Volume 24/2, December 2022, pp. 281-292 | PDF
Ghada Majadli and Hadas Ziv
Abstract
In this paper, we seek to contextualize amputations sustained by Palestinians during the Great March of Return within a framework of settler-colonial ideology and practice. Utilizing case studies identified in our advocacy work at Physicians for Human Rights Israel, we evaluate the conditions in which these amputations occurred and their relationship to the politicized Palestinian body, land, and nation. Through evaluating themes of intentionality and subjugation, the politicized Palestinian body, and reflections on the challenges of navigating human rights and humanitarian possibilities, we reflect on our work and the ability to advocate for health justice in inherently violent and eliminatory bureaucratic and legal systems. We conclude with a discussion on the utility of a human rights approach that is divorced from a structural and historical analysis of the dire situation on the ground.
Introduction
Settler-colonial control over health access
Since 1948 and with the establishment of the state of Israel, Israel has been deploying physical and structural violence against Palestinians in multiple well-documented ways, all aimed at the erasure, subjugation, and oppression of the Palestinians, in line with what Patrick Wolfe has called the “logic of elimination” in settler-colonial states.[1]
Israel’s colonial ideology is manifested in the “daily assault on Palestinian life as a result of settler-colonial ideology that renders them killable as a part of and a furthering of their removal from their land.”[2] For Palestinians, health is inextricable from the ongoing Israeli settler-colonial project of dispossession and erasure, creating a colonial reality that is fundamental to all other determinants of health—be they clinical, economic, social, or political.[3]
While the control and the responsibility over most health determinants that Israel has vis-à-vis Palestinians obligates it to ensure their protection and implement their right to health, Israel ignores its legal obligations as stipulated in international human rights law, as well as its duties under international humanitarian law as an occupying power. The Israeli state denies Palestinians health care resources, blocks their access to medical care, and attacks health care infrastructure and units.[4] Israel argues categorically that it bears no responsibility for the health care of Palestinian residents in the occupied Palestinian territories (oPt), which runs contrary to several human rights conventions, including the Geneva Convention. Since Israel controls all exits and entries between the occupied areas (East Jerusalem, Gaza, and West Bank), impacting the flow of people, medical equipment, and pharmaceuticals, the Palestinian system thus depends on Israeli permits for every referral and development. However, backed by numerous high court decisions, Israel defines the granting of such permits as a humanitarian gesture and not as an obligation, and thus is always subordinating it to Israeli “security” priorities.
The Great March of Return
The Great March of Return (GMR) saw thousands of Gazans protesting near the fence between the artificial borders of the Gaza Strip and Israel. The demonstrations occurred weekly, every Friday, between March 30, 2018, and late 2019, demanding to return home—or more precisely, to march home to nearby villages depopulated of their Indigenous people during the Nakba of 1948 and claimed by Jewish settlers. The protest was also aimed against the ongoing land, air, and sea blockade of the Gaza Strip imposed by Israel. Peaceful and unarmed for the most part, Palestinians in Gaza challenged Israeli soldiers and snipers posted 700–1,000 meters away from them, fully protected and armed.
Israeli forces responded with excessive, lethal force, including rubber bullets and live ammunition, mostly fired by snipers. As a result, 214 Palestinians, including 46 children, were killed, and over 36,100, including nearly 8,800 children, were injured. One in five of those injured (over 8,000) were hit by live ammunition. Over 7,000 of the live ammunition injuries (88%) were limb injuries, followed by injuries to the abdomen and pelvis. Amputations were required in 156 of the limb injuries (126 lower limbs and 30 upper limbs). At least 94 of the 156 cases involved secondary amputations due to subsequent bone infections.[5]
The continuing Israeli siege and de-development of Gaza’s health care system posed a serious challenge to medical staff during the GMR protests. Timely evacuation of the injured during the GMR from the place of injury to the hospital depended on the military’s respect for the medical teams and their safety—but several attacks on Palestinian medical staff operating during the GMR led to the injury and sometimes the killing of those medical teams.[6] Moreover, arrival at the hospital was not always followed by adequate care. Hospitals with limited capacities, overwhelmed by large numbers of casualties every Friday (the day of the protests), were pushed beyond their limits, making adequate treatment unavailable.[7] Shortages in expertise and medical equipment were among the obstacles faced by physicians in Gaza’s hospitals, resulting in referrals for treatment outside Gaza. Those patients faced the hurdle of seeking financial coverage from the impoverished Palestinian Authority. And if this ordeal were not enough, they had to apply for an Israeli permit to exit the Gaza Strip—a long bureaucratic procedure that delayed or sometimes even prevented their exit.[8]
According to the World Health Organization, “In 2018, Israel continued its requirement for the submission of non-urgent patient permit applications 23 working days in advance of any hospital appointment, increased from 10 working days in 2017.”[9] Yet applying ahead of time does not necessarily guarantee that patients will obtain permits, as applications are often delayed or denied. In 2018, for example, only 61.4% of applications from Gaza were approved, meaning that patients had to go through the bureaucratic procedure of reapplication.[10] Out of the 604 permit applications submitted for people injured during the GMR, only 17% were approved; 28% were rejected, and 55% did not receive an answer in time for the medical appointment.
