"Ill Morals":

Grave Violations of the Right to Health during the Israeli Assault on

Gaza

March 2009

Written by: Dan Magen

Preface written by: Dr. Ze'ev Winer and Hadas Ziv
Research: Tom Mehager, Reut Katz, Eyal Niv, Miri Weingarten, Salah Haj-Yahya,
Ran Yaron
Editing: Ran Yaron
English Translation and Editing: Saul Vardi, Tami Sarfatti, Gila Norich

1
 Table of Contents

Preface ……………………………………………………………………………… 3

Summary ……………………………………………………………………………. 6

Introduction ………………………………………………………………………… 9

Gaza Health System on the Eve of the Crisis ...………………………………...... 12

Evacuation of the Wounded to Medical Centers Outside the Strip.……….….. 15

Attacks on Medical Crews ……..…………………………………………………. 25

Evacuation Inside the Gaza Strip – Injured and Trapped Civilians ………..…. 34

Attacks on Medical Installations in the Gaza Strip …….………………………. 41

Injury to Chronically and Acutely Ill Patients...……………..………………….. 45

Conclusion …………………………………………………………………………. 51

Appendices ………………………………………………………………………… 55

2
 Preface

During its attack on Gaza, Israel put in place various obstacles, such that Palestinian
civilians found themselves under a state of siege for hours and sometimes days,
without water food or electricity. The wounded too were forced to wait long hours,
even days, for evacuation. Medical crews and facilities sustained direct fire. The
testimonies presented in this report underscore the suspicion that a qualitative
transformation occurred in the army’s ethical conduct vis-à-vis civilians injured
during the fighting. This report limits itself to a discussion of the ways in which the
army related to injured civilians, and does not discuss the broader topic of the change
in the means and methods of fighting.

Many works that deal with the moral and ethical dilemmas which have arisen due to
the change from conventional to urban warfare, like that employed in the fighting in
the Occupied Palestinian Territory ask the question of whether the ethical
considerations guiding the Israeli military should change as well.1 In reality, it seems
that the question has been answered and Palestinian civilians are paying for it with
their lives. The Israeli public’s perception of its enemy as one which does not value
human life (whether by “attacking Israeli civilians” or “using its own civilians as
human shields”), has brought about a change in the conduct of the Israeli military

The army has found partial endorsement in controversial ethical codes like those
justifying targeted assassination, in contradiction to international law. This, in
addition to on-going demonization of Palestinians2, erosion of moral considerations as
the conflict wears on, and disappointment arising from the seeming absence of a

1
See Nevo Baruch, Shor Yael, Musar, Etica ve-Mishpat bi-Lehimah, (Morality, Ethics and Law in
Warfare), The Israeli Institute for Democracy: Army and Society Project, (2003).
2
See for example: “There are enemies that are personally in an ethnic or religious confrontation with
us. Their goal is to kill as many Jews as possible, to deliver us from our land or to take away our
independence. They are willing to commit suicide to this end and to make an effort to their last breath
in order to execute their attacks. An enemy of this kind, even when wounded, continues to be an
enemy. [and is therefore not under the defence of international treatise]. The oath of the paramedic
does not distinguish between an enemy and a friend, and in that it stands in contradiction to Jewish law
[Halachah] that does make that same distinction. Due to the fact that every Jew is under oath since
Biblical times to follow the laws of the Torah, this paramedic oath is not binding by Jewish law. In
addition one might comment that nowadays medical treatment and life-saving procedures are very
expensive. The Paramedic Oath reflects a superficial kind of morality, and is irrelevant in modern
reality. " Rabbi Dror Baramah, answering a soldier's question. http://www.ynet.co.il/articles/0,7340'L-
3439603,00.html

3
political solution; as well as systemic forgiveness awarded to all deviations from
stated military norms.3 All these have led to a situation in which the lives of civilians
have been sacrificed.

