In late March and early April 2019 I traveled to Jordan and the West Bank (Palestine) with two colleagues, Sonia Dettman and S. Komarovsky, first to attend the Lancet Palestine Health Alliance conference in Amman and then to explore and better understand the lives of refugees and the workings of UNRWA, with a focus on the status of refugee health.
The 10th Annual Lancet Palestine Health Alliance (LPHA) conference titled “Health of Palestinians inside and outside the occupied Palestinian territory” was part serious scientific meeting, part determined act of political and cultural resistance, and part joyous celebration. The meetings were organized by the Institute of Community and Public Health at Birzeit University in collaboration with the Faculty of Health Sciences at the American University of Beirut and hosted by the Jordan University of Science and Technology. Professor Rita Giacaman, Director of the Institute of Community and Public Health at Birzeit, is the visionary spark that brings scientists from all over the world to present, critique, debate, and stand in solidarity, particularly over rather large amounts of excellent food, this being a Palestinian event, and a presentation of the Palestinian History Tapestry project.
The conference was held (like scientific meetings all over the world) in the Grand Hyatt in Amman, Jordan (which I learned after multiple attempts to communicate with the Uber driver is called the Grand Hy-yett with an accent on the second syllable – see cultural confusion). After the formal opening speeches, the schedule included topics like “Appraising the methodological quality of the Clinical Practice Guideline for Diabetes Mellitus using the AGREE ll” (Mahmoud Radwan from Tehran University) and “Anti-D versus immunoglobulin for the treatment of Acute Immune Thrombocytopenia in children: A 10 year Palestinian experience” (Mohammed El-Habil from Al-Rantisi Pediatric Hospital, Gaza).
But there was much that I would not see at a medical conference anywhere else in the world: “Health attacks and protection strategies during Gaza’s Great March of Return: A mixed methods study utilizing data from WHOs Surveillance System for Attacks on Healthcare” (Walaa Shehada and Hyo Jeong Kim from WHO West Bank and Gaza Strip). Or “Executions and maiming of unarmed demonstrators during 30 weeks of the Great March of Return” (Khamis Elessi from Islamic University, Gaza). Or “Spatial Agency among children living in Dheisheh refugee camp: engendered space and place as risk and protection from political and military violence in a refugee camp in occupied Palestine” (Guido Veronese from University of Milan). The extensive poster sessions also reflected this broad look at health from a more traditional to a global/political/contextual lens. The researchers from Gaza were mostly not able to obtain permits and their absences were noted by empty chairs at the time of their presentations or blank walls at their poster sessions. Some were able to deliver their papers via the internet which was an act of resistance in itself, a symbolic breaking of the siege.
Professor Graham Watt of Glasgow University and chair of the steering committee for the LPHA, described the alliance as a loose network of Palestinian regional and international researchers engaged in advocacy-based science that meets once a year to share research, network and inspire. He summed up much of what has happened to Palestinians over the past decade with the quote: “Smile they said, life could be worse. So I did and it was.” He sees hope in new female leadership and I also found the number of young female presenters impressive. He noted that as Einstein is said to have commented, “Not everything that counts can be counted, not everything that can be counted counts,” suggesting that the job of the Alliance researchers is to develop scientific methods and research that is culturally sensitive and specific for Palestinians, and to increase the capacity of research and collaboration in this de-developed area of the world. He noted that the survival and growth of the Alliance is a major achievement and an important point of resistance.
An obvious example of this kind of out-of-the-Western-box thinking lies in basic definitions. Can a Palestinian living in the West Bank or Gaza have post-traumatic stress disorder (PTSD) if the trauma is never really “post?” How do you name and treat the anxiety, hyper-vigilance, and bedwetting that is epidemic in Palestinian children? Is an anxious, angry, hyperactive child exposed to repeated tear gas, shootings, and death in a refugee camp mentally ill or responding appropriately to a sick environment? Does structural violence always lead to psychological disorders; how does that relate to agency and life satisfaction as protective factors in this setting? In the West there is much talk of “caring for the caregiver.” How do you do that for a health care provider in Gaza who is not only dealing with a massive amount of young men with multiple explosive, fragmented bullet wounds to their legs, not to mention a steady stream of dead children and pregnant women, but is also at risk for being shot and killed herself while doing this work? The intersection between disease, wellness, politics and war becomes painfully obvious.
I had the opportunity to interview Professor Watt after his talk. The starting point for the Alliance began with Richard Horton, the editor of The Lancet, after he visited Palestine over ten years ago and bravely decided he wanted to publish information about the injustices he saw in the journal. The pushback was and continues to be fierce and unrelenting. Working with Dr. Rita Giacaman and Professor Huda Zurayk, an internationally recognized scholar on reproductive health and health in the Arab world at the American University of Beirut, it took two years to produce five articles with 37 authors, of whom 19 were based in the Occupied Palestinian Territory. The Lancet has published about half of the LPHA abstracts after appropriate peer review and Professor Watt noted that there is a learning curve for researchers, both in the quality of research and analysis and in how to write for scientific publications (in English). Much of the work in the region is surveys and reviews: the Palestine Center for Bureau of Statistics and the United Nations Relief and Works Agency (UNRWA) tend to have good data. Iain Chalmers, one of the founders of the Cochrane collaboration, (a research tool that is one of the foundations of evidence-based medicine), worked in Gaza as a young doctor and continues to work with Gazan doctors, so the Strip is actually ahead of the West Bank in the use of evidence-based medicine and clinical audits.
