Besieging healthservices in Gaza:a profitable business

A Corporate Watch briefingby Tom Anderson and Therezia Cooper

OverviewThe Israeli siege of the Gaza Strip prevents theproper functioning of Palestinian healthservices and the effective treatment of sickpatients. At the same time the Israeli economy,and particularly Israeli pharmaceutical andtransport companies, benefit from the captivemarket provided by a population living underoccupation.

In summary, the interviews below show thatthe Israeli siege is detrimental to health servicesin Gaza in the following ways:

Health services, health workers andtheir patients are subject to directmilitary attacks.

Health services have a shortage ofmedicines, fuel, medical equipment andspare parts as a result of the siege.

Sick patients are often prevented fromtravelling outside Gaza to obtaintreatment.

The fuel shortage means that someservices have been reduced and it putsa financial strain on health services,which have to run on generators.Patients are put in danger by the fuelshortage.

The fuel shortage results in injuriescaused by people undertaking riskytasks in the dark and by fires caused by

candles. Health workers are often unable to go

abroad to receive training and foreigndelegations are unable to enter Gaza,isolating the services from the rest of theworld.

The shortage of clean water, partlycaused by the siege, has had adetrimental effect on people's health.

The economic effects of the siege havehad a knock-on effect on how muchmoney people can spend on theirhealth.

The interviews uncover the following ways thatthe Israeli economy benefits from the siege ofhealth services in Gaza:

Israeli pharmaceutical companies benefitfrom the captive market created by thesiege.

Revenue is created by the transport ofgoods through Israel to Gaza - Since theclosure of the tunnels from Egypt, andbecause of the almost complete closureto goods of the Rafah crossing fromEgypt, all medicines and supplies tohealth services in Gaza must enterthrough the Karam Abu Salem crossingfrom Israel (the crossing is known asKerem Shalom in Israel). This benefitsIsraeli transport companies, whichtransport the goods through Israel to thecrossing.

Besieging healthservices in Gaza:a profitable business

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Health services in Gaza are required topay for the storage of equipment inIsrael while it undergoes lengthy Israelisecurity checks, often taking manymonths.

Since the closure of the tunnels Israelicompanies have supplied all fuel usedin Gaza.1 Since the fuel crisis healthservices have been forced to buy fuel torun generators in order to keep servicesrunning.

Many patients from Gaza who cannotreceive the treatment they need in theStrip have to receive treatment in Israel.This treatment is paid for by thePalestinian Authority while families ofsick patients pay for transport andaccommodation in Israel. This includespatients who have been injured inattacks by the Israeli military.

The health workers we interviewed hadimportant messages to convey to theinternational movement for boycott, divestmentand sanctions against Israeli state policies. Thelast part of this article follows their calls forinternational action.

The interviewsCorporate Watch researchers visited Gazaduring November and December 2013 andinterviewed health workers from the Union ofHealth Work Committees (UHWC),2 thePalestinian Medical Relief Society (PMRS),3 and

the Palestinian Red Crescent Society (PRCS),4 aswell as a representative of the Ministry ofHealth (MOH) In Gaza.5 This article highlightsthe problems that Palestinian health workersface when carrying out their work under siegeand details the ways that the Israeli economybenefits from the situation.

The health servicesThe MOH has over 4000 workers in Gaza andruns 14 government hospitals and 54 healthinstitutions, as well as 80 ambulances. UHWC,established in 1995, is a not for profit, non-governmental health provider with 466employees and five medical centres across theStrip. UHWC established and provides servicesin Al Awda hospital. PMRS is a primary healthservice provider that has been established for34 years and has five health centres across theStrip. It runs pharmacies, assisted equipmentloan centres and offers physiotherapy services.PRCS was established in 1968 and is a part ofthe International Red Cross and Red CrescentMovement. It has 4200 employees in the WestBank and Gaza, operates 45 ambulances inGaza, staffed by 110 paramedics, as well asoffering psychosocial services.6

Corporate Watch approached the UnitedNations Relief and Works Agency (UNWRA),which operates healthcare centres and dentalclinics for refugees in the Strip. However, theagency refused to meet with us.

PRCS medics help a demonstrator

suffering from teargas inhalation at a

demonstration at Nahal Oz checkpoint

- September 2013

(Photo taken by Joe Catron)

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A healthservice underdirect militaryassault...Most of the health workers Corporate Watchinterviewed reported direct attacks by theIsraeli military on their workplaces.

