Looking at the Israel-Palestine conflict through a Public Health Lens

There is a health crisis in Palestine – 52% of the families live below the poverty line, access to fuel, electricity, water, and raw materials has been limited because of increased restrictions on goods since 2007, the prevalence of stunting in children has increased and the child mortality rates stalled at 1990s rates, and after the recent Israeli offensive, 22.6% of housing units were destroyed or damaged. (1,2) Many critics may see this situation as a combination of unrelated and unfortunate results in a volatile Middle East; however, these realities have a compounding effect on the health of all Palestinians.

The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.(3) A more recent report by the WHO took this a step further by acknowledging the role social determinants play on health including housing, employment, sanitation, and a social security network.(4) Health does not exist in a vacuum and affecting it takes comprehensive measures. This could not hold truer in Palestine.

The poor health status of Palestinians matters for multiple reasons, not limited to it being a “fundamental right of every human being” as stated by the WHO constitution.(3) It can also matter to American foreign policy and to our security. In President Obama’s recent speech addressed to the Muslim world, he argued that a Palestinian state living in peace and security is in the interest of all stakeholders involved including Israel. He goes on further in his speech to say, “And just as it devastates Palestinian families, the continuing humanitarian crisis in Gaza does not serve Israel’s security…Progress in the daily lives of the Palestinian people must be part of a road to peace…”(5) Taking this viewpoint, one can see how improving the health of Palestinians in a comprehensive manner, can lead to a safer, just world.

Israel has been perpetually intertwined with Palestinians’ health since its creation in 1948. Countless battles, uprisings, peace treaties, and occupation have stymied progress and hope in both areas. In more recent times, escalation of war and force has taken a disproportionate toll on Palestinian society. Since 2000, more than 6000 Palestinians have been killed by the Israeli military and over 35,000 injured. Hamas’ Gaza takeover in 2007 has triggered a strong response from Israel including increased checkpoints and the construction of the separation wall (10% of which is built on Palestinian land) which severely restricts the free movement of goods and people. This has a drastic effect on people traveling for religious or social reasons, limiting and/or delaying access to medical care, and restricting economy to the extent that 98% of industrial operations shut down the following year within Palestine.(1,2) Another example lies in the fact that within one month in 2007, there were 40 recorded cases of ambulances being denied access to patients in the West Bank.(6)

In Israel’s latest offensive on Gaza, a more direct hit was taken on the Palestinian health care system when 16 medical personnel were killed and 25 wounded while being on duty.(7) Israel has a right to self defense and to defend their freedom of life. However, they must do so with respect to the International Code of Medical Ethics which obligates physicians to “give emergency care as a humanitarian duty” unless assured that others can provide this care and their own army’s ethics code which states, “IDF [Israel Defense Forces] soldiers will not use their weapons and force to harm human beings who are not combatants”.(8,9) Israel’s hold on Palestinian life from food and medical supplies to land and shelter is complete and does not bode well for the overall health of Palestinians. This repressive approach only leads to increased vilification on both sides.

The current system of health care in Palestine is a hodgepodge consisting of the Palestinian Ministry of Health, Palestinian non-governmental organizations, the UN Relief and Works Agency, and the private sector. The public sector was only started in 1994 following the Oslo Accords which handed over certain administrative duties from Israel to Palestine. Since then, it has been characterized by a lack of coordinated funding, poor prescription drug practice, supply shortages, non-existent health information systems, and corruption. Palestinian’s lack of involvement in health leadership during the 1967 to 1994 Israeli occupation has further hampered development of the health system. Health worker shortages, especially within the allied health field, and poorly trained staff create more inefficiencies and increase costs.(6)

President Obama gave strong words towards developing the everyday lives of Palestinians as part of the peace process, but he must bring action along with oration. Over the next decade, the US will be supplying $30 billion in military aid to Israel ($2.38 billion last year alone), while $225 million economic aid was given to Palestine as of February 2009.(10,11,12) It is both counter intuitive and counter productive to fund a peace process in this manner.

In a study looking at life-satisfaction scores, Palestinian students scored the lowest compared with 35 other countries.(1) It is a dire situation, however, if we decide to look at this from a health and human rights point of view, legitimate steps can be taken towards peace. Israel must loosen its grasp on Palestine allowing for the free movement of people and goods, hand over control of their water, land, and environment, and use force responsibly and sparingly. The funding of the health system from multiple outside donors should be linked towards long term health care projects and shifted from a relief mindset to an empowering and sustainable one. Lastly, the Palestinians must join together towards establishing ethics within the public sector, using money wisely towards sustainable projects such as allied health schools and health information systems, and establish public health infrastructure.(5) There is hope in improving the health of Palestinians and a peaceful Middle East if we can look at this issue with humanity and health as a guiding force for policy

References
1. Giacaman R, Khatib R, Shabaneh L, et al. Health status and health services in the occupied Palestinian territory, The Lancet, Volume 373, Issue 9666, 7 March 2009-13 March 2009, Pages 837-849, DOI: 10.1016/S0140-6736(09)60107-0.
2. Batniji R, Rabaia Y, Nguyen-Gillham V, et al. Health as human security in the occupied Palestinian territory, The Lancet, Volume 373, Issue 9669, 28 March 2009-3 April 2009, Pages 1133-1143, DOI: 10.1016/S0140-6736(09)60110-0.
3. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
4. Commission on Social Determinants of Health. The World Health Organization 2006. Backgrounder 2: Closing the gap in a generation – how? http://www.who.int/social_determinants/thecommission/finalreport/closethegap_how/en/index.html (accessed July 23rd, 2009)
5. Obama, Barack H. Remarks By The President on a New Beginning. Cairo University. Cairo, Egypt. 4 June 2009. http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-at-Cairo-University-6-04-09/ (accessed July 23rd, 2009)
6. Mataria A, Khatib R, Donaldson C, et al. The health-care system: an assessment and reform agenda, The Lancet, Volume 373, Issue 9670, 4 April 2009-10 April 2009, Pages 1207-1217, DOI: 10.1016/S0140-6736(09)60111-2.
7. Physicians for Human Rights—Israel, Ill morals: grave violations of the right to health during the Israeli Assault on Gaza http://www.phr.org.il/phr/files/articlefile_1237966037140.pdf (accessed July 23rd, 2009)
8. World Medical Association International Code of Medical Ethics. DUTIES OF PHYSICIANS TO PATIENTS. http://www.wma.net/e/policy/c8.htm (accessed July 23rd, 2009)
9. The Israeli Defence Forces. Spirit of the Israeli Army. http://dover.idf.il/IDF/English/about/doctrine/ethics.htm (accessed July 23rd, 2009)
10. Sharp, Jeremy. Congressional Research Service Report for Congress. U.S. Foreign Aid to Israel. 2 January 2008. http://www.fas.org/sgp/crs/mideast/RL33222.pdf (accessed July 27th, 2009)
11. Erlanger, Steven. "Israel to Get $30 Billion in Military Aid From U.S." The New York Times 17 Aug. 2007. http://www.nytimes.com/2007/08/17/world/middleeast/17israel.html?_r=1 (accessed July 27th, 2009)
12. Zanotti, Jim. Congressional Research Service Report for Congress. U.S. Foreign Aid to the Palestinians. 20 February 2009. http://assets.opencrs.com/rpts/RS22967_20090220.pdf (accessed July 27th, 2009)