Medical apartheid in Palestine

ABSTRACT

The International Convention on the Suppression and Punishment of the Crime of Apartheid (1974) and Article 7 of the Rome Statute of the International Criminal Court (1998) recognise apartheid as a crime against humanity, characterised by a practice of systematic oppression and violations of human rights with the intent of one racial group to maintain domination over another. The term ‘medical apartheid’, although without a formal definition in international human rights law, has been used similarly to refer to situations of pervasive segregation and discrimination in health care, based upon race, and characterised by stark inequality in health care accessibility, availability, acceptability, and quality. This paper, using a combination of literature review; data on attacks on Palestinian health facilities, workers, and transport; and information from Palestinian and Israeli government authorities on referrals to specialised health care services, examines the ways in which Israeli policies and practices can be understood to constitute a form of ‘medical apartheid’ that deprives Arab residents of the Palestinian territories the full realisation of their right to health.

KEYWORDS:

• Medical apartheid
• discrimination
• human rights
• Palestine

Introduction

Apartheid is an Afrikaans word meaning ‘separateness’, or ‘the state of being apart’, literally ‘apart-hood’. Its first recorded use was in 1929, but apartheid as a specific ideology supported by the South African National Party (NP) government was introduced in 1948. In South Africa, apartheid was enforced by laws that mandated that racial groups live separately, banning interracial marriage as well as social and residential integration between racial groups (Mhlauli & Mokotedi, 2015).

Although the Convention on the Suppression and Punishment of the Crime of Apartheid (Apartheid Convention) was adopted by the General Assembly in 1973 and declared apartheid to be a crime against humanity and a violation of the Charter of the United Nations, contemporary claims of apartheid continue to be made, including in South Africa, China, Myanmar, and Israel (Amnesty International, 2017; Kushner, 1979; Mhlauli & Mokotedi, 2015; Munsterhjelm, 2019).

In 2007, South African jurist John Dugard, in his capacity as UN Special Rapporteur on the situation of human rights in the occupied Palestinian territories (oPt), issued a report that Israel’s practices, in place since 1967, in the oPt had assumed characteristics of colonialism and apartheid (Dugard, 2007). More recently, Richard Falk (who served as UN Special Rapporteur on the situation of human rights in the Palestinian territories following Dugard) and Virginia Tilley examined the question of whether Israel’s policies amounted to apartheid, finding that they did (Falk & Tilley, 2017). Leading international human rights organisations such as Amnesty International (2022) and Human Rights Watch (2021) have also alleged that Israeli authorities have been responsible for the crime against humanity of apartheid.

By contrast, the term ‘medical apartheid’ is not specifically defined by international treaties. Generally, the term has been adopted, especially in the United States, to refer to situations of pervasive segregation of health care, based upon race or ethnicity, as well as discriminatory, exploitative and abusive treatment in health care settings and, in some cases, non-consensual medical experimentation (Brooks et al., 1991; Golub et al., 2011; Washington, 2006). Related to medical apartheid is the concept of ‘vaccine apartheid’ which has, with the onset of the COVID-19 pandemic, increasingly been identified as a type of global apartheid with inequitable access to vaccines among low- and middle-income countries (Parray et al., 2022).

In Palestine, the recognition of a broad system of apartheid, combined with the acute recognition of COVID-19 related vaccine apartheid, has led to increasing identification of Israel’s medical policies and practices as a system of medical apartheid (Barghouti, 2021). While often used colloquially, an examination of the mechanisms and characteristics of medical apartheid in Palestine, as both a part (and consequence) of the system of apartheid and as an intentional instrument to subjugate Palestinians by depriving them of their health and well-being has yet to be engaged by public health scholars.

Drawing upon an understanding of medical apartheid as a discriminatory system of policies and practices seeking to reinforce racial or ethnic segregation and resulting in direct harm and stark inequality in health care accessibility, availability, acceptability, and quality, this paper seeks to examine if and how current Israeli policies and practices in the oPt in terms of access to medical care may constitute medical apartheid and to explore the consequences on Arab Palestinian’s realisation of the right to health. We will also look at how Israel’s policies favour those Palestinians contributing to the Israeli state. While providing the context of policies implemented over the past five decades, our review looks specifically at data from 2019 through 2022, reflecting current conditions and impacts.

