The borders between Israelis and Palestinians are among the most formidable in the world. The walls are high, the guards on both sides are well-armed, and the consequences of being caught on the wrong side can be severe. Those are only the physical borders; the emotional borders can be even more heavily fortified. And yet they can be porous when it comes to blood, illustrating that – even in this fractious part of the Middle East – preserving life with blood transcends borders.
Speaking with ASH Clinical News, Asher Moser, MD, deputy director of blood services at Magen David Adom (MDA), Israel’s Emergency Medical Service, recalled an incident that exemplified cooperation between the Jewish and Arab citizens of Israel. In 2006, a Palestinian man set off a suicide bomb in Israel, and, presumably, didn’t know he had a globoside-deficient P2K phenotype, one of the rarest blood types in the world. MDA arrived on the scene, but the man’s rare blood type posed a problem: His family members and compatible donors were over the border in Palestine. Special arrangements were made with the Palestinian Red Crescent Society, a humanitarian organization associated with the International Red Cross, that allowed an MDA phlebotomist team to meet the family members at a border crossing with a mobile blood unit. There, they collected seven units of compatible blood and saved the bomber’s life.
To the rest of the world, it may appear that the Jewish and Arab populations of Israel and the West Bank have few social interactions, but blood services is one area where these groups have established a working relationship. This month, ASH Clinical News spoke to people on both sides to offer a revealing look at the collection and provision of blood and blood products in Israel and the Palestinian territories.
The Vein-to-Vein Chain
MDA is a nongovernmental organization charged by the Israeli government with a host of responsibilities. Their 2,500 employees and more than 20,000 volunteers (from all religions and communities in the country) provide emergency medical services across Israel and much of the Palestinian territories. MDA also runs the national blood services, coordinating the donation, processing, and dispersion of not just blood and blood products but also rare blood types and cord blood.
“A few years ago, it was considered that [Arab Israelis] wouldn’t be willing to donate, and very few donated regularly, in part because they thought the blood would be supplied to soldiers in the Israeli Defense Forces,” Dr. Moser explained. “We conducted some fruitful meetings with leading figures in the Israeli Arab community, clarifying that most of the blood is supplied to civilians and that we need them to donate so we have enough for everyone who needs it,” said Dr. Moser.
Now, the Arab citizens of Israel donate in proportion to their numbers: “They represent about 20% of the population and they donate about 20% of the blood we collect,” said Dr. Moser, who keeps a close eye on a ticker on his computer that monitors how much blood has been collected each day.
To maintain an adequate supply, MDA needs to collect about 1,000 units per day, six days per week. Blood is not collected on Saturday, the Jewish sabbath.
“Blood is the one area where there is complete brotherhood and
sisterhood between Jews and Arabs in this country, and good coordination and cooperation between Jews and Palestinians in the territories.”
—Asher Moser, MD
On Jewish holidays, the Arab, Druze, and Bedouin populations pull their weight, according to Eilat Shinar, MD, director of MDA Blood Services. Those days, “we schedule extra blood drives in Arab villages and cities, and among the Druze in the north and the Bedouins in the south, and they know we really count on them,” she said. “Everybody donates because everybody looks at it as saving lives, which I think is amazing. We don’t separate donations as Jewish blood or Arab blood.”
“If somebody says they don’t want their blood to go to this or that population, we simply do not collect that unit. We say, ‘Thank you very much, but you cannot donate here because we take from those who donate and give to those who need it,’” Dr. Shinar added. “These are the two ends of the vein-to-vein chain and there is nothing in between.”
For Drs. Moser and Shinar, both hematologists by training, a second career in blood services was not a foregone conclusion. They both trained in Israel and the U.S., spending many years practicing clinical hematology before joining MDA.
Dr. Shinar, who was a fellow and senior physician at Hadassah Medical Center in Jerusalem prior to joining MDA, said the decision was an easy one. “In the blood services, we work with 260,000 volunteers a year – not just the blood donors, but also the people who help run the blood drives. When you work with volunteers and everyone’s work is constantly saving lives, it is very meaningful,” she commented. “I went to medical school to help people, and at MDA I’m doing this now on a much larger scale.”
Beyond East Jerusalem, farther into the West Bank, where a person gets blood (and other health care) depends to some extent on where that person lives. In 1995, the Oslo II Accord (an agreement to establish an interim Palestinian government with the goal of a future peace agreement) divided the Israeli-occupied West Bank into three administrative areas: A, B, and C.
