The Dilemmas of Practicing Humanitarian Medicine in Gaza

As a Palestinian physician based in Haifa, I had been waiting enthusiastically for the opportunity to help the medical workforce in the Gaza Strip care for their fellow residents living in conditions of utter deprivation.[1] So, I was grateful to have the opportunity to join the delegation of Physicians for Human Rights – Israel (PHRI) on two trips to Gaza, in December 2019 and January 2020. PHRI is an Israeli human rights organization founded in 1988 to promote the equal right to health for all people in Israel and for those who live under Israeli occupation. It provides humanitarian aid through free and mobile clinics, operates a legal department to help Gazan patients secure permits to exit Gaza for medical treatment and advocates for policy changes. It is one of the only Israeli organizations allowed to regularly enter Gaza, which they do with their mobile clinic, bringing in physicians and medical staff who are Palestinian citizens of Israel along with medicine and equipment.

There is a basic logic to all humanitarian medicine. It goes like this: War and siege cause a humanitarian crisis resulting in a shortage of doctors and medications. Delegations of physicians from outside the war zone deliver medications to ease the suffering and provide humanitarian relief. This logic was shattered during my visits.

Israeli attacks on Gaza tend to fill the media with images of dead bodies, injured families, shattered buildings and pitted streets. Most images of medical aid in Gaza are thus also tied to these wartime scenes and reveal bombed hospitals, war injuries such as burns or amputated limbs and children with severe malnutrition. Everyday life under siege, on the other hand, with its toxicities, anger, frustration and power cuts along with the suffocation of dreams, aspirations and mobility (not to mention the crippling notion that you might live and die without ever leaving Gaza) occupies very little of the outside world’s conception of life in Gaza.

To prepare for the trip I had researched what possible medical challenges I might encounter. I wondered what material I should review and re-read or what possible equipment or medications I could bring. But I was surprised to discover that when Israel stops bombing, direct war-related causes of mortality drop from first place to 35, while diabetes, hypertension and heart disease take over the top of the list.

After attacks cease, people return to dying—in far greater numbers—of the usual chronic “middle class diseases” that we as physicians cannot treat or cure in a weekend visit. These are diseases that require ongoing treatment and follow-up care in a well-equipped health system. The continuing Israeli siege and de-development of Gaza make the prevention, treatment and management of these chronic diseases much harder and causes avoidable death and disability. The same is true, for example, with the neonatal mortality rate, which is seven times higher in Gaza than in Israel and almost four times higher than the rate for Palestinians inside Israel, according to the World Health Organization. This tragic reality is greatly shaped by displacement, occupation, siege and its resulting life conditions.

My experience during the missions raised questions about the practice of medical aid in Gaza and in Palestine more generally. For example, what are the repercussions of the traditional medical humanitarian framework that makes these delegations possible? How can we evaluate and critique the narratives they promote, since there are no medical tools to measure their effects? These questions are not meant to dismiss the good intentions of the delegations and doctors aiding Gazan patients. At the end of the day, that work is an intuitive and instinctive response to the suffering of others. Nevertheless, the working hypothesis of the humanitarian aid framework and the discourses it produces need to be critically examined.

 

The Gaza Strip as an Open-Air Prison

 

The Gaza Strip, when not under direct attack, is significantly different from other war zones, conflict areas or geographic regions where the tradition of interventionist humanitarian medicine originated. It is not a battlefield between two armies, or a temporary host to a population of migrants fleeing war elsewhere. It is the opposite: Gaza is the permanent home of a besieged population primarily made up of refugees who were expelled from their original homes and nearby villages into Gaza in 1948. Despite the fact that 1.4 million refugees live in Gaza, out of a total of 1.9 million residents, and 75 percent of the population suffers from poverty and unemployment, it is not a rural area with malnutrition and epidemics.

It is a small urban and suburban strip of about 345 square kilometers, which has been under a tightly controlled closure by Israel since 2007. In this crowded open-air prison, the intense pressures for life to continue and housing to be rebuilt, coupled with the need of donors to fund reconstruction, leaves no room for the ruins of war to remain as evidence for war crimes’ testimonies. The Gaza Strip has been rebuilt multiple times, and now looks like any impoverished neighborhood in megacities like Cairo or Delhi, with densely packed housing and decrepit, crumbling infrastructure.

The only way to enter this open-air prison from Israel is through the Erez checkpoint in the north of Gaza. It is one of the most highly secured checkpoints in Israel, which people with special permission, like the medical delegations, can use to enter from the Israeli side. Not even those with family members or spouses in Gaza can enter the strip. To leave Gaza through Erez as a Palestinian is a mission impossible. Permits are granted solely for specific and limited reasons such as medical treatments, what Israel defines as “humanitarian exceptions.” Therefore, the term “crossing” that is used by the Israeli government sounds like a sarcastic joke. Rather, the Erez entry normally operates as a one-way prison gate.