In a testimony published by Physicians for Human Rights Israel (PHRI) on April 20, 2018, Abed Al-Majid Klub, head of vascular surgery at the European Hospital in Gaza, said, “When 10–15 injured demonstrators arrive at the hospital at the same time, the small staff cannot treat them as fast as their condition requires … some lost their legs and even their lives due to shortage of medicines and medical equipment.”[11] He also said that five people who suffered liver injuries died due to the lack of an expert in hepatic surgery.
Amputees needed urgent care and rehabilitation; others needed to access specialized treatment in medical facilities in the West Bank, East Jerusalem, and Israeli hospitals, as Gaza can provide only basic prosthetics.[12] Yet Israel denied most injured protestors’ medical permit requests to access specialized treatment and more advanced medical centers. Many wounded protestors were thus denied a fair chance at saving their limbs, which they might have had if treatment were available in Gaza or if Israel had not deprived them of their right to timely access to adequate treatment, mostly in Palestinian hospitals.
Palestinian health and settler-colonial ideology
This paper brings the health of Palestinians into conversation with settler-colonial ideology and practice, utilizing the backdrop of case studies identified through our roles in PHRI. We examine Israel’s deliberate amputation of the individual Palestinian body and the ways it symbolizes and carries with it the amputation, or fragmentation, of the Palestinian nation and land. Combining direct and bureaucratic violence, Israel divides Palestinians into classes with different civil status (citizens, residents, subjects), deprives them of capacities and resources, and attempts to reduce their lives to a bare minimum. These practices have been implemented for decades through the use of different legal categories and frameworks that govern in different ways the lives of Palestinians citizens of Israel, Palestinians residents in occupied East Jerusalem, stateless Palestinians under military rule in the West Bank, and Palestinians besieged in the Gaza Strip. This semblance of legal practices, while maintaining an active violent military occupation, creates a situation in which “the state of law and pure violence, are not more separated, neither temporally nor conceptually.”[13] Israel’s ability to enact its power continued even after the 1994 Oslo Accords and the creation of the Palestinian Authority (PA) as a body with limited sovereignty to govern Palestinian lives under a supposedly temporary occupation. This situation allowed Israel to disregard its obligation as an occupying power and outsource it to the PA, while de facto maintaining an active belligerent military occupation.[14]
We contextualize amputations in the Gaza Strip during the Great March of Return by looking at the conditions in which these amputations occurred and at the Palestinian body as a political body. Based on our experience while advocating for access to adequate care for numerous Palestinian patients, we also aim to draw a link between amputations and “healthy” body politics, as articulated by Danya Qato, while simultaneously examining not just the state of health in which these amputations occurred but also the state of health in which they were treated or alternatively rendered disposable.[15] We then reflect on the efficacy of both humanitarian interventions and human rights frameworks, suggesting that lacking the historical political context, they are destined to be extremely limited and in some cases can even reinforce the very systems they attempt to change.
Physicians for Human Rights Israel
PHRI is a nongovernmental Israeli organization working to promote the right to health for all people living under Israel’s sovereignty and control. PHRI delivers humanitarian assistance to Palestinians in the West Bank and the Gaza Strip, and it documents violations of the right to health committed by Israel. The organization works to overturn unjust policies using legal, advocacy, educational, and public activities. One of the pillars of PHRI’s activities is to use legal interventions to challenge Israeli authorities’ permit regime and their denial of medical permits for patients from the Gaza Strip and the West Bank.
During the months of April and May 2018, PHRI’s staff handled multiple cases of injured protestors and held countless conversations with medical staff in Gaza hospitals and with the families of the wounded. PHRI filed petitions with the District Court and the High Court of Justice in five separate cases of injured individuals whose applications to exit for urgent and lifesaving treatments, mostly in Palestinian hospitals in the West Bank and East Jerusalem, were denied. It was not the first time PHRI has advocated for the victims—including amputees—of Israeli aggression in the Gaza Strip; PHRI conducted similar advocacy efforts after the 2014 aggression on the Gaza Strip..[16]
However, in our context, where we operate within the Israeli court system—which is the same legal system used to regulate and maintain the occupation and which provides a legal justification for the structures of domination over Palestinian lives—the human rights legal framework inherently operates in the realm of a system built by and for powerful and oppressive entities that use the same laws to justify and obscure their violence.[17]
In this paper, we display two case studies of individuals injured by the Israeli military during the GMR, where we have worked with and within the Israeli court system. We then discuss the tensions and the challenges we face when having to operate within a colonial militarized legal structure while advancing and advocating for a human rights-based approach.
Case studies
The following two cases are crucial for understanding the health care system in which these amputations occurred and were treated. They highlight the Israeli-made bureaucratic ordeal faced by the injured and their families as they try to access adequate and respectful medical care following the injury they sustained by Israeli snipers. Moreover, these two cases manifest the snare of humanitarian and human rights work—the temptation to continue using these approaches but also their constraints and the danger they can pose.
