Yara M. Asi examines why many health indicators of Palestinians lag behind the health rates of neighboring Arab states and those of Israeli citizens, finding that Palestinians are forced to depend on external health services and must seek care outside of the occupied Palestinian territories.

Since the beginning of the Israeli occupation in 1967, and especially since the Oslo Accords in the mid-1990s, there has been a growing research base meticulously documenting and describing the state of Palestinian health. Primarily led by Palestinian researchers, much of this research did not shy away from the political and social realities—occupation, blockade, apartheid, settler colonialism—that lead to poor health outcomes in Palestinians. While a massive influx of humanitarian and development aid in the post-Oslo period has led to significant increases in many quantitative measures of health, like vaccination rates and life expectancy, many health indicators of Palestinians in the occupied Palestinians territories (oPt; the West Bank and Gaza Strip) not only lag behind the health rates of neighboring Arab states, but are significantly worse than those of Israeli citizens. This is notable as Israel, which remains the Occupying Power despite the passage of the supposedly interim Oslo Accords, retains certain responsibilities towards Palestinian health.

Health systems and health outcomes suffer in conditions of armed conflict—this is not surprising, and has been reported in hundreds of studies, especially as violence has been increasingly, and rightfully, considered a determinant of health. All settings of conflict report dips in life expectancy, increases in maternal and infant mortality, under-resourced health facilities, and threats to health care personnel and facilities. Studies have captured the health impacts of war in historical and contemporary contexts around the world, from Vietnam to Iraq, Rwanda to Yemen, Guatemala to Syria. Palestine, in this sense, is no different.

As I argue in the October 2022 issue of Middle East Law and Governance (Volume 14, Issue 3), “Palestinian Dependence on External Health Services: De-development as a Tool of Dispossession,” featured in the special section Recentering Palestinian Society in the Study of Politics, edited by Wendy Pearlman, there is a distinct difference between the typical destruction of health systems in armed conflict and the destruction, de-development, and harsh restrictions applied to the Palestinian health system. As stated in the piece, the structural and direct violence imposed on Palestinian health “should be recognized not just as outcomes of conflict, but as purposeful tools of ongoing dispossession in what multiple human rights organizations, including Human Rights Watch, Amnesty International, and B’Tselem, have likened to an apartheid regime.” A regime that exists, as most recently argued by Palestinian human rights organization Al Haq, in service of ongoing settler colonialism. 

The de-development of the health system (adopting the conceptualization of Sara Roy) in the occupied territories is part of a broader effort of dispossession, disconnecting Palestinians from their land and from each other. Thus, my focus in the article is on how Palestinians are forced to depend on external health services, including those in Israel, due to the human-made deficiencies in their own health system. I begin with a brief description of the Palestinian context, including the geographic and political fragmentation, the manifestations of Israeli settler colonial aims (including consistent settlement expansion, seizure of Palestinian lands, and demolition of Palestinian homes), and the lack of investment in social services by the Palestinian Authority.

I then discuss how Palestinians—fragmented by class, geography, citizenship, and other characteristics—access health care within the occupied territories. The Palestinian healthcare system is composed of multiple stakeholders, including the Ministry of Health and other public entities, but with significant representation from private facilities and non-governmental organizations, some Palestinian and some international. However, these services can rarely fully meet the needs of Palestinians. This is in part due to the import restrictions Israel places on Palestinians as part of their “dual use” policy, which limits goods and resources like scanners, cement, steel, and certain chemicals. Although Palestinians have attempted to repurpose equipment and materials available in the territories, they are unable to meet the needs of many, especially those in need of advanced care.

As a result of these deficiencies, many Palestinians must seek care outside of the oPt. I identify three mechanisms in which this occurs: 1) a medical permit to a heath facility in East Jerusalem or Israel, which requires approval from the Israeli entity that manages the oPt and are often delayed to the point of missing appointments or denied entirely; 2) personal travel, akin to medical tourism in most settings, where individuals use personal funds to travel to another country to receive care, usually Jordan, Egypt, or Lebanon; and 3) NGO-funded travel, where an NGO will fund a trip for a Palestinian to travel to another country to receive a needed procedure or prosthetic.

Why is the Palestinian health system so inadequate? I identify several drivers, including movement restrictions, population fragmentation, donor and air ineffectiveness, and insufficient preventive care and health promotion. The consequences of this de-development are significant, leading to further fragmentation among the Palestinian population and dispossession from their land, as well as feelings of betrayal and dissatisfaction of the governance structures that are meant to advocate for them.

With the incoming Israeli government predicted to be among the most nationalist and overtly anti-Palestinian the country has had, there is little to be optimistic about in terms of meaningful change and any sense of justice for Palestinians. However, I end the piece with recommendations that can be initiated even under current, and dire, circumstances. First, the many international actors that either directly or indirectly work in Palestine need to be accountable to the ways they may be perpetuating the current state of injustice and violence, and use their platforms to work towards change for Palestinians that would acknowledge the current reality and not an outdated vision of Middle East “peace.” 

Importantly, Palestinians must take control of the levers they have available to them. This may include changing the medical curriculum and bolstering the healthcare workforce, prioritizing the promotion of preventive care that would limit the need for advanced health services, and investing in real public health to meet the needs of Palestinians that cannot wait for a nebulous political solution to seek life-saving and quality-of-life-improving care. These efforts should be undertaken not just to improve Palestinian health, but as part of a broader national movement towards liberation.

*

Yara M. Asi, PhD, is an Assistant Professor at the University of Central Florida in the School of Global Health Management and Informatics and a Visiting Scholar at the FXB Center for Health and Human Rights at Harvard University. She is also a 2020-2021 Fulbright US Scholar and a Non-resident Fellow at the Arab Center Washington DC. Her work focuses on health, development, and human rights in fragile and conflict-affected settings. 

Find Yara on Twitter: @Yara_M_Asi