Three basic theoretical formulations frame the state of the health debate among Palestinians in the West Bank and Gaza. The biomedical/clinical framework is generally espoused by the majority of the medical and allied health care establishment, most of whom have been trained in the Western medical tradition. This biomedical framework views disease as a malfunction of systems and organs that can be corrected by technical intervention on the part of qualified health care providers. By this conception, medical care and healing occur almost solely within the limits of the clinic, the hospital, the laboratory and the pharmacy. Causal relationships are clear-cut and unidimensional. [1]
Absent from this framework is any concept of disease as being due to multiple causes, and particularly to interaction between body and environment. Also absent is the notion that health and disease are the consequences of particular socioeconomic contexts. The question of how society is organized and the way in which it is structurally constrained by specific forms of domination is never raised. This view pays little if any attention to relationships between forms of social organization and the production and reproduction of ill health.
Many of the constraints that define the limits of the Palestinian health debate today are a consequence of this mode of thinking. Health problems are discussed in terms of the insufficient number of hospital beds, clinics, laboratory facilities and other technical services. They are seen in terms of insufficient budgets and the lack of trained specialists. The major fault is thought to be insufficient technological progress, to the exclusion of other determinants. [2]
The second framework, that ill health is a consequence of colonialism, largely derives from the political/national argument. The Palestinian national movement currently devotes increased attention to health and health care, as part of the national question. Health and its investigation serves at least two important functions. The first is to show that the health status of the Palestinian population living under Israeli occupation is deteriorating, and to further indict the policies and practices of the military occupier. This Palestinian logic suggests that health problems can only be solved by means of a just settlement of the national question, through the establishment of an independent Palestinian state. [3] Thus health serves a mobilizing function.
From this perspective, the second function that health serves is that of “steadfastness.” Through the delivery of basic services and the fulfillment of basic needs not being met by the military occupier, the nationalist organizations hope to encourage the Palestinian inhabitants to withstand the various occupation pressures towards migration out of Palestine. This is of particular importance in view of the fact that the occupied territories represent the only remaining Palestinian social entity that still possesses the basis for a future reconstruction of Palestinian society. Here Palestinian life and culture has been continuous, albeit in an abnormal form, despite the loss of political identity. For the diaspora Palestinians, in contrast, life and culture were completely and permanently disrupted. As stateless refugees, their only prospects for security rest with the creation of a Palestinian state in the occupied areas. In this context, health and health care assume an important political function.
The third framework conceives of health as a means for achieving political mass mobilization around the problems of basic needs. Largely the initiative of the left, this approach to the national question and health is a sophisticated form of the mainstream national view. It arose as a response to the failure of adequate mass mobilization around the national question, especially in rural areas, where about 70 percent of the population lives. It relies on the principle of directing the largely unmobilized population, in particular women, into the mainstream national struggle, utilizing health and other necessary services as instruments through which this sector of the population can be activated. It was primarily the progressive women’s committees movement that first discovered the neglected rural areas. [4] They formulated the first workable model for this trend. Since then, a variety of committees have been created, by both men and women, to serve the needs of and to mobilize specific sectors of the population. [5]
Political Setting
Though this third framework for conceiving health and development in general is by far the most interesting that has emerged so far, and although it is clearly influenced by a progressive ideology, it shares problems with the mainstream movement. It theoretically conceives of health as being determined not only by the political setting, in this case colonialism, but also by other economic and social relations. In practice, despite increasing popular support and substantial achievements at a certain level, it remains limited by its frequent inability to turn theory into concrete action. [6]
What is particularly striking about the Palestinian health debate is the tendency towards generalization and reductionist logic. The terms of the debate are set to serve only one purpose: to incriminate the Israeli military occupation. It is as if other factors and problems internal to Palestinian society do not exist. No one doubts the substantial impact of the structures and processes of domination imposed by the military occupation on health conditions in the area. But those are clearly affected and influenced by other factors as well, such as regional, class and gender inequalities.