Both patients were injured by Israeli snipers during the GMR and eventually forced to undergo leg amputations. While in one case both patient and family were in need of an Israeli permit, in the other—where the patient was detained and thus brought to the hospital by the army—only the family required one. Our experience showed that the Israeli authorities explained their rejection of a request for a permit (of either the patient or his family) by the applicants’ participation in the activity of defiance that led to their injury. Thus, the mere fact of being injured by the Israeli army is enough to reject one’s application to exit Gaza for medical care for that very injury, on the ground that the individual is inherently a security threat to Israelis. But even when access is not the problem—as in the second case study—the perception of what care must be provided is narrowed down so it becomes, we believe, deeply flawed ethically.
Case study 1: A, aged 12 (name anonymized to protect privacy), was injured in the left leg by soldiers’ gunfire on the morning of April 17, 2018, while participating in demonstrations in the Al-Bureij camp in the Gaza Strip. Physicians at Al-Shifa Hospital decided to transfer him to a hospital in the West Bank because they did not have the capacity to treat him in a way that would prevent an amputation. His permit application to travel to the West Bank was denied until PHRI stepped in. After our urgent appeal to the Gaza District Coordination and Liaison Office went unanswered, we petitioned the Israeli High Court that evening, demanding that the decision be reversed and a permit be granted to both A and his mother. He was then issued a permit to leave for treatment and was transferred to the hospital in Ramallah that night. His mother did not receive an exit permit that would allow her to accompany her son. The hospital was unable to save his leg, and it was amputated that night.
The state’s position was clarified in its response to a petition filed with the Israeli Supreme Court in another limb injury case. The two petitioners therein suffered gunshot wounds to the leg during GMR protests and sought medical treatment in the West Bank in an attempt to save them from amputation. The state contended that “the respondents did not accept these requests because the petitioners’ injuries were caused as a result of their aforesaid participation in violent riots organized by Hamas.”[18]
Case study 2: On June 27, 2018, S, aged 15, was brought to Barzilai Hospital in Ashkelon, Israel, and detained after being shot by soldiers in the right thigh while taking part in the GMR protests near the Gaza fence. After a series of surgeries and treatments, the attending physicians determined that his leg required amputation below the knee. Throughout this time, his parents were unable to stay by his side and were not informed of his medical condition, although his mother applied for an Israeli permit to visit him through the Gaza District Coordination and Liaison Office. On July 10, after two weeks in the hospital, during which his leg was not amputated, S was discharged. His medical file notes he was “discharged home” and to “IDF [Israeli army] custody.” The nursing report, however, clearly states that “the patient is at high risk of falling … has not yet given spontaneous urine.”
Due to his condition and the severe pain he suffered once at home, his family took him to Al-Shifa Hospital in Gaza on the morning of July 11, where his leg was amputated above the knee.
PHRI’s attempts to understand how physicians at Barzilai Hospital decided to discharge S without performing the amputation were dismissed by the hospital director: “I wonder how uninterested you are in the procedures that were performed to save his life and leg when he reached the hospital in a state of shock with materials suspected as life-threatening ammunition in his pocket.” Although we obtained a waiver of medical confidentiality from S’s parents, S’s medical file was given to us only after months of legal advocacy.
Two PHRI volunteer physicians and a nursing professor went over the medical reports and reached the conclusion that S should never have been discharged in his condition and that, without a doubt, it would have been better to perform the amputation at Barzilai Hospital. The hospital claims that this was impossible since S was a minor and that it could not reach his parents to receive their consent. Only following our petition to the Israeli High Court of Justice did we receive a somewhat more detailed answer, insisting that the discharge had been coordinated with the army so S would receive care near his home and that the state had no obligation to provide anything more than lifesaving medical treatment. Why S’s discharge was not coordinated with a hospital in Gaza remains unclear.
To conclude, as we will show in the discussion, S’s story is also the story of a medical system whose integrity has been compromised to the point where it experiences no conflict between the injury it enables and its professional, ethical commitment to equal care. But it is also no less the story of a nation trying to return to its homeland. S, coming from a family of refugees, like 64% of the population in the Gaza Strip, tried, even if only symbolically, to make his way home on his two healthy feet during the GMR.[19] The village of Hiribya, from which his family was expelled during the Nakba, is only 14 kilometers away from the fence between Gaza and Israel (two kibbutz communities now occupy the area: Zikim and Karmiya), a distance a young person can easily cover on foot. The state’s response to our legal petition states that S’s case “does not represent standard practice, and [he] did not enter to receive medical care using the optimal route,” an odd description given that any patient from Gaza seeking exit for medical treatment goes through a long, Kafkaesque ordeal before they are allowed to do so.[20] The optimal route is what S and many youths in Gaza tried to fight for—their right to return—and it earned him a bullet to the thigh. The shot aimed at S carried with it Israel’s repression of any Palestinian attempt to integrate what was fragmented by returning to their homeland.
