Hebrew University-Hadassah School of Public Health and Community Medicine
Several months ago, following Richard Horton’s essay in The New York Review of Books (“The Palestinians: The Crisis in Medical Care”: Vol. 4, March 15, 2007), I thought I would write a commentary rebutting what I felt were its errors, biases and distortions. Horton’s essay, which appeared after the Hamas election victory, was based on impressions from his own site visit, interviews and meetings in Gaza with Palestinian doctors and in Israel with several Israelis, notably representatives of Physicians for Human Rights-Israel, and various literature sources. It presented a grim picture of the medical and social situation in Gaza, and Horton holds Israel largely to blame for this crisis. I had to put this exercise aside for all the usual reasons, including, ironically, the need to meet serial deadlines for a joint research proposal with a Palestinian colleague at Al Quds University for an epidemiologic study on intra-uterine exposures to endocrine disrupters and pesticides and subsequent post-natal effects in babies, and then getting involved in a successful fight against a decision by the US State Department’s Agency for International Development to cancel its annual funding (some 10 million dollars) for the Middle East Regional Cooperation Program (at a time when the Administration was reportedly proposing to spend some 50 million dollars on beefing up the Palestinian security apparatus in the West Bank.
But since then, much has happened: the kidnapping of Alan Johnston, the BBC TV correspondent, the continued Kassam rocket attacks on Sderot, the tunneling and smuggling of rockets, missiles and arms across the Egypt-Gaza border, the brutal takeover by Hamas of Gaza, with its gangland-type killings and executions, the lethal fighting between armed groups allied to Hamas and Fatah and, up to now, the imposition of a strange kind of order and quiet in Gaza, followed by still more fighting between Hamas and Fatah, the Israeli targeted attacks on terrorists, and the continued downhill drift of its economy and life. In the meantime, there were the renewed calls for a boycott of Israeli academic institutions, now declared illegal by the British Union of Academics legal advisor; the British Medical Journal’s publication of a debate on the proposed boycott between Tom Hickey, an academic trade union activist once photographed under a placard promoting the work of Roger Giraudy, the French Holocaust denier, and Professor Michael Baum, the distinguished British surgeon; the appearance of Farfur-the Hamas copy of Mickey Mouse-to incite to hatred and violence, on a Palestinian TV children’s show; and stateside, the publication of Jimmy Carter’s book accusing Israel of running an apartheid occupation and another one by John Mearsheimer and Stephen Walt on what they consider to be distortions in American foreign policy produced by the all too pervasive influence of the Israel lobby, the terror murder of an Israeli by PA policemen on the eve of the Annapolis conference and, right after, a TV program denying the Holocaust, along with repeated calls for the “return of the refugees” and denial of the existence of Israel on the official PA television station. By now it is clear that Horton’s essay was not an isolated event but part of a trend, the climax of which was Columbia University’s invitation to President Ahmadinejad to speak there at the end of September. Only time will tell if the video clips of Professor John Coatsworth shaking hands with Ahmadinejad will be cataloged in our collective memories alongside the film clips of Neville Chamberlain announcing that Herr Hitler-whom Coatsworth also would have invited to Columbia-had achieved “peace in our time.”
Richard Horton is editor-in-chief of the Lancet, perhaps the world’s most influential medical journal. The Lancet has published very good papers on global international health. Its publication of the papers on the evidence for genocide in Darfur and the statistical models of the estimated deaths in Iraq were examples of bold uses of new epidemiologic and statistical methods to estimate death tolls under conditions of extreme barriers to access to the truth. Horton himself has been courageous in challenging his publisher’s (Elsevier) participation in the arms industry, although the Lancet, like all human creations, is not infallible: several years ago, it retracted a totally fraudulent paper with forged results submitted by a group of Norwegian scientists. So what Horton has to say needs to be taken seriously. His status as editor of the Lancet gives him not only authority, but special accountability.
Horton first trips up badly in the seventh line of his essay, when he describes Gaza, a twenty-five by five mile strip of land, as one of the most densely populated and impoverished regions in the world today. Its population is estimated to be somewhere between 1.2 and 1.5 million, and its population density is of the order of 3500 to 4000 persons/km2. But Hong Kong’s population is almost 4-5 fold higher-some 7,000,000-and the population density is approximately 60% greater: 6,500 persons/km2. Both Gaza and Hong Kong are less crowded than Gibralter (11,000 persons/km2), Singapore (19,000 persons/km2), Monaco (>40,000 persons/km2), and Macau (70,000 persons/km2)-all city states or separate enclaves which are prospering. Gaza’s population is certainly impoverished. The GDP in Gaza is hovering around $1500 per capita, but in more crowded Hong Kong, it is almost $25,000 per capita. As for infant mortality, for 2002-2006 in Gaza-West Bank combined, it is 17.5 (Gaza is about 22.4 and the West Bank approximately 16) per 1000 live births-the latter ten times higher than that of Hong Kong, where the rate is 2.5 /1000. In neighboring Syria, Jordan, Lebanon and Egypt, the rates are 16.0, 19.4, 25.9, and 29.3 respectively. In the US it is 6.3 and in Israel it is 4.7.
