Mohammed Alkhaldi, Rachel Coghlan, Simon Miller, Aisha al Basuoni, Osama Tanous, and Yara M. Asi
In early June 2021, Scientific American published a statement by health care workers, calling on health care systems, academic institutions, and health care professionals in the United States to “unequivocally condemn Israel’s long-standing oppression of the Palestinian people” and the ongoing decimation of their health.1 Similar statements were issued by other health professional groups.2 These statements of solidarity with the Palestinian people came following the May 2021 deadly bombings in the Gaza Strip and violence in the West Bank and East Jerusalem, and amid a shifting global recognition of the realities of systemic discrimination, racism, and settler colonialism against Palestinians in the occupied Palestinian territories (oPt) and Israel. Around the world, awareness has been growing of the illegal and immoral crimes committed against Palestinians by Israeli government policies, soldiers, and settlers, and of the impacts on health resulting from persistent oppression amid this profound power disparity.
The Scientific American solidarity statement has since been retracted, replaced with an editor’s note that the article “fell outside the scope of Scientific American.” The same day this statement was initially published, BMJ Opinion featured an article highlighting the dangerous new precedent for political censorship on Palestine in academic journals.3 This opinion piece described the publishing and subsequent retraction by the Lancet from its website and print journal of a letter on the potential devastation of COVID-19 in Gaza. While the letter remains accessible through other sites, it has been removed from the Lancet journal itself.4
As public health academics and practitioners working around the world who believe in the right to health as a basic human right, closing the health equity gap and the attainment of universal health coverage, the importance of evidence-based health care, and the ethical principles of ensuring good health and well-being that underpin our health education and training, we fully support the call to action from health care colleagues originally published by Scientific American, and we are appalled that their voices have been silenced post-publication.5 Further, we appeal to all health care scientists and professionals, health care organizations, global health academic institutions, and global health academic journals to take steps to hold to account the states and institutions that deprive people anywhere, including Palestinians, of their right to health, and to reproach any attempts to censor calls for the realization of this right. Building on recent global momentum, we propose the establishment of an independent observatory of prominent and powerful health professionals and institutions to ensure a more effective accountability mechanism for the health of Palestinians.6
Health as a universal human right, “without distinction of race, religion, political belief, economic or social condition,” was first agreed on by states in the Constitution of the World Health Organization and the Universal Declaration of Human Rights, and enumerated in many international agreements since.7 Ironically, the Universal Declaration of Human Rights was adopted the same year that Palestinian people were initially dispossessed—1948, the year of the Nakba—and Palestinians living under Israeli settler colonial rule have since endured seven decades of violence, gross human rights violations, and poor health outcomes.8
Why, then, is there continued disregard by states and the wider global health community toward accountability for the good health of Palestinians, regardless of race, religion, or political belief? Bluntly put, state accountability for the health of Palestinians has failed. How can we, as a global health community, ensure such accountability and overcome the impunity afforded to Israel for its role in exiling Palestinians from their right to health? “Silence,” the health care workers wrote in their (paradoxically now-retracted statement), “is complicity.”9 We are at a critical new juncture—and silence is no longer an acceptable response.
