Peace (building) through Health – Health Care
Professionals Should Focus on Measurable
Individual and Community Health
Improvement within a, whenever possible,
Democratic, Community and Civil Society
Framework
Norbert Goldfield, Zeev Wiener,
Heidar Abukteish
The health of the people is really
the foundation upon which all
their happiness and all their
powers as a state depend
Benjamin Disraeli
A New Definition of Health by the
European Region of the World
Health Organization
• Health is the extent to which an individual
or group is able , on the one hand, to realize
aspirations and satisfy need, and, on the
other hand, to change and cope with the
environment. Health is therefore seen as a
resource for everyday life, not the objective
of living; it is a positive concept
emphasizing social and personal resources
as well as physical capacities
Diabetes as a case example
• Diabetes is the most common chronic illness
afflicting Israelis and Palestinians affecting
approximately 10% of both populations, a large
percentage of whom are poorly controlled.
• Diabetes is best controlled (as measured both
biochemically and from the subjective perspective
of the individual which includes their perception of
empowerment/engagement) within a framework
individual empowerment in a setting of active
community and political support.
• Psychosocial and socioeconomic challenges, most
notably, settings of conflict significantly exacerbate
the ability of individuals to control their diabetes
Diabetes (cont)
• Interventions aimed at Israeli and
Palestinian diabetics must focus on
measurable individual improvement while
taking into account the political, economic
and cultural barriers to improved diabetes
control.
Diabetes study design
• Small groups of people;
• Cooperation across the divides – soft
measure
• Validated outcomes measures – clinical,
patient derived and societal impact
• If outcomes measure positive rapidly
disseminate
Characteristics of Orientalism
• The Orient is an idea that has a history and a
tradition of thought, imagery and vocabulary that
have given it "reality." Its reality and stability
comes from its status as a geopolitical entity.
• The relationship of Occident and Orient is that of
power, of domination, and varying degrees of a
complex hegemony. Hegemony, according to
Gramsci, is the form of cultural dominance over
other cultures, formed by consent in civil society,
rather than in political society.
Difference between PeaceBuilding and Peace Initiatives
• Health professionals working in their
professional capacity can contribute to
peace-building
• Peace (through health or any other area) is a
political process and requires the
intervention of individuals/groups that have
political standing
Conflict sensitive health
interventions can produce lasting
benefits even when the general
political situation generating
conflict is not easily solved.
Peace-Building Through Health:
Potential Roles of Health
Professionals
Israeli and Palestinian health care
professionals not infrequently
make the “jump” into being
politicians. These individuals can
actively contribute to the peace
process via the political parties
they are members.
Communication of Knowledge
• One can assist with Communication of
Knowledge, thereby putting a human
face on suffering, and this information
may be considered the most credible,
unbiased sources of information. Such
organizations may be seen as impartial,
uniquely treating people of all sides
without prejudice.
Healing of the Individual and Society;
Strengthening of Communities
• By their very presence, as one
institution persisting throughout a
conflict, they can develop, foster, or
sustain a structure for post-conflict
rebuilding. Though not their primary
objective, they can also help with
Healing of the Individual and Society
(physical, psychological and at times
even spiritual), and Strengthening of
Communities.
Extend Solidarity
• Medical professionals can Extend
Solidarity merely by their presence; that
is, by risking their own lives to treat
people in war zones. Such gestures can
give hope to the relatively powerless
side of a conflict, strengthening their
struggle for fundamental human rights.
Broaden the Concept of Altruism
• Medical personnel may Broaden the
Concept of Altruism, treating victims
impartially in a war zone when military
and other civilian personnel are
propagandised into believing that
people on the opposite side of a conflict
have and deserve fewer rights as they
are different.
Personalize the Enemy
• On a larger scale they may personalize
the Enemy, opposing war leaders who
seek to diminish, depersonalize, and
dehumanize the ‘enemy’. Professional
and personal connections with patients
and colleagues throughout the world
make the concepts of ‘enemy’,
‘foreigner’, or ‘out-group’ people seem
bizarre.
Non-co-operation and Dissent
• Non-co-operation and Dissent describes
the refusal of medical personnel to
participate in what are considered
unjust war campaigns of their
governments, such as Israel in the
Occupied Territories, the US in Vietnam
and Iraq, or Russia in Chechnya, or to
oppose weapons systems such as
nuclear weapons.
Diplomacy
• Bolstered by the legitimacy conferred by the
Nobel Peace Prize, prestigious medical
organizations such as the ICRC, IPPNW and
MSF are able to engage in Diplomacy.
IPPNW had contacts with the highest level of
Soviet administration and with various
members of the US Congress and
administration. No less a personality than
Mikhail Gorbachev credited IPPNW with
convincing him to push for arms reduction
agreements.
