Raquel Selcer and Sanjna L. Surya
The World Health Organization (WHO) last week declared the situation in Gaza to be approaching “humanity’s darkest hour”.[1] Israel has killed over 19,000 Palestinians in Gaza to date, over 7,000 of whom are children, in what some human rights officials and scholars have called an unfolding case of genocide.[2] This staggering rate of human loss is virtually unprecedented in modern warfare.[3] The war has rendered nearly 80% of the hospitals and 75% of the primary healthcare facilities in Gaza non-functional, with dozens of hospitals and ambulances damaged in direct attacks.[4] There is a severe shortage of critical medications such as anesthetics, antibiotics, and blood products.[5]
Refugee camps, themselves targets of bomb attacks, are overflowing with displaced Palestinians living in unsanitary conditions with up to 700 people sharing a single toilet.[6] There is a dire shortage of clean water, and a consequent twenty-fold increase in diarrheal cases among children.[7] Oxfam has warned that epidemics such as cholera loom on the horizon.[8] In addition, 52,000 pregnant people live in Gaza and over 5,000 babies have been born in the last month with little to no access to maternal or pediatric care and over 60% of neonatal incubators no longer functioning.[9] The mental health consequences on Gaza’s traumatized population are unfathomable. After a visit to Gaza last week, president of the Red Cross Mirjana Egger called the situation “beyond anything that anyone should be in a position to describe.”[10]
Medical and public health professionals in the United States are witnessing what has rightly been called by Médecins Sans Frontières (MSF) Canada as the “brutal annihilation of an entire population’s health system”.[11] In our search for a moral solution to this devastation, we cannot ignore the 75-year history of settler colonialism and military occupation of Palestine and the consequent devaluation of Palestinian life. Too often the violence of the Israeli government inflicted on the Palestinian population is described by the US media, academic institutions, and the government as the unfortunate consequence of “conflict” rather than colonial violence—made possible by US support—inflicted on an occupied people. Palestine has been experiencing a health crisis that far predates this current escalation, and without an understanding of its root causes we cannot envision a path towards Palestinian health.
Settler colonialism is a system of oppression by which a community obtains and occupies land by displacing and eliminating the Indigenous population using violence, land theft, and exploitation of resources.[12] Israeli settler colonialism led to the expulsion of 700,000 Palestinians from their homes in 1948, and today 5.2 million Palestinians—2 million of whom live in the Gaza strip and West Bank—constitute one of the world’s largest refugee populations.[13] The process of dispossession and displacement is an ongoing one that involves the continuous demolition of Palestinian homes and construction of settlements on Palestinian land, both of which have been declared illegal by the UN.[14] As an example, over 900 structures in the West Bank were demolished by Israel displacing over 1000 Palestinians in 2022 alone.[15]
The tactics of settler colonialism are both overt and insidious and lead to detrimental effects on the health of the Indigenous population.[16] For instance, the blockade of goods into Gaza has incapacitated its health system by restricting the entry of communications equipment, X-ray machines, oxygen cylinders, and many other items deemed “dual use” for military utilization.[17] The chronic shortages of critical medications and equipment creates dependence on the Israeli health system which cannot be accessed without special permits. In 2022, 33% of the permits submitted by Gazan patients were not approved in time for them to make their appointments, affecting patients like 19-month old Fatma who died while awaiting the third attempt at a permit approval for the repair of an atrial septal defect.[18]
Israel also controls Palestinian water sources and diverts rainwater away from Palestinians to the Israeli settlements, leading to 1.4 million Palestinians living with a “severe or catastrophic” need for clean water and an abundance of diarrheal illnesses that primarily affect children and pregnant women.[19] The blockade and deliberate destruction of cultivable land have caused severe food insecurity affecting 1.8 million Palestinians and soaring rates of malnutrition, stunting, and rickets among children.[20] Hundreds of roadblocks and checkpoints cause chronic stress and anxiety from constant surveillance and harassment and obstruct medical care by forcing the transfer of critically ill patients from one ambulance to another (an average delay of 1 hour during ambulance transfers was reported in 2022, and Palestinian women have given birth to infants who have died while held up at checkpoints).[21]
Violence under the occupation is a constant feature of life in Palestine, with both Israeli forces and Israeli settlers killing and injuring hundreds of Palestinians a year.11 The ongoing attacks on healthcare are a continuation of the longstanding and deliberate destruction of health infrastructure and violence towards healthcare workers in Palestine—between January 2018 and October 2023, WHO documented a staggering 1382 attacks on healthcare facilities.[22]
Palestinian health therefore cannot be viewed in isolation from the occupation, which affects every facet of life. In Gaza and the West Bank, life expectancy is ten years lower among Palestinians compared to Israelis and the infant mortality rate is seven times higher, and these inequities exist for Palestinians living within the state of Israel as well.[23] Over 40% of households in Gaza and 12% in the West Bank have at least one member with an acute mental health disorder, including nearly half of all Palestinian adolescents.[24] Palestinians endure continuous trauma stress under occupation, a diagnosis distinct from PTSD.[25] The occupation has created a system of medical apartheid that we, as healthcare professionals in the United States, should be familiar with given our own history of apartheid and settler colonialism and its effects on the health of Black people and Native Americans today.[26] How can we advocate for Palestinian health if we ignore the conditions that make it impossible for Palestinians to live healthy lives?