The Israeli military's code of ethics, “The Spirit of the IDF”4 constitutes the official
educational foundation for soldiers. The "Purity of Arms" clause states: "A soldier
will use his weapons and his might only to fulfill the task at hand, to the extent
required, and will maintain his humanity even in combat. The soldier shall not use his
power and his weaponry to harm those who are not combatants or who are taken
prisoner, and will do all within his ability to prevent harm to their lives, bodies, honor
and property." The clause dealing with human life states: "a soldier will act rationally
and safely in all his actions, by acknowledging the utmost importance of human
life..." In 2004, in a controversial attempt to adapt the code of ethics to the reality of
the war against terror fought in civilian population centers, the Israeli military
established a forum comprised of officers and professionals whose mandate was to
draft “The Ethical Code for the War on Terror,” to be used as an addendum to the
official code of ethics. It states, among other things, that "soldiers are obliged to
provide adequate health services as conditions allow, equally to themselves and to the
enemy."5

Within the military forces as a whole, medical personnel have a special role to protect
civilians. Their unique profession and role necessitates a heightened level of ethical
conduct as compared to other fighters. They are obliged to care for the wounded and
the sick, regardless of the individual’s political, national, religious, racial or sexual
affiliation. This position is expressed in numerous codes and treatises, from the

3
“At the beginning of the Al Aqsa Intifada the Military Attorney office has changed its policy in
regards to opening investigations by the military Criminal Investigation Division (CID) in cases of
death of Palestinian civilians. During the first Intifada the army opened investigation in each case of a
Palestinian civilian's death except in cases when the victim took part in combat. With the beginning of
this Intifada the military attorney declared that CID will open investigations only in such cases where
"soldiers will severely deviate from rules of opening fire and cause injury to body and soul." See
Btselem site: http://www.btselem.org/hebrew/Accountability/Investigation_of_Complaints.asp. See
also Yesh Din, "Irregularities: putting soldiers on trial during the second Intifada and after, 2000-2007"
September 2008
4
The Israeli Defense Forces. Spirit of the ISRAELI ARMY.
http://dover.Israeli Army.il/ISRAELI ARMY/English/about/doctrine/ethics.htm
5
http://he.wikipedia.org/wiki/%D7%A8%D7%95%D7%97_%D7%A6%D7%94%22%D7%9C

4
Hippocratic Oath to the International Code of Medical Ethics formulated by the
World Medical Association. The latter states:

"A physician shall always bear in mind the obligation to respect human life. A
physician shall give emergency care as a humanitarian duty unless he/she is assured
that others are willing and able to give such care."6

This statement asserts that in times of war, the ethical obligation to provide optimal
medical assistance to the population in a war zone falls under the responsibility of the
fighting powers in general and to medical teams in particular. An enemy that does not
comply with these stipulations makes their implementation extremely difficult.
However, this should not preclude the Israeli military from acting in accordance, in
light of the moral, judicial and ethical reasons fundamental to all who wish to
preserve the character of Israeli society and the state as one that respects human rights
and complies with international declarations which defines it as part of the modern
community of nations.

In light of the Israeli military’s course of action, one which necessitated close contact
with civilian populations, the army should have included, from the early training
stages of soldiers and officers all through their military service, the rules for caring for
civilians in a time of war. To do so requires not only the intervention of the army, but
that of the political echelons as well. For it is evident that there is a close connection
between political decisions and demands placed on the army and the means by which
they are put into practice. There is a need to rethink and examine the changes in the
Code and ethical conduct of the armed forces; not only with regards to the impact on
the change on the fighting itself, but out of consideration for the long term effects on
the character of Israeli society and its ability to recognize the humanity of those it
defines as the enemy. For it is with that enemy with whom we will eventually talk
peace.

6
http://www.wma.net/e/policy/c8.htm

5
 Summary

The International Code of Medical Ethics formulated by the World Medical

Association states that in times of war, the ethical obligation to provide optimal
medical assistance to the population in a war zone falls under the responsibility of the
fighting powers in general and of medical teams in particular. Numerous international
treatises assert the obligation to give medical care without discrimination to all
victims in a war zone. More specifically, the Israeli army's code of ethics asserts that
the soldier will maintain his humanity even in combat; he will acknowledge the
utmost importance of human life and will not use his power and his weaponry to harm
those who are non combatants. In a later addendum to the code, that relates to the War
on Terror the Israeli army's code asserts that soldiers are obliged to provide adequate
health services, as conditions allow, equally to themselves and to the enemy

The purpose of this report is to call attention to occurrences of violations of the

international humanitarian law and the Israeli army's ethical code during the course of
Israel's attack on Gaza named Operation Cast Lead. These violations included attacks
on medical personnel; damage to medical facilities and indiscriminate attacks on
civilians not involved in the fighting. Furthermore, Israel placed numerous obstacles
in the course of the operation that impeded emergency medical evacuation of the sick
and wounded and also caused families to be trapped for days on without food, water,
and medications. PHR-Israel believes these violations and the humanitarian crisis that
they entailed should take center stage in the moral reckoning that should take place
within Israeli society as a whole, and especially within its armed forces.
The report focuses on the medical aspects of the crisis and is based on numerous first
hand testimonies that were brought to the attention of PHR-Israel during the attack.
These testimonies formed a picture that the state of Israel made a considerable effort
to conceal through the sweeping prohibition on the entry of international media into
the area and its vague responses given to the High Court.

