The “occupation” of medical journals by pro-Israel professionals without any “preoccupation” about health issues
I am the author, with 23 other health and science professionals, of an Open Letter for the People in Gaza (1) published in The Lancet on 22 July 2014. The letter prompted friends of Israel in the medical profession to demand the dismissal of the magazine’s editor, Dr Richard Horton and the withdrawal of the publication; there was also a defamation campaign against the authors.
Neither of the first two demands succeeded, but a smear campaign against the letter’s signatories continues. A recent letter by a group of doctors led by Dr M Pepys (2) unleashed again the defamatory accusation against myself and my fellow signatories as well as Dr Horton. An invited comment by J Yudkin and J Leaning (3) in the British Medical Journal supported the decision by The Lancet to publish and was followed by a number of smear letters in the BMJ against us (referenced as responses in 4), taking advantage of the duty for the journal to publish responses.
Here I will write about facts and the lack of facts, and the absence of intellectual, moral and professional adequacy. First, though, some context behind the original letter.
My main concern in asking colleagues to co-author the open letter, after the first 10 days of Israel’s attacks on Gaza last summer, was to draw attention to what was the predictable great loss of civilians lives and damage to health in the already fragile situation that the Palestinians in Gaza find themselves in.
We acknowledged that the fragility was a consequence of the Israeli-led blockade of the Strip; the main keys to the doors of Gaza are not in the hands of any of the Palestinian players, but with the Israeli government. We noted endless public declarations in the media by Israel’s political and governing elite over the past 10 years which are unanimous in their conviction that Gaza has to be silenced; the debate, if there was one, was about how to keep Gaza quiet, not necessarily only by political means. We also registered the menacing reaction of Israel’s prime minister to the attempts at political and factional reconciliation made by the Palestinians, indicating that an autonomous Palestinian government, let alone a state, is not regarded by him as an option.
This point notwithstanding, our opinion about Middle East politics was not the motivation for writing the letter to a major medical journal; nor was that the core message.
Our shared main motivation to send the letter was to address the concern for that fragile, almost collapsing, health sector meant to cater for 1.8 million people effectively “caged” in the Gaza Strip. We wanted to share our knowledge of the accumulating scientific and clinical evidence of the effects that war and post-war environmental conditions pose on people’s physical and mental health, while very few in-depth studies or remedies have been developed. We felt a responsibility to “avoid further damage” and illustrated the situation as we knew it to be, to encourage attention for studies, professional support and for remedies, even if we knew that we could not immediately stop the war.
My colleagues and I, and the linked medical journals, were then attacked because we wrote about Gaza and not Syria or any of the other dire situations around the world. Why Gaza? From our perspective is was the obvious choice because we all had direct experience of the situation there; in modesty and professional truth, therefore, we could speak about what we knew and the consequences we could predict in our areas of competence and knowledge.
So there was no conspiracy; it was simply the fact that we knew the situation on the ground which inspired us to write the letter and gave the editorial team at The Lancet the confidence to publish it. I believe that if medical or other professionals have equal knowledge about the situation in, say, Syria or Yemen, and submit an article or letter for publication, it too would be published in the same journal.
For the time being, I guess that we who sent the letter and the editor who published it will have to accept the attacks against us merely for publicising the truth about the situation in the Gaza Strip. We hope, however, that we may have a role in encouraging positive steps for health preservation and care, each through our own independent work and activities. I can only express the utmost gratitude for the medical journals that care enough to provide a space for contributions about the relationships between health and occupation, and health and wars, wherever and whoever they come from. The editorial staff fulfil their duty to free speech by keeping that space open, while we authors fulfil ours by sticking to what we know.
Let me emphasise here that none of the hundreds of letters sent by our detractors, all of whom appear to be health professionals, raised any health-related issues. Their contribution to medicine and related matters in this case was negligible, and so their motivation in writing at length about what we said has to be questioned. It is interesting, too, that few demonstrated any in-depth knowledge of the local issues in question. Accusing a medical journal of not giving coverage to all wars around the world as a means to attack a specific published item – in this case our letter – is neither a medical nor a scientific point of value.
The final sentence from Tony Demonthe in the Christmas 2014 editorial in the BMJ (5) expresses well what we aimed at as signatories of the open letter: “I think future generations will judge the journal harshly if we avert our gaze from the medical consequences of what is happening to the occupants of the Palestinian territories and to the Israelis next door.” This applies to journals as well as to individual professionals.
