First published in:
Journal of Critical Study of Communication and Disability
https://doi.org/10.48516/jcscd_2024vol2iss2
or https://criticalstudycommunicationdisability.org/index.php/jcscd/article/view/45
Abstract:
Plain language abstract: The over-a-yearlong Israeli assault on Gaza after the October 7 Hamas attack has left the Gaza Strip in ruins, with destruction of much of the health care, educational, housing, sanitation, and agricultural systems. 2.3 million people face extreme hunger, displacement, infectious diseases, and massive amounts of physical and mental stress and trauma. Women, children, and the disabled have been disproportionately affected. What is the responsibility of healthcare workers in the face of a horrifying live-streamed genocide? The ongoing silence of the medical profession presents a severe challenge to the ethical principles of the healing professions.
Formal abstract: The Israeli assault on Gaza after the October 7 Hamas attack has left the Gaza Strip in ruins, with destruction of much of the health care, educational, sanitation, housing, and agricultural infrastructure, and massive amounts of displacement, injury, and death. 2.3 million people face extreme hunger, infectious diseases, and life-threatening levels of physical and mental stress and trauma. Women, children, and the newly and chronically disabled have been disproportionately affected. This war occurs in the context of over a hundred years of settler colonialism in the region, the genocidal intent expressed by Israeli leaders, and years of Palestinian resistance. The silence of the medical profession in the face of this live-streamed genocide presents a severe challenge to medical ethics, with health care students and workers who criticize Israeli policies facing pushback, job loss, and accusations of antisemitism. Silence in the face of war crimes only enables the medical and military institutions to ignore, condone, or commit further atrocities.
Positionality Statement: I am a white, Jewish woman, retired obstetrician-gynecologist, author of three books on health and human rights in Israel/Palestine, two Palestine focused books for children, a memoir in verse, and a contributor to numerous medical journals, anthologies, webzines, and poetry magazines. I have been working on health and human rights issues in I/P for over 25 years, traveled to the region almost annually since 2004 and was last in Gaza in August 2023. I am an active member of Jewish Voice for Peace Health Advisory Council and mentor liaison for We Are Not Numbers, a mentoring program for Gazan writers.
Introduction: To write of Gaza in 2024, is to make real the unimaginable. According to the United Nations (2024), as of October 8, almost 42,000 Palestinians have been killed in relentless and widespread Israeli attacks, with the numbers of direct and indirect likely reaching beyond 186,000 (Khatib et al., 2024). Women and children, clearly innocent victims, account for most of the slaughtered (UN News, 2024b). In a strip of land twenty-eight by six miles in size, close to 100,000 people have been injured, pummeled by tens of thousands of bombs, some weighing 5,000 pounds, dropped in urban areas, crowded refugee camps, “safe zones,” and “deconflicted areas,” apparently an acceptable level of “collateral damage” according to the Israeli military (Duggal et al., 2023; United Nations, n.d.-b). A total of 88.5% of Gaza has been placed underevacuation orders (Gritten, 2024).
Most of the healthcare system lies in rubble; hundreds of healthcare personnel have been arrested (United Na-tions, 2024), detained, tortured (Chekuru, 2024), and killed in Israeli prisons. According to satellite and spatial analysis (Wispelwey et al., 2024) housing, water and sanitation facilities, educational institutions, libraries, archives, industry, and agriculture have suffered unparalleled levels of systematic and targeted destruction.
Food and clean water have been weaponized and are in meager supply (United Nations, n.d.-a); some Gazans have been reduced to eating animal feed and grass. Electricity and fuel are severely limited and most of the population is chronically hungry, deficient in calories, protein, fresh fruits and vegetables, as well as critical nutrients, with close to a million reaching levels consistent with famine. Public health conditions are deteriorating due to military attacks, repeated evacuations, displacements, contaminated water, horrendous sanitation with raw sewage in the streets, flowing into the Mediterranean Sea.
