Sunday, November 13, 2016

Health Sumud, Settler Colonialism and the Layers of Elimination in Historical Palestine

In August of this year, two Israeli mainstream Zionist scholars debated Hannah Arendt’s concept of ‘the banality of evil.’ The divergent views of Eva Illouz1 and Danial Blatman2 on the theoretical issue converge in a new phenomenon: Both agree that evil is being committed in the occupied Palestinian territories (though both use the term ‘Judea and Samaria’ in appeasement of their subjects of criticism). In the pages of a major Israeli newspaper, both concur that the occupation is a colonial project (though they eventually blame it on the settler movement). In the past, such views would have been automatically condemned and rejected out of hand in Israel; they would not have seen the light of day.
Outside the Israeli framework, it is easy to see that occupation, war and conflict contain the seeds of dis-ease. By definition, they negate the basic notion of care and of health as a state of physical, mental and psychological wellbeing. Combining ‘healthcare’ and ‘conflict’ in the same breath is oxymoronic. Military occupation undercuts the validity of using the customary professional tools for assessing healthcare. Put simply, it makes no sense to continue counting orthopedic surgeons in the West Bank while Israeli armed forces continue kneecapping Palestinian youth as part of their regular operations.3 Ironically, the mundane public health task of surveying the nutritional status of Gaza’s children becomes weaponized as a tool in Israel’s cynical practice of keeping that population at the edge of starvation.4 A reality check calls for a paradigm shift. It is time we Palestinians reframe our discourse to reflect our reality: We should no longer address our ill health and injuries only as biomedical challenges in the bodies of individuals, as issues of efficacy of medications and therapies, separate from their underlying causes. First and foremost we must call on the world to address the source of our dis-ease, to focus on the lack of justice, freedom and peace that cause our suffering. That is the logic underlying this intervention: Stopping the ongoing settler colonialist assault on Palestinians is an essential part of tending to their health. Or, at a minimum, permit them to tend to their own wounds.

In 1948, Zionist forces ethnically cleansed most of the Palestinian nation from its native home5 and in 1967 it further occupied the remainder of historical Palestine. The remaining Palestinians’ citizenship or residency in Israel was emptied of many socioeconomic benefits that impact the general health of a population, such benefits being exclusively reserved for members of the Jewish nationality. The Zionist settler colonialist project that shapes these events contains within its folds the destructive seed of the “logic of elimination6” of the native population. This process, referred to by Ilan Pappe7 and Michael Ratner8 as “incremental genocide,” best explains Israel’s conduct towards the Palestinian people as a whole. Inflicting injury and ill health on the Palestinians and impeding Palestinian efforts at improving our living conditions is part and parcel of this ongoing Apartheid process on both sides of the Green Line.

Viewed from the colonizer’s side, the zero-sum internal logic of settler colonialism runs counter to the survival of the native population. When the land is “our holy land” the natives can’t farm it; they shouldn’t fish off “our coast;” ultimately their breathing depletes the oxygen in “our atmosphere;” their elimination is the apriori condition for the success of our project. Settler colonialism is inimical to the natives’ health and survival. The degree of responsibility that international law assigns to Israel for the health of the different Palestinian groups under its control places some constraints on its behavior towards them, but cannot undo it’s ultimate goal of replacing them.

The settler colonialist successes of 1948 and 1967 are fortified by the apartheid ‘othering’ of Palestinians as ‘unpeople.’ Noam Chomsky coined this term to explain such Israeli practices as the killing of more than two Palestinian children a week on average over the past 14 years9. The daily life experience of Palestinians in Jerusalem, the West Bank and especially in Gaza mock and debase the elementary concepts of health leaving little space for meaningful healthcare. Given these facts, it is limiting to focus on healthcare and within that to recount the static numbers of such standard criteria as hospital beds, clinical facilities, doctor’s visits, and medical personnel per thousand Palestinians in this or that location. No tallying of the numbers of facilities, staffing and patients can reflect the relevant health concerns of an occupied and fragmented people, not to mention an exiled one. Let us remember that in the best of cases healthcare ranks fourth as a determinant of a population’s health10.