Methods

In assessing evidence of medical apartheid by Israel in the oPt, we examined: (1) the financing of health care in the oPt; (2) attacks on health facilities, workers and transport in the oPt; and (3) referrals to health care services for Palestinians to non-MoH providers in West Bank, Israel, East Jerusalem, and other destinations between 2019–2021. Together these elements examine the basic foundation of health systems, specific threats to their operations, and mechanisms for ensuring advanced and high-quality care.

Drawing upon the framework of Arksey and O'Malley (2005), we conducted a scoping review for literature on financing of health care in the oPt, including information on the history, development, and funding of the health care system. Articles that met the following criteria were sought in our review: (1) Published in a peer-reviewed English-language journal between 2000 and 2022; and (2) Focused on the policies and evolution of the health care system after 1967 (e.g. the occupation of the West Bank and Gaza). Further sources were identified through an examination of citations of those articles identified in our preliminary search. We excluded conference proceedings, abstracts, book chapters, and articles for which the full text was not available in English.

Data about attacks on health facilities, workers, and transport were drawn from a review of reports prepared by the Safeguarding Health in Conflict Coalition (SHCC) and the non-governmental organisation Insecurity Insight documenting attacks between 2019 and 2021. The SHCC and Insecurity Insight reports rely upon diverse sources for documenting and validating attacks on health. For attacks in the oPt these include media sources and publicly shared information from health workers; information provided by Medical Aid for Palestinians (MAP); and information from the WHO surveillance system on health care. Incidents are included based upon the WHO’s definition of an attack on health care as ‘any act of verbal or physical violence, threat of violence or other psychological violence, or obstruction that interferes with the availability, access and delivery of curative and/or preventive health services’ (World Health Organization, 2020).

Finally, information on referrals for care and permits to access health care services were extracted from reports issued by the WHO Regional Office for the Eastern Mediterranean. While reports between January 2011 and March 2022 were available, only reports starting in 2019 examined both patient and companion applications from the West Bank and the Gaza Strip, and these reports are the focus of our analysis. Specific variables examined are identified in Text Box 1.

Box 1. Key variables.

 Gaza Strip:

• Referrals to providers that are outside Palestinian Ministry of Health

• Number of patients’ applications from Gaza to Israeli authorities to cross Erez/Beit Hanoun to access healthcare

• Percentage of Gaza patients approved, denied, and delayed (receiving no definitive response to their application by the date of their hospital appointment)

• Number Gaza patients called for security interrogation

• Number of companion applications to Israeli authorities from Gaza to cross Erez/Beit Hanoun to access healthcare

• Percentage of Gaza companion applications approved, denied, and delayed (receiving no definitive response to their application by the date of their hospital appointment)

• Number of patients and companions from Gaza exited through Beit Hanoun/Erez to access health care

West Bank:

• Referrals to providers that are outside Palestinian Ministry of Health

• Number of patient permit applications from the West Bank to access healthcare in East Jerusalem and Israel

• Percentage of West Bank patients approved, denied, and delayed (receiving no definitive response at the time of monthly reporting)

• Number of companion applications to access healthcare in East Jerusalem and Israel

• Percentage of West Bank companion applications approved, denied, and delayed

We used Tabula to extract data from the WHO reports and then calculated annual averages alongside summations for the different variables reported by WHO. Missing data were omitted from all analyses, including: all records from August and November 2019; and West Bank referrals between January and March 2019. In 2020, omitted data from the West Bank consisted of all data between June and December, which is due to The Civil Affairs Office closing for patient and companion permit applications. For the Gaza Strip, data between June and October was missing for certain variables (e.g. percentage of patients denied, delayed, and most data on companion applications). Overall, from the retrieved reports across the three years, data on referral numbers, number of patients and companions crossing through Beit Hanoun/Erez were the most comprehensive, followed by data on the Gaza strip patient applications and rates. For the Gaza Strip, we calculated number of approved, delayed and denied applications through multiplying the rates provided by the number of applications submitted, then we used the number of approved, delayed, and denied applications to calculate annual rates. For the West Bank we averaged the provided rates.

As data from 2021 was complete for Gaza and the West Bank, we examined the monthly reports for that year in greater detail to comprehend the latest information on the patients. The data highlights the age distribution of patients, destination of referral, and health condition.

