Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
ISRAELI AND PALESTINIAN CIVILIANS
VICTIMS OF AN ENDLESS CONFLICT
Press Conference
July, 21, 2003
There are no right or wrong victims…
1 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 ISRAELI AND PALESTINIAN CIVILIANS
VICTIMS OF AN ENDLESS CONFLICT
Two-part survey :
First Part Second Part
"Operation "Protection Wall" "Israeli civilians victims of Nabulus" attacks by armed Palestinian groups"
Médecins du Monde – FIDH joint Médecins du Monde survey mission survey mission West Bank – May 2002 Jerusalem – August 2002
Published: July 2002 Published: July 2003 Report available from Médecins du Report available from Monde Médecins du Monde www.medecinsdumonde.org www.medecinsdumonde.org
Report hereunder
Médecins du Monde, 62 rue Marcadet 75018 – Paris Tel. (33-1) 44 92 15 15 F. (33 1) 44 92 99 99 www.medecinsdumonde.org
2 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Israeli civilians victims of attacks
by armed Palestinian groups
"Life will never be the way we once imagined it could be. I would like to thank you because this is the first time anyone has come to us to try to evaluate the consequences of the attacks".
Ana, victim of an attack in a bus, in Afula, April 6, 1994
Directeur de la publication : Dr. Claude Moncorgé Coordination du Rapport : Médecins du Monde, 62 rue Marcadet 75018 Paris www.medecinsdumonde.org
3 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Overview
"There are no right or wrong victims". from a certain number of Territories and These words were first spoken in 1979, during the transferred some responsibilities to the Palestinian founding mission of Médecins du Monde, in favour Authority. Three zones were defined. of the Vietnamese Boat People in the China Sea. In Zone A, containing 98% of the Palestinian They have now become a part of our population of the West Bank, internal affairs and organisation's identity. domestic security were under Palestinian control, only external security remained under Israeli Since that first mission, the history of Médecins du responsibility. In Zone B, domestic and external Monde has been marked by the concern to security were both under Israeli control. Zone C provide medical care for civilians and to bear was completely under Israeli control. witness to the traumatic experiences of civilian populations caught up in countless conflicts; from The failure of the Camp David and Taba the early 1980s, in El Salvador, Afghanistan, Iraqi negotiations and the outbreak of the Al-Aqsa Kurdistan, the Hutus and Tutsis in Rwanda, Intifada in September 2000 led to an escalation of Croatian, Serbian and Moslem Bosnian violence that has persisted to this day. communities in Yugoslavia, the Albanian majority then the Serbian and Gipsy minorities in Kosovo, Since 2002 and, in particular, since "operation today in Chechnya, and the list goes on. defensive shield", the Israeli army has made a large number of incursions into the different zones in There are no right or wrong victims. These words the West Bank and in the Gaza strip, and also apply to the civilian populations in the Israeli- reoccupied certain locations. Today, these zones Palestinian conflict. are no longer a reality, for the Israeli army has reoccupied zone A from which it had previously withdrawn its forces. Military operations now take Recent historical background place in all 3 zones. According to a statement by the Israeli Prime Minister "Oslo has been buried". In the wake of the 1967 "Six Day War" involving several neighbouring Arab states and Israel, Israel took control of different territories. Civilians are the main victims These were the West Bank and East Jerusalem, which were part of Jordan, the Gaza strip which As a humanitarian medical organisation, for many was under Egyptian administration, and the Golan years now Médecins du Monde has been Heights, belonging to Syria. developing medical programmes for the benefit of The UN Security Council resolution 242 the Palestinian population. demanded, on the one hand, the withdrawal of Israeli forces from the Occupied territories, and, Alongside its programmes, Médecins du on the other hand, the right of all the nations MondeDwishes to denounce, in the context of this present in the region to live in peace with safe, conflict, the violence perpetrated against the recognised borders. civilian populations by the forces present.
However, East Jerusalem was officially annexed by The civilians on both sides have paid heavily for the Israel and, over the years, many Israeli settlements escalation in violence, in Israel as in the Occupied were set up in the Occupied territories. territories. The UN Security Council demanded in vain that Israel renounce the building of these "settlement A first document was produced a year ago, based colonies" in the Occupied territories1. on field surveillance work. This report described, assessed and qualified, with respect to International After the Oslo agreements were signed in 1993 by Humanitarian Law, the actions of the Israeli army the Palestinian Liberation Organisation (PLO) and against the Palestinian civilian population, within the Israeli government, the Israeli army withdrew the framework of the "Defensive shield" operation in the town of Nablus2.
1 See Security Council resolution number 465 of March 1st, 1 1980. 2 Médecins du Monde – FIDH report on operation "Defensive shield" in Nablus, July 2002
4 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Here we are presenting the second part of the observed that they are still just as keen to meet work conducted by our teams. The purpose is and work together. once more to describe, measure and qualify, again with respect to International Humanitarian Law, In September 2003, Médecins du Monde will be the actions of the armed Palestinian groups aimed involved in the "medical days for peace" organised at the Israeli civilian population, which are a part of by the city of Lille, which is twinned with the the armed conflict between Israelis and towns of Nablus and Safed. Palestinians. In this way, Médecins du Monde initiates medical co-operation and tries to help maintain bridges The role of civil societies between the medical communities of the two sides.
Médecins du Monde is convinced that civil societies But we also know that the breaches of the on both sides have a key role to play to escape this fundamental principles of International spiral of terror and commit to a peaceful solution. Humanitarian Law have a radical effect, day after day, on public opinion. These breaches nurture Hundreds of Palestinian intellectuals, well-known hatred and destroy the forces for peace. They personalities and politicians have signed an appeal render vain the efforts to find a political solution for an end to the attacks against civilians. The and therefore durable peace in the region. signatories can see no benefits arising from We therefore feel obliged to describe these violent "military" operations aimed at civilians in Israel, acts, from our work in the field and from "apart from the consecration of hatred between our eyewitness accounts, and to qualify them with people and the Israeli people and the widening of the respect to International Humanitarian Law, gulf between them. They kill the hope of seeing two denounce them, call upon the parties in the conflict peoples living side by side in neighbouring states". to respect the principles of this legislation, and call upon the international communities to do The same peace initiatives exist and are active in everything possible to make sure these principles Israel. They are expressed on a political level by are respected. the Shalom Arshav movement (Peace Now), by the political party Meretz, by the voices of intellectuals This is what we endeavoured to do in the first such as Amos Oz, David Grossman, academics like report presented in July, 2002, jointly with the Ilan Greilsammer or Eli Barnavi, Human Rights FIDH, entitled "Operation "Defensive shield" organisations such as B’Tselem, Physicians For Nablus". Here, we are presenting the second part Human Rights, and religious personalities such as of our work, based on the observations we made Emile Shousani (Nazareth priest) and the religious in 2002. organisation "dove" Netivot Shalom (the Paths of Peace).
Médecins du Monde has always endeavoured to strive in this direction : to help to bring the Israeli and Palestinian medical communities closer together. In 1992, we organised a first colloquium in Paris, between Palestinian and Israeli colleagues. At the end of 2000, when the 2nd Intifada was in full force, a second meeting was organised at the organisation's headquarters, to help maintain the dialogue between the two medical communities. Since then, in Israel and in the Palestinian territories, we have continued to keep the dialogue open and encourage co-operation. We have Summary
A first report was produced a year ago, jointly with the FIDH, based on the findings of a field investigation. That report described, evaluated and qualified, with respect to International Humanitarian Law, the behaviour of the Israeli army against the Palestinian civilian population, in the framework of operation "Defensive shield" in the town of Nablus in April 2002.
5 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
We are presenting here a second investigation by our teams, the aim of which is also to describe, measure and qualify, again with respect to International Humanitarian Law, the acts of the armed Palestinian groups with respect to the Israeli civilian population.
Executive Summary of repeated attacks. The attacks against Israeli civilians take place both in Israel and in the Since the start of the Al-Aqsa Intifada in September Occupied territories. However, the Geneva 2000, hundreds of Israeli civilians were killed, Conventions clearly indicate that "The civilian thousands injured and many more were population as such, as well as individual civilians, 3 traumatised psychologically by attacks from armed shall not be the object of attack ". And there can Palestinian groups. be no justification, either political such as "struggling against occupation" or military such as We have coined the following term to name the declaring "we have no tanks or aircraft to fight the attacks during which the attacker blows himself up Israelis with", for violence against civilians, even in in the middle of a crowd of civilians: "democide" the Occupied territories. attack. The weapons used against civilians are varied, as On the basis of an investigation in the field, a this document indicates, but explosives are the comparison of several different sources of most frequently used and are the most deadly. The information, and numerous eyewitness accounts technique of democide attacks whereby an from surviving victims, Médecins du Monde individual blows himself up in the middle of a notes that the violent acts conducted by the armed crowd is particularly used by the armed Palestinian Palestinian groups mainly affect civilians. Now, the groups. This form of indiscriminate 1949 Geneva Conventions, and International assassination, deliberately directed against Customary Law are based among other things on civilians, with the addition of wounding the principle of distinction. From this principle agents in the bombs such as nails and bolts results the legal obligation for parties to a conflict to cause additional suffering should be to make the distinction between military targets qualified, according to protocol 1 of the and the civilian population. The non-respect of this Geneva Conventions, as "inhumane acts". principle constitutes a breach of International The Geneva Conventions explicitly prohibit "Acts Humanitarian Law. Although not a nation, the or threats of violence the primary purpose of Palestinian Authority must respect the customary which is to spread terror among the civilian norms of International Humanitarian Law. population", according to Article 3, common to all Resolution 244 dated December 19, 1968 of the three conventions. General Assembly of the United Nations states that governmental and non-governmental entities The medical consequences of the attacks are must not launch attacks against civilians. analysed both on a physical level and a psychological level. Particular attention is given to Among the civilians affected, the report shows that the consequences on the mental health of the there is a significant proportion of women, a large direct victims (Post Traumatic Stress Disorder) but percentage of young people, including children, and also of other "people involved". The impact of this senior citizens. The poorest Israelis are the most violence on Israeli society is highlighted, taking the exposed to the attacks. The victims of the armed example of school children, employees of the Palestinian groups' attacks are therefore among Egged bus company, and first-aid workers. the most vulnerable members of Israeli society. All phases involved in the organisation of first aid after an attack are described. Hospital Neither are the health care professionals and the admittance disrupts the organisation of care. vehicles used to help the wounded or injured There is a description of the responses of the spared. various Israeli organisation involved: from the psychiatric sector, to the municipal council and other non-governmental sectors taking care of the This report stresses that the organisation of psychological consequences and their prevention in attacks in public places that are not a priori located the event of attacks. in proximity to military targets, leaves no doubts as to the intention of targeting Israeli civilians and to hit as many of them as But it is the whole of Israeli society that is possible. Markets, leisure environments, concerned, first of all symbolically, as the universities, and public transport were the targets 3 Article 51 of additional protocol 1 of the Geneva Conventions.
6 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 survivors of the Shoah being the victims of attacks, This report carries the reminder that on several then in its very way of life, where security occasions children under 18 were used in imperatives modify daily habits, and on an democide attacks and other armed actions. economic level. The main political consequence is to annihilate the There are nonetheless forces present in development of peace camps in Israel. Palestinian society who, while vigorously defending their own cause, cry out against these crimes. The International community and The perpetrators of these acts of violence targeted citizens organisations must encourage them. against civilians are clearly known, since organisations such as Hamas, the Islamic The attacks committed against Israeli civilians Djihad, Al-Aqsa Martyrs Brigades or the constitute war crimes according to International PFLP, to mention but the most active, have Humanitarian Law. The attacks, in particular the claimed responsibility for such "operations". The democide attacks, due to their "systematic or organisers and their accomplices, but also those at generalised" nature, with the stated intention of the top of the chain of command of these killing civilians and of spreading terror in the Israeli movements, who give the orders, are responsible population, constitute crimes against humanity, for serious breaches in International Humanitarian with respect to the Statutes of the Internal Penal Law. Court.
The Palestinian Authority cannot evade Recommendations have finally been formulated for responsibility, even if only because of its ambiguity. better protection of civilian populations
7 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Warning and lexicon
We propose to use the neologism "democide" to describe the attacks aimed at civilians where the assailants take their own lives in order to kill as many people as possible around them. The term democide4 is made up of two words:
- demos: Greek word for people, population - cide: from the Latin coedere, to kill
For in fact, up till now, the expressions "suicide bombers" or "kamikaze attacks", neither of which is appropriate, were used indifferently. When we speak of a suicide bomber, the accent is placed not on the victims but on the attacker who takes their own life, which is unfair to the victims. Kamikaze refers to the action of Japanese military airmen during the second world war, who sacrificed their lives by dive-bombing onto enemy military targets. But in the so- called "kamikaze" attacks, the clearly identified target is not military but to kill as many civilians as possible.
The term democide attack avoids misunderstandings, and makes the reality of the action more explicit.
However, this neologism has no legal value.
Democide attacks are not specific to the Israeli-Palestinian conflict. They were used by the Tamil Tigers in Sri- Lanka and more recently on September 11, 2001 in the destruction of the Twin Towers in New York, then in Moscow a few months ago, within the scope of the Russia-Chechenya conflict.
By extension, other types of violence against civilians can be qualified as democide acts. Such is the case of the parcel bomb left in a public place, so that when it explodes it causes a considerable number of victims. Or the attack on the rue de Rennes in France in 1985 or again the one in the Bali nightclub, frequented by young Australians in 2002.
The word terrorism is not used in this report, for there is no international political consensus on the use of this term.
In this document, "Occupied territories" designate the territories that passed under the control of the Israeli army as a result of the war of June 1967, with the exception of Sinai, which was returned to Egypt as part of a peace agreement.
Acknowledgements
We would like to thank the Israeli humanitarian organisation LATET, for assistance with logistics, and for faithfully facilitating the fieldwork of the team from Médecins du Monde.
LATET, 118 Ahad Ha'am street, Tel Aviv 65208, ISRAEL www.latet.org.il
4 We consulted Alain Rey and Josette Rey-Debove, editors-in-chief of the "Petit Robert" dictionary, to approve the neologism "democide" to name this type of attack
8 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Introduction
In the conflict opposing Israelis and Palestinians, Furthermore, we wanted to broach the subject of the first democide attack organised by an armed the impact of the terror spread by the repetition Palestinian group took place in 1994, just a few of these acts of violence on the daily lifestyles of months after the signing of the Oslo peace the people and on their organisation, but also on agreements. the social positioning and the perception public opinion has of the war objectives of the In the first instance, we have listed the various Palestinians. attacks perpetrated against the Israeli civilian population, since the month of September 2000, In the second instance, we analysed the the date marking the outbreak of the 2nd Intifada. circumstances surrounding these events, the responsibilities involved, detailing the legal We have assessed the medical, psychological and qualification of these acts, according to social consequences of these actions. The International Humanitarian Law and established provision of care for these patients has changed recommendations for better protection of civilian the organisation of the care system in Israel. The populations. humanitarian medical organisations, even the most hardened, working in conditions of armed conflict, do not have experience in providing mass care to people traumatised by attacks. We therefore sought out the response of Israeli practitioners when faced with this situation.
9 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
The purpose of the mission
Starting in August 2002, a mission from Médecins du Monde, comprising Doctor Carole Dromer, medical coordinator for Médecins du Monde, who took part in the testimony mission "Operation "Protection Wall" Nabulus", and Eric Ghozlan, clinical psychologist, carried out an investigations into the medical, psychological and social consequences of the attacks on civilians in Israel and in the Occupied territories, perpetrated by armed Palestinian organisations who claimed responsibility for them.
Methodology
The mission gathered information and eyewitness accounts, in the regions of Tel-Aviv and Jerusalem, from:
surviving victims, families of victims, health care professionals or people involved in taking care of victims, Magen David Adom, the police, the army, Foreign Affairs Ministry, Health Ministry, the municipal council of Tel-Aviv –Yaffo, social security services, the Egged bus company, Non-governmental organisations (NGO) and associations, Zaka, Selah, Physicians for Human Rights, Latet, Eran, Natal, Beth-Rham.
The team from Médecins du Monde carried out field visits in the following places:
Hospitals in Jerusalem (Bikur Cholim, Sharé Stédek, Hadassa Ein Kérem), Hospitals in Tel Aviv (Tel Hashomer, Bellinsson, Irilov), Gertner Institute for Epidemiology and Health Policy Research, Ramat Gan Medico-psychological Centre.
The mission was completed by reading, analyses, comments on documents, quantitative and qualitative data, drawn from activity reports submitted by various state institutions (Foreign Affairs Ministry…) or NGOs (Natal, Eran, etc.) and gathered during the investigation phase.
10 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
CHAPTER I. The sources of information
I.1- The figures
I.1.a – Multiple sources The Israeli army (Israeli Defence Forces: It is extremely difficult to be exhaustive and precise IDF/Tsahal in Hebrew), in listing the people who have died or been injured in the attacks or other acts of violence perpetrated For the same dates, 4,476 people were injured and by the armed Palestinian groups, for the different 608 killed. These figures include civilian losses and institutions in relation with the victims use those of the security forces but do not take into different systems for counting. Our report is account the losses of the assailants conducting the devoted to the question of Israeli civilians in the attacks («democide» attackers killed or injured by conflict, so we will take into account only those the security forces). sources that mention this. The Israeli police force, Magen David Adom (MDA), for its part, expresses its data in terms of years, in in English red star of David, is the Israeli medical figure 1 below. The figures for 2002 stop at emergency service with a status roughly equivalent July18th. They include the total number of dead and to the Red Cross. injured. Between January 1st and July18th, the From September 29, 2000 to August 1st 2002, number of dead was 335 and the number of MDA treated and evacuated 4,310 victims of injured was 1,676. attacks: 511 died on the spot and 3,799 were injured. These figures include civilians and members of the security forces. Members of the army, taken into care by the army's own emergency services, are not included here. The number of victims includes the people perpetrating the attacks ("democide" attacks or other acts of violence).
Figure 1: Change in number of victims of Palestinian attacks (source: Israeli Police)
2500
2000 2011
1733
1500
1000 Number of victims
717 633 598 585 500 529 520 508 405 301 206 126 0 year 1990 year 1991 year 1992 year 1993 year 1994 year 1995 year 1996 year 1997 year 1998 year 1999 year 2000 year 2001 year 2002 (au 18/07)
The Foreign Affairs Ministry
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gives 2,826 injured and 601 dead for the period The statistics of the Hadassa Ein Kerem between September 29, 2000 and August 12, 2002 hospital (Jerusalem) inclusive. Among these victims are military and other security forces, some of whom were clearly account for 219 dead and 2,071 injured in the on duty. The number of injured is much lower than period between September 29, 2000 and other sources for the same period, for the data December 31, 2001. The data presented by the from this ministry only includes events where Hadassa Ein Kérem hospital represent all the there was at least one death. information available on the number of victims during this period in Jerusalem or elsewhere.These different data can be compared in the following table.
Table 1 – Number of victims from January 2000 to August 2002 (sources: see below)
Total number Number Number of Source Period of victims of dead injured 29/09/00 Army 12/08/02 5,084 608 4,476 01/01/00 Police 18/07/02 4,045 nc nc 29/09/00 Magen David Adom 01/08/02 4,310 511 3,799 29/09/00 Foreign Affairs Ministry 12/08/02 3,427 601 2,826 29/09/00 Hadassa Ein Kérem Hospital 31/12/01 2,290 219 2,071 nc: not communicated.
I.1.b - The geographical distribution of attacks (See map on next page) The Bikur Cholim hospital situated in the The attacks of armed Palestinian groups concern centre of the old town of Jerusalem cared for 492 the entire country and the Occupied territories. injured, of whom 216 were admitted to hospital This explains the very high number of victims taken for 20 attacks, 4 of which were committed within a into care by the hospital care structures in radius of less than 50 metres around the hospital, Jerusalem. from May 27, 2001 to June 19, 2002. The inhabitants of Jerusalem are much more exposed Table 2 – Attacks by region in Israel to acts of violence . (source: Israeli police)
Region 1st half of I.1.c - Where the attacks take place 2001 2002 Tel Aviv 57 Places where people meet or congregate are North 15 46 particularly targeted, such as markets, leisure environments such as discotheques, restaurants Centre 20 15 and cafés, places of study, such as a university or a Jerusalem 36 49 yeshiva (places of religious study) and public South 14 34 transport: buses and bus stations. By targeting these places, the intention is to hit the largest possible number of people and in particular civilians.