The report begins by describing the situation of the health system in Gaza on the eve
of the attack. Gaza's health system suffered from acute shortage of medical equipment
and medication due to the blockade imposed by Israel since June 2007. Its medical
staff training too was hindered by prohibitions that made professional connections and

6
training outside Gaza almost impossible. It is this system that was to face the
enormous challenge of having to provide treatment to thousands of wounded; a
challenge that would have overwhelmed any health system. The healthcare for the
chronically ill was severely restricted due to the emergency state and the higher
priority given to life threatening injuries of the attack, as well as due to the closure of
the crossings through which these patients were previously able to have access to
medical treatment outside Gaza.

The report further calls attention to the problems caused by the obstacles to referrals
of the attack victims outside Gaza. Many of those suffering severe injuries and who
were in need for emergency referrals to more advanced medical centers, suffered from
the bureaucratic impediments imposed by Israel and Egypt during the first days, and
the Palestinians reluctance to cooperate with Israel in the treatment of the injured
later. The prompt televised evacuation of three members of Dr. Abu Al'Aish's family
in Israeli ambulances and helicopter, demonstrated that when Israel's image was at
stake it found the way to overcome all obstacles.

The report shows how medical staff became a legitimate target to the attacks of the
Israeli forces. According to a WHO report 16 medical personnel were killed and 25
wounded while being on duty. PHR-Israel documented 12 such incidents and they are
brought in the report. The attacks on medical staff occurred both before and after an
appeal to the Israeli High Court by PHR-Israel and other Israeli human rights
organizations. In addition to attacks on medical personnel and emergency vehicles,
many medical facilities were destroyed as a result of direct attack on them or as a
result of attacks on their vicinities. Israel's accusation that the heads of Hamas were
hiding in hospital basements was strongly denied by directors of hospitals with whom
PHR-Israel kept in contact throughout the Israeli offensive.

Access to the wounded and evacuation of the dead were held back by these ongoing
attacks. Ambulance operators of MoH, PRCS, Civil Defence and UHWC all reported
areas that could not be reached at all. As a result, the wounded waited for hours and
days for evacuation.
The report uses two examples to demonstrate, step by step, the resulting tragedy of
these impediments to evacuation. The first case is that of the Al'Aeidi family whose

7
twenty members, some of them wounded, were trapped for seven days; the second
example is that of Mr. Shurrab and his two sons who were shot by Israeli soldiers on
January 16, as they were in their car on their way to Khan Yunis. One of the sons died
immediately, the other bled to death for twelve hours. All that time the Israeli
soldiers were within a short distance from the Shurrabs but did not provide any
assistance despite the father's repeated requests.

It is PHR-Israel's belief that in moral terms Israel’s image has been stained by the
manner in which it pursued the attack; by its disproportionate use of force; and by its
gross disregard for requests from local and international human rights organizations in
the face of the humanitarian crisis in the Gaza Strip. The process of demonization of
Palestinians bears a heavy price for Israeli society. This process reached its nadir
when soldiers in an army that flaunts its morality declined to help evacuate injured
civilians and trapped families; when soldiers acted in trigger-happy manner as they
opened fire on ambulances, medical installations, and medical personnel; and when
Israel’s leaders employed doublespeak in order to deny the existence of a
humanitarian crisis in the Gaza Strip.

8
 Introduction
On December 27 Israel began a military attack on Gaza, (referred to as Operation
Cast Lead), which lasted until January 18. The following table and figures include
data collected by the Palestinian Centre for Human Rights in Gaza (PCHR) which
reflects the number of casualties on the Palestinian side,7 as compared with the
number of casualties on the Israeli side, as reported in Israel.8

Causualties
Israeli Palestinian
Civilians 0.207% 66.344%
Police 0.000% 16.517%
Combatants 0.691% 16.240%
Total 0.898% 99.102%

The wounded Palestinians numbered 5,303 individuals (including 1,606 children and
828 women).9 186 Israelis were reported wounded, and an additional 584 individuals
diagnosed as ‘anxiety stricken.’10 To these numbers one should add tens of thousands
of Palestinians that, if diagnosed, would have probably been defined as 'anxiety
stricken' as well. In addition, hundreds of public buildings, including medical
facilities were damaged or were completely destroyed. More than 100,000 people
were left without shelter.