Dr Mona El Farra, Deputy Chair of PRCS inGaza, told us that in my experience from 2000until now, ambulances have been attackedeither directly or caught in the crossfire. Israelnever respects ambulance drivers. Hospitalshave also been attacked. I remember in 2006Al Awda hospital was caught in a crossfire oftank shells. Flechette ammunition7 was firedinto the hospital. In 2009 [during the Israeliattack known as 'Operation Cast Lead'] whenAl Quds hospital [in Gaza City] was attackedsome of the patients were injured. Some of thechildren from the Samouni family were there.Patients were going from trauma to trauma [21members of the Samouni family were killedduring the bombing of a residential area in2009]. Schools are not immune to attack.Health workers have been killed despite clearsigns that they are working. The Red Crescentbuilding is close to the police headquarters.The size of the bombs dropped on the policeHQ meant the ceiling of our building wasdamaged.

After five to six days of attack we ran out ofsome supplies, for example blood transfusionbags,intratracheal tubes, equipment fortransfusions and medicine for blood pressure,heart disease and asthma. After popular protestsome supplies were allowed through the Rafahcrossing by the Egyptian government.

According to Dr Tayseer Sultan of UHWC, in2009 windows and doors were broken at bothAl Awda Hospital and UHWC's health centre in

Beit Hanoun. Arafat Abd Al Dayem,8 aparamedic working for UHWC, was killed [byan artillery shell] on 4 January 2009 whileworking on an ambulance. His colleague,Brahim Shabat, who was working in the sameambulance as Arafat, suffered multiple traumafrom an attack by an Apache [helicopter]. Ouroffice also had its windows and doors broken.Another of UHWC's staff was injured in Israel'sNovember 2012 attacks on the Strip.

In 2009 health workers from different agenciesin Gaza made a call for solidarity that said thatduring Operation Cast Lead alone we lost 16members of our teams, and sustained 57injuries. 29 of our ambulances were damaged,and 35 health facilities were attacked. Wafa andAl Quds hospitals were directly targeted usingwhite phosphorous.

...and undersiegeSince 2006 Israel has initiated restrictions onmovement, closures of crossings into Gaza andrestrictions on goods entering the Gaza Strip.These conditions amount to a siege of theStrip, backed-up by US and EU boycotts of theHamas government and closures of the Rafahcrossing by the Egyptian government.

The biggest effect of the siege is on freedom ofmovement for the people of Gaza. The tightclosure makes it extremely difficult for peoplewho need treatment outside Gaza to obtainpermits to leave. Patients wanting treatmentoutside are required to enter Egypt through theRafah crossing or Israel through the BeitHanoun (Erez) crossing. Rafah was open only9 days out of 30 during November 2013. TheIsraeli authorities require sick patients to obtaina permit to enter Israel, which is not at all easy,and often force patients to undergo humiliatingsecurity checks and arrests at the crossing.

These strict controls on patients leaving Gazaare in the context of a health crisis which has

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been caused by Israeli attacks and by the siege.

The siege prevents the free flow of medicineand medical equipment into Gaza. Medicinesare only allowed through the Rafah crossingvery occasionally and in exceptionalcircumstances. For example, in 2009 medicalrelief was allowed through the Rafah crossingbecause of the health emergency caused by theIsraeli attack, and in 2013 the 'Miles of Smiles'solidarity convoy obtained permission to bringmedicine and other supplies through thecrossing.

Prior to July 2013 medicine was broughtthrough tunnels from Egypt. The MOH told usthat 30% of their medicines used to be sourcedfrom the tunnels, while PRCS said that theyreceived 15%. Israel and Egypt have beenwaging a war against these tunnels and Hamasgovernment sources now claim that no moresupplies are coming through.9 As a result,currently all medicines, medical equipment,fuel and other supplies for health services inGaza come through the Karam Abu Salemcrossing from Israel.

The siege also has long-term effects on thehealth of people in Gaza. The unemploymentcaused by the prevention of exports from theStrip, the closure of businesses andconstruction sites due to the prevention of theentry of raw materials into Gaza, and the

uncertainty over whether government workerswill receive their salaries caused by therestrictions placed on banks, have caused adeteriorating economic situation, which in turnaffects people's health. Dr Bassem Zaqout ofPMRS said: The siege affects the economy firstof all, but this in turn affects people's health.People do not have enough money for healthneeds. For example, they don't pay for routinechecks such as for breast cancer. People don'thave any savings anymore. There is notenough data yet to link the impacts of the siegeto chronic illness but I can say that there is anincrease in iron deficiency and anaemia. I thinkthat this is linked to people trying to savemoney and a decrease in the quality of food.

Trucks waiting to go to the Karam Abu Salem crossing to load up with goods which have been transported through

Israel to Gaza - November 2013. (Photo taken by Corporate Watch)

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"The siege affects theeconomy first of all,

but this in turn affectspeople's health. People

do not have enoughmoney for health

needs."

Patients needingtreatment abroadSome of the most damaging aspects of thesiege are the difficulties faced by sick patientsneeding treatment outside Gaza. Many of thehealth problems which people are seekingtreatment for are direct results of Israel'smilitary attacks or of the siege itself. The factthat people are unable to obtain suitabletreatment is often a result of the siege'sparalysing effect on health services in Gaza.