Geographic localisation of attacks , october 2000 / july 2002
12 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
13 Israeli civilians victims of attacks by armed Palestinian groups
I.2 – The victims of violence
Médecins du Monde considers as civilians (or protected people, by virtue of article 3 common to the Geneva Conventions): "Persons taking no active part in the hostilities, including members of armed forces who have laid down their arms and those placed hors de combat by sickness, wounds, detention, or any other cause".
Israeli civilians killed by Palestinian civilians and by There is no source that centralises the data to give the Palestinian security forces. This figure the exact number of Israeli civilian victims of therefore does not take account of civilians of Palestinian attacks. However, the comparing of other nationalities who were killed. different information items we were able to collect does show an abnormally high number of civilian The Israeli police, for its part, recorded victims to think that these victims are collateral between September 29, 2000 and August 10, 2002: damage only. 2,968 civilians injured and 468 killed.
According to the figures from the Hadassa Ein The statistics given by the Israeli army show Kerem hospital (Jerusalem), between September 3,198 civilians injured and 426 civilians killed 29, 2000 and December 31, 2001, including all the between September 2000 and August 12, 2002. dead and injured, there were 2,290 victims. Of this These figures should be compared with the human total, 1,908 are civilians (83.3%), and 6 are first-aid losses of the security forces: 1,278 injured and 182 workers from MDA. killed. It should be noted that for Tsahal, the only Among the other people hit, 87 belonged to the people considered as civilians are those people police when the events took place (3.8%), and 289 who do not belong to the security forces. This were military, in service, at the time of the events means that a policeman or soldier not on duty at (12.6%). the time of the event is still counted in the This total of 1,908 therefore includes military and "security force" category. police who were not on duty at the time of the According to this source, 71% of the dead and 70% events. The calculation method is therefore of the injured are civilians. This data corroborates different from that of the army. that of the Foreign Affairs ministries for the people killed. For its part the non-governmental organisation B'Tselem listed, between The different elements of information and their September 29, 2000 and August 12, 2002, 393 sources are shown in the table .
Table 3 – Number of civilian victims from September 2000 to August 2002
Proportion of Proportion of civilians Overall proportion of civilians killed injured compared to security civilian victims Source Period compared to security forces forces (number of civilians compared to security (number of civilians killed) injured) forces
Army 29/09/00 - 12/08/02 71% (426) 70% (3,198) 70.5% (3,624)
Police 29/09/00 - 10/08/02 77% (2,968) (3,436)
Foreign affairs 29/09/00 - 12/09/02 (427) n.c. n.c. ministry
B'Tsélem 29/09/00 - 12/08/02 (393) n.c n.c. Hadassa Ein Kérem Hospital, 29/09/00 - 31/12/01 n.c. n.c. 83% (1,914) Jerusalem n.c.: not communicated
14 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Whatever the sources consulted, state or non-governmental, medical or police, the proportion of civilians among the victims is very high and at least equal to 70%.
The acts of violence conducted by the armed Palestinian groups mainly affect civilians. Now, the Geneva Conventions and their Additional protocols, and international customary law, are based on "the principle of distinction" that obliges parties to a conflict to distinguish between military targets and civilians.
These are breaches of International Humanitarian Law.
I.3 - Who are the civilian victims?
I.3.a - Women and men
The injured taken to hospital are most often masculine and which were feminine: 27 times out men of 390 it was not possible to determine the sex. For the others, the global calculation of the ratio of According to the Gertner Institute of Epidemiology men to women is 1.3. This sex ratio, compared to and Health Policy Research, 72.9% of the injured that of the Israeli population, which is 0.99 (2001 are men. Men represent the majority of injured estimation), shows that men are more affected people who arrive at the hospital. than women. Expressed as a percentage, 58% of the people killed are men. This difference is As many women as men among those killed especially due to the people killed in the Occupied To determine the ratio of men to women in the territories, as shown in the table below. people killed, we took the list from B'Tsélem concerning the Israeli civilians killed (period from November 2, 2000 to August 10, 2002). From the list, we determined which first names were
Table 4 – The distribution of men/women among Israeli civilians killed, depending on whether they were located in the Occupied territories or inside Israel.
Location of attacks Percentage of men among the Percentage of women among civilians killed the civilians killed Occupied territories 67% 33% Inside Israel 49% 51% Total 58% 42%
The proportion of women killed is abnormally high inside Israel.
I.3.b - Distribution of victims depending According to the Gertner Institute of Epidemiology on age and Health Policy Research, (Tel Hashomer, Israel), 60% of the injured who arrive at the hospital are The injured admitted to hospital between 15 and 29, 20% are between 30 and 44. The other age groups each represents less than
15 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
10% of the injured. The Gertner Institute Only the age of people killed is available. According performed this work on all injured whether civilian to the sources of the human rights NGO B'Tsélem, or military. the majority of Israeli civilians killed are over 50 and under 20. If we refer to the under 30s we see that they alone represent 45% of deaths.
The distribution by age according to this source is presented in the figure below. People killed
Figure 2
Age of Israeli civilians killed during Palestinian attacks, from Septemver 29, 2000 till August 12, 2002 (source: B'Tselem)
0-10
61-70 4%
7% 11-20
21%
> 70
9%
51-60
12%
21-30
20%
41-50 13% 31-40 14%
Old people represent an abnormally high In addition, the fact that old people with multiple proportion of the dead (16% of victims are over traumas have less chance of surviving their injuries 60, while they only represent 10% of the than younger people should be taken into account. population).
Children, victims of attacks and of violence The reason for this is possibly the attack on the From September 2000 to February 28, 2002, 720 Park Hotel at Netanya, during Easter religious children were gravely or moderately injured in celebrations. The Seder ceremony is a very attacks by armed Palestinian groups and 70 important family get together. Jewish people, children and teenagers from 4 months to 19 years particularly older ones, who do not have their old were killed (source: Amnesty international). children with them on that evening, wish to share While no region in Israel was spared, Jerusalem the event with other guests at group celebrations was the most affected, with 300 injured children organised in hotels. 29 people were killed that taken into hospital (source: Israeli Ministry of night, 19 of them were over 70 years old. Education, April 2002).
I.3.c - The social status of victims
The risk of being in a place where an attack happens is higher for an inhabitant of Jerusalem with a modest working class background, who regularly takes the bus and goes to open air
16 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 markets, than for an executive living in the posh The information gathered from the MDA and suburbs of Tel-Aviv who drives around in a car and Shaaré Tsédek hospital indicate that first-aid has groceries delivered to the door. workers are also the object of attacks targeted by armed Palestinian groups. Between September 29, Statistical data gathered from the NGO Selah, 2000 and August 12, 2002, 11 members of MDA specialising in assistance to new immigrants, shows were hit. Most were busy caring for the injured at that 25% of the victims of attacks, whether injured the time. or dead, are "new immigrants " (the time criteria chosen to qualify an immigrant as "new" is 7 years). Certain first-aid workers who arrive after a first explosion are hit by a second explosion, victims of The victims also include workers of foreign what is known as the "double attack" technique. nationality, like Ling Chang Mai, 34, who arrived from China 4 months ago to work on building sites Others were hit when their ambulances were in Jerusalem. He was shopping at the market on attacked. On March 31, 2002, an MDA emergency April 12, 2002 when he was killed in an attack. The centre was the direct target of an attack. This was same destiny befell his fellow Chinaman, Chai Siang the MDA Efrat centre, in the Occupied Territories. Yang, 32. A Palestinian carrying a bomb blew himself up there. Furthermore, there are also Israeli Arabs among the victims. Iman Kabha, aged 26, living in the Arab Israeli village of Barta in Galilee, was the 6th of 7 Attacks on relief vehicles children. He was studying special educational needs During this same period, 5 ambulances were and Hebrew. He was killed, along with 29 other destroyed (photo), 78 vehicles were damaged victims, in the "democide" attack on a bus in (photo). Most were vehicles used for emergency Jerusalem on June 18, 2002. medical interventions (97%). I.3.d- The health care professionals
The relief teams
Photo : MDA ambulance set on fire on September 29, 2000 in Jerusalem (photo MDA)
Photo: damaged MDA ambulance (photo MDA)
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Attacks by armed Palestinian groups concern a very high proportion of civilians, particularly including old people, young people and children. Women are not spared either.
The more modest social categories are affected most. These victims are therefore often found among the most vulnerable members of Israeli society. The first aid workers who rush to save them are not protected.
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CHAPTER II. Eyewitness accounts "Now the battlefront has shifted to the street cafés" observes an Israeli civilian.
II.1- Eyewitness account from Ellad, injured in a market
25 year-old Ellad sold vegetables at the market in passed out. When I came to again, I looked all round Netanya. Originally from Ethiopia, his parents about me, everything had been knocked over. I was brought him over when he was 7. He was the transported in an ambulance. I passed out again and I victim of an attack perpetrated on May 19, 2002 by woke up at the hospital in Netanya. My father was a Palestinian who blew himself up in the middle of screaming beside me, he thought I was dead". the crowd buying food from the stalls. The PFLP claimed responsibility for the attack. Medical report:
"I was working at the market, and everything was fine. D8 Paraplegia due to a piece of metal stuck in the Business was good. Around 15:45, I left my stall to go bone marrow; 27 nails distributed all over the and have something to eat. I didn't stop and sit down body. Underwent surgery to remove nails at a table, for I had to see someone. I came back to threatening vital functions: in the right side of the my stall. There was a potato on the ground, and I bent neck, threatening the carotid artery, in the thorax down to pick it up. I heard a loud explosion, then there threatening the lungs and in the abdomen, where a was black in front of my eyes. I fell on my back. I nail had pierced the large intestine.
X-ray of Ellad, 25 X-ray of Ellad, 25 Large number of nails inside the body Screws and shrapnel beside spine
19 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
II.2 – Eyewitness account from Paulina injured in the attack on the discotheque at the Dolphinarium
"It was June 1st, I was with two friends. We had just I saw my friend behind a car, with policemen, one of taken the first part of our baccalaureate exams, and whom we knew. I hid with them behind the car. I didn't we wanted to celebrate. There were few people when understand what was happening to me. I was sore all we got there. I said to my friends that I thought it over, I felt burnt, I had blood everywhere, but I couldn't would be boring, that it would be better to leave. My understand. My friend kept on screaming, I wanted friend insisted, and I stayed, but I wasn't happy about some silence. A group of Israelis came towards me, staying. We were queuing up to get in. We had noticed telling me everything was going to be all right. They a group of friends, boys and girls, who were at the top started to talk, I didn't understand what they were of the queue. One of them came to say hello to us and saying, and I couldn't concentrate. I wanted to find my offered to take us to the top of the queue. We didn't other friend and leave. I wanted to have a shower to feel like it, we already had our tickets and we were get rid of all the blood. I wanted to get up and leave sure we would get in. She went back to the top of the but I couldn't get up. I took my leg in my hands to get queue. She is dead. up. My friend screamed even louder: "Look at your leg". I looked at it, there was a huge gaping hole in it. When the explosion rang out, I didn't understand that Somebody carried me to an ambulance. On the way, I it was a bomb. I woke up because something was saw all the bodies and the people injured. When we burning my arm. I was covered in blood. Everything was arrived at the hospital, I saw a doctor who looked as if burnt all around me. The smell was terrible. Everybody it was all too much for him. There were dozens of was screaming. I saw my friend running away, and I stretchers arriving and somebody was saying: "seriously wanted to do the same, but I couldn't get up. I cried injured", "moderately injured", "slightly injured"; that's out. Somebody pulled me out by my hair. Then I got up when it dawned on me that there had been an and I started to run. There were a lot of cars. explosion. For an emergency examination, I went from one room to another, and the television screens were on, displaying the names of the dead. I saw my friend's name on the screen."
ATTACK AT THE DOLPHINARIUM - TEL AVIV
Date: June 1st, 2001 Town: Tel-Aviv Place: sea front, open air discotheque, entrance queue Type of attack: "democide" attack Characteristics: Friday night, heavy traffic on the sea front Number of deaths: 21 (17 dead at the scene of the attack) Number of injured: 120 (Foreign Affairs Ministry sources) of which 86 treated and evacuated by Magen David Adom Responsibility claimed by: Ezzedine el Qassam Brigades (armed branch of Hamas)
st Figure 3 : Distribution of victims, Dolphinarium attack, Tel Aviv, Israel, june 1 , 2001
Died at the scene
17%
Moderately injured 52% Severely injured
31
20 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
II.3 - Eyewitness account from Itzak, injured in the attack at the cafeteria of the Hebrew University of Jerusalem
Itzhak is a 57-year-old worker. On July 31, 2002, I didn't feel anything, no pain. I just looked for the way he was having lunch at the "Frank Sinatra" cafeteria out. I managed to get out and I sat down on a low wall of the Hebrew University of Jerusalem. A and I saw people running. I lost consciousness; it took parcel bomb had been placed there. perhaps 2 to 3 minutes. I woke up again, help was arriving. I wanted to call my wife, but I had lost my mobile phone. That's when I noticed that the skin had "I work in the building trade; on July 31st, I was on a been taken off my arm; but I didn't think they would building site at the Hebrew University of Jerusalem. carry me away in an ambulance." When the lunch break came round, I went to eat at the cafeteria. After my meal, I got up to say hello to a friend and help her to carry her tray and at that moment the explosion happened. It was so close I thought it came out of my plate. I fell on the ground. I thought there was an electrical problem.
ATTACK AT THE HEBREW UNIVERSITY OF JERUSALEM
Date: July 31, 2002 Town: Jerusalem Place: Frank Sinatra Cafeteria Type of attack: Bomb (parcel bomb) Characteristics: lunch time Number of dead: 9 (of which 7 at the scene of the attack) Number of injured: 85 (source: MAE), of which 78 treated and evacuated by Magen David Adom
Figure 4 : Distribution of victims, Mont Scopus University, Jerusalem, July 31, 2002
Died at the scene 8%
Severely injured 25%
Moderately injured 67%
21 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
II.4 – Eyewitness account of Schimon, bus driver and survivor of an attack
Buses have been the objects of attacks on a large number of occasions. It should be emphasised that the injuries caused in a closed space are much more severe. The effect of the blast is amplified.
encouraged to do so. There are beads of sweat on his Shimon, 56, has been a bus driver with the Egged brow). company for 35 years. He lives in Tel-Aviv. On March 20, 2002, the bus The policeman thought it was the terrorist, but it wasn't he was driving on line 823 between Tel-Aviv and him, it was a passenger who got on at Tel-Aviv. He had Nazareth, was the object of an attack at the long curly hair. The terrorist had very short hair. Of the Musmus crossroads (Wadi Ara). A passenger, 6 people who got on at the last stop, the terrorist was member of a Palestinian armed group, blew himself the only one to have the exact price of the fare. He up in the midst of the other passengers. pushed one of the old people who were waiting for change, and so she wasn't able to pick it up. When I I left Tel-Aviv at 5.30 am. With this bus, I stopped at went towards this head, I saw it was covered in blood. all the stations. At Wadi Ara, an Arab village, I stopped. It wasn't easy to recognise, but I remembered him, he 6 Arab passengers got on: 3 school children, 2 adults had long hair, it wasn't the terrorist. around 65 and another a bit younger. The youngest one was the terrorist. I set off again and after the When I went back to the bus, the policeman asked me second set of traffic lights, the man-bomb exploded. to switch the ignition off. When I got back into the bus, I saw the woman who was dead next to my seat. There I heard screaming, then after that I didn't hear were also three soldiers sitting down, but they were anything. Everything had exploded, the ceiling, the dead. An Ethiopian, three rows behind me, was also windows. Some of the victims had been thrown through dead. That was a real shock. The ambulance came and the windows. Everyone was hurt. There were 7 dead got me and took me to the hospital. They examined and 32 injured. The people who could get up went out me and kept me in for 4 days. For three whole weeks I through the front door and the windows. The back door couldn't hear a thing. was blocked. The dashboard had fallen on top of me and it took me a long time to free myself, and then I I have a lot of trouble sleeping. I sleep two hours a got out too. As I got up, I kicked a lady who was lying night. I just lie and watch television till 1:30 am. In the on the floor. She was dead. She had been sitting three evening I suffer from vertigo, and also sometimes seats behind me. There was smoke everywhere. Two of during the night. I fall asleep and I wake up with a the seats had caught fire. start. It's been 5 months already, and I'm still taking pills to sleep and to calm me down. The reason I don't Water was brought in to put out the fire. The sleep is because the images keep coming to me over ambulances arrived and evacuated the people who and over again, reminding me what I saw in the bus were outside, because all the people still inside were and outside it. At night, I sweat and grit my teeth, I already dead. never used to do that before. I'm not getting any better. My neck is sore, I can hear better but the dizziness The most disturbing thing I remember is that a gets worse every now and then. I have to live with it, policeman came towards me and asked me to identify I'm trying to make it through this difficult time. I see a someone, or something, that was lying at the side of psychologist, a physiotherapist and an ear nose throat the road. A head and legs (the driver pauses here for a specialist. This is the hell I'm living though at the long time and only starts talking again when moment.
22 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
ATTACK At MERONCROSSROADS
Date: August 4, 2002 Place: Meron Crossroads (northern Israel) Type of target: Bus (Egged company) Type of attack: "democide" attack Characteristics: Jewish pilgrimage Number of dead: 9, including 3 soldiers (all dead at the scene of the attack) Number of injured: 56 (sources: Israeli army medical body), of which 48 treated and evacuated by Magen David Adom Responsibility claimed by: Ezzedine el Qassam Brigades (armed branch of Hamas)
Figure 5 : Distribution of victims, Meron attack, Aug 4, 2002, Israel
Died at the scene 16%
Severely injured 19% Moderately injured 65%
The injured were evacuated to the hospitals of others exhibited the usual type of injuries for this Safed and Tibériade. kind of bomb (injuries to the lungs, abdomen, 47% of the people taken to the emergency service cerebrum, heart, vascular system, open and closed of these two hospitals were suffering solely from fractures to limbs, spinal injuries, facial injuries, signs of acute stress (no physical injuries). The particularly to eyes).
23 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
II.5. Eyewitness account from Shmuel, victim of an attack in a yeshiva
Civilians are still civilians, even in the Occupied territories, and these attacks are not the only acts of violence perpetrated on the civilians. Other types of violence are perpetrated by the armed Palestinian groups. For example, there are operations where a Palestinian sacrifices himself by attacking Israelis in a place that is quite well guarded, where he has little chance of surviving once the advantage of surprise is lost.
Shmuel lives in the Moshav Beith Gamliel ambulance. There were 5 dead and 30 injured. I was (agricultural co-operative) situated between taken out of the Occupied territories in an armour- Réhovot and Yabné. plated ambulance then an ambulance took me to the Sorroca de Beer hospital at Shéva. "I was studying Judaism at Atzmona in a preparatory school for a year, while I was waiting to join the army. I was burnt by shrapnel and a bullet broke my We were sitting in class before Pessah (Easter thighbone and now I have a metal pin in my left leg. celebrations). It was 23:30. I heard an explosion, Shrapnel also pierced my lung,1.8 litres flowed into my which is quite normal, then we heard firing close by. right lung and I almost died from this injury. My body That's when we understood that a terrorist had slipped was pierced by more than 15 pieces of shrapnel, one into the settlement. They switched the lights out, some of which cut my spinal cord at the level of the 7th people lay on the ground, others went outside. vertebra. When I woke up, I had already undergone surgery on my lungs and my legs, but I didn't know I I rushed to the window, and saw him 5 meters away was paralysed. I was in pain, I was being given from me. He started to shoot and threw four grenades morphine and it was only after 4 days that the doctors in through the window. One of them exploded 40 realised that I could not move my legs. I was paralysed. centimetres from me and a few seconds later I passed out. When I woke up at the hospital, friends told me Now every morning it takes me over an hour and a that by chance the terrorist did not manage to come in half just to have a shower, brush my teeth and get through the door because the watchman arrived in a dressed. I have physiotherapy every day. To begin with, Jeep and the terrorist fired at him. There were 30 of us I couldn't move my fractured right arm. I have shrapnel students in one room and 60 in the other. The terrorist all over my body and it regularly works its way up to fired for 10 minutes, he "went to town" for 10 minutes, the surface of the skin. For a month now, I've been then a man killed him. spending every Shabbat at home." Shmuel told us he doesn't want to talk about all I was seriously injured, the doctor thought I would only that any more to the psychologist he met when he live for about a minute. He hesitated to evacuate me. It arrived at the hospital. is very complicated evacuating someone from the Occupied territories, you need an armour-plated
ATTACK IN THE SETTLEMENT OF ATZMONA, GAZA STRIP
Date of the event : March 7, 2002 Place of the event : Atzmona, Gush Katif in the Gaza strip. Type of attack : Shooting and grenade throwing by a Palestinian civilian. Responsibility claimed by: Ezzedine el Qassam Brigades (armed branch of Hamas) Number of injured : 23 injured, of which 14 slight, 6 moderate, 3 serious, (source Maguen David Adom)
From September 29, 2000 to August 10, 2002, 65% (see map on the location of attacks, I.1.b – Table of the civilians who died were killed inside Israel 2).
