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Thursday, 30. March 2023


Settlements and separation in the West Bank: Future implications for health

The conflict and socioeconomic isolation that has been engendered by the policies of settlement expansion and separation barrier construction is the arguably the most pervasive threat to the health status of Palestinians in the West Bank. The acquisition of 60% of the West Bank, known as Area C,for ‘near exclusive’ Israeli control has become a major obstacle to delivering basic services. The example of Western Bethlehem is typical of the broader situation across the West Bank where the completion of the separation barrier is projected to reduce access to essential services for over 23,000 Palestinians by separating nine communities from their surrounding agricultural lands. Aida Refugee camp, with some five thousand refugees, is situated within the West Bank town of Bethlehem. Presently, the Israeli Defence Force (IDF) are stationed at watchtowers along the separation barrier between Aida camp and the Israeli settlements of Har Homa and Har Gilo. Clashes between refugees in the camp and the IDF have now become a matter of routine. Typically the IDF respond to stone-throwing protesters using tear gas canisters and rubber-coated metal bullets (a type of ‘non-lethal’ round used with conventional weapons).

Serious injury is a common outcome on both sides but the predominance of injuries to children is particularly concerning. Whilst some children are actively engaged in stone-throwing most are simply bystanders. In one such incident witnessed by us (PB, WK), following the arrival of the Palestinian Civil Police Force to disperse a small stone-throwing crowd, two rubber bullets were fired by the IDF patrol. The first hit a teenager in the leg, whilst the second passed further behind the police line, unfortunately hitting a seven-year old boy in the head causing major peri-orbital trauma. Although IDF engagement rules require rubber bullets to be aimed at the legs; the reality is that these rounds strike all parts of the body. Misaimed rubber bullets are not the only threat to children, with the use of stun grenades and a worrying increase in the amount of tear gas canister injuries documented.

Contact rules currently operated by the IDF mean that there is also no discrimination over location of engagement with protesters. The Lajee community centre in Aida camp mostly looks after children between the ages of three and fifteen, but it is currently the focus of hostile clashes between the IDF and protesters. As IDF patrols are an almost daily event, it is not unusual for occupants of the community centre to be exposed to more than two hours of tear gas, two to three times per month. The evacuation of the centre is difficult when rubber bullets pose a serious threat of injury to the children when outside. The work of James Garbarino has examined how exposure to chronic violence poses a serious threat to childhood development. Presently, this long-term exposure is undermining the efforts of community workers.

Additionally, the isolation enforced by the separation barrier and frequent military operations also creates a real stranglehold preventing Palestinians from accessing essential services such as education, health, or even water. Our field work outside the camp documented the military demolition of wells in the Bedouin village of Umm Al Kheer, south of Bethlehem and Hebron. It is evident that the Bedouins are an extremely vulnerable population in both Israel and Palestine and will likely face similarly poor health outcomes as those we have observed in Aida and Dheisheh Refugee Camps.

The interactions between settlers, soldiers and Palestinians are creating a worrying trend towards a selfperpetuating cycle of violence. The ability to record such injuries caused by violence is highly relevant for both policy and diplomacy, in order to allocate limited resources more effectively. The UN Office for the Co-ordination of Humanitarian Affairs (OCHA) in the occupied Palestinian territory undertook surveillance indicating showing that in 2012, 3,179 injuries and 9 fatalities were recorded due to direct conflict, the majority of these were from riot dispersal methods. In 2013, with increasing ‘search and arrest operations’ by the IDF, UNOCHA reports a concerning increase in the rate of injuries, particularly to children. Further to this, there is no evidence of any military accountability for injuries inflicted.

We found a notable absence of injury surveillance within UN Relief and Works Agency for Palestine Refugees (UNRWA) health centres. Health workers report an inability to record such data due to potential loss of identifiable patient information to the IDF resulting in a risk to the patient which may include imprisonment for involvement in protests. Additionally, capacity to collect injury data is limited both by time-constraints and paper-based record keeping. The local health centre in Dheisheh Refugee Camp, near Bethlehem provides free primary care for more than 17,000 registered refugees, including those from Aida, equating to 107 daily patient consultations per doctor.

More broadly, the continued development of the separation barrier and settlement expansion are creating an environment where IDF operations bring the local population into continued exposure to riot dispersal methods and their associated morbidity and injury. Most Palestinians have seen their access to the most basic needs cut down by the barrier itself, settlement expansion, or even by marking the areas around them as Area C and subsequently declaring these as military ‘Firing Zones’.

Inevitably these policies of separation barrier construction and settlement expansion will lead to poorer health outcomes across the population. A resolution to this is imminently required for both sides to the conflict particularly given that the next generation consists of a young urban demographic. Solving this will require a political solution to halt further settlement expansion and cessation of construction ofthe separation barrier in Western Bethlehem, alongside a much broader rethinking of the ‘strategic impasse’ of IDF operations within the West Bank due to the implications for Israel’s long-term security and Palestinian health.


1. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Area C of the West Bank: Key Humanitarian Concerns. January 2013. 2013 [Accessed 23 September 2013]; www.ochaopt.org/documents/ocha_opt_area_c_factsheet_January_2013_english.pdf.

2. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). The Humanitarian Impact of the Barrier. July 2013. 2013 [Accessed 23 September 2013]; www.ochaopt.org/documents/ocha_opt_area_c_factsheet_January_2013_english.pdf.

3. UN Relief and Works Agency for Palestine Refugees (UNRWA). Where we work. 2013 [22 September 2013]; http://www.unrwa.org/where-we-work/westbank/campprofiles?field=12.

4. Garbarino, J., An ecological perspective on the effects of violence on children. Journal of Community Psychology, 2001. 29(3): p. 361-378.

5. Palestinian Central Bureau of Statistics (PCBS). Census Final Results in the West Bank Summary (population & housing) – Population, Housing and Establishment, 2007. 2008. [Accessed 11th October 2013]; www.pcbs.gov.ps/Portals/_PCBS/Downloads/book1487.pdf

6. Catignani, S., The strategic impasse in low-intensity conflicts: The gap between Israeli counter-insurgency strategy and tactics during the Al -Aqsa Intifada. Journal of Strategic Studies, 2005. 28(1): p. 57-75.