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What can cooperation between Israeli and Palestinian doctors achieve?
Published 25 June 2010, on British Medical Journal (BMJ)
What can cooperation between Israeli and Palestinian doctors achieve?

By: Jumana H Odeh, director(1), A Mark Clarfield, professor of geriatrics (2), Tony Waterston, retired paediatrician (3)

1 Palestinian Happy Child Centre, Ramallah jhodeh@gmail.com, 2 Medical School for International Health, Ben-Gurion University of the Negev, Beer-sheva, Israel markclar@bgu.ac.il, 3 Newcastle upon Tyne A.J.R.Waterston@newcastle.ac.uk

A discussion between Mark Clarfield (Israel) and Jumana Odeh (Occupied Palestinian Territories), facilitated by Tony Waterston
Tony Waterston: As a frequent visitor to the West Bank in my role as director of the Royal College of Paediatrics and Child Health’s teaching programme, I am often asked, why the programme doesn’t work with Israeli paediatricians as well as with Palestinians. I am aware that many Israeli doctors would like to work much more closely with the Palestinians, as they used to in the past. Yet when I brought up this notion with colleagues in Ramallah and East Jerusalem (where the main medical school is based), it was met with antagonism. Like many Israeli doctors, Mark Clarfield, a geriatrician and fellow BMJ blogger, is positive both to the idea of working more closely with Palestinians and to dialogue on health topics—and to the outsider this seems entirely appropriate. I have worked for nearly 10 years with Jumana Odeh, who is one of the originators of our teaching programme. She is a fine humanist and always tries to build bridges rather than create barriers. However, her ideas on dialogue were quite different from Mark’s and seemed to be shared by most of her Palestinian colleagues. I asked them whether they thought there was benefit in doctors working across frontiers and political barriers.
Jumana Odeh: Doctors do work together across frontiers and political barriers but only in individual cases and under very particular conditions. I have given first aid to Israelis injured in road crashes. Israeli doctors have also cared for members of my family.

But for Israelis, there are no frontiers between Israel and Palestine. For Palestinians, frontiers begin just outside our homes and are enforced by military checkpoints and other coercive means. So it is not possible, under any circumstance, to equate between the occupiers and the occupied. I believe that conscience should come first. I expect doctors not to accept the injustice that is practised systematically and daily against the Palestinian people by the Israeli military occupation.

What would be the basis of this dialogue? The occupation is preventing Palestinians from developing a proper health system; the country is fragmented, resources are limited, and people’s movement is restricted. It’s not only that patients can’t reach their treating doctors, or doctors can’t reach their patients. I have no problem entering into a dialogue, but only one with a clear and open agenda. My experience has taught me that some dialogue has no benefit for Palestinian children and some is led by Israeli politicians who are abusing the health system. The occupiers are interested in working with Palestinians only in cases where they can benefit from this collaboration, such as in the case of disease being transmitted from the Occupied Palestinian Territories into Israel proper, or in cases where damage to infrastructure inside the occupied territories can harm Israeli resources.

A Mark Clarfield: Fortunately, dialogue between Israeli and Palestinian physicians is nothing new. It has gone on for decades, as has cross border cooperation. It is true that for many reasons the level of clinical and research cooperation has diminished of late. But I must take issue with Jumana’s claim that "the occupiers" are only interested in disease transmission. It would be fairer to recognise that the majority of Israeli doctors would be happy to work together with their Palestinian colleagues under appropriate conditions. And clearly, a fair reading of the history of this tortured land will show that not all the blame can be found either with the Palestinians or the Israelis. We have both missed opportunities for peace. Two separate narratives are at work, and the barriers are not just on one side.
An instructive example: recently I was at a meeting with one of our hospital medical administrators. We were interrupted by his secretary, who put in front of him an urgent request to accept a baby from Gaza who needed emergency cardiac surgery.

Within minutes, and after only one phone call to the head of paediatric cardiology, the authorisation was given. No fuss, no bother, no publicity. Unfortunately, for political reasons this kind of collaboration has diminished of late. The politicians do not suffer, but the people do.

