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Access to health care and emergency medical services have been key issues throughout the current Israeli-Palestinian conflict, caused in part by the severe restrictions on freedom of movement instituted by the Israeli authorities since September 2000.

It is a fundamental principle of international humanitarian law that the wounded, sick, and infirm are entitled to particular protection and respect during armed conflict. Israel's obligations to ensure medical access were succinctly expressed by Rene Kosirnik, head of the local ICRC delegation, in a press briefing in Jerusalem on April 22:

    As long as Jenin refugee camp was occupied by the Israeli Defense Force, the first responsibility lies with the IDF to save lives. It is the responsibility of the force concerned to deliver services, to care for friend and foe. That is the rule.109

Israel, having ratified the Fourth Geneva Convention, is obliged to respect and protect the wounded, as set out in article 16 of the Convention; emergency medical personnel, as set out in article 20; and to permit recognized national Red Cross and Red Crescent societies to carry out their operations. During the period that the IDF directly controlled Jenin camp, Israel was also obliged to ensure that the civilian population had adequate access to food and medical supplies, as set out in articles 55 and 59. 110

The IDF incursion into Jenin began in the early hours of Wednesday, April 3. For the first day and a half, ambulance crews of the Palestinian Red Crescent Society (PRCS) had access to the camp. Some seven dead and twenty wounded were taken by the PRCS to the government hospital at the camp's edge during this period. From the afternoon of April 4, however, the IDF denied the PRCS crews access to both Jenin city and Jenin camp. The government hospital was sealed off by two IDF checkpoints on either side of its main entrance.

The director of the PRCS Jenin, Ibrahim Dababna, told Human Rights Watch how the PRCS initially began to experience difficulties getting into the camp:

    Whenever tanks saw the ambulances, they blocked their way. They also shot at them on several occasions. They knew those in the camp needed help, but the tanks at the entrance to the camp forbade our passage. After this we went to the ICRC and asked them to urgently intervene. 111

After several hours, the ICRC called back and said that the Israeli authorities had informed them there was no prohibition on PRCS access to the camp, and that PRCS ambulances were free to go there. This official position, however, was not reflected by the actions of soldiers on the ground. The PRCS again tried to respond to the many calls for help it was receiving from residents within the camp but, Dr. Dababna said:

    Whenever we sent ambulances the tanks would shoot at us and tell us to go back. We repeated this several times: calling, being informed permission was granted, and then being shot at. It was like they were tricking us. But there were so many injured and dead we just began to try anyway.

On April 7, PRCS ambulances resumed operations in Jenin City, though they were sometimes blocked by tanks and were subject to frequent searches. They continued to be denied access to the refugee camp until April 15, eight days later. Human Rights Watch encountered two cases in which sick or injured civilians were treated by IDF medics or assisted to the hospital, but found no evidence of any systematic IDF practice to provide emergency medical care itself. Injured Palestinian combatants, and the vast majority of injured civilians, were effectively denied medical access for the two-week incursion period. All hospital administrators, ambulance staff, and international humanitarian personnel interviewed by Human Rights Watch were in agreement that almost no injured persons from the camp were brought to the hospitals by ambulance from April 5 to April 15.

During the IDF incursion staff members at the government hospital and al-Razi charitable hospital were trapped in their buildings, unable to return home. Medical equipment and buildings were damaged by gunfire, at least in some cases coming from the IDF, and the distribution of medications ceased. Hospitals and the PRCS struggled to operate without water and electricity, and with reduced numbers of staff.112 Unable to reach medical facilities, camp and city residents telephoned the hospitals continuously for advice on how to give first aid, cope with chronic medical conditions, and treat the rising number of health problems brought on by the lack of food and clean water.

Lack of Access to Medical Treatment
Jihad Hassan, forty-two, is an elementary school teacher. He lived with his wife, mother, and eight children in al-Mohatta street, near the camp entrance.