24 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
According to the association B'Tsélem, 61% of Israeli civilians killed by Palestinians were inside The Adora settlement was attacked on April 27, Israel. 2002, when a Palestinian assailant entered a house and killed Danielle Shefi, 5 years old, who was In the Occupied territories, a large number of hiding under her bed. Her brothers Uriel, 4, and people living inside the Israeli settlements are Eliad, 2, and their mother were injured. This action armed. Several military bases are located inside left 4 dead and 7 injured. The PFLP and the these settlements, especially in Gaza. They are Ezzedine el Qassam Brigades, the armed branch of clearly identifiable, there can be no confusion. The Hamas, claimed responsibility. inhabitants of these settlements are civilians and therefore cannot be taken as targets.
Yossi Ishram and Kobi Mandel, both under 14, Acts of violence deliberately intended to were found dead on May 5, 2001. They went out terrorise civilians for a walk close to the Goush Etzion settlement The attacks are often perpetrated during festivities where they lived. Their bodies were found, and such as the celebration of bar mitzvah, the Easter their skulls had been crushed with rocks, in such a Seder ceremony or in leisure areas such as way that their families could not recognise them. discotheques, cafés and restaurants. Dental impressions were required to identify them.
ATTACK ON THE PARK HOTEL
Date : March 7, 2002 Town : Netanya Place : Hotel dining room Type of attack : "democide" attack Characteristics : Eve of Jewish Easter, group of elderly people getting together on their own for this celebration Number of dead : 29, of which 18 died at the scene of the attack Number of injured: 144 (sources: Israeli army medical core) of which 101 treated and evacuated by Magen David Adom Responsibility claimed by : Islamic Jihad and Ezzedine el Qassam Brigades (armed branch of Hamas)
Figure 6 : Distribution of injured and dead, Park Hotel attack, Netanya, Israel, March 27, 2002 ((sources Magen David Adom)
Died at the scene 15%
Severely injured 18%
Moderately injured 67%
The injured were taken to three hospitals, one in 51% of the people who came to the emergency Netanya (Lianado hospital) and two other nearby service at these three hospitals showed signs of hospitals. acute stress only (no physical injuries). The others were suffering from various degrees of injuries
25 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 normally observed in this type of bomb attack which has claimed responsibility for several actions (injuries to the lungs, abdomen and cerebrum, of this type, is very clear on the objectives of these cardiac and vascular injuries, open fractures of attacks. "These operations affect Israel at its weakest limbs, spinal injuries, facial injuries especially to the points. This causes more losses than any other kind of eyes) operation. It will destroy their social life. They are afraid and nervous, and it will force them to leave the country, In an interview by the Guardian, on June 12, 2002, because they are afraid". a member of the Islamic Jihad, an armed group
The repeated attacks by armed Palestinian groups in public places not situated in the proximity of military targets leave no doubt as to the deliberate intention to target Israeli civilians and to harm as many of them as possible.
However, according to International customary law5, the Parties to the conflict are prohibited from attacking civilians. The armed Palestinian groups, who claimed responsibility for these actions, explicitly target civilians as the objects of their attacks, in defiance of International Humanitarian Law. And yet it is this same law that the Palestinian leaders quote when they protest against the acts of violence perpetrated by the Israeli army6.
There can be no justification, either political such as "struggling against occupation" or military such as declaring "we have no tanks or aircraft to fight the Israelis with", for violence against civilians, even in the Occupied territories.
There can be no doubt about the fact that these very frequent attacks, perpetrated by people carrying bombs who blow themselves up in public places, are deliberately intended to spread terror among the Israeli population.
The Geneva Conventions explicitly prohibit "Acts or threats of violence the primary purpose of which is to spread terror among the civilian population".
5 Article 51 of Protocol 1 6 Published in the Palistinian daily newspaper Al qods
26 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Chapter III. The weapons used against civilians
III.1 – A variety of wounding agents
The methods used to attack Israeli civilians are The data given in the following table, from an extremely varied: stones, knives, lynching, bullets, Israeli military source, only concerns the number cars and explosives. Among the firearms used, we of people killed between September 29, 2000 and find all sorts of pistols and rifles including August 12, 2002. Kalachnikov AK47 assault rifles and M16 rifles.
Table 5 – Weapons and causes of death
Wounding agent that caused death Security forces Civilians Total Stones 0 2 2 Knife 0 5 5 Lynching 2 13 15 Car 7 1 8 Bullets 102 148 250 Explosion 68 257 325 Other 3 0 3 TOTAL 182 426 608
II.2 – Explosives are the weapons used most often
The armed Palestinian groups use different Explosive attacks in general or attempted attacks techniques. The explosives are sometimes placed have increased: 609 blasts in 2001 and 465 in the on the ground, disguised in objects (bags, first 6 months of 2002 (up to July 18). flowerpots, watermelons, etc.), installed in booby- trapped cars. More and more often they are worn All of the attacks with firearms or grenades have on a belt, against a person's body, or hidden in a increased considerably: from 1990 to 2000, the car driven by someone who knows they are going police counted 35 acts or attempts. There were to die in an explosion, in the middle of a crowd of 119 for the first 4 months alone in 2002. civilians.
27 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
III.3 - The "democide" attacks responsible for the most deadly attacks
The distribution of the number of deaths caused by these explosions is shown in the table below:
Table 6 – Number of victims depending on the type of bomb
Type of explosive Security forces Civilians Total device that caused death Explosive charge on ground 28 22 50
"democide" attacks 23 227 250
Booby trapped car 16 8 24
Mortar 1 0 1
Total 68 257 325
Figure 7 : Types of weapons used to kill civilians in Palestinian attacks between September 19, 2000 And August 12, 2002
Other 5%
Bullets 35%
Explosions 60%
60% of the civilians are killed by explosive devices. Among these are the "democide" attacks that cause the most deaths.
28 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
III.4 - Bombs with "special" contents
These bombs, in addition to the explosive charge, Recently, different chemical products have been contain screws, nails, bolts, ball bearings and other found on the injured people or on the scene of the metallic materials. This phenomenon is not new. attack but none of the injured has been poisoned. What is new, though, is the increased quantity of These products are rat poisons (fewer than 10 explosive that causes more damage. cases) and organophosphoric pesticides in the most recent attacks. Rat poison can cause bleeding In the 1990s, some bombs also contained glue, (impaired blood clotting) later on, and the which, in addition to the burns caused by the pesticides could cause neurological symptoms explosion, adds deep chemical burns. some time after the attack.
Photo 1: x-ray of the chest of a 19-year old man, injured in a "democide" attack: presence of nails and another metal item (full arrows) in the cardiac area; presence of other metallic items at some distance from the cardiac area (dotted arrows). One of the nails was located in the muscles, under the skin, another was found in the cardiac muscle itself and has also pierced the diaphragm and the adjacent liver.
Photo 2: nails and metal materials removed by the surgical team
Photos 1 and 2 on loan from Dr Michael Stein, Surgeon, Trauma centre, Bellisson Hospital, Tel-Aviv
29 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Photo 3: Injuries to a lower limb by the Photo 4: bolts removed during surgery projection of bolts for a fracture of the thighbone.
photos 3 and 4 loaned by Dr Sharon Einav anaesthetics and intensive care service, Hadassa Hospital, Jerusalem
Dror, 31, Israel. He introduced me to an Italian student. I wanted The day before our interview, Dror left the to show him the university campus, the open-air intensive care service where he spent 11 days. His theatre and to take shelter from the heat, we decided parents came over from France the day after the to go to the Frank Sinatra cafeteria. We just said 'bon attack. The interview took place with his parents appétit' and there was an explosion. I was injured on present at his bedside. the arm and the leg, I couldn't see my foot. I said to myself this isn't true, it's not possible, this just doesn't happen to me, here. I saw David fall off his chair and I "I've been living in Israel for 6 years. I study and teach thought he had fainted. Very quickly, they evacuated Political Science at the Hebrew University of Jerusalem. me from the cafeteria and they reassured me, saying The day it happened, I had arranged to meet a French "you're alright, you're alright'. I could hardly breathe, student, David Gritz, who was starting a year's study in there were a lot of people around me".
These mass, indiscriminate attacks, deliberately targeted at the civilian population, with the addition of wounding agents such as nails and bolts, in order to cause increased suffering can be qualified as "inhumane acts7". The same objectives are sought by multiplying the attacks against civilians. These types of violence are deliberately intended to cause grave suffering or grave threats to the physical and mental integrity of the victims and represent breaches of International Humanitarian Law8.
7 ICRC press release, may 05, 2002 : The ICRC condemn bombing attacks against civilian population 8 see article 3 common to Geneva Conventions
30 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Chapter IV. The medical consequences of attacks on the civilian population
IV.1 - Injuries caused by bombs
21% of the victims present serious injuries (source: MDA Palestinian attacks from September 29, 2000 to August 1st, 2002).
These are second and third degree burns, deep organic wounds caused by nails and small metal objects, but also paraplegia or temporary motor handicaps or again sensory handicaps such as partial or total deafness or blindness.
Injuries inflicted by firearms or knives do not pose any particular problems from a medical point of view. In the case of mass shootings, however, a certain amount of organisation is necessary since many injured arrive at the hospital at the same time. But the protocols for clinical and complementary examinations as well as the admittance into therapy care are codified. Bullet entry wounds, sometimes even exit wounds, can easily be recognised. The damage caused by the trajectory of projectiles is known to doctors. In this respect, the experience acquired by military medicine is very useful.
The situation is totally different, however, for victims of explosions, who often suffer from multiple trauma. There may be a combination of several different effects that render the situations more dangerous: blast, blast wave, projection of debris and thermal effect.
According to the Gertner Institute for Epidemiology and health Policy Research (Tel Hashomer, Israel), 10% of the injured have a combination of injuries to the limbs and blows to the head or neck, or injuries to limbs and chest. On arrival at the hospital, 16% have a very high trauma severity score (Injury Severity Score (ISS) between 25 and 75), which is a sign that they will die quickly if nothing is done. The mortality rate at the hospital is 5%, a rate that medical specialists consider high.
gaseous organs may be affected, for instance, the IV.1.a - The blast brain, the liver, the spleen, etc.). The power of the blast to cause injury depends on the characteristics of the explosive, which vary Torn off limbs are the injuries most specific of the according to the type and the quantity used. The blast but these injuries are practically never seen environment in which the blast is propagated on survivors. On the other hand, they are very confers on it a greater or lesser injuring power. frequent on the dead, and affect the people close This is greater in an enclosed space such as a bus to the explosion. Torn off limbs are so with the windows closed, or a restaurant dining synonymous with death that when the emergency room. Other elements are involved, such as the teams arrive, someone with this kind of injury is distance between the people and the explosive, considered dead. Injuries to the lungs and digestive body mass (a person with a high body mass will system may only appear afterwards, up to 24 hours resist the blast more). This explains why later, for example, which does not simplify sometimes, even at very close distances, some treatment. Fortunately, doctors are well aware of victims may die and others survive. this today.
The blast essentially damages organs containing air. Blast injuries, although serious, do not pose any The ear is the most sensitive organ, particularly the particular diagnostic problems to the care workers, ear drums, more rarely the ear bones. The lung is for they are frequently encountered in war the critical organ. Lung damage is in fact the main surgery. cause of death after an explosion. The other organs containing air that are affected are the IV.1.b - "The blast wave" larynx, the trachea and the digestive tract (non This is the movement of a very large mass of air immediately following the blast. The initial speed in the proximity of the explosion is very high, in the order of several hundred kilometres per hour – in
31 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 other words, faster than a tornado or a cyclone. is made much more complicated by the inclusion of This blast wave projects the people and objects nails, screws, bolts or other metallic materials exposed to it onto hard surfaces that sometimes cause injury. Over distance, this blast wave falls "A man with 'slight' wounds arrived at the emergency very quickly. A person behind a wall will be service, and walked around, on his own, not protected from it, without, however, being complaining. When he was examined, they found that sheltered from the blast. The body being moved in his stomach had been perforated by a nail". this way can cause different types of injuries, deep (Eyewitness account of Dr Stein, Surgeon, Hospital or superficial wounds, particularly open fractures Bellinson, Tel Aviv) to limbs. These items behave relatively differently from the The generation of debris projected by this shrapnel of bombs that war surgeons are familiar phenomenon can be varied: with. Nails create a very small entry wound, sometimes only a millimetre and most of the time Broken material such as bits of glass or small there are a number of them. It is impossible in this metal objects. case to say from the outside what the deep down damage is. These are the wounds that pose the Pieces of clothing: buttons or cloth. most difficult diagnostic problems.
Human debris not belonging to the injured "The patient had what looked like several superficial such as bone or blood. The risks here are the skin injuries. He could walk, his behaviour was transmission of a virus such as the HIV-AIDS, practically what you would expect after an attack. X- hepatitis B, or hepatitis C. There is a rays of the skull, performed systematically, showed a documented case where the perpetrator of nail in the frontal region. The patient was re-examined the democide attack had hepatitis B. All the and a tiny entry wound was found at the back of the injured receive, in emergency, the first neck (occipital region). The nail had passed through the injection of a vaccine against hepatitis B, their entire brain". The nail was left in place and the blood and the blood of the attacker(s) are patient is alright. tested for these viruses. (account from Dr Einav, anaesthetics and intensive care service, Hadassa Ein Kérem Hospital) But the real difficulty resides in the contents of the bomb and/or its container. The job of the care staff
X-ray of the cranium: no visible fracture, presence of a nail in the frontal region (circle)
32 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Cerebral scan: Path of the nail, entered in Left occipital, stopped in Front right
IV.1.c - The thermal effect
Because of this, all the patients are at least given an When an explosion takes place, heat is released. x-ray of the front and profile of the head and the This thermal effect is limited in time and depends spinal column, chest and abdomen. Scanners are on the nature of the explosive and on the eventual still the best kind of examination, in the hospitals presence of flammable products that have been that have them. A full scan is excellent for the added. The type of burns observed on the people purpose of diagnosis. However, not all the injured injured by explosions, at least since September can have this type of examination, which is still 2000, affect especially the uncovered parts of the very expensive. body and are relatively superficial -- first or second degree (cf. eyewitness account of Itzhak who was There is no protocol for coping with this type of wearing shorts and sandals), these are flash burns situation and the factor that counts most in the as seen when explosives are detonated without acceptance of these patients for care is the flammable products being added. They normally do experience acquired by the clinical specialists. not pose any problems and the recourse to skin grafts is rare. For years now, these types of projectiles have been known to all the care staff who take care of attack It may happen, however that the explosion creates victims. On the other hand, what has changed since a fire which causes burns from flames. These burns September 2000, is that they pierce further into are radically different from the flash burns (cf. the body, because higher explosive charges are eyewitness account of the bus driver when the being used. They therefore cause more damage. fires started). The nails and bolts that have injured vital organs are removed surgically while the injuries are being Of course, some survivors suffer from a repaired, where repair is appropriate. Nails and combination of all these effects with the possible bolts that pose a threat because they are situated medical consequences described (see also the close to a vessel, or a nerve, are also removed. different eyewitness accounts). The other projectiles are left in place, sometimes at the cost of serious psychological problems for In total, these "blast victims, injured, burn victims" the victims. more often need intensive care units, and surgery. They stay in hospital for longer. Itzhak, 57 I still have a bolt there under the skin (back of chest). I Paulina, Victim at the Dolphinarium wish they would take it out but they don't want to. I "I was injured in both legs. In the right leg the hole was don't want to keep it inside me. 19 cm long. It was deep but it didn't break the bone. I have shrapnel on the sole of the right foot. I have "One woman has a piece of foreign bone in the chest, trouble walking, it hurts. I have electricity under the sole she has been looking everywhere for a surgeon to take of the foot. I have several holes in the left foot. Behind it out but nobody wants to do it" (Dr Michael Stein). the knee I have a big one too and further down, as if bullets had gone through me. I got burnt, too. On the sole of my right foot there is a bolt that wasn't removed and that annoys me. My back was also burnt and hit by shrapnel. Since then I hear noises in my ears, it stops me from concentrating and gives me a headache. My muscles ache and it feels as if I can no longer walk in Israel. I've had 4 operations, and I'll have another one in November. I was hoping they could do something for the shrapnel, but they can't do anything. I was also hoping they would do something for the scar
33 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 on my foot. I went back to school but it was painful, I Dror, 31 had trouble sitting the exams" "An ambulance took me to the nearest hospital. After "I speak slowly, I do everything slowly, I don't feel as if I examinations I had an operation on my leg and my have any strength for anything. All this since the attack. œsophagus and they put drain in my lung. What Even the way I think is slower. I forget things, and I happened next is rather vague. David is dead; he was sometimes get confused. Before I was always under 6 feet away from me. Yesterday I got out of intensive pressure for time. Now, it's as if it doesn't matter care. This stay in intensive care was a bad experience. anymore, I am always either late or early". Opposite me there was another victim who moaned all Paulina did sit for her baccalaureate and she the time. He was suffering from burns. passed. She now wants to study to be a It is still difficult for me to stand up. I have trouble psychologist in the United States. seeing the consequences this will have on my life. I feel as if I'm waking up from a nightmare. I have tinnitis in Medical report : the left ear, which makes me anxious. There is still a lot of work to be done. besides the various scars on the skin, injury to the posterior right tibial nerve (partial chronic injury, Medical report: no motor deficit). The handicap has been set at 84% until 31/10/02. It will subsequently be Left pneumothorax (pleura punctured by a bolt) reviewed. which has been drained. Injury to left lung (related to the passing of the same bolt). Tear of the œsophagus (related to the same bolt), surgically repaired. Partial non-severe injury of the left brachial plexus (passing of the same bolt) causing a reduction in sensitivity in territory C8 left. Fragmented compound fracture of the right tibia and fibula (surgically repaired).
X-ray of Dror right leg : multiple fragmented open fracture of fibula tibia. The metallic material visible is surgical equipment (plates, screws and staples)
X-ray of Dror chest: presence of a metallic object in the mediastinum
ITZHAK, 57
34 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
I had second degree burns over 25% of my body. I took the blast from behind and my right leg is in a mess (deep burn). It was very painful when they put the drain in my lung. …The skin came off my hands. I didn't want to go into After the morphine injection I wasn't in pain anymore the ambulance, I thought I could just go home. Then I and I started to crack jokes with the people around me. had trouble breathing, I couldn't breathe anymore. 3 My first name means "he will laugh". strong men carried me in the chair to the ambulance. It was far away, at least 200 yards; I was taken to the Medical report hospital and there were 10 or 15 people around my Fractured ribs, pneumothorax and lung injury bed all doing their job, sticking tubes everywhere, from bolts asking me my name, my identity numbers, my home Second degree burns on 25% of body surface telephone number and who to call.