In Areas A and B, health services are provided by the Palestinian Ministry of Health and emergency medical services by the Palestinian Red Crescent Society. Together, these areas constitute about 40% of the entire territory and include no Israeli settlements.
Area A is under full civil and security control of the Palestinian National Authority (PNA). Jewish citizens of Israel are forbidden by law to enter Area A and are discouraged from traveling to Area B, which is under Palestinian civil control and joint Israeli-Palestinian security control.
“In Areas A and B, the PNA established a central blood bank in Ramallah, which supplies most of the hospitals in that area, but they lack training and technology in some special procedures, like solving problems of antibodies and rare transfusion reactions,” Khaled Khleif, director of the Blood Bank at Al Makassed Hospital, an Arab hospital of the Makassed Islamic Charitable Society in East Jerusalem, said. “We don’t supply all their needs, but we give them some of their platelets, red blood cells, and plasma.”
Area C of the West Bank, which constitutes the remaining 60% of the territory, is under Israeli civil and military control, and is home to approximately equal numbers of Jews and Palestinians. The Israeli population in Area C is administered by Israeli authorities, while the Palestinian population is administered indirectly by the PNA in Ramallah.
This has created a patchwork map of responsibilities: MDA provides emergency medical services to Area C, but not to Areas A or B. Palestinian residents of Area C also rely on the Palestinian Red Crescent Society for emergency medical services, while the PNA is responsible for non-emergency medical and educational services.
But to Dr. Shinar, these distinctions are virtually meaningless. “If somebody from Ramallah or Beit Jala calls us and says, ‘Listen, I have a patient with a rare blood profile, can you help?’ and we have that unit in inventory, we’ll send it. If we don’t have it, we’ll try to help them find it.”
“I honestly don’t care if it’s Area A, B, or C. If a hospital calls us and they need blood, we provide it if we can,” she added.
“Everybody in the world is in the blood family. As a member of the International Federation of Red Cross and Red Crescent Societies, we have given and received rare blood units with countries that Israel doesn’t even have diplomatic relations with,” Dr. Shinar continued. “And, if we have a patient in need, we’ll also go to the International Blood Group Reference Laboratory in Bristol [in the U.K.] and receive help.”
Dr. Shinar noted that since 1993, when the Oslo I Accord was signed and Gaza went under direct Palestinian administration, the health authorities there have neither asked for nor received blood products from Israel.
A Bomb Shelter for Blood
MDA runs Israel’s only blood processing center in Tel HaShomer, a Tel Aviv suburb that is in range of Hamas rockets in the Gaza Strip and Hezbollah rockets in southern Lebanon. To protect the blood supply, the agency devised a creative solution: bury it 15 meters below ground.
In 2016, MDA started constructing a new underground blood processing, testing, storage, and distribution facility, to be named the Marcus National Blood Services Center.
The threat to the nation’s blood supply cannot be overstated. “If a blood center in the U.S. goes down for any reason, there are 15 other centers across the country that it can tap, but here, we can’t rely on that,” said Dr. Moser. He noted that, should their blood system collapse for any reason, MDA has an emergency contract with Blood Centers of America, a network of more than 50 blood collection and supply centers in the U.S. “If I call and say, ‘We need help,’ within 48 hours there will be thousands of units flown to Israel.”
So far, such drastic action has been avoided, but there have been a few close calls. On July 8, 2014, MDA Director-General Eli Bin called Dr. Shinar to warn her of possible rocket attacks from Gaza in response to tensions in the area. Staff and volunteers mobilized to relocate the nation’s blood supply and equipment from the upstairs laboratories at the National Blood Center to their 400-square foot underground bomb shelter. For the next 50 days, they remained underground while still processing and shipping approximately 60,000 units of blood to hospitals and the Israeli Defense Forces. The latter relies on MDA for 100% of their blood needs because there is no separate military blood bank in the country.
In addition to needing a more secure site, MDA is building the new center to increase capacity and earthquake resistance. Israel lies on a fault line and expects to be hit by a major earthquake within the next 20 years.
“Our current center was built in the 1980s, when we were processing about 175,000 units each year,” Dr. Shinar said. “Today, we are processing 250,000 units each year, and we need to be prepared in another 20 or 30 years to handle half a million units each year.”
Within two years, the MDA will move their central blood services to the new center in Ramla, a mixed Jewish-Arab town about 15 kilometers south of Tel Aviv. With three floors above ground and three below, the blood stores upon which the country depends will be safe in the event of war, but also when the expected earthquake hits.
