EDITORIAL Reassembling the Pieces: Settler Colonialism and the Reconception of Palestinian Health

Volume 24/2, December 2022, pp. 229-235 |  PDF

Yara Asi,* Weeam Hammoudeh,* David Mills,* Osama Tanous,* and Bram Wispelwey*

In health as in many disciplines, too often the perspectives and framings of the very populations in question are obscured in favor of staid and acceptable discourses born out of the Global North and its attendant neocolonial and settler-colonial logics. Indigenous scholars and practitioners across the globe have long been disregarded when assessing, examining, and tending to their own health and well-being.1 The health issues of Indigenous and otherwise marginalized and racialized populations are thus frequently analyzed without sufficient historical or political context, rendering them as mere victims of humanitarian misfortune rather than as groups that are deliberately harmed and discounted in service of broader political, and often territorial, aims. So while the fragmentation of the Palestinian people and land is now increasingly understood to be the legacy of more than a century of Zionist settler colonialism, the hegemonic discourses on Palestinian health often perpetuate their dismemberment in eliding this history and their ongoing dispossession.2

Amid recurring Israeli bombardments on the Gaza Strip, for example, or the violence directed at its protesting inhabitants during the 2018–2019 Great March of Return, the ensuing high rates of morbidity and mortality are often described as the inevitable if unfortunate downstream effects of war and framed under the auspices of “conflict health.” Palestinian refugees fall generically under “refugee health,” where the focus on “closing the gaps” in outcomes ignores the fundamental dispossession that has generated these gaps in the first place. For Palestinian citizens of Israel, who fare worse in almost all key health indicators compared to their Jewish Israeli counterparts, “minority health” and the associated behavioral, cultural, and social determinants are commonly used to explicate outcome gaps and provide avenues for policy and programmatic intervention.3 And while the framing of “health under occupation” for Palestinians in the West Bank, East Jerusalem, and the Gaza Strip engages with the political, it often stops short of the critical historical connection necessary for policy makers and human rights practitioners to target the settler colonialism that lies “beyond [the] ‘causes of causes’” of Palestinian ill health.4 Getting to the root that connects these otherwise seemingly disparate health determinants allows the emergence of an appropriate diagnosis of accountability and responsibility for the Palestinian right to health. It also exposes Israel’s security discourse, often defensively marched out in the health literature, for what it is: an invariable trope of all settler colonies in seeking legitimacy for their ongoing policies of expansion and native dispossession.5

The overarching umbrella of a humanitarian framework serves to further divorce the question of Palestinian health from the historical and political, providing ample distance from controversy for donors and organizations to safely engage in emergency health interventions, even when these emergencies continue for more than seven decades.6 Meanwhile, the global health community has failed to appropriately describe and challenge the Israeli policies that propagate this humanitarianism into perpetuity.7 As a form of epistemic violence that obfuscates the fundamental historical and political upstream drivers of their health, discursive complicity in the fragmentation of the Palestinian people is more than just an error. And despite ongoing and concerted efforts to contextualize and de-exceptionalize Palestinian health, gatekeeper censorship and intimidation surface regularly to distort narratives and protect the Israeli policies and practices that amount to the crime of apartheid.8

This special edition is imaginable, in part, as a result of the recent transnational surge of interest in the multi- and interdisciplinary field of settler-colonial studies, allowing examination of this social formation and its ongoing impacts within disciplines where it was previously undetectable—as is now occurring, thanks largely to Indigenous scholars, in public health and medicine.9 The legacy of theorizing and describing settler colonialism as a specific mode of domination has deep Palestinian roots. While settler colonialism’s tenets have long been theorized and discussed among Indigenous communities resisting its eliminatory violence, it was Palestinian American civil servant and scholar Fayez Sayegh who first penned the concept in 1965 in Zionist Colonialism in Palestine.10 Despite this history, in their 2012 introduction to one of the first special issues of Settler Colonial Studies, Omar Jabary Salamanca and colleagues note that settler-colonial analysis has “largely fallen into disuse in Palestine studies,” a comment that seems remarkable scarcely a decade later.11 In the intervening years, as Areej Sabbagh-Khoury details, Palestinian academics have been largely responsible for its rapid reascent in the literature, reaching even activist circles and popular debate.12 Building on this momentum, Palestinian American public health scholar Danya Qato set the stage for health outcomes investigation by confirming that “scholarship on public health in Palestine and for the Palestinian people has not adequately addressed the intimate connections between settler colonialism and health.”13 While there is much work to do, this special section exists as a further attempt at rectifying this absence in the literature.