Dr Tayseer of UHWC told us: We have chronicemergencies due to Israeli attacks. Manypeople need reconstructive surgery but due tothe siege we cannot give proper treatment.Despite this, many people can't go abroad fortreatment.

Mohammed Azzam was 15 when he wasseverely injured in a missile attack by an Israelidrone on his way to school in Gaza City in2006.10 Mohammed spoke to Corporate Watchabout his journey to Israel to have an operationat Ikhilov hospital: I went by ambulancethrough Erez. I was taken out of theambulance for 30 minutes, left outside on astretcher. I had had an operation the daybefore. It was cold, I had had anaesthetic, itwas hard.11

Even in cases like this, where the Israelimilitary is directly responsible for attacks oncivilians, the Israeli hospital bill is footed bythe Palestinian government, while the family ofthe patient have to pay other associatedexpenses. According to Mohammed, thehospital costs were funded 100% by the PA -my father paid for transportation. It cost 4000shekels in transport costs.

Cancer patients are prevented from receivingtreatment in Gaza due to the restrictions onequipment and drugs caused by the siege, andoften die while waiting for a permit to traveloutside for treatment. Because of the siege,several drugs needed for the treatment of

cancer are not available in Gaza. Radiotherapyand chemotherapy are not available due to alack of equipment caused by Israeli restrictionson imports.

Dr El Farra of PRCS told us: For cancerpatients in Gaza there is no chemotherapy.Patients need to be referred to Israel or theWest Bank or Egypt. Many patients have diedwhile waiting for treatment, especially if theirfather or brother has been in the Israeli jails.Rafah crossing is unreliable for these patients.My friend had stomach cancer. He got a permitonce to go to Israel but was unable to goagain. He died. I know of a 4 year old childwho got a permit to go to Israel but theirparents didn't get one they didn't go and thechild died. 900 patients have died whilewaiting for treatment. According to Dr ElFarra, one of the things they are affected by isthe stress of waiting itself.

Cancer patients areprevented from

receiving treatment inGaza due to therestrictions on

equipment and drugscaused by the siege,and often die whilewaiting for a permitto travel outside for

treatment.

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Creating ashortage ofmedicine in Gazaand a captivemarket for IsraelipharmaceuticalcompaniesDuring the 1990s, a series of economicagreements between the Israeli governmentand the Palestinians, all of which related to theso-called Oslo 'peace process', were signed.These agreements, which masqueraded as'peace' accords, were in fact an exercise inconsolidating Israeli colonial domination of theWest Bank and Gaza Strip. The most significantof these was the Paris Protocol, which outlinedthe future economic relations between Israeland the PA. On paper, the Protocol ensures thatagricultural and industrial goods (includingdrugs) enjoy free movement between the twosides and that these goods are exempt fromdirect taxes, in theory ensuring that Palestinewould have the right to export its produce toexternal markets. In practice the application ofthe agreement is one-sided. Palestinians areprevented from exporting goods, exceptthrough Israeli companies, while Israel enjoys ataxation-free market in the OccupiedPalestinian Territories for its products. This isthe case for Israeli pharmaceutical products,which are benefitting from Israel's siege ofGaza.

There is a shortage of medicines in the GazaStrip. This is caused by the need to coordinatewith the Israeli authorities when importingmedicine into Gaza, and by the Israeli bans onthe import of certain products.12 A MOHspokesperson said: 141 drugs are not foundhere [in Gaza]. These are from a list of 470 sortsof drugs that we should always have they are

necessary drugs.

PMRS told Corporate Watch: There is a drugshortage caused by division between the WestBank and Gaza, financial pressure, a lack ofbudgeting and Israeli restrictions. We usuallyorder from a Palestinian company in the WestBank. Often we order things from the WestBank and then we don't receive them for 6months. The problem is coordination withIsrael.

Dr Sultan told Corporate Watch: At UHWC 300items are at zero stock. We have a shortage ofdrugs, especially for chronic illness. It's easy topurchase from local companies in the WestBank but from abroad it's more difficult. It'scheaper to buy Israeli than internationalproducts, as international products need to gothrough Ashdod [port] and there are delays.When UHWC orders products frompharmaceutical companies in the West Bankthere is a delay. With international productsthere are sometimes restrictions on themcoming into Gaza at all."

Mona El Farra of PRCS told us that 30% ofmedicines and 38% of supplies (e.g. syringes,needles, sutures etc) are currently lacking inher organisation.

The MOH told us that as a result of the siege,there had also been a decrease in the amountof drugs received in donations frominternational organisations. For example:When the Palestinian Authority wasestablished in 1994 we used to bring drugs viasupport from the World Bank. Before the siegethe World Bank was sending Gaza 40% of itsmedicine and 60% to the West Bank. After thesiege [began in 2006] the World Bank begansending 100% to the West Bank. According tothe Ministry, the amount of these medicinesthat were received for use in Gaza hasdecreased dramatically since 2006.