From our vantage point, Palestinian health is shaped by how the settler colonialists have applied the “logic of elimination” to the various segments of our native population. Conceptually, Israel’s conduct toward the native population in the area of health in historical Palestine constitutes a continuum of harmful practices: from discrimination and neglect of the Palestinian citizens of Israel, through impeding the daily processes of normal life in Jerusalem and the West Bank, all the way to extrajudicial executions and waging periodic wars on Gaza. The voracity of “elimination” attempts at various segments of the native Palestinian population depends, among other things, on the value of their targeted resources, their level of resistance and the degree to which Israel’s Hasbara—propaganda—has tarnished their image in in the international media. This requires us to view healthcare through the prism of Health Sumud—steadfastness— and the form and extent of local Palestinian resistance strategies.

Layers of elimination:
1. Heath Inequality for Palestinian Citizens of Israel:
Within the Green Line we need to examine the over fifty discriminatory laws11 that reserve major benefits to members of the Jewish race and establish structural inequality in every aspect of life. The near full segregation of residence locales by ethnicity facilitates the application of such laws. In this context, the underlying othering and dehumanization of the Palestinians (even when they are increasingly indispensable as staff) leads to such scandalous practices as the separation of mothers and their newborn babies by ethnicity in maternity departments12. The experience of the Palestinian citizens of Israel points to ongoing separate and unequal development of services despite the 1995 compulsory health insurance law that guarantees them equal services and equal taxation. The absence of a hospital in my area of residence in central Galilee, a contiguous collection of Palestinian towns of over 120,000 people in total despite the current oversupply of health professionals, is another stark example of the persistent and institutionalized discrimination. Not a single hospital has been established in an Arab community in Israel since the establishment of the state. We estimate our current level of services to be at 70-80% of the level provided in adjacent Jewish locales.

Israel has never mustered the political will to aim for equal health conditions for its Palestinian minority, currently over one fifth of the total. Judging by the persistent and widening relative gap in health status outcomes of Arab versus Jewish co-citizens in Israel (such as Infant Mortality Rates and Life Expectancy at Birth) a full investigation of contributing factors is called for.

Ideologically, in the eyes of the average Jewish citizen of Israel, we, their Palestinian co-citizens, represent the “other”. To them we embody the enemy, unwelcome remnants of the Arab and Islamic masses against whose will the Zionist settler colonial project was imposed. Take for example the logic of Maternal and Child Health. Its spirit and practice are contradicted by such concepts as the ‘demographic time bomb’ and ‘existential threat to the state,’ concepts well entrenched in official circles and among the majority regarding the reproductive health of the minority. In political terms, this is of the same essence as Benjamin Netanyahu’s alarmed SOS call on the Jewish public in the 2015 elections to save his premiership from the threat of Arab voters coming out “in droves.”13 As David Lloyd explains:
“In Israel, those Palestinians who remain on sufferance are faced with the malicious shell-game of holding formal citizenship (ezrahut) while being denied the right to nationality (le’om), which is reserved for Jews only and which grants the most substantial rights, including that of return. … [They survive] in a post-holocaust world where the traditional forms of genocide directed at native peoples are no longer publicly acceptable.”14
Beyond the ‘black and white’ examples of discriminatory laws, we suffer discrimination in the application of laws not explicitly discriminatory. Our homes are nearly the only ones demolished for lack of building permits; our crops are the only ones sprayed with agent orange for being planted on contested land; our youth are the only citizens killed by trigger happy policemen; our defendants are found guilty much more often and receive harsher sentences; the national media deals with our issues without our participation in over two thirds of the time; our schools receive one half to one sixth the subsidies Jewish schools receive per student. Every such separate and unequal practice impacts health. Yet the main focus of the Unit for Equality in the Ministry of Health (established in 2010 and run with one fulltime and another recent part-time worker) has been the disadvantaged Ethiopian Jewish community. This blinding preoccupation with the ethnic identity of the state to the exclusion of Palestinians reinforces Israel’s security-mindedness in all aspects of life including its health services. This has played socio-cultural havoc in hospitals to where show of power has replaced compassion.15

2. Violating Life In the Occupied Palestinian Territories of Jerusalem and the West Bank:
Israeli occupation controls all aspects of Palestinians’ daily life in the OPTs. The essence of Israel’s military occupation has evolved to empower its settlers to access Palestinian land at will. In the process, the natives’ freedom of movement is obstructed by a maze of military checkpoints, some 630 in the West Bank, and surrounded by a wall three times the height of the Berlin Wall. In the process the rhythm of normal life is disrupted, access to services is impeded, ambulances are delayed, women in labor deliver at checkpoints and acutely ill patients expire. Further afield medical teams are attacked, ambulances are targeted16 and commando units violate the sanctity of health facilities commandeering a patient in a wheelchair and shooting up a hospital ward.17 Such Illegal acts under international law gain legitimacy among Israelis and their allies by camouflaging them with security related claims. In the process, natives’ health and life are devalued to zero.