X-ray of the chest: presence of a metal object (bolt still under the skin) Injury to left lung
IV.2 – The consequences of the attacks on the mental health of the civilians
IV.2.a - Post Traumatic Stress Disorder9 Paulina,19 (PTSD) Psychiatric Certificate written at Irilov hospital. Paulina is in observation at the Irilov hospital in Tel When an individual is exposed to a traumatic Aviv. event, it provokes an intense fear, the effect of She is having therapy with a psychologist. which is the development of psychological symptoms that incapacitate daily life. This trouble "Everything annoys her, gets on her nerves. Poor expresses itself by the persistent re-living of the results at school. Doesn't do her homework and falls traumatic event, with obsessive memories asleep during the classes. Wants to become a (thoughts, images), repetitive nightmares psychologist. Does not sleep at night, has nightmares, (repetition syndrome), phobic behaviour, a dulling dreams about what has happened. Two friends who of general responsiveness and a state of died there, were lying close to her, and she sees them neurovegetative hyperactivity. all the time. She has no energy for anything, wants to sleep all the time. She doesn't do anything with her friends. She is afraid she will get blown up in a bomb attack. Never goes out the house except to go to her therapist or to school. Everything reminds her of the wound that hurts her. She is angry. She feels she wasn't protected enough.
Nothing matters. Has a constant headache. Slight improvement in the afternoon. It's the morning and the evening that's the hardest. Doesn't eat meat any more,
9 has lost weight. Walks with slow steps but doesn't limp. according to the WHO's classification of mental troubles
35 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Doesn't talk spontaneously, short words, elocution not Injuries, particularly those caused by the explosion clear, voice weak sometimes totally inaudible. The of bombs, have considerable psychological mood is slow, tinged with sadness and confusion; thinks repercussions: burns affect the skin, which, as the slowly. Mental exhaustion that is expressed in every French psychoanalyst Didier Anzieu has suggested field, indifference, withdrawal and stays shut up at ("I am my skin"), is the organ of perception whose home. Insomnia transforms the nights into days. She is surface constitutes the border between the body sleepy during the day. No suicidal thoughts and hopes and the outside world. one day to become a psychologist. Foreign bodies penetrating the body of the victim Diagnostic: mental exhaustion with signs of depressive cause massive anxiety. syndrome."
Degrees of recognised handicap: - 20/08/2001 to 31/12/2001 -- 100% Itzhak, 57, - 01/01/2002 to 31/10/2002 -- 84% It frightens me to feel the object (pointing to his chest with his hand). I don't want to live with that inside my body. I don't want to set off the metal detector at the airport!" Dror Sullape, 31 The day before our interview, Dror left the Itzhak is sitting on a hospital chair, having difficulty intensive care service where he spent 11 days. His breathing. The violence of the explosion was such parents came over from France the day after the that his body image and spatio-temporal attack. The interview took place with his parents orientation systems were completely present at his bedside (…). A committed left-wing overwhelmed: no feelings of pain; slightly confused thinker, he thought that the Hebrew university, state; in denial of the reality of the explosion; "I which was a melting pot of cultures and different thought there was an electrical problem"; denies the people, constituted a sort of protection against seriousness of his condition "but I didn't think they terrorist attacks (high proportion of Arab would take me away in the ambulance". students). His surprise was all the greater: "this isn't true, it's not possible, this just doesn't happen to me, It is in the aftermath that the physical pain appears, here". Despite the precautions taken to protect his when Itzhak realises that he has been the victim of safety "this" happens to him, and in this place of an attack. The psychological shock is deep, open dialogue and of culture. He cannot believe it. proportionally related to the element of surprise of the explosion. It was at his place of work that Dror is in a state of shock when we meet him. He the attack took place and the hypothesis that shows no emotion for anything that concerns him comes to mind to explain the explosion is directly and he reacts very strongly to the emotions felt by related to the job he was doing. his father. He seems to be obsessed and strongly affected by the death of a young French student, There may be underlying feelings of guilt, at the David Gritz, whom he had met a few days time of the explosion he feels partly responsible previously and whom he liked very much. for it. At the time, the idea that it is a bomb attack does not enter his mind. The penetrative violence On a psychological level, it is impossible to predict is psychological, it is a source of psycho-trauma; what the long-term effects will be. Dror must but it is also, in Itzhak's case, physical. Shrapnel has psychologically assimilate several wounds, he must penetrated his body, a piece of metal entered grieve for his friend David who "fainted" before his through his back and got stuck in his chest, making eyes. Lucid, he does not know what his life will be it difficult for him to breathe. Every breath he takes like after this “democide” attack. reminds him of the event and Itzhak is afraid of this piece of metal stuck in his body.
36 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
IV.2.b - The phenomenon of serial post- traumatic stress disorder is visible and When we arrived in Israel, my daughter was nine. As frequent soon as we arrived, I started teaching in a secondary school, I settled in quickly. In April 6, 1994, one year PTSD also affects people who have not been after we arrived, a man blew himself up near me, in a injured, even people who were not present at the bus at Afula. It was the first attack in the series, at that time we were close to peace. Eight people were killed. scene of the attack. It can also affect those who are nd related to the victim in some way (close family, For two years I envied the ones who got killed. I had 2 friends, neighbours), those who are normally degree burns on 75% of my body and had suffered present in the place of the attack, children who go intoxication from the smoke. For a month and half I to the same school as the victims. Also at risk from had a general anaesthetic every day to change my this syndrome are the emergency teams, bandages. I had 12 operations and was in hospital for journalists, policemen and all the people who find eleven months. When I got out, I didn't recognise themselves projected, through their profession or myself. I hadn't been able to act like a mother for two social mission, onto the scene of the attack. years. I had become ugly.
Serial post traulmatic stress disorder carries along 8 years have gone by since then. I am alive, I am here, a group of individuals after each attack. It is difficult I'm talking to you, I am a volunteer at Selah; this to quantify the consequences, for the effect of the organisation, beyond all the statistics, represents the repetition of the attacks greatly increases the human face of Israel. I was adopted by this family who number of victims affected directly and indirectly. give me support to overcome this trial: people who Israel has a population of 6 million, so, given the came to see me at the hospital, who took care of my number of victims since September 2000 daughter, a girl with neither father nor mother in a (approximately 5,000 victims, dead and injured) foreign country. All these years, through volunteer work, which is a little under 1% of the total population, I have found a lifeline. I was in the emergency team for the probability for each inhabitant of Israeli of the attacks on the Dolphinarium and the Park hotel in knowing directly a victim is high. To compare with Netanya in April. At the Dolphinarium, the majority of the population of France (population 60 million), an the people killed and injured were immigrants. attack such as the one at the Dolphinarium (21 Life will never be the way we once imagined it could be. dead and 120 injured) would have had ten times the number of victims, that is to say 210 dead and I would like to thank you because this is the first time 1,200 injured. anyone has come to us to try to evaluate the consequences of the attacks". So a situation that is completely unknown up till now is produced by the repeated attacks in a space Medical observation (only the external of time. All the local specialists agree that they do appearance that is immediately apparent is noted not know what the long term consequences on the here). No major impediments to walking. Israeli population will be. Dr Zeev Wiener suggests Retractile scar tissue from burns on the forearm, that the entire community has reactions, contracture of the last fingers of the hands. Same malfunctions, many troubles that are not type of injuries on the face, especially the chin. catalogued as pathological, but which could well become so.
Nor do we understand the psychological The repetition of "democide" attacks will have consequences of being injured by a piece of a medium and long term effects which we cannot foreign body, which may well belong to the predict for the moment. Up until now, it was very perpetrator of the attack. One woman is currently exceptional that an individual find themselves in a living with a piece of foreign bone in the chest situation where they could be traumatised by the (quoted by Dr Stein). same event, several times in a row, in the course of their lives and in a relatively short space of time Ana, 47 , has been living in Israel for 9 years. She (less than two years). Let's take the case of Arkadi used to live in Odessa (Ukraine). Weiselman who survived the attack at the Park "Last week my daughter called me on the phone Hotel March 27, 2002 and was killed in the attack around 8 am to tell me she was alright. It was the day at the open air market in Netanya on May 19, of the bus attack in the north, at the Merron 2002. crossroads, on August 4, 2002. I listened to the radio, and then I had to take a tranquilliser. Then I called my Several cases were reported to us of people who daughter back, she was in a bus. My daughter and I are victims of several attacks. What are the spoke, but neither one of us mentioned the attack. psychopathological effects of these serial "democide" attacks on a person who is in the
37 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 wrong place at the wrong time? If this happens But what about someone who escapes with their once, the person probably develops what is known life twice or even three times? in the psychiatric literature as "survivor syndrome".
IV.3. - The "people involved" are also victims of psychological trauma
In the terminology of emergency psychiatry, the "people involved" in an attack are close family, friends, teachers, classmates, neighbours, work colleagues and acquaintances, all marked or traumatised by the impact of the attack even though they were not actually present at the time of the event.
In this way the blast of an attack propagates in increasingly wide concentric circles, which affect an ever increasing population due to the multiplication and repetition of the attacks.
Dr Elie Picard, father of Eran Picard, 18, living in Jerusalem West. Paediatrician, pneumonologist and resuscitator at Shaare Tzedek hospital in Jerusalem. His son Eran was killed on March 7, 2002 in Atzmona, Gush Katif in the Gaza strip, during a Palestinian attack.
"I have four children, my second son, Eran, was killed by someone sent by Salah Chéhadé (chief of the Ezzedine el Qassam Brigades, armed branch of Hamas, shot down on July 22, 2002 by the Tsahal), while he was studying in a yeshiva. Five children were killed, including my son and his friend Ariel Zana, aged 19. One of my son's friends, Shmuel (cf. eyewitness account III.4) was paralysed, and is in a wheelchair. I was on duty the day my son was assassinated. For the past 5 months, I have been a different man. I still go to work, but when I get home in the evening, I see my wife in despair. She is a gynaecologist. Eran was to join the army on July 21, 2002. My second son was happy to be alive, he was the soul of the house. He was cultured, we come from a family that is well-known in the Jewish community in France. My parents founded the Yavné school and the Lucien de Hirsch school, we were educated in a spirit of tolerance and respect for others. Moral values that I transmitted to my children. My family has now lost a vital member and we somehow have to carry on living. My eldest son has lost his brother who was his best friend. The whole family is shocked"
After an attack, there is a high degree of IV.3.a - The impact on the other absenteeism, many children stay at home, kept in segments of Israeli society by their parents who fear for their lives. School heads are obliged to remind parents that school is School children and the attacks compulsory from 5 to 16. The attacks by armed Palestinian groups lead to the manifestation of post traumatic syndrome on The meeting with Mosché Alone of the municipal schoolchildren, especially if one of their council of Tel-Aviv explains that to cope with schoolmates is affected or concerned or if the acts particular events such as attacks, precise of violence occur in their proximity or even quite procedures have been implemented and each simply by seeing the pictures on television. person, according to their function, knows the role they play in the global care mechanism that The immediate reactions are loss of concentration, concerns 100 schools and 40,000 pupils. If a the incapacity to act in daily life, the phobia of serious event occurs, the psychologists and buses or public places, isolation at home. On a psychiatrists from other towns in the country psychological level, the school plays the role of provide assistance. "container" that allows exchanges between children and teachers, in a social place, and can “The attack at the Dolphinarium claimed many victims therefore be beneficial. among the young Russian immigrants and Russian- speaking psychologists came from all over the country to help. Five of the victims who died were studying in the same school, Sheva Mofet High School in Tel-Aviv. Exceptionally, the school opened the day after the attack even though it was a Saturday, which is not a
38 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 working day in Israel, to receive the children and give The Consequences of attacks for the Egged them support to cope with the ordeal of having lost five bus company : of their schoolmates and knowing that a large number of others were injured. A memo was posted on the The number of passengers has dropped by 15 to notice board to ask the children" to write their name 20%, of the 2 million passengers who travel on and their class below the name of the person whose Egged and Dan buses each day. Just after an attack, funeral they wished to attend. Each child can only the number drops by 50%, then gradually rises attend one ceremony". again to a figure 20% lower than the usual figures. “This decision was made to protect the children from repeated exposure to the funeral of someone close to Bus drivers are given training to spot the signs that them.” enable the identification of assailants. But the exercise is very difficult. The armed Palestinian groups sometimes send people dressed as Israeli The "Egged" bus company soldiers, or very well-dressed people, even men Interview with Pinir Rosenberg, in charge of the dressed as women, as in the attack on June 2, bus company's social department 2002.
Egged is a large transport company, operating as a Shimon, 56, has been a bus driver for the Egged co-operative, with 8,000 employees and 4,000 company for 35 years. buses. It is a national symbol, for it is a private He lives in Tel-Aviv. On March 20, 2002, the bus company that fulfils a public service function. It he was driving on line 823 between Tel-Aviv and shares the largest part of the public transport Nazareth was the target of an attack at the market with the company called "Dan", which has Musmus junction (Wadi Ara). A passenger, also been the victim of several attacks, including member of an armed Palestinian group, blew the one at Immanuel in June 2002. himself up among the other passengers. The buses on line 823 had already been targeted before, on Since September 2000, buses have been the target November 29, 2001 (there were 3 dead and 9 of around 200 "acts of hostility", using firearms, injured) and on March 5th, 2002. Shimon had Molotov cocktails, grenades etc. 15 of these already been close to a previous attack, when he attacks were deadly: firearms, explosions, attacks heard shooting at the Afula bus terminal: this in the proximity of a bus or car-bomb attacks were shooting, on October 2, 2001 left 2 people dead, some of the acts of violence perpetrated against and 15 others were injured. buses of the Egged company. One hundred people have been killed, including a "It's something terrible that comes back all the time, bus driver, and 600 people have been injured, something you can't escape from. When someone including 20 bus drivers. blows themselves up in a bus, what you see is unspeakable. New security measures were taken for buses I have a friend in Tel-Aviv who is also a bus driver for circulating in the Occupied territories such as Egged. He was a few hundred yards behind me when armour plating and bullet-proof windows. my bus blew up. He saw the bus blow up. Two months Watchmen, paid by the government, guard the later, the same thing happened to him, his bus was buses and bus stations, which pushes up the price blown up, and he was injured in the leg. It was a of tickets set by the government. In June 2002, at booby-trapped car, on June 5, at Megido, there were Immanuel, two Palestinians, disguised as soldiers in 17 dead and many injured. When I heard the story, I the Israeli army, fired on the passengers after did not sleep for 48 hours. My experience came back setting off two bombs on the road. to me. And every time there is a new attack the same thing happens, it brings it all back. I'm not afraid of dying. The most painful thing for me, because I have been working on this bus line for many years, is what happened to my passengers and not to me. Some passengers I knew very well were killed. You know, I've been a driver with Egged for 35 years, lots of people know me, a lot of my passengers came to see me in hospital, some of them were Arabs. I have Arab friends. The most important thing is that we don't have to hear or experience things like this again."
Medical report: perforation of both ear drums, currently scarred
39 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
"The lifeline is unbroken". describe the appearance of the terrorist. A driver was profoundly traumatised by the vision of the There has been no specific cell set up in response head of the terrorist, presented to him by a to the situation of serial attacks that affect the policeman for identification. employees of the Egged company. No extra Many drivers were involved in the war. They say doctors, social workers or psychologists have been that they have seen bodies in buses after an taken on by the company to take care of the explosion that are "terrible", compared to what employees who have been the victims of acts of they saw in combat. A bus driver who was a victim violence. of the attack at Méguido (17 dead, 45 injured), was saved and told us that his experience as a tank Employees of the company who are the victims of driver during the Kippour war was nothing an attack during work, are taken care of financially compared to the scene of his passengers burning and psychologically. It may happen that there is a before his very eyes. member of the driver's family among the passengers. At Meron, the daughter of one of the In the company's museum at Haïfa visitors can see employees killed was in the bus that was attacked. a bus that exploded in an attack in 1978: "the blood She was given help by the company. If a driver is bus" that caused a "national trauma". injured, and this causes a handicap, such as blindness or deafness, they are given priority for a transfer to another job within the company. The rescue workers Psychological support groups are offered after each The emergency rescue workers are the first to attack. "All bus drivers could do with psychological arrive on the scene of the attack. They are the support". They keep on working and feel invested eyewitnesses of the material and physical effects of with a public service mission, identifying strongly the explosion. The vision of the destructive scene with their company. in the immediate aftermath of the attack has a When the tension becomes too much due to the disorientating effect on the psychic make-up of the recurrence of the attacks, some drivers take sick rescue workers. It is difficult to evaluate the leave to recover, but most carry on without asking frequency, the severity and the post-traumatic for a change of line. The solidarity inside the consequences in the long term. company is very strong. Bus driving is a man's job and the values of strength, friendship and cohesion Haïm is a police officer and a former military cement the company. Asking for a change of line is almoner. He is currently a Zaka volunteer team like showing personal weakness, and beyond this, leader. exposing a colleague to a danger one can no longer Haïm never announces a death to a family, for he cope with. "works on the bodies" and the emotional charge This cohesion in the company procures a sort of would overflow if he were to talk to relations of psychological security that is shared by the drivers the deceased. He himself sometimes suffers from who perform a mission they must ensure the post-traumatic symptoms. As an officer, he sets up continuity of. The motto of Egged is "the lifeline is a talk group after each mission, but orthodox Jews unbroken". are reticent about expressing their feelings; they consider themselves to be accomplishing a highly This feeling of belonging creates a sense of identity religious mission. However, Haïm is attentive to among the drivers who are victims of acts of each of his fellow team members and talks to each violence. Every time a bus is blown up, all the of them individually after a mission. drivers feel concerned and become more vigilant. He tells us the story of Yoram. Yoram is a friend The phobia that could naturally take hold among of Haïm's, and like him an officer experienced in the operators is transferred onto their families this type of mission to identify bodies and human who fear for their father or their husband and are remains. themselves afraid to take the bus. The families of bus drivers are therefore indirect victims. Some drivers have lived through more than one attack and have been repeatedly traumatised psychologically. Employees are sometimes injured outside the bus or in other vehicles that were close to the one that exploded. Due to this, they At Netanya, an attack occurred and 19 soldiers witness scenes of horror. were killed. Haïm noticed that Yoram was behaving strangely, checking the same body four times. After When an attack takes place, the bus driver is the the mission, Haïm called his friend to ask how he first person to be questioned by the police, to was and asked him amicably to tell him how his day
40 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 went from the moment he was beeped and asked to go to the scene of the attack. Yoram could not Professor Arié Shalev tells us: "we can see that there remember what he had done during a period of is a form of protection active when responsibilities are one hour. He does not remember who the first assumed and then we are amazed, given the exposure person he spoke to was. of the police, Zaka and MDA rescue teams, that there Haïm arranged a meeting with Yoram and two is not more than a 60% rate of PTSD10. A kind of other friends, and offered to note down on a "esprit de corps" protects them during their mission. board what they did that day, hour by hour. By But what about delayed reactions?" . comparing, Yoram was able to remember what he had been doing during that hour he had deleted Policeman Gil Kleiman, journalist Hadas Staif, Haïm from his memory. Nügelblatt of Zaka or even David Abadi of the A quarter of an hour before the attack, Yoram Maguen David Adom admitted to us that they do dropped his son, a soldier, off at the bus station not go straight home after an intervention at the where the explosion took place. When he arrived scene of an attack. They all need some respite at the scene, he saw a pair of red shoes sticking between their "work" and getting back home to out from under a blanket that was covering a dead their families. body. Shoes that were the same colour as the shoes his son had been wearing. This was why he In the MDA teams, the same kind of sessions are checked the same body four times. He kept all this offered systematically, 48 hours after an to himself, and did not tell anyone that he had just intervention. To begin with, everyone said they did dropped his son off at the scene of the attack. He not want to join in, thinking they were strong did his "job" as usual. "Since that day, Yoram hasn't because they had been in the army, then the teams been the same man". felt the necessity to talk to people outside their families. In the rescue teams, sick leave is very rare. Haïm was marked by another scene he lived Transfers to other services are accepted on through on a rescue mission. A soldier is placing a request. The cases listed concern nursing staff. drip on the arm of a comrade and falls over onto him killed by a second explosion that goes off a quarter of an hour after the first attack. "Every time David is a 26 year old man who lives in Tel-Aviv. I go to a rescue, I see this scene again". He was a nurse with Maguen David Adom (MDA) then medical secretary at Irilov hospital in Tel Aviv. He is currently working as a volunteer on the Haïm confesses that after the intervention, and the administrative staff of MDA. hours spent at the morgue trying to reconstitute the bodies, the only way to evacuate the tension He has twitches on his face and he trembles. He accumulated during the mission and at the morgue went to the scene of 6 or 7 attacks where the is black humour. When the Mahané Yéhuda, victims, dead and injured, were mainly adults. "It Jerusalem's popular market, was the target of an was in 1996, during Purim (the religious celebration attack, the explosion occurred opposite a where children get dressed up), I was the first to butcher's stall. Twelve packets of "meat" were sent arrive on the scene of the attack on the Dizengoff to the Abou Kabir morgue to be identified. His Center11, I was a nurse. This time, 95% of the victims team had to sort human remains from beef and were children. Children who were burnt, impossible to chicken. At 3 o'clock in the morning, they were identify. The explosive charge contained petrol. I saw hungry, and one of the volunteers went to buy children with their vital organs hanging out, with limbs some food. He came back with Chawarma (grilled missing. Due to the extreme heat of the explosion, meat sandwiches). "Not everybody was able to eat there were fingers stuck to the light posts. At the time I them". was 19½ . After we cared for the injured, I had to pick up the human remains. I picked up the head of the terrorist: the skin was pale and the eyes were open. I had already seen dismembered corpses during other attacks, but not the bodies of children".