On April 4, the second day of the incursion, Hassan walked up to the second floor of his house to fetch formula for his youngest son. As he walked back down the steps, an IDF missile entered through an exterior window and slammed into a neighbouring room. Hassan, startled, fell down the stairs and broke his leg in four places. The missile exploded: two others hit the house shortly afterwards, setting the first and third floors alight: Hassan's family told him later "it was like the burning fires of hell."113

Hassan's wife and mother telephoned for an ambulance. Hassan told Human Rights Watch:

    I tried to stand up, but I couldn't lift my leg. There was a lot of blood. An ambulance arrived [at the camp entrance], just fifty meters from my home, but the IDF refused to let it reach the house. We talked with the Red Crescent, the Union of Palestinian Medical Relief Societies, and with the hospital. Everyone said the same thing: they could not come.114

Hassan took two painkillers, and his family tried to treat the wounds with water and salt. His wife and mother telephoned for first aid information. Hassan remained in his house without further treatment from April 4 to April 9. Only a short distance from the camp entrance, he could see the hospital from his window. On April 5, IDF soldiers entered and searched his house, but refused his requests for medical assistance. They ordered his elderly mother to accompany them from floor to floor as they searched the house, and then left.

On the seventh day of the incursion, April 9, many residents began to leave the camp. Although he did not hear any IDF warning, Hassan also decided to leave.

    I saw everyone leaving the camp as a group. I felt something dangerous was going on and thought that this would be a good opportunity to go to the hospital and get treatment. I said to my family, "it is time." We left about 9:00 a.m. The boys took a mattress and put me on a ladder in order to carry me to the hospital. People tried to help carry me to hospital, but the IDF stopped us. I saw lots of young people stripped to their underpants, being arrested by the IDF. They ordered me to stay with the people they arrested. After an hour I was alone, under the sun, with one other injured person. We stayed there for seven hours.

As evening fell, one soldier called an officer, Captain `Adil. The captain authorized an ambulance to approach under guard some fifty meters from the camp entrance. A doctor was permitted to enter the camp after raising his shirt, and Hassan was carried to the ambulance on a stretcher. When the ambulance arrived at the IDF position next to the hospital gate, Hassan was checked again by the soldiers. Tanks barred the hospital entrance.

    After half an hour I was allowed to enter. That was after they checked my ID, the nature of my injury, and the fact it was from missiles. I heard the soldiers tell them [the hospital staff] that it was the last patient they would receive that day.

Human Rights Watch documented two cases of civilians who died as a result of their wounds, having been denied access to medical treatment. Fifty-eight-year-old Mariam Wishahi was wounded inside her home by tank fire in the morning of April 6. Her husband tried to obtain medical assistance for his gravely wounded wife, but the IDF repeatedly refused to allow an ambulance to reach the scene, located just a few hundred meters from the main hospital in Jenin:

    I tried to get an ambulance. I asked my neighbor to get an ambulance. A Palestinian Red Crescent ambulance came, but [the soldiers] shot it. When a second ambulance came the next day, the soldiers made the driver and the nurse take off their clothes next to my house. The driver was telling them he needed to get someone from the house. I started shouting that we needed an ambulance, and the soldiers started shouting to my house, telling me rudely in Arabic to get back inside. My wife kept saying she needed to go to the hospital. On Sunday night, at 11:00 p.m., she died. Every time I called the ambulance, they told me that the IDF were shooting at them and they could not come inside the camp.115

Qassim `Abd al-Jabr recalled similar difficulties in obtaining medical assistance for his son Nayif who was seriously wounded in an IDF attack outside the refugee camp: "We called an ambulance to come but the driver was prevented from reaching the area. The fire truck also came to try and help but were also prevented-the IDF soldiers prevented them from reaching the area."116 Only about twelve hours after his son was wounded was his father able to take him to a hospital. Nineteen-year-old Nayif `Abd al-Jabr died from his wounds the next day.

