“Nothing is changing,” says Dr. Jamil Suliman, a pediatrician and now the director of Beit Hanoun Hospital in Gaza. On a quiet January morning, he shows me a clean and well-equipped emergency room, modern X-ray facilities, a pharmacy, and a basic yet functioning laboratory. Dr. Suliman oversees a medical team of more than fifty doctors. But the outlook for the health and well-being of his community, three quarters of whom live in accelerating poverty, is not good.

Beit Hanoun sits close to the border of Gaza, a twenty-five-by-five-mile strip of land that is one of the most densely populated and impoverished regions in the world today. As a meeting point between Asia and Africa, Gaza has been fiercely fought over for centuries. With the dismantling of Israeli settlements on the strip in 2005, this tract of land is now wholly Palestinian. Yet its people have hardly any control over their lives, their movements, or their economy. And so Gaza’s troubles have not receded.

Gaza exists in a cage. I entered through the Erez checkpoint at its northern tip. Armed Israel Defense Forces and bored young military conscriptees control the cylindrical steel turnstiles and electric gates that greet visitors. After walking through a three-hundred-meter camera-laden concrete tunnel, one exits into a landscape of bombed homes, blasted roads and bridges, and fields torn apart by armored vehicles. The debris of Palestinian life lines the road into Gaza City. Vans loaded with young Palestinian members of armed militias pass by freely. Men carrying Kalashnikovs stand at most street corners in the center of the city. Gaza feels like a lawless place under permanent siege.

Gaza is also a land of children. Sixty percent of its 1.5 million people are under eighteen. Children spill out of every home onto dusty and dirty alleyways. They drive donkey carts that carry everything from people to bananas. Children weave their bodies and bicycles between the cars that engorge Gaza’s narrow city streets. Young smartly dressed Palestinian girls carry their clipboards to and from school. (With families often having as many as seven children, the demand for schooling is high. Teachers run several classroom shifts daily to meet the rising need.) Early each morning, one can watch children standing in shallow boats on Gaza’s beautiful Mediterranean shoreline, pulling in their nightly catches.

In a survey completed by the Gaza Community Mental Health Program, over 90 percent of children below the age of eleven experience severe anxiety, nightmares, and physical expressions of stress, such as bed-wetting. Half fear that their parents will not be able to provide essential family necessities, such as food and a home. Forty percent have relatives who died during the second intifada, which began in 2000.

Many of these relatives live on as “martyrs,” Palestinians who have died fighting the Israelis. The faces of these young men and women are remembered on billboards and posters covering the walls of almost every building in Gaza, including hospital clinics and Ministry of Health buildings. They are often depicted carrying weapons. They are images that must press on the conscience of every child. It would be hard not to conclude that Gazan children are brought up to revere, even aspire to, the lives of these “martyrs.” There is nothing noble about indoctrinating violence into children. But it is clear how these ideas are fostered and fixed into the collective psyche of Palestinians.

Back at Beit Hanoun Hospital, Dr. Suliman is still learning the lessons from some of the most recent violent Israeli incursions into Gaza. In November 2006, following armed clashes between Palestinians and Israelis, he faced an incident that few pediatricians could have trained for. A little boy, no more than five years old, was rushed into the ER alive, but with charred lower limbs, a badly burned head, and loops of intestine hanging out of his burst abdomen.1 He had been the victim of Israeli shelling. The medical and surgical teams struggled to resuscitate him. At first, the young boy was conscious, moving his head from side to side. But after five days, he died.

When Palestinians and Israelis start firing at one another across the Gaza border, Israel may decide to quell the exchange by entering the strip. When this takes place at Beit Hanoun, from which Palestinian militants frequently fire Qassam rockets into Israeli territory, tanks isolate the town from the rest of Gaza. Israel sends in special forces and armored vehicles to flush out Palestinian militia. In November, the hospital itself was isolated by two tanks. Ambulances were prevented from leaving, says Dr. Suliman. The Israeli invasion cut off water, electricity, and communication to the hospital for seven days. Staff members asked for urgent assistance from the Palestinian Ministry of Health in nearby Gaza City. The Israelis refused their request. Instead, they ordered over a thousand civilians to leave their homes and to take refuge in the hospital.


In their defense, Israeli officials would surely argue that they used appropriate force in response to the rocket attacks from Beit Hanoun. Dr. Suliman understands this argument. But he cannot accept the harm inflicted carelessly on children. After all, he tells me, the inhabitants of Beit Hanoun should not be punished for the actions of a few extremists.