During the days of the attack, PHR-Israel received many appeals, reports, and
testimonies regarding obstacles set in place by Israel preventing the Gaza Strip Health
System from providing proper response in accordance with the circumstances of the
military operation. Many were trapped for hours and sometimes days without water,
food, shelter or electricity, without any way to escape attacks. The price was
especially paid by the wounded that appealed to PHR-Israel to assist in evacuations to
medical centers within the Strip and were forced to wait hours and even days for
evacuation that in the end, often arrived too late. Other injured and chronically ill

7
http://www.nrg.co.il/online/1/ART 1/865/601.html?hp=0&loc=3&tmp=7652
8
Ha’aretz, January 19, 2009
9
See note 7
10
See note 8

9
patients requested evacuation to advanced medical centers outside the Strip to no
avail. Medical personnel and facilities paid the price ass well. Many were hit by the
Israeli army.

The information received by PHR-Israel presented in this report paints a picture of

systematic breaches of International Humanitarian Law concerning health and
medicine in times war, to which, as signatory to the Geneva Convention, the State is
obliged to uphold. On the other hand, the firing of missiles by the Hamas to the south
of Israel, was too a severe and systematic violation of International Humanitarian
Law.

This report seeks to focus on cases and events brought to PHR-Israel during the days
of the attack on Gaza, specifically issues of health and medical care. It aims to supply
information on PHR-Israel's actions during the period of December 27th- January
18th, and to paint a picture for the reader of the realities on the ground, based on facts
revealed to the organization from first hand testimonies. The violations in the area of
health and medicine, part of which are described in this paper, deserve centre stage in
any and all future public moral debates which we hope will take place in Israeli
society, the army, and within the security system.

The character of the information and the type of the appeals received by PHR-Israel
during this period focus on six main issues and are discussed in this report as follows:

The situation of the health system in Gaza on the eve of the

crisis

Impeded evacuation of wounded to medical centers outside the
Strip

Attacks on medical personnel

Impeded evacuation of wounded to medical centers within the
Strip

Attacks on medical facilities

Harm inflicted on chronically ill patients

10
This report does not pretend to cover all aspects of the health system that were
affected by the Israeli attack, only those that were dealt with directly by PHR-Israel,
information brought to us through first hand accounts. In order to form a more
comprehensive picture about the health system during those days, and to understand
the context within which PHR-Israel operated, this report utilizes information
gathered by other organizations, Israel and international, and by doctors and officials
within the Palestinian Ministry of Health.

PHR-Israel corresponded with different parts of the Israeli government during the
offensive on Gaza regarding various issues that now appear in this report. The
responses of the Israeli authorities are brought in the appendix to this report.

The last chapter of this report presents an analysis of the conclusions reached by
PHR-Israel regarding violations of human rights committed by Israel during the
attacks, particularly concerning the field of health. The conclusion relates to specific
considerations which both guided Israeli policy and deviated from the official line.
The report concludes with recommendations issued by PHR-Israel which the
organization believes should be adopted by the State in order to prevent such
violations from occurring in the future.

11
 Gaza Health System on the Eve of the Crisis
At the beginning of the Israeli attack on Gaza on December 27, 2008, the Health
System in the Gaza Strip was already on the verge of collapse. Since June 2007, the
Israeli blockade of the Gaza Strip restricted the proper functioning of the entire health
system. Development was hindered by lack of knowledge, expertise and experience as
well as reoccurring power cuts preventing medical staff to treat complex illnesses and
injuries.11 Adding to the situation was a severe shortage of medical supplies12, and a
shortage of adequate personnel.13 It is within the context of these and other dire
conditions that the Gaza health system was forced to cope with complex cases and
multiple injuries.