This reductionist “blame everything on the occupation” view, locking Palestinians into the category of victims, fails to open the discussion on the possibilities of intervention in such a way as to go beyond the steadfastness jargon or the services approach to health. For it is possible to mobilize people and help them create the conditions under which sanitary habits, work conditions, incomes and educational levels could be improved. Intervention in these and other areas could yield very positive results on health status, if health is conceived as a social phenomenon not constrained solely by conditions of occupation. This approach implies very restricted possibilities for action: Short of the removal of military occupation, nothing can be done. It is thus self-defeating to the extent that genuine steadfastness requires a non-victim consciousness.
If this approach has gone beyond the biomedical paradigm for understanding health, it has done so to link ill health and the national question in a manner that is only functional to the needs of the national political argument. It has failed to locate arguments about ill health within an overall social explanation and essentially lumps all Palestinians together, ignoring internally generated differences as determinants of health status. The health status of those who are poor, for instance, is not the same as that of those who are rich. And inequalities between the sexes are reflected in unequal health status — for instance, the higher incidence of malnutrition among girls. Disparities between urban and rural areas also create differential health and disease pictures. Because this approach does not conflict with the biomedical one, it has been effective in linking the medical establishment into its orbit in a workable fashion.
The implications of this are clear: Given the right political conditions — that is, national liberation — the biomedical framework would be the umbrella under which health care is conceived, planned for and practiced. Already the result of this alliance has been to create a pervasive and dominant ideology of health under military rule with severely limited conceptual boundaries. It sets the stage for what may prove to be a rather unhealthy future even after liberation.
By the beginning of the 1980s, it was becoming increasingly clear to some that the efforts put into health promotion during the 1970s had left most health problems untouched. [7] The emergence of the alternative progressive initiative embodied in the committees movement may be an indication of this growing dissatisfaction. [8] The women’s movement is conscious of the gender question and its relevance to health and the general well being of women. [9] The Union of Palestinian Medical Relief Committees is aware of the disparities between rich and poor, men and women, and urban and rural areas. Both movements have managed to shift the center of debate and action from one that concentrates on centralized urban medical facilities to one based on a perception of health as a social construction. The popular response to these movements has so far proven to be remarkable. Even before the intifada erupted, the committees proliferated to an extent that forced the mainstream national and medical establishment to acknowledge their presence as a social force. Some even hold that this popular movement formed the basis around which the population was mobilized during the uprising.
So far, though, the women’s committees movement has not been able to formulate programs that deal concretely with specific problems of inequality not directly linked with the purpose of national political mobilization. Thus, although the women’s committees are actively involved in providing much needed services to women such as literacy education, health and child care facilities, they appear to do so mainly in order to expand their constituency and thus improve their bargaining power as ideological groups along national political lines. In the end, what determines the course of action is the need of the national factions of men and women to assert their position within the Palestinian political balance. Consequently, there have been cases where more than one women’s committee has gone into a village and sparked rivalries that are not exactly in the best health interests of the people.
Though the health movement has successfully incorporated basic preventive principles into its framework and has shifted the center of attention in health care provision from the town to the rural areas and from the doctor to the village health care worker, it remains locked into the constraints of factional competition generated by those who still cannot see the value of mobilizing middle class health professionals within the framework of a broad national front.
Strategy of Postponement
The problem here is one of balance between national aims and of a more equitable social order. The progressive initiative has incorporated a strategy of postponement rather than confrontation. Indeed, the primacy given to the national political contradiction has so far been the major deterrent to the formation of a united women’s movement; splits among the women’s committees follow identical factional lines to those of the national political movement. The problematic Palestinian political scene presents the progressive popular movements with serious dilemmas. If conflicts other than the national one do not get more attention now, it may prove very difficult to deal with them in the future. [10]
There is a fourth framework which can loosely be called the international development agency approach. Although very few Palestinians espouse this approach, it has had an impact as a result of the proliferation of aid agencies in the region. Their conception, in one sense the complete opposite of the national political one, situates health and development in a political and economic vacuum. When the determining effects of political and economic relations on health must be acknowledged, the tendency is to pay lip service to the idea and then place it firmly on the shelf.