On the eighth day of the Israeli siege, eighteen Palestinians were killed, ten of them children. Israel admitted that its forces had made an error. Prime Minister Ehud Olmert called it a “technical failure.”


During the past twelve months, the health systems in Gaza and the West Bank have begun to disintegrate rapidly. After the Oslo accords were signed in 1993, health became the responsibility of the Palestinian Authority. Without a sovereign state, the newly created Ministry of Health found it hard to devise and implement a coherent policy for the West Bank and Gaza. But until January 2006, when a Hamas government was elected by Palestinians, progress was slowly being made against the odds.2

After the Oslo accords, the Ministry of Health launched a five-year plan to improve primary health care. The failure to proceed rapidly toward final-status negotiations on a future Palestinian state contributed to bureaucratic paralysis. By 2000, the onset of the second intifada finally destroyed hopes not only of significantly upgrading primary care but also of developing much-needed hospital facilities. Instead, according to the health officials I spoke with, the best the ministry could do was to protect emergency services. With no systematic welfare system and over a third of the population unemployed, Palestinians were quickly moving toward a health crisis.

Into this vacuum, thankfully, came international relief agencies and NGOs. I traveled in the occupied territory with CARE International, an aid organization that has worked in the West Bank and Gaza on humanitarian and development programs since 1949. Their presence, together with that of other groups, has been vital for the survival of thousands of Palestinians.

The Palestinian Ministry of Health is now trying to coordinate the complex and often overlapping efforts of numerous different international projects. Since the Hamas government was elected, these challenges have only been compounded. Tens of millions of dollars in aid from the US and European Union to support the Palestinian government have been withheld on the grounds that Hamas is a terrorist organization that does not recognize Israel. Israel has cut off the funds it collects on behalf of Palestinians, money that amounts to half the Palestinian Authority’s total revenue. A strike by workers in the public sector last year in response to widespread international condemnation of the election result added to Palestinian misery still further. Health workers, like many other Palestinian civil servants, have seen their salaries either stopped or severely cut.3 And money for the Ministry of Health now has to follow a politically acceptable but slow and extremely inefficient route—first, through the office of Mahmoud Abbas, the president of the Palestinian Authority, and, second, via the Authority’s Ministry of Finance.

A critical obstacle to improving Palestinian health remains lack of access to specialist care. The occupied territory sends patients to Egypt, Jordan, and Israel for advanced treatment. The costs are great, especially in Israel, creating an unsustainable burden on Palestinian health budgets. The best strategy would be to develop local services for Palestinians, but the present chaotic political circumstances preclude such a solution. With scarce funding, there can be no new facilities and few trained staff. The Authority’s inability to pay salaries has meant that—despite the dire need for medical care—four hundred doctors are already unemployed in Gaza alone. There are desperate shortages of vascular, orthopedic, neurosurgical, and mental health services. Procurement of medicines is difficult. Diagnostic facilities are unavailable to large sections of the population.

Most health workers I spoke with were pessimistic about the immediate future. They saw the political choreography between President Abbas and the Hamas government, which might result in a unified Palestinian Authority, as an unlikely mechanism to deliver genuine benefits for ordinary Palestinians. Unless the recent meetings between Abbas and the Hamas leaders result in an effective government, the most probable outcome over the next two years, they say, is a tense status quo. Hamas will gain support among people dismayed at the lack of concern shown by the international community for civilian health. Israel will continue to build its separation wall and expand settlements in the West Bank. Iraq will remain a medium-term distraction. And, in any case, the world seems fatigued by the Israeli–Palestinian impasse.

The best that might be hoped for right now is a scaled-up response by civil society—people and organizations independent of government. Dr. Yousef Mousa, who chairs the Union of Health Work Committees, offers one example of what can be achieved in the face of apparent hopelessness.


In 1985, he created a volunteer organization to assist marginalized Palestinians in Gaza and the West Bank. He began in two rented rooms in the Jabaliya refugee camp. His organization has now grown to become the largest local NGO, providing primary care and hospital facilities throughout the Gaza Strip. His ambitious goal is to deliver comprehensive programs for physical, mental, and social well-being to all Palestinians. In Gaza, for example, he employs 350 staff members, who include both Muslims and Christians.

Visiting his clinics and the al-Awda Hospital in Gaza City, I was struck by the astonishing scope of Dr. Mousa’s project. He offers legal advice as well as health education to women. He provides a well-stocked library for children of all ages. He organizes dancing and life-skills classes, Internet access, speech therapy, and a safe haven for children to come and play during school vacations.