During my medical studies I volunteered at the free clinic of PHRI in Jaffa, serving undocumented patients, mainly Palestinians and African asylum seekers. Later, as a physician, I joined their mobile clinic in the Occupied West Bank, working mainly in remote villages lacking good access to health care. The moment I learned they were activating the mobile clinic to Gaza, I applied enthusiastically. To my surprise the applications were fully approved only one day prior to the scheduled travel date. Gaza is a destination you cannot fully plan for in advance with any kind of certainty. When I heard the news, I tried to immediately connect with friends and family of friends in Gaza who have been cut off from the outside world for years. The question in my head—”What can I possibly bring to them?”—already sounded absurd. A bottle of wine? Not a good idea when passing through Hamas control inside Gaza. A box of chocolate? Too pathetic for a visit to a prison. Ceramics from Jerusalem, a present that I would normally bring to my friends abroad? But I am not going abroad, I am going to my people.

Putting Erez checkpoint into the navigation system and making the one and a half-hour drive from Haifa was an extremely strange experience. Gaza always seemed beyond reach, not the kind of place you can actually drive to. But apparently—as for any other prison—you can park for free at its entrance gate. Our group of 20 physicians, physiotherapists and psychologists, all Palestinian citizens of Israel, gathered outside the checkpoint.

As a new addition to the staff, I was impressed by the level of altruism and organization of some of the other doctors: A female family physician told me that she had already started to gather donations, medications and medical devices from her local community in Jerusalem a month before our visit. An orthopedic doctor in his forties had collected leftover medicine and medical devices from the families of deceased patients in his town in northern Galilee. Both were fueled by a strong impulse to provide any kind of help and relief to their brothers and sisters on the other side of the wall. But there were also those among us who treated it as an adventurous school trip, excited and unprepared, with cellphone in hand ready to post their heroic acts on social media.

Now here we were, ready to cross. Nothing speaks more of what Hannah Arendt described as the “banality of evil” than the Erez checkpoint. The only facade of one of the longest and most brutal sieges in modern history is a relatively clean and calm transit hall with odd posters warning visitors about Hamas members and a friendly blond soldier saying, “Oooh, you are with the medical team, please follow me.” No drama, no humiliation and no overt violence. Simply a young female soldier on another boring workday, making sure the hermetically sealed siege of 2 million people goes uninterrupted.

After we passed Israeli control, we next had to make it past the hurdle of the Palestinian checkpoint. Nothing speaks more of the misery of the current Palestinian political spirit and fragmentation than the chaotic checkpoints of first Fatah—the ruling political party of the Palestinian Authority in the West Bank—and then Hamas, the party in control in Gaza. It was the first time I had seen a Palestinian checkpoint: No such checkpoint exists when you enter the West Bank. Here it seems to operate as an attempt to claim some limited Palestinian control. But given the current state of Palestinian politics, the immaturity of the employees and the lack of any coordination or actual power on the ground, these checkpoints are only an impotent reminder of internal divisions.

For us, Palestinians with Israeli passports, entering Gaza was bizarrely uneventful. We exited the terminal and met the representatives of the Palestinian Center for Human Rights who were waiting with a bus to distribute us to the various clinics and hospitals where we would start our work on the ground.

 

The Reality of Humanitarian Aid in Gaza

 

By midday I was sitting in a characterless clinic with white walls and neon light, part of a larger clinic complex in the Gaza City neighborhood of Al Shuja’iyya. It was chilling to enter a place directly connected to a massacre: In July 2014 Israeli shelling killed over 60 people and left massive destruction. Today, the line of worried mothers with their children was long. I felt I was in an endless loop of repeating one of three scenarios. One—reassuring mothers that their child has a simple viral disease and does not need any antibiotics. Two—providing free painkillers and other over the counter medications. Three—apologizing to the parents of children with complex conditions resulting from premature birth, genetic diseases and heart surgery by telling them that such cases need a panel of specialists to create a detailed plan of treatment and follow-up care, which cannot be performed during a two-day medical visit.

I felt that I was making very little, if any, actual contribution. But the tens of patients I saw were still, on paper, being counted as a measure of successful humanitarian medical aid. I turned with frustration to a colleague of mine, a well-known heart surgeon who normally practices in Rambam. I thought to myself, after all, he works with his hands and performs sophisticated surgeries that actually save lives according to our evidence-based medicine. I told him with envy, “you are lucky to be actually contributing and modifying disease outcomes. If you did not perform a cardiac valve replacement or an open-heart surgery, it would simply not happen.” But even this, he informed me, was futile since hospitals in Gaza lack the full infrastructure of a cardiac intensive care unit staffed around the clock with trained personnel and the necessary expensive medications. The follow-up care for patients after major surgeries requires an entire structure of physicians, nurses, medications and equipment in order to ensure the health outcomes we see in countries with plentiful resources, many of which are not allowed entry into Gaza by Israel.