The agency approach differs from the biomedical one insofar as it stresses decentralized services, especially in rural areas. The emphasis is generally appropriate technology transfer and self-help projects, suggesting that the problems of underdevelopment in the region are due to the lack of appropriate technical backing and to popular attitudes and behavior. The agencies appear oblivious of the difficulties of treating villages as homogeneous entities, for conflict between and among strata exists even at the village level. [11] This problem they share with some Palestinian groups.
A reformulated understanding of health and its determinants in the context of military occupation is clearly needed in order to enlarge the framework within which questions regarding health and disease are raised and to incorporate the various forces that act as determinants of the health status of the population into one analytical framework. Within the medical tradition, the disciplines of epidemiology, preventive medicine and community health have recognized the role of the environment in generating disease and the importance of prevention as opposed to temporary cures. Here health is conceived as the sum total of biological, environmental and personal determinants — water, air, housing and work conditions, among others. This approach considers the need for activities and services other than those centered on the clinic or hospital, and the need for health care providers other than the traditional doctor and nurse. It accords a prominent role to health education and recognizes social and political factors as potentially instrumental in bringing about changes in the physical environment. This in turn opens up the possibilities for a reduction in morbidity and mortality rates and improvement in people’s health status. [12]
While this extended view of health does represent an advance over laboratory medicine, the emphasis in practice remains largely on individual behavior. Health educators treat social class differences as influences on behavior rather than as sources of conflict. [13] Class and gender are key determinants of health status in the Palestinian villages we have studied. Yet community health workers tend to restrict the scope of their activities to direct medical care, and community mobilization to solve environmental and attitudinal problems, without struggling also for basic social change.
This criticism applies equally well to the international aid agency approach. Years of experience and the persistence of mass disease have led such agencies to reformulate their conception of health, and the primary health care strategy came as a response to the inadequacy of the previous strategies. [14] Yet the primary health care strategy is as inherently deficient as the previous basic needs strategy. The new concepts are largely derived from the contemporary experience of advanced industrial societies, and fail to take into account the sociopolitical context within which communities operate, as if individuals are free and able to choose, organize and change their lot in life without the interference of dominating structures. [15] The failure of this strategy ultimately lies in the incessant refusal of those who shape it to acknowledge the necessity of critically questioning the status quo and the way in which it determines the health status of communities and their ability to respond to specific interventions.
The primary health care framework, by excluding external structures and processes of domination, assumes that underdevelopment and ill health are a result of internal social problems. One is thus left wondering about the role of imperialism and colonialism in providing the foundation upon which Third World poverty is based, the impact of cultural imperialism on medical education and policy in those countries, and the role of multinationals in propagating and perpetuating irrational drug therapy and harmful food and drug consumption and use patterns. [16] These are among the many questions that need to be considered when investigating health problems in underdeveloped countries, including the occupied Palestinian territories.
Endnotes
[1] See, for instance, Winthrobe, et al (eds.), Harrison’s Principles of Internal Medicine, 7th edition (New York: McGraw- Hill, 1974); A.S. Benson, ed., Control of Communicable Diseases in Man (New York: American Public Health Association, 1981). For an overview of the evolution of Western scientific medicine, see Leslie Doyal, The Political Economy of Health (Boston: South End Press, 1983), pp.27-36.
[2] See, for instance, World Health Organization (WHO), Health Conditions of the Arab Population in the Occupied Arab Territories, including Palestine , Document A36/13, Geneva, April 28, 1983, p.6.
[3] See, for instance, the statement of the Palestine Liberation Organization representative to the 34th World Health Assembly, WHO Document WHA34/181/Rec/3, Geneva, May 4-22, 1981, pp.344-346.