Infectious diseases are rising, including the recent discovery of the polio virus. Longstanding vaccination programs have broken down, leaving a vulnerable young population likely to suffer from a paralytic polio epidemic (Shbair et al., 2024). The first cases have already been detected. The United Nations, UNICEF, and the Israeli military negotiated a brief series of three-day ceasefires to permit health workers to vaccinate 640,000 children, a program that some experts predicted would be challenging due to the number of children, lack of trained personnel, chaos of displacement, lack of reliable electricity and refrigeration, continued Israeli bombing, and the dearth of functional roads and transportation (Euro-Med Human Rights, 2024). Due to the determination of health workers and the commitment of parents, 560,000 children were successfully vaccinated. A campaign to provide the second required dose began in mid-October. A UN school in Nuseirat intended as a vaccine location site, was bombed by Israeli forces on October 14 (Euro-Med Human Rights, 2024). Of concern is that malnourished children are also less likely to mount a vigorous immune response, so the success of these programs remains to be determined. In addition, United Nations officials note a “frightening increase” in hepatitis A, especially in children, who have little access to basic health care and weakened immune systems due to malnutrition, lack of basic hygiene, and overwhelming stress (UN News, 2024a). The youngest Gazans are also vulnerable to measles, once a deadly disease of childhood, due to the collapse of vaccination programs. Such viral out-breaks threaten not only Gazans but surrounding communities; viruses know no boundaries.
Pregnant women are not receiving prenatal care; most are internally displaced and often deliver in rubble, over-crowded shelters and homes, tents, or hospitals where they compete for attention and care with the injured and the dying (Rothchild, 2024). Maternal and infant mortality and morbidity are rising from pre-October 2023 levels (ACAPS, 2024; International Rescue Committee, 2024), and doctors are reporting surging levels of stillbirths, prematurity, and low birth weight newborns (Da Silva, 2024). There are reports of women undergoing cesarean sections without anesthesia or electricity (Elnakib et al., 2024). While health care and civil defense workers continue to function at what can only be described as desperate and heroic levels, often without receiving their salaries and dealing with their own injured and dead family members, there has been a breakdown in general law, order, and public safety, compounded by severe restrictions on humanitarian relief by Israeli authorities. “More than one million people did not receive any food rations in southern and central Gaza during August,” according to the United Nations Office for the Coordination of Humanitarian Affairs (United Nations, 2024b). Aid trucks that do enter the Strip are faced with cratered, impassible roads and repeated Israeli attacks in supposed deconflicted zones, as well as gangs commandeering aid and selling food in an exorbitant black market. By the end of August 2024, United Nations humanitarian aid operations and the World Food Program were forced to suspend their activities due to direct Israeli attacks and evacuation orders (Godfrey, 2024). Aid groups reported that approximately 1,600 trucks containing essential medicines and food were trapped at crossing points along the Gaza perimeter (AFSC, n.d.).
The population faces unprecedented levels of physical and mental trauma, with widespread anxiety, depression, panic, chronic traumatic stress disorder, reports of increasing gender-based violence, and bed-wetting in children. The psychological impacts are layered onto decades of disorders secondary to the occupation, siege, repeated Israeli assaults, and the inability of traumatic stress disorder to ever be “post”. As reported by the Gaza Community Mental Health Program (2024), “In November 2023, Médecins du Monde also published a report stat-ing that even before the current crisis Palestine had one of the highest levels of mental health issues and psychological disorders in the eastern Mediterranean region.” (p.3) According to GCMHP, even after the assault in Gaza ends, “poverty and deprivation will affect a sizable portion of the population for years to come…This is primarily because of the extent of human life and limb loss, loss of human capital and capabilities, and destruction of socioeconomic infrastructure” Gaza Community Mental Health Programme. These circumstances will have immediate, chronic, and epigenetic impacts on the mental health of the Gazan population, particularly because children have experienced unprecedented levels of trauma, violence, and lack of safety, while their parents and mental health providers suffer from the same assaults, distress, and lack of security that prevent the process of repair.
In this setting, it is important to consider the experience of the newly, as well as the chronically disabled. Before the Israeli attack that started after the Hamas assault on Israel on October 7, 2023, Gaza suffered from 57 years of Israeli occupation and 17 years of intense siege, with an Israeli policy of deliberate de-development of the health care system and the economy (Roy, 2016) There were severe restrictions on the entry of medicine and equipment, on permits for doctors to seek specialty training, and for patients to reach higher level care out-side the Strip. For Gazans with disabilities, the physical structure of cities, towns, and refugee camps was challenging with a lack of easily navigable sidewalks, elevators, well-paved roads, and frequent major and minor Israeli assaults, as well as a health care system on chronic life support. The year of the weekly Great March of Return, (2018-2019), resulted in over 6,000 orthopedic injuries as the largely peaceful protesters were met by Israeli snipers, shooting at the lower extremities of mostly young men (United Nations, 2020). Orthopedic care was pushed beyond its limits, and surgeons, physical therapists, and limb replacement manufacturers were forced to do their best in a highly stressed and poorly resourced system.