Results

Underinvestment

The health system in the oPt has been interconnected with the political context throughout its history and is a product of the frequent transitions of the entities assuming responsibility in the region (Giacaman et al., 2003). In 1967, Israel (78% of Mandate Palestine) expanded across the green line by capturing the West Bank including East Jerusalem and Gaza Strip after the Six-Day War. Territories beyond the green line are considered under military occupation by the international community (Falah, 2004; J Street, n.d.; The United Nations, n.d.). After the occupation of the West Bank and Gaza Strip, the Israeli Civil Administration usurped the governmental health care system while restricting the involvement of Palestinians in leadership (Mataria et al., 2009). This period was distinguished by restrictions on funding for health care in the oPt (Giacaman et al., 2003)^. For example, in 1975, the health services budget in the West Bank was equivalent to about 60 percent of the budget of one 260-bed Israeli hospital for the same year (Giacaman, 1994). Ten years later, in 1985, the budget for all nine government hospitals in the West Bank were 17 percent of the budget of one Israeli hospital (Giacaman, 1994). By 1986, the average expenditure on health services in the West Bank and the Gaza Strip was less than US$ 30 per capita per year, compared to US$ 350 per capita in Israel (Giacaman, 1994). Shortages in staff, beds, medications, and specialised services forced Palestinians to seek referrals to Israeli hospitals for tertiary care (Giacaman et al., 2009).

After 1993, a series of agreements between Israel and the Palestine Liberation Organisation (e.g. Oslo Accords, Protocol on Economic Relations, etc.) resulted in the establishment of the Palestinian Authority (PA), and the division of the West Bank into three administrative zones (Areas A, B, and C). Initially, the regions were intended to be temporary (five-year transitional period), while discussions on important topics like refugees, Jerusalem, settlements, security, relations, and borders occurred (Said, 2007). The regions still divide the West Bank until this day. In Area A, comprising 18% of the West Bank, the PA oversees civil and security matters in eight Palestinian cities and their surrounding areas. In Area B (22%), the PA oversees only civil matters, this area includes around 440 Palestinian villages and their nearby lands. In Area C (60%), where most Israeli settlements are located, Israel maintains full control (Jazeera, 2019; American Near East Refugee Aid, n.d.). While Area C is a continuous territory, Areas A and B are divided into 166 separate areas, fulfilling Former Prime Minister of Israel Ariel Sharon’s vision when he said ‘Don’t build fences around your settlements. If you put up a fence, you put a limit to your expansion … We should place the fences around the Palestinians and not around our places.’ (Gordon, 2008; Kadman, 2013)

The establishment of the PA resulted in the transfer of authority to the Palestinian Ministry of Health (MoH) (Giacaman et al., 2003). The PA and MoH announced a mission of creating a self-sufficient independent health system aided by external donor funding. However, in the context of an increasing population, inflation and sharply declining donor support, per capita health expenditure declined between 1994 and 1998 (The Secretariat of the Ad Hoc Liaison Committee, 1999). Several factors contributed to the decrease in external funding, including shifting donor priorities, focusing on relief rather than development, and the increasing expenditure on referrals to non-MoH providers. For insistence, the total expenditure on treatment by non-MoH providers was almost half of the MoH’s budget in 2004 (Mataria et al., 2009).

Currently, there are five leading health service providers within the oPt. As a percentage of all Primary Health Care centres, the MoH manages 63%; the Palestinian Military Medical Services (PMMS) manages 2%; the United Nations Relief and Works Agency for Palestine Refugees (UNRWA) manages 9%; and Palestinian nongovernmental, nonprofit organisations (NGOs) manage 26%. In addition, individual physicians run private for-profit health clinics providing various services to Palestinians (Palestinian Ministry of Health, 2020).

In the Palestinian West Bank, the MoH authority is complicated by the division of the region into the Areas A, B and C. Although the MoH regulates the health sector overall, it has no control and minimal access to area C, restricting assistance to marginalised Palestinians living there. Further, the mobility of people in these areas is limited due to the presence of Israeli checkpoints, which restrains access to health services in areas A and B. As a result, the MoH provides services to areas A and B in the West Bank and Gaza Strip, where the Hamas government leads an adjacent Palestinian Health Ministry. In comparison, NGOs existed before the MoH and have hospitals, PHCs, and mobile clinics throughout all areas, reaching marginalised populations living in areas C (Kheir-Mataria, 2019).