Following PHRI’s appeal to the High Court of Justice, the hospital and the Ministry of Health looked deeper into the case. However, the court accepted the hospital’s explanation that S was discharged to another medical center and thus that there is no ethical flaw, contrary to what was evident in the medical reports, where it was clearly written that he was discharged to his home. The judges praised PHRI’s appeal for clarifying the circumstances of S’s discharge but refused to accept our analysis, claiming that “there is no basis to think that someone tried to do something that is medically invalid.”[21]
Reflections on PHRI patient advocacy
Although the de-developed health care system in Gaza lacks the means and expertise to avoid amputations, only 20 wounded sought permission for medical treatment outside of Gaza in April and May 2018. As PHRI was informed by the General Authority of Civil Affairs in Gaza, this represents a small proportion, given that the number of injured in need was far greater. Even in cases where the injured did exit for treatment, the time that elapsed between injury and arrival at advanced medical centers, due to delays by Israeli authorities, thwarted efforts to avoid amputation. Additionally, relatives feared the injured would be arrested by Israeli security forces once they arrived at the “Erez” crossing, the only checkpoint for patients to leave Gaza, as has happened in various cases in the past. We learned later through personal communication with the Palestinian Civil Affairs Committee in Gaza that a decision had been made by Gazan authorities to refer the majority of the injured to Egypt and Jordan to avoid such hurdles.
Our advocacy, while succeeding in acquiring a permit in the first case and exposing inappropriate conduct of the Israeli health and security systems when treating an injured Palestinian protestor, failed in several respects. Both individuals failed to receive timely treatment that could have left them with a less radical amputation. And in both cases, no accountability was achieved for those delaying or preventing the care, nor did the relevant authorities acknowledge their systematic failures, let alone the fact that the system is devised to structurally discriminate against Palestinians. In the Israeli legal system, both cases were reduced to—at most—an administrative mistake without malevolent intent.
Discussion
Israel’s policy of intentional subjugation
Israel’s policy of segregating the Palestinian land and population, and subduing Palestinian resistance, is woven into its permit system, which has operated with different intensities over the years.[22] Ron Lobel, who served as chief medical officer for the Israeli Civil Administration in Gaza from 1988 to 1994, when Gaza was still directly governed by the military occupation and before the health duties were outsourced to the PA, describes this attitude as one in which
whatever we offered them were acts of mercy on our part, not rights which they deserved. The attitude was applied without distinction to a woman in labor and to a hospital director in Gaza. In dealing with the Civil Administration, each and every Palestinian went through a process that was intended to be as difficult as possible. This policy was not expressed officially, but it was clearly enforced and understood.[23]
Further, as Lisa Hajjar explains, “Israel rejected the claim that it had any legal responsibility to the Palestinian population under the Fourth Geneva Convention from the outset of the occupation, while also affirming that it would nonetheless respect its humanitarian provisions.”[24]
Additionally, public statements from top Israeli government and military officials over the years reveal an intention, or at least a mindset, to keep Gaza on the edge of collapse. An example of this can be found in statements made by Major General Amos Gilad, who spoke of letting the Palestinians “keep their heads above the water,” and, when trying to downplay the severity of the situation in Gaza, claimed that “hunger is when there is a lack of basic products, and people wander around with a bloated belly, collapse and die. There is no hunger now.”[25] Another can be found in statements made by Benny Gantz, former chief of staff and current minister of defense, who boasted during his election campaign that “only the strong win—6,231 targets were destroyed. Parts of Gaza returned to the stone age.”[26] Former Chief of Staff Aviv Kochavi spoke of deploying a lethal, efficient, and innovative army: “At the conclusion of every stage of combat, we need to examine the scope of the enemy and the targets that were destroyed, and not only the conquest of territory as such.”[27] Accounts given by Israeli snipers reveal that statements like those of Gantz and Kochavi resonate in their conduct more than the army’s official rules of engagement published on the army’s website.[28]
In 2017, Israel’s Political-Security Cabinet issued orders to deny relatives of Hamas members exit from Gaza for medical treatment, as leverage against Hamas for the return of Israeli prisoners and missing persons.[29] Indeed, in many other cases, the health needs of Gazan patients who requested an Israeli medical permit have been exploited by Israel for collecting intelligence information and exerting control over the population in Gaza, facilitated by the very existence of the Israeli permit regime.[30] Through its policy of shooting to maim, Israel goes one step further by first targeting the healthy body and then imposing restrictions on the injured person’s access to adequate medical care outside of Gaza.
When we analyzed the data on casualties, we noticed a shift toward more maiming relative to killing during Israel’s attacks on Gaza, 2014 excepted, as the proportion of deaths among the total casualties trended downward while casualties increased overall.[31] Israel has used the shift from killing or causing head injuries to maiming as a defense against accusations of disproportionate killing and as ostensible proof that it was not only abiding by international law but also acting morally.[32] This line of defense received a stamp of approval from the country’s highest court when it rejected petitions filed against Israel’s open-fire regulations.[33]
This evidence suggests that orders to snipers to target the limbs, abdomen, and pelvis were refined as protests continued. Israeli snipers can target any part of the Palestinian body, as they are trained to be exceptionally precise. Yet the orders as seen in Israel army’s open-fire rules clearly state that “when employing potentially lethal force, IDF [Israeli army] forces aimed to wound and not to kill.”[34] To achieve this, snipers were required to aim below the knee and not to aim live ammunition at the center of the body.