Scholars like Rita Giacaman, however, have played a critical role in shifting the conversation and centering the political and structural determinants of Palestinian health. This special section is possible due to the brave and often undocumented and uncelebrated struggles of those, like Giacaman, who have long fought academic silencing. In refusing to reduce Palestinian health to a charity case in front of the donor community or in rejecting the pressure to engage in health collaborations with the political or medical systems of their colonizer, these scholars have built an intellectual and ethical foundation, even if often unpublished, on which this issue is built. It is vital to acknowledge the community of scholars who have made this work possible: Palestinians like Giacaman, Abdelhamid Afana, Yasser Abu Jamai, Ghassan Abu-Sittah, Mona El-Farra, Hatim Kanaaneh, Samir Quota, Eyad Sarraj, and Nadera Shalhoub-Kevorkian, along with allies like Brian Barber, Mads Gilbert, Ruchama Marton, Raija-Leena Punamaki, Cindy Sousa, Derek Summerfield, and Guido Veronese, have long focused on incorporating social and political factors when investigating Palestinian health. And extensive efforts by Palestinian, Israeli, and international human rights organizations have demonstrated the power of a human right-based approach in linking the political sphere to Palestinian health access and outcomes. Whether analyzing military checkpoints, the permit regime for health access in the occupied territory, late-night home invasions, torture, home and village demolitions, or the detaining of children without charge, the human rights-based approach has been essential to both documenting rights violations and forming the bedrock of international advocacy. To date, however, this approach has remained largely separate from, if not inimical to, a settler-colonial framing.

This special section was born out of the conceptualization and launching of the Palestine Program for Health and Human Rights (PPHHR), a partnership between the Institute of Community and Public Health at Birzeit University and the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University. The PPHHR seeks to broaden understandings of Palestinian health through transformative framing in knowledge production, education, and community engagement, as highlighted in this issue. The PPHHR is a multidisciplinary space that engages the fields of health, history, law, the social sciences, and politics, most recently highlighted by a Radcliffe Institute workshop, “The Past, Present, and Future of Palestinian Health,” that produced a joint statement advising appropriate framing and approaches to the practice, scholarship, and advocacy for Palestinian health (see Annex for the full statement).14 As the leadership collective of the PPHHR, we envision this special section not only as a means of knowledge production through novel scholarly output but as a guiding narrative for the program’s ongoing commitment to transformative change in Palestinian, Indigenous, and racialized population health around the world.

We are thus inspired by the new scholarship in this special section, which explicitly challenges traditional, colonization-friendly framings through the lenses of settler colonialism, structural racism, resistance, and human rights. We highlight a multidisciplinary cohort of authors whose pieces, while topically and methodologically wide ranging, converge on a singular question: How does settler colonialism and its enduring structures impact health across Palestine? Bringing our attention immediately to this question in their opening paper, Benjamin Bouquet, Rania Muhareb, and Rhona Smith examine the construction of race as a social determinant of health inequities in Palestine. They point to the importance of legal freedoms and entitlements as critical pathways for understanding these health inequities, while elucidating how they are shaped by the deployment of racialized legal categorizations. They offer critical and thorough engagement with important theoretical frameworks and key features of settler colonialism to propose an iterative model that outlines the symbolic and systemic constitution of racialized health inequities in Palestine. The inclusion of freedoms and entitlements to this framework is a key contribution that refocuses our attention not only to the material conditions resulting from the structural determinants of health but to the denial and deprivation of human rights as core intermediary drivers.