"I remember the stench of burning flesh. I used to eat A team of American journalists were recently meat every day, but for two to three years I couldn't preparing a documentary about Zaka to be smell, touch or even look at any kind of meat". broadcast on September 11, 2002 along with 11 films from other countries who have been victims of attacks. They asked him if the film resembled 10 Post Traumatic Syndrom Disorder the reality and Haïm replied spontaneously: "the 11 the shopping centre situated in the heart of Tel Aviv. only thing that's missing is the smell of burning flesh".
41 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Immediately after he intervened on the scene of impotence of 1996 on a similar traumatic scene. the attack, David had an "extreme" panic attack, Even though he says that he suffered no trauma on developed trouble with sleeping, with recurring this occasion, a new series of symptoms appeared nightmares during which he saw himself back at the a few weeks later. scene of the attack in the middle of dismembered In July 2001, after drinking Vodka, "I ran away children's bodies with their vital organs hanging towards the sea, the police brought me back, I was in a out, "scenes of blood". His personality changed confused state. I didn't speak for ten days and I was durably: excitation, irritability, "extreme incontinent". nervousness", asthenia (pathological tiredness), "That's when I decided to take life differently, to come insomnia, anorexia, stuttering, aggravation of back to the life I had before. Since December 2001, essential trembling. I've been working as a volunteer in the administrative department of the MDA". David has a feeling of impotence when faced with the disaster he sees visually. The rescue mission he David has not assimilated the traumatic event into invested all his available energy in is replaced by his life story, it marks a break, a before and after this intense feeling of impotence, a corollary of a the traumatic moment. This has engendered a feeling of guilt. Severe depression with persistent profound global change in his personality which is insomnia combined with anorexia led David to polarised by the traumatic event and encysted in cease all activity. "I went to the Bitour Léoumi chronic traumatic neurosis. In the course of the (equivalent of the Social Security, in France) to the interview, David showed neurovegetative department that specialises in people injured in symptoms and hyperemotivity (paleness, sweating, attacks". trembling) and psychomotor reactions (twitches, stammering). He devoted a large part of his Because he cannot rescue, he unconsciously account to claiming the status of a victim of an identifies himself as a victim of the attack and attack which he esteems is not sufficiently constantly tries to plead this subjective position to recognised by the Bitouar Léoumi medical the social institutions responsible for defining his commission that assigns the rate of invalidity and rate of handicap. He has been in hospital 3 times. meets every 6 months. This feeling of prejudice, of non-recognition, insufficient payment, changes his On June 1st, 2001, when the attack on the personality, making him irritable and dominates his "Dolphinarium" occurred, David was working in speech. intensive care in the Irilov hospital. "I worked 25 hours on the trot, and I wasn't traumatised at all!" Degrees of handicap recognised by Bikur Léumi: 100% (1996 to March 1997); 70% (March 1997 to David was probably in a euphoric and hyperactive February 1998); 0% (March 1998 to April 2000); condition, he did not feel tired and used all his 36% (May 2000 to December 2002). energy to rescue the young victims of the attack on the "Dolphinarium"; actively re-playing his
Date of the event: 1996. Place of the event: Dizzengoff Center. Date of the event: June 1st, 2001. Place of the event: Dolphinarium Type of attack: "democide" attack Diagnostic: grave traumatic neurosis becoming chronic over a period of 6 years
42 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
IV.3.b - The impact on society as a The daily life of the Israelis has been profoundly whole disrupted by the recurring attacks by the armed Palestinian groups. Some cafés, restaurants and The victims of the Park hotel, the shops now have iron bars to protect them. Armed symbolic impact watchmen check customers one by one, sometimes with metal detectors. Police roadblocks The Israelis, as a society, were traumatised by the are frequent in urban centres. After an attack, fact that the survivors of the Shoah, considered to public places are deserted and the streets are be among the very builders of the Nation, perished empty of passers by. in "democide" attacks. Theatres and cinemas have seen a drop in business, From this point of view, the attack at the "Park while video rentals are on the rise. The tourism Hotel" marked the Israeli citizens for a long time sector has collapsed because of the repeated to come. Among the twenty-nine victims who died, attacks against civilians, while companies offering nineteen were over seventy years old. The oldest, security guards and security systems are Chana Rogan, was ninety years old. To perish in an flourishing. Home delivery firms in the big towns attack in Israel after having survived deportation to are benefiting from the fear the Israelis have of the Auschwitz death camps shocked the Israeli going out. population. This was the case of at least 6 of the victims of this attack, which claimed 29 lives. Social work in difficulty: the association Frieda Britvich, 86 and Alter Britvich, 88, from Beith Ham Netanya Born on the border between Rumania and Interview with Henri Cohen-Solal, meeting on Czechoslovakia, she was a survivor of Auschwitz. August 14 After a long and winding path, she met her husband. They got married and moved to Netanya "Beth Ham is deeply involved in the life of the in 1947. The couple both died in this attack. Jerusalem young inhabitants on the edge of society, be they Jews or Arabs. The association's youth clubs are Sarah Levy-Hoffman, 89, from Tel-Aviv designed as "an alternative to the street". Born in Czechoslovakia, survivor of Auschwitz and Since 1990, one of them is situated in the heart of immigrated to Israel in 1949. the town, on King George Street, which is only a few dozen yards from a place where 4 "democide" Eva Weiss, 75, from Petah Tikva attacks have taken place. “Of course, the difficulty for the parents is to keep their children at home to avoid Ernest Weiss, 79, from Petah Tikva the risks of the street, drugs, organised gangs and for Eva and Ernest Weiss survived deportation. They the past two years, the attacks.” married in 1946 and immigrated to Israel in 1964. Now security problems are in the foreground, for Anna Yakobovitch, 78, from Holon 10% (around a hundred) of the adolescents who Died of her injuries on April 11. Wife of George frequent the youth club have been injured in Yakobovitch, 76. Like her husband, Anna was a attacks. The social workers of Jerusalem are active Hungarian Shoah survivor. They had been married around teenagers. for 20 years and knew each other since childhood. Anna's son André Fried and his wife, Idit, were killed in the attack.
Marianne Lehmann Zaoui, 77, from Netanya Born in Germany, she took refuge in France and lived her childhood under a false identity near Lyons. After the war, she went to England then returned to France where she taught English. Marianne emigrated to Israel 10 years ago. Before October 2000, the youth club was a place for meeting people, frequented by both Jews and Arabs. The Oslo agreements The attacks against civilians change daily had allowed dialogue to be built up between habits the young people in the town but this link between young Jews and young Arabs has deteriorated.
43 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
tourists per 55 10 160 200 90 50 "The terrorist action is extremely effective in destroying month the network of relations between Jews and Arabs for which Beth Ham has worked hard. The terrorist virus Household consumption, direct foreign has invaded the social relation". investments and the business of small companies are strongly penalised by the reigning insecurity. According to Médecins du Monde, the action The national budgets for 2001 and 2002 were of the armed Palestinian groups, and some severely affected by the economic recession and by behaviours of the Israeli armed forces, the need to increase expenditure on defence. qualified as war crimes12 render the political Budgetary cuts were imposed on unemployment positions on both sides more radical, making benefit, family allowances, health and education. such a dialogue impossible today. The Israeli Institute of Democracy, at its annual conference known as the Caesaria conference, in Delinquency during the attacks June 2002, published the following comparative According to the statistics gathered by the Israeli data on budget efforts in terms of security per police, a comparison of the periods January to June head of population. 2001 and January to June 2002 reveals several phenomena:
- 3% drop in the number of criminal acts reported - 3.2% increase in acts of violence and juvenile delinquency, +2.5% drugs, +12% against property - drop in number of road accidents, but 3.2% increase in the number of deaths. - 13.4% drop in car thefts - 1.6% increase in the number of rapes - 6% drop in armed robberies
The economic consequences (Source: Israeli Ministry of finance)
The Israeli economy has been in a deep recession for 2 years. In 2001, the GDP dropped 0.6% and the per capita GDP by 2.9%. The forecasts for 2002 are a drop of 1% in GDP and 3% drop in per capita GDP. These drops are unprecedented in the history of Israel.
The recession is the result of several elements. Of course, there is the slowdown of the global economy, the crisis in the high technology sector, and a high business activity in Israeli export goods contributed, in particular, to this result.
But the acts of violence against civilians and the terrorising nature of the attacks were a significant element in the collapse of tourism.
Year 1984 1991 1996 2000 2001 08/20 02 Thousands of
12 Report by FIDH and MÉDECINS DU MONDE "Operation defensive shield Nablus" joint investigative mission by Médecins du Monde and FIDH West Bank, April 28 – May 5, 2002
44 Israeli civilians victims of attacks by armed Palestinian groups
Table 7 – Budget efforts in terms of security per head of population (data in USD)
Israel United States France Sweden Germany Italy Belgium Japan 1690 1030 708 626 401 395 363 325
children wouldn't see the pictures and yet my son This same institute estimates the cost to the Israeli talked about it for 2 days". economy of the second Intifada at from 3.5 to 5% of the Gross National Product, or a loss of 7 to 8 Véronique, his wife, adds: "When I go to fetch my billion dollars. son from the crèche, I come straight home without hanging about. And when the crèche closes for the According to the Ministry of Employment and holidays, I feel oppressed. What can I do with the Social Affairs, the number of Israelis living below children? We can't go out. When I had to go to the the poverty line increased by 81,000, including paediatrician, Dr Michèle Kaddosh, who was in the 50,000 children, in 2001. This brings up to centre of the town, King George Street, I didn't sleep 1,170,000 the number of poor people for this same the night before the appointment. The medical practice year, of which 531,000 are children. at the Paamon centre where 20 doctors work is totally deserted. The town centre is empty, although it was very busy before. My paediatrician has had to move, The population's general feeling of because she had no patients any more. insecurity The children's games have changed -- they play at Every Israeli knows someone in his or her ambulances! My heart bleeds, I feel skinned alive. I try immediate circle who has been injured or victim of to protect myself; I don't look at the pictures, I don't an attack. want to know all the details. I read in the newspaper after the attack in Immanuel that one seriously injured Jonathan and his wife Véronique give an woman lost her husband, her mother and two of her account of the changes in their daily life due to the children. I can't bear it. I can't sleep at night any more. attacks. They live with their two children aged 1 Some children were made orphans, in the attack on and 3, in a small house in the Nahlaot quarter, King George Street; the parents were coming out of the right next to the Mahané Yéhouda market in scan clinic. Their eldest two were being looked after by Jerusalem. Jonathan remembers the moment the the grand parents." attack took place: "When two people meet, they systematically talk about "I was playing with my son. At 14:00, I heard a huge politics and security. On the phone when you ask explosion and I feared the worst. I found out later that someone how they are, they answer, "thank God, today my cousin was there, towards Yaffo street, she turned there have been no attacks". This situation invades our back to buy something she had forgotten. She was in a whole life. And we don't know when it will stop, this state of shock for several days, paralysed by fear and war that hides on all the street corners. Our Army is frightened to go out of the house. She was extremely very strong, and paradoxically its capacity to act is sad and didn't talk, traumatised by what she saw. extremely limited" I have a friend who was very seriously injured in the attack at the Hebrew University on July 31, 2002. On a financial level, Jonathan personally accepted a Among my close friends, I know 2 of the victims 20% drop in salary, one of his friends had to accept personally. a 50% pay reduction to keep his job in a hotel. Before this attack, we used to go to the market once a Among his acquaintances, several people, including week with the children. Now we only go very rarely and heads of families, were paid off due to the we don't take the children. We never go out to economic decline of the country since the start of restaurants or cafés anymore, or even to the cinema. the second Intifada. Two of them worked in the We are on the lookout for information and high technology sector as a graphics specialist and a paradoxically our television hasn't been working for 2 systems engineer. The other was a tourist guide months. We don't get it repaired for fear that the and had to reconvert to another business sector. children will be shocked by the pictures they show continually during the attacks. The day of the Allemby street attack, the television was on during the news broadcast. I switched it off straight away so that the
45 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
The success of emergency phone help, a Eran in the torment of the attacks: symptom The armed Palestinian groups' attacks on civilians Presentation of the Eran emergency hotline, have created a climate of insecurity, exacerbating interview with David Koren relational tensions and personal problems. Since October 2000, Eran has noticed an increase of 12% In existence since 1971, Eran is a 24-hour in 2001 and of 15% in the first half of 2002 in the telephone hotline for people who are lonely, number of calls directly related to "democide" depressed, or in a crisis situation. The hotline has attacks and attacks against the Israeli population. been available in Arabic since 1996. 80% of callers are women and young people suffering from Paradoxically, the calls stop after an attack, for loneliness or mental illness; the same service has people are busy looking for the information about been available in Russian since 1993. their close circle or watching television.
In 2001, in 10 stations throughout the country People start phoning again a couple of days later, (Beer Sheva, Jerusalem, Richon Letzion, Tel-Aviv, to talk about what they have seen or experienced. Kfar Saba, Netanya, Hadera, Haifa, Carmiel and A child of 12 called twice in a row, in a really Nazareth), over 800 volunteers took calls from distressed state, just after an attack, worried about 99,312 people, which is an increase of 14% her parents who had not come home yet! compared to the previous year. From January to June 2002, there were In the first half of 2002, 950 volunteers took approximately 2,500 calls concerning the terror 53,638 calls, with 110,000 calls expected for the situation. These calls can be divided into three whole year. categories:
In 2001, 25 Russian-speaking volunteers answered - People who would not call in normal 125 calls a day, which is an increase of 25%. circumstances, who want to share their feelings of anxiety with the volunteers. 15% of the calls are from children and teenagers - People seeking advice on how to manage their under 20. 4% of the callers express suicidal children's fears. thoughts. 2% relate to physical, sexual or mental - People asking for help faced with the abuse. expression of post-traumatic symptoms.
46 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Chapter V. Taking care of civilian victims
V.1 - The organisation of rescue services: the phases of rescue operations on the scene when an attack occurs
Rescue operations are not organised on the basis of past attacks but rather on the experience of the Gulf war. For in fact it is only really since that time that the Israelis have been prepared to receive large numbers of victims at once.
Doctor Stein, surgeon, Trauma Centre, V.1.a - The alert Hospital Bellinsson, Tel-Aviv
The number to call for emergency medical care is He was on standby the Friday morning we met 101. The calls are transferred to the closest him. He also had a mobile phone and 3 beepers. regions and centres to the place of the event, in When one rang, he recognised the ring of Magen this instance to the Magen David Adom centres. David Adom. Immediately he read the message The hospital services are warned so that the first "Alert at the airport". A few minutes later, the aid (Trauma Centers) and psychosocial teams are same ring "the LED that shows landing gear is ready. The first people warned may also be the working properly has not come on"; and he police or the radio, in particular Gaalei Tsahal, the seemed reassured, saying that it happens a lot and army station. In this case, they relay the most often it is just the light bulb that is not information to warn the emergency rescue teams working and not the landing gear. A few minutes and Zaka. The people in charge at MDA, at the later "15 ambulances in place at the airport". Then medical-surgical centres, in the police, Zaka and "50 passengers in the aircraft"; then "landing in 10 Gaalei Tsahal are all equipped with several beepers minutes", "error, landing not yet announced", and have mobile phones. They are able to "landing in 10 minutes", "aircraft ready to land" distinguish between all the different ring tones. "aircraft landed no problem". It all lasted 25 minutes. And the surgeon told us: "you see, for the Hadas Shtaif, journalist with Gaalei Tzaal attacks it is the same, it's like a film you can't see for a few minutes, but when you listen to the She covers the events inside Israel, from Modi'in to story, you are kept hanging on with baited breath. Afula. She used to have the title of regional Very stressful!". journalist; since the events of September 2000, her title is now security journalist. She met us in the Tel Aviv area, in a service station close to a major V.1.b - The "chaos" phase road artery, to be able to set off in her car immediately in the event of an alert. She only told This is the period immediately following the attack us where we would meet 10 to 20 minutes before the emergency teams turn up. It ends when beforehand. During the interview, she had her they arrive and may last anything from a few mobile phone with headphone sitting on the table minutes to 20 minutes, if the site is in an urban in front of her and a few beepers on her belt. The zone that is difficult to get to. During this time, phone rang an innumerable amount of times, she those who can walk have already left the area by answered in a second. Nothing urgent that day. their own means and may even have taken themselves to the nearest hospital. Theoretically, Haïm, team leader, volunteer, police officer, those people are the ones who are only slightly Zaka. injured.
Haïm has the same communication devices, including 3 beepers (Magen David Adom, police and army). During the interview, he gets a call on one of these beepers "threat from Hamas of an attack this evening at 23:00". V.1.c - The reorganisation phase
47 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
This phase can take up to an hour, depending on the extent of the event. V.1.d - The Zaka teams The MDA rescue teams, guided and coordinated by a leader, identify the injured whose lives are in They work on the scene where the attack took immediate danger. First aid is given where place. They are responsible for retrieving all human necessary; the most seriously injured are remains, even the smallest part. These parts are transported first. The emergency medical care then taken to the morgue and DNA tests are done system is therefore very different from the French to be certain which deceased person they belong system, which prefers to treat the victims at the to. The aim is to be able to bury all the parts of the scene of the attack. body of a person who has died, as required by the Jewish religion. The Israeli system is based on the American one and makes use of "Advanced Trauma Life The Zaka association has been in existence Support®". The injured are sorted into "serious, since 1997, it was set up by Orthodox Jews in moderate and light" categories and evacuated as response to Jewish religious orders requiring, quickly as possible. The rescue teams are before proceeding to bury a dead person, the particularly careful to monitor the progress of the following: injured. This is because the use of small metallic materials, such as nails, along with the explosives - Establish the identity with as much certainty as means that even a tiny entry wound of a few possible. millimetres could cause massive internal - Bury all the parts of the body, if the death was haemorrhaging or a suffocating pneumothorax. violent, after bringing together all the parts, even the smallest strips of flesh. Other teams look for victims who may not be immediately apparent, hidden under debris for If someone is found dead in the street everyone example or partially disintegrated. For example, has to stop what they are doing to perform the the presence of a pram or pushchair with no child burial in order to pay their last respects to the in it is a clue to look for a "hidden" victim maybe individual with the dignity due to a human being. hurled some distance away by the blast. Zaka is an association of volunteers, which has As for the sorting at the scene of the attack, a grown considerably over the past 2 years and now person with one or more limbs torn off is has 600 volunteers in Israel, spread over 6 regions, considered dead. This is because it is a known fact 200 of whom are in Tel-Aviv. A new department that that kind of damage is caused by the blast and has been created for the victims of attacks, and in these cases there are fatal lung injuries. The comprises several services: gathering up and victim was too close to the explosion to be alive. identification of body parts, announcing the death of the victims to their families, accompanying the The hospitals are informed of the people who are parents to identify the body in the morgue, going to be brought in. The victims are distributed psychological follow up with the families. Bodies according to their injuries to the appropriate having suffered burns are very difficult to identify hospital. Special care is taken to avoid and as long as the deceased has not been certified overstretching a hospital. For the same attack, 2 or and officially confirmed by the DNA tests, the 3 different hospitals may receive injured patients. name of the victims remains secret. The journalists find out the identity of the victims from the The security forces secure the site but the rescue morgue. teams do not wait for the go ahead to act. They look for the second explosive charge (which is In Israel, a rabbi issues the burial permit. It is Haïm, often present and designed to hit the rescue police officer, former military almoner and workers), block the exits, evacuate the crowd, and currently volunteer with Zaka, who signs the burial facilitate the transport of people injured. certificates, in his capacity as team leader.