Critique of the Model
• The model presented here has been criticized
as being Euro-centric, biomedical, and
neglectful of the roles of other professionals
and alternative practitioners, or dismissive of
the role of other non-health professionals. It
also appears to limit discussion to the roles of
outsiders in a conflict. Indeed, although
evidence may be found for all of these
charges, the intention of the model is not to
be a static, comprehensive model for peace,
but to explore ways for those outside
immediate zones of ‘hot’ conflict to contribute
Health indicators:
• Infant mortality; population mortality
• Deaths and injuries caused by weapons of
war
• Nutritional status
• Communicable diseases
Political indicators:
• - level of public political participation
• - multi-communal political parties; fair and
free elections
• - political representation
• - emergency rule in parts or all of a country
• - freedom of movement
• - the right not to be deprived of one’s
nationality or to be exiled
PTSD IN ISRAELI CHILDREN
100%
80%
60%
40%
40%
28%
27%
16%
20%
0%
Jerusalem
Katif
Data: Gallili-Vistov, HMC Jerusalem.
Lavi, TAU, 2002.
Efrat
Gilo
ISRAEL'S SOCIAL STATUS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
1990
Finland
Denmark
Sweden
Canada
Norway
Hungary
Czech Rep
Switzerland
Austria
Germany
USA
Netherlands
Australia
Japan
Belgium
France
UK
Poland
New Zealand
ltaly
Portugal
Israel
Spain
Korea, Rep
lreland
104
103
103
103
102
102
101
101
101
100
100
100
100
99
99
98
98
97
97
96
95
94
94
93
91
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
1996
Finland
Sweden
Norway
Denmark
Netherlands
Switzerland
Canada
Austria
Australia
Germany
Czech Rep
Hungary
USA
Japan
France
UK
Belgium
New Zealand
Poland
Israel
Korea, Rep
lreland
Portugal
Spain
ltaly
103.9
103.2
103.1
102.9
101.8
101.6
100.9
100.4
100.2
99.9
99.8
99.7
99.7
99.3
99.1
99.0
98.7
98.0
95.4
94.7
94.6
94.3
94.1
93.8
93.6
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
2002
Finland
Norway
Denmark
Netherlands
Sweden
Switzerland
Austria
Canada
Hungary
Australia
USA
Germany
Czech Rep
France
UK
Japan
New Zealand
Belgium
lreland
Portugal
Poland
Spain
Korea, Rep
Israel
ltaly
104.0
103.9
103.4
103.2
103.2
102.1
101.2
101.2
101.0
100.2
100.0
100.0
99.8
99.7
99.5
98.7
98.5
98.4
96.7
96.5
95.9
95.8
95.6
94.6
94.4
ISRAEL'S STATE OF MIND (2)
%
PROUD OF THE STATE
100
90
80
70
WANT TO LIVE IN ISRAEL
60
50
SEP 99
APR 00
FEB 01 APR 03 NOV 03
%
90
80
70
60
50
40
30
20
10
0
FEB
98
JAN
99
JAN
00
APR
01
FEB
02
APR
03
NOV
03
PERCEIVED RESILIENCE AND WILLINGNESS TO
SACRIFICE:
TEL-AVIV vs TERRITORIES YOUTH
Perc. Resil past
Perc. Resil today
Sacrif past
Sacrif today
2.5
2.45
2.4
2.35
2.3
2.25
2.2
2.15
2.1
2.05
Tel-Aviv
Territories
Laor n, Wolmer L. 2002. Unpublished Data.
The term structural violence has been used
to designate people who experience
violence (and violation) owing to extreme
poverty. That violence includes the high
rates of disease and death, unemployment,
homelessness, lack of education,
powerlessness, a shared fate of misery, and
day-by-day violence of hunger, thirst, and
bodily pain
It costs approximately $100 to
give a box of fortified milk and a
fortified wafer to
one child every school day during
the nine month school year.
Thus, this program will cost
about $1.3 million for 13,000
children during the 2004-2005
school year.
After disengagement, will basic provisions
still be imported from Israel? To date,
according to businessmen and government
officials, there are no negotiations or
discussions on this very essential Palestinian
need. And as the above noted statistics on
containers moving from Israel to Gaza
indicate, Gaza is highly dependent on Israel
for most of its basic supplies.
Economy
Unemployment
2000
2004
Total
10%
28.6%
West Bank
7.5%
23.6%
Gaza Strip
15.5%
39.7%
Healing Across the Divides
Executive Director
Norbert Goldfield, M.D.
The mission of Healing Across the
Divides, an American organization,
is to assist Israeli/ Palestinian health
care organizations to improve the
health of Israelis and Palestinians via
increased health professional
mediated health and human rights
improvements and policymaker
decisions.