In a series of interviews conducted by a Haaretz journalist with several snipers, the disposability of the Palestinian body is apparent.[35] “For a soldier like that, that shot is his purpose, his self-definition … you turned them into a machine, you made them think small, you reduced their possibilities of choice, diminished their humanity and their personality. The moment you turn someone into a sniper—that is his essence.”[36] Indeed, to be able to accomplish these precise injuries, Israel needed a war machine, so it set out to turn its snipers from men and soldiers into machines, at least for the time they were on duty. To this end, snipers are trained, and given the illusion of almost complete security with their highly sophisticated equipment and protection, so they can confidently do their job. This loss of humanity is reflected in turning the protestor into a target, his body into parts that are a desirable hit: “I remember the view of the knee in the crosshairs, bursting open,” relief when learning it was a precise hit, one that they could add to their record.[37] The encounter includes the desire to subdue those who dare look back: “At one stage he stands opposite me, looks at me, provokes me, gives me a look of ‘Let’s see you try.’”[38]
During the GMR, the execution of the army’s order rendered Palestinian protestors disabled until their bodies healed or, in 156 cases, permanently. Although Israel’s interest in avoiding criticism for a high death toll may seem reasonable to us, we believe that decades of impunity resulting from the reluctance by external states to hold Israel to account encourages an examination of amputation through the lens of colonial violence. With this lens, Israel’s attempt to maim the Palestinian body reflects its larger desire to disable the Palestinian medical system and nation, part of the same intentional scheme of control.
Israel’s policy: The Palestinian body as a political body
Beyond the immediate incapacitating of the protestor, injury and amputation have far-reaching implications. Indeed, leaving the defiant Palestinians alive allows Israel to maintain its perpetual presence in their lives through “a young Palestinian generation walking on crutches.”[39] A study on Palestinian amputees in Gaza found that most were young (median age 25 at the time of injury) and educated.[40] Sixty-three percent were the main breadwinner in the family before the injury. Most of them (85%) suffered a major amputation above the knee and reported long-term pain. Long-term ramifications were observed in their own and their families’ lives. Amputees reported physical and psychological problems in relation to their limb loss, with pain being the most common one; half reported being unemployed due to their disabilities, thus bringing new burdens to them and their families.[41]
Indeed, social suffering caused by extreme distress and trauma is remembered and carried by one’s body, even without a physical injury. As we have demonstrated in the case studies, under the guise of a “rational” permit system, suffering is also inflicted on parents who cannot accompany their sons at the most painful time of their lives, as was the case with A. Indeed, even after the medical care is completed, the suffering of the family and community continues as they are still destined to live under siege, and more casualties are only a matter of time. This decades-long political and colonial violence affects Palestinians and their capacity to support their injured members and to respond to and recover from trauma.[42] This prolonged social suffering should be seen not as a side effect but rather as an intentional policy of Palestinian subjugation and dependence. We see this clearly in the effects on the Palestinian health system in Gaza. While its development is restricted by Israel, it is forced to cooperate with its oppressor so Palestinian patients can access the adequate care that cannot be offered locally. This vulnerability exposes Gaza’s health needs to a humanitarian discourse, one that does not address the root causes of its distress.
Human rights and humanitarian discourses: Weaknesses and challenges
When considering the role of humanitarianism and its associated health discourse, it is important to note how this discourse successfully serves Israel in shifting the siege on Gaza from its historical context of settler colonialism into narratives of securitization.[43] Humanitarian efforts can dilute the discussion about national liberation and military occupation, as they emphasize the details of who and what is allowed in or out of Gaza, always trying to reform or improve the “content” of this list, never effectively challenging the existence of the occupation and blockade more broadly. While the medical system, with its core humanitarian values, might be well-positioned to challenge the hierarchy of lives, this system and its professionals run into a core tension in Israel. Showing how these ethical values and standards are differentially applied, when met with USAID’s criticism about the humanitarian emergency of acute and chronic malnutrition in Gaza, Israeli health professionals defended the state by claiming that as long as malnutrition in children remains below 10%, the level is reasonable and that “only in Gaza the levels are above the reasonable.”[44] Because the medical system is ultimately operated by the architects of the health disaster, the care for Palestinians from Gaza not only is limited and castrated but becomes a propaganda tool in perpetuating the disaster.[45]
Indeed, Israeli officials and hospital managers boast about treating Palestinians, even when the care is paid for by the PA and conditioned on a permit regime. This “service” is used by Israel to fend off claims that it violates Palestinians’ right to health. It is no wonder, then, that Israel’s claims are met with Palestinians’ piercing criticism.[46] When struggling to improve the care provided to an individual, PHRI and other human rights groups must sometimes appeal to Israeli authorities, only complicating this dynamic further. We sometimes make concessions to their regulations: for example, we can appeal on behalf of patients only when their first request for a permit is refused, thus losing valuable time. Similarly, when appealing to the High Court of Justice, we must style our language on the grounds of humanitarian needs, as numerous rulings have not accepted PHRI’s analysis of Israel’s obligations to allow the exit of patients unconditionally. Once this language is used, it has an effect that goes beyond the single appeal or patient, enabling these systems to stay intact through precedent.
When presented with the humanitarian disaster it causes, Israel touts as a defense its professional, benevolent medical system, or the mere fact that it allows international organizations to operate in the oPt. In both cases, the decontextualization allows it to disguise the structural violence that creates the need for these services and the fact that the PA or external organizations are actually shouldering the financial burden.