JO: Mark, the example you give about the baby from Gaza is a lucky exception. Usually things are much more complicated. Most doctors might be willing to help, but the Israeli military authorities have a permit system that places obstacles in the paths of babies and mothers wanting to travel.
I know of many examples when patients could not reach treatment because of the lack of a travelling permit. Many of my Israeli colleagues have expressed frustration at not being able to help patients who needed their treatment.

Patients can’t reach their doctors; doctors can’t reach their patients. Medical students can’t reach their universities. This means a new generation of doctors and paraprofessionals will not be available.
Palestinians have become dependent on the Israeli health system after so many years of military occupation.

I have no psychological barrier to referring my patients to the Israeli system to save lives, but the challenges are gigantic. Patients usually have to pay privately for the services. Israeli doctors are often willing to receive patients but we are not able to send them because they don’t have a permit. Sometimes a baby can get a permit to go to Israel for treatment but the mother cannot.

The same difficulties appear when referring a Palestinian patient from the West Bank or Gaza to any of the East Jerusalem Palestinian hospitals. There are two well equipped hospitals in East Jerusalem with qualified professionals. Even the doctors need permits to reach their patients and work place.

When my Dad was diagnosed and treated privately in an Israeli hospital, he was given the best treatment ever, medically and psychologically. His treating professor is a symbol of humanity, commitment, devotion, and professionalism. She gave my dad quality of life till he passed away with dignity.

But, once, after a chemotherapy session, my dad developed fever at night and needed hospital treatment. We brought him to the hospital but we were denied entrance because his permit was valid till 7 pm and we arrived at 9 pm. Even an 83 year old Palestinian patient has to develop his fever according to military order. In trying to treat him, his professor was faced by the discriminating, ugly "security paranoia" of the system that tries to destroy the last hope of a dying patient. Fortunately it did not, simply because the treating professor and my late dad were unique individuals.

AMC: I agree, but Jumana you are surely aware of the legitimate concerns that we in Israel have about the threat of terrorism, which has fortunately diminished but not yet disappeared. Like the Palestinians, the Jewish people have lived through a painful history, and I worry about my children’s safety. But I appeal to you to try to move on. You seem to see the main problems as how to cooperate with doctors from the "occupying" side and being forced to go through the difficult and sometimes humiliating process of receiving permission to cross from the territories to Israel.

However, for many years restrictions were less onerous and, in fact, non-existent; even today, where there is a will there can be a way.

I find it both sad and indeed wasteful to see my Palestinian colleagues choosing to invite specialists almost exclusively from abroad. (Even our good colleague and interlocutor Dr Waterston falls into this category).

I would certainly never oppose outside experts coming to our area, but it does seem unfortunate that we neither take advantage of each other’s experience nor share experts who do visit the region. When, for example, was the last time a visiting medical authority gave a talk in both West and East Jerusalem, or both Tel Aviv and Nablus?

As well, we cannot help but be perplexed by the longstanding general unwillingness of our Arab medical colleagues to cooperate with us in any way. For example, despite Israel having treaties with both Egypt and Jordan, neither country’s national medical association has, to the best of my knowledge, ever opened up to any kind of dialogue with Israeli colleagues. Only recently, for example, Egyptian physicians succeeded in keeping Israeli doctors from attending an international conference held in Cairo (International Society of Thrombosis). Whom does this benefit?

Many Arab physicians whom I have met over the years at conferences abroad have told me directly that although they have nothing against me personally, they would suffer serious professional disadvantage if they were to be seen to be in dialogue in any way with Israeli doctors.

Another example is the Arab countries’ absurd insistence that Israel not be allowed to be part of the World Health Organization local grouping of states. Iraq is, but Israel isn’t. This is just crazy.

JO: We are humans, and it is not easy for a Palestinian to forget her or his oppressors—even if some doctors do not fall in this category. Personally I refuse to take the role of a victim. I continue to believe that I’m rather a survivor of an ugly, paranoid, and temporary occupier and a fighter against the injustice of the situation.

I do not remember ever feeling the "humiliation" that is inflicted systematically and daily on Palestinian people. I rather feel angry, frustrated, and disgusted. In fact, I’m always ready for the worst and well equipped with courage and hope. I always know why the occupiers are trying to break our spirit, but do they really know why they are doing so?

Israeli doctors should realise that there is no way that they will be accepted by the international medical community in general, and the Arab medical community in particular, until the Palestinian people get their rights to self determination, which starts with ending the occupation. Israeli doctors will continue to be isolated, and it’s their choice.