Attacks on Ambulances and Medical Personnel
When permitted to move, ambulances were subject to lengthy coordination and search procedures. Ambulance staff spoke to Human Rights Watch of exhaustive search procedures, in which staff stripped to their underwear and ambulance contents were examined in detail. IDF soldiers also checked patients' identities and, in some cases, took them from the ambulance into Israeli custody.117

Such search and arrest procedures, if conducted appropriately and in a way that does not endanger medical access, are legitimate. More troublesome are the repeated incidents in which IDF soldiers fired, without warning, on PRCS ambulances and medical staff. Human Rights Watch has previously documented cases in which IDF soldiers in the West Bank have fired on ambulances.118 The number and frequency of reported IDF shootings at Palestinian ambulances rose steeply from March 2002, immediately prior to Operation Defensive Shield.119

On April 3, the first day of the attack, IDF fire killed a uniformed nurse, twenty-seven-year-old Farwa Jammal, who had come to the assistance of a wounded civilian on the outskirts of the camp. As the nurse and her sister were trying to reach the wounded man, they came under IDF fire. The nurse was killed with a gunshot wound to the heart, and her sister was severely wounded (see above, "Attacks on Civilians").

On April 4, an ambulance crew was dispatched to try and rescue injured people in the Atareh area, near al-Razi hospital. Ala`a Salah, himself a PRCS volunteer, lived nearby. At 10:00 a.m. he heard an ambulance siren outside. He and his wife went to the balcony door to look.

I heard the ambulance siren. I looked out the window, and saw the ambulance stop. Five seconds later two guys from the ambulance opened the passenger doors and jumped out. I heard the sound of shooting, heavy fire. The ambulance was in the middle of the road with its motor running and the siren on.120

The area was quiet, under curfew and away from the camp. Salah heard no shooting prior to the sound of the ambulance siren. Salah saw the two ambulance staff run behind the ambulance as the shooting continued.

There was still shooting. I think they were shooting around the car. They shot at it maybe two minutes, it sounded like 800mm tank rounds [.50 caliber machine gun fire]. We can distinguish between four and five different kinds of ammunition in these operations, we've heard the sounds a lot.121

According to PRCS Director Dababna, the PRCS informed the ICRC of the incident, and the ICRC liaised with the relevant Israeli authorities. The IDF denied having fired on the ambulance.122 Several hours later, PRCS staff were given permission to move the ambulance. The .50 caliber rounds that Salah believed were used during the incident suggest that the IDF was responsible for the shooting. IDF use of .50 rounds is routine during military operations, while armed Palestinians rarely have such heavy weaponry in their arsenal. Palestinian use of .50 caliber machine guns has been reported in Beit Jala, however.

Haytham Muweis, a thirty-four-year-old ambulance driver, said, "Of course there were soldiers who were just frightened, and fired around the ambulance. But at other times we were shot at directly." Several ambulance and humanitarian personnel told Human Rights Watch they believed that the spate of incidents in which IDF soldiers fired on ambulance staff represented a policy of deliberate obstruction of ambulance movement.

Muweis told Human Rights Watch of several incidents in which his ambulance had been fired on while attempting to reach patients. In one such incident, on April 6 or 7, PRCS crews were informed that the IDF had given permission for three PRCS and one ICRC vehicle to enter Jenin camp. The ambulances proceeded past the two IDF positions outside the government hospital, and were subjected to a five-hour search. The PRCS ambulances then attempted to enter the camp, videoed by the IDF. According to Muweis:

    They videotaped us and let us enter ten meters from behind the government hospital into the camp. We saw many snipers in the surrounding area, and then shots began to be fired around us. When we were shot at, we reversed and told the soldiers we could not go in. Then we were sure the video was just for media purposes. I heard that day they said on the news that the IDF had let ambulances enter the camp. That is not true. We do not know exactly where the shots fell, and we felt they were doing it just to scare us away. But it was clear to us that if we went further forward, we would be shot.123

One week later, circa April 13, Muweis went to collect an urgent case, a woman in the Sana'iyya area of Jenin city. He left the ambulance station at 11:30 p.m., navigated through streets subject to shifting checkpoints, and collected the patient. On his return, two tanks loomed out of the darkness in front of him, some twenty meters away. The tanks immediate opened fire around the ambulance.

    The woman had been sleeping, but she woke up and became extremely distressed. I tried to shout at them that I had an injured woman with me, but no one seemed to be listening. I was yelling from inside the car, but if I had stepped outside I would have been shot. It lasted about five minutes. I stayed there until the tanks left, and then I drove off. They did not ask any questions or try to search me. Shooting has become a kind of talking for them.