Teams of journalists from radio and television also arrive on the scene in this phase, keeping listeners and viewers informed of the events. Information is gathered: number of injured or dead from the MDA, type of attack from police sources. They The association fulfils this mission for violent interview eyewitnesses. And everything is deaths, where the decomposing or badly damaged broadcast live on radio and the television. body requires time to respect both civil law and the Jewish religion. Scientific methods, DNA tests
48 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 and dental examinations, are used for the identification of the dead; each piece of body found on the site of the attack is taken to the morgue. V.1.e – The site clean-up phase
In the event of an attack, the police are in charge The length of this phase also varies and can be up of closing off the sector to avoid a second attack. to 100 to 180 minutes starting from the initial But there are insufficient human resources to take event. care of gathering up the pieces of bodies. Zaka The last victims with the lightest injuries are volunteers are in charge of this task and are evacuated. appreciated an respected for this sensitive mission, which is extremely difficult on an emotional level. The rescue teams do a last check to make sure they have not missed any victims. Haïm is also director of the security and emergency department of the municipal council of Zaka continues his job at the scene of the attack, Bné Brak next to Tel-Aviv. He has a direct beeper gathering up and grouping together human connection to the police, Maguen David Adom and remains, while another of their teams is at the the army. Every day a team of 15 volunteers is in morgue, so that once the police has identified the on standby, ready to rush to the scene of an attack bodies, they can inform the families of the deaths as quickly as possible. and sign the burial certificates. The social services at the hospitals are kept informed of the names of Haïm is a man with long experience of the injured the deceased. and the dead. As a military almoner, he was in charge of the identification of bodies during the The first names of the deceased are announced by Lebanese war. He sometimes has "flashes from this the media. Very quickly, the reporters interview period that stay in the head and come back". At the families. The principle is to give an identity, a Beirut airport the Israeli army bombed a line of its name, a family, and a background to the deceased, own tanks by mistake. so that they live on. "The families know this is what will constitute the memory of their deceased and most "Take care of the survivors": of the time they are very co-operative" says Hadas Shtaif, journalist. A school camp has been organised by Zaka, from August 11 to August 15, 2002 in a hotel at Eylat to help seriously injured children to "overcome their V.1.f – Last phase pain", but also to support the children who have lost a member of their family. Called "it's nice to be This phase is not clearly defined. It follows after alive" this action involves 110 children who have the clean up and lasts 24 to 48 hours. The been the victims of attacks. The project was surveyors take measurements to repair material originally to involve 50 children, but 350 children damage; people with light injuries continue to showed willing to participate. arrive in the hospitals, sometimes very far from the site after having gone home. Most of the time these are moderate scratches and grazes, tinnitis (slight hearing trauma) with no visible signs of trauma, acute emotional stress, initial signs of psychological trauma.
The medical emergency teams resume their initial size in terms of people and resources. The counting of the victims stops 24 hours after the event.
49 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
V.2 - Medical care in hospital
All over the world where the level of experience V.2.a - The difficult choices care workers and skills are sufficient, it is first of all the least have to make experienced doctors who examine the injured, followed by someone more experienced, and, Globally, the victims of the attacks suffer injuries where necessary, the treatment ends with the that are more severe and use more expensive most experienced practician. Due to the difficulties medical services than any other type of trauma, caused by the people injured in attacks, the such as road traffic accidents, for example. pyramid is inverted. One of the consequences of this is that the most experienced are in great When doctors and surgeons are confronted with demand, cannot easily rest and especially cannot go extreme situations, the ethical problems that arise very far -- leaving the country is a big problem for can be sometimes extremely trying. some.
Doctor Michael Stein, surgeon at the Bellinson The medical and social structures which in hospital in Tel-Aviv. times of peace are designed to deliver care, are, due to the attacks, currently mobilising "The rescue teams are so effective that hopeless cases a major part of their energy recovering or arrive at the emergency department with vital signs. preserving the physical or psychological But for some of them, we don't see what we could do. health of the Israeli civilian population. And so we must decide to do nothing, which is very difficult for the teams. Once a rescue worker arrived carrying in his arms a child with a blanket over it. The nurse lifted up the blanket and almost fainted. The V.2.c – Mass consumption of specialists cranium had been blown away and the brain was largely visible. There was still a pulse. Maybe one day The attacks use the skills of many more specialists I'll faint, too". than any other type of accident, even massive ones. Each injured person is examined by an intern, a Later, he showed us a photograph of the child, for surgeon, an ophthalmologist, and an ENT specialist. besides their medical-surgical equipment, the Radiologists, anaesthetists and nurses are all doctors are equipped with digital cameras. A young mobilized. doctor is usually responsible for taking photos for The Gertner Institute indicates that 12% of the medical purposes, to use them for training. injured are transferred to other hospitals, where the skills required for the gravity of the injuries are Another difficult choice to make is the decision present. "who do we take into intensive care?"
Sometimes there is not enough room for the number of injured who arrive. And we know that V.2.d - Training doctors in ATLS® - the chances of survival after a multiple trauma are Advanced Trauma Life Support largely related to the close monitoring of the injuries in this type of ward. Since 1989, all practising doctors should be trained in this system of care for the injured. Up until now, 21.4% of the injured are admitted to hospital in an more than a third of the medical population have intensive care ward according to the Gertner been trained. Institute.
The length of stay in the hospital is longer, on average, than for people traumatised by a road accident (almost 20 days for a person injured in an attack compared to 12 for a road traffic accident victim) due to the severity of the injuries.
V.2.b - The inverted pyramid of emergency care workers
50 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
1 and a half million shekels. He was saved and is today V.2.e - The presence of the care workers in prison".
At the Shaaré Tsédek hospital, 30% of the personnel live outside the green line. Some are Israeli Jews, others are Arab Israelis (30%). The V.2.g – Operating theatres always frequent blocking of the Occupied territories and available, scheduled operations the dangerous nature of the journey make it cancelled. difficult for medical and non-medical staff to travel to work, particularly in Jerusalem. "Some days they The threat of attack and therefore the possibility of came, other days they didn't come, and we had to a mass arrival of victims means that there is always organise ourselves with the personnel present that day" an operating theatre closed and ready in each (Dr David Appelbaum, emergency service). hospital. This therefore restricts the possibilities for routine operations.
When an attack happens, if the hospital knows V.2.f Relations between Israeli doctors they are going to receive injured people, in and Palestinian doctors approximately 15 minutes the emergency department is totally evacuated. Either the patients Relations have broken down since October 2000. go home, if they are well enough, or they are They have not had any news from each other and transferred quickly to another service. All the they all regret this, both the Israelis we met within scheduled operations are cancelled and the framework of this investigation and the systematically deferred. "Afterwards we have to catch Palestinians, with whom we worked on our up with the backlog, manage the duty, on call and programmes in Nablus, Jenine, Gaza, etc. Fewer presence rosters, which is not easy, we ask a lot of the Palestinian patients are referred to Israeli hospitals, staff." (Dr Ari Shamis, Assistant Director, Tel more are referred to Jordan. Agreements have Hashomer Hospital) been signed for the ATLS training of Palestinian doctors, and the training courses had started, but they have been interrupted. V.2.h – Overstretched emergency Doctor Elie Picard, paediatrician-pneumologist services at the Shaaré Tzedek hospital in Jerusalem. Despite the fact that injured people are sent to "Until October 2000, we had regular exchanges with more than one hospital, the emergency services our Palestinian colleagues who have very good medical are often working to capacity in the minutes knowledge. We receive patients from Judea-Samaria. following an attack in the vicinity. "Ten or fifteen Since the start of the second Intifada, the Palestinian years ago, the slightly injured didn't come to the doctors refuse all contact with us for fear of being hospital. Now, It’s different, people come to look for considered collaborators and of being subjected to help even if they were hardly affected" (Dr David reprisals against themselves or their families. I continue Applebaum, emergency service, Shaaré Tsédek to care for young Palestinian patients whenever Hospital, Jerusalem). "The very first ones to arrive are necessary. often the more lightly injured and they make their own I think that the medical programmes of NGOs like way to the hospital" (Dr Michael Stein, Trauma yours are necessary." Center, Bellisson Hospital, Tel Aviv).
The doctors and social workers we met told us of The Gertner Institute estimates that half of the their willingness to renew the links with their people injured require some sort of surgery. Palestinian colleagues. Scientific relations at first diminished then ceased abruptly after the second Intifada. Shaaré Tsédek Hospital, Jerusalem.
Injured Palestinian assailants and Israeli doctors. An analysis of the data over almost a year, Recounted by Dr Stein between May 14, 2001 and April 12, 2002, shows that for this period, the emergency service "In the only Bellinson Hospital in Tel Aviv, 15 terrorists received 378 injured, which is more than one per were treated, one of them, a suicide bomber, spent 15 day. days in intensive care. He cost the national community 84 injured were received in one day, at the time of the attack on December 1st, 2001, in a pedestrian
51 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 street in Jerusalem town centre. Two men blew themselves up a few minutes apart and a booby- In 2001, this hospital received 50 injured, of whom trapped car exploded not far from there, a little 5 were Palestinian, said to be "connected" with later. Exceptionally, there were 12 people "terrorist acts" as indicated in the report given to considered as severely injured (therapeutic us. In the first 6 months of 2002, they had already measures to be taken immediately to save life), 14 received 80 injured including 10 Palestinians. were moderately injured (therapeutic measures to be taken within the following few hours, no The 2001 report shows that 82% of the injured immediate vital threats). This meant that 31% of Israelis received are civilians. the injured taken into care were in the urgent The average age of the injured Israeli civilians is 31 category. (extremes 10 – 64).
On the "other days of attacks", a more usual The distribution of the severity of the injuries to proportion of injured people in the urgent the Israeli civilians is shown in the figure below. 2 category, for this hospital, was observed at 10 to of them will die of their injuries, which gives a 20%. mortality rate at the hospital of 4.4%.
Tel Hashomer Hospital , Tel-Aviv Note that this hospital is highly equipped, and often receives severely injured people. With 1,800 beds, this is the biggest hospital in the country. The operating theatre handles over 35,000 operations per year.
Figure 8 : Distribution of the severity of injuries in those admitted to Tel Hashomer hospital , Tel Aviv, year 2001
ISS 9-15 11%
ISS 1-8 ISS > 16 53% 36%
ISS 1-8 trauma severity score light ISS 9-15 trauma severity score moderate ISS 16-75 trauma severity score severe
52 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
V.2.i - The Bikur Holim hospital on "the When an attack occurs, several difficulties arise for battlefront" this small hospital in the town centre:
Some hospitals have had to change the type of - How to receive a completely unforeseeable equipment they have. This is the case of the Bikur large number of injured people Holim hospital in the centre of Jerusalem. This - Evacuate the emergency service and establishment is regularly confronted with arrivals simultaneously intervene on the scene of the of large numbers of injured people, which attack to evacuate the injured. The time frame sometimes means moving its teams as a first is very short - between 1 and 15 minutes recourse to the scene of the attack. The hospital between the event and admitting the injured has had to expand its emergency service and to the hospital. acquire new imaging devices. - Manage telephone switchboard saturation.
Four attacks have occurred within a radius of 50 This particular geographical situation is what yards around this hospital. Located in the old town prompted Dr Dviri, head of the emergency service of Jerusalem since 1866, the hospital is situated in a at Bikur Cholim to say that the hospital is situated densely populated quarter. on the "battlefront" at the heart of Jerusalem.
V.3 – Psychological care for civilians
The particular situation created by the repetition of the attacks against the population has forced Israelis psychiatrists to re-think their strategies for providing the victims with psychological care. New proposals are formulated then implemented. The public health services, local authorities, the non-governmental sector, all play a part in coping with the new reality.
V.3.a - "Confer psychological immunity Mental health professionals therefore decided to on the population" develop the training sector that uses voluntary The original work of the Tel Aviv Mental workers as a resource. Health Center : Starting from the general idea that the number of This is a sector psychiatric care centre that social workers and psychiatrists is insufficient to provides mobile care for patients from birth to old take care of the victims in the event of a huge age. This service is directed by Pr Nathaniel Laor, catastrophe (attacks, war, collective catastrophe), and Dr Wiener is the clinical specialist in charge. the Centre is involved in a pilot project set up in 5 quarters of Tel Aviv (Jaffa; south quarter; Centre; The centre is associated with the system of care Ramat-Gane, A hayal), chosen for their type of for victims of attacks, set up by the municipal population (Arab, foreign workers, underprivileged council of Tel-Aviv, described previously, which is social classes, upper social classes, mixed responsible for coordination in the event of an population). emergency situation. Within these quarters, co-ordinators were Its main task is to provide care for patients in the selected then trained to know how to react in the Ramat-Gan quarter. Clinical follow-up concerns event of a non-conventional war. How to avoid approximately 5,000 patients, the victims of attacks panic and depression? What practical steps can be represent around 10%, or 500 people of all ages. taken? How do you create a support network in the quarter to find the people who are suffering The large number of patients being treated who from psychological problems ? have been victims of attacks has required an increase in human resources in response to these The degree of adaptability and flexibility in a stress needs, which overstretch the care service. situation determines the capacity to effectively take care of the victims. The more static the system,
53 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 the more it is rigid and the less likely it will be able psychological immunity on the population", to make it to respond effectively to the situation. stronger and allow people to cope with collective catastrophe situations. The high degree of involvement of the inhabitants of a quarter at community level makes it possible to create a system of mutual aid. The long-term aim is to observe how these pilot quarters cope V.3.b - Mobilizing the municipal council with situations of mass catastrophe compared to of Tel-Aviv other quarters that are not prepared. This system has been put in place by the municipal council of Information gathered from Moshe Alon Tel Aviv, and is to be implemented across the The town of Tel-Aviv has been organised to deal country. with attacks since the Gulf war. The municipal council then took steps to prepare to react in the The theoretical model starts from this empirical event of a massive catastrophe and developed observation, that a person prepared to react in the Emergency Treatment System (E.T.S) in response event of a situation of acute stress will develop to different emergency situations, including war, fewer problems than a person who is not terrorist acts, natural disasters, industrial disasters, prepared. Applied at community level, this etc. pragmatic attitude determines a choice of training the population, as a part of preventive medicine. Two teams of 20 professionals, social workers, educational psychologists, doctors and para- This experience has been expanded since the Gulf medicals are on permanent alert and are ready to war in 1991 and was applied on the occasion of the intervene on radio information without waiting for earthquake that occurred in Turkey in 1999. The orders. This unit offers immediate social and Gulf war for Israel was a war without a battlefront: psychological assistance at the place of the attack the missiles were fired from Iraq to inside the for those who suffered from the attack, such as country, and mainly on Tel Aviv. eyewitnesses, the people evacuated, etc. A co- ordination centre can set itself up on the scene of The operation concerns between 700 and 1,000 the event and the other team goes directly to the people, and draws more on public health practices Abou Kabir morgue to receive bereaved families, than on conventional psychiatric positions. The aim provide them with psychological support during is to take into account the cases of post trauma in the process of identifying their lost loved ones, the whole of the population at local level and not then offer to help them co-ordinate the funeral. only the 10% that turn out to be true cases of The unit has six teams comprising a member of the PTSD. police council, a rabbi, a doctor or nurse, two social workers and a police officer. Use is made of the quarter's resources, its existing medical and social structures, the psychiatrists, To avoid movements of panic in the population, psychologists, teachers and more generally all the the 6 regional hospitals in the Tel-Aviv conurbation people involved in education or teaching at the communicate the list of the injured to the scene of the attack. The co-ordinators or field coordination centre. Another information unit workers are trained and given support by the informs the public. programmes established by the centre's psychiatrists, in relation with the municipal council A "Hot Line" provides immediate psychological of Tel Aviv. This system of people acting as field help, in the short term, to callers. It comprises 4 workers in the quarters makes it possible to reach teams, each including 5 psychologists and 3 social people who are "normal", and who under normal workers. The emergency phone numbers are circumstances would have no need of psychiatric always reserved and they are publicised for the care. population in case of need.
This project was the subject of a 10-day training Experience shows that in a case of necessity, the session, destined for other municipal councils. The population on the whole shows itself willing to help implementing of a similar network awaits the the municipal council and the community to deal agreement of the Ministry of Health to be with the crisis situation. A unit co-ordinates the produced with the Manhattan schools situated volunteers and donations. It is made up of social around "Ground 0" (Twin Towers, attack on workers, and uses a database of volunteers and of September 11, New York). community activists who wish to help. This original approach is described by Doctor Zehev Wiener like an attempt to "confer
54 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
V.3.c - The contribution of the NGOs disorders related to the attacks against civilians. The therapists constitute groups of activities using Interview with Saar Uzieli, from the NATAL non-verbal therapy through drawing, dance, and centre, "Israeli centre for the victims of traumas singing. Talk groups or individual therapies are caused by terrorism and war". proposed where appropriate.
Natal is a non-governmental institution, founded in The aim of the attacks of the armed Palestinian 1998 by Dr Yossi Hadar, to support people who groups is to kill and maim civilians but also to suffer from the traumatic effects of terror and war. destabilise the social structures that create a From July 1998 to October 2000, the larger part of feeling of security on an individual or group level. the consultations concerned people suffering from chronic PTSD. In fact, according to Professor Laor, "individual and group reactions in the event of an attack are From October 2000, everything changed. The unpredictable, uncontrolled and random, due to the injured and witnesses of attacks came to seek a fact that they have the effect of disorientating the consultation, as well as people who feel a very mind" oppressive threat but have not experienced an attack and lastly the individuals for whom the Three stages have been identified, and while the current events reactivate previous traumas related first concerns the direct effects of the event, the to the war of Kippur or other events. secondary effects have an impact on the operation of the social network and the tertiary effects have A telephone line offers help to victims of attacks, an impact that changes individual daily behaviour. 3,000 people called this service up until September 2001. Since October 2000, the number of calls has It is the community infrastructure that receives the increased from 30 to 150 a month. After a deadly impact of the traumatic event. attack, the volunteers handle up to 150 calls a week. The responses of the care workers therefore draw on the mobilisation of society and the search for Furthermore, Natal is the only non-governmental new models for the treatment of psychological care centre exclusively devoted to the treatment trauma. of people affected by post-traumatic stress
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CHAPTER VI. Characterisation of the attacks according to International Humanitarian Law
The attacks of armed Palestinian groups against civilians and International Humanitarian Law
In the dispositions regulating the conducting of Israeli army and the armed Palestinian groups. hostilities, International Humanitarian Law dictates Whatever the relevance of the debate and the that forces having recourse to violence must qualification decided on (national liberation make the distinction between military struggle, international armed conflict or internal targets and civilians. armed conflict), International Humanitarian This principle, called the "principle of distinction", Law and International customary law constitutes the main pillar of the protection prohibit the use of terror against civilians. afforded to non-parties to a conflict by the law governing armed conflicts. It is stated in the four Article 51-2 of the First additional protocol to the Geneva Conventions dated August 12, 1949 and Geneva Conventions, explicitly prohibits "Acts or the two Additional protocols of 1977, and must be threats of violence the primary purpose of which is respected in all circumstances. The First additional to spread terror among the civilian population". protocol, in particular, contains a set of precise rules intended to guarantee the protection of While the acts of violence taking place today civilians. These rules are part of international constitute an armed conflict under the terms of customary law, and the armed Palestinian groups International Humanitarian Law, the attacks must respect them. deliberately intended to hit civilians, as described in the present report, should be considered war Article 48 of the First Protocol specifies that the crimes. Under the terms of the Statute of the parties to the conflict must "(…) only direct their International Criminal Court, adopted in 1998, war operations against military targets". Consequently, crimes include "Intentionally directing attacks attacks deliberately launched against civilians are against the civilian population as such or against prohibited13, as well as "indiscriminate" attacks that individual civilians not taking direct part in target military targets and civilians indifferently or hostilities", in the same way as "murders" and cause disproportionate damage to civilians14. The "voluntary homicide"15. bombings perpetrated in places frequented by civilians (for example buses, restaurants, hotels), The attacks committed since October 2000 which Médecins du Monde was led to investigate constitute crimes against humanity. Crimes constitute particularly flagrant breaches of against humanity are not necessarily committed the obligation to distinguish between during an armed conflict and may have been civilians and parties to a conflict. perpetrated in times of peace or in times of war. In the definition used in the Statute of the Any military presence amid the civilian population International Criminal Court16, crimes against the as, for example in public transport or in places humanity are acts such as "murder" or other open to the public, cannot have the effect of inhumane acts "intentionally causing great suffering, depriving civilians of the general protection they or serious injury to body or to mental or physical are entitled to, and cannot therefore legitimise health" committed "as part of a widespread or attacks that cause civilian losses. systematic attack directed against any civilian
It is not up to Médecins du Monde to decide how 15 Article 8 of the Statute of the International Criminal Court. to qualify in legal terms the conflict opposing the The Statute is the most advanced expression of international criminal law. It has not, however, been ratified by Israel, and cannot be adopted by the Palestinian Authority because they do 13 Article 51-6 of the First additional Protocol: "The civilian not have a nation that is recognised internationally. The armed population as such, as well as individual civilians, shall not be the Palestinian groups, like the Israeli armed forces, are nonetheless object of attack" still subject to the rules of international customary law, which 14 These rules are stated in articles 51-4 and 51-5 of the first prohibits atacks against civilians. additional protocol 16 Article 7 of the Statute of the International Criminal Court
56 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 population", and "pursuant to or in furtherance of a State or organizational policy to commit such attack".