While the medical system has sided with the state, there is also the potential of the judicial system, using international law as its basis, to hold Israel accountable. However, the judicial route is also limited. One striking example is the treatment of the United Nations Fact Finding Mission on the Gaza Conflict, whose final report is known as the Goldstone report. Despite clear evidence resulting from Israel’s attack on Gaza in 2008–2009, following a well-orchestrated campaign that included personal attacks, Richard Goldstone, head of the fact-finding mission, retracted his assertion that those crimes were intentional, citing a lack of substantiated proof—proof that is by definition in the hands of the belligerent occupying power.[47]
Palestinian organizations speak up and resist this system, yet too many human rights organizations, both Israeli and international, refer to either the judicial or the humanitarian discourses and routes as the only available options, subjugating concerns to a depoliticized intervention landscape. To hold Israel legally accountable for war crimes, one must prove intent—an almost impossible mission when military documents and secret information are inaccessible to the plaintiffs. In the human rights context, organizations practice extra cautiousness as they subordinate their evidence to what is required to establish proof in the courts. This makes them use “safer” language, and thus their discourse is tamed. On the humanitarian side, it is clear to all that in order to receive the cooperation of Israeli authorities—timely answers to our requests for permits for patients or for the entries of our medical delegations—we are expected to maintain “working” relationships; even if we voice our criticism, the consequences of doing so are always on our minds. This catch-22 allows Israel to avoid accountability and successfully navigate between the available discourses.[48] Therefore, it is clear that any struggle for implementable human rights must address the root causes and historical injustice that affect the right to health to this day.
Recent developments, however, such as the Human Rights Watch and Amnesty International reports on apartheid, which echo the longstanding Palestinian discourse, may signal a way toward holding Israel accountable and avoiding the judicial-humanitarian pitfalls.[49] Although groundbreaking, the discourse of apartheid has its own limitations and can be broadened by the prism of settler colonialism.[50] Similarly, since our discussion lies outside the realm of international law, we do not strive to prove intent in its judicial sense but rather claim that the magnitude of the maiming—of both the Palestinian body and people—proves that there is a system at hand. Effects and results that are consistent over decades cannot be seen as a coincidence or a by-product. They must be seen for what they really are—intended either by design or by systemic neglect to avoid them.
Summary and conclusion
We write this paper with heavy hearts, following years of trying to advocate for the right to health of Palestinians in the oPt. Based on our experience, we can regretfully assert that over the years, this right was never guaranteed but always conditioned on Israel’s definition of its security needs, and it has never been, even for one moment, regarded as a right held by Palestinians. Israel has shifted from considering Palestinians’ right to health as a limited obligation it has by virtue of its occupation and control to viewing it as a humanitarian favor granted out of “good will” following the Oslo Accords. Even more discouraging is the indifference of Israel’s medical community. The Israeli Medical Association defines these life-and-death matters as political and accepts Israel’s security discourse.[51] The medical system internalizes the official state discourse and follows the regulations, resulting in Palestinian patients receiving unequal care and falling victim to unethical conduct.
Bringing cases to court, like the case of S in which the judicial process narrowed the discussion to the circumstances of his discharge from the hospital, has failed to bring accountability. Even if S could have undergone the amputation in Israel’s advanced medical center, it would not have changed his life circumstances in the Gaza Strip, a city that has been bombarded so many times it lacks the infrastructure of pavements and roads that would facilitate walking with crutches. Significantly, S and other youth will continue to be targeted, both their aspirations and bodies locked behind the fence.
As an organization that is working within the human rights framework and delivering humanitarian assistance, there is a certain limitation to the “traditional” or “legitimate” tools we can use. When we speak of historical context and Israel’s responsibility for the Nakba as foundational in forming the debate around Israel’s policy toward Gaza and security justifications, we are deemed “political,” and some of our public legitimacy with both Israelis and international stakeholders is tainted. In addition, the “neutrality” ethos of the medical community seems to be a silencing force for such a discussion. This is a constant source of frustration for those of us in the human rights community, who understand the urgent need to reframe the discussion and move beyond this limited framework into one of social responsibility and accountability. In such a discussion, humanitarian gestures or balancing those with “security considerations” are insufficient, and that requires moving to dismantle the structures of control and power. Further, in such a discussion, one will not demand reforms of a flawed policy but instead call to dismantle it altogether.
But even in this climate of devaluing Palestinians’ lives, even after decades of working in PHRI, the realization that harm to Palestinians’ health is not collateral damage but a necessary condition in Israel’s policy is still somehow shocking. With time, it became clear to us that this entire landscape we operate in, with its permit regime, the appeals to courts, and the humanitarian intervention and considerations, functions within a logic of bureaucratic violence. The military violence, with its practice of shooting to maim but not kill and its resonance with the demand for proportionality in international law, runs parallel to the bureaucratic violence that often reinforces the military violence and provides it with a liberal and rational disguise. These two violent systems, military and bureaucratic, allow Israel continuous control without accountability. To understand this and still fight for Palestinians’ right to health sends us on this task of exposing what must be exposed so what is tolerated by too many people can no longer be tolerated.
Ghada Majadli, MA, is director of the department of the occupied Palestinian territory at Physicians for Human Rights Israel, Haifa, Israel.
Hadas Ziv, MA, is a director of ethics and content at Physicians for Human Rights Israel, Tel Aviv, Israel.
