Public Health
Promoting Arab and Israeli cooperation: peacebuilding through health initiatives

Published online January 25, 2005 http://image.thelancet.com/extras/04art3217web.pdf

Harvey Skinner, Ziad Abdeen, Hani Abdeen, Phil Aber, Mohammad Al-Masri, Joseph Attias, Karen B Avraham, Rivka Carmi, Catherine Chalin, Ziad El Nasser, Manaf Hijazi, Rema Othman Jebara, Moien Kanaan, Hillel Pratt, Firas Raad, Yehudah Roth, A Paul Williams, Arnold Noyek

This article describes a positive experience in building Arab and Israeli cooperation through health initiatives. Over the past 10 years Israeli, Jordanian, and Palestinian health professionals have worked together through the Canada International Scientific Exchange Program (CISEPO). In the initial project, nearly 17 000 Arab and Israeli newborn babies were tested for early detection of hearing loss, an important health issue for the region. The network has grown to address additional needs, including mother-child health, nutrition, infectious diseases, and youth health. Our guiding model emphasises two goals: project-specific outcomes in health improvement, and broader effects on cross-border cooperation. Lessons learned from this experience and the model provide direction for ways that health professionals can contribute to peacebuilding.

Concern is mounting about our ability to address global health issues in the 21st century in a climate of national, ethnocultural, and religious conflicts. The middle east, in particular, presents immense challenges for improving regional disparities in health and fostering peaceful coexistence. The personal and public health consequences of this conflict are tragic. [1] In a recent Commentary, Horton [2] asks what role health professionals can play in alleviating the Palestinian-Israeli conflict: “Doctors are, variously, its healers, its casualties, and its perpetrators. But is there a larger part that doctors might play in a solution?”

Since 1995, we have been engaged in collaborative work in the region involving Israeli, Jordanian, and Palestinian colleagues as part of the Canada International Scientific Exchange Program (CISEPO). This article provides a synopsis of our activities, which began with a focus on congenital hearing impairment- a priority issue for the region. Lessons learned from our partnership provide direction and hope for effective peacebuilding roles for health professionals in regions of conflict. A model is described for organisation of international initiatives to achieve both project-specific health outcomes and broader effects through cooperation networks. This approach provides a realistic way to address human development and primary determinants of health in the region.[3]

Lessons learned

CISEPO (http://www.cisepo.ca) is a Canadian non­governmental organisation based at Mount Sinai Hospital and the University of Toronto. During the current political turmoil, CISEPO continues successfully to bring together and sustain academically-based pro­grammes involving Israeli, Jordanian, and Palestinian colleagues. In recognition of these accomplishments (panel 1), CISEPO received the Canadian Red Cross Power of Humanity Award presented by Queen Noor of Jordan on April 28, 2004.

In 1995, CISEPO was invited by the private office of the late King Hussein to consider how a Canadian organisation might facilitate cross-border collaboration between Arabs and Israelis. The vision was simple yet compelling-to use health needs as a basis for cooperative projects that enhance the people-to-people requirement of the Jordanian-Israeli peace treaty signed in 1994. This builds on the Health as a Bridge for Peace concept advanced by WHO.[4, 5] Shortly thereafter, the Israeli Ministries of Health and Foreign Affairs and the _fPalestinian Ministry of Health issued similar invitations to CISEPO

A key lesson was that these high level connections opened doors for CISEPO in initiating discussions among academics and health professionals regarding cross-border activities. For example, CISEPO began a fruitful collaboration with colleagues at the Royal Medical Services of Jordan. Also, these senior contacts proved invaluable for expediting cross-border security clearances for colleagues to attend regional activities (panel 1). Ongoing attention was given by CISEPO to keeping senior level officials (ministers and ambassadors) in the region updated about specific programming, while striving at all times to keep the work from being politically influenced by using a Canadian programme for coordinating activities.

Early on, a special need was identified-the detection and habilitation of infants and children with impaired hearing. This public health challenge has arisen in part from consanguinity, which is estimated to be around 36-50% in Jordan and 53% among Israeli Arabs.[6] Hereditary sensorineural hearing loss is the most common form of congenital hearing impairment.[7,8] Undetected hearing loss has serious social and economic consequences for children, families, and the community.[9} Recognising sensorineural hearing loss as a regional problem, CISEPO helped to broker creation of the Middle East Association for Managing Hearing Loss, under the patronage of a member of the Jordanian royal court (FR, co-author of this article). Important lessons here are that we began with a high priority health concern for the region, and helped to sustain the collaboration through creation of a cross-border professional association.

Our work began in the region with small, practical steps such as continuing education workshops (panel 1). Additionally, CISEPO helped to support a leading Palestinian and Israeli basic science research programme in the genetics of hearing loss between Bethlehem University and Tel Aviv University.[10] This programme has generated joint-authored publications describing the prevalence of connexin 26 in both the Israeli and Palestinian deaf populations.[11,12] Building on these steps, our first large scale project during April, 2001, to June, 2004, involved the screening and habilitation of nearly 17 000 Israeli, Jordanian, and Palestinian newborns for hearing loss. Our next project is testing 130 000 infants in underserviced communities, and will link deaf children and their families with community-based habilitation services. Thus, we work incrementally, creating momentum through many small steps (continuing education, fellowships, scientific exchanges) leading to large-scale projects.

Challenges faced in the first infant screening project were examined by key informant interviews with three Canadian, three Israeli, three Jordanian, and three Palestinian participants (unpublished data).[13] Panel 2 summarises important factors in the success of such programmes, based on our qualitative analysis. In particular, the involvement of a trusted third party coordinator (CISEPO) was seen as vital for attracting colleagues and managing cooperation during periods of conflict-a role that has been underscored in other Arab and Israeli initiatives.[14-16]

Panel 1: Examples of Arab and Israeli cooperation facilitated by CISEPO

Relationship building

· In May, 1998, the Middle East Association for Managing Hearing Loss (MEHA) was established as the first joint Arab and Israeli professional association. Six meetings of the MEHA steering committee have been held in the region

· Active partnerships built with more than 20 hospitals in the middle east (12 Israeli, eight Jordanian, one Palestinian); nine universities (five Israeli, two Jordanian, two Palestinian); the Royal Medical Service of Jordan; dozens of Arab and Israeli mother and child health centres and non-governmental organisations

· Three meetings (Jerusalem, June, 2001; Cyprus, October, 2002; Beer Sheva, June, 2003) of Deans or their representatives from all four Israeli medical schools (Tel Aviv University, Hebrew University of Jerusalem, Ben Gurion University of the Negev, Technion-Israel Institute of Technology) and the University of Haifa, and senior representation from the Arab Israeli medical establishment; two Jordanian medical schools (University of Jordan; Jordan University of Science and Technology) and the Royal Medical Services; and two leading Palestinian universities (Al Quds University Medical School; Bethlehem University)

Practical and policy effects

• During April, 2001, to June, 2004, nearly 17 000 Arab and Israeli newborn babies have been tested for hearing loss in cross-border MEHA project 1. A new project will link screening with rehabilitation services for 130 000 infants in underserviced communities
• Over 300 Canadian hearing aids have been distributed to poor and needy newly diagnosed deaf infants in the region, and hundreds of children have been supported in their habilitation with hearing aids, cochlear implants, auditory therapy, and family and professional education
• Building on the success of CISEPO/MEHA programming, as of July, 2003, universal screening of hearing in newborn babies has been implemented by the Royal Medical Service of Jordan, and the Ministry of Health of Jordan is proceeding towards a programme of universal screening throughout the country

Education and training

• Since 1996, CISEPO has organised continuing education conferences, training workshops, and exercises involving Israeli, Jordanian, and Palestinian individuals and institutions in Amman (1996, 1998, 1999, 2003, 2005), Gaza (1997), Nablus (1997), Petah Tikvah (1998); Jerusalem (1999, 2001); Abu Dis (1999); Tel Aviv (1999, 2001, 2003); Toronto (2000, 2004); Bethlehem (2000); Cyprus (2002); Haifa (2003); Beer Sheva (2003), Aqaba (2003), Brussels (2004), and Petra (2004)
• Electronic distance-education programmes between Mount Sinai Hospital, University of Toronto, and the middle east were initiated in 2002
• Student University Network for Social and International Health (SUNSIH) and CISEPO held 6-week summer programme in June-July, 2003, involving two Israeli, two Palestinian, and two Canadian medical students; programme expanded in summer 2004 to include Jordanian students
• In December, 2003, the first combined Arab and Israeli exchange programme in cochlear implant surgical training (in Israel) and cochlear implant surgery (in Jordan) was implemented

Research

• Ground-breaking research in the genetics of hearing loss between Bethlehem University and Tel Aviv University, including joint training of an MSc and PhD Palestinian graduate student
• Joint Israeli-Palestinian authored articles on the genetics of hearing loss published in Human Genetics (2000, 2002)
• Joint Arab-Israeli presentations and publications on newborn hearing screening at NHS2002 conference (May, 2002) and NHS International Conference, May 27-29, 2004, Cernobbio, Italy
• Only cross-border project funded by the Canadian Institutes of Health Research in its inaugural Global Health Research Initiative
• New initiative involving youth health promotion: Arabic/Hebrew adaptation of a youth smoking prevention website; and Bedouin youth engagement around community health projects (http://www.GlobalYouthVoices.org/middle-east/greetings-en.html)

Although this project was scheduled to be finished in 2 years, completion was slowed due to tension surrounding the second intifada (uprising of Palestinians that started on Sept 28, 2000). CISEPO needed to secure additional funding because of the extended timeline. Special attention was given to maintaining good relationships and morale through

numerous telephone calls, internet connection, and face-to-face meetings in the region. Canadian colleagues acted as “honest brokers” keeping everyone connected through frequent bilateral and trilateral communication channels. Having active involvement of Jordanian colleagues gave CISEPO flexibility in coordinating activities with Palestinian and Israeli partners. These regular exchanges not only focused on moving project activities along over numerous hurdles, but also strengthened personal relationships and confidence among colleagues during this difficult time.

Panel 2: Critical factors for the success of cross-border cooperation

Connection

• Trusted third party: non-governmental organisation base (CISEPO) provides a trusted and flexible mechanism to build connections and quickly mount “on the ground” activities
• Humanitarian attraction: like-minded colleagues are engaged due to a common concern for the health of people and communities, regardless of political opinions, personal preferences, and conflicts
• Relationship building: professional and personal contacts are fostered by being inclusive, showing mutual respect, and ensuring equity exists in the partnership if not in current circumstances

Action

• Needs focus: address significant clinical and public health concerns for the region
• Incremental steps: bottom-up approach building on short term initiatives (eg, regional workshops, fellowships, continuing education) to gain momentum, while laying the groundwork for larger scale projects
• Tangible deliverables: successfully completing projects that have practical outcomes and affect health policy

Sustainability

• Capacity building: a long-term commitment to professional and community development; building financial support and infrastructure
• Regional profile: manage political and media exposure to minimise political pressure and possibility of personal threats
• Academic grounding: draw on interdisciplinary expertise, longer term focus, academic values, international connections, professional associations

Cooperative capacity building provides a basis for attracting new colleagues and sustaining relationships. Colleagues gain by sharing their knowledge and resources, while advancing their careers through joint academic outputs (grant proposals, conference presentations, publications). For example, CISEPO organised a first International Scientific Symposium with more than 50 Arab and Israeli participants on Oct 23-24, 2002, in Cyprus. Subsequently, a meeting of 25 investigators on our Canadian Institutes of Health Research grant was held at Ben Gurion University, Israel on June 24, 2003. More than 60 Arab and Israeli investigators and practitioners attended a research priorities workshop at Aqaba, Jordan, on Oct 23-24, 2003, and our second International Scientific Symposium was held on Oct 10-12, 2004, at Petra, Jordan. Equally importantly, these meetings provide an informal social context for fostering mutual understanding.

Care is taken to manage the profile of our activities in the region, since participants at times receive negative reactions from colleagues. We do not avoid the media, but focus media and public attention on our shared humanitarian goals and tangible outputs for improving the health of people and communities. Also, academic leadership has played an important part in supporting participants in our cross-border initiatives. For example, the Presidents of Al-Quds University and the Jordan University of Science and Technology brought the issue of faculty participation in CISEPO programmes for approval at their faculty council and council of deans, respectively.

Another critical element is a shared humanitarian focus on health needs. At times when interactions ventured into sensitive political areas, our Canadian colleagues played a respectful part in refocusing the discussion to address health needs and project activities. This common denominator enabled our partnership to work beyond national confrontations and political disagreements. In tangible ways, our example of cross­border cooperation helps create a social infrastructure in the region for peacebuilding.

Two birds in one tree

Our work is guided by a bi-level model that integrates specific goals (achieving improvements in health outcomes through specific projects), with broader goals (building cooperation networks through cross-border collaboration). Like-minded individuals are attracted to our work by these dual goals, characterised by one colleague as “two birds in one tree”. This approach provides the opportunity to expand one’s professional career by addressing a health concern in the region, while also building bridges between neighbours in this conflicted region.

Critical mass is created by linking projects drawing on systems analysis.[17] CISEPO has expanded from an initial focus on congenital hearing loss, to include activities on health of mothers and children, promotion of health in young people, nutrition, and infectious diseases. Overlapping components to each theme include co­authorship of presentations and papers, joint research meetings, international exchanges and training, visiting scholars, fellowships, continuing education, and distance electronic learning.

A higher-level synthesis works across networks to expand reach and effect through the creation of knowledge networks. [18] For instance, a new development underway for CISEPO is expanding cooperation beyond the health sector to bridge with the spheres of education and information and communications technology to support electronic learning initiatives.

Cooperation built on established relationships will help breathe life into any new agreement, such as the recent Declaration of Principles of Palestinian-Israeli International Cooperation in Scientific and Academic Affairs signed on May 4, 2004, at the University of Rome La Sapienza by the rectors and presidents of five Israeli and four Palestinian academic institutions. In this respect, CISEPO has already organised three successful meetings in 2001, 2002, and 2003 involving deans or their representatives from all four Israeli medical schools, the two Jordanian medical schools and Royal Medical Services, and two leading Palestinian universities including a medical school (panel 1).

In conclusion, our work has shown that it is possible to bring Arabs and Israelis together to achieve common goals under very difficult circumstances. Our network has proven durable and grown at a time when other networks have disappeared and new ones are difficult to establish.[19]From our experience, three essential ingredients for successful cooperation include a focus on common health needs with practical outcomes, a proactive and honest third party broker, and a critical mass of “bridge-builders” in the region who are prepared to get involved. The health sector provides a powerful venue for building international cooperation, trust and confidence. Our ongoing experience and model give direction for health professionals in peacebuilding-a primary determinant of global health.

“The role of physicians and other health workers in the preservation and promotion of peace is the most significant factor for the attainment of health for all.”[20]

World Health Assembly

Contributors

H Skinner was the principal writer of the manuscript, helped by the co­authors. All authors had substantial roles in the Arab and Israeli health initiatives described in this study, as part of CISEPO. A Noyek is the founding Chair of CISEPO. All authors approved the manuscript to be published.

Conflict of interest statement

We declare that we have no conflict of interest.

Acknowledgments

We dedicate this article to the memory of our Jordanian colleague Mohammed Al Omari-his courage and good humour will be greatly missed. We thank our colleagues in the middle east and Canada for their encouragement and involvement in CISEPO cross-border health initiatives. The study was supported by grants from the Canadian Institutes of Health Research (CIHR) Global Health Research Initiative (H Skinner, principal investigator) and from the Canadian International Development Agency (CIDA; A Noyek, principal investigator). The funding sources had no role in the writing of the paper.

References

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[2] Horton R. Doctors in conflict: understanding Israel’s despair. Lancet 2003; 362: 928-29.

[3].United Nations Development Program. Building a knowledge society. Arab Human Development Report 2003. Geneva: United Nations Development Program, 2003.

[4].Garber R. Health as a bridge for peace: theory, practice and prognosis-reflections of a practitioner. J Peacebuilding Devel 2002; 1: 69-84.

[5] Santa Barbara J, MacQueen G. Peace through health: key concepts. Lancet 2004; 364: 384-86.

[6] Vardi-Saliternik R, Friedlander Y, Cohen T. Consanguinity in a population sample of Israeli Muslim Arabs, Christian Arabs and Druze. Ann Hum Biol 2002; 29: 422-31.

[7] Grundfast KM, Lalwani AK. Practical approach to diagnosis and management of hereditary hearing impairment (HHI). Ear Nose Throat J 1992; 71: 479-93.

[8] Nadol JB Jr. Hearing loss. N Engl J Med 1993; 329: 1092-102.

[9] Ben-Simhon K. One in twenty. Haaretz (Tel Aviv), June 2, 2004.

[10] Adam D. Windfall spurs rare Israeli-Palestinian research effort. Nature 2003; 421: 777.

[11] Sobe T, Vreugde S, Shahin H, et al. The prevalence and expression of inherited connexin 26 mutations associated with nonsyndromic hearing loss in the Israeli population. Hum Genet 2000; 106: 50-57.

[12] Shahin H, Walsh T, Sobe T, et al. Genetics of congenital deafness in the Palestinian population: multiple connexin 26 alleles with shared origins in the Middle East. Hum Genet 2002; 110: 284-89.

[13] Skinner HA. Building Arab-Israeli cooperation through health research-a peace making approach. Munk Centre for International Studies, University of Toronto, Nov 21, 2003 (invited presentation). http://www.healthbehaviorchange.org/recent_ publications.htm (accessed Jan 23, 2005).

[14] Scham P. Arab-Israeli research cooperation, 1995-1999: an analytical study. Middle East Rev Int Affairs 2000; 4: 1-16.

[15] Barnea T, Abdeen Z, Garber R, et al. Israeli-Palestinian cooperation in the health field, 1994-1998. Study report, JDC-Brookdale Institute, JDC-Israel, AJJDC and Al Quds University, 2000. http://www.jdc.org.il/jdcisr (accessed Jan 23, 2005).

[16] Dajani KK, Carel RS. Neighbors and enemies: lessons to be learned from the Palestinian-Israeli conflict regarding cooperation in public health. Croat Med J 2002; 43: 138-40.

[17] Skinner HA. Promoting health through organizational change. San Francisco: Benjamin Cummings, 2002.

[18] Stein J, Stren R, Fitzgibbon J, MacLean M. Networks of knowledge. Toronto: University of Toronto Press, 2001.

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[20] WHO. Resolution 34: 48. Geneva: World Health Organization, 1981.

www.thelancet.com Published online January 25, 2005 http://image.thelancet.com/extras/04art3217web.pdf

University of Toronto, Toronto, ON, Canada (Prof H Skinner PhD, P Aber MSc, Prof C Chalin PhD, Prof A P Williams PhD, Prof A Noyek MD);
Al Quds University, Abu Dis, West Bank (Prof Z Abdeen PhD, H Abdeen MD, R O Jebara MA);
Jordan University of Science and Technology, Irbid, Jordan (Z El Nasser MD);
University of Haifa, Haifa, Israel (J Attias PhD);
Tel Aviv University, Tel Aviv, Israel (K B Avraham PhD,Y Roth MD);
Ben Gurion University of the Negev, Beer Sheva, Israel (Prof R Carmi MD);
Mount Sinai Hospital, Toronto, ON, Canada (Prof C Chalin, Prof A Noyek);
Royal Medical Services of Jordan, Amman, Jordan (M Hijazi MD);
Bethlehem University, Bethlehem, West Bank (M Kanaan PhD);
Technion-Israel Institute of Technology, Haifa, Israel (Prof H Pratt PhD);
Harvard University, Boston, MA, USA (F Raad MPH);
and Amman University, Amman, Jordan (M Al-Masri PhD).

Correspondence to: Dr Harvey Skinner harvey.skinner@utoronto.ca