Dr Ashraf Al Qedra told us that the Ministry ofHealth in Gaza is unable to purchase medicinesdirectly from Israel because Israel sees Gaza asenemy territory. All medicine has to be

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purchased through the PA's Ministry of Healthin the West Bank.

Non-governmental health service providers inGaza purchase medicines through Palestinianintermediary companies such as MedicalSupply Services, Zant and Trans-Orient. Thesesupply companies make regular requests formedicines to be delivered through the KaramAbu Salem crossing point.

Corporate Watch interviewed one worker forMedical Supply Services who wished to remainanonymous.13 She told us that the coordinationwith the Israeli side precludes the fast,effective provision of medicine to Gaza. Ifthere are free samples which are unexpected ina shipment, the Israelis will send back thewhole container. We have to coordinate withthe [Israeli] transportation company and theworkers at the crossing. No one takes any careof our products and there is often damage.When we complain they blame it on thetransportation company. She also pointed outthat the closure of the Al Montar (Karni)crossing from Israel had increased the costs ofbringing medicine into Gaza, as it had addedanother 25-30km to the journey.

The health services interviewed try to purchasemost of their drugs from Palestinianpharmaceutical companies in the West Bank,such as Birzeit pharmaceutical company,Pharmacare (popularly known as Dar A-Shiffa)and Beit Jala Pharmaceuticals. However, evenwhen they do this the Israeli economy benefits,as Israeli transportation companies transportthe products to Karam Abu Salem. When healthservices in Gaza purchase drugs from theinternational market they come into Israelthrough the port of Ashdod but are notpermitted to travel the 35km to Karam AbuSalem directly. Instead they are transported tothe Bitunia checkpoint into the West Bank andstored in Ramallah, where a permit is appliedfor to transport them to Gaza, significantlyincreasing the length and expense of thejourney.14

As a result of these restrictions and manyothers highlighted in the excellent 'CaptiveEconomy' report by Who Profits?, Israelipharmaceutical manufacturers are put at anadvantage over their Palestinian counterparts.This is in spite of efforts by health serviceproviders in Gaza to boycott Israeli companieswhere possible (see below). Israelipharmaceutical companies such as Teva,Perrigo, Dexcel and Taro PharmaceuticalIndustries are benefitting from the captivemarket of the besieged Gaza Strip, whoseinhabitants often have no choice but topurchase from them.

Israelipharmaceutical

companies such asTeva, Perrigo,

Dexcel and TaroPharmaceuticalIndustries are

benefitting fromthe captive market

of the besiegedGaza Strip, whoseinhabitants often

have no choice butto purchase from

them.

Preventing vitalequipmentfrom reachingsick patients,and profitingfrom it, tooPerhaps the most shocking example of theprevention of equipment from entering Gaza isthe restrictions on equipment for cancertreatment. According to the Ministry of Health:The Ameer Naif centre for treating cancer isnot working because of a lack of spare parts;this is the only centre for treating cancer herein Gaza. Many pieces of equipment stoppedworking at the beginning of the siege becausethe companies were not able to come here andrepair them or bring them back for repair.

This lack of equipment has led to thedownsizing of other services in the Strip. PMRStold us that they had planned to set up adiabetic food centre but had to reduce theirplans to a diabetic food unit with less servicesbecause of a lack of the availability ofequipment.

Dr Zaqout of PMRS told us: We needdisposable equipment for pulmonary functiontests, spare parts for vehicles, spare parts forblood test devices, but we don't know whenwe will get them. New pieces of equipmentbased on wireless systems are not allowed. Weorder them but the intermediary companies saythey can't get it.

We ordered a powered wheelchair for childrenwith cerebral palsy. We waited for 8 monthsand then the supply company said that Israelhad not allowed it. Some equipment we don'ttry and order because we know it won't be

allowed because it's not available in the localmarket. For example, we know that we won'tget the equipment needed for hyperbaricoxygenation, so we haven't ordered it.

Dr Tayseer Sultan of UHWC told us: We havea shortage of spare parts that Israel doesn'tallow. These include endoscopes [forendoscopy] which are currently not workingand we can't repair them. UHWC's ambulancesalso need repairing but the repairs cannot becarried out due to a shortage of spare parts. Itis also not possible to send broken equipmentoutside for maintenance.

Haneen Wishah of UHWC told us: Ourelevator was kept at Ashdod for 1 year 8months; it was needed to carry patients to theIntensive Care Unit (ICU) on the 4th floor.During the attacks in 2009, people werecarrying patients on their shoulders to the ICU.We are sure that the elevator was prevented, asIsrael knew it was going to Al Awda.