Wounded in hospitals

Photo: Salah Haj Yahya

11
For information on medical fields of expertise lacking in the Strip see PHR-Israel published report:
The Disengagement Plan and its Affects on the Right for Health in the Gaza Strip, (January 2005)
12
For example: in the field of oncology, there is no access to equipment used for nuclear medicine,
isotope examinations, and radiotherapy because of Israel’s refusal to let this equipment along with
knowledge of its operation to enter the occupied Palestinian territories.
13
Since June 2007 Israel fully prevented the medical community in Gaza from establishing contact
with their colleagues in the West Bank, Israel, and the rest of the world. Three requests submitted by
PHR-Israel on behalf of three medical personnel who wished to exit the Strip for the for professional
reasons, were refused by the Israeli army which claimed that these requests did not pertain to the
State’s humanitarian criteria for granting exit out of the Strip.

12
A number of organizations have documented the dismal situation of the Palestinian
health system in Gaza. The UN Office for the Coordination of Humanitarian Affairs
(OCHA) reported on December 15, 2008 that the quality of health services was
severely affected as a result of the blockade imposed on the Gaza Strip by Israel in
June 2007 and the recent strike of medical personnel between the months of August
and November 2008. Over this time, medical equipment had broken down due to
reoccurring power shortages, lack of spare parts and maintenance. Between
September and November 2008 only three trucks carrying medicine were sent from
the Ministry of Health in Ramallah to Gaza. As a result, the overall supply of
available medicines was expected to last only a month, while 20% of essential
medication was at “zero level".14

Between August and October 2008, the World Health Organization (WHO) reported a
gradual rise in the percentage of medications and essential medical equipment missing
entirely from the Ministry of Health’s storage facility. In August, a 11.5% shortage
was reported; in September the number had risen to 15% and by October, 22.6% of
essential medications and equipment were reported lacking or in short supply.15

Between 18-20th December, prior to the attack on Gaza, a delegation of PHR-Israel

doctors had visited the Gaza Strip and reported a shortage of approximately one
quarter or 105 various medicines ordered by the Ministry of Health in Gaza, thirty of
which are required for life-saving treatment and twenty one of which are needed to
treat cancer liver and/or kidney disease. Two hundred and twenty types of medical
equipment needed to perform operations and operate Intensive Care Units were
completely unavailable. The delegation also reported that several appliances at the
Pediatric Hospital used to purify breast milk had stopped functioning.16

14
Gaza Humanitarian Situation Report: The Impact of the Blockade on the Gaza Strip. (OCHA,
December 15, 2008)
15

Http://www.emro.who.int/palestine/reports/monitoring/WHO_monthly_monitoring/Gaza%20Strike_no
v08.pdf
16
The shortage had already been reported in June 2008 on the occasion of a previous delegation of
PHR-Israel in Gaza. That delegation reported that out of 72 dialyze machines in the Strip, 13 were out
of use and therefore only 59 machines cater to a population of 450 kidney patients. In addition, the
delegation found that 91 types of essential medical equipment were unavailable at all, while 173 other
types were available in amounts that would be sufficient for one to three months. See PHR-Israel:
“The Gaza Strip – Medicine under “” 9.7.2008

13
Emergency Services
In early 2008 the Palestinian Ministry of Health (MoH) in Gaza owned and operated
58 ambulances. By the end of the year, half of the ambulance fleet had fallen into a
state of disrepair. Due to the lack of spare parts for the vehicles themselves and their
medical equipment and a shortage of diesel, batteries, lining and upholstery for seats,
the Ministry of Health rented 64 cars that served the purpose of transferring patients
to medical centers. These vehicles however, were not properly outfitted to serve as
emergency vehicles.17

During the Israeli attack on Gaza, the emergency services suffered from inadequate
communications due to the collapse of the two cellular carriers operating in Gaza,
Jawal and Mirs.18 This rendered communication between emergency vehicles, the
wounded and their families, the Red Cross, hospitals and the Israeli authorities, in
other words, the entire path of coordination and communication necessary to evacuate
patients, extremely difficult if not virtually impossible.

Under these dire circumstances then, the health system was forced to deal with the
consequences of the Israeli attack which already on its first day brought the number of
injured victims to 400 persons.19 Each day, an average of 300 wounded individuals
were admitted to hospitals and 60 people died.

