Health and Hope across the Wall

Katja Tolstrup from Denmark, EAPPI, 11 November 2005

Palestinian patients living in the southeast Jerusalem area have trouble reaching the Augusta Victoria Hospital on the Mount of Olives in East Jerusalem. The following includes an interview with hospital Chief Executive Officer, Dr.Tawfiq Nasser, explaining how he has to find alternative ways of securing patients their right to treatment in spite the Israeli Occupation with its physical and bureaucratic obstacles.

The bell-tower of Augusta Victoria Hospital is visible from most parts of downtown East Jerusalem and from a wide range of neighbourhoods and villages to the southeast of Jerusalem. From a viewpoint just behind the hospital, Augusta Victoria’s CEO Dr. Tawfiq Nasser points toward Abu Dis, just down the valley. He explains how patients from this area, with only a 10-minute drive to the hospital, used to form the main group of patients for the hospital. But not any more.

For the last two years, patients, from for instance Abu Dis, have been facing increasing problems when trying to reach the Augusta Victoria Hospital. This has been a result of the construction of the Israeli-built Wall or Security Barrier, which is blocking direct and quick access for people to Jerusalem. The Wall will – once finalised – cut people off from Jerusalem, being the Palestinian centre of commerce, culture, health, etc. With a complicated and much-criticized system of permits and checkpoints run by the Israeli army and authorities in the West Bank, there is fear that future access to for instance Augusta Victoria and other vital institutions in Jerusalem will be slowed down further or maybe even made impossible.

Israel started building what it calls the “Security Fence” or “Separation Barrier” in 2002, a construction built with the official justification that it will protect the Israeli population against terror attacks emanating from the West Bank. However, the route of the Wall cuts deep into West Bank territory and separates Palestinians from Palestinians.1

As documented by various United Nations offices2 as well as Israeli and Palestinian human rights organisations, the Palestinian population suffers unduly from this construction, which confines and restricts them as well as causing them a wide range of humanitarian, economic, and social problems.3

The problem of access to Augusta Victoria also relates to the staff, as around 80% of doctors, nurses, and administrative staff commute from the West Bank, including Dr. Nasser himself.

The only place for paediatric dialysis and cancer treatment

The Augusta Victoria Hospital is the second largest hospital in East Jerusalem with 164 beds and over 20,000 inpatient days plus various outpatient services. Augusta Victoria Hospital has for the past years focused on four areas of medical specialisation. The hospital runs a paediatric dialysis ward and a newly built, but not yet running, cancer-centre will be the only place in the West Bank where people can receive radiological oncology treatment or cancer treatment.

The Palestinian Authority is sending patients to Jordan for treatments that are no longer or have never been available to a sufficient degree in the Occupied Palestinian Territories (OPTs). Augusta Victoria Hospital tries to complement the Palestinian Authority system by establishing some of these needed services.

A history connected to Palestinian refugees

The Augusta Victoria building was completed in 1910 and built by Kaiser Wilhelm II in honour of his wife, Empress Augusta Victoria, originally as a pilgrims’ hospice. Having been used for military purposes by both the Turkish and the British armies, Augusta Victoria was turned into a hospital in 1948 initially run by the International Red Cross for the Palestinian refugees displaced during the 1948-49 Israeli-Arab war.

Augusta Victoria has been run by The Lutheran World Federation (LWF) since 1950 as a hospital and it served Palestinian refugees exclusively until 1993. With the establishment of the Palestinian Authority in 1994, following the Oslo process, the responsibility of, for instance, the health sector was transferred to the PA, except for the refugees. The United Nations Relief and Works Agency for the Near East (UNRWA) has responsibility for Palestinian refugees – including health services –in the West Bank and Gaza. Today, UNRWA refers 60-70% of the patients to Augusta Victoria.

Buses and satellite clinics

Dr. Nasser underlines the rights of patients to have access to the treatment needed as a major humanitarian concern. He explains how Augusta Victoria serves as a community hospital, with the same families using the same hospital for many, many years.
So, what does a hospital CEO do if the patients cannot reach the venue of sometimes vital treatment and if the staff meets obstacles in trying to reach the hospital?

“We have done two things; we have set up our bus-system and we are continuously working on developing our satellite-clinic system,” says Dr. Nasser.

In the beginning of September 2004, the “Health and Hope Across the Wall” bus-system was initiated. Dr. Nasser explains that the name refers to health for the patients and hope for the staff. The two routes, which are currently running, pick patients up from the areas south of Jerusalem. Two more routes have been planned for; one which will collect patients from villages just south of Ramallah, and one route bringing in patients from areas closer to Ramallah.

People have to pay public transportation prices when travelling on the buses; however that only covers 1/3 of the actual expenses. The remaining costs are raised directly from the donors and both DanChurchAid and the Norwegian Foreign Ministry have provided the hospital with money for the operation of the buses.

“I do two things with this bus system,” Dr. Nasser explains. “I get my patients to hospital and I employ people from the very slow tourist business as well as use their buses.”

Dr. Nasser continues saying that in this specific context, the bus system challenges the ideas that the patients cannot reach their hospital and that the hospital lacks patients.