Similarly, a fluoroscope was held at the borderfor six months. During that time rats hadgnawed at the wires of the machinery.According to Dr Tayseer: Israel always benefitsfrom imports of equipment into Gaza. If theequipment comes in by port then you need topay for storage if the borders are closed.

A fluoroscope washeld at the border

for six months.During that time ratshad gnawed at the

wires of themachinery.

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Fuel crisisAccording to Dr Mona El Farra of PRCS: Israelis not directly responsible for the powerproblem but the origin of the problem isIsrael. The context of the fuel crisis in Gaza iscomplicated. During the period of the Oslopeace process, Israeli energy company DorAlon was awarded a monopoly on the sale offuel to the PA amidst a heavy stench ofcorruption. Dor Alons monopoly on the sale offuel to Gaza was broken in 2012 by rival Israelicompanies Paz and Oil Refineries Limited.Since 2006 the European Union has funded thepurchase of this fuel by the PA. In the past thismoney was used by the EU to purchase thefuel from Dor Alon directly, but more recentlythe money has been given to the PA in theWest Bank, while the government in Gazapurchases fuel from the PA. However, a disputehas arisen over the price charged for that fuel,and specifically whether the PA has a right tocharge tax for the fuel which is supplied toGaza. This dispute has stopped the shipmentsof fuel to the Gaza power plant, forcing theplant, which generated roughly 33% of theelectricity used in Gaza, to close down. As aresult, during Corporate Watchs visit to Gaza,power was distributed for 12 hours a day on asix-hours-on, six-hours-off basis. At times thiswas reduced to just 6 hours of power a day. Adonation of fuel from Qatar has provided atemporary alleviation of the crisis, but mainselectricity is still limited to between 8 and 12hours a day.

The immediate cause of the fuel crisis is adispute over the amounts paid by the Hamasgovernment in Gaza to the PA for fuel.However, the root cause of the problem is theagreements of the 1990s, made within thecontext of colonial domination, which havemade the Palestinian economy dependent onpurchasing fuel from its occupier.

On another level, the European Union'scomplicity in the siege of Gaza has paved theway for the crisis. After the election of Hamasin 2006, the EU has followed a policy of aboycott of the Hamas government and support

of the PA administration in Ramallah. After theIsraeli bombing of the Gaza Power Plant in2006, the EU agreed to donate millions ofEuros for Gaza's fuel but refused to deal withthe Hamas government, instead hoping that itsdonation would weaken Hamas and supportthe Ramallah administration. This has laid thefoundations of the current dispute between thegovernment in Gaza and the PA.15

On a legal level, the Israeli state is theoccupying power in the West Bank, EastJerusalem, Syrian Golan and Gaza Strip and, assuch, is responsible for the welfare of theirinhabitants. This obligation overrides anyagreements which have been made betweenthe occupier and the occupied. It is clear thatthe Israeli government is failing in this legalobligation to provide for the needs of thepeople of Gaza. Instead, since the election ofHamas, Israel's occupation policies have beenaimed at obstructing the provision of servicesto people in Gaza. The effects of this policy arestarkly illustrated by the effects of the fuel crisison health services.

When our interviews were carried out inNovember/December 2013, mains electricitywas only supplied for 8-12 hours a day. All ofthe health workers we spoke to said that theirservices were required to rely on generators.This has dramatically increased the cost ofrunning services and has caused some servicesto shut down completely.

Bassem Zaqout of PMRC said: We need to pay$6000 dollars a month extra for fuel and cutdown on the provision of some services. Ourservices used to run from 8am-2pm before thepower cuts; now they run from 9pm-1pm.There is a risk our equipment will be harmedby being run from a generator. We can runlights etc on a generator but not heavymachinery.

Haneen Wishah of UHWC told us that it wasparticularly vital that the hospital's refrigerationunits and maternity unit did not lose powerand that Al Awda Hospital needs 22 litres offuel per hour to run, while UHWC's PrimaryHealth Care Centres require 6000 litres per

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month. A press release from the Committee inNovember 2013 read: 320 surgeries areperformed monthly in the operations unit inthe hospital, while the number of births in thematernity unit reaches 4000 annually, with therate of 300 a month. The hospital is alsoresponsible for all natural and C section birthwith the agreement of the UNRWA, in additionto all surgical operations that are transferredfrom the UNRWA from different parts of theGaza Strip. The fuel shortage is impeding allthese services.

The MOH told us that it ran 45 operationrooms, 130 incubators, 11 maternity rooms forcaesarians and 54 vaccination centres, all ofwhich require a reliable supply of electricity tooperate.

Dr Al Qedra of the MOH told us: The MOHuses generators for between 12 and 16 hours[daily]. These generators use 500 000 litres offuel monthly. They should only be on for 5 to6 hours max to be used correctly; we use themfor 12. It costs us more to rely on generatorsand it affects services. 10 days ago in Shifahospital the generators stopped working andthe workers [in the Intensive Care Unit] had todo manual breathing for kids for 15 minutes.