Dr. Mousa is a large, jovial man. He is not immune to the realities of his work. As we drive the length of the Gaza Strip, he holds a Kalashnikov for security reasons in one hand and a cigarette in the other. He is disappointed by the lack of support he receives from many international humanitarian aid agencies. He is especially scathing about the lack of help he gets from the World Health Organization.

The US and European Union are unfairly punishing Palestinians for electing a Hamas-led government, he says. Worse still, the cessation of Western aid is jeopardizing his efforts to protect civilian lives. While Dr. Mousa does not sanction an academic boycott of Israel (in contrast with many other Gazan doctors and health sector groups) or violence against Israel, he refuses to submit to anti-terrorist vetting procedures imposed by American donors. He welcomes transparent evaluation of his work, he says, but he will not accept money tied to conditions. The current pressure being exerted on Palestinians is, he tells me, nothing less than “torture.”


I visited three CARE-supported clinics in the southern part of the West Bank. Each reflected different partnerships between CARE and local health providers. The first was at Khirbet Zakariya, a small hillside village of four hundred people on the way from Bethlehem to Hebron. CARE collaborates with the Health Workers Committee here to provide medicines, equipment, and staff for a primary-health-care clinic. Dr. Islam Abdeen received a medical degree from al-Quds University in East Jerusalem in 2004. He now treats a range of conditions in the village, from diabetes to amoebiasis.

The clinic is under threat. For many years village leaders had requested permission from the Israelis to build a school at Khirbet Zakariya. The Israeli authorities refused, citing security concerns. With no easily accessible schools in this desolate region of the West Bank, villagers decided to take matters into their own hands and build a school themselves. In a small building completed in 2004, they now have three classrooms where children from several grades are taught together. The conditions are barely adequate, but at least the village can now offer its children a basic education. The clinic is located in a small side room at one end of the school.

Israeli forces are deployed throughout this part of the West Bank. When they saw villagers building a school, they intervened to stop them. According to the village’s leader, Abu-Ibrahim, Israeli officials have issued nineteen written and verbal warnings, promising to demolish both the school and the clinic. The most recent letters date from 2006. I saw one of these letters, which was written in both Arabic and Hebrew. It came from the Inspection Committee of the Civil Administration in Judea and Samaria.

Referring to previous warnings, the Israeli authorities said that they had provided villagers with ample time and opportunity to justify their actions. But the inspection committee was now “convinced that the building has been completed without legal permission.” The villagers had to remove what they had constructed within seven days: “If you do not comply, legal procedures will be implemented, including the destruction of the building.” The site would have to be restored to its original state, the villagers were told, at “your own expense.”

The clinic in this small school has already saved dozens of villagers’ lives. If it were demolished, their health would be left to the mercy of chance. In what amounts, in Abu-Ibrahim’s view, to nothing less than a provocative act of humiliation, the Israelis have built a brand-new school for their own settlements, together with a swimming pool, on the promontory directly opposite Khirbet Zakariya. It is not humanly possible to believe that the Israelis, under cover of imprecise security concerns, wish to destroy this small and already fragile Palestinian community, depriving its children of education. But their strictly enforced policies are leading to exactly this: wholesale de-development of rural Palestinian villages.

The second clinic I visited is run jointly with the Palestinian Ministry of Health in the ground floor of the mosque at Masafr Bani Naim, to the east of Hebron. It serves a mainly Bedouin community. The chief obstacles to delivering care here are delays caused by multiple military checkpoints in the area.

Akram Shrouf, the project coordinator in Hebron, told me that ambulances are frequently obstructed from going about their work. This Bedouin community is very poor. Many of its children are undernourished and anemic. Unemployment is high. With only forty-five doctors to deliver all primary care services in the rural Hebron region, any additional hindrances to providing health services have a disproportionately large impact, Mr. Shrouf told me. When delays in access to care do occur, complaints can be made to the Israel Defense Forces. But by then it is too late. No amount of complaining through official channels seems to ease the restrictions on movement.

Finally, we entered Hebron where our third stop was a tiny clinic overlooking the divided old city. Cars are prohibited from approaching the clinic because the building in which it is housed lies close to an Israeli settlement. The area is heavily protected by Israeli forces and only pedestrian access is allowed. Patients who cannot walk have to be carried by relatives about fifty meters to reach the clinic entrance.