[4] The term progressive is used here in the sense of advocating social advancement and the elimination of gender and class as well as national forms of exploitation.
[5] Examples include women’s, medical, agricultural relief and voluntary work committees. On the women’s committees, see R. Giacaman, “Palestinian Women and Development in the Occupied West Bank,” presented to the Seventh UN Seminar on the Question of Palestine, Dakar, August 1983.
[6] Union of Medical Relief Committees, Statement of Purposes and Activities (Jerusalem, 1983) and Lights on Medical Problems in the West Bank (Jerusalem, 1984); Voluntary Work Committees for the West Bank and Gaza, Statement of Purpose and Activities; Bulletin of the Palestinian Working Women’s Union in the West Bank and Gaza Strip (Jerusalem, August 1983).
[7] This was one reason the Arab Thought Forum in Jerusalem initiated a program for rural development research in the early 1980s.
[8] The UMRC statement of purpose states the group’s ultimate objective as “the establishment of an alternative model for a health programme that is compatible with the reality of deteriorating health conditions,” p.1.
[9] Report to the Second General Conference of the Women’s Work Committee, March 1983, p.2.
[10] E. Fee, “Women and Health Care: A Comparison of Theories,” International Journal of Health Services 5,3.
[11] This discussion stems from my experience with some international development agency representatives in the West Bank and from discussion among Palestinians concerning the role of the aid agencies in the occupied territories. An example of this approach can be found in Catholic Relief Services, “Health Education Project, Historical Background,” 1982 Annual Report.
[12] See D. Barker and G. Pose, Epidemiology in Medical Practice, 2nd edition (Edinburgh: Churchill Livingstone, 1979); J. Muir Gray and G. Fowler, Essentials in Preventive Medicine (Oxford: Blackwell, 1984); G.J. Ebrahim, Child Health in a Changing Environment (London: Macmillan, 1982).
[13] R. Brown and G.E. Margo, “Health Education — Can the Reformers be Reformed?” International Journal of Health Services, 8,1 (1978), p.7.
[14] See the Alma Ata Declaration of the WHO, 1978; M.T. Feurstein and H. Lovel, “Community Development and the Emergence of Primary Health Care,” Community Development Journal 18,2 (1983). pp.98-100.
[15] L.Crandon, “Grass Roots, Herbs, Promoters and Preventions: A Re-evaluation of Contemporary International Health Care Planning, the Bolivian Case,” Social Science and Medicine 17,17 (1983) pp.1281-89; E. DeKadt, “Community Participation for Health: the Case of Latin America,” World Development 10,7 (1982), pp.573-84; M. Waseem, “Local Power Sturctures and the Relevance of Rural Development Strategies: A Case Study from Pakistan,” Community Development Journal 17,3 (1982), pp.225-33; D.C. Constantine, “Issues in Community Organization,” Community Development Journal 17,3 (1982), pp.190-201; I.H. Oswald, “Are Traditional Healers the Solution to the Failure of Primary Health Care in Rural Nepal?” Social Science and Medicine 17,5 (1983), pp.255-57; and R. Giacaman, “The Raymah Health Project: An Evaluation,” unpublished report for Oxfam U.K., 1984.
[16] P.J. Donaldson, “Foreign Intervention in Medical Education: A Case Study of the Rockefeller Foundation’s Involvement in a Thai Medical School,” M.B. Bader, “Breast Feeding: The Role of Multinational Corporations in Latin America,” and D. Lall and S.Bibile, “The Political Economy of Controlling Transnationals: The Pharmaceutical Industry in Sri Lanka, 1972-76,” in V. Navarro, ed., Imperialism, Health and Medicine (Farmingdale, NY: Baywood Publishing Co., 1981). See also D. Bull, A Growing Problem: Pesticides and the Third World Poor (Oxford: Oxfam, 1982) and D. Melrose, Bitter Pills: Medicine and the Third World Poor (Oxford: Oxfam, 1982).