At the European Gaza Hospital the electriccontrol box stopped working. No one has diedbecause our workers and doctors take a lot ofcare and there are workers watching thegenerators all the time we have had toemploy extra staff to do this. These challengesare part of what we go through in facing thesiege. Dr Al Qedra said that the MOH hadmanaged to improve its services despite thesiege but that he was worried that theseimprovements would be lost due to the lack ofelectricity.

The effects of the electricity crisis on people'sdaily lives and health in Gaza are too all-encompassing to measure. Many injuries arecaused by undertaking complex and risky tasksin the dark. At a meeting in Nuseirat refugeecamp, people told us that children had beeninjured by fires caused by candles being usedbecause of the lack of electricity. One man toldus, I was heating bread, the electricity wentout. I grabbed my daughter to check she wasok and not near the stove but because of thedark I burned my arm. People are also unableto sufficiently heat their homes, a problem thatis becoming increasingly significant with theonset of cold weather.

Gaza's power plant, closed due to lack of fuel - November 2013. (Photo taken by Corporate Watch)

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IsolatingGaza's healthservicesThe development and effective functioning ofhealth services in Gaza is further hampered bytheir isolation from the outside world. Thesiege makes it extremely difficult for healthworkers to receive training outside Gaza or toparticipate in conferences.

Maha Elbanna of PMRS told Corporate Watch:Out of 110 staff, 2 have managed to trainabroad its also not easy for people to comehere and train us we are invited to participatebut can't make it because of the borders issue.

The conditions of the siege also prevent Gaza'shealth services from receiving foreigndelegations, trainers and specialists and affectrelationships with international donors. Severalof the people we interviewed mentioned thattheir participation in international projects wasjeopardised by their inability to attendmeetings, and that project targets were alsojeopardised due to the restrictions placed onthem by the shortage of electricity anddifficulty acquiring equipment.

Doctor Sultan of UHWC told us: Ourendoscopic project is due to end on 13November 2013, but the equipment has still notbeen delivered. We are asking the donors toextend the project in order for the equipmentto come through Erez. Another project wasthrough the World Bank; it was due to bedelivered in 2008 but actually delivered in2010. This damages our relationship with largeinternational donors.

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The Beit Hanoun (Erez) checkpoint in the northern Gaza Strip, which controls movement into Israel.

(Photo taken by the Beit Hanoun Local Initiative)

Water, anexistential threat90% of groundwater from Gaza's aquifer is notsafe to drink without treatment and mostPalestinians in Gaza do not have access toclean water. Most, if not all, tap water in Gazais undrinkable. This is because the aquifer hasbeen polluted by seawater, which in turn hasbeen tainted with raw sewage. 90 000 cubicmetres of raw sewage is currently pumped intothe Mediterranean Sea off the coast of Gazadue to a lack of proper sewage infrastructure.According to the UNWRA, the water crisis isan existential threat to the Gaza Strip as aliveable place."16

The water crisis in Gaza is, in part, an effect ofthe occupation and siege of the Strip. In 2009the Israeli military bombed a wall of one of theraw sewage lagoons of the Gaza Waste WaterTreatment Plant, which caused the outflow ofmore than 200 000 cubic metres of raw sewageonto neighbouring farmland.17

The conditions of the siege prevent thedevelopment of solutions to the water crisis.Since the conflict between Hamas and Fatah in2007, in which Hamas took control of the Strip,Israel has tightly controlled the entry ofconstruction materials. This prevents therebuilding of water infrastructure destroyed inIsraeli attacks. According to Tarek Rabbad fromthe Ministry of Economics in Gaza, there havebeen many attacks and we would need 3200tonnes of steel, 6500 tonnes of iron and 10 000tonnes of stone daily for 3 to 5 years to rebuildeverything [i.e. everything destroyed by Israeliattacks, not just infrastructure].18 The boycottof the Hamas government by the US and EUmeans that even less funds are available forrebuilding and make it unlikely that sanitationinfrastructure will be improved quickly enoughto avert the crisis deepening. Although UNWRAclaims that it will launch some projects torecharge the acquifer with run-off water andimprove the water distribution network, it isclear that the crisis is unlikely to be solved

before there is an end to the siege.

Dr Sultan of UHWC told us that the dailypumping of sewage into the sea and theconsequent effect on drinking water means thatdiarrhea, gastritis, colitis, parasitic diseases andgastroenterological illnesses are on the rise. 1child in 10 suffers from water borne diseasesdue to contamination by sewage. Because ofthe lack of clean water we have a well at AlAwda and filter the water in the hospital. Thewater filter requires power to run, increasingthe running costs of the service.