The bombing attacks on Israeli civilians are undoubtedly systematic in nature. They are conducted in application of a stated political objective of killing civilians and spreading terror in the Israeli population as a whole. Consequently, they are widespread in nature.
Médecins du Monde carried out investigations in the field and publicly condemned the breaches of the laws and customs of war committed by the Israeli army during operation "Defensive Shield"17. The violence directed against the Israeli civilians cannot be justified by the behaviour of the Israeli armed forces in the Occupied territories. For, in fact, International Humanitarian Law prohibits "Attacks against the civilian population or civilians by way of reprisals"18: the Israeli civilians should therefore not be deliberately targeted under any circumstances.
17 Médecins du Monde – FIDH report on operation "Defensive shield" in Nablus, July 2002 18 Article 51-6 of the first Additional protocol to the Geneva Convention
57 Israeli civilians victims of attacks by armed Palestinian groups
Post script
Since the information was gathered and this work was drafted, different events have taken place that are within the scope of the report. Attacks against Israeli civilians have continued. Two of them are of particular significance:
On November 11, 2002, a man went into the Metzer Kibbutz, located inside Israel. There, he killed a man called Ytzhak and a woman called Tirza. He then entered a house and assassinated 5-year-old Matan, 4-year-old Noam and their mother Revital. The Al-Aqsa Martyrs Brigades, an organisation close to the Fatah, claimed responsibility for the action.
This attack is significant for two reasons:
- on the one hand, it took place during a meeting organised in Cairo, under the auspices of the European Community and Egypt, between the Fatah and Hamas to ask the latter to cease the attacks inside Israel,
- secondly, it concerns a kibbutz which is reputed to have links with Meretz, a left-wing Israeli political party, that preaches the evacuation of the Occupied territories and the creation of a Palestinian State along the 1967 borders.
On November 28, 2002, in Mombassa, Kenya, a hotel belonging to an Israeli company, frequented by Israeli tourists, was the object of an attack killing 10 Kenyans, 3 Israelis (2 of whom were children) and the 3 perpetrators of the attack. This was a new type of democide attack, this time aimed at Israeli tourists, with the assailants blowing up their vehicle in the middle of the hotel foyer. Responsibility was claimed by a hitherto unknown organisation, "the Army for Palestine".
For its part, the Israeli army has continued to act against the armed Palestinian groups, provoking a large number of Palestinian civilian victims.
The nomination of a Palestinian Prime Minister, Mahmoud Abbas, and the application of "the roadmap", recommended by the United States, the European Union, Russia and the UN, were the most significant events of these past few months.
At Charm-El-Cheik, the heads of state from Egypt, Jordan, Saudi Arabia and Bahrein published a release stating "condemn terrorism under all its forms and make sure that the assistance destined for the Palestinians goes to the Palestinian Authority and not into the coffers of extremist organisations like Hamas".19
At Akaba, Mahmoud Abbas stated: "There is no military solution to this conflict. We denounce terrorism and violence under all their forms against the Israelis and we are renouncing it. These methods are in contradiction with our religious and moral traditions, a dangerous obstacle to the creating of an independent and sovereign nation (…) founded on human rights and respect for the law".20
19 Le monde.03.06.2003 20 Le monde06.06.2003
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RECOMMENDATIONS
Médecins du Monde demands:
1/ That the armed Palestinian groups, in particular, Hamas, Islamic jihad, PFLP, Al-Aqsa Martyrs Brigades and Tanzim
In Israel and in the Occupied territories,
Cease the attacks against civilians immediately:
definitivly stop the repeated and systematic attacks against civilians that make these acts crimes against humanity, in breach of the most fundamental rules of International Humanitarian Law to which the Palestinian Authority and the armed groups are Parties
the absolute respect of civilian buildings and places frequented by the population such as markets, streets, shops, restaurants and cafés, schools, universities, places of worship, etc.
thereby comply with the Geneva Conventions, their Additional protocols and international customary law, which regulate war law and protect the civilian population, according to the principle of distinction between the civilian population and the parties to a conflict, as well as between civilian objects and military targets, and consequently only direct their operations against military targets
immediately stop "any act or threat of violence of which the principal aim is to spread terror in the civilian population", by virtue of article 3 common to the Geneva Conventions
thereby comply with additional Protocol I, article 51, paragraph 2, which prohibits such actions including "indiscriminate attacks"
comply with Protocol II, article 13, which extends the previous rules to armed conflicts that are not international
abandon immediately forms of acts of violence intentionally causing great suffering, or serious injury to mental or physical health. In any armed conflict, the right of the Parties to the conflict to choose the methods or means of war is not unlimited
thereby respect additional Protocol I, article 35, that prohibits the use of arms, projectiles, materials and methods of war of a kind that could cause superfluous harm
the non-enrolment of children under 18 in the hostilities and thereby respect the additional Protocol to the Convention of the children's rights
Special protection for medical personnel, the transport of the sick and injured.
do not take as targets the medical personnel, in particular during deferred attacks when the first-aid workers arrive on the scene of the attacks
do not attack ambulances and other means of transport for the sick and injured
do not target care centres for the sick and injured
respect the Geneva Conventions and the Additional protocols that allow special protection for medical personnel, the transport of the sick and injured
2/ That chairman and the Prime minister of the Palestinian Authority
59 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
do everything in their power to prevent the armed Palestinian groups from perpetrating attacks against civilians
arrest and try and sentence the organisers of war crimes and crimes against humanity, their accomplices and those giving the order in the armed Palestinian groups
denounce and remind, in particular through Arab language channels, that the systematic and repeated attacks against civilians in Israel and in the Occupied territories, represent serious breaches of International Humanitarian Law and qualify as crimes against humanity
call upon the Palestinian population to no longer support the armed groups who commit the attacks against civilians, for "they kill the hope of seeing the two peoples live side by side in neighbouring states"
discourage the apologue of the Palestinians who have died attacking Israeli civilians in democide attacks or other types of actions, in the media in Arabic and among the population, particularly young people
refrain from calling people who die trying to kill civilians "martyrs", in the media in Arabic and among the population, particularly young people
accept the help of the instances of international justice through the International Criminal Court who are today able to judge the perpetrators of Crimes against humanity
prevent the recruitment of children in the armed groups and arrest their leaders and have them tried; discourage regularly by all means of communication the enrolment of children in the hostilities
• commit sincerely to a peace process with the Israelis
3/ That the Palestinian and Arab religious authorities.
unequivocally denounce the attacks against civilians
discourage the apologue of the Palestinians who have died attacking Israeli civilians in democide attacks or other types of actions
refrain from calling people who die trying to kill civilians "martyrs"
encourage dialogue between human groups of different religions
4/ That the Israeli Prime Minister and the Israeli government
respect International Humanitarian Law, and in particular stop all forms of extra-judicial execution
distinguish between Palestinian civilians and parties to a conflict in all circumstances, including in military actions to prevent or repress the perpetrators of the attacks against the Israeli civilians
ensure the respect of the principle of discriminate attacks to protect the life of Palestinian civilians
respect the principle of proportionality of the means employed
investigate these breaches and try those responsible
guarantee access to humanitarian aid for the Palestinian civilian population and do not hamper the work of the medical teams, in particular the evacuation of the injured
prevent armed settlers from attacking Palestinian civilians, arrest and try them if they commit such actions
evacuate and dismantle the settlement in the Gaza strip and the West Bank
60 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
allow the Palestinian Authority the possibility of taking action against the perpetrators of the war crimes and crimes against humanity among the armed Palestinian groups, particularly by not destroying police stations, law courts or prisons by way of reprisals without helping to pursue the criminals
ratify the statute of the International Criminal Court
commit sincerely to a peace process with the Palestinians
5/ That the Israeli religious Authorities
stop encouraging settlement in the Occupied territories
6/ that foreign governments.
unequivocally condemn the attacks against civilians and the organisations who claim responsibility for them
refrain from giving political or material support, in particular financial or military support, to organisations who target civilians
encourage and help the Palestinian Authority to arrest and try the organisers, their accomplices and the people who give the order for attacks against civilians
and for State who are parties to the Geneva Conventions and Additional protocols to provide material assistance to the Palestinian and Israeli legal authorities to exercise justice and combat impunity for all breaches of International Humanitarian Law; to undertake systematically, at all meetings with the Palestinian Authority, the Israeli government and/or the armed Palestinian groups, to recall the terms of the Geneva Conventions and make every effort to have them applied in compliance with their commitment as signatories of these Conventions
seize the International Criminal Court so that it can try the perpetrators and people responsible for the crimes against humanity, if they have not been judged by a Palestinian jurisdiction 21
encourage the State of Israel to adhere to the International Criminal Court
and in particular, to the countries in the "quartet": United States of America, Federation of Russia, European Community, and the United Nations Organisation, to do everything in their power to re-engage a peace process between Israelis and Palestinians, to support existing initiatives to consolidate the process now underway between Israelis and Palestinians.
21 according to court statute.
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CONCLUSION
Médecins du Monde observes that civilians are the foremost victims of the Israeli-Palestinian conflict. There are no right or wrong victims.
Our long-standing dialogue with Israelis and Palestinians has convinced us that both peoples have the right to an independent, sovereign state living in peace and security.
Médecins du Monde, due to its legitimacy providing care in the field and its ethic of responsibility, strives to render the reality observed during its care actions in terms of international law and Human Rights and International Humanitarian Law. These observations of bilateral breaches incite us to firmly recommend that all the political and military leaders concerned respect them.
We shall continue to work and maintain the links between the medical communities on both sides, in all circumstances. If Médecins du Monde programmes already exist on the Palestinian side, others are in projects on the Israeli side. Keeping links between medical parthnership reinforce dialogue et mutual comprehension, essential elements to establish a culture of peace.
Over the past few weeks, the political and military situation has been moving towards a bilateral implementation of the "Road Map". The armed Palestinian groups have just declared the stopping of armed attacks for a period of three to six months. The Israeli army has withdrawn from the Gaza Strip by transferring responsibility for peace keeping to Palestinian security forces. The Palestinian authority, held by the Prime Minister, is officially recognised by the Israeli government who accepts him as political interlocutor. This hope for peace, however slim, seems to be reinforced by support actions from the two civilian communities: Ami Ayalon, former head of Shin-Bett and Sari Nusseibeh, president of the Al-Quods University and former PLO representative in Jerusalem, have just published on 18 June this year, the "People's Voice"22, a document whose objective is to serve as a base for a peace agreement between Israelis and Palestinians: "Each of the two parties recognises the other's historical rights over the same land. Two States for two people. Both parties declare that Palestine is the only State of the Palestinian people and Israel is the only State of the Jewish people".
Médecins du Monde is convinced that the forces for peace have a greater grip in the civilian population than the active minorities. These are the forces we must encourage and support in order to promote durable peace between Israelis and Palestinians.
22 www.Peacenow.org.il
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ANNEXES
POLITICAL ELEMENTS Several analyses have been made on that subject. See the work of Human Right Watch and Amnesty International. For our part we mentioned the following points :
The perpetrators: the armed Palestinian groups and their motivations Most of the time, the armed Palestinian groups claim responsibility for the acts of violence they perpetrate. Sometimes more than one organisation claims responsibility for the attacks against civilians. Messages addressed to the Middle East media or telephone calls to the press agencies are how responsibility for the action is revealed.
The armed Islamic groups Hamas This is the acronym for Harakat al-Moukawana or Islamic Resistance Movement. It claims allegiance with the Brothers of Islam. Sheikh Ahmed Yassin founded the movement in Gaza back in 1987 and since then has remained its "spiritual guide". The Charter of Hamas23 states that it is a fundamentalist Islamic group that considers Palestine "an Islamic waqf", a piece of sacred Moslem property (article 11). This founding document states: "there is no solution to the Palestinian question except jihad " (article13) or again, in the preface "Israel exists and will continue to exist until Islam eliminates it". In article 31 the text specifies: "The Islamic Resistance Movement is a humanist movement. It is concerned with human rights. It is guided by Islamic tolerance when it deals with the faithful of other religions. It only opposes them when they are hostile. Under the banner of Islam, the faithful of the three religions can co-exist peacefully. But this peace is only possible under the banner of Islam".
The Hamas organisation has two branches. One is very active in social work in the Occupied territories. The other is the military branch, which acts under the name of the Ezzedine al Quessam Brigades and claims responsibility for a large number of deadly actions against the Israeli civilians. The first "democide" attack took place in 1994 in the middle of the peace process. Since then, this type of operation has become the specialty of the organisation. One of Hamas' bases is in Damas in Syria, from where Abou Musa, one of the main leaders on the outside, willingly comments on the attacks committed by the military branch. The leaders of Hamas usually deny any organic links between the politico-social branch and the armed branch. However, Salah Chéhadé, commandant of the military branch of Hamas said : “The Azzédine Al- Qassam Brigades are a small army subject to political decisions, like all the armies in the world. The politicians don't tell us how to do things or which operations to lead : political wing is sovereign, but related to the military wing. And so national decisions go before military decisions, without invading on them.24” And when the Fatah wants to negotiate a truce on the attacks inside Israel, as at the meeting in Cairo in November 2002, the negotiations take place with the political arm of Hamas.
The Palestinian Islamic Jihad - Harakat al Jihad al islami al Filistini. Founded at the start of the 1980s by Palestinian students in Egypt among whom were Fathi Chakaki, Abdelaziz Odeh and Bachir Moussa, this organisation originated from the Brothers of Islam and was then influenced by Khomeiny's Islamic revolution in Iran. The organisation's ambition is for the Palestinian struggle to be a catalyst for the Islamic Revolution throughout the Arab world. The expulsion to the Lebanon of several of its leaders by the Israeli government in 1988, allowed the Jihad to organise and take advantage of international aid from the neighbouring countries. It brings together several armed groups such as the Al-Aqsa Batallions or the Islamic Jihad Tanzim and devotes itself exclusively to: "opening all the battlefronts against the enemy". This organisation is very secret and closed and has its general secretariat in Damas, Syria, from where Ramadan Shallah speaks.
The Fatah and its military branches The Palestine Liberation Organisation (PLO) of which Yasser Arafat is the chairman, represents, in a federative mode, the main Palestinian movements. Neither Hamas nor the Islamic jihad are part of the movement. However, their influence is certain and can be measured in the use of "democide" attacks against the Israeli civilians by lay forces. Many observers have come to the conclusion that militarisation of the Intifada especially profited the armed Islamic groups and speak of the "islamisation" of the Palestinian Authority and of the Fatah, but also of Palestinian public opinion".25
23 http//www.palestinecenter.org/cpap/document/charter.htlm 24 interview on website islam.online, MEMRI www.islamonline.net/arabic/politics/2002/05/article25shtlm
25 Reuven Paz www.washingtoninstitute.org/watch/Peacewatch #337 ;19.07.2002 accessed on 25.11.2002
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Thus, Farouk Kaddoumi, chief of the political bureau of the PLO and member of the central committee of the Fatah, declared that "the suicide bombers in the Occupied territories are a legitimate response to occupation. This is a legitimate form of resistance recognised by the international conventions that have recognised the right of the peoples to fight for their liberty including through armed struggle". But he adds "Israel has not set out its borders, therefore no one can certify that these operations are taking place on Israeli territory".26 This lay, nationalist organisation constitutes the principal political force of the PLO. Yasser Arafat, current chairman of the Palestinian Authority, was one of the founders in 1958 and is still chairman. In its national charter, the articles that refused Israel's right to exist were removed in 1996.
Many military organisations gravitate around the Fatah:
The Tanzim. This is the armed branch of the Fatah. It has claimed responsibility for several shootings against Israeli civilians.
The Al-Aqsa martyrs Brigades. They have claimed responsibility for a large number of attacks against civilians and take their name from the Jerusalem mosque where the second Intifada started in September 2000. The Brigades originated from members of the Fatah. The movement would appear to have been founded at the beginning of 2001, when activists from the Balata camp near Nablus decided to create a military organisation that was lay but exploited religious feeling. When they became more radical and started to use attacks, which was new for an organisation originating from the nationalist Palestinian current, according to several declarations, it was related to the death of their leader, Raed Karmi, killed by the Israeli army in January 2002. When interviewed, Nasser Badawi, a founding member, stated that: "The Al-Aqsa Brigades were not set up by official order, but by themselves and their actions are their own. We do not receive orders from officials." 27 Ousama el Najar, official representative of the Brigades specifies in an interview: "The members of the Al-Aqsa Martyrs Brigades are warriors free of any political influence, who do not maintain relations with the leaders of the Palestinian Authority, even though some of them have key posts in the Authority's ministries or in its security services. There has been no friction between the Brigades and the Palestinian Authority"28. In the Al Ayyam newspaper, Jibril Rajoub, the chief of Preventive Security for the West Bank, described the Brigades as "the most noble event in the history of the Fatah, because they have restored the honour of the movement and raised the politics and security of the executive leaders of the Palestinian Authority". Marwan Bargouti, general secretary of the Fatah, whom the Israelis arrested and whom they accuse of being the main leader of the Brigades, which he denies, supposedly said: "The Brigades constitute the most important development the Fatah has known in military terms for the past 25 years. They will continue to exist as long as the occupation lasts"29. On March 3, 2002, while the democide attacks in Israel and in the Occupied territories were on the increase, he celebrated "the heroic operations against the soldiers and the settlers". A press release that was impossible to identify, on April 1st, presented Barghouti as the chief of the Al-Aqsa Brigades 30. As regards the attacks on civilians, Marwan Barghouti, general secretary of the Fatah, told Amnesty International that the Israelis living in the West Bank and in Gaza were not civilians, for "the whole country is occupied"31.
The Al-Aqsa Martyrs Brigades were the first to use women to carry bombs and blow themselves up in the midst of civilians. In several democide attacks, the bombs were carried by children under 18.
The Palestine Popular Liberation Front (PPLF) This is the main organisation of Marxist inspiration, founded by Georges Habbache. It has never recognised the existence of the State of Israel, but sits in the PLO. The PPLF has claimed responsibility for several "democide" attacks and the assassination of the Israeli minister for tourism, Zeevi32, to avenge Abu Ali Mustapha, its former secretary general, killed by Tsahal on August 27, 2001. Its military branch is in fact called the Abu Ali Mustafa Brigades. The people responsible for the murder of Rehavam Zeevi, including the general secretary of the PPLF, Ahmed Saadat, were arrested, condemned by a Palestinian military tribunal and transferred to Jericho prison under international control. This judgement was pronounced while the Israeli army was surrounding the headquarters of the Palestinian Authority where they were held in detention, in April 2002.