Although the fourteen-day blockage of medical access to Jenin camp was unprecedented in IDF military operations, the difficulties faced by ambulance crews and medical workers during Operation Defensive Shield were not limited to Jenin. PRCS ambulances were prohibited from operating for periods of several days in Ramallah and Bethlehem; more limited, but still serious limitations on ambulance movement were in effect in other locations. On April 8, the PRCS reported that seven PRCS ambulances had been destroyed or damaged beyond repair since March 29.124

The operations of the International Committee of the Red Cross were also seriously affected. On April 4, the ICRC issued a press statement noting its regret at "the frequent and often serious instances in which medical personnel were prevented from performing their life saving duties," explaining that "ICRC delegates were regrettably prevented from working because of a sudden degradation of the usual lines of communication between themselves and the Israeli authorities."125 On April 5, the ICRC reported that it would be limiting its movements in the West Bank to a strict minimum, stating:

    [O]ver the past two days, ICRC staff in Bethlehem have been threatened at gun point, warning shots have been fired at ICRC vehicles in Nablus and Ramallah, two ICRC vehicles were damaged by IDF tanks in Tulkarem and the ICRC premises in Tulkarem were broken into. This behaviour is totally unacceptable, for it jeapordises not only the life-saving work of emergency medical services, but also the ICRC's humanitarian mission.126

Denial of Humanitarian Access
By the end of the IDF operation in Jenin camp, enormous media controversy had arisen over the question of assistance to the wounded and the disposal of the dead. The IDF, rejecting calls for the participation of independent monitoring or humanitarian groups, announced its intention to collect and dispose of the bodies of those killed, some via burial in a remote cemetery in the Jordan valley, but this was opposed by local human rights organizations, who brought a court injunction to prevent the burials from going ahead. While Human Rights Watch found no evidence to confirm allegations that the IDF had conducted mass burials prior to April 15, the IDF's six-day prohibition of medical access to the injured and sick in Jenin camp is a clear violation of the Israeli obligations under international humanitarian law.

ICRC and PRCS officials were finally permitted to enter Jenin camp after midday on April 15, the day after Israeli authorities and local human rights organizations reached an out-of-court agreement on means of access and the burial of the dead. Accompanied by an IDF liaison jeep, on the first day they transferred seven bodies to the government hospital, as well as nine wounded and sick.127 According to the ICRC press officer, ICRC explosive disposal experts and other delegates have since had satisfactory access to the camp area.128

Humanitarian organizations also faced severe problems in gaining access to the camp. Remaining camp residents lacked food, water, medication and basic supplies-none of which could be delivered until April 16. The United Nations Relief and Works Agency for Palestine refugees (UNRWA), provides services to the residents of Jenin camp. UNRWA officials were prohibited from delivering supplies to the camp from April 2 to April 15, despite the fact that food, medical supplies and other emergency items were stored in close proximity. Two UNRWA trucks entered the camp for the first time in the late afternoon of April 15, but could travel only fifty meters due to the rubble and destruction. UNRWA staff began to unload the trucks, but IDF soldiers forbade them from doing so. As dark fell, UNRWA staff decided to withdraw rather than encourage camp residents to put their lives at risk by trying to get to the food in the dark and under curfew.129

Human Rights Watch interviewed several humanitarian officials on a confidential basis between April 15 and 18.130 All expressed severe frustration at the difficulties surrounding humanitarian access to the camp-ranging from the lack of battlefield clearance and continual unfulfilled promises of access, to the absolute lack of coordination between the Israeli Civilian Administration and local commanders on the ground. Several recounted to Human Rights Watch how, after being assured by IDF Central Command or the Civil Administration that the relevant orders had been given, troops on the ground refused to let them pass. The Director of UNRWA West Bank operations, Richard Cook, was himself refused access to the camp on April 15, ostensibly because he had not notified the IDF of the number of his car license plate in advance.131 In other cases, requests for equipment, assistance, or permission to access the area received no reply. UNRWA had orally requested permission to organize specialized rescue equipment from the Israeli authorities on April 20, and followed up the request in written form two days later. By April 29, UNRWA had still not received any reply.