According to the MAIA Project, a PalestinianNGO based in Gaza, contamination of theaquifer by seawater has caused high levels ofchloride, which can result in kidney disease,heart failure, neurological symptoms, lethargyand high blood pressure. The seepages ofwaste water into the aquifer, as a result ofinadequate sanitation infrastructure, cause highlevels of nitrate, linked to a life threateningdisease called methemoglobinemia or 'BlueBaby Syndrome'.19

The people of Gaza, unable to travel outsidedue to the military blockade, have to deal withthis crisis. Those who can afford it buy bottledwater or use purifiers where they are available.However, bottled water and purificationequipment must be imported through theKaram Abu Salem crossing from Israel. UNWRAalso sources its construction materials fromKaram Abu Salem and often purchases fromIsraeli companies.20 Thus, the Israeli economybenefits from the water crisis perpetuated by itsongoing siege.

"1 child in 10 suffers fromwater borne diseases due

to contamination bysewage."

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Resisting thesiege throughboycottThe health workers we spoke to are workingunder conditions which are made unbearablebecause of Israel's continued military assault,the Israeli occupation, and the siege imposedby Israel with the assistance of the UnitedStates, the European Union and the Egyptiangovernment. As detailed above, the conditionsof the siege leave ample opportunity for theIsraeli economy to profit, and make itimpossible for health workers in Gaza toprovide proper treatment to their patientswithout sending their patients to be treated inIsrael. They must purchase medicines fromIsraeli companies and obtain equipment anddrugs through the Karam Abu Salem crossingfrom Israel. Despite this, the health workers weinterviewed were uniformly enthusiastic aboutthe movement for boycott, divestment andsanctions against Israel and had many ideas forhow people outside Gaza could take action.

All of the health workers that we spoke to toldus that their organisations had a policy ofboycotting Israeli medicines except where theyneeded that medicine in order to protect lifeand were not able to procure it from anothersource.

Dr El Farra of PRCS told us that the policy ofour organisation is to buy from localorganisations, even if Israeli products arecheaper, but of course we can't rely completelyon ourselves. We buy Israeli medicines if theyare needed to protect life. We buy heartdisease, diabetes and renal dialysis drugs fromIsrael as Arab companies don't produce them.

Dr Zaqout of PMRS said: We don't buy Israeliequipment and it is a policy to boycott Israeliproducts in PMRS.

The Ministry of Health told us that it has begun

to try to deal with the problem by buyingdrugs from European and Islamic countries,rather than Israel. It also tries to bringinternational delegations of health workers toGaza and encourages aid convoys of drugs tobreak the siege.

When asked about the international campaignfor a boycott of the Israeli Medical Association,Dr Zaqout of PMRS told us: The boycott of theIsraeli Medical Association is a good thing. Notparticularly because of the IMA itself butbecause of a boycott's potential effect on Israelipolicies. If they see that there is a growingcampaign in Europe maybe they will thinktwice about launching new military operationsin Gaza.

Dr El Farra told Corporate Watch: The growingof the BDS movement is a strong way ofresisting the injustice that has been imposed onPalestinian people for decades. As physicians,our role goes beyond medical services, so it isimportant and crucial to remind all healthworkers and pharmaceutical companies to jointhe campaign of boycotting companies thathave strong economical ties with Israel. Teva isan example here.

The healthworkers we spoke to were in favourof a boycott of Teva, the largest Israelipharmaceutical company and the largestcompany on the Tel Aviv Stock Exchange. Tevaoperates in 60 countries globally and is theworld's largest supplier of generic drugs.

Dr Sultan of UHWC told us: It's very importantto raise awareness about these companies. Wehave experience of working with friends inBelgium who are asking doctors there not towrite prescriptions for Teva. If we had a choicewe would not purchase from Teva. We don'thave a choice but we support the internationalcampaign.

According to Dr Zaqout: By buying Teva youare making the Israeli economy stronger andtherefore making the settlements stronger.

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Notes1. See Who Profits?

Dor Alon http://whoprofits.org/company/dor-alon

Paz - http://whoprofits.org/company/paz-oil

Ferrara and Rabinowitz, Gaza's Gas (2013) -

http://whoprofits.org/content/gazas-gas-eu-millions-smoke-

cecilia-ferrara-assia-rabinowitz-hagar-shezaf

Ynet (2012), Paz extends PA gas supply deal -

http://www.ynetnews.com/articles/0,7340,L-4235207,00.html

2. Corporate Watch, interview with Dr Tayseer Sultan and

Haneen Wishah (UHWC), carried out in Gaza City on 12/11/13

3. Corporate Watch, interview with Maha Elbanna and Dr

Bassem Zaqout, Project Coordinator at the Gaza Palestine

Medical Relief Service, 18/11/13

4. Corporate Watch, interview with Mona El Farra, Board of

Directors (Deputy Chair), Palestinian Red Crescent Society,

carried out in Gaza City on 10/11/13

5. Corporate Watch, interview with Dr Ashraf Al Qedra,

Director of Media Relations at the Palestinian Ministry of

Health, 26/11/13

6. ICRC (2009) -

http://www.icrc.org/eng/resources/documents/update/palestin

e-update-010109.htm

7. Anti-personnel shells generally fired from a tank. The shell

explodes in the air and releases thousands of metal darts

8. Al Mezan human rights centre (in personal correspondence

with Corporate Watch, February 2014) told us that Arafat Hani

Abd Al Dayem worked as paramedic volunteer in UHWC,

killed on 4/1/2009 while working on ambulance. He was killed

by artillery shell"