Here the Palestinian Medical Relief Society runs a service for a community of around 20,000 people. Staff members see forty to fifty patients each day and they provide the only primary care in the area. I was told that the reason their windows are covered with metal grilles is to stop the stones thrown by Israeli settlers from breaking the glass.4


I wanted to discuss the effects of Israeli security policies on Palestinian health with Israeli doctors. Dr. Yoram Blachar is the president of the Israeli Medical Association (IMA). He is a pediatrician with a quiet and approachable manner. He has had his own fair share of confrontations with the Israeli government over its domestic health policies. He is critical of Israel’s insufficient spending on health, its lack of attention to promoting good health among the population, and the often senseless restrictions on doctors’ clinical freedom in the name of cost containment. He regrets the fact that security dominates his country’s political agenda, to the detriment of the IMA’s wish to raise the quality of health care.

When it comes to the Palestinians, he tries to steer a careful, although understandably defensive, course. The IMA does not get involved in purely political matters, he says. The IMA’s members encompass views ranging from extreme conservatism to radical leftism. The IMA could not possibly reflect these broad opinions in a single policy toward the Palestinians without alienating half its membership. We are “not a human rights organization,” Dr. Blachar emphasized.

However, he was quick to stress that the IMA has not abandoned Palestinian health issues entirely. When medical students at al-Quds University living in the West Bank found that they were unable to gain ready access to their campus in East Jerusalem, the IMA successfully negotiated passes for them that allowed entry.

The IMA publishes pamphlets and brochures that try to dispel the idea that it cares little about Palestinian health and welfare. Dr. Blachar cites the appointment of a senior Israeli physician as a liaison between the Israel Defense Forces and the Palestinian civilian population to facilitate medical care. The IMA has introduced training for Israeli Defense Force doctors on the protection of human rights during times of conflict. And Dr. Blachar told me that the association tries to resolve conflicts rapidly, as when Israelis detain at checkpoints Palestinians in need of medical attention.

I was shown letters to the minister of defense by Dr. Blachar urging government officials to investigate reports of interference by the Israel Defense Forces with medical services to the Palestinian people. The IMA has stated publicly that “medical teams are entitled to absolute immunity from harm and the assurance of unrestricted freedom of movement, while they are strictly engaged in the fulfillment of their professional duties.”

I came away from my meeting with IMA officials in Tel Aviv convinced that they believed in the sincerity of their opinions and actions. But I am equally convinced that a few days spent traveling in the West Bank and Gaza, talking to Palestinian doctors and health workers, and listening to the experiences of Palestinian citizens would show them that their public statements, official assurances, and strongly promulgated arguments sadly count for very little alongside the horrific realities of daily life for Palestinians in Gaza and the West Bank.

There is now abundant well-documented evidence that Israeli policies have harmed Palestinians suffering life-threatening illnesses, including women who need twenty-four-hour access to hospital care. Patients with cancer have endured insulting indignities when trying to seek specialist treatment.5 Studies of perinatal and infant mortality show that checkpoints and military barriers frequently obstruct women seeking care during critical periods of labor and delivery.6 Israeli doctors do not to intervene in person to assist free movement of those in need of medical attention. The IMA cannot be blind to this evidence. Yet, apart from the letters and general statements they showed me, Dr. Blachar and his colleagues prefer to ignore it. For any medical association, this selective attention to the facts is disturbing and unacceptable.

The IMA’s position does not represent the views of all Israeli doctors. With a membership of around 1,500, Physicians for Human Rights–Israel (PHR-I) argues strongly that the Israeli state, as an occupier, has direct responsibility for the health of the Palestinian population. It acts as an advocate on behalf of Palestinians whose right to health has been violated by the Israelis. PHR-I regularly sends a mobile clinic to the occupied territory, giving expert care in general medicine and women’s health. The president and founder of PHR-I, Dr. Ruchama Marton, sees these clinics as “an act of protest against the occupation and the different aspects of it in the daily life of the Palestinians. It is not another humanitarian act of good professionals in the face of the terrible health conditions in the [occupied territory].”

Dr. Bella Kaufman, a breast cancer specialist at the Chaim Sheba Medical Center in Tel Aviv and a member of PHR-I, told me that Israeli physicians are beginning to see the adverse human consequences of their government’s actions. They are far more receptive, she says, to the principle that Israelis have a continuing duty toward Palestinians. She believes that a cultural shift in professional Israeli public opinion may be taking place.