Our decision to send this letter to The Lancet and not to the mainstream media was motivated in part by the hope that medical journals will host an open debate on the issue, and that this would be achieved by signalling the ongoing damages and their potential consequences of such professional attention. More specifically, we hoped that this audience would contribute to the opening of medical and scientific investigations and generate help for the health sector which we knew was dire from the very first acts in the war
It turns out that we were correct in our expectations about the dire nature of the consequences, and even modest in our anticipation of the amount and severity of the damage caused. And the extent of the damage to health is wide despite the claims of the Israeli NGO Amuta or Israel’s Terrorism and Intelligence Information Centre (6, 7) about “bias” by the sources of the numeric data of victims reported by UN organisations. To put the record straight, these Israeli sources used the same database as the UN agencies but lowered their published number of civilian victims by reducing the age of majority to 15 years old; male victims were also excluded from the list of civilian victims on the basis of imprecise and secret information about them.
What has happened after the Israeli offensive?
Following the ceasefire in August 2014, reduced access due to Israel’s ban on almost anyone entering the Gaza Strip, hindered both independent and institutional investigations, including those looking at the health sector. The official UN commission of inquiry has not been allowed to travel to Gaza, nor has the UN rapporteur. Nonetheless, those few who managed to skip the blockade were reliable for first views and interviews of a cohort of victims and situations, verifying a number of registered accidents and their modalities (8-18). Their reports illustrate different angles taken of the events and their conclusions about Israel’s responsibility under international laws and conventions will not be disclaimed easily in a fair analysis, but they are not directed specifically at the health sector.
Thus, it remains true, once again, that every independent fact-finding investigation was obstructed by the Israeli government, including that of the “UN special enquiry commission” (19) by refusing permission to enter the enclave. Similarly, most EU political representatives were stopped from visiting Gaza, and there has since August 2014 been even greater difficulties for anybody trying to be a direct witness to the damage caused by Israel, including that within the health sector. There is no doubt that Israel created serious hindrances to fact-finding and support in health by denying entry permits.
The issue that we presented in our letter last July was what could be done “to avoid harm”. The issue for medical journals has never been pro-this or anti-that – especially not anti-Semitism – among individual contributors or editors. The journal did not present the case of Palestine and not of Syria for the sake of it; the professional issue at hand was, “What can be done to limit and then heal the damage?” This is the sort of issue to be debated in medical journals by anyone and everyone who has pronounced the Hippocratic Oath or sticks to the ethics of scientific research.
As an issue, “What can be done to limit and then heal the damage done?” is rooted in the Gaza situation, both for the physical and mental damage, as well as the long-term consequences of the war. There aren’t the same numbers of physically damaged civilians in Israel and there may be a lot fewer mental health issues among Israeli civilians as a result of the war. I guess that they would be proportionate to the stress and number of people involved in or affected directly by the conflict.
Turning then to the real issue, professionals and medical journals are required to document, assess, discuss and produce support for those who would like to work in the healing and reduction of damage, working with those who can help the structures still active in the health sector to provide care and support to those who are permanently disabled (of which there are hundreds, perhaps thousands, including many women and children), the traumatised and the children.
In the Gaza Strip, the consequences of the war for the health sector are even worse than we predicted. Gaza and its people remain unhealed, and the possibilities for receiving help are limited, while the worst environmental conditions persist.
The severe limitations put in place by Israel to reduce both access and the effective working capabilities of professionals in the health and science fields, while the needs have actually increased since the war, have not diminished. Such professionals could provide support and training in Gaza, and Palestinian professionals could leave the enclave for training abroad (and many have fellowships to do just that) but this is not being allowed. Even travel by patients seeking expert help overseas has been restricted by the Israeli blockade.
The presence of thousands of newly-handicapped people, young and old alike; of traumatised children and adults; of conditions potentially inductive of long-term effects on fertility, reproductive health and diseases at large (20); and of the difficulties to cope with chronic illness for lack of medicines and instruments, continue to persist. Indeed, all are in a much worse situation than before the war.
It has not been possible to reduce this toll, due to the blockade which prevents professionals and medical supplies from entering Gaza. Under Israel’s restrictions and control, much-needed health and professional support is largely inaccessible.
Thus Gaza is, to this day, experiencing the destruction of infrastructure; food and medicine insecurity; mental problems among thousands of homeless civilians and families which have experienced loss, and children; the scarcity of energy and water; and a broken sewage system that flows untreated into the sea and pollutes the wells. Potentially toxic powders still fly in the air; its hospital and clinic facilities are reduced in effectiveness due to destruction; and medical supplies are always limited and erratic in delivery. All of these are health issues that should and could be dealt with, but all are impossible to resolve because of the blockade by Israel.