Healthcare institutions do not operate in an abstract world. Our work is grounded in the realities of trauma, inequality, and injustice experienced by people from all walks of life. We as healthcare workers are quick to respond to individual acts of violence—a gunshot wound, a fight—but are often slow when it comes to recognizing the violence perpetrated by larger systems. Over the years, discussion about the social determinants of health—racism, transphobia, gender-based violence, food and housing insecurity, and mass incarceration among others—has increasingly entered mainstream discourse. Academic institutions and medical organizations have rightfully begun to recognize their moral obligation to address structural inequities that are not taught in conventional medical curricula.[27] We are slowly recognizing that health does not exist in a vacuum; health is political because political realities shape health. Yet our leaders and institutions are unable or unwilling to identify the structural violence affecting Palestinians. They are unable to name the culprits of colonialism and occupation as critical determinants of Palestinian health. In this regard, we are failing in our moral obligation to uphold health and justice for everyone.
Today, the world is witnessing a genocide in Gaza that no amount of humanitarian aid will be able to fix. Nearly 20,000 lives have been lost. Infants have lost their entire families. The infrastructure of Gaza has been destroyed to the bone. Billions of US tax dollars have gone towards financing the war and supplying the very bombs and weapons that are being used to kill Palestinian children—tax dollars that could have been used for housing and healthcare for our own patients.[28] The project of settler colonialism is unfolding again in front of our eyes in Palestine. Decades of denying and normalizing the occupation and violence experienced by Palestinians has led to this current catastrophe, the consequences of which will reverberate for generations, and as healthcare professionals our neglect has made us culpable in Palestinian suffering.
We must call for a permanent ceasefire now—but we must do more than that. We must learn from our mistakes and use our collective voice as healthcare professionals to speak out against colonialism and occupation as forces that destroy health, while uplifting the voices of those who live under occupation. We must advocate against the use of our tax dollars to fund war and genocide at the cost of healthcare for our patients, and for the divestment of our institutions from the military-industrial complex. The fight is not just for a ceasefire but for the liberation, dignity, and ultimately the health of Palestinians and all oppressed people everywhere.
Raquel Selcer, MD is a resident physician in internal medicine and pediatrics, Boston, United States. Email selcerraquel@gmail.com
Sanjna L. Surya, MD is a resident physician in internal medicine and pediatrics, Boston, United States. Email sanjnasurya96@gmail.com
References
[1] C. Robinson, “Israeli Forces Intensify Assault on Khan Younis as U.N. Official Decries ‘Apocalyptic’ Situation.” Havana Times (December 6, 2023), https://havanatimes.org/news/israeli-forces-intensify-assault-on-khan-younis-as-u-n-official-decries-apocalyptic-situation/
[2] R. Segal, “Statement of Scholars in Holocaust and Genocide Studies on Mass Violence in Israel and Palestine since 7 October”, Contending Modernitis, University of Notre Dame Keough School of Global Affairs (December 9, 2023), https://contendingmodernities.nd.edu/global-currents/statement-of-scholars-7-october/; S. Burga, “Is What’s Happening in Gaza a Genocide? Experts Weigh In.” Time (November 4, 2023), https://time.com/6334409/is-whats-happening-gaza-genocide-experts/.
[3] L. Leatherby, “Gaza Civilians, under Israeli Barrage, Are Being Killed at Historic Pace.” The New York Times (November 25, 2023), https://www.nytimes.com/2023/11/25/world/middleeast/israel-gaza-death-toll.html; J. Borger, “Civilians Make up 61% of Gaza Deaths from Airstrikes, Israeli Study Finds.” The Guardian, (December 9, 2023), https://amp.theguardian.com/world/2023/dec/09/civilian-toll-israeli-airstrikes-gaza-unprecedented-killing-study.