Quite a lot of attention has been given to the bus system, says Dr. Nasser. The system has – even for the short time it has been running – been an example of successful coordination with the Israeli army and the Civil Administration.4

Says Dr. Nasser: “We have to look for options that provide win-win situations for the people. Civil society has to start working in these times of distress – and Augusta Victoria could serve as a model institution in this respect.”

All the children living outside Jerusalem who are going for dialysis treatment – usually three times a week – are picked up by the bus, about 16 children on a daily basis. In addition, another 10-22 patients join the buses and these are primarily patients scheduled for special surgery at Augusta Victoria Hospital.

The Augusta Victoria Hospital also runs four village health clinics that have been operating since 1952. As of now, the hospital is trying to sustain them and have them refer patients to Augusta Victoria Hospital. Dr. Nasser considers the satellite clinics an attempt to reconnect with Palestinian communities in rural areas that are un-served or under-served.

Dr.Nasser became the Chief Operating Officer in 1997, when, at the age of 32, he entered with his management group and in his own words “turned things around.” He has served as the CEO of AVH since 2001. He was actually born in his current office and he laughs when saying that he might also one day be buried here: “Here I am, trying to run a hospital and then I have to take care of buses and travel permits for both my staff and the patients!”

Threat from tax-exemption revocation

Another standing threat to the continuing operation of the Augusta Victoria Hospital is the issuing by the Israeli state of a petition arguing for the revocation of the hospital’s tax-exemption. On December 22nd, 2002, the Israeli District Court in Jerusalem de facto revoked a tax exemption agreement between the State of Israel and the Lutheran World Federation (LWF), the latter being the owners of the hospital. The revocation of the exemption will, if the appeal by the LWF is unsuccessful, pose a severe threat to the work done at Augusta Victoria, as the hospital will not be able to budget for such an increase in expenses. Handing the bill to donors is unrealistic, says Dr. Nasser.

The tax exemption was originally extended to the LWF by the Jordanian government in 1966. Israel confirmed the exemption when it occupied East Jerusalem in 1967. The Israeli Supreme Court is expected to give a ruling on the matter sometime in 2005. If LWF loses the case, Augusta Victoria Hospital would have to pay taxes and would no longer enjoy VAT (value-added tax) exemption on medicine and medical equipment.

Dr. Nasser draws a current picture of a very challenging situation for the AVH:

“What is important to understand is that Augusta Victoria faces a lot of different manoeuvres that makes life impossible; the construction of the Wall, which separates people from the hospital; and then there is the system of applying for permits from the Israelis. While the Israeli Civil Administration is issuing many permits to hospital staff and patients, it is very difficult to employ newly-educated staff, such as nurses or young medical students going for their clinical training because of the long process of applying for travel permits. The Israeli law states that no one under the age of 24 can get such a permit, regardless of their security clearance. And then, if we have to pay taxes, which of our donors would help us do that? Money coming from service-fees cannot pay the taxes. If the exemption is revoked, this will pose a serious threat to Augusta Victoria.”

Obstructed access to health

A few international donors have raised questions about the sustainability of Augusta Victoria altogether. The donors say they can do nothing about the Occupation but Dr. Nasser stresses that if donors shun away from investing in institutions in East Jerusalem, then that is denying patients the needed treatment as well as giving in to the Israeli Occupation. The focus on specific medical treatment and the proof – via the bus-system – that the future running and existence of Augusta Victoria builds on patients in need of treatment, underlines the need for and sustainability of Augusta Victoria Hospital. Furthermore, Augusta Victoria is a living witness to ecumenical church work carried out in Jerusalem.

“Look at this,” Dr. Nasser says, “Abu Dis and three other major urban communities are cut off from Augusta Victoria. If the Wall is for Israeli security, then that is fine, they have every right to protect themselves. But punishing the patients like this is an exaggeration. Funding behaviour might create realities that we might not want, concerning human rights and so on. Anybody claiming that I could do a better job, sustaining a hospital in Ramallah is absolutely right – but we need to ask ourselves the reasons why a community hospital – in what constitutes the centre for the Palestinian society, concerning trade, transport, culture, employment, etc. – cannot offer hospital services to its immediate surroundings?”

Notes:

1 The “Separation Barrier” consists of earth mounds, eight-metre tall concrete Walls, trenches, and numerous checkpoints and roadblocks. The cost is estimated at around 3.4 billion dollars, the most expensive building project in the history of Israel according to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA). It will – if the current projections are followed – be around 630 kilometres long, with around 15% running on the 1967 Green Line. See the route of the barrier on http://www.reliefweb.int/hic-opt (OCHA) or consult NGO websites concerning the Wall, such as PENGON - Anti-Apartheid Wall Campaign (www.stoptheWall.org).
2 See for instance The West Bank Barrier, Humanitarian Status Report, The Jerusalem Barrier and Humanitarian Access, December 2003, OCHA.
3 Read for instance the International Court of Justice Advisory Opinion on Israel’s “Separation Barrier” (http://www.icj.org/world_pays.php3?id_mot=24&lang=en).
4 The Civil Administration is staffed by military personnel and is the Israeli authority from which the Palestinians have to apply for permits for traveling, building, etc.