How then could someone as experienced as Horton repeat the oft-recited claim that Gaza is one of the most crowded places in the world, with the implication that its “high” population density per se is part of the problem? At about the time of his visit, I personally heard Dr. Mustafa Barghouti, a physician and the Minister of Information in the government formed before the Fatah-Hamas blow-up, and one of Dr. Horton’s hosts, make the same statement. Barghouti is a well-traveled, academically well-connected and articulate physician and who is an advocate on non-violent protest. He is not an ordinary political hack, and has criticized the PA for its corruption and terrorism. Therefore one would have been expected him to be more careful on such an elementary fact. The same point applies doubly to Horton, whose very mission as editor of the Lancet is to be an arbiter of truth. And if crowding is the problem, a claim refuted by the Gaza-Hong Kong comparison, why is there no comment on why Egypt does not allow the use of its empty desert expanses in Sinai to accommodate the population spillover?
Horton writes about the shortage of cash as one of the causes of the crisis in health care in Gaza. But he omits to mention that in 2006, the PA received 1.2 billion dollars in aid from the EU, more than in 2005, and to date is the highest per capita recipient of western aid in the world. These are facts which raise questions as to how the money was spent. Now Western and Arab countries have pledged 7.5 billion USD for a several-year program of economic and social development. Unfortunately, Horton appears to be going along with the victimhood theory of political failure. He writes that “Without a sovereign state, the newly created Ministry of Health found it hard to devise and implement a coherent policy for the West Bank and Gaza.”
But Hong Kong, both as a quasi-sovereign British Protectorate and as part of China, has done very well. And, closer to home, we rediscover evidence for the theory that while health may create wealth, wealth does not necessarily create health. In oil-rich Saudi Arabia and Libya infant mortality rates are 18.8 and18.0. In Iran, which contains the world’s largest oil reserves, it is 30.6 after a quarter-century of Islamic revolution, as compared with 8.2 in the United Arab Emirates, a less closed set of places. Furthermore, as Daniel Pipes has pointed out, recent data show striking correlations between time trends for increases in foreign aid to the Palestinian Authority and time trends for Israeli deaths from terror one year later, which strongly suggests that much of the aid has been siphoned off to fund terror. It might have been more honest to say that under the corrupt, heavy-handed Byzantine rule of Yasser Arafat, many of those who tried to bring normal administration were sidelined, marginalized, or pushed out, and of these, many left Gaza. Indeed, in the West Bank, Mahmoud Elayan, administrative director of the Red Crescent, is quoted by Ruth Eglash in a recent article in the Jerusalem Post as saying that while there are many reasons why there are not decent hospitals in the PA-controlled territories-as compared with Palestinian-run hospitals such as Makassed and Augusta Victoria in Jerusalem which, because they are under Israeli rule, are required to adhere to Israeli standards-lack of money is not one of them. “The main problem is corruption and lack of organizational thinking,” he is quoted as saying. In December, an extremely senior physician from Gaza said the same thing to me in a private conversation. Since this Intifada, my own hospital, Hadassah Medical Organization, with two separate hospitals in Jerusalem (Ein Kerem and Scopus), has provided subsidized care for uninsured Palestinians and has been committing $3 million/year for treatment, reducing fees by over 50% for those in need, or waiving them altogether-out of a total annual budget of some 300 million USD per year (Ron Krumer, Director, Hadassah Hospital Department External Relations). There is no question that barriers and checkpoints slow things down, but Elayan, quoted in the Jerusalem Post, blames the situation on those who, during the Intifada years, used ambulances and pregnant women to smuggle explosives into Israel. “They spoiled everything. Because of them the security measures became so tight,” he says. “But now, Israelis have to cut us some slack. The situation has changed. If we want to trust each other, each side has to change. I understand that there need to be security measures. But they should be more reasonable.”
Elayan’s admirably blunt statements pose two questions. The first is: has the situation changed? From Jan. 1 to June 30, 2007, the IDF found and confiscated the following weapons at roadblocks and checkpoints: 5 explosive belts, 87 bombs, 92 guns and knives, and 15 grenades, or a total of 199 terrorist weapons (Walter Zanger, 2007). Every day the IDF intercepts and aborts tens of terror attempts. If,, based on past data, each “successful” suicide terror attack with an explosive belt, bomb or grenade can be expected to kill average of 7-10 victims, then these confiscations saved anywhere between 700 to a 1000 lives, –not including additional individuals killed with guns and knives.
The second question is: what does it mean to be “more reasonable” were the roadblocks to be removed? We already know the answer: the smuggling into Gaza following the disengagement via its now porous border with Egypt and the tunnels has introduced horrendous amounts of lethal weapons. Horton says a great deal about the barrier but nothing about the arms smuggling and these tunnels of death. The words “tunnel” and “arms smuggling” are absent from his essay. On Jan 13, 2008, the Israeli Border Authorities announced they confiscated the explosive material sufficient for 500 rockets which a group was attempting to smuggle into Gaza as part of a shipment of humanitarian aid.