Cook commented to Human Rights Watch:

    I have a feeling that the Israeli army works in a very fragmented manner. While it's sometimes the case that the left hand does not know what the right hand is doing, it's more probably the case that the left hand simply does not care what the right hand is doing.132

From April 2 to April 15, the IDF had direct control over medical and humanitarian access to Jenin camp. During this period Israel was obliged under international humanitarian law to provide the sick and wounded with access to emergency medical care, and to ensure the supply of food and medical supplies to the civilian population. According to evidence gathered by Human Rights Watch, injured civilians, combatants, and the sick in Jenin camp had no access to emergency medical care from April 4 to April 15, a period of eleven days. After the camp's surrender, civilians continued to suffer as the IDF failed to facilitate access to food, water, and other emergency services, despite its obligations to do so and despite the fact that, for nine days, emergency personnel and supplies were available in close proximity to the camp.

109 Quoted in Chris McGreal and Brian Whittaker, "Israel Accused Over Jenin Assault," The Guardian April 23 2002.

110 Geneva Convention IV, Art. 55 and Art. 59.

111 Human Rights Watch interview, Ibrahim Dababna, director of PRCS Jenin, April 20, 2002.

112 Hospitals operated with those staff members present at the time the incursion began. As a result of an IDF missile strike on a PRCS ambulance on March 4 that killed the ambulance director and seriously injured three staff members, the PRCS was operating with nine out of thirteen staff members. The IDF later apologized for the incident.

113 Human Rights Watch interview, Jihad Muhammad Yassin Hassan, April 19, 2002.

114 Ibid.

115 Human Rights Watch interview with Issa Wishahi, aged sixty, Jenin, April 19, 2002.

116 Human Rights Watch interview with Qassim Nayif Qassim `Abd al-Jabr, aged fifty-seven, Jenin, April 20, 2002.

117 PRCS Jenin Director Ibrahim Dababna also told Human Rights Watch of an incident in which the IDF arrested an entire ambulance crew, consisting of two drivers, one nurse, and one volunteer. The soldiers ordered them to strip, bound their hands, and transferred them to Salem military base for questioning. All four were released in the village of Zabooba, twelve hours later. Some twenty PRCS personnel in the West Bank were arrested while performing their duties during Operation Defensive Shield.

118 Human Rights Watch, Center of the Storm: A Case Study of Abuses in the Hebron District, May 2001, p. 327.

119 Four staff members of the Palestinian Red Crescent Society were killed during this period, and ten were injured. See Human Rights Watch, "Israel: Cease Attacking Medical Personnel," press release, March 9, 2002. Israeli authorities had made and retracted several allegations that ambulances operated by the Palestinian Red Crescent Society (PRCS) were used to smuggle weapons. On March 27, the IDF reported that a PRCS ambulance was apprehended in the Jerusalem area carrying an explosive belt with eight to ten kilograms of explosives.

120 Human Rights Watch interview, Ala`a al-Din Salah, April 20, 2002.

121 Ibid.

122 Human Rights Watch interview, Ibrahim Dababna, director of PRCS Jenin, April 20, 2002.

123 Human Rights Watch interview, Haytham Muweis, April 22, 2002.

124 Palestinian Red Crescent Society, "April 8 Update," April 8, 2002. Available at: <>.

125 Middle East: A Solemn Appeal By The International Committee Of The Red Cross & The International Federation Of Red Cross And Red Crescent Societies, April 2 2002, ICR C02/22 Geneva.

126 International Committee of the Red Cross, Press Release "ICRC Restricts Its Movements in the West Bank," Tel Aviv, April 5 2002.

127 International Committee of the Red Cross, Press Release "ICRC Called for Foreign Specialised Teams to Assist in Jenin Rescue," Tel Aviv, April 18, 2002.

128 Human Rights Watch interview, ICRC Press Officer Jessica Barry, April 23, 2002.

129 Human Rights Watch interview, Richard Cook, Director of UNRWA Operations West Bank, April 24, 2002; Human Rights Watch confidential interview, humanitarian official, April 15, 2002.

130 Human Rights Watch, confidential interviews with humanitarian officials, April 15-18, 2002. Names and interview notes are held on file at Human Rights Watch.

131 Human Rights Watch interview, Richard Cook, Director UNRWA Operations West Bank, April 24, 2002;

132 Ibid.

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