“All the laboratories will be below ground and it won’t look like a big bomb shelter, but we can turn it into a shelter very quickly and do all our processing, testing, and distribution from a secure place under ground,” Dr. Shinar explained.
Building a rocket-proof home is just one effort the MDA has undertaken to protect the country’s blood supply. The daily accounting of how many units of fresh blood are available at each of the major hospitals and within MDA facilities is compiled manually. Nothing is trusted to cyberspace.
“The hospitals call in every day – no email, only phone – and tell us how many units they have,” Dr. Moser explained. “We keep a chart on a computer but in a completely closed circuit, no connection in or out.”
“We are the only blood bank for the entire country, so we are very concerned about what might happen if the system is ever hacked,” he added.
Blood Supply in Palestinian Territories
Maintaining a plentiful and safe blood supply in the Palestinian territories also is challenging, partly because donation levels are lower. Historically, the value of blood donation is less ingrained in Palestinian society, and blood banks sometimes struggle to get enough donations, especially during the 29 or 30 days of Ramadan when observant Muslims fast from dawn to sunset.
According to Mr. Khleif, things have improved. “Back in the 1980s and ‘90s, it was hard to get people to donate, but the new generation believes more in giving blood and they understand the benefits of giving blood, so they come [to our center] more,” he said. “All our donations now are unpaid. They get some sweets and juice, and that’s it.”
East Jerusalem – where Al Makassed Hospital is located – was annexed by Israel after the 1967 Six-Day War. Today, its residents receive similar medical benefits to Israeli citizens. Augusta Victoria Hospital, one of six Palestinian-run hospitals in East Jerusalem, is expanding from a secondary-care hospital to a “specialized center of medical excellence” that provides hematology and bone marrow transplantation care, among other services.
Mr. Khleif’s hospital-based blood bank collects between 500 and 600 units a month and separates 95% of what they collect into blood components. The blood and blood products are used in-house and sent to several other hospitals in East Jerusalem and other Palestinian locales, including several hospitals in Bethlehem and Beit Jala. Both of these towns are in Palestinian-ruled areas of the West Bank, where health services fall under the responsibility of the Palestinian Ministry of Health. Despite their virtually all-Palestinian service area, Al Makassed Hospital receives blood services from the MDA.
“If we need rare blood or have a shortage in some blood type, we call the MDA’s National Blood Center in Tel HaShomer and they send it,” Mr. Khleif told ASH Clinical News. “They are very honest to deal with and very cooperative in sending us whatever we need.”
“We are responsible for East Jerusalem, and we give them the best service that’s available to everybody, with no compromise,” said Dr. Moser.
Blood Brothers (and Sisters)
In a heartening sign of the potential for further cooperation and understanding, all of the individuals who spoke with ASH Clinical News agreed that blood, and medicine more generally, is and should be above politics. And the relationship appears to be working for the most part. When asked about his pain points, Mr. Khleif mentioned that he would like his staff to receive advanced training in transfusion medicine at the Israeli National Blood Center in Tel HaShomer, “but this requires authorizations and the politics are complicated,” he said.
“We don’t want to be involved with politics; we just want to be treated as a group coming for training in transfusion medicine, and not let anything else interfere with that,” Mr. Khleif said. (Editor’s note: This message was passed to Dr. Shinar, who said that she would be pleased to provide such training and would personally work to overcome any security issues.)
“Blood is the one area where there is complete brotherhood and sisterhood between Jews and Arabs in this country, and good coordination and cooperation between Jews and Palestinians in the territories,” said Dr. Moser. —By Debra L. Beck
Sixty years of near-continual conflict have produced some difficult issues in the delivery of medical care in the Palestinian territories. The magnitude and causes of these difficulties depend on who is interpreting the data. Reports from pro-Israeli, pro-Palestinian, and supposedly unbiased sources can be markedly divergent.
The official provider of health care in Palestinian-controlled parts of the West Bank is the Palestinian Ministry of Health, but this group relies heavily on support from the World Health Organization (WHO) and other nongovernmental entities. Hospitals in the territories often are poorly equipped to provide advanced medical care.
Palestinians unable to receive necessary care locally can apply to Israeli authorities to access health care at one of the Palestinian hospitals in East Jerusalem or in hospitals in Israel. According to the WHO, in February 2019, West Bank patients or caregivers submitted 16,622 applications to Israeli authorities to access care in East Jerusalem and Israel. Of these, 81% were approved, 17% were denied, and 2% were pending at the time of monthly reporting.1
Many women above age 50 and men above age 55 are exempt from the requirement mandating a permit to travel, given certain conditions, as per the WHO.