During the entire period, representatives of PHR-Israel were in close contact by

telephone with the staff of the Gaza health system who reported the situation first
hand:

Dr. Hassan Khalaf, Deputy Minister of Health in Gaza, told representatives of PHR-
Israel on December 28 at noon: "240 wounded were admitted to Shifa’ Hospital and
the number of wounded continues to rise every hour. The hospital has been operating
since Saturday [when the attacks began] in emergency mode, and operating rooms, all
twelve of them, are working 24 hours a day with all the staff present in the hospital.

17
See data collected by PHR-Israel's delegation from December 18, 2008.
http://www.phr.org.il/article.asp?articleid=1013&catid=26&pcat=6&lang=HEB
18
Ibid,
19
Twenty two days of extreme humanitarian suffering in Gaza Strip, Palestinian Red Crescent Society,
(January 2009), p.2

14
The number of injured and the insufficient number of operating rooms has caused us
to convert 4 delivery rooms in the maternity ward into operating theatres, and as of
today, we cannot admit women in labor to the hospital. Our day clinics and our four
ICU for burn victims have all been admitting individuals injured by the Israeli
attacks."

On the same day, Dr. Zaki Zakzuk, a senior oncologist in the European Hospital in
Khan Younis, told a representative of PHR-Israel: "As of today we have thirty
wounded individuals in very grave condition. Most of them are suffering from head
and neck injuries and urgently require complex neurosurgical treatment. All of them
are in need of ICU beds for ventilation machines, but because of the lack of such
equipment only half of them are able to receive the ventilation treatment while others
are resuscitated manually. In addition, there is an extreme need for additional blood
units, especially type O Negative. The lack of refrigeration equipment and emergency
vehicles is making it impossible for us to transfer blood units from Shifa’ Hospital."

Dr. Khalil Nakhali, from the Intensive Care Unit at Shifa’ Hospital told
representatives of PHR-Israel on 30 December, just three days after the beginning of
the Israeli attack: "the situation is very serious because we do not have any vacant
beds. All beds in our unit, 10 in number are occupied by the most gravely wounded.
The hospital has taken 15 more beds from our other departments and utilized them as
Intensive Care beds, and now, all 25 are occupied. Yesterday, for example, 3 or 4
severely wounded people arrived, and we did not have a place for them. After some of
the wounded were transferred to Egypt, some beds were freed up and at the moment,
there are no wounded waiting for intensive care beds. The hospital is now operating in
emergency mode meaning we cannot accept patients with basic injuries. We accept
the urgent cases for life saving efforts, operations etc., and if possible we transfer
them to other hospitals. At the moment 9 wounded individuals remain in Intensive
Care, 6 them are children and two women are being resuscitated."

After only three days of combat, the health system in Gaza was forced to treat about
1,700 wounded suffering various levels of injury. At that point there were 362

15
casualties of whom 15% were women and children.20 The inability of the medical
centers in Gaza to provide adequate relief to the large numbers of injured from the
attack and to patients, who had been hospitalized prior to the attacks, created an
urgent need to refer patients to medical centers outside the Strip. This was not only
due to the lack of medical services available in the Strip, but also due to the
insufficient number of hospital beds and operating rooms available to cope with the
high volume of victims. In addition, impeded evacuation due to the lack of
coordination with the Israeli authorities and other general problems of communication
brought the health system in Gaza to a point where it was increasingly difficult to
respond to the needs of the population on its own.

Wounded in Shifa’ hospital

Photo: AP

20
This item of data was given by Mr. Hamam Nasman, spokesperson for the Ministry of Health in
Gaza, on December 30, 2008.

16
 Evacuation of the wounded to Medical Centers outside the Strip
On Friday January 16, three members of Dr. Az-Addin Abu AlAish's family were
evacuated to an Israeli medical center by ambulances of the Magen David Adom.21
This doubled the number of wounded Palestinians evacuated to Israel since the
beginning of the offensive to six. Considering the dire situation of the health system
in Gaza on the eve of the attack and the large numbers of individuals wounded in the
Israeli offensive, there was an urgent need to refer many outside the Strip at the very
beginning of the offensive, yet this only occurred on the 20th day of fighting, two days
before the ceasefire. The delay in referring the injured to hospitals in Israel will be
elaborated in the following section. As for the option to evacuate injured to Egypt, it
is important to note that on the crucial first days of the Gaza operation, with Gaza
hospitals filled to capacity, all regional players choose to keep the crossings to Egypt
and to Israel closed.