Please address correspondence to Ghada Majadli. Email: ghada@phr.org.il.
Competing interests: None declared.
Copyright © 2022 Majadli and Ziv. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
References
[1] P. Wolfe, “Settler Colonialism and the Elimination of the Native,” Journal of Genocide Research 8/4 (2006); O. J. Salamanca, M. Qato, K. Rabie, and S. Samour, “Past Is Present: Settler Colonialism in Palestine,” Settler Colonial Studies 2/1 (2012).
[2] L. Tabar and C. Desai, “Decolonization Is a Global Project: From Palestine to the Americas,” Decolonization: Indigeneity, Education and Society 6/1 (2017).
[3] J. K. Puar, “The ‘Right’ to Maim: Disablement and Inhumanist Biopolitics in Palestine,” Borderlands 14/1 (2015); D. M. Qato, “Introduction: Public Health and the Promise of Palestine,” Journal of Palestine Studies 49/4 (2020).
[4] United Nations, “COVID-19: Israel Has ‘Legal Duty’ to Ensure That Palestinians in OPT Receive Essential Health Services – UN Expert” (March 19, 2020), https://www.ohchr.org/en/press-releases/2020/03/covid-19-israel-has-legal-duty-ensure-palestinians-opt-receive-essential; M. Alkhaldi, R. Coghlan, S. Miller, et al., “State Accountability for the Good Health of Palestinians Has Failed: What Can the Global Health Community Do Next?,” Health and Human Rights Journal 24/1 (2022).
[5] United Nations, “Two Years On: People Injured and Traumatized during the ‘Great March of Return’ Are Still Struggling” (April 2020), https://www.un.org/unispal/document/two-years-on-people-injured-and-traumatized-during-the-great-march-of-return-are-still-struggling/.
[6] M. Barghouti, “Razan Ashraf al-Najjar,” Lancet (2018); Y. M. Asi, O. Tanous, B. Wispelwey, and M. Alkhaldi, “Are There ‘Two Sides’ to Attacks on Healthcare? Evidence from Palestine,” European Journal of Public Health 31/ 5 (2021).
[7] Y. Asi, “Occupation in the Time of COVID-19: Holding Israel Accountable for Palestinian Health,” Al-Shabaka (November 15, 2020), https://al-shabaka.org/briefs/occupation-in-the-time-of-covid-19-holding-israel-accountable-for-palestinian-health/.
[8] World Health Organization Occupied Palestinian Territory, Right to Health 2018 (October 2019), https://www.emro.who.int/images/stories/palestine/documents/who_right_to_health_2018_web-final.pdf.
[9] Ibid.
[10] Ibid.
[11] Physicians for Human Rights Israel, “Gaza: Treating Injured Demonstrators in the European Hospital” (May 14, 2018), https://www.phr.org.il/en/gaza-treating-injured-demonstrators-in-the-european-hospital/.
[12] Human Rights Council, Report of the Detailed Findings of the Independent International Commission of Inquiry on the Protests in the Occupied Palestinian Territory, UN Doc. A/HRC/40/CRP.2 (2019).
[13] Alkhaldi et al. (see note 4).
[14] D. Filc and H. Ziv, “Exception as the Norm and the Fiction of Sovereignty: The Lack of the Right to Health Care in the Occupied Territories,” in J. Parry (ed), Evil, Law and the State: Perspectives on State Power and Violence (Amsterdam: Rodopi, 2006).
[15] Qato (see note 3), p. 14.
[16] M. Abu Arishe and M. Efrat, Amputees: The Challenges Faced by Gaza Strip Amputees in Seeking Medical Treatment (Physicians for Human Rights Israel May 2016).
[17] S. Ben-Natan, “The Dual Penal Empire: Emergency Powers and Military Courts in Palestine/Israel and Beyond,” Punishment and Society 23/5 (2021).
[18] Physicians for Human Rights Israel, “Wounded in The Gaza Strip” (May 2018), https://www.phr.org.il/en/wounded-in-the-gaza-strip/.
[19] Palestinian Central Bureau of Statistics, “The International Day of Refugees 2019,” https://www.badil.org/phocadownloadpap/Statistics/(PCBS)The-International-Day-of-Refugees-2019-eng.pdf.
[20] G. Majadle and Y. Rosner, Responsibility Shirked: Israel and the Right to Health in the Occupied West Bank during COVID-19 (Jaffa-Tel Aviv: Physicians for Human Rights Israel, 2021).
[21] PHRI v. Minster of Health HCJ 4277/21 (Hebrew).
[22] H. Ziv, A Legacy of Injustice: A Critique of Israeli Approaches to the Right to Health of Palestinians in the Occupied Territories (Jaffa-Tel Aviv: Physicians for Human Rights Israel, 2002).
[23] Ibid.
[24] I. Feldman, “Gaza’s Humanitarianism Problem,” Journal of Palestine Studies 38/3 (2009).
[25] Ibid.
[26] Editorial, “Gantz’s Stone Age,” Haaretz (January 23 2019), https://www.haaretz.co.il/opinions/editorial-articles/2019-01-23/ty-article-opinion/.premium/0000017f-ea56-dc91-a17f-fedf73940000.