The year 2007 is the fortieth anniversary of the Six-Day War. The cycle of violence continues. The most provocative recent Israeli action affecting the welfare of Palestinians has been the construction of the separation wall. Whatever the wall’s political intent and whatever the petty humiliations inflicted on Palestinians seeking to cross it,7 the wall’s humanitarian impact has been profound. Along with checkpoints that are difficult to cross, the wall stops Palestinians who live in small towns and rural areas from traveling to specialist medical centers in nearby cities.8 I visited one town in the northern West Bank, Seer, where women are regularly blocked from reaching Jenin to receive obstetric care. The result has been a steady rise in maternal mortality, according to Dr. Allam Jarrar from the Palestinian Medical Relief Society.

Traveling further north on the West Bank to Deir Ghazala, I met Nadia Zakarna, the chairwoman of a women’s center in the town. She too described access restrictions in travel to Jenin (even for emergencies), disrupted vaccination programs, the poverty-inducing effect of chronic unemployment, and the intimidation that women feel when approaching Israeli checkpoints. “We want to live in peace and dignity,” she told me. “Our suffering will not end without ending the occupation.” These words did not come from a fanatic, from a Kalashnikov-wielding member of Islamic Jihad, or from a member of Hamas. They were the words of a frustrated woman and mother, trying to shore up her collapsing community.

The separation wall has created a series of enclosed Palestinian city-states—Ramallah and Jenin, for example—across the occupied West Bank. Political leaders, locally and within the Palestinian Authority, are powerless to improve health services for people living within these urban prisons. To Palestinians, the separation wall is not a benign fence erected simply to protect Israel from terrorism. For many, it is seen as an aggressive act inflicting severe human harm.

I walked with Nadia Zakarna and Dr. Allam Jarrar to what is called the “fence” at Arabuna in the northern tip of the West Bank. A fence does not adequately describe what is, in fact, a carefully carved partition in the land, intended to divide communities. Rolls of razor wire form the first barrier facing Palestinians. Families have to watch their children constantly to ensure that they do not get caught and cut by the sharp steel. A trench shielded by huge boulders follows, with a tall electrified fence, a road, and more razor wire completing the border. In English, Arabic, and Hebrew, a sign greets villagers who walk too close to the partition: “MORTAL DANGER—MILITARY ZONE. ANY PERSON WHO PASSES OR DAMAGES THE FENCE ENDANGERS HIS LIFE.”

What does the future hold for the health and the well-being of Palestinians? In the absence of reconciliation, both are unlikely to undergo a reversal of their current precipitous decline. A position of permanent dependency on Israel and on external aid seems probable, perhaps fatally disabling the already handicapped Palestinian Authority. Partly this is because of political infighting among Palestinian elites and continued episodes of violence against Israelis. Partly it is because Palestinians have been unable to make use of the press and television to present their story in a strong and convincing way to the world.9 Partly it is because powerful members of the international community have abandoned the Palestinian people, relying on the convenient but cruel excuse that the democratically elected Hamas government continues to hold positions it finds objectionable. Partly it is because the Israeli government prefers to reject any humanitarian impulse to assist Palestinians, let alone adhere to its past commitments to end the occupation of Palestinian land.

Western governments have demanded that Hamas renounce violence, recognize Israel, and honor previously signed accords before questions of Israeli settlements, the right of return of Palestinian refugees, the fate of East Jerusalem, and the creation of permanent borders can even be raised.10 But a sense of profound historical and current injustice is palpable in every encounter one has with Palestinians and cannot be ignored by the Quartet—the US, the European Union, Russia, and the UN—as it reflects on how to reactivate the peace process. Demands made by the international community, however reasonable they might seem, imply for many Palestinians I talked to that they should abandon resistance, renounce many of their claims, and ignore Israel’s own record of violence and its violations of past agreements, especially during the nearly forty years of occupation. Such demands, I was told, have little hope of acceptance. They will be seen by most Palestinians as further concessions for which they can expect no reward. Unless something tangibly positive can be delivered to ordinary Palestinians, a violent, even if self-defeating, conflict seems likely to continue.

There is one element of hope. Palestinians have an undimmed engagement with their future. Discouraged and immobilized they may be, but their commitment to the creation of a Palestinian homeland—a nation-state—remains very much intact. Every conversation I had about health turned to politics sooner or later, and usually with heightened passion. Palestinian health workers are not passive observers in a political process. Through civil society organizations such as the Palestinian Medical Relief Society and the Union of Health Work Committees, they are daily inventing the systems and institutions to protect the health of their people now and in the future. In short, Palestinians are laying the foundation for sustainable self-reliance in a territory where people have reluctantly come to understand that they can rely on no one but themselves. The struggle over Palestine was once a battle against an occupier over territorial self-determination. It is now an urgent fight for self-preservation.

—February 14, 2007

This Issue

March 15, 2007