Israeli security measures also restrict the ability of the MoH in providing services to Palestinians in East Jerusalem, where there are six hospitals where the MoH refers patients for services. Patients from the West Bank and Gaza Strip make up over 50% of the patient population in these hospitals while required to get permits from Israeli authorities to access the services. These hospitals offer specialised services such as oncology, renal care, and cardiac surgeries scarce elsewhere in Palestine (Medical Aid for Palestinians, 2017).

Currently, the political context and continued Israeli control (resulting from the prolonged transition period of the Oslo Accords) conspire to prevent the full development of the health care system in the oPt. For instance, the Protocol on Economic Relations has enabled the dependence of the oPt’s economy on Israel and created a ‘customs envelope’ between Israel and the PA, (Protocol on Economic Relations, 1994), which allows Israel to control and withhold funding for the PA. In an evident abuse of the Paris Protocol, Israel often withholds tax revenues owed to the PA and Palestinian workers (nearly $1 billion annually), hampering the sustainable development of the health care system (Qato, 2020). In addition, the Protocol deterred the development of the pharmaceutical industry in Palestine through Israeli companies’ tax-free access to the oPt’s markets and cut off the oPt from other possible Arab exporters, leading to increased pharmaceuticals’ prices (Almi, 2012).

Related to the underinvestment in health in the oPt, and to the political control exerted by Israeli authorities on health care spending, is the denial of permits for the importation of medical equipment, such as CT, PET, and X-ray scanning machines and spare parts, into Gaza, based upon a claim of ‘dual use’ (Medical Aid for Palestinians and Al Mezan Centre for Human Rights, 2022). For example, in 2021, the Palestinian Authority submitted 120 requests for the entry of such equipment, of which only 30 were approved by February 2022 (World Health Organization, 2022). Israel’s obstruction of the entry of aesthetic gas (nitrous oxide) has also threatened to halt surgical and emergency operations (Al Mezan Centre for Human Rights, 2021).

Attacks on health care

In 2019, 226 incidents of violence against health care facilities, workers, and transport occurred in the oPt. At least 304 health workers were injured, and two health workers were killed. A majority of these incidents occurred during the Great March of Return protests in Gaza, where Israeli forces used live ammunition, tear gas, and rubber-coated steel bullets (Safeguarding Health in Conflict Coalition, 2020). According to the WHO (2020), at least 279 Palestinian health workers were injured and at least 35 ambulances were damaged.

2020 witnessed a sharp decrease in the number of attacks on health care compared to 2019 due to COVID-19 related measures. In 2020, 61 acts of violence against health care facilities, workers, and transport happened in the oPt. Of these incidents, 5 health facilities were damaged, 28 health workers were injured, and 10 were threatened. Most of these attacks happened during protests in the West Bank when Israeli forces entered health facilities and injured patients, patients’ visitors, and health workers, and when Israeli forces fired at, damaged, or forcibly boarded ambulances (Safeguarding Health in Conflict Coalition, 2021). In one incident, a volunteer health worker providing first aid to an injured protestor came under attack by Israeli forces, who threw stun grenades and tear gas canisters at the ambulance and forced their way on board in an attempt to arrest the patient (Safeguarding Health in Conflict Coalition, 2021).

In 2021, there was an increase in reported incidents of violence against health care facilities, workers, and transport compared to 2020. The SHCC report identified 169 incidents where 61 health workers were injured, and 30 health facilities were damaged or destroyed, including primary, emergency, oncology, and rehabilitation services, as well as COVID-19 testing services. Many of these incidents occurred during the May 2021 11-day military operation in Gaza. The use of air-launched weapons by Israeli forces during that operation impacted hospitals, clinics, and health workers at least 53 times, and at least 30 health facilities in Gaza were damaged or destroyed. In the West Bank, 94% of transfers to East Jerusalem were subject to delay due to the ‘back-to-back’ policy, where injured patients are required to be transferred from a Palestine-registered to an Israel-registered ambulance when entering Jerusalem (Safeguarding Health in Conflict Coalition, 2022). Israeli policies and military operations have also reduced the availability of essential health care resources, including medicines, consumables, and essential equipment such as medical imaging devices (Safeguarding Health in Conflict Coalition, 2022). In the first nine months of 2022, the Palestine Red Crescent Society (2022) reported 19 cases of obstruction of ambulances, 331 cases of denial of access for paramedics to the scene of emergencies, and 14 attacks on staff and volunteers.