Closing the Crossings

Erez Crossing, the only crossing point for residents of Gaza into Israel, and from there
to the West Bank, East Jerusalem and Jordan, was closed on December 26, its staff
dismissed.22 The following day, Israel began its air attacks on the Gaza Strip. In
response to an inquiry made by PHR-Israel, the Israeli intervention officer at the
District Coordination Office (DCO) informed PHR-Israel that the army was still
receiving exit requests from the sick and the wounded but that actual exit was not
possible. No information was provided as to when the Erez Crossing would again re-
open.23 Mr. Rif'at Muheisen, the head of the Palestinian Civil Affairs Committee in
Gaza, confirmed the information that the Crossing had been closed, and that as for
that hour, no coordination was possible with the Israeli Army.24

For the first three days of the attack, while the Rafah Crossing remained closed, there
was no possibility to transfer wounded patients to Egypt. On 30 December, the
Egyptian President formally declared that the Rafah Crossing would remain closed to
Palestinians as long as Hamas remained in power over Gaza, however, in practice, the

21
Magen David Adom is the Israeli Emergency Evacuation Service
22
PHR-Israel knows of one cancer patient that was able to exit on the morning of December 26 to
receive treatment in Israel.
23
Telephone conversation between Tom Mehager and Irit Raz,
24
Telephone between Mr. Muheisen and a representative of PHR-Israel on December 28, 2008.

17
Egyptian President was willing to open the crossing for the evacuation of the injured
25
to Egypt. After three full days of fighting therefore, the first wounded, 22 in
number, were referred for treatment to Egypt.26 Though discrepancies exist regarding
the exact numbers of wounded patients who passed through the Rafah Crossing
during the attack, hundreds of patients were able to access care via this passageway.
The Palestinian Ministry of Health in Gaza reports 1003 individuals passed through
for treatment in Egypt, in several cases from there on to other countries. The World
Health Organization reports 608 individuals crossed the border for medical care.27
The same day as President Mubarak opened the crossing to injured victims, PHR-
Israel appealed to the minister of defense to authorize the passage of six individuals
who had sustained head injuries and were in a coma28 for treatment in Israeli medical
centers who had agreed to admit them on that very day.29 Among the six injured were
two women, a man, and three children, ages 5, 7, and 8. Dr. Fauzi Nabulsiah, Director
of the Intensive Care Unit at Shifa’ Hospital, had informed PHR-Israel that their
30
critical condition did not allow their referral to Egypt and therefore could only
receive proper care in Israel.

Israel conditions exit on prior financial obligation by the Palestinian Authority

According to reports received by PHR-Israel from hospitals in Gaza, correct to
December 31, out of the 1800 wounded, as reported by Gaza health officials and
international organizations, only three individuals were referred to Israel.31 In
December 31 telephone conversation PHR was informed by Lieutenant Colonel Uri

25
http://dailystaregypt.com/article.aspx?ArticleID=18784
26
http://www.shanghaidaily.com/sp/article/2008/2008122008/20081230/article_386441.html
27
The WHO reports that 608 wounded exited Rafah Crossing: 512 were transferred to Egypt, 61 to
Saudi Arabia; 9 to Turkey; 8 to Jordan; 8 to Libya; 6 to Belgium and to 4 Morocco. The information
was received from Ms. Dalia Salahah, a representative of the WHO in Gaza.
28
For a copy of the letter please refer to:
http://www.phr.org.il/phr/article.asp?articleid=1020&catid=26&pcat=1&lang=HEB
29
After an urgent appeal to PHR-Israel from Dr. Fauzi Nabulsiah, Director of the ICU at Shifa’
Hospital on December 29, PHR-Israel appealed to three Israeli hospitals that agreed to accept the
patients. Prof. Raphael Walden, Vice Director of Tel Hashomer Medical Center stated that the hospital
would accept one patient. Dr. Yitzhak Berlovitz, Director of Wolfson Hospital, agreed to receive one
patient from the proposed list, Dr. Yuval Weiss Director of the Medical Centre at Hadassah Ein Karem,
Dr. Turc and Dr. Ido Yatsiv from the Pediatric ICU said there was an open bed that could accept one of
the injured.
30
One of the injured, Ms. Fatmeh Salem, 45, was transferred to Egypt on the evening of 31.12.08
through the Rafah Crossing because her state had deteriorated.
31
This information is taken from the daily briefing of the Palestinian Red Crescent Society. 31.12.08.
The information was valid for 10:00 a.m. on that day.