The failure of global health accountability to protect the health of Palestinians
Accountability for health is rooted in international legal obligations and human rights. Israel has continued to ignore duties under international human rights law and the right to health—as well as its obligations under international humanitarian law as an occupying power—by denying Palestinians essential health resources, actively obstructing access to health care, and deliberately attacking health infrastructure.10 This denial and obstruction includes a stifling blockade of the Gaza Strip; a separation wall, expanding settlement infrastructure, and an extensive checkpoint system in the West Bank; and a medical permit system, controlled by Israel, for travel out of the West Bank or Gaza Strip to receive health care unavailable in the territories due to these same Israeli restrictions. Israeli authorities’ denial of permits, often without explanation, for Palestinians wishing to access urgent and often lifesaving health care outside Gaza and the West Bank has led to the unnecessary deaths and suffering of many patients, especially those with cancer.11 Moreover, the May 2021 period of heavy Israeli bombardment on Gaza led to the direct targeting of key roads and access routes, preventing ambulances from reaching hospitals and health clinics.12
While countries have scrambled to vaccinate their populations against COVID-19, Israel has unashamedly withheld vaccines from the Palestinian population.13 As of November 18, 2021, just over 53% of Palestinians across the West Bank and Gaza had been vaccinated, while Israel has been lauded for the success of its mass vaccination campaign of its own citizens.14 Last year’s escalation of violence increased the risk of likelihood of COVID-19 transmission, and damage to health facilities—including Gaza’s only COVID-19 diagnostic testing facility—hindered the ability to properly respond to the pandemic, as did the killing of Abu al-Ouf, the physician leading the pandemic response at the largest hospital in Gaza.15 In intensive care units, 36% of those admitted during the escalations were patients with COVID-19-related complications.16
In March 2020, Michael Lynk, the United Nations (UN) Special Rapporteur on the situation of human rights in the Palestinian territory occupied since 1967, appealed to Israel’s legal duty, anchored in article 56 of the Fourth Geneva Convention, to ensure all necessary preventive means available to combat the spread of contagious diseases and epidemics and ensure that Palestinians receive essential health services.17 In October 2020, Lynk reported to the UN General Assembly that “Israel as the occupying power has the primary responsibility to ensure respect, protection and fulfilment of the right to health of Palestinians in Gaza to the full extent of their actual control” and that the ongoing Israeli-imposed blockade on Gaza contravenes international law, specifically article 33 of the Fourth Geneva Convention, amounting to “the collective punishment of the entire civilian population in Gaza” and an experiment “in human despair.”18
Global health accountability mechanisms are supposed to exist to ensure that governments, health policy makers, and health systems follow through on their legal and moral duties to improve the health and well-being of all people, especially the most vulnerable.19 Accountability processes are supposed to play a vital role in driving progress toward health equity commitments that governments, institutions, and organizations have made.20 “Without accountability,” says Lynk on Palestine, “the possibility of political reconciliation, let alone its flourishing, is unattainable. And without accountability, social wounds metastasize, leaving unchecked retaliation, rather than measured restitution, as the likely response to the injustices of the past and present.”21
A number of multilateral mechanisms exist to keep Israel’s adherence to duties, including health, in check. The Office of the UN High Commissioner for Human Rights in the occupied Palestinian territory is responsible for monitoring and reporting publicly on the human rights situation there.22 The Special Rapporteur on the situation on human rights in the oPt, the Special Committee to Investigate Israeli Practices Affecting the Human Rights of the Palestinian People and Other Arabs of the Occupied Territories, and the UN Secretary-General himself regularly investigate and report on the situation in Palestine. The Security Council is the custodian for ensuring international peace and security and has the authority to impose international sanctions when peace and security are threatened. The World Health Organization’s Right to Health Advocacy program in the oPt works specifically to strengthen the monitoring of barriers to the right to health, including obstacles to health access and attacks on health care.23 Reports on progress toward Palestinians’ right to health are provided to member states at each World Health Assembly by the Director-General of the World Health Organization.24
But what have these mechanisms achieved to improve the health of Palestinian people? Israel continues to act with impunity under the world’s watch, other global powers allow this impunity without consequence, and private corporations continue to play a significant role in propping up and profiting from the illegal Israeli occupation and settlements. The veto powers of the permanent members of the Security Council undermine the very accountability mechanism that exists to maintain peace and security and perpetuate an agenda with colonial roots.25 Appeals—over decades—to Israel’s legal, human rights, and moral duties have fallen on deaf ears; and international condemnations for grave breaches to health rights and humanitarian law have failed to make Israel accountable in practical terms. Even the decision to report on progress toward Palestinians’ health at the World Health Assembly has caused division among member states.26 The international community of nation-states and key UN bodies have failed the Palestinian people. As Rashid Khalidi recently voiced to the UN Security Council:
Since the founding of the United Nations, the Security Council has passed multiple resolutions on the Palestine problem and the Israeli-Arab conflict. These issues that have taken up more of the time and energy of this body than any other global problem. Most of these resolutions have not been implemented or respected. They are dead letters. This systematic disrespect for Security Council resolutions, encouraged by the impunity I have described, has left this Council, and the United Nations itself, in justifiable disrepute. More seriously, this impunity has been a major obstacle to establishing peace, justice and security for all who live in Palestine and Israel.27
First steps toward accountability for the good health of Palestinians
In 2019, Lancet editor Richard Horton published an article titled “The urgent need to protect global health accountability.”28 What can be done? What can we do?