Considering the impossibility of people escaping all of this, assuming that they would want to, of course, the issue is something that should be debated, discussed, evaluated and reported on in medical journals. What is the impact on people’s health of Israel’s policies and what can be done to overcome the limitations facing the Palestinians in the Gaza Strip? This is what the medical media should be engaged with instead of the racist, ethnic or religious discrimination that we have seen for the past 11 months. Such “exercises of free speech” can and should be hosted elsewhere.
The seriously worrying aspect of the endless accusations of “anti-Semitism” hurled at us represents a “determination to abuse a medical tribune” for a sectarian “witch hunt”, without entering into discussion of the relevant medical points. It is a waste of energy in the context of medical care.
Furthermore, this emphasis also confirms how racism, ethnicity and confessional divides, as handled by the medical professionals who have made it their job to attack us, are indeed a main political determinant of Gaza’s health. I am afraid that the professionals responsible for the smears have, in a personal capacity, forgotten their medical oaths and scientific ethics.
I submit that there are possibilities other than the present debate on Semitism and anti-Semitism which need to occupy the space about Palestine in medical journals. The current state of the health sector there should be the subject for discussion in a medical journal, within the framework of the medical profession’s mission to define how we can “not collaborate to do harm, and heal when possible”, without fear or favour in terms of race, creed, age or gender.
So let us ask Dr Pepys and the others if they intend to continue diverting attention from the health sector crisis in Gaza. If the answer is no, then let them act by encouraging Israel to lift the ban for health professionals from abroad to travel and collaborate with our Palestinian colleagues in Gaza; and for Israel to let Gaza’s medical and science professionals – men and women of any age – to travel abroad for training. Let our critics ask their Israeli contacts to allow medical supplies, drugs, instruments, prosthetics, surgical necessities and other items to get into Gaza; and allow the hospitals and clinics destroyed by Israel’s bombs to be rebuilt, instruments and machines to be replaced, and ambulances to be repaired. Such pressure on the authorities is the responsibility of medical professionals everywhere.
Will they, according to their professional standards, lobby for the blockade on health care and professional work to be lifted; for patients, trainees and local professionals to travel out of Gaza; and for international professionals to have free access to Gaza? Will our critics submit research papers if they feel that Israel is under-represented in journals? This seems to be a burning issue for them, though it is unclear how it can be requested simply on a nationalistic basis for debatable reasons. Or will they simply rewrite their defamatory pamphlet? Will doctors and scientists in general, as authors in medical and science journals, carry out research and studies on the impacts of war on health and submit the results for peer review?
I labour this point because it is worrying that for the 11 months that the pro-Israel “lobby” has been engaged in what I believe is “defaming” the authors of the Open Letter for the People of Gaza and the editor of The Lancet, our detractors appear to be completely oblivious to the health consequences of Israel’s attacks on Gaza. I take it as sign of their personal and professional inadequacy that they have only attempted to deflect the responsibility for maiming, destroying and killing their own civilians onto the Palestinians in Gaza, as if they staged some form of collective suicide.
Although our “detractor colleagues” have missed all of the facts that motivated our warning in July 2014, the same is not true of 20,000 others who co-signed the letter on line within a week. They did so in order for us not to be the only ones taking the pro-Israel flak. I believe, therefore, that we achieved what we set out to do; we raised awareness of the real problems facing the Palestinians in the Gaza Strip among an audience who may be able to do something to help in the field.
Eleven months down the line, though, and the detractors – along with that Israeli NGO – still ignore the health-related topics in their comments. It’s time to say enough is enough and push them to explain how they mean to fulfil the terms of their professional oath and square up to the breach of the requirement to “do no harm” and “possibly heal”. Everyone in the medical profession should ask themselves this question before taking sides.
The context of the facts is not a unilateral whim, nor is there only one narrative being masticated for months while insults are thrown at us. Acceptance of a broad narrative does not depend on force or intimidation, nor by the repetition of wrongs. Frankly, the discourse of the detractors who have dedicated themselves to harassing my colleagues and The Lanceteditor for almost a year reveals a particularly nasty mindset; it is not intended to change anyone by appealing to hearts and minds. How can it when respect for the facts and truth is completely absent?