18
Zinger, a representative of COGAT32 that the army would deal with exit permit
requests only for injured individuals who had been guaranteed financial undertakings
from the Palestinian Authority.33 When PHR-Israel requested that patients be allowed
to pass through Erez Crossing without prior financial undertaking, their requests went
unheeded. In response to PHR-Israel's efforts to further clarify the issue of referrals,
Mr. Hezi Levi, Director of Medicine at the Ministry of Health, reported that the Israeli
Health System had prepared in advance for the possibility of accepting referred
patients from Gaza, and had even set aside space for them at one of Israel’s leading
medical centers. The problem, he said, was that the Palestinian Civil Affairs
Committee had been unwilling to submit permit requests to the Israelis at the Erez
Crossing.34

Palestinian Authority in Ramallah Refuses to Refer Wounded Patients to Israel.

On December 31, representatives of PHR-Israel appealed to the Director of the
Palestinian Civil Affairs Committee in Gaza, an office under the authority of the
Ministry of Health in Ramallah.35 Mr. Muheisen confirmed the decision of the
Ministry of Health in Ramallah not to refer the wounded to Israel, only to Egypt. On
the same day, PHR-Israel petitioned the Israeli Minister of Defense and the Israeli
Minister of Health with a requesting to eliminate financial coverage as a pre-condition
for the referral of wounded to Israel.36

This policy of the Palestinian Authority was later repeated by Dr. Fathi abu Mughli,
the Palestinian Minister of Health in Ramallah in his reaction to the establishment of
an Israeli clinic at the Erez Crossing to treat Palestinians wounded in the attacks. The
minister gave a statement in which he strongly criticized the army’s initiative, calling
it deceptive propaganda meant to “hide their horrible crimes.” He further concluded,

32
This is the military office of Coordinator of Government Activities in the Territories
33
The phone conversation on 31.12.2008 was held between Ran Yaron, PHR-Israel representative and
Major General Uri Zinger.
34
The phone conversation between Mr. Hezi Levi and Ms. Hadas Ziv from PHR-Israel occurred on
31.12.08.
35
The conversation was with Mr. Rif'at Muheisen, of the Palestinian Civilian Committee for Health.
36
To read the letters see:
http://www.phr.org.il/phr/article.asp?articleid=1024&catid=26&pcat=_.1&lang=HEB. To this day,
there has been no response from either the Ministry of Defence or the Ministry of Health.

19
“The occupying forces that brought on such massive devastation, have no right to
treat our wounded.”37

On March 3, 2009, Deputy Minister of Health in Ramallah, Dr. Anan al-Masri

officially confirmed this policy in a meeting with representatives of PHR-Israel’s
Occupied Palestinian Territory Department. On January 22, 2009, 4 days after the
military operation had ended, Mr. Itshak Herzog, the recently appointed Minister of
Humanitarian Issues told a representative of PHR-Israel that the financial
precondition for referral of the injured has in fact been eliminated.38

Three Wounded Palestinians Referred to Israel

On December 31, PHR-Israel was informed that three injured individuals were
referred for medical treatment in Israel. This occurred only after external
organizations intervened with a pledge to pay for treatment. On December 29, a 16
year old boy was referred to Ichilov Hospital in Tel Aviv. UNRWA pledged to
finance the case. On December 31 two more children were referred to an Israeli
hospital. Their treatment was financed by the Peres Center for Peace.39

At that point in the military campaign a high number of severely injured required
referrals and visa for outside care. The Palestinian Ministry of Health told PHR-Israel
that between the 29 and 30 of December, 54 patients had been referred to Egypt,
fifteen of which were in Intensive Care.40

The three patients mentioned above, whose emergency medical care was covered by
UNWRA and the Peres Center for Peace were the only patients referred to Israel for
the first 21 days of the Israeli attacks. On Thursday, the 22nd day of the attack, Israel
finally evacuated three more wounded, all of them family members of Dr. Abu
AlAish. Details of this significant turn of events appears in the following section.

37
The full statement was received by email at PHR-Israel and is available.
38
This was said in a meeting between Minister Herzog and representatives of Israeli Human Rights
organizations: Gishah, Btselem, PHR-Israel and the Association for Civilian Rights.
39
The children were referred to Shiba and Schneider Hospitals in Israel.
40
http://www.phr.org.il/phr/article.asp?articleid=1024&catid=26&pcat=6lan=HEB

20