Referrals and permits

The WHO provided a total of 34 reports between January 2019 and December 2021 on the number of referrals for advanced care (to West Bank, Gaza, Israel, East Jerusalem and abroad) approved by Palestinian authorities and the number of permits subsequently authorised by Israel (WHO Regional Office for the Eastern Mediterranean, n.d.). No reports were available for August 2019 and November 2019, and specific variables were sometimes omitted (see methods section) or presented in non-standardized ways (e.g. data on the West Bank from February, April, May, and June 2019 combined the statistics for patients and companions together).

Overall, at least 242,554 Palestinians were referred to non-MoH facilities between 2019 and 2021. Out of this number, permit applications from the West Bank, and permit applications from the Gaza Strip were 156,233 and 44,105 respectively. Yet only 33,178 Gazan patients (75% of total applications from Gaza) exited, and only 26,943 Gazan companions exited (55% of total companion applications number from Gaza) in the past 3 years.

In 2021, referrals to East Jerusalem represented 38% and referrals to the West Bank represented 48% of all referrals issued. Referrals to Israeli Hospitals and within the Gaza Strip represented 5% each of all referrals. The rest of referrals (4%) are to other countries, most notably Jordan, Egypt, and Turkey. Patients from the Gaza Strip are required to apply for permits to access health care services in those countries.

The Gaza Strip

In 2019, WHO reported that 30,149 patients from Gaza were referred to non-MoH facilities. Of this number, 20,709 applications (69%) were submitted for permits to access healthcare outside of Gaza. Of these, 1776 (9%) were denied, 5460 (26%) were delayed beyond medical appointment, and 13,515 (65%) of permits were approved by Israeli authorities. A total of 16,401 patients (representing 54% of all patients referred, and 79% of applications number) exited Beit Hanoun/Erez crossing to access healthcare. In addition, 13,757 companions accompanied those patients who exited at the Beit Hanoun/Erez crossing. And 58 patients were called for interrogation that year.

By comparison, in 2020, 17,540 patients from Gaza were referred to non-MoH facilities. Of this number, 7,924 applications (45%) were submitted for permits to access healthcare outside of Gaza. 517 (7%) were denied, 1,729 (22%) were delayed beyond medical appointment, and 5,527 (71%) of permits were approved by Israeli authorities. A total of 6,351 patients (representing 36% of all patients referred) exited Beit Hanoun/Erez crossing to access healthcare. In addition, 5,051 companions accompanied those patients who crossed at the Beit Hanoun/Erez crossing. And 29 patients were called for interrogation that year.

In 2021, 22,462 patients from Gaza were referred to non-MoH facilities. Of this number, 15,472 applications (69%) were submitted for permits to access healthcare outside of Gaza. Of these, 85 (1%) were denied, 5,715 (37%) were delayed beyond medical appointment, and 9,669 (62%) of permits were approved by Israeli authorities. A total of 10,426 patients (representing 46% of all patients referred, and 67% of all patients applied) exited Beit Hanoun/Erez crossing to access healthcare. In addition, 8,135 companions accompanied those patients who crossed at the Beit Hanoun/Erez crossing. And 39 patients were called for interrogation that year.

The West Bank

In 2019, WHO reports indicated that 35,604 patients from the West Bank were referred to non-MoH facilities. And 50,970 applications were submitted for permits to access healthcare in East Jerusalem and Israel. 84% patient applications were approved, 13% were denied, and 3% didn’t receive an answer by the time of monthly reporting.

By comparison, in 2020, 60,939 patients from the West Bank were referred to non-MoH facilities. And 21,966 applications were submitted for permits to access health care in East Jerusalem and Israel. 76% of patient applications were approved, 16% were denied, and 8% didn’t receive an answer by the time of monthly reporting.

In 2021, 75,865 patients from the West Bank were referred to non-MoH facilities. And 83,297 applications were submitted for permits to access healthcare in East Jerusalem and Israel. 86% of patient applications were approved, 10% were denied, and 4% didn’t receive an answer by the time of monthly reporting.

In 2021, 66% of referred patients from the West Bank and Gaza Strip needed advanced care for the following specialties: Oncology (27%), Cardiac Catheterisation (7%), Cardiology (6%), Ophthalmology (5%), Urology & Nephrology (8%), Haematology (4%), Medical Imaging (4%), Radiotherapy (3%), and Paediatrics (3%). 21% of patients were under 18 years and 29% were above 65 years in age – making the elderly and children 50% of all referrals in 2021.