[4] World Health Organization Occupied Palestinian Territory, “oPt Emergency Situation Update Issue 17” (December 14, 2023) https://www.emro.who.int/images/stories/Sitrep_-_issue_17_for_review.pdf?ua=1
[5] Ibid.
[6] Ibid.
[7] Ibid.
[8] Oxfam America. “Palestinians in Gaza face threat of cholera and other infectious diseases, says Oxfam”. (October 17, 2023), https://www.oxfamamerica.org/press/press-releases/palestinians-in-gaza-face-threat-of-cholera-and-other-infectious-diseases-says-oxfam/
[9] See note 4.
[10] Agence France Presse, “Red Cross Chief Arrives in Gaza, Calls For Political Solution”. Barron’s (December 4, 2023), https://www.barrons.com/news/red-cross-chief-arrives-in-gaza-calls-for-political-solution-451d4b7c#
[11] Doctors Without Borders/Médecins Sans Frontières [@MSF_canada]. “This brutal annihilation of an entire populations health system stretches beyond what humanitarian aid can fix…” Twitter, 23 Nov 2023. https://twitter.com/MSF_canada/status/1727782822566568398
[12] B. Wispelwey, O. Tanous, Y. Asi, et al., “Because its power remains naturalized: introducing the settler colonial determinants of health”, Frontiers in Public Health 11 (2023).
[13] United Nations, “About the Nakba”, https://www.un.org/unispal/about-the-nakba/
[14] Amnesty International, “Israel’s Apartheid Against Palestinians: a cruel system of domination and a 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/
[15] World Health Organization, “Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan”, UN Doc A76/15 (May 17, 2023)
[16] See note 12.
[17] See note 15.
[18] See note 15.
[19] Amnesty International, “The Occupation of Water”, (November 29, 2017), https://www.amnesty.org/en/latest/campaigns/2017/11/the-occupation-of-water/
[20] World Health Organization (see note 11); “Herbicidal Warfare in Gaza.” Forensic Architecture, https://forensic-architecture.org/investigation/herbicidal-warfare-in-gaza.
[21] World Health Organization (see note 11); Haaretz, “Humiliation at the Checkpoints”, Haaretz (July 8, 2023). https://www.haaretz.com/2003-07-08/ty-article/humiliation-at-the-checkpoints/0000017f-e3a3-d38f-a57f-e7f3c6c60000; General Assembly, Office of the United Nations High Commissioner for Human Rights (OHCHR), The Question of Palestine: Issue of Palestinian pregnant women giving birth at Israeli checkpoints, UN Doc. A/60/324(2005).
[22] World Health Organization, “Surveillance System for Attacks on Health Care (SSA)”, https://extranet.who.int/ssa/LeftMenu/Index.aspx?utm_source=Stopping%20attacks%20on%20health%20care%20QandA&utm_medium=link&utm_campaign=Link_who
[23] See note 15.
[24] See note 15.
[25] I. Farajallah, Continuous Traumatic Stress in Palestine: The Psychological Effects of the Occupation and Chronic Warfare on Palestinian Children. World Social Psychiatry 4(2):p 112-120, May–Aug 2022
[26] Y. Barhoush and J. J. Amon. “Medical apartheid in Palestine,” Global Public Health. 2023 Jan 2;18(1):2201612.
[27] American College of Surgeons Board of Regents and American College of Surgeons Committee on Ethics, Call to Action on Racism as a Public Health Crisis: An Ethical Imperative (2020), https://www.facs.org/about-acs/responses/racism-as-a-public-health-crisis/; American Medical Association, “New AMA policy recognizes racism as a public health threat” (November 16, 2020), https://www.ama-assn.org/press-center/press-releases/new-ama-policy-recognizes-racism-public-health-threat ; American Psychological Association, “Apology to People of Color for APA’s role in Promoting, Perpetuating, and Failing to Challenge Racism, Racial Discrimination, and Human Heirarchy in the US”, (October 29, 2021), https://www.apa.org/about/policy/racism-apology
[28] S. Zhang, “Israel Used 22,000 US-Provided Bombs on Gaza in Just Six Weeks, Report Reveals.” Truthout (December 11, 2023), https://truthout.org/articles/israel-used-22000-u-s-provided-bombs-on-gaza-in-just-six-weeks-report-reveals/; J. Maslin and N. Youssef, “U.S. Sends Israel 2,000-Pound Bunker Buster Bombs for Gaza War – WSJ.” The Wall Street Journal (December 1, 2023), https://www.wsj.com/world/middle-east/u-s-sends-israel-2-000-pound-bunker-buster-bombs-for-gaza-war-82898638