John R. Cohn is Clinical Professor of Medicine, Clinical Assistant Professor of Pediatrics at Thomas Jefferson University, Philadelphia, PA 19107 USA
Richards and Rehwagen deserve praise for devoting, with considerable difficulty considering the nature of the topic, an issue of the British Medical Journal to the health problems of the Middle East, but the result is disappointing.[1] The goal of scientific journals is to seek and disseminate truth, not as they imply, “avoiding causing offence”. As they demonstrate, sometimes it is impossible to do both.
As the editors noted, there is no formal definition of the “Middle East”. They cited three: from the World Health Organization (WHO), the Arab League and the Gulf Cooperation Council. Israel is excluded from the Arab League and the Gulf Cooperation Council, but it is also not a member of the Eastern Mediterranean Region (EMRO) of the World Health Organization. By contrast Afghanistan, Pakistan and Morocco, none of which even remotely border the Eastern Mediterranean, are included in the EMRO. Palestine, primarily a geographic designation which has never existed, and certainly not in modern history, as a sovereign state, is also included in EMRO.
Richards and Rehwagen provide a clue to the origin of this geographic and political peculiarity, with their observations about the “unprintable response of one Arab reviewer to a request to review a paper from a US author and the Lebanese professor who would not write for us because the issue contains Israeli voices.” Unfortunately, acquiescence to such prejudice is seen throughout this issue.
As Maziak observed in another essay, “Arab countries currently produce less than 0.5% of the papers that are published in the world’s top 200 medical journals.”[2] By contrast, as shown in a study of the top 1% of highly cited publications, authors from Israel, a nation with a population of just over six million, accounted for 1.27% of such publications between 1997 and 2001.[3]
Despite Israel’s success in publishing quality scientific research in other venues, out of 36 Middle East related items in the BMJ’s special issue, only two originated exclusively from Israel. One was a report on Israeli doctors charged with fraud,[4] while a letter by Dr. Shapira discussed the problems Israeli physicians faced over the past years of heightened violence.[5] The BMJ special issue contained no manuscripts addressing the problems of Israeli victims of the Palestinians’ campaign of deliberate and calculated attacks on civilians nor any concerning difficulties experienced in confronting the consequences of terrorist attacks in Israel, Iraq and elsewhere. There were no full length papers of exclusively Israeli origin. Perhaps this reflected the preferences of the external advisors, none of whom were from Israel, despite Israel’s recognized scientific accomplishments.
Four contributions contained the phrase “occupied Palestinian territory”, another term never defined by the BMJ’s editors, although apparently it includes Palestinian ruled Gaza.[6],[7],[8],[9] Implicitly and at times explicitly, Israel is blamed for the region’s problems.
Without any hint of criticism from the editors, Brennan and Sondorp suggest the necessity of working with groups like Hezbollah in providing relief, noting that while Hezbollah “is considered to be a terrorist organisation by many Western governments” it “had a good reputation as a provider of social services before the war and operated a network of clinics and hospitals at lower cost than other providers”.[10] The United Nations, hardly a supporter of Israel, noted in resolution 1701 that the most recent heightened hostilities in Lebanon and Israel began with “Hizbollah’s attack on Israel on 12 July 2006”. [11] Hezbollah and others who engage in deliberate attacks on civilian targets while provoking more violence are the region’s primary problem. Their criminal behavior disqualifies them from being part of this region’s solution.
As Maziak also observes, a notion reiterated by the issue’s editors, “For many people in the region, health improvement must start somewhere else-with education, equality, and security.”ii But that is like focusing on better chemotherapy for advanced lung cancer, rather than keeping teens from smoking.
We can lament the attacks on healthcare workers and misuse of the neutrality of patients and ambulances[12] and decry the destruction violence has brought to Darfur, Iraq, Israel, Gaza and elsewhere; but the common thread through all of these calamities is the deep-seated religious and racial intolerance that causes Iraqis to massacre each other in mosques and markets, the ethnic cleansing of Darfur that has resulted in deaths and displacement by the hundreds of thousands, and the absolute rejection of Israel’s right to exist on a small fragment of the Middle East’s land. Since 1948 Palestinian Arabs have repeatedly rejected sovereignty if the result is that Israel lives. When the hatred stops, everything will be possible. Yet even today, the Palestinians popularly elected Hamas government, along with Hezbollah and others refuse to consider any solution that includes a permanent Jewish state alongside the region’s dozens of Islamic countries.
Physicians know the frustration of trying to help patients determined to engage in self-destructive behavior. Without a commitment to peace and rejection of violence by those in the Middle East now bent on creating havoc and destruction, there is unfortunately little the health care community and editors with even the best of intentions can do.
John R. Cohn, M.D.
john.cohn@mail.tju.edu
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[1] Richards T, Rehwagen C. Messages from the Middle East. BMJ 2006;333 (21 October).
[2] Maziak W. Health in the Middle East. BMJ 2006;333:815-816 (21 October).
[3] King DA. The scientific impact of nations. Nature 430, 311- 316(15 July 2004)
[4] Siegel-Itzkovich J. Israeli doctors are arrested in investigation. BMJ 2006;333:823 (21 October).
[5] Shapira SC. Lessons learnt from the front line in Israel. BMJ 2006;333:862 (21 October).
[6] Hill AG, Clark CJ, Lubbad I, Bruderlein C. Hope and despair over health in Gaza. BMJ, Oct 2006; 333: 845 – 846.
[7] Musani A,Shaikh I. Preparedness for humanitarian crises needs to be improved.BMJ, Oct 2006; 333: 843 – 845
[8] Jabbour S, El-Zein A, Nuwayhid I, Giacaman R. Can action on health achieve political and social reform? BMJ, Oct 2006; 333: 837 – 839
[9] Editor. Learning from conflict and disaster in the Eastern Mediterranean region.BMJ, Oct 2006; 333: 843
[10] Brennan RJ, Sondorp E. Humanitarian aid: some political realities. BMJ 2006;333:817-818 (21 October)
[11] UN Security Council Resolution 1701, Adopted by the Security Council at its 5511th meeting, on 11 August 2006
http://daccessdds.un.org/doc/UNDOC/GEN/N06/465/03/PDF/N0646503.pdf?OpenElement
[12] Cohn JR, Romirowsky A, Marcus JM. Abuse of health-care workers’ neutral status. Lancet. 363:1473, May 1, 2004
Competing interests: None declared