One of the most disturbing feelings during my visits was of being the “foreign expert.” Since we had studied and trained in Israeli hospitals, the patients afforded us a higher status and believed that we were more reliable than the Gazan doctors who are relatively isolated from ever-changing medical updates, trainings, conferences and development options. I was sickened by the feeling of being seen as the foreign expert who is saving the patient from the ill-equipped Gazan physician. Frantz Fanon wrote in A Dying Colonialism of the “organic confusion” by which colonized people perceive the European doctor. But here I witnessed a more mutilated confusion where a native doctor—caught in the settler’s polity and trained in the settler’s system—is perceived as a Europeanized doctor, invoking a mixture of envy and respect from both the colonized doctor and patient. Fanon describes the native doctor in Algeria as feeling compelled to demonstrate his admission to the rational colonial universe, but here I felt embarrassed to be considered a part of the colonial aid system, trained in the colonial hospital.

After my time seeing patients, and still feeling that my presence was of very little value, I decided to prolong my stay. Erez checkpoint completely closes on Saturdays due to the Sabbath. Therefore, the delegation usually goes in on Thursday and leaves on Friday. I stayed until Sunday and spent my time traveling the strip and meeting physicians and managers of wards, hospitals and medical aid organizations in order to more fully understand the challenges facing the medical staff and the larger community. In this way I hoped to develop more realistic goals and formulate a better working strategy.

A recurring theme during these meetings was the crippling lack of sovereignty. In a way, the creation of the Jewish state in 1948 not only expelled Palestinians from their homes and land but also expelled them from history into a liminal time. As Ghassan Hage notes, “A viable life presupposes a form of imaginary mobility, a sense that one is going somewhere.”[2] In Gaza, no one was going anywhere. It is a waiting room between a previous war and an impending one. Between the optimistic development promises of turning Gaza into a “Singapore on the Mediterranean” and the threats of being bombed back to the stone age.[3] In this unpredictable liminal time, it is impossible to know what medications or equipment will be allowed into Gaza next month or which patients will be allowed to travel out of the strip to receive therapy. The constant uncertainty makes creating strategic medical plans that require interventions seem like an unattainable luxury.

If the catastrophic effects of the occupation and siege were not enough, the strife between Fatah and Hamas has further fragmented the health care system. I was shocked to hear from physicians about the difficulties that occur when some positions are appointed by the Ministry of Health in Ramallah by Fatah and others by the ministry in Gaza under Hamas. This uncoordinated system creates confusion and tension in the workplace hierarchy: It is unclear who supervises the work of whom and who can hire or fire workers. Another often cited example is the difficulties encountered when attempting to secure permission for medical staff to leave Gaza for trainings or workshops, which not only requires permission from Israel, but also an agreement between Fatah and Hamas both in the hospital and at border checkpoints. Sadly, this process often deteriorates into a childish struggle of one side attempting to obstruct the work of the other, adding another layer of frustration that easily leads to a sense of collective self-hatred.

My nights were spent wandering the port and the streets. I tried to absorb as much as I could from the city and from the faces and gestures of my friends as they told their brilliant stories of life under war and siege and their ability to find joy, humor and love, as well as the energy to carry on.

 

Doctors In, Patients Out

 

Beside bringing physicians and medical supplies into Gaza, a significant part of humanitarian medicine is securing permission for patients to leave to receive treatment in Israel, East Jerusalem, Egypt or Jordan. As a student I encountered Gazan patients in Israeli hospitals and was often puzzled to hear Israeli doctors talk about treating them without addressing the larger context. How could the massacre of men, women and children go unnoticed by the doctors? They seemed unaware of the absurdity of the situation where, for example, a patient with cancer or heart abnormalities is transferred to Israel for expensive and sophisticated treatment (that often requires long and costly follow-up care) only to be sent back to Gaza to possibly die from another season of bombing or the effects of the siege.

During my visits I witnessed how little trust Gazans have in their health system and how every simple medical diagnosis is followed by a marathon effort to get a second opinion and treatment outside of the Gaza Strip. But this is not an option for everyone. Aid organizations have, perhaps unwittingly, created a class of recipients that is seen as the most worthy of humanitarian services by emphasizing an aura of innocence to “elicit sympathy and counter the usual mix of fear and hostility” toward Gazans. [4] These ideal innocent victims are mainly women and children and often cancer patients. The icon of the ultimate victim is often a Palestinian child, preferably female, waiting to receive chemotherapy. The campaigns of humanitarian aid groups that focus on her innocence and misery unintentionally divide Gazans into worthy and unworthy patients. Those who are innocent enough and sick enough might receive permission to exit Gaza to receive the life-saving treatment they need.