I am not so naïve as to think that the narrative promoted on behalf of the more vulnerable members of society, in this case the Palestinians, is ever likely to win in the short-term; the pro-Israel lobby is too well organised and influential for that, even when what it promotes is not factually accurate. Yet, we will have to see to it that the narrative which takes into account the facts and the people’s health wins in the end over that of any other party whose aim is to hide reality underneath a barrage of insults.
In conclusion, and hopefully to put an end to speculation about my personal position, I believe that I am innocent of the charge of anti-Semitism. I am appalled that within a European culture of freedom of information and expression I can be attacked so viciously for sharing information already in the public domain, albeit being unpalatable. That I can be labelled, without any evidence, as an “anti-Semite” and “white supremacist” for publishing facts in a well-respected medical journal is a disgrace in a continent which professes freedom of speech.
I am a scientist, and a woman, and I have struggled for freedom of information, opinion, differences and debate which we still (temporarily) enjoy in Europe. Should I exercise self-censorship and refrain from sharing information to any of my contacts? Should I not let my peers, friends and students form their own opinion and then discuss the issue? Who are my detractors to attack me and hang me out to dry, and threaten me?. Europe cast off the shackles of fascism decades ago; the pro-Israel lobby should not be allowed to bring them back.
Since this article was written on 15 June, the Israel government has published its own report on the attack on Gaza, acknowledging as a source the data quoted here. It has also refused entry in Gaza for the second time to Makarim Wibisono, the UN’s special rapporteur on human rights in the occupied Palestinian territories, who is supposed to report to the UN Human Rights Council on 29th June.
Statement of interests
I am a Geneticist and experimental biologist, with a curriculum in molecular, cell and development biology in mammals. I retired in 2014 from the position of Professor in Genetics in the University of Genoa, Italy. I have worked in Gaza since 2010 and I also work in Italy. In both places I am an unpaid volunteer professional doing research on determinants of reproductive health. To have transparency in the position of investigator and access to donations and their utilisation for research expenses, I am a member of the volunteer association for research, NWRG.
In Gaza, I have learnt about the good aspects and shortcomings of the hospital and health provision, and about the needs of the patients, the rise in infertility and the difficulties in treating serious chronic diseases; the impact of the blockade on the specialisation of doctors and nurses; and about obtaining suitable medical instruments. Being a simple person, I also learnt in Gaza about the cost and availability of food and other market products, the cost of living, the ongoing reduction in the availability of supplies, electricity cuts and poor water quality; and about the limited assistance available for the needy, the multiple shifts in schools, and so on. In doing so I have observed how the Palestinians overcome all such difficulties, educate their children and work, even when wages are cut.
From my colleagues I learnt how they do their best to help their patients with the meagre means at their disposal; how they struggle for a permit to send a child for treatment abroad; how they wait in frustration for the missing drugs for their patients; and how they desire to develop their professional competencies.
Being a scientist, I usually learn from all of the sources that I can possibly find, or are presented to me, which report facts and/or interpretations. I discuss them with my peers often, before I formulate a judgement or hypothesis; only then do I act on this and take the next research step.
The same rules apply to the task of understanding the social and political determinants of health. I am not infallible, but I can say with all humility that what I understood is nearer to the truth than my detractors are; I do not lie for convenience or personal benefit.
Notes
1-Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S, Hay A, Rose S, Rose H, Stefanini A, Balduzzi A, Cigliano B, Pecoraro C, Di Maria E, Camandona F, Veronese G, Ramenghi L, Rui M, DelCarlo P, D’agostino S, Russo S, Luisi V, Papa S, Agnoletto V, Agnoletto M (2014a). An open letter for the people in Gaza. Lancet 384:397-8.http://www.thelancet.com/gaza-letter-2014
2- Pepys M (2015). Complaint to Reed Elsevier. Email sent to 58 Israeli recipients. 24 February. https://handsoffthelancet.files.wordpress.com/2015/04/pepys-24-feb-2015.pdf
3- John S. Yudkin and Jennifer Leaning, “Politics, medical journals, the medical profession and the Israel lobby,” The British Medical Journal,http://www.bmj.com/content/350/bmj.h2377,May 12, 2015,
4- “Politics, medical journals, the medical profession and the Israel lobby,” The British Medical Journal rapid responses http://www.bmj.com/content/350/bmj.h2377/rapid-responses
5 -Tony Delamothe. Don’t look away now, 2014. http://www.bmj.com/content/349/bmj.g7622
6- Issues Related to UNOCHA’s “Protection Cluster” Regarding Gaza- Written statement* submitted by the Amuta for NGO Responsibility, a non-governmental organisation in special consultative status, august 25, 2014.