The attitude of the Palestinian Authority33
26 Interview at Rabat, with newspaper Al Qods Al Arabi from London 07.06.2002 27 The Guardian 23.03.2002 "killers revel in kudos of a US terrorism designation". Suzanne Goldenberg ; www.guardian.co.uk ; consulted on 26.11.2002 28 interview for El Intikad, weekly publication of the Hezbollah (17 August in the Lebanon), source www.intiqad.com extracted 10.11.2002 29 quoted by radio Canada on the website radio-canada.ca extracted 10.11.2002 30 Le Monde 04.02.2002 31 Amnesty International report "breaches in the principle of distinction: the attacks against civilians perpetrated by armed Palestinian groups", London, July 2002 32 see A.I 33 On that subject see a the detailed analyse in Human Right Watch Report : Suicide Bombing attacks against israeli civilian, chp VII, th Role of the Palestinian Authority p1-23 www.hrw.org
64 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
On many occasions, Chairman Arafat has condemned the attacks against civilians and in particular, democide attacks. However, the Palestinian Authority has never arrested the organisers nor have they tried them in court let alone found them guilty.
From all these elements, it appears that the Palestinian Authority by its ambiguity, bear some political and moral responsibility, if only for the absence of positive results in stopping the attacks against Israeli civilians
SOCIO POLITICAL ELEMENTS
The question of "democide" attacks and martyrs Because of their frequency, the "democide" attacks have become an important part of Palestinian political and social life and military activity.
A specialty of the Islamic groups, which is gaining popularity with the other armed groups It was at the beginning of 1994, while Israelis and Palestinians were engaged in a peace process, that Hamas claimed responsibility for the first attack of this type, thereby inaugurating a long series. Israeli security services counted, up to September 30, 2002, 206 Palestinians who have blown themselves up amidst other people, mostly civilians. Before the start of the Intifada, the 60 perpetrators of the "democide" attacks were all members of Islamic movements such as Hamas (40) or the Islamic Jihad (20).Since the start of the Intifada, while the number of "democide" attacks committed by members of the armed Islamic groups is still significant, with 52 for Hamas and 35 for the Islamic Jihad, 40 are related to groups reputed to be close to the Fatah, 5 from the PFLP and 13 did not appear to belong to any particular organisation.34
"How do we pick our martyrs?" Salah Chéhadé, commandant of the armed branch of Hamas, talks about the four selection criteria: - First of all, acceptance of religious principles. - Then, we make sure the young martyr obeys his parents' wishes and is loved by his family, that his death will not prejudice family life: the candidate must not be the head of a family and must have brothers, for we do not wish to deprive a family of an only son. - Thirdly, his capacity to seize the nature of the task that befalls him and comprehend the gravity of it. - Fourthly, his martyrdom should encourage other people to act in the same way and strengthen the love of the jihad in the hearts of the population. We always give precedence to candidates who are unmarried. The regional leadership of the military branch of Hamas puts forward a candidate, who can be accepted or refused.35
The attack, organisation that is fastidious and… expensive An attack against civilians requires a certain amount of preparation. First, you have to find the best place to hit as many victims as possible, know what goes on there daily, manufacture the explosives and hide them then select and train the candidate for "martyrdom", take him to the chosen place. This requires substantial organisation, far removed from a spontaneous act of desperation. On the contrary, a real team is indispensable to the "success" of the operation. The cost of an attack against civilians varies depending on the weaponry used. "Attacks with automatic rifles cost the price of the weapon and the equipment: at least 250 bullets and an average of 10 grenades. But some operations are much more costly; between 3,500 and 50,000 dollars, it all depends on the target".36
Bomb attacks as an integral part of political strategies The acts of violence against civilians are often carefully timed to have an impact on a political situation. And so the Israeli electoral campaign opposing Benyamin Netanyahu and Shimon Peres was studded with several attacks from Hamas, leading to the defeat of the former Nobel Peace prize. More recently, general Anthony Zini's peace mission in the Middle East was
34 Haaretz 30.06.02 35 last interview before being killed by the Israeli airforce in an operation that cost the lives of civilians including children, on the website islam.online, MEMRI www.islamonline accessed 25.05.02 36 ibid
65 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003 marked by a deadly attack by Al-Aqsa Martyrs Brigades, rapidly annihilating the possibility of dialogue between the two camps. The Arab summit in Beirut that was to examine the Saudi peace plan was welcomed by another violent action. And the last meeting between the Fatah and Hamas, held in Cairo with European mediation to plan a pause in the attacks in Israel, was hailed by the attack on the Metser kibbutz on November 11, 2002, by the Al-Aqsa Martyrs Brigades, which killed 5 people including 2 children. A spokesman for the Brigades specified, "this attack was a message to the negotiators in Cairo that the Al-Aqsa Martyrs Brigades will not cease their struggle and their attacks against Israel."37
Moral support for the attacks against civilians Moslem religious leaders, such as the grand Mufti of Saudi Arabia, Sheikh Aboulaziz Al-Shalikh, unequivocally condemn the attacks. But more and more the perpetrators of these bombings are extolled as "martyrs" to be imitated. Hamas spokesman Mahmoud Zahlar stated that according to religious dignitaries, the bombings were "the highest form of martyrdom"38. Abdel Aziz Rantissi, leader of Hamas in Gaza, specifies, however, that: "this is not simply to get to heaven and find virgins there. But because we are under occupation and we are weak"39. Important religious dignitaries in the region, such as the grand mufti of Syria, who welcomed the Pope to Damas in May, 2000 stated that "the actions of the martyrs […] represent the highest degree of sacrifice and honour", or the grand mufti of Egypt, Sheikh Ahmed al-Tayeb, speaks of the "democide" attacks as "one of the highest levels of martyrdom". Various Saudi Ulamâ have said similar things. Recently, the grand mufti of Jerusalem who has been preaching at the Al-Aqsa Mosque since 1994, nominated and paid by the Palestinian Authority, announced, in the daily newspaper Al-Ayyam, dated June 1st 2002, that Islam did not condemn the attacks as a form of resistance. Previously he was reported to have told a major Egyptian newspaper, talking about child martyrs: "the younger the martyr the more immense the respect he deserves" and also "we have not sacrificed enough to deserve the liberation of Al-aqsa" or again, in a German publication: "from an Islamic point of view, Palestine stretches from Jordan to the Mediterranean. The Jews who lived in this territory before can stay there. As for the others, they should go back to where they came from. Jews from Germany should, for example, go back to Germany. After all, you are really very fond of them, are you not?"40. The spokesman for the Orthodox Church in Jerusalem, father Atalla Hanna, was replaced for saying, among other things: "We are participating in the combat, whether by means of suicide bombings or some other means".41 The assistant to the patriarch Irinéïos, father Jibraïl Naddaf answered: "Even if I wasn't a patriarchal priest, as a human being, I cannot accept such statements. We never call to murder or massacre. This is absolutely unacceptable. These operations are attacks on peace in the Middle East". Palestinian psychiatrist Doctor Lyad Sarraj observes with concern that according to the reigning mode of thought in Palestinian society today: "terrorism and the assassination of civilians can be condemned, but martyrs can't be condemned, for martyrs are [considered to be like] prophets "42 Farhad Khosrokhavar43, analyses the double situation created in this way: those who have succumbed to sacred death call on the living to join them; those who live exalt the memory of the martyrs and replenish their energy against the diabolical enemy.
The perpetrators of democide attacks are impregnated with this morbid ideology that consists in the desire to leave this world passionately adoring death, and overcoming the taboo of assassinating the other, the enemy, the occupier. This staged ideology (video cassettes, giant posters, etc.) is full of basic phraseology that is sublimated through indoctrination and mental conditioning. In the specific case of the Palestinians, however, it is not a case of the jihadists from the world metropolis like those who operate around the constellation of Al Qaïda, even if the use of the technique of the democide attack connects them. A persecution complex, the feeling of humiliation and religion all play a part in giving legitimacy to these deadly, criminal acts. In Palestine, it is clearly a case of dying for the nation rather than for Islam, with a few exceptions, particularly among members of the Islamic Jihad.
The contradiction between the religious order that prohibits killing and the identity perceived as threatened, are part of the political field: nationalists demands are mixed with "the charria of the war". The perpetrators of democide attacks act under constant pressure and oppression, incited by the leaders of the armed groups and mobilized by a radicalised religious standpoint such as that of Sheik Yassin. What is fuelling this seems clear: a daily reality that is fraught with economic difficulties, restricted movement, repeated military controls, the development of settlements, tentative peace agreements in tatters. Whereas the speeches justifying the democide attacks highlight the "sacred" demands:
- The return of the Palestinian refugees who arrived in 1948 and their descendants - Jerusalem, capital of a future Palestinian state - A Palestine stretching from the Mediterranean sea to Jordan
37 Jerusalem post 12.11.2002 www.jpost.com consulted on 12.11.2002 38 AFP 08.05.02 39 The Guardian 12.06.2002 40 Al Ayyam 01.06.2002; Al-Arham al-Arabi 28.10.2002 ; Die Welt 17.01.2001 quoted by Marwan Haddad for www. proche-orient-info seen 08.11.2002 41 www.gulf-news.com 20.06.02 42 New-York Times 21.06.02 43 Nouvel observateur 19-25.09. 2002
66 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Social recognition for the attacks against civilians In addition to the religious dimension, "martyrs" receive powerful posthumous social recognition. Their portraits are displayed and a pre-recorded tape is shown. The families receive a lot of visitors. Hamas leaders take particular care of the parents of the "martyrs". At the University Al-Najah, the traditional base of Hamas and the Islamic Jihad, an exhibition shows a reconstruction of the attack perpetrated in the Sbarro pizzeria in Jerusalem in August 2001. Fake blood was spread all over and pieces of false corpses were hanging from the ceiling as if they had been blown into the air44. Considerable financial reward is provided by countries such as Iraq and Iran. Iraq has never concealed its political support for the strategy of the attacks. Through the intermediary of a small Palestinian organisation, the Baas party, affiliated to the Arab Liberation Front, it compensates the families of the perpetrators of the attacks with the sum of 25,000 dollars, while the parents of Palestinians killed by the Israelis receive 10,000 dollars. These payments are the subject of public demonstrations, in this way rewarding crimes against civilians. The Palestinian Authority does not try very hard to stop this encouragement. Large sums of money also come from Saudi foundations such as the Saudi Committee for the support of Al-Qods Intifada.
Considerable popular support Various opinion polls seem to show support for the attacks against civilians45. There are several explanations that may help to understand this. The permanent conflict with the Israeli army and the inhabitants of the settlements are an essential element. But the Palestinian Authority's air of impunity and even accommodation also help to explain why these actions are not rejected. In these difficult conditions, the ICRC tries to recall the principles of International Humanitarian Law. "Our programmes for publishing humanitarian law are particularly intended for the media and Palestinian Universities". Patrick Vial, of the ICRC, finds that "the young are particularly impressionable with regard to extremist ideas, exposed as they are to an incredible level of violence, humiliation and the impotence of their parents. The cult of sacrifice is reaching worrying proportions"46
The countries which support the attacks against civilians Iran and Syria were accused by the United States and Israel of supporting armed groups such as Hamas, the Islamic Jihad or the PFLP. Iran and Syria deny these accusations and claim that they provide only moral support. According to Ali Nouri Zadeh, correspondent of the Saudi daily newspaper Al Sharq al Awsat47, Iran recently decided to increase the funding and training of the armed Palestinian groups like Hamas or the Islamic Jihad, who go against the peace efforts. The headquarters of several armed groups, such as Hamas, the Islamic Jihad and the PFLP, are situated in Damas in Syria. They are allowed to set up training camps in the Bekaa valley, in the Lebanon, where Syrian troops are stationed. As a non-permanent member of the Security Council in 2002, Syria always refused to issue condemnations of groups such as Hamas or Islamic Jihad for their crimes against civilians. For his part, chairman Arafat, in the follow up to attacks against the Israeli civilians, stated that these actions were outwith his control and that they received the support of the countries and regions, without naming them.
The armed Palestinian groups clearly premeditate and organise serious breaches in International Humanitarian Law, by targeting Israeli civilians. Their political leaders have a heavy responsibility for they are at the top end of the chain of command that leads to the order to kill civilians.
The Palestinian Authority also bears responsibility, for allowing a climate of impunity to grow up around those who kill civilians; for not having taken effective steps to oppose these attacks; for not having mobilized the means of communication at its disposal to incriminate the attacks and their perpetrators; for having maintained ambiguity about moral support for the people who organise or commit these crimes.
The use of Palestinian children in the attacks against civilians
On several occasions children under 18 were involved in democide attacks. They were:
44 David Brooks, "The Atlantic monthly, June 2002 "The Culture of Martyrdom" 45 According to the Palestinian Institute Jerusalem Media and Communication Center, www.jmcc.org, survey 21 /25.09.2002, 70% of Palestinians support the military operations, among them 21% inside Israel only and 46% inside Israel and in the Occupied Territories. 46 swissinfo Frédéric Burnand 20.06.2002 47 MEMRI; special release 12.06.2002
67 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
- Mohamed Daraghmed, 17, blew himself up at the exit to a synagogue in Jerusalem, on March 2, 2002, killing 11 civilians, including 5 children and leaving 17 injured, - Issa Bdeir, 16, blew himself up at Rishon Letzion, on May 22, killing 2 civilians who were playing chess and injuring 27, - Majd Atta, 17, blew himself up in the midst of people eating falafels, in Jerusalem, on July 30, 2002 leaving several injured.
When questioned about the increasing number of victims among children attacking the settlements or the Israeli military posts in the Gaza strip, Salah Chéhadé, commander of the military branch of Hamas replies: "The spirit of the jihad and this trend in child martyrs are not being properly exploited. Although this phenomenon is positive in itself, it requires monitoring, to make the children aware of their acts and allow them to join a specialised section of the military branch… which would teach them to distinguish between what they have to do and what they should not do, and to decide when to become a martyr and when to use a weapon". And when he is asked for an explanation of the number of young candidates for "martyrdom", he says: "The number of young people reflects their good (mental) health as well as their understanding of Palestinian society, not deviating or the desire to flee the despair and frustration. There are a large number of candidates for the jihad."48 However, the Palestinian Authority, then the Islamic Jihad and Hamas denounced the attacks carried out by children, without saying at what age they became acceptable. A young 16-year-old boy, sent by Hamas, was stopped by the Israeli authorities before he blew himself up on a bus. The youngest perpetrators of democide attacks were sent by the Al-Aqsa Martyrs Brigades. The Palestinian union of journalists asked the armed Palestinian groups to refrain from taking photographs of children with weapons, because this is a breach of children's rights and because of the negative effects these photos have on the Palestinian people".49 What should be condemned, however, is arming children and not photographing them. In the Palestinian Authority's holiday camps, a large number of children, sometimes very young, were taught to handle weapons and trained in combat. Pictures of these activities were shown on many television stations50. For his part, the columnist on the Palestinian Authority's daily newspaper, Al Ayyam, analyses the reasons that push children into becoming "martyrs". With particular reference to the children in Gaza, he says they are subjected to the influence of the school, the mosque and meetings extolling sacrifice and martyrdom. "By the same token, the funerals of the martyrs and the celebrations held in their honour are always accompanied by speeches about the future life and the eternal peace [which martyrs enjoy] in paradise, which leads people to say to themselves: why wait and struggle to live a miserable life when all you have to do is press a button or simply stand in the way of Israeli fire to reach paradise?". Al-Ajrami incites the people to make efforts to get rid of this phenomenon, by taking care of the children, meeting their moral needs, following their activities closely and encouraging them to take a healthy interest in things and engage in constructive activities, looking after their psychological balance. "The same should be done in the schools and at the mosque, these are responsibilities of the Palestinian Authority" .51
As far as children's rights are concerned, Médecins du Monde recalls the moral obligations of the Palestinian Authority in order to prevent the enrolment and attacks on the lives of children. In this regard, it is interesting to underline that the Palestinian Authority participated in the work of the Special Session of the United Nations devoted to children, which was held in New York in May, 2002.
Steps should be taken by the Authority to prevent children from taking part in the hostilities, and to arrest and try the leaders of the armed groups who do not respect these commitments. Educational campaigns in the Palestinian media should aim to prevent children from taking part in military activities.
48 islam.online/MEMRI; special release n°403; le 24.07.2002; consulted 17.11.2002 49 Associated Press, August 26, 2002 50 see, in particular, the film by Charles Enderlin on France2, Autumn 2002 51 Al Ayyam, May 3, 2002
68 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Palestinian reactions against the attacks
Politicians High-ranking officials in the Palestinian Authority have condemned the operations against civilians. This is the case of the Minister of the Interior, Abd El-Razzaq Al-Yahia, who referred to his former opposition to armed confrontation, preferring a popular Intifada52. The same point of view is expressed by Nabil Amru, former Minister for Parliamentary Affairs, speaking about the suicide bombers: "I am not allowed to rejoice that the sons of my people blow themselves up in this manner. I could not send my sons to perpetrate such an act. Besides, political reality and the Palestinian leadership both discourage these operations."53
Intellectuals The appeal signed by hundreds of intellectuals, high-ranking civilians and Palestinian political leaders for the attacks against civilians in Israel to cease represents a new element and marks a political turning point. This text, initiated by Sari Nusseibeh, chairman of Al-Qods University, representative of the Palestinian Authority in Jerusalem, and Hannan Ashrawi, former Minister of Education of the Palestinian Authority and currently elected Palestinian representative, "wishes that the people who give the orders for the military operations against civilians in Israel would re-examine their policy and review their calculations and cease to incite our young people to commit these operations. For we see no advantages to be drawn from them whatsoever, apart from the consecration of the hatred between our people and the Israeli people and the widening of the gulf between them. They kill the hope of seeing the two peoples live side by side in two neighbouring states"
The families In a letter to the Arab daily newspaper Al-Hayat published in London, on October 8, 2002, Abou Saber, father of a young Palestinian responsible for a "democide" attack quoted the Koran: "Act for Allah, and may your own hands not project you into destruction. When the pure body of my son was scattered in pieces, the last signs of life were also extinguished in me, at the same time as any hope or desire to live or exist. " Speaking of the leaders of Hamas and the Islamic Jihad, "what right do these leaders have to send young people, including young boys in the prime of life, to their death? Yes, I call that death and not martyrdom. As soon as the Intifada was declared, Al-Zahar sent his son to Great Britain and the wife of Rantisi sent her son Mohamed to finish his studies in Iraq".
The Palestinian media The Palestinian site Amin is indignant: "So what was this glorious contribution that those who planned the Jersusalem attack made to the Palestinian cause? They killed school children and workwomen. What a feat! Have they brought forward the hour of liberation? Did they convince the Israelis that our claims were just? All they did was to give Sharon a new pretext to oppress us."
Some Palestinians have clearly criticised the attacks against Israeli civilians while vigorously upholding their cause. The international community, particularly the States party to the Geneva Conventions and citizens' organisations must publicly support them and encourage them to pursue this course of action.
52 Al-Hayat al-Jadida le 09.02.2002 53 Al-Qods 29.05.2002
69 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
Contents
Overview p4 Summary p6 Warning and Lexicon p8
Introduction p9 Subject and methodology p10
I. The sources of information I.1 – The figures p11 I.2 – The victims of violence p14 I.3 – Who are the civilian victims? p15
II. Eyewitness accounts II.1 – Ellad, in a market p19 II.2 – Paulina, in a discothèque p20 II.3 – Itzak, in a university cafeteria p21 II.4 – Shimon, in a bus p22 II.5 – Shmuel, in an agricultural co-operative p24
III. The weapons used against civilians III.1 – A variety of wounding agents p27 III.2 – Explosives p27 III.3 – The attacks p28 III.4 – Bombs with "special" contents p29
IV. The medical consequences of the attacks on the civilian population IV.1 – Injuries caused by the bombs p31 IV.2 – The consequences on the mental health of the civilians p35 IV.3 – The psychological trauma of the "people involved" p38
V. Taking care of civilian victims V.1 – The organisation of rescue services p47 V.2 – Medical care in hospital p50 V.3 – Psychological care for civilians p53
VI. VI. - Characterisation of the attacks according to International Humanitarian Law p56
Post script p58 Recommendations p59 Conclusion p62 Annexes p63
70 Israeli civilians victims of attacks by armed Palestinian groups © Médecins du Monde Juillet 2003
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