Healing Across the Divides
• While many are convinced that the peace process
is today on life support, many Israeli and
Palestinian health professionals believe that one
option is to concentrate on improving the health
status of both populations via cooperation between
Israeli and Palestinian health care organizations. If
these initiatives are successful and receive
attention both in and outside the Middle East,
health professionals hope that they can contribute
at the appropriate time to a reawakening of a
serious commitment to peace.
Israeli and Palestinian health care professionals (and
American and European health professionals
interested in Israeli/Palestinian peace building) work
on peace (building) in two ways
a. as a by-product of activities that focus on
individual health improvement/ maximizing
human dignity/autonomy within a,hopefully,
democratic organizational framework.
b. as a by-product of activities that focus on
community wide health improvement that
acknowledge the social determinants of health
Healing Across the Divides
• The idea for this new organization emanates from
a successful U.S. “tour” that Israeli and
Palestinian physicians undertook in March 2004 in
which they spoke of the promise and challenge of
already existing cooperation “across the divides”.
Divide is framed in the plural to recognize that
this organization will not only focus on the divide
between Israelis and Palestinians but also the
divides that exist within Israeli and within
Palestinian societies.
Speaking engagements included:
• Joint session Harvard University School of
Public Health and Medicine, Boston, MA
• Carter Center, Atlanta, GA
• American Task Force on Palestine,
Washington, DC
• American Jewish Committee,Boston+ NYC
• State Department
It is important for Israeli and Palestinian health professionals
with the assistance of outside professionals from outside the
Middle East to identify:

concrete health and ethical problems,

research questions that are significant,
need resolution, and are

resolvable by the parties coming to
the meeting and join forces to form a
common strategy to tackle the problems.
Under the guidance of a Board of Directors and
Board of Scientific Advisors, Healing Across the
Divides will pursue initiatives that will result in:
• Documented improved health status of the
population served
• Increased clinical knowledge base for both
Palestinian and Israeli health professionals but
particularly the former
• Increased knowledge base and exchange of ideas
on issues pertaining to violence and its prevention
particularly for health professionals and health
care students.
Initiatives (cont)
• Enhanced awareness of health and human
rights as it pertains to health professionals
in the light of the current conflict.
• Increased awareness, on the part of
policymakers and other interested parties, of
the obstacles to improvement in the health
of both populations.
Board of Directors as of January
2005
• Heidar Abu Kteish, MPH, Director of Prevention
Programs, Union of Palestinian Medical Relief
Committee, Ramallah, Palestine
• Ziad Asali, M.D., Executive Director, American
Task Force on Palestine, Washington DC
• Paul Hassoun, M.D. Johns Hopkins University
School of Medicine, Baltimore, MD
• Alfred Khoury, M.D., Chair, Medical Committee,
ANERA (American Near East Refugee Aid),
Washington DC
Board of Directors (cont)
• Larry Lowenthal, PhD, Executive Director,
American Jewish Committee, Boston Chapter,
Boston, MA
• Margaret O Kane, MPH, President, National
Committee for Quality Assurance, Washington,
DC
• Leonard Rubenstein, J.D. Executive Director,
Physicians for Human Rights – USA, Washington,
DC
• Hadas Ziv, Executive Director, Physicians for
Human Rights – Israel, Tel Aviv Israel
International Committee of
Expert Scientific Advisors
Examples of projects we will pursue
beginning in 2005 include joint:
• Initiative to improve health status of
diabetics and hypertensives
• Training program to enhance medical
ethics among health professionals.
• Course on Peace-Building Through
Health at an American college, Spring
2005
By improving the health of
Palestinians and Israelis we are
attempting to accomplish this via
a human rights lens and thus
enhance the dignity of each
human being impacted by these
programs.
Initial Project Partners
• Union of Palestinian Medical Relief
Committees
• Physicians for Human Rights – Israel.
• The Galilee Society
Examples of potential roles for
Palestinian/Israeli academic institutions
• Assist in identification of appropriate
projects – prevalence of chronic illnesses
among Palestinians. Ongoing study (?) at Al
Quds on prevalence of chronic illnesses
• Assist/ direct evaluation of initiatives
• Assist in ongoing evaluation/ critique of
project models.
Financing for Healing Across the Divides
• $100,000 in initial funding
• Cost of pilot diabetes projects (approximately 100
Palestinian and Israeli individuals) will be modest
• If medication/glucose monitoring equipment is
available free of charge (donation etc) the cost of
providing care from a community health
perspective to 1000 Palestinians will be
approximately $10000.
• Additional monies as needed will be applied for
from private individuals and government grants.
I have pessimism of the intellect,
optimism of the will – Gramsci,
1920’s
To move even slightly from
pessimism of the intellect to
optimism of the will we need to
successfully implement at least
one project on a small scale that
measurably improves the health
of both Palestinians and Israelis.