This current war has made life for disabled people infinitely more challenging, not only because of the ecocide (Badri, 2024), the destruction of the environment, which is difficult to navigate even for people without disabilities, but almost impossible for Gazans missing limbs, in wheelchairs, using crutches, and other assistive devices. There is also an extreme lack of the basic surgical medications and equipment necessary to care for injuries to the extremities, sudden onset of blindness or deafness, traumatic brain injury, as well as a lack of functioning re-habilitation facilities, with the only limb replacement factory bombed early in the war and physical therapists left to deal with the most severe and urgent cases with minimal to no resources for long-term rehabilitation or access. This is especially devastating for the thousands of children who have lost one or multiple limbs in bombing incidents or buried under rubble; they will need multiple orthopedic procedures going forward if they are to maximize their abilities to negotiate the environmental challenges that Gaza presents.
In Gaza, I visited the extraordinary Aftaluna Society for Deaf Children. A recent report from Atfaluna reveals that emergency instructions are not inclusive and are usually not interpreted to sign language (Atfaluna Society for Deaf Children, 2024). A majority of persons with disabilities found severe inadequacies in the training of emergency teams, and deficiencies in the provision of evacuation, shelter, assistive devices, psychosocial support, suitable healthcare, increasing the risks of neglect and abuse, particularly for women and girls. This reality is partially a reflection of years of active de-development of the health care system by the Israeli government, a restrictive permitting process that prevents patients from getting higher level care and health care workers receiving up-to-date training outside the Strip and obstructs the import of medications and equipment.
This catastrophe occurs within a recognizable context that is over a hundred years old, namely the desire for Palestinians to live in their indigenous homeland with dignity and self-determination and the refusal of Jewish settlers before 1948 and Israeli Jews after the founding of Israel to recognize Palestinians as human beings with human rights equal to their own. As the Israeli scholar, Ilan Pappé, meticulously documented in The Ethnic Cleansing of Palestine, one of the Israeli goals of the war in 1948, the Nakba or Catastrophe for Palestinians, was to rid historic Palestine of its indigenous peoples; the war in 1967 was supposed to finish the expulsion. This is the nature of settler colonialism. During this current assault, Israeli leaders have repeatedly expressed racist, genocidal language that reflects a persistent desire to cleanse Gaza of its population: “Fighting ‘human animals.’ Making Gaza a ‘slaughterhouse.’ ‘Erasing the Gaza Strip from the face of the earth.’” They have even spoken of creating a “Gaza nakba 2023.” (Goldenberg, 2023; Tov, 2023)
In this context, Palestinian resistance over the years is understandable as both a reaction to decades of Israeli subjugation and the right of an oppressed people to resist their colonizers. The international community has mostly given the Israeli government free rein because of the history of European and United States antisemitism, the Nazi Holocaust, and the supposed uniqueness of Jewish trauma, as well as Israel’s perceived geopolitical usefulness. This current genocidal war has sparked a global explosion of criticism from people, governments, and institutions focused on human rights and international law. Even hundreds of thousands of Israelis, traumatized by the October assault and its sequelae, are calling for a cease-fire, hoping to get the remaining hostages home alive (Kahn & Clyde, 2024).
What is the responsibility of healthcare providers in the face of what has become a horrifying, live-streamed genocide? In the United States, the silence of the medical profession, medical institutions, and foundations has been deafening, given the level of well-documented catastrophe. Multiple humanitarian, medical, and human rights organizations have named the current assault on Gaza a genocide with violations of the Fourth Geneva Convention, repeated war crimes, and collective punishment of an entire caged population (Albanese, 2024; Foulkes, 2024). The American Public Health Association made one brief statement calling for a ceasefire in 2023 after prolonged discussion and negotiation; leadership has challenged a more explicit statement in 2024. Ortho-pedic, pediatric, obstetric, and general medicine organizations and journals, and the American Medical Association have shied away from calling out the levels of trauma and death. Demands for a ceasefire are often met with false accusations of antisemitism (Hess, 2024).