Achieving accountability for the good health of Palestinians will require that we as individuals and the organizations we work with and for do not allow a sense of helplessness to overcome us. The big-picture situation in terms of ending the occupation of Palestine undoubtedly needs resolution, but we as a global health community can take some immediate, smaller steps—including steps to hold accountable those who perpetuate the poor health outcomes and unnecessary suffering of Palestinians, and calling out those complicit in censorship.
Accountability means raising our united voices as health-focused institutions, organizations, and individuals to challenge settler colonization, racism, and asymmetries of power and demand that the health needs of Palestinians be met.
History has universally demonstrated that the cost of colonization and systemic racism is the good health of the colonized and subjugated. In the case of the Palestinian population, colonization, systemic racism, and conflict are root causes of adverse health outcomes, unnecessary suffering, and preventable deaths.29 There can be no accountability for good health if governments, institutions, and organizations continue to perpetuate imbalances of power by excusing policies and practices that support structural violence and oppression.
Discourse on the decolonization of global health has gained momentum in the past year, amid racial reckoning following the Black Lives Matter movement. The decolonizing global health movement fights against ingrained systems of dominance and power to improve the health of populations.30 We have a greater understanding of the impacts of systematic oppression and occupation on health; and now is the time to challenge and correct asymmetries of power and dominant discourse by promoting decolonial narratives with regard to the health of Palestinians.
For decades, improving the health of Palestinians has been framed as a “humanitarian issue” under the responsibility of the international community.31 Though humanitarian assistance to Palestinians is well intentioned, this framing relieves Israel of its duty as a belligerent occupying power to assure the good health of Palestinians. It also has the effect of categorizing Palestinians as a class of victims to be saved with donations, aid, and service provision by humanitarian actors. A more just and historically rooted approach would be to frame the situation as it is—an Indigenous population resisting a settler colonial regime in order to achieve sovereignty and rebuild its own health care system.
We have been encouraged by recent calls for the decolonization of journalistic reporting and academic scholarship on Palestine, as well as by academic solidarity in support of the self-determination and liberation of the Palestinian people against Israeli colonialism.32 We are also heartened by growing public support for Palestinians in all corners of the globe. Health professionals are increasingly rallying against health violations targeting the Palestinian people.33 The Lancet Palestinian Health Alliance, established in 2009 as a network of Palestinian and international researchers, has provided an important platform for research, advocacy, and action on health in Palestine.34 We are uplifted by the recent statements of health workers and professionals in the United States in support of Palestine, including the retracted solidarity statement.35
Now is the time to expand such statements and build on the work of the Lancet Palestinian Health Alliance and other collective efforts. Global health institutions and bodies, health academics, practitioners, and policy makers are “uniquely positioned to respond to the social, political, and economic structures affecting our patient’s health” and to act on evidence-based truths.36 It is incumbent on us to do so, and to do so collectively.
The first important step is to keep pressing forward with the decolonizing health discourse through formal statements and calls to action across all health systems, global health academic institutions and journals, and health care colleagues. We need a critical mass of health professionals and institutions campaigning for the right to health in Palestine.
In the immediate term, we must collectively call on Israel to do the following:
- take responsibility for repairing and restoring the health care infrastructure decimated by the May 2021 bombings;
- commit to a cessation of military and civilian violence directed toward the Palestinian people;
- end attacks on health care workers and health care infrastructure;
- permit free, easy, timely, and sustainable access to essential health services and goods in Gaza and the West Bank; and
- permit free, easy, timely, and sustainable access for people requiring essential medical care outside of Gaza and the West Bank.