Unfortunately, health care in the occupied Palestinian territory is fragmented with the Ministry of Health, UNRWA, NGOs, and private clinicians all providing care with duplications, gaps, and chaos complicated by the priorities of international aid groups and donor agendas. The conference developed in an attempt to address many of these issues. If this was not Palestine, people would have founded a national scientific organization, gotten funding, and become an official group, but that is not possible in this world. Professor Watt explained that there is little culture of collaboration between Palestinian institutions, partly because they have no experience and everyone is guarding their turf and funding, plus travel is hard and unpredictable and one never knows who will show up. Additionally, when studies find important research findings, it is often impossible to implement changes: the siege of Gaza continues, the IDF continues its aggressive military policies, people continue to die.
Professor Watt explained that the main success of the LPHA is existential, “We exist,” and the data adds to the Palestinian narrative in a new way. He noted that it is ironic that we are having this conversation while bombs are dropping on Gaza, a medic was shot in the Deheisheh Refugee Camp today, and a medic was killed in Gaza 12 hours earlier. “This is a long term game. Palestinians need to hang on. They need to be still standing when Israel falls or changes.” He felt that doctors on the frontline have responsibilities because they bear witness but, “Anger without discipline is mere cursing. We must have passion with rigor. As a scientist, all research is passionate but disciplined.” He noted “This is an academic effort with an implicit signing up to the use of the scientific method to gather data. Our voice is getting bigger and stronger and more connected. We need to move from the unsatisfactory present to the future. You do not negotiate for power, you fight for it.” I usually don’t hear such opinions from a very respectable older looking gentleman sitting elegantly in a tie and suit in an upscale hotel.
Dr. Mads Gilbert, the Norwegian surgeon famous for his work in Gaza in 2008 and 2014 and for his painfully graphic books, “Eyes in Gaza and Night in Gaza”, has a different style. At the LPHA he sponsored a disturbing poster describing unexpected findings from war-related extremity amputations in Gaza. We sat down for an intense interview during a brief break in the afternoon. Dr. Gilbert talked about how he seeks to describe reality using scientific tools, what he calls “evidence-based solidarity,” to strengthen advocacy and justice. As opposed to humanitarian work, this “medical solidarity” involves, “going there, working under Palestinian leadership. They say ‘When you come we are not alone.’” His goal is to do medical care, gather data, and tell the world what he has seen in a systematic way. “As an activist, the tool is evidence; medicine and science may be more dangerous to the oppressor than slogans. We produce irrefutable evidence.” Collecting data and demonstrating how there are violations of international law serve a larger effort than just strict science.
He found the LPHA a perfect meeting place for sharing knowledge and it is now an important movement to reinforce Palestinian studies done by Palestinians, and to educate and inspire Palestinians who define research objects and tools to build the field of Palestinian research. He noted that Giacaman and Horton’s objective was, “to build a movement of the international community of key academics for solidarity in order to change the world.” Research is thus not only a way of obtaining clear answers to clear questions, it is also a basis for values- based advocacy and for pursuing social justice and peace, to “be intellectually calm in the midst of our outrage.”
He began his amputation studies (examples here and here) and drone studies in 2006, exploring the effects of the Israeli attacks on Gazans). He found that with so much need for medical care in Gaza it was difficult to do research, but the LPHA gave Palestinians an opening, “Oppressed people can define their medical reality in a scientific way.” Dr. Gilbert disliked the term “giving voice to the voiceless.”–“No, they were made voiceless, they were muted. Our job is to de-mute them.”
He said he works as an academic and an activist, “to transition despair and shouting, to document and describe atrocities. Health workers, in particular emergency staff like myself, have a particular responsibility because we are working in ‘the fog of blood’ and we would betray our ethics if we don’t ask, how can we stop this bloodshed, not just patch up the wounds and soak up the blood on the floor. And the simple answer is: stop the bombing, lift the siege, end the occupation of Palestine[…]This is – in fact – not a ‘difficult conflict’ – this a difficult and unbearable occupation! The relief industry never questions the root causes of the disaster; this is the colonial morphine of oppression.”
People are kept oppressed by “denying access to the root causes, i.e., Israeli apartheid.”
I think about the American Public Health Association, (APHA), probably the most progressive medical society in the US, where it has been impossible to successfully organize a statement to the effect that the Israeli occupation is a public health problem. I think about the International Association for Relational Psychoanalysis and Psychotherapy (IARPP) which prides itself in focusing on the individual’s relationships in society, (“committed to doing away with privilege and discrimination in our field”), and has scheduled its next international conference in…. Tel Aviv. I think about the remarks by Dr. Akihiro Seita, head of health care for UNRWA, where he outlined the successes and challenges facing UNRWA, the political and social determinants of health, and the need for data. Then he said, “Life without LPHA: no network, no scientific papers, no advocacy, no moral support, no friends.”
Not your usual medical conference. Next year in Birzeit.