AMC: Jumana, these are strong words, and I too from my side could use the same but, in the interests of our dialogue, I will forgo such a response. Casting blame and name calling is not, I hope, the purpose of our dialogue. Again, I suggest that we leave politics to the politicians and try to concentrate on our patients.

A discussion between an Israeli and Palestinian doctor over what the final border arrangements should be will be less useful than talking about how to deal with the spread of H1N1 influenza across the border in either direction.

As individuals we all have our political beliefs, but I believe it’s more beneficial at this stage to stay away from the overtly political. In the end our two peoples will have to stop demonising each other and live together—more or less—in peace.

Building cross border relationships in health should help the political process by encouraging a positive feedback loop. Successful engagement in matters medical will encourage the peace process, which will in turn help facilitate health projects and build trust.

As even the Palestinian prime minister, Salam Fayyad, stated recently in the International Herald Tribune (www.nytimes.com/2010/04/30/opinion/30iht-edcohen.html), "Let us not allow ourselves the luxury of acting the victims forever . . . It’s time to get on with it and end the conflict. Let’s move on."
JO: Mark, in health, blaming the victim is a known powerful instrument; it is wrong to blame the other side rather than admit that occupation is not a healthy phenomenon. This is not to say that we Palestinians do not have to be critical of our faults regarding the health system.

I, too, believe it is our destiny to live together, whether we like it or not. Eventually this will be the future, but with the continued arrogance of power of the Israeli political leaders I can’t see how it could be possible.

AMC: In order, as you put it so well, to "live together" I offer that it is probably better for us as doctors, at least initially, to address clinical and training issues to develop relationships and build trust.
Afterwards, we could move on to more "public health" issues in which the political elements tend to be more salient—for example, water and food safety, sewage systems, and environmental protection.
JO: Israel wants to cooperate on topics such as immunisations, infections, and epidemics, because we are all in the same geographical space. But water and sanitation and environmental protection fall under the full control of the Israeli military occupation. Palestinians are not allowed to build a water treatment plant or drill a well without a permit from the Israeli authorities.

Palestinian water is stolen and provided to the settlers, living illegally in the occupied Palestinian territories. I also wish that the Israeli authority would stop dumping its waste and sewage into the Palestinian territories.

When there was an outbreak of polio in Al Khdera, Israel, in 1989, the Israeli authority hurried to vaccinate first the army, then its own citizens, and then the Palestinians living in the occupied territories.

AMC: I am not familiar with this claim, and in any case 1989 is long time ago. In order to move on, it would probably be best if Israeli and Palestinian doctors initially met under third party auspices, preferably somewhere outside either Israel or Palestine.

Cyprus would be ideal. It is both close by and enjoys cordial relations with both sides. In fact, several years ago I participated in just such a regional meeting with Arab colleagues organised by an American colleague.

Organisations such as the Canadian International Scientific Exchange Program (CISEPO) have long laboured, sometimes quite successfully, not only to bring both sides together but to deal with clinical issues of direct relevance to all people in the area—for example, hearing loss and child health.
If Dr Waterston and the Royal College of Paediatrics and Child Health wanted to lead and sponsor cooperative training in child health, I am sure many Israeli doctors would be pleased to join with their Palestinian colleagues.

JO: Health dialogue without a political content will seem clichéd and be very superficial and unrealistic. My father’s case shows that there is no way to avoid politics even when both sides try. When I accompanied him for chemotherapy, I used to be sad thinking that if Palestinian and Israeli patients can share pain and suffering, why don’t we share joy and freedom?

Mark, I’m not sure about involving third parties. There were several attempts and they failed in most cases. I believe that it should be from within the two societies.

Maybe if more Israeli doctors joined groups such as the Israeli Physicians for Human Rights and showed interest in supporting Palestinian people in their struggle against the occupation, this could improve relations.

I also suggest that Israeli doctors cross the checkpoints and go through the many turnstiles and just get the feeling of what it means to be Palestinian trying to go about your daily life.

Most are not located in the border between Palestinian and Israeli land but inside the Palestinian territories, and their purpose is mainly to humiliate Palestinians systematically, protect Israeli illegal settlers, or prevent Palestinians from reaching their agricultural land.
Politics first?