I will give my own answer to the second question: There should be zero tolerance for terror.
Horton writes that “Tens of documented deaths, including of children, have been attributed to checkpoint delays. Most Western citizens and perhaps many Israelis are unaware of the living conditions endured by ordinary Palestinians,” citing a study by Rita Giacaman,  ” Horton further refers to delays in ambulance transport time for Palestinians resulting from security checkpoints by the Israel Defense Forces, and cites studies purporting to show such delays, but ignores the published peer-reviewed critiques of a flawed study published in the British Medical Journal. In April 2006, a group of investigators from Denmark attributed increased risk for medical complications requiring hospitalizations to delays from checkpoints, detours and curfews imposed by the Israeli Defence Forces. The authors based their findings on a study in January 2005-described as “a relatively calm period in the West Bank.” Of all 2228 contacts, 394 (17.7%) were delayed, and of these, 125 (32%) required hospitalization, resulting in an overall risk of 5.6%. But, as my colleagues Dr. Avi Rivkind, Rony Blum and I pointed out in a published rebuttal, 51 of the 125 would have been hospitalized anyway, based on expected risks of hospitalizations in those not delayed for military reasons. A closer examination of the evidence indicated that 74 hospitalizations-or 3.3% of all contacts-were specifically attributable to delays, which were self-reported, and simple arithmetic calculations indicated that travel time, based on the authors’ own data, was, on the average, increased from 50 to 58 minutes by the checkpoints. In our published comment, we pointed out that it seemed a bit odd that a 16% increase in median travel time-an additional 8 minutes, which is within the golden hour of emergency medicine-should account for 59.2% of the 125 delays. The BMJ article about the checkpoints, like Horton’s, was blandly indifferent to the reasons for the checkpoints, detours, curfews and-of course, the barrier, or what Jimmy Carter calls the apartheid wall. Furthermore, contrary to the claims of its authors, the period leading up to January 2005 was anything but calm for Israelis. From Sept. 2004 through Feb. 2005, terror attacks, originating mostly from Palestinian regions, killed 76 and wounded another 234 persons, mostly Israeli civilians, Jewish and Arab, and foreigners. The checkpoints-themselves not very safe areas-foiled other attacks and smuggling of arms. These findings, to put it mildly, did not make a persuasive case for the role of IDF checkpoints, detours and curfews in producing major delays in access to emergency health care. 3 In a later comment, the editor in chief of the BMJ, Dr. Fiona Godlee herself, acknowledged that the paper-which the authors were invited to submit-was not adequately reviewed. 
On the day this mss was posted on SPME, it was reported that the Israeli Border Authorities had confiscated two trucks concealing enough explosive reagents for 500 rockets in a shipment of humanitarian supplies. 
Horton’s article appears to be part of a trend which I consider to be an upscale variant of classical anti-Semitism. This trend seems to apply different standards to the value of life of Israelis and Palestinians and attributes the problems of the latter exclusively to the barriers, curfews and checkpoints, and not to the failures of Palestinian leadership to take charge of its own society. Horton did not devote any space in his article to the reason for the barriers, curfews and checkpoints: the danger of attacks directed against Israelis of all ages, sexes and backgrounds in restaurants, shopping centers, busses and malls, and the fact that these barriers, together with improved intelligence and the attacks, killings and capture of terrorists have been part of a package of measures which have been effective in dramatically reducing the death toll from terror attacks since they peaked prior to the Jenin attack. , Death tolls from terror attacks were 43 in 2000, 201 in 2001, 426 in 2002 (a number equivalent to 18,260 deaths among 300 million Americans), 117 in 2003, 109 in 2004, 50 in 2005 and 24 in 2006 (as well as163 killed during the second Lebanese War) and 13 in 2007. If anything, the graph showing the drop in deaths when and where the barrier was constructed was even more powerful a case for the barrier than the graph showing the fall in cholera deaths in London following the removal of the handle from the well of the Broad Street Pump in 1854, the source of the Vibrio Cholera. John Snow’s removal of the pump is considered to be the iconic event in modern epidemiology, even though we now see that his intervention occurred when the epidemic had already abated.
As Horton well knows, the story of Snow’s epidemiologic investigation (Snow was the first doctor to use anaesthetic gasses on a member of the royalty, Queen Victoria) is used to illustrate the point that interventions can be highly effective if we know the pathways of transmission of a disease, without knowing what is the true cause-the agent. Snow’s investigation ushered in modern epidemiology and his intervention-removing the handle of the pump-preceded by some 30 years the isolation of Vibrio Cholera-the bacterial microorganism that was the pathogenic agent for cholera. In other words, as Horton would be expected to have recognized, we do not have to wait for the search for what are misleadingly called “root causes” of terror attacks-a point I will get into later-to stop deaths from terror attacks.
In the case of Horton, his indifference-and that of many others-to the dramatic fall in deaths following the construction of the barriers conveys the message that some lives are less equal than others.
An article in Risk Analysis by Bogen et al has noted that for Israelis, the risk of being killed in a terror attack per capita has been 100 to a thousand times hundred times that of for years 1968-2004, Israel had a fatal fraction of casualties about half that of all other regions combined, but has experienced relatively constant lifetime terror-related casualty risks on the order of 0.5%–100 to a thousand times more than those experienced in the rest of the world, in which it increased approximately 100-fold over the same period. The authors also note that individual event fatality has increased steadily, the median increasing from 14% to 50%. These types of comparisons, so basic to any statement about medicine and public health, were not present in Horton’s essay.
Horton, despite his concern for human life, does not address the terror toll on Israelis, says nothing about the fact that the very object of these terror attacks is to kill Israelis, and betrays the same selective blindness and double standard towards the value of human life as does Jimmy Carter, despite his religious convictions about the sanctity of life. Horton’s essay did not have one single reference to the 2774 rockets, missiles and mortars that have been targeted at the civilian population in Sderot, the small town at the edge of the Gaza strip, and he ignores the elementary body of data on the comparative epidemiology of the distribution by age and sex of the casualties of the conflict between Israel and the Palestinians.
The Herzeliah Center for Interdisciplinary Studies, a college and Israeli think tank, has published data showing that since 2000-and for that matter, 1993, following the Oslo Accords-the age-sex distributions of the dead among Israelis and Palestinians indicate that Israelis have been targets of genocidal terror on the part of Palestinians aimed at the entire population. Among Israelis, there has been a disproportionately high number of females and older people-e.g. non-combatants. Among the Palestinians, the age-sex distribution of the deaths seen everywhere in the world-predominately young males-suggests a pattern of Israeli use of force aimed against the perpetrators of terror-predominately males in the age group 15-30, although, tragically, many children have been killed as well.
This asymmetry in civilian/combatant ratios has characterized the history of violence before, during and after the Oslo agreements, yet it escapes the scrutiny of Horton, and is ignored by Barghouti. In 2007, Betzelem, a human rights organization, reported that the “number of Palestinians killed by the Israel Defense Forces decreased by 43 percent since last year, to 373, but the total number of Palestinians killed reached a record high because of the 344 Palestinians killed in the internecine conflict”  There was a significant drop in the proportion of civilians killed, which decreased from 54 percent of the 657 Palestinians killed by IDF fire in 2006 
The vast majority were killed in the Gaza Strip. I use the term ‘genocidal terror’ because I believe that terror directed against civilians is quite simply genocide by an NGO, and simply cannot be airbrushed away by the use of the term “resistance.” If genocide is defined as a set of actions intended to destroy, in whole or in part, a group, then I believe the time has come to recognize that terror directed against non-combatant members of that group becomes a subset of genocide, and that the use of force to stop that terror cannot be equated with the terror itself. Horton comes nowhere near that recognition.
In our electronic version of our letter to the BMJ on the checkpoints, my colleagues and I wrote:
“What is striking is the asymmetry between the deaths and injuries from genocidal terror and the admittedly stressful, but usually inconsequential delays necessitated by the need to protect everyone-Jews, Arabs, tourists, foreign workers and others-from terror’s lethal reach, which has included the misuse of Red Crescent ambulances to smuggle terrorists and weapons past checkpoints. No one should be denied access to health care anywhere. Israeli hospitals have done their maximum to ensure that this care was provided to all during the last 5 years of what the authors call armed conflict. The authors’ data, if anything, suggest that the IDF is doing what it can to honor its commitments to clear ambulances within 30 minutes, despite the dangers. We suggest that the authors work to persuade the new Palestinian Hamas government to renounce genocidal terror. Then there would be no need for checkpoints, curfews, barriers, or soldiers.”
The BMJ cut the above section in quotation marks from the hard copy published version. It used the space to publish a picture of that section of the barrier which is a concrete wall. The barrier-Jimmy Carter’s ‘apartheid wall’-has come to symbolize infringement of the rights of Palestinians, and there is no doubt that it, along with the checkpoints, has made life much more difficult for thousands to tens of thousands. Yet I would have been more impressed if alongside the wall the BMJ had published a picture of the pictures of faces of the victims of Islamist terror-i.e. a measure of the medical outcome of concern: loss of life. Funerals are forever, but walls, barriers and fences, like checkpoints, which prevent funerals, can be taken down, moved, and opened. Horton ignores the point that the barrier, like the checkpoints and curfews, is an expression of the first responsibility of all sovereign governments-to protect the lives and safety of their citizens, and was extremely effective in doing so.
Horton, to his credit, is clearly troubled by the toxic effects on children of incitement in the mosques, and school texts, and TV-as the world discovered when Farfur made his debut. Horton himself writes “that 40% have relatives who died fighting in the second intifida. Many of these relatives live on as “martyrs,” Palestinians who have died fighting the Israelis. The faces of these young men and women are remembered on billboards and posters covering the walls of almost every building in Gaza, including hospital clinics and Ministry of Health buildings. They are often depicted carrying weapons. They are images that must press on the conscience of every child. It would be hard not to conclude that Gazan children are brought up to revere, even aspire to, the lives of these “martyrs.” There is nothing noble about indoctrinating violence into children. But it is clear how these ideas are fostered and fixed into the collective psyche of Palestinians.”
This brilliant excerpt is flawed by the fact that Horton’s term, “died fighting the Israelis,” delicately sidesteps what kind of fighting the young men revered as martyrs were involved in: launching terror attacks against all Israeli civilians, or defending themselves from Israeli counterattacks directed at the perpetrators -the “targeted killings” which are designed to avoid harming civilians. The fact that such attacks have resulted in many deaths of non-combatants, including civilians, is, tragically, unavoidable, but these would not occur were there no terror attacks, Kassams, and the indoctrinating violence-i.e. state-sponsored incitement. Where Horton slips up is in failing to explore the intergenerational effects of such mass commemoration of martyrdom. It is my opinion that unless we are direct about such effects, there will never be any possibility of any sustainable solution via diplomatic agreements at the top. Interestingly, it is Dr. Suliman, the heroic founder of a set of clinics and social care programs for indigent Gazans, who seems to understand the reasons for the use of Israeli force. Horton writes: “In their defense (of forced evacuation of civilians and taking refuge in a hospital), Israeli officials would surely argue that they used appropriate force in response to the rocket attacks from Beit Hanoun. Dr. Suliman understands this argument. But he cannot accept the harm inflicted carelessly on children. After all, he tells me, the inhabitants of Beit Hanoun should not be punished for the actions of a few extremists.” But if 40% of all families know someone who has been killed “fighting the Israelis,” i.e. launching terror attacks or defending their perpetrators, it would seem that we are dealing with population-wide involvement in such terror attacks, and not a “few extremists.” My own point of view, based on past work in the area and continued contacts, is that many of those involved have been dragged into the fray by the threats against those who do not join up-especially now that Hamas is in total charge.
As far back as 2001, before 9/11, Dr. Eyad Serraj, the director of the Gaza Community Mental Health Program, warned that children in the territories dreamt of martyrdom, or shahada, the way normal kids in the US dream of going to Disneyland. Now, seven years later, Giacaman reports that the children of the West bank, notably from the refugee camps, suffer from humililation resulting from having seen Israel’s harsh response-the patrols, the searches, the arrests. I commend Giacaman for reporting these outcomes, but ask what she has done to curb the incitement-itself a form of child abuse-which, until proven otherwise, can only have toxic effects on the psychological and educational development of an entire new generation of children. I myself recall how, at the beginning of the second Intifida, a Palestinian mother reported that with the withdrawal of Israeli soldiers from the major population centers in the West Bank in the years 1995-2000, these collective memories of a new generation of children were disappearing. All that progress was destroyed by Intifida No. 2.
My own point of view is that, as is the case with all exposures to toxic agents, it is children who are the most vulnerable to hate language and incitement. Perpetrators of genocide or genocidal terror use hate language and incitement to stigmatize and dehumanize the “other”– without which they cannot recruit their followers. Hate language and incitement programs the next generation to patterns of hate and violence. If the Kassams are the hardware of genocidal terror, the incitement-Farfur and the Hamas bee-of children and youths provides the software. The same point applies to the hate language in the mosques calling Jews pigs, cancer and other dehumanizing epithets-and the use of similar language by rabbis who have just been indicted by the Israeli government for similar racist incitement.  Is it too much to expect Barghouti, now a Minister in the Palestinian Authority’s cabinet, and Dr. Giacaman, who is Barghouti’s wife, to investigate and speak out about the toxic effects of incitement in Palestinian society in indoctrinating the next generation for hate, violence and terror-just as the State has indicted rabbis for such incitement? I would have expected Horton, out of concern for the lives of Jewish children and the mental health of Palestinian children, to expand on this one provocative observation and make some comments on how essential it is to stop the endemic incitement that is part of every narrative in the Palestinian world and its Arab hinterland.
My personal point of view is that the claim that the occupation is the cause of the terror, and by implication, the cause of the incitement to terror, simply is not sustainable. The incitement reappeared in the Palestinian textbooks with the establishment of the PA and Israel’s first withdrawals, and its ebb and tide bear no relationship to subsequent Israeli withdrawals. For that matter, its use dates back to the export of Nazi-style anti-semitic motifs and the use of mass propaganda to propagate them in the Mideast in the 1930’s.
One of Horton’s two Israeli contacts were members of Physicians for Human Rights-Israel. * I admire this organization’s field volunteer work for foreign laborers and Arab and Jewish groups. During the 1980’s and 1990’s, I participated in its field investigations of the effects of the use of tear gas, the health status of security prisoners in Israeli prisons, an epidemic investigation of brucellosis in an Arab village in the West Bank, and risks for toxic exposures to Bedouin near Israel’s national toxic waste dump. In 2005, I wrote the medical brief on behalf of Bedouin from unrecognized villages in the Negev, represented by Physicians for Human Rights-Israel, whose wheat fields were sprayed with Roundup, the world’s most widely-used weed killer and a herbicide used to kill cocaine in Columbia. The brief was successful, eventually, in forcing the government to stop the spraying. As an environmentalist, I also have supported their protests against sonic booms of Israeli aircraft flying over Gaza. Although the medical knowledge on the health effects of citizen populations in time of conflict is limited, I have personally protested the use of sonic booms as a weapon of psychological warfare by the IAF. I see no strategic, military or political gains from a measure the major effect of which is to increase sleep disorders and bedwetting among young children. I was also against Israel’s bombing of Gaza’s power station following the kidnapping of Corporal Gilad Shalit, although now, with Hamas becoming a formidable military force for terror, I am ambivalent about what my position would be in the future should Hamas fail to stop the Kassaming.
But PHR’s ever more radical leadership, in its political positions, applies a double standard to the protection of life: one for the Palestinian victims of the occupation’s heavy hand, and a lesser one for Israeli victims of the terror, the reason for the heavy hand. As I have made clear, Horton himself applies these double standards. He is silent on the impact of terror on Israeli life, although his many observations hint that he sees its disruptive effect on Palestinian society-Dr. Soliman, one of his sources, has to carry a Kalashnikov at all times. He cites the position of PHR-I that the “occupation is the cause of the Palestinian health crisis”-and not the corruption, violence, terror and diversion of funds for arms. But he fails to address a harsh truth. There is no proportional relationship between less occupation and less genocidal terror, including the Kassam attack. In fact, ever since the Oslo accords, the opposite has been the case-when and where this less occupation, there is more terror— a relationship I ruefully was forced to accept after once believing the opposite.
If it is the health of the Palestinians that we are talking about, and health includes mental health, then my own point of view is that state-sponsored and -supported incitement is the root cause of the terror.
When the terror stops, and the incitement of terror stops-for good, and that means a generation-I will be out there demonstrating to take the barrier down, or at least to increase the openings in the barrier. The real issue of concern is defending the right of all to life and safety. In my view, this principle means zero tolerance not only for terror but also for incitement to terror. I disagree with Prof. Zvi Bentwich, a distinguished immunologist and internist, and Dr. Ruhama Morton, a psychiatrist, both of whom are active in PHR-I, and who, in a WHO-sponsored magazine devoted to Israeli-Palestinian cooperation in health, formulate the dilemma facing Israel as one of choosing “security” over “human rights,”. This formulation does not recognize that “security” is, at the end of the day, a shorthand for protection of the most fundamental of all human rights-the right to life and safety-or as my colleague Gerald Steinberg once put it, the right of my child and me to get on and off a bus without being blown up. I should add that the Israeli Government neglects to declare this principle-in my opinion, the most colossal example of its ineptitude in explaining Israel’s case not only to the world, but to itself and its own citizens.
When I protested to PHR-I that it was wrong in joining the challenge to the International Court of Justice to the barrier on the grounds that there was a need to acknowledge its role in preventing deaths, this organization refused to acknowledge my protest, and Bentwich never followed through on his promise to me to arrange for an open discussion of my objections with the PHR Board.
So why is Gaza in such a mess? Horton, on entering Gaza, “which exists in a cage,” sees bombed-out homes, bridges and fields, and vans loaded with members of armed militias-a lawless place under permanent siege. What he sees in his first few minutes helps tell us why. Gaza, with EU aid, is not Hong Kong, and Hong Kong, without EU aid, is not Gaza-or Taiwan, which, had it adopted the Gazan model of development, would have become Devil’s Island. What he does not ask is why the vans are loaded with members of armed militias, who we now know are more killing each other with ever increasing intensity. During the Hamas takeover, there were video clips of Hamas groups carrying out group executions of rival fighters.
In the 1980’s, when running a small case-control epidemiologic investigation of asthma in Gaza refugee camps together with Gazans and Europeans, we would drive to Gaza, and even in the 1990’s this was still possible. Gaza’s economy was driven by wages of Gazans working in Israel. The possibility of take-off, based on regional economic cooperation and supported by massive EU aid, was there. But Gaza became a cage because the Palestinian Authority, under Yasser Arafat, opted to engage Israel with terror, and tunnels for smuggling arms, and rocket attacks, and incitement of its youth, and its government wallowed in sleazy corruption, squandering the billions it received from the EU. Gaza could have been a Riviera on the Mediterranean. After Oslo, a nascent tourist industry began to develop, directed at an Israeli market. It was nipped in the bud by terror and Yasser Arafat’s regime of repression and corruption. By contrast, Hong Kong became a democracy and opted to do business with China and the world.
Palestinian leadership has to choose between going in the direction of Hong Kong and Singapore. This leadership has to take responsibility and going for the model of the creation of wealth and health-or continuing to wallow in the cesspool of violence, corruption, terror, internecine killing, self-pity and victimhood.
The role of health professionals and those concerned with human rights from the outside is to report, interpret and act on the evidence: not just to uncritically accept what they hear, but to ask about what they do not hear-and to serve as a force for promoting cooperation in the protection of life and the creation of health and wealth. There are, strangely enough, many projects involving cooperation between Israelis and Palestinians, and Jordanians, Cypriotes, Turks, and Tunisians, in public health and environment. PHR-I is just one of many organizations, official and unofficial, doing their best to provide healthcare to members of a society whose own political leadership until recently, whether it be Fatah or Hamas, seems to be less than concerned with the effects of the mix of incitement, violence and corruption and its effects on the well-being of its population. Giacaman herself has published a claim that these projects in regional cooperation do no good and has made untrue accusations against her colleagues and me that we profit personally from them-an easily refutable canard. These kinds of accusations are just the tip of the iceberg of the kinds of pressures to which those working on joint projects are exposed. I suspect that Horton heard nothing about these pressures since it is too dangerous for those subject to them to speak out against them.
Richard Horton’s selective observations and his errors of omission and commission in his assessment of Gaza’s dismal problems did not add to our understanding of what has happened in the Palestinian Authority. o
My personal perspective is that of a part-time participant, at times hesitant, at times enthusiastic, now somewhat saddened, in joint Israel-Palestinian projects in public health and environmental medicine which have left me with ideas which I believe others, including Horton, could use to help promote a healthier Middle East. In the 1980’s and 1990’s, my investigations of toxic exposures to lead in the community from battery plants led me to work for a project to promote a regional standard for controlling industrial lead exposures to protect workers. These hopes were dashed by the outbreak of the second Intifida. To this day, I hear from my colleague in Gaza, there is a smelter in Gaza City right in the middle of one of its slums contaminating the earth all around it and producing extremely high blood lead levels in the children there.
Here is what I learned from the cooperative projects I was involved in: when there is a project with clearly-defined goals and public health benefits, and opportunities for capacity building, especially one which results in some kind of international recognition “out there,” such as the ultimate status symbol of medicine and public health-a peer-reviewed publication in a major journal-contacts will remain and work will move forward. Nothing, including the foolish and misdirected British attempt to boycott Israeli academics, deterred all those who were in the original project from signing on the final publication of a joint Israeli-Palestinian-Jordanian project on lead poisoning. ** But the constraints imposed by the conflict prevented the participants from exploiting their hard work for the sake of promoting preventive interventions which transcend political borders.
To Dr. Horton, I say that there is a very specific role for health professionals in time of conflict. Our mission is to support life and light and repudiate the culture of death. Aid from the big-and little-funders should support regional projects which reward and promote cooperation on health and the environment involving the regional players. If the EU, the USA and the oil-rich Arab states had given the region as much funds for joint regional projects for cooperation as Saddam gave for suicide bombers and related terror activities, and Iran now massively supports with reportedly even more funding, training of terrorists and materiel, the Middle East would be a much less unhappy place today.
The international public health community should not be a silent bystander, indifferent to the effects of genocidal terror and the use of money to fund and finance terror rather than joint projects to promote health. Tony Blair’s efforts to promote and fund sustained joint regional projects requiring cooperation between Arab states and Israel on just some of the big issues-water, carrying capacity, prevention of road and work injury and solar energy-are a good idea.
Finally, it is essential to ostracize and eliminate incitement and hate language. Endemic hate language is the most dangerous environmental exposure in the Middle East. Hate language is a recognized predictor and early warning sign of both genocide and genocidal terror because it is required to mobilize practitioners of genocide. In the Holocaust, Bosnia and Rwanda, its use mobilized the foot soldiers of genocide. Children exposed to hate language become programmed to carry out its messages, explicit and otherwise, when they grow up, and this vertical transmission thereby ensures the perpetuation of violence through the generations. Those who use hate language to incite to genocide or to genocidal terror by poisoning children’s minds are not only engaging in child abuse, but committing crimes against humanity, as specified in the Rome Statute of the International Criminal Code. There is an urgent need for developing a regional transnational surveillance program for tracking hate language, modeled after surveillance networks for the spread of diseases such as bird flu influenza. Such programs should trigger interventions including bans and sanctions.
Medicine and public health are sanctuaries which cannot easily be insulated from the political debates and conflicts of our time. But certain principles override these debates and conflicts. The right to life trumps all other human rights, and the world medical community should assign the highest priority to new frameworks which bring together those on different sides of a political conflict to work on projects which are of mutual benefit to all.
Right after the Oslo accords, my son’s closest friend and one other young man was stoned to death while hiking in the Judean desert. Yet, I remained optimistic, and persisted in promoting projects for regional cooperation, hoping against hope that the forces of life and light would prevail over those of death and darkness. Since then, thousands more have died. Horton’s essay leads me to believe they may have died in vain. To undo the damage from his essay, I invite Richard Horton to join a world campaign to promote respect for life and to repudiate the culture of death–totally.
Professor Elihu D. Richter MD MPH
Hebrew University-Hadassah School of Public Health and Community Medicine
Genocide Prevention Program
I am indebted to Dr Emily Tall for her generous and painstaking editorial assistance, although the responsibility for all the veracity and opinions in this essay is mine.
Elihu D. Richter has published some 100 papers in the peer- reviewed literature and many others in environmental and occupational medicine, public health and injury prevention. Over the past 25 years, he has participated in or initiated investigations by human rights groups on the use of tear gas, the health conditions of Palestinian prisoner detainees, and initiated, supervised and participated in joint Israeli-Palestinian projects to investigate and prevent epidemics of lead poisoning, asthma in refugee camps, and oversaw a large project to assess lead exposure in children in Israel, Jordan and the Palestinian Authority. Most recently, he is involved in a joint project to investigate intrauterine exposures to phthalates and pesticides in Israeli and Palestinian infants. His current interest is in the epidemiology and prevention of genocide and genocidal terror, with emphasis on incitement.
*But my past involvement with PHR led me in another direction. In surfing for information on the herbicide, I found myself reading a press release of Monsanto citing the reports of Prof. Hans Olav Adami of the Swedish Karolinska Institute. Adami, it emerged, had become Monsanto’s consultant after the retirement of Sir Richard Doll, a man considered to be the greatest epidemiologist of our time. But a search of Doll’s records by investigators in Sweden indicated that he too had not disclosed the fact that he modified his scientific reports, apparently to suit industrial funders which he did not disclose. This information was disclosed in an article published in the American Journal of Medicine, and there are questions as to whether Adami may have been continuing to serve “greenwash” on behalf of Monsanto. Lancet and the British Medical Journal published many of Doll’s papers on various carcinogenic risks, all of which were considered as definitive in their time but are now being reexamined in the light of what today would be considered a failure to declare an undisclosed conflict of interest. See Hardell L, Walker MJ, Walhjalt B, Friedman LS, Richter ED. “Secret ties to industry and conflicting interests in cancer research.” Am J Ind Med. 2007 Mar;50(3):227-33.
**Just prior to approving the proofs of a joint Palestinian-Israeli-Jordanian paper with some 12 or so coauthors, I wrote Professor Steven Rose, who originated the idea of the academic boycott of Israeli academics, for instructions as to what advice I should give the Palestinian coauthors as to how they could comply with the boycott. To my astonishment, he wrote back, referring me to a website giving detailed instructions. This humorless individual did not realize I was mocking him and his boycott.
 “The Limitations on Choice: Palestinian Women’s Childbirth Location, Dissatisfaction with the Place of Birth and Determinants,” European Journal of Public Health, Vol. 17, No. 1 (February 2007).
 Rytter, Kjaeldgaard, Bronnum and Helweg-Larsen’s “Effects of armed conflict on access to emergency health care in Palestinian West Bank: systematic collection of data in emergency departments,” BMJ online, April 3, 2006.
 Richter ED, Blum R, Rivkind A, “Access to emergency care in Palestinian West Bank: interpretation of results is flawed.” BMJ. 2006 May 27;332(7552):1276
 Ministry of Foreign Affairs. “Victims of Palestinian Violence and Terrorism since September 2000.” Accessed April 6, 2006 http://www.mfa.gov.il/MFA-Terrorism
. Israel Ministry of Foreign Affairs. www.mfa.gov.il/…/Palestinian+terror+since+2000/ see also Amos Harel, Haaretz, “Shin Bet data shows dramatic drop in 2007 terror fatalities”, http://www.haaretz.com/hasen/spages/940526.html 1.01.08
 Richter ED: ” The Barrier: Protection of the right to life from incitement and terror in the Israeli-Palestinian Conflict: An Epidemiologic Working Paper” 30 pp (unpublished available on request) Feb 28 2004. Submitted to International Court of Justice in The Hague.
 Richter “ED The Barrier: Protection of the right to life from incitement and terror in the Israeli-Palestinian Conflict: An Epidemiologic Working Paper”30 pp (unpublished available on request) Feb 28 2004 Submitted to International Court of Justice in The Hague.
 Suicide bombing is a short cut to glory for kids…According to the Bethlehem-based Palestinian Center for Research and Dialogue, 76.5% of Palestinians support suicide bombing. …Itamar Marcus (director of Palestine Media Watch) argues that the PA has been consciously feeding this cult of martyrdom. …[He] has over 7,000 video cassettes or broadcasts- news programs, politically charged music videos and pastiches of random violence-recorded from the Palestinian Authority since 1997. (NB-or 700 per year or almost 2 per day) …Some call for outright martyrdom. One music video broadcast some 500 times in 2001 shows a child surrounded by playmates presenting his father with a note telling him that he will become a shahid. In 2002, Palestinian TV ran a video clip starring Mohamed al Dura, ….In the video, a child actor playing Dura runs in what is meant to be Paradise, and beckons little children to join him. There is a lit-up ferris wheel in the distance-shades of Disneyland. (10) Jack Kelley June 26, 2001, USA Today. Devotion, desire drive youths to martyrdom (I am indebted to Israel Charny for bringing this citation to my attention in his book, Fighting Suicide Bombing).
 Izenberg Dan, Jerusalem Rabbis indicted for racist incitement. Jerusalem Post, Jan 13 2008, p. 5. The report quotes Rabbi Yitzhak Batzri as saying the “The Arabs are donkeys and beasts. They are inferior. What do they want? ….They are imbued with the filth of the snake. …they are impure.