[27] Y. Levy, “The Israeli Army Chief’s Geometry of Death,” Haaretz (May 27, 2021), https://www.haaretz.com/israel-news/.premium.HIGHLIGHT.MAGAZINE-the-israeli-army-chief-s-geometry-of-death-1.9851238.
[28] H. Glazer, “42 Knees in One Day: Israeli Snipers Open Up about Shooting Gaza Protesters,” Haaretz (March 6, 2020), https://www.haaretz.com/israel-news/2020-03-06/ty-article-magazine/.highlight/42-knees-in-one-day-israeli-snipers-open-up-about-shooting-gaza-protesters/0000017f-f2da-d497-a1ff-f2dab2520000.
[29] Physicians for Human Rights Israel, “Remarkable Achievement for Human Rights Organizations” (August 2018), https://www.phr.org.il/en/remarkable-achievement-for-human-rights-organizations/.
[30] R. Yaron, Holding Health to Ransom: GSS Interrogation and the Extortion of Palestinian Patients at Erez Crossing (Jaffa-Tel Aviv: Physicians for Human Rights Israel, 2008); Physicians for Human Rights Israel, “Dramatic Increase in Refused Permits to Travel Out of Gaza” (August 2018), https://www.phr.org.il/en/dramatic-increase-in-refused-permits-to-travel-out-of-gaza/.
[31] United Nations Office for the Coordination of Humanitarian Affairs – Occupied Palestinian Territory, “Two Years On: People Injured and Traumatized during the ‘Great March of Return’ Are Still Struggling” (April 6, 2020), https://www.ochaopt.org/content/two-years-people-injured-and-traumatized-during-great-march-return-are-still-struggling; United Nations Office for the Coordination of Humanitarian Affairs – Occupied Palestinian Territory, “Data on Casualties,” https://www.ochaopt.org/data/casualties.
[32] IDF Editorial Team, “IDF Use of Potentially Lethal Force,” IDF Website (February 2022). Available at https://www.idf.il/en/minisites/q-a-concerning-the-violent-riots-and-attacks-occurring-on-the-border-between-gaza-and-israel-during-2018-9/idf-use-of-potentially-lethal-force/.
[33] Adalah, “Israeli Supreme Court Gives Green Light to Continued Use of Live Fire, Snipers against Gaza Protesters” (May 2018). https://www.adalah.org/en/content/view/9522.
[34] IDF Editorial Team, “Operational Response: How Does the IDF Regulate the Use of Force?,” IDF (February 2022), https://www.idf.il/en/minisites/questions-and-answers-concerning-the-violent-riots-and-attacks-occurring-on-the-border-between-gaza-and-israel-during-2018-9/gaza-border-events-qa/operational-response/.
[35] See Glazer (see note 28).
[36] Ibid.
[37] Ibid.
[38] Ibid.
[39] D. Akkad, “’Shoot to Maim’: How Israel Created a Generation on Crutches in Gaza,” Middle East Eye (March 2019), https://www.middleeasteye.net/news/shoot-maim-how-israel-created-generation-crutches-gaza.
[40] H. E. Heszlein-Lossius, Y. Al-Borno, S. Shaqqoura, et al., “Life after Conflict-Related Amputation Trauma: A Clinical Study from the Gaza Strip,” BMC International Health and Human Rights 18/34 (2018).
[41] Ibid.
[42] R. Giacaman, “Reframing Public Health in Wartime: From the Biomedical Model to the ‘Wound Inside’,” Journal of Palestine Studies 47/2 (2018).
[43] G. Abu-Sittah, “The Virus, the Settler, and the Siege: Gaza in the Age of Corona,” Journal of Palestine Studies 49/4 (2020).
[44] “There Is No Hunger in the Territories, Situation Is Severe Only in Gaza,” Haaretz (August 8, 2002) [Hebrew].
[45] A. Ophir, “Moral Technologies: Disaster Management and Life Abandonment,” Theory and Criticism 22 (2003).
[46] R. Giacaman, “The Health of Palestinians,” Lancet 392/10161 (2018).
[47] “Judge Goldstone Expresses Regrets about His Report into Gaza War,” Guardian (April 3, 2011), https://www.theguardian.com/world/2011/apr/03/goldstone-regrets-report-into-gaza-war.
[48] Merriam-Webster Dictionary, “Catch-22,” https://www.merriam-webster.com/dictionary/catch-22.
[49] Human Rights Watch, A Threshold Crossed: Israeli Authorities and the Crimes of Apartheid and Persecution (New York: Human Rights Watch, 2021); Amnesty International, “Israel’s Apartheid against Palestinians: Cruel System of Domination and Crime against Humanity” (February 1, 2022), https://www.amnesty.org/en/latest/news/2022/02/israels-apartheid-against-palestinians-a-cruel-system-of-domination-and-a-crime-against-humanity/.
[50] S. Asaad and R. Muhareb, Dismantle What? Amnesty’s Conflicted Messaging on Israeli Apartheid, Institute for Palestine Studies (February 2022), https://www.palestine-studies.org/en/node/1652565#.Yg-0te_0r4I.facebook.
[51] G. Majadle and O.Tanous, “A Medical School in the Service of Colonialism,” +972 Magazine (March 2022), https://www.972mag.com/ariel-university-adelson-medicine-colonialism/.