9. Corporate Watch, interview with Tamer Mahmoud Al Zweidi,

Ministry of National Economics, carried out in Gaza City on

25/11/13

10. The Al Mezan Centre for Human Rights record of the

incident says: At approximately 7:05 am on Monday 6

November 2006, an Israeli drone fired a missile targeting a

group of students near Al Sheikh Zayed crossroads opposite

Jabaliya Youth Club. The students were on their way to school,

which is 700 metres away from the place of attack. As a result,

Ramzi Al Shrafi, 16, was killed and other six students were

injured. (Correspondence with Corporate Watch, February

2014)

11. Corporate Watch, interview with Mohammed Azzam, Gaza

City, 18/11/2013

12. A list of these products can be found at Who Profits,

Captive Economy: The pharmaceutical industry and the Israeli

occupation (March 2012) -

http://www.whoprofits.org/content/captive-economy-

pharmaceutical-industy-and-israeli-occupation page 67

13. Corporate Watch, anonymous interview with worker from

MSS, November 2013

14. Who Profits (March 2012), Captive Economy: The

pharmaceutical industry and the Israeli occupation -

http://www.whoprofits.org/content/captive-economy-

pharmaceutical-industy-and-israeli-occupation

15. See Ferrara and Rabinowitz, Gaza's Gas (2013), Ibid

16. UNWRA (May 2013), Gaza in 2020 -

http://www.unrwa.org/userfiles/file/publications/gaza/Gaza%2

0in%202020.pdf page 12

17. UN (2009), Report of the United Nations Fact Finding

Mission on the Gaza Conflict, executive summary - available at

http://ap.ohchr.org/documents/dpage_e.aspx?si=A/HRC/12/48

page 22

18. Corporate Watch, interview with Tarek Rabbad, Ministry of

Economics, carried out in Gaza City on 28/11/13

19. The MAIA Project, Middle East Children's Alliance (2013) -

http://www.mecaforpeace.org/projects/maia-project

20. Corporate Watch, interview with workers for UNWRA who

we have chosen not to name, Rafah, December 2013

21. See

http://www.europalestine.com/spip.php?article3942&lang=fr

and http://palsolidarity.org/2010/05/bds-action-against-israeli-

pharmaceutical-company-at-cosmofarma-expo/ for links to

campaigns and calls to action

15

Front cover photo:

Israeli military outpost overlooking Palestinian farmland in Beit

Hanoun - November 2013. (Photo taken by Corporate Watch)

Take actionBDS campaigners across Europe21 are intensifying campaigns to boycottTeva. There is a counter-argument that campaigners should be careful intargeting the manufacturers of drugs used to treat sick people. However,

there is also a need to treat the greater illnesses of military occupation andcolonialism. What makes boycotting Teva easier is that it generates the bulkof its revenue through generic medicines, which can easily be supplied by

other manufacturers.

Teva UK claims that it provides 1 in 6 prescriptions supplied on the NHS.The first goal in the UK should be persuading doctors and pharmacists that

people are not happy with being prescribed generic medicines made byTeva. BDS campaigners, when given Teva generics, could ask for

alternatives and explain to the pharmacy why they are making this choice.Teva has five main locations in the UK: a distribution centre in West

Yorkshire, offices in Harlow, a packaging operations facility in Eastbourneand a manufacturing facility in Runcorn.

To find out more about the UK Teva campaign seehttps://www.facebook.com/pages/Stop-TEVA-from-bleeding-the-NHS-and-

the-Palestinian-People/443392919113731

For the French campaign against Teva see europalestine.com

To read more about the Israeli pharmaeutical industry, check out CorporateWatch's book, Targeting Israeli Apartheid, pages 169-178 and the excellentreport by Who Profits?: Captive Economy: The pharmaceutical industry and

the Israeli occupation.Another way to act in solidarity with health workers in Gaza is to supportcalls for the Israeli Medical Association's expulsion from the World MedicalAssociation over its complicity in Israeli militarism and apartheid. For more

details see boycottima.org

"The growing of the BDS movement is a strong way of resisting theinjustice that has been imposed on Palestinian people for decades."

Dr Mona El Farra - Palestine Red Crescent Society

Corporate Watch 2014 corporatewatch.org corporateoccupation.orgcontact@corporatewatch.org 020 7426 0005 ISBN 978-1-907738-13-5