We must publicly reproach efforts to censor Palestinian voices and stories in favor of “balance” or the “cruel false equivalence.”37 It is incumbent on us as individuals and organizations in global health to hold accountable any person or organization that attempts to silence the voices of those who advocate for the good health of Palestinians.
Accountability means bolstering independent processes for monitoring and reporting on violations to the right to health, with sanctions imposed when the right is not met.
Israel continues to shrug in the face of immunity from consequences for violating legal duties and societal norms, a path smoothed by other dominant global powers and large private corporations. Despite credible monitoring and documentation on progress (or lack thereof) toward Palestinians’ health and human rights by institutions such as the World Health Organization and the Office of the United Nations High Commissioner for Human Rights, existing accountability mechanisms have failed. We propose bolstering independent mechanisms for health accountability toward Palestinians in the oPt, with representation, input, and lobbying from a formalized independent observatory of prominent and powerful health professionals and institutions.
There is precedent for such independent mechanisms. In 2012, the independent Expert Review Group on Information and Accountability for Women’s and Children’s Health was created in response to the failure of UN agencies, donors, and countries to achieve improvements in the health of women and children, and in recognition of the need to better track progress on and resources for women’s and children’s health. The group was made up of leading global health academics and practitioners, including Horton, editor of the Lancet, serving in an independent capacity. In their first progress report, the independent reviewers wrote that
our shared view is that independent accountability is, and will increasingly become, a powerful force to accelerate progress towards both national and international health and development targets … We want to see independent accountability not only become a new norm in global health, but also demonstrably improve the lives of women and children worldwide.38
Monitoring and reporting alone are not sufficient for successful accountability. A new and formalized alliance of powerful global health scientists and professionals, health care organizations, global health academic institutions, and global health academic journals committed to achieving the right to health, starting with Palestinians’ health, could achieve the following:
- form a secretariat and seek registration as a nonstate observer to the World Health Organization;
- use existing evidence to call on states to take action to enforce health and human rights norms; and
- demand the enactment of sanctions when right to health violations are reported and key health outcomes are not met. This would include seeking an end to all partnerships with private corporations that uphold Israel’s occupation and oppression of the Palestinian people and revisiting all government aid that may perpetuate the occupation.
To have an impact that shifts the balance beyond politics as usual, such an observatory would require the support of powerful and respected public and private health institutions. Health advocates and institutions must be prepared to stand firm in the face of fear of reprisal, harassment, or silencing from any government, institution, or funding body.39
This observatory would help communicate to the world in a relatable manner the impacts of structural racism and oppression—for example, vaccination rates of the population of Israel versus vaccination rates for Palestinians; access to lifesaving cancer treatments for Israeli patients versus access to lifesaving cancer treatments for Palestinian patients; and advancements in health care resources, infrastructure, and technology in Israel versus the destruction of health care facilities in Palestine.
If proven effective in improving health-focused accountability for Palestine, such an independent observatory could also seek to achieve improved health across other contexts of occupation or conflict around the world where the right to health of people living in conflict is ignored or undermined, such as Syria, Yemen, and Myanmar—in this way aligning with and reinforcing the World Health Organization’s Health and Peace Initiative, which promotes a health care lens to address the underlying causes of conflict.40
There must be accountability for the acute and longer-term impacts on Palestinian health that flow from the bombings in Gaza and violence in the West Bank and East Jerusalem. Israel has not been held to account for the recent escalation of violence or for the willful obstruction of the passage of essential care and resources that would protect the Palestinian people from COVID-19. Israel has also not been held to account for creating and perpetuating the conditions that have led to the chronic degradation of the Palestinian health system and the poor health of Palestinians.
States that act to degrade the health of whole populations must not be permitted to continue doing so with impunity. It is time to end our tolerance for companies and institutions that are complicit with or support the structural violence of colonization and racism that is denying the good health of Palestinians—a right that all Palestinians are entitled to enjoy. Strengthening health accountability toward people living in conflict settings can open new avenues for assuring good health, ending oppression and violence, and building peace. As a global health community, we must raise our collective voices and reproach censorship and attempts to silence us.