures in Gaza have been victims of intense attacks only seen during war time.

These attacks have occurred in a context where the health system has been challenged to its limits in terms of casualty management while also dealing with a deep structural crisis characterised by the lack of drugs, disposables, salaries and equipment.

Beyond the evident physical marks of live ammunition on the bodies of healthcare staff, these attacks and the death of their colleagues have left strong psychological scars.

The general consequences in terms of service provision are difficult to quantify or measure beyond the untold stories of the injured or killed because those who were supposed to help were also injured.

Beyond its medical activities, MDM is actively working on raising awareness among Palestinian NGOs and CBOs on the importance of improving safety and reducing risks for healthcare personnel.

Despite the latest efforts, the international community has not been able to ensure proper accountability and protection for healthcare personnel, structures and ambulances.

During the Gaza 2018 demonstrations, Israel has failed its duty to respect and protect healthcare personnel, structures and ambulances, breaching international law.

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RECOMMENDATIONS Considering the IHL and IHRL obligations to which the state of Israel is binded, MDM calls Israel to: • Ensure that the ISF comply in accordance with international human rights standards for law enforcement; • Hold all perpetrators accountable for the unlawful use of force; • Guarantee that all healthcare services and personnel are protected; • Incorporate IHL provisions in the national legal frameworks, including sanctions.

Israel should abide to UN Security Council resolutions calling for the protection and accountability of all attacks against healthcare.

Third states should ensure they are not indirectly related to these kinds of violations, in particular when selling weapons which are then used to commit them.

Third states should ensure proper accountability through international institutions such as the International Criminal Court.

All actors are encouraged to condemn all attacks against healthcare personnel, structures and ambulances, and to promote awareness on the importance of their protection.

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Contact: Marcos Tamariz Advocacy Coordinator Médecins du Monde France - Mission Palestine +972 (0) 595 94 06 50 - + 972 (0) 549 08 73 63 coord.adv.palestine@medecinsdumonde.net © Médecins du Monde France, June 2018