TW: The recent Lancet series on Palestinian health (www.thelancet.com/series/health-in-the-occupied-palestinian-territory) concluded that political factors underlie many of the health problems facing Palestinians and therefore need to be tackled before the health problems improve. Do you agree, and do you think that doctors on both sides can work together in this respect, and if so how?
AMC: I and many other physicians found that particular Lancet series highly politicised and biased. The editor, Richard Horton, is clearly one sided in his support for the Palestinian position and unalloyed hostility to Israeli medicine. This stance is, of course, his right, but for dialogue to take place, it would be better to find a more honest broker, one more acceptable to both sides.

JO: I think it was a great step forward for the respected Lancet to have the series on Palestinian children’s health issues.
It is not a competition between two people; this issue came right after the aggressive attack on Gaza, which was a wake-up call for many people all over the world. The articles were developed in a very modest environment and with limited resources; I think also that the articles were community oriented, culturally sensitive, and reflect evidence based practices.

They were written by Palestinian doctors and other health professionals who just happened, unluckily, to be living under the longest military occupation in the 21st century.

The Lancet’s editor decided to take a non-biased, professional approach in a case of injustice and take the side of the oppressed. As a doctor his conscience came first. He deserves our recognition as well.

AMC: I really don’t think it is too conducive to a dialogue between doctors to bring up history, as each side has its own legitimate claims and the circle of argument is endless . But if Jumana wants to bring up the "aggressive attack" on Gaza (from which Israel had previously withdrawn), I am sure she is aware that Israel’s response followed eight years of endless unprovoked missile attacks on the southern part of the country—and I should know as I worked under these conditions. But I appeal to you to keep talking medicine and health with me. There are other forums for political and historical discussion.

Looking ahead, a dialogue such as this one is a wonderful first step. I thank Jumana for taking part with me and am grateful to Dr Waterston and the editors of the BMJ for initiating and publishing our dialogue.

Future steps would be meetings of the professional physicians groups from both sides to present the clinical, teaching, and research aspects of clinical problems of mutual interest. Examples include child health, the growing challenge of ageing, or more contemporary issues such as a regional approach to H1N1 influenza or rabies (a recurring problem in Israel and Palestine).

After a successful meeting, preferably on "neutral" territory, each side should invite the others to visit its hospital facilities and trade technical and clinical insights.

Whenever I despair of the prospects for peace in our small crowded part of the planet, I look at Germany and France or Croatia and Serbia. Even the situation in the UK with Ireland (not something of which the British people can be too proud) can offer us some cautious optimism.

Here one can see that while these neighbours may not exactly love one another, they do live in peace and hopefully in the future in some kind of harmony. So too could Israel and Palestine.

I believe that although doctors alone cannot make peace, we can cooperate to the benefit of our respective medical systems and our patients.

It also means there will be partners in civil society who are both ready and willing to strengthen and encourage every attempt at finding a lasting and political solution to our tragic conflict when peace does finally come knocking on our door.

JO: To build trust, the initiatives should come from the Israeli doctors, simply because they are the ones in power and not the Palestinians. All Palestinian doctors from the West Bank and Gaza, including the minister of health, are not allowed to move freely. Would it be possible to build trust without feeling free to move as a doctor?

My priority is to prevent more damage to the next generation of Palestinians. Again, I’m not sure how cost effective meetings abroad are. Truly speaking, I do not have a ready made prescription regarding how doctors from both sides can work together under current circumstances.

Although I’m a strong believer that doctors can and should make a difference in the lives of children, Israeli politicians made it difficult for us to even breathe and think normally.

AMC: My response: we must keep trying to work together as doctors and, in the words of Winston Churchill, "Never despair." Our patients are depending on us. As to initiatives, I invite you to visit. You will be most welcome.

Cite this as: BMJ 2010;340:c3081
Competing interests: All authors have completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that they have (1) no financial support for the submitted work from anyone other than their  employer; (2) TW leads the Royal College of Paediatrics and Child Health teaching programme in the West Bank, which is funded by Medical Aid to the Palestinians; (3) no spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; and (4) no non-financial interests that may be relevant to the submitted work.

Provenance and peer review: Commissioned; not externally peer reviewed.
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