This has led to a severe challenge to medical ethics in the United States (Abi-Rached & Reinhart, 2024). Medical students and residents report pushback from colleagues and administrators, loss of residency options, and charges of antisemitism when educational sessions or protests are organized (personal communication, names not included to protect those impacted). Medical personnel have been fired for speaking out on the Gaza genocide (Matthews, 2024). Health workers who have been outspoken on other international crises, such as Ukraine, have been silent or silenced when speaking out about Gaza. At the same time, the UN Special Rapporteur on Human Rights in the Occupied Territories issued a report entitled Anatomy of a Genocide, and the UN Human Rights Council stated there was reasonable grounds to believe the Israeli military was committing genocide (Abi-Rached & Reinhart, 2024). The International Criminal Court has sought arrest warrants for both Israeli and Hamas leaders for war crimes and crimes against hu-manity following the October attacks (Ebrahim, 2023).
Health workers are facing multiple political and moral issues: structural and individual racism, anti-Palestinian racism in particular (Abu-Laban & Bakan, 2022; Muhareb et al., 2021), Islamophobia, dehumanization, othering of Arab/Palestinians, fear of powerful “pro-Israel” groups that attack anyone sympathetic to the history and realities of Palestinians, and the impact of these attitudes and Israel’s settler colonial behavior on the health and human rights of an indigenous population. Health workers understand that health and healing occur in a socio-political context, and the current war in Gaza is resulting in the destruction of the entire public health system, the violence largely funded, enabled, and tolerated by the United States (Jeong et al., 2024). Silence in the face of this level of human suffering goes against the oath of physicians and the healing missions of healthcare institutions. Silence in the face of war crimes only enables the medical and military institutions to ignore, condone, or commit further atrocities.
I met Dr. Eyad el Saraj, founder of the Gaza Community Mental Health Program, in 2005 in his office in Gaza City. He taught me that health in its broadest sense, cannot occur without human rights. Gazans are sorely lac-ing in both. I write this as a physician, a human rights activist, and a Jewish person who has been advocating for peace with justice in Israel/Palestine for over twenty-five years. Initially struggling with the consequences of the Israeli occupation for Palestinians, I came to understand that there were fundamental flaws in the Zionist movement. I once believed Zionism was a liberation movement for the Jewish people, but I came to see the ideology as a racist, ethno-national program that privileges Jews over Palestinians and is grounded in harm to Palestinians, in Israel and the territories.
This political awareness was born of years of working and documenting the conditions in the region, waiting at checkpoints, and visiting clinics and hospitals. My knowledge came from joining in and getting teargassed at demonstrations against the separation wall that divided Palestinians from their olive trees and agricultural land, university students from their educational facilities, and villagers from markets and other resources. I observed the massive explosion of Jewish settlement growth and illegal land seizures in the West Bank and East Jerusalem, with full support from the Israeli army and settlers. Working with Palestinians and Jewish Israelis involved with Physicians for Human Rights Israel, I cared for women living in the occupied West Bank who lacked basic health-care because of restrictive Israeli policies. I heard Palestinians share their stories when I was welcomed into their homes, honored to be invited as a guest, often the first Jewish person folx had met who was not carrying a gun and wearing a military uniform. I cannot un-see the discrimination and bias that I witnessed; there is no neutral position when health care occurs in this context.
I have also found being involved with Jewish Voice for Peace, focusing on the JVP Health Advisory Council (n.d.) gives me the opportunity to blend my doctorly skills and knowledge of human rights law with my activist skills, to document and share the health and human rights consequences of Israeli occupation, siege, and racism to-wards Palestinians within Israel and the occupied territories and to add my voice to this struggle. Working with We Are Not Numbers, a mentoring program for young Gazan writers, has allowed me to hear voices from the ground sharing their personal narratives. The stories since October 2023 have been powerful and devastating.
Silence is no longer morally acceptable.
Conflict of Interest Statement The author declares that there is no conflict of interest related to the content of this article.
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