Well beyond Israel’s neglect of Palestinian health and of its obligations under international law as an occupier, the state has directly caused mental and physical injury to the subjects of its occupation on daily basis. Many Israeli physicians break the ethical axiom of “do no harm” and participate in teams conducting torture as interrogation18. A new law disposes of internationally accepted humanitarian principles and permits them to force-feed hunger strikers whose only demand is not to be held indefinitely under administrative detention19. Beyond the checkpoints with trigger-happy teenagers acting out their fears of their inner demons, the environmental damage caused by the Israeli state exacts a heavy toll on Palestinian health.  Whether it is the theft of the Palestinian aquifer to the tune of 84% of its output, or hilltop settlers regularly releasing raw sewage on Palestinian towns and villages below, the health impact is high. All in all it adds the excess burden of PTSD and clinical depression reported at 40% of adults20.

3. Inflicting Death and Disability in the Gaza Strip:
It would be demeaning to the public health profession were I to stand here and rattle off healthcare statistics about Gaza. Israel’s naked aggression against its charges in Gaza’s open prison is appalling. It should shame us all as health professionals and as human beings. Between attacks on Gazans as collective punishment and testing new weapons systems21, it is obscene to even speak of Israel’s obligations under international law towards occupied and besieged Gazans while sidestepping its fully articulated genocidal practice towards them of regular “mowing of the lawn22.” The image of members of the Israeli public lounging on a hill in Sderot23 with cold beer in hand to view the Phosphorus lightshow over Gaza is emblematic of our collective complicity Our pretention of caring about the inflicted suffering, whether in Syria, Yemen or in Palestine, by lecturing to each other at this safe distance is a measure of our culpability and collective loss of humanity..

In the open-air prison of the Gaza Strip, one of the most crowded spots on earth, the logic of elimination of settler colonialism is more stark and direct. The enclave under Israeli siege is judged to become unlivable in four years from now24. Palestinian children aged 8 years and older have lived through three prolonged Israeli attacks in which nearly all of them lost family members. They continue to live under the constant threat of a repeat of the same trauma any minute. The resultant PTSD cases are more the rule than the exception. Healthcare facilities and their staff and clientele are routinely targeted from the air, land and sea. Palestinian patients needing healthcare modalities not available in Gaza and their families are regularly subjected to a process of bargaining the lives of their sick loved ones against collaborating with the occupier and informing on their next of kin, friends and neighbors25. Physical survival is a constant issue at the collective and individual levels with families constantly staring death in the eye. Read the writings of Dr. Mads Gilbert and marvel at human cruelty and at human resilience26.

Health Sumud:
The “logic of elimination” of settler colonialism necessitates a survival strategy on the part of the native population, the “logic of Sumud.” It is the Palestinians’ default option, their ingrained mode of peaceful resistance. For many millennia their predecessors practiced steadfastness intuitively in the face of life’s vicissitudes, natural or manmade. To quote activist anthropologist Jeff Halper:

Despite the flight of many middle-class Palestinians, one cannot but be impressed by the steadfastness (sumud) and resistance to occupation on the part of the peasants, working classes, and petite bourgeoisie—resistance that takes the form of daily coping, an insistence on carrying on one’s life and a refusal to be cowed, as well as active and intentional forms of struggle. Be it intifada, evading checkpoints, tax revolts, or merely posing a “demographic threat,” Israel has not succeeded either in driving or “transferring” Palestinians out of the country or even in routinizing its control of them.”27

It is testing to single out one illustrative sammple of health Sumud from the life of the Palestinian communities under discussion. An example from the field of health manpower development comes to mind: Within my professional lifetime, the supply of indigenous health professionals among the Palestinian citizens of Israel has gone from near zero to a glut. With the separate and unequal educational system and discriminatory higher education, our high school graduates find admission to Israeli universities in the health field most challenging. They study abroad at great expense to their working-class families. Parents, older siblings, aunts, uncles and grandparents pool their meager savings to support such investments in the youth. With few exceptions, the students return to their home villages. Despite the bottleneck of the national licensing exams they now flood the Israeli healthcare market. Some of our towns claim to have the highest ratio of physicians to population of any community in Israel, perhaps in the world, estimated at one MD for every 70 people in my hometown where, in 1970, I was the first Western-educated physician ever.