Discussion

Our analysis of the literature on underinvestment in health, data on attacks on health facilities, workers, and transport, and on the rates of refusal of referral for advanced health care, present strong evidence of a system of medical apartheid imposed by Israeli policies and practices. In addition, Israel’s policy of excluding approximately five million Palestinians in the oPt from its COVID-19 vaccination program but including 666,000 settlers living in the same territories presents further evidence of systematic segregation of medical care and public health interventions based upon religion and ethnicity (Canadians for Justice and Peace in the Middle East, 2021). The effect of this system of medical apartheid is manifest in stark health inequities between Israel and the oPt, including a 9-year difference in life expectancy, and 6-fold difference in infant mortality rate (Rosenthal, 2021).

These inequities should be understood as the intentional and foreseeable effect of longstanding Israeli government policies. Between 1967-1994, health care in the oPt was controlled by the Israeli Civil Administration, a part of the Ministry of Defense (Giacaman et al., 2003; Gordon, 2008). Palestinians needed approval from Israel’s General Secret Services (GSS) to establish medical clinics (Gordon, 2008), and funding levels for Palestinian health services were markedly less than for health services in Israel. Mismanagement and underinvestment in the oPt’s health care forced Palestinians to depend substantially on the Israeli health system and complicated MoH’s subsequent mission to develop an independent sovereign health care system after 1994.

In addition to this historical underinvestment, Israel has frequently targeted the health care system through violence against health workers and interference with health facility operations. For example, between 2000–2002, during the second intifada, the Palestinian Red Crescent Society (PRCS) alone reported 174 attacks on their ambulances and 166 attacks on their EMTs, resulting in 3 deaths and 134 injuries. The UNRWA reported 75% of its ambulances were targeted by gunfire. Additionally, Israel restricted the movement of health personnel, leading to the closing of health centres due to high levels of staff absence (Jamjoum, 2002). In 2008, the WHO reported 58 hospitals, clinics, and 29 ambulances were damaged or destroyed in Gaza, with 25 injured and 16 killed medical workers. In 2012, in Gaza, 16 hospitals, clinics, and 6 ambulances were damaged or destroyed, with 3 medical workers injured. In 2014, 73 hospitals, clinics, and 45 ambulances in Gaza were damaged or destroyed, and 78 medical workers were injured and 23 were killed (Medical Aid for Palestinians, 2017). While some of these attacks may be considered lawful as a matter of international humanitarian law, many could be considered indiscriminate, and some, such as deliberate firing at ambulances, represent clear violations. In all cases, international humanitarian law requires taking necessary precautions, including minimising harm to civilians and international humanitarian law, as well as human rights law, obligate Israeli authorities to not obstruct access to health care (Footer & Rubenstein, 2013).

A 2019 investigation by the UN Independent Commission of Inquiry on the Protests in the Occupied Palestinian Territory found that Israeli Forces killed three clearly marked paramedics (United Nations Office of the High Commissioner for Human Rights). While Israel claims that attacks on health care are for self-defense purposes, many scholars have rejected these claims, describing such attacks as ‘a pattern of illegal targeting’ (Asi et al., 2021).

In its 2004 Advisory Opinion on the Legal Consequences of the Construction of a Wall in the Occupied Palestinian Territory, the International Court of Justice confirmed the applicability of international human rights law to situations of military occupation such as Israel’s occupation of Palestine and noted that, in the territories under its occupation, the occupying power was bound by the human rights provisions of the International Covenant on Economic, Social and Cultural Rights (ICESCR) and of the Convention on the Rights of the Child (CRC), as well as other treaties (Evans & Breau, 2005). The Court found a range of provisions relevant to ensuring human rights protections for Palestinians including the right to an adequate standard of living, the right to food, clothing and housing, and the right to education (Evans & Breau, 2005). Israel’s ratification of the ICESCR, in particular, makes it legally bound to ensure that the right to health is respected, protected and fulfilled for all territories and populations under its effective control (United Nations Committee on Economic Social and Cultural Rights, 2003). This point was made explicit by the Committee on Economic, Social and Cultural Rights (CESCR) which provides authoritative interpretation of the ICESCR, and found that the treaty obligated Israel to give full effect to its ICESCR obligations in Palestine, ‘as a matter of the highest priority, to undertake to ensure safe passage at checkpoints for Palestinian medical staff and people seeking treatment.’ (United Nations Committee on Economic Social and Cultural Rights, 2003).

Yet, health care remains underdeveloped in the oPt, leading to a high number of referrals to non-MoH providers. Whether it’s Palestinians from the West Bank needing to access health care from non-MoH providers in East Jerusalem (which is considered part of the oPt), or the residents of Gaza needing to access health care anywhere, because of restrictions on rights to freedom of movement, both populations require permits from Israeli authorities. However, permit applications get denied and delayed frequently, with companion applications denied and delayed at even higher rates, depriving patients of the psychological and physical support of a companion, which is especially necessary in the case of children and the elderly. Another psychological stressor for patients and companions is security interrogation by Israeli authorities. Restrictions in accessing health care are reportedly greater for Palestinians who had participated in any political activity, including protests (Gordon, 2008), and for patients with relatives considered to be a threat by Israeli authorities (Medical Aid for Palestinians, 2017).

By contrast, approval rates are higher for medical referrals from the West Bank compared with individuals from the Gaza Strip, perhaps because of Israel’s dependence on the West Bank for labour. In 2021, 145,000 Palestinians worked in Israel; of this number, 22,000 worked in settlements in the oPt (Palestinian Central Bureau of Statistics, 2022). These workers were included in the first Israeli vaccine campaign (Canadians for Justice and Peace in the Middle East, 2021). Some researchers viewed this selective vaccination of Palestinian workers in Jewish communities as only on account of their economic utility for the Jewish state (Howard & Schneider, 2022).

The importance (and power) of even short delays in approvals of medical referral is underscored by the most common reason for referral, which in 2021, was for oncology and cardiac catheterisation. Studies have concluded that a small delay in cancer treatment is associated with increased mortality (Hanna et al., 2020) and patients awaiting cardiac catheterisation may experience major adverse events, such as death (Natarajan et al., 2002). In 2017, 54 Palestinians died awaiting Israeli permits, 46 of whom had cancer (Human Rights Watch, 2018).

Historic underinvestment in health, ongoing economic dependency and targeting of health workers, facilities and transport, permit requirements, and restrictions on freedom of movement for residents of the oPt function jointly to deprive Palestinians of the full realisation of their right to health. Together, these components result in a system that can be best understood as a form of medical apartheid that disfavours the Arab, non-Jewish citizens of the oPt. These policies have deep historical roots which continue, for example, with the use of permits, to the present (Gordon, 2008).

Articles 50 and 55–56 of the 4th Geneva Convention oblige an occupying power to facilitate the proper working of educational institutions, ensuring proper medical supplies and maintaining hospitals and public health. In their article entitled, Apartheid, International Law, and the Occupied Palestinian Territory, John Dugard and John Reynolds, make the claim that: ‘Israel leaves the welfare of the occupied people to international donors and has created a cycle of aid dependency’ (Dugard & Reynolds, 2013, p. 45).

Within the human rights framework is an understanding of rights holders and duty bearers (World Health Organization, 2018). Ordinarily, rights holders are recognised as the individuals within the state who have claims to the rights to which the state has pledged, through traditional practices, laws, constitutions and regional and international treaties, to uphold. While the Palestinian Authority and Hamas can rightly be seen as having obligations to advance the right to health for Palestinians, and having unevenly upheld those obligations, in the case of the oPt, where the West Bank and Gaza Strip have been under Israeli military occupation for over 50 years, the primary responsibility for the right to health of Palestinians in the West Bank and Gaza Strip lies with Israel as an occupying power (World Health Organization, 2018). Like other entities worldwide, the Palestinian leadership is faced with pushback and punishment when protesting human rights violations and occupation. For example, at the beginning of 2023, Israel withheld $36 million in tax revenue from the PA in response to Palestinian effort to involve the International Court of Justice in providing an opinion on the legal consequences of Israel's occupation (Reuters, 2023).