Because there have been documented cases where ambulances from the West Bank were found to be transporting bombs or people with terrorist intent disguised as patients, the vehicles are stopped and searched at border crossings.
When they are prevented from passing, a “back-to-back” procedure is employed: The Palestinian ambulance brings the patient to the border crossing and transfers him or her to an MDA Israeli ambulance, which transports the patient to the final health care facility. However, this practice can slow the transport of seriously ill patients by up to 20 minutes.
Security issues may make it difficult for Palestinian health care workers to train and function normally, according to the Coordination of Government activities in the Territories (COGAT), the Israeli unit of the Ministry of Defense. This unit is charged with administering the government’s civilian policy in the territories. In 2015, 1,700 Palestinian physicians participated in medical trainings in Israel and abroad, and more than 100 worked in Israeli hospitals to gain experience with the public health system in the territories.2
Payment also is an ongoing point of contention. Israel deducts payment for services rendered to Palestinian residents from tax revenues they collect for the PNA. Recently, the Palestinian Ministry of Health complained that the amounts charged are excessive. Instead, it will send patients to medical centers in Jordan.3
“We will no longer refer patients to Israeli hospitals because Israel has been overcharging us for medical services and taking funds for medical bills without our permission,” PNA Health Ministry spokesperson Osama al-Najjar told The Times of Israel in March 2019, hinting at the persistence of deep-rooted contentions between the areas. According to most sources, about 100,000 Palestinian patients are treated in Israeli hospitals every year.
In Gaza, the situation is far bleaker. According to the United Nations, Gaza is suffering from a long-term health crisis as a direct result of continual conflict with Israel and the Israeli blockade of goods to the region. Extended noncooperation between the PNA in the West Bank and Hamas in Gaza and underpaid health workers only intensifies the situation.4 There also is credible evidence that hospitals in Gaza – some of which have been damaged by Israeli air strikes – have sheltered terrorist activities.5
The WHO reports that, in February 2019, 1,637 patients applied to cross from Gaza into Israel for medical care, about 24% below the average number of applications. Of these, 72% were approved, 7% denied, and 21% delayed, meaning they received no definitive reply to their request before their scheduled hospital appointments. (The WHO does not provide information as to whether these delayed applications were submitted with enough advanced notice before the scheduled appointments.)
Most of these applications requested appointments in East Jerusalem hospitals, and one-fifth of applications were for West Bank hospitals. Permit applications for the top five specialties accounted for more than 65% of referrals: oncology (32%), orthopedics (10%), hematology (8%), cardiology (8%), and pediatrics (7%).
Another option for Gazans is to travel to Egypt, but this has become more difficult since 2013, when the Egyptian government began closing the Rafah Crossing between Gaza and Egypt for all but a few days each month. When Rafah was regularly open, Egypt accepted thousands of patients for treatment each month.
In December 2018, 98 patients crossed from Gaza to Egypt for health care, according to the WHO. (No data have been made available for the number of patients crossing in 2019.) Despite the dire situation in Gaza, no medical aid or medical delegates entered Gaza via the Rafah terminal during the month.
- World Health Organization. Monthly Report. Health Access: Barriers for patients in the occupied Palestinian territory, February 2019. Accessed June 2, 2019, from http://applications.emro.who.int/docs/Pal/Monthly_report_PAL_Feb_2019_en.pdf?ua=1.
- Coordination of Government Activities in the Territories. Healthcare. Accessed June 2, 2019, from http://www.cogat.mod.gov.il/en/Judea_and_Samaria/Pages/JSHealthSection.aspx.
- The Times of Israel. PA stops referring Palestinian patients to Israeli hospitals. Accessed June 2, 2019, from https://www.timesofisrael.com/pa-stops-referring-palestinian-patients-to-israeli-hospitals/.
- United Nations Office of the High Commissioner. UN experts say Gaza health care at “breaking point.” Accessed June 2, 2019, from https://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=23236&LangID=E.
- The Washington Post. Why Hamas stores its weapons inside hospitals, mosques and schools. Accessed June 2, 2019, from https://www.washingtonpost.com/news/morning-mix/wp/2014/07/31/why-hamas-stores-its-weapons-inside-hospitals-mosques-and-schools/?noredirect&utm_term=.a0112703ce41.