Another example close to my heart is the Galilee Society, the organization that three colleagues and myself established in 1981 to deal with the many neglected health issues in our community. For my volunteer role in leading that nonprofit institution, in 1992 the Israeli minister of health interfered personally to fire me from the highest-ranking position for a non-Jew in his ministry. Today he is in jail for corruption while the same NGO has a major headquarter, plays a central civil society role in our community, boasts a regional research center with a dozen PhDs, maintains a regularly updated data base on all aspects of life of the Palestinian citizens of Israel and much more, all thanks to the persistent low-grade fever of Sumud that simmers in our veins.

A more heroic struggle goes on in the West Bank, further impeded by the occupation’s military rule and travel permit regime. Suffice it to point out that Palestinian civil society handles most of the population’s healthcare burden on a volunteer basis and keeps their health outcome statistics at the top of the MENA region. No less heroic is the Palestinian population of Gaza, one of the most crowded and most severely punished and under-sourced open prison systems in the world. Their mere physical survival against all odds defines the very concept of Sumud. The legendary self-healing efforts of Dr. Eyad El Sarraj28 on behalf of Gaza’s traumatized population are but one of many examples.

What relevant lessons in the area of health can we learn from the native Palestinians’ struggle against Zionist settler colonialism over the past century and a third?
  1. No healthcare system reliant on the goodwill of an occupier and on its compliance with international humanitarian law can be adequate or sustainable. (Of course, the transfer of responsibility to international donors feeds a dependency on foreign generosity and further diminishes the efficacy of such a system.)
  2. The medicalization of the consequences of a people’s suffering under war, imprisonment, occupation and apartheid diverts attention, efforts and resources from the basic required recipe of justice, peace and freedom.
  3. Conceptually, no significant health improvement is possible independent from the collective socio-economic, cultural and environmental determinants of health. Given the reality on the ground in historical Palestine, only one possible winning option remains to reach such a goal: living together in peace, freedom and equality. Israeli current decision makers show no sign of containing their mythology-inspired dream of greater Israel devoid of its native population.
Fortunately, a rising minority of enlightened anti-Zionist Israelis and Palestinians, particularly among intellectuals and academicians, gives hope for an alternative future. But only concerted outside support by a groundswell of international activists can reverse Israel’s settler-led megalomaniacal colonial process. That is why even pure public health considerations lead us to the unavoidable logic of Boycott, Divestment and Sanctions. BDS is the international rendition of Palestinian Sumud, a modality of peaceful resistance. Barring total genocide of the Palestinian people, it is destined to succeed.

1.    Eva Illouz, The Monster in ordinary men, Haaretz, Aug. 5, 2016.
2.    Danial Blatman, Each one evil in its own unique way, Haaretz, Aug. 19, 2016.
3.    Amira Hass, Is the IDF Conducting a Kneecapping Campaign in the West Bank?, Haaretz, Aug. 27, 2016.
4.    Amira Hass, 2,279 Calories per Person: How Israel Made Sure Gaza Didn't Starve, Haaretz, Oct. 17, 2012.
5.    Ilan Pappe, The Ethnic Cleansing of Palestine, London and New York: One World, 2006.
6.    Wolfe, P. (2006). Settler colonialism and the elimination of the native. Journal of Genocide Research, 8(4), 387-409
9.    Noam Chomsky, in On Palestine, Frank Barat, ed., Haymarket Books, 2015. (Kindle Edition.)
11. Most legal issues covered in this presentation are drawn from documents available at Adalah’s website:
14. David Lloyd, Settler Colonialism and the State of Exception: The Example of Palestine/Israel, Settler Colonial Studies, 2:1, 59-80. (2012)
15. Eva Illouz, The militarization of the system: What the death of my father taught me about the demise of Israeli compassion, Haaretz, Mar 14, 2015.
17. Amira Hass, These Are Israel's New Heroes? Haaretz, Nov. 21, 2015.
22. Noam Chomsky, op. cit.
26. Mads Gilbert, Night In Gaza, London: Skyscraper Publications, 2015.
27. Jeff Halper, A Strategy within a Non-Strategy: Sumud, Resistance, Attrition, and Advocacy, Journal of Palestine Studies, V.35, 20056.

28. Brittany Dawson and Zeina Azzam, Interview with Dr. Yasser Abu Jamei: The Gaza Community Mental Health Programme, Journal of Palestine Studies, V45, 120-126.

No comments: