• Child Abuse

Separation of children from their parents as a result of state policy is one of the severest violations of the United Nations Convention on the Rights of the Child (UNCRC), which states in Article 91:

States Parties shall ensure that a child shall not be separated from his or her parents against their will, except when competent authorities subject to judicial review determine, in accordance with applicable law and procedures, that such separation is necessary for the best interests of the child. Such determination may be necessary in a particular case such as one involving abuse or neglect of the child by the parents, or one where the parents are living separately and a decision must be made as to the child’s place of residence.

Article 16 of the Universal Declaration of Human Rights2 also states that ‘The family is the natural and fundamental group unit of society and is entitled to protection by society and the State’.

The impact of separation on the child is well known from work done in the days when it was common practice for children to be separated from their parents on admission to hospital.3 Bowlby4 first described the three phases of protest: prolonged crying, despair (apathy and non-responsiveness to carers) and detachment (inconsistent responses to parents when returned to their care). Later experimental work3 demonstrated the following symptoms in separated children (particularly under the age of 4 years): anxiety, poor eating, more postoperative complications, withdrawal, poor sleeping patterns and aggression. Prolonged separation may also lead to developmental trauma,5 which can present as attention deficit hyperactivity disorder, oppositional defiant disorder and cognitive impairment.

Nowadays, every effort is made to avoid any such separation and to prepare children in advance for periods of hospitalisation, where parents are involved in the care of the children throughout. This practice is not only beneficial to children but also alleviates the burden on nursing staff of mitigating both the emotional and physical scars of a period in hospital. Hospital practices have been modified over the last 50 years to allow parents to stay overnight with their child, visit at unrestricted times, contribute to nursing care, accompany their children to anaesthesia and receive full and open information about the medical procedures being carried out. These changes have come about largely through the pressure of anxious parents and also by paediatricians and nursing staff going back to the days of Sir James Spence6 in wartime Newcastle upon Tyne, who became aware of the damage being done to the separated children under their care.

Unfortunately, children are still separated from their parents at the hands of the state despite the knowledge of the harm that may be caused. One such situation is separation at the border of the USA for immigrants and asylum seekers, which was described in the BMJ in 2020 in a blog entitled ‘Government sanctioned child abuse’.7

The same term could equally well be used for the separation of Palestinian children from their parents at the Gaza–Israel border when children are referred for treatment in Israeli or Palestinian hospitals outside Gaza. It has long been known that this issue is a serious cause for concern, as described by WHO.8 Further background to the political situation in Palestine can be found in a previous publication in BMJ Paediatrics Open9: Access to Healthcare for Children in Palestine.

Owing to the deterioration of hospitals and health services in Gaza following over a decade of sanctions and other measures by the Israeli authorities, many children with both emergency and long-term conditions require more specialised services than are available in Gaza, for conditions such as cancer, heart disease and metabolic disorders. The majority of referrals are to Palestinian hospitals in East Jerusalem and the West Bank, while some are made to Israeli hospitals which have proven over the years to offer high-quality non-discriminatory treatment and management. However, Israel requires all Palestinians—including those who pass through Israel to reach Palestinian hospitals in East Jerusalem—to request a permit from the Israeli authorities before they can leave Gaza.

Parents also require a separate permit to accompany children (an accompanier’s permit). For a large number of children, such accompanier permits are withheld by the Israeli authorities on security grounds, with the consequence either that the referral cannot take place or that another family member (usually grandparent) or an unrelated friend travels with the child. This leads to severe distress on the part of the child and often imperfect communication with the family over the management of the child’s condition.

In a recent publication,10 Physicians for Human Rights (Israel) (PHRI) has reported on data collected over a 2-year period on the number of permits declined, and also on the failure of Israeli medical and paediatric organisations to appeal to Israeli authorities to change the regulations to be consistent with the UNCRC. Here we consider both the data and their implications, and the responsibilities of medical associations.

PHRI carried out the project between 2018 and 2022 in which assistance was offered to parents residing in Gaza whose child had been referred to a hospital outside the enclave. The parents (primarily mothers) of 180 children between 2 and 18 years (including breastfed babies) who were denied permits requested such assistance. Problems leading to the referral included cancer (26%), heart disease (18%), neurological ailments (10%) and smaller numbers of genetic, ophthalmic, renal and intestinal problems. Following the intervention of PHRI, 65% of permit requests were accepted and 35% were refused.

Further, PHRI states that Israeli Ministry of Defence figures show that in 2019, 20% of the children who left the Gaza Strip for medical care did so without their parents. Only 4165 accompanier permits were granted, while 5289 medical exit permits were granted to children. Hence, at least 1124 parents were not allowed to accompany their children for medical care outside of Gaza. Of 80 children received from Gaza in 2020 by Augusta Victoria Hospital in East Jerusalem, 20 came without parents (14 were with grandparents, 5 with an aunt and 1 with a neighbour).

The reason for refusing accompanier permits to parents is normally stated as ‘security’ and there is no appeal possible. One patient cited in the report, a child of eight, has been attending an Israeli hospital for 4 years for thyroid cancer. On repeated application for a permit by the parents, the response has been that the request is ‘under review’. However when PHRI intervened, a permit was immediately granted. Such arbitrary responses cause great anxiety and stress to parents who are already undergoing much hardship owing to their child’s severe illness. They also demonstrate the often unreasonable and capricious nature of refusal said to result from security concerns.

It would be hoped that Israeli paediatric and medical associations would urge the authorities to reform their policies in line with the UNCRC. Is it within the remit of such associations whose primary responsibility is the well-being of their members, to advocate for the public health of the population? There is much precedent for such work and it has long been part of tradition of doctors across the world, to speak out on behalf of their patients. The role of advocacy in politics was recently emphasised by Professor Martin McKee writing in the BMJ11 in March 2022. Further, the Lisbon Declaration on the Rights of the Patient12 states that ‘The following Declaration represents some of the principal rights of the patient that the medical profession endorses and promotes. Physicians and other persons or bodies involved in the provision of health care have a joint responsibility to recognize and uphold these rights. Whenever legislation, government action or any other administration or institution denies patients these rights, physicians should pursue appropriate means to assure or to restore them.’

In the UK, the Royal College of Paediatrics and Child Health13 14 has been a strong advocate for the UNCRC in relation to child poverty and undocumented migrants.

It is undoubtedly true that such advocacy may have undesirable consequences in a state where dissent is not accepted and may lead to a prison sentence. This should not be the case in Israel, where PHRI and international paediatric organisations have requested that the Israeli Medical Association (IMA) and Israeli Pediatric Association (IPA) intervene to uphold children’s rights. However, the response from the associations is that they ‘do not believe this is the mandate of any medical organization’.15

If what is being seen currently in Gaza is in fact state-sanctioned child abuse, then we would urge all those within Israel and specifically child health professionals to speak out on behalf of these children and ask the IMA and IPA to do the same.