The evidence and analysis presented here for medical apartheid in the oPt as a result of Israeli government policies and practices does not address other issues that could further bolster the claim, related for example, to Israeli settlements in the oPt in violation of the 1998 Rome Statute of the International Criminal Court, and described as a war crime by the UN Special Rapporteur on the situation of human rights in the Palestinian territories (United Nations Office of the High Commissioner for Human Rights, 2021). In addition, the seizure and destruction of Palestinian homes has resulted in severe impacts on the livelihood and the mental state of children and their families. According to a study conducted by Save the Children, many families have lost their access to services, such as health care, water and electricity, in addition to loss of food security (Shi, 2021).

Israel’s occupation of the Palestinian territories can also be seen as a form of settler colonialism that aims to rupture the relationship between an indigenous people and its territory, that is, deny the right to self-determination. The right to self-determination is fundamental for the recognition of all human rights and accordingly is recognised in Article 1 of both the International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on Economic, Social and Cultural Rights (ICESCR) (1966e, 1966d). Israel’s policies of settler colonialism and control over the freedom of movement (ICCPR, 1966a) of Palestinians impact on the right to health is also manifest through its impact on the social determinants of health, through violations of a host of other rights including the ability to work, (ICESCR, 1966c) the rights to housing and to own and enjoy property (ICESCR, 1966c), the inherent right to life (ICCPR, 1966g), the right to engage in political activity (ICCPR, 1966d), the right to liberty and security of the person (ICCPR, 1966c), the right to an adequate standard of living (ICESCR, 1966b), and the right to be free from arbitrary interference with one’s privacy, family and home (ICCPR, 1966i).

Collectively, Israeli policies and practices infringe upon the rights of the Palestinians to control their natural resources, the right to their own culture, religious practices and heritage, and their right to economic and social development (ICCPR, 1966b, 1966h, 1966a). The overall impact of Israel’s policies and practices of medical apartheid is a violation not only of the right to health, but also of the rights to equality and to be free from racial and ethnic discrimination (ICCPR, 1966f).

Conclusion

Claims of apartheid, as with claims of human rights violations more broadly, are often contested by governments through denial, intimidation, appeals to state security, rhetorical parsing, and bureaucratic opacity. Whether the focus is on ethnic cleansing in Myanmar (Beyrer & Kamarulzaman, 2017); torture and cruel, inhuman and degrading treatment of people who use drugs in east and southeast Asia (Amon et al., 2013); or forced sterilisations, forced placement of intrauterine devices, and forced abortion among the Uyghurs in China (United Nations Office of the High Commissioner for Human Rights, 2022); governments accused of human rights abuses frequently hinder factual investigation and issue blanket statements that the evidence for such claims are false or based on disinformation and lies.

As much as an investigation of a cholera or COVID outbreak, the tools of epidemiology, and specifically political epidemiology, can provide insight into how laws, policies and their enforcement (such as police harassment and abuse, discriminatory laws and practices, and policies that deny or delay access to prevention and treatment) impact health (Amon, 2014). Similarly, public health scholars and practitioners have in recent years increasingly focused on ‘decolonizing global health’, seeking to better understand, and dismantle, structural inequality and power asymmetries at the root of health disparities while emphasising the centrality of social justice to advancing community health (Abimbola & Pai, 2020).

The practice of a system of medical apartheid in the oPt can be drawn from the start of the occupation by Israel in 1967, violating the right to health of Palestinians. However, the lack of formal definition and explicit prohibition of medical apartheid by the international human rights community has delayed explicit recognition and examination of Israel’s policies and practices and their impact on access to health care and realisation by Palestinians of their right to health. Formal definition of what constitutes apartheid, as well as medical apartheid, for example by the Committee on the Elimination of Racial Discrimination, would benefit efforts to monitor, eliminate and hold accountable those responsible for systems of racial segregation in access to health care wherever they occur (Baldwin, 2021).

In our analysis, we examined three policies that directly disfavour Arab non-Jewish citizens in the oPt. Firstly, the systematic deprivation of funding for a sustainable independent Palestinian health system. Secondly, the frequent attacks on health care infrastructure. Thirdly, the policy of requiring Palestinians from the oPt to apply for permits to access healthcare, then denying and delaying patients’ applications and those for their companion.

In the short-term, international attention should focus on ensuring that the rights of all Palestinians are protected. Over the longer-term, UN agencies and others should endeavour to develop explicit definitions of medical apartheid and investigate settings where credible claims of medical apartheid have been made. These efforts can lead to the development of international instruments that define medical apartheid and build a consensus for its global elimination.

Disclosure statement

No potential conflict of interest was reported by the author(s).