This overemphasis on innocence was vividly embodied in a petition by Gisha—the Israeli legal center for the freedom of movement—and other human rights groups to the Israeli supreme court in July of 2018 after the Israeli government’s refusal to allow seven female cancer patients from Gaza to receive life-saving treatment at hospitals in occupied East Jerusalem, on the grounds that they are first-degree relatives of Hamas members. This decision was part of Israel’s efforts to pressure Hamas to return the bodies of two Israeli soldiers as well as two missing civilians allegedly held in Gaza. During the hearing, the human rights organizations emphasized two main points: the women were innocent of any involvement in what the state perceives as prohibited activities—their only “crime” was being related to a Hamas member; and, unless they received the treatment, which is not available in Gaza, these women would most likely die. This emphasis on innocence, though pragmatic and sometimes efficient, creates an ever-shrinking space for those considered worthy of treatment.

This framing of certain patients as innocent victims worthy and in need of life saving care encourages a sense among Israeli physicians of being savior doctors with superior knowledge and power. For Israeli doctors treating Palestinian children in Israeli hospitals, the patients are simply coming from a “less privileged place” to a “developed country.”[5] The patients will be treated by a well-intentioned staff that is “blind” to their nationality but not to their suffering, while making sure they do not feel discriminated against.[6] This kind of humanitarianism not only provides the doctors with experience and academic publications, it allows them to stand outside of history, in a place of neutrality, where they can ignore the political and historical circumstances that created the victims they are saving. It allows them to bypass politics and intervene only enough to stop the suffering in front of them.

 

The Limits of Humanitarian Medicine

 

After each return from Gaza, I kept thinking about the revolving door of humanitarian medicine, which aims to allow as many physicians and medications in as possible and the exit of as many patients as possible. A huge matrix of detailed rubrics is thus assembled—the age, sex and identity of the patients, their innocence, the urgency of the medical condition, the ability to get permits and treatment, the number of delegations, drugs or equipment entering Gaza. The information is tallied up and successes are celebrated as victories. But this approach avoids the core questions of occupation, justice and the refugees’ right of return. Even when scholarship connects the ill health of Gazans to the Israeli occupation, its publication in medical journals can be successfully blocked by sophisticated lobbying efforts. Meanwhile, celebrations of collaboration on aid flows between the occupier and occupied continue, revealing the limits of the humanitarian aid framework.

The Israeli siege has created a unique, extremely complicated lived reality and health situation in Gaza, which is significantly different from conflict zones in other parts of the world. When people suffer primarily from chronic diseases, a quick visit from a physician is of very little, if any, use. The outdated framework for such medical intervention needs to be significantly re-assessed and revised to allow for other kinds of medical aid that are sustainable for a population contending with difficult and shifting living conditions—from bombing to siege. For example, technological advancements, such as the use of tele-medicine as seen in Syria, could bypass Israeli regulations and undermine the siege by allowing doctors to train and consult with health care workers in Gaza. By neglecting the larger political context of occupation while shielding themselves with a self-appointed neutrality, Israeli organizations and the entire medical humanitarian system actually remain active participants in (and in some ways, beneficiaries of) the cruel and repetitive cycle of destruction and reconstruction.

 

[Osama Tanous is a pediatrician based in Haifa and a public health scholar. He is currently a Fulbright Humphrey fellow in the Rollins School of Public Health at Emory University, Atlanta.]

 

---

 

Endnotes

 

[1] The author would like to thank Muna Haddad for her insights and essential contribution.

[2]  Ghassan Hage, “Waiting Out the Crisis: On Stuckedness and Governmentality,” in Ghassan Hage, ed. Waiting (Melbourne University Press, 2009) p. 97.

[3] Toufic Haddad, “From Singapore to the Stone Age,” in Mandy Turner, ed. From the River to the Sea: Palestine and Israel in the Shadow of Peace (Lanham, MD: Lexington Books, 2019).

[4] Miriam Ticktin, “A World Without Innocence,” American Ethnologist 44/4 (2017).

[5] Eldad Erez, et al, “Surgical Treatment of Palestinian Patients with Congenital Heart Disease in a Medical Center in Israel: Challenges and Outcome,” EClinicalMedicine 10 (2019), pp. 42-48.

[6] Miri Nehari, Bella Bielorai and Amos Toren, “Palestinian Children in the Hemato-Oncology Ward of an Israeli Hospital,” Clinical Medicine: Oncology 2 (2008).