7- Meir Amit Terrorism & Intelligence Information Centre, “Preliminary, partial examination of the names of Palestinians killed in Operation Protective Edge and analysis of the ratio between terrorist operatives and non-involved civilians killed in error,” http://www.terrorisminfo.org.il/Data/articles/Art_20687/E_124_14_1121292827.pdfhttp://www.terrorism-info.org.il/en/article/20715July 28, 2014,
“Based on the examination of the lack of appropriate methodologies and independent verifiability regarding the claims of the three key NGOs, the civilian casualty statistics and claims produced by the OCHA are unreliable”… When the names of alleged civilian casualties were examined by the Terror Information Centre in Israel, many were shown to be members of terrorist groups. UNOCHA, however, has failed to respond to the analysis published by this Israeli NGO, magnifying Protection Cluster framework must be considered unreliable.”
8-https://www.ochaopt.org/documents/ocha_opt_sitrep_19_07_2014.pdf
Situation Report (as of 18 July 2014, 1500 hrs): “The impact of hostilities on Palestinian children has been particularly devastating: 59 killed (11 in the past 24 hours) and 637 injured since 8 July… 48,000 persons hosted at UNRWA shelters and another 700 displaced families hosted by relatives, are in need of emergency food and other assistance… The vast majority of households receive electricity only four hours a day, due to damage to ten feeder lines; water supply has been further undermined”
“As of 20 July (16:00), a total of 425 Palestinians have been killed in Gaza (112 children, 41 women and 25 elderly over 60 years) and a total of 3008 Palestinians have been injured (904 children, 533 women and 119 elderly over 60 years). The ongoing ground incursion, begun July 18, has greatly accelerated the casualty rate over the past two days, as well as the numbers of displaced families… during 12 days of escalated violence in Gaza (July 7-19), 2 medical staff, 3 paramedics and 15 emergency medical services staff and volunteers were injured in attacks. A pharmacist was killed in his home. 17 health-related facilities have been damaged by that hit the structure directly or in the area of the facilities (2 MoH hospitals, 1 NGO hospital; 4 MoH clinics, 5 UNRWA clinics, 3 NGO clinics; 2 NGO nursing care centers; 1 NGO emergency medical services centre). Four Palestinian Red Crescent ambulances have been damaged. There are critical concerns with hospital supplies, as both medicines and medical disposables are in serious shortages, both in MoH and NGO hospitals due to the large number of casualties and serious shortages even before the escalation of violence.”
10- UN OCHA opt, 2014. “Fragmented lives. Humanitarian overview 2014. March 2015.http://www.ochaopt.org/documents/annual_humanitarian_overview_2014_english_final.pdf
11- Defence for Children International – Palestine. Operation Protective Edge: A War Waged on Gaza’s Children. http://issuu.com/dcips/docs/ope.awarwagedonchildren.160415?e=0April 2015.
12- Bachmann J, Baldwin-Ragaven L, Hougen HP, Leaning J, Kelly K, Özkalipci O, Reynolds L, Vacas L (2014). Gaza, 2014.Findings of an independent medical fact-finding mission. Physicians for Human Rights Israel.https://gazahealthattack.files.wordpress.com/2015/01/gazareport_eng.pdf
13- B’Tselem. Black Flag: The legal and moral implications of the policy of attacking residential buildings in the Gaza Strip, Summer, 2014. January 2015. http://www.btselem.org/gaza_strip/2015_black_flag
14- Amnesty International. Families Under The Rubble. Sept 2014.https://www.amnesty.org/download/Documents/8000/mde150322014en.pdf
16- Breaking the Silence http://www.breakingthesilence.org.il/pdf/ProtectiveEdge.pdf , May 2015
17- Drone footage shows how entire neighbourhoods in Gaza were razed to the ground by Israel’s bombardment last summer. https://www.youtube.com/watch?v=nZ54x5x9CuQ
18- Satellite recognition http://www.unitar.org/unosat/maps/PSE
19- Netanyahu: UN inquiry commission’s report on 2014 Gaza war is “waste of time”http://www.haaretz.com/news/diplomacy-defense/.premium-1.661066, June 14, 2015
20- P.Manduca http://www.bmj.com/content/349/bmj.g5106/rr/763475
The author is a professor of genetics at the University of Genoa, Italy.