Raymond Rosenbloom and Rebecca Leff conduct a scoping review of emergency care in the occupied Palestinian territory (oPt) and apply a human rights-based analysis to demonstrate how administration of the occupation has contributed to disparities in access to emergency medical care. While more traditional approaches to public health might consider these to be natural outcomes of a weak Palestinian health system relative to a well-resourced and more proficient Israeli system, the authors astutely show that the broader context of structural racism is critical for appropriately understanding these deficiencies and disparities.

In their study of Israeli officials’ statements regarding Israel’s COVID-19 vaccination campaign, Emily Schneider and Nicolas Howard explore how Israel evades the responsibility of ensuring vaccine access in the oPt while presenting itself as committed to public health and human rights. The authors identify that Israel’s refusal to vaccinate Palestinians on the basis of the purported independence of the Palestinian Authority obfuscates Israel’s control over the Palestinian economy and its responsibilities as an occupying power.

Similarly, Ghada Majadli and Hadas Ziv draw on their collective decades-long experience working within the Israeli human rights organization Physicians for Human Rights Israel to provide an illustrative example of Israel’s role in both causing and then evading responsibility for the damaged health of Palestinians. In utilizing case studies from the Great March of Return protests, and through themes of systems of subjugation, intentionality, and the politicized Palestinian body, the authors highlight the contradictions and tensions faced by human rights and humanitarian organizations attempting to simultaneously seek justice and provide urgent medical care for Palestinians. This paper, like the others in this issue, reinforces the importance of calling for accountability and revealing the settler-colonial structures that impede the realization of the right to health for Palestinians.

The final two papers in this issue shift the focus to mental health, broadly defined. While studies focused on Palestinian agency and resistance are rare, Nadera Shalhoub-Kevorkian and Razzan Quran highlight these crucial concepts as well as the importance of healing through collective action. The authors connect the right to health and children’s play by drawing on observations of Ghummeida—hide and seek—and explore the reclamation of space as an act of healing and resistance. Maria Helbich and Samah Jabr trace the process of mental health’s depoliticization in the oPt and, in particular, critically examine the field’s standard practice of neutrality. They argue instead for an ethic of “non-neutrality” that can be strengthened and mobilized through the adoption of a liberation psychology framework. In contextualizing psychosocial health within the broader context of settler colonialism, these papers position psychosocial well-being as inherently rooted in social justice and collective resistance. They function as reminders that trauma discourse must be included within a wider human rights framework, and the right to health cannot be realized as long as other fundamental rights are denied.

Taken as a whole, the papers in this special section offer a transformative framing of Palestinian health that goes beyond biomedical and decontextualized approaches. While the contributions represent an important continuation and solidification of the discourse on settler colonialism’s role in determining health in Palestine, several key areas of Palestinian health are absent. The health contexts of Palestinian refugees and Palestinian citizens of Israel remain to be more fully engaged in future works. Additional areas to explore include settler colonialism’s distorting impacts on Palestinians’ natural and built environment, nutrition, modes of labor, access to care, class formations, and other social determinants. The health of sizeable and exploited sectors of Palestinian society, such as prisoners and construction workers, remains largely unstudied, and primary data collection aimed at describing and analyzing what Bouquet, Muhareb, and Smith describe as settler colonialism’s “strategies of elimination” is greatly needed.

In Palestine, as in other settings, settler colonialism is not a finished business. Palestinians continue to struggle, resist erasure, and fight for a better life and better health. Even under the harshest conditions, Palestinians have organized to create voluntary medical committees and other community-based health initiatives aimed at resisting, if not yet transforming, the structural and political drivers of health.15 In Palestine, as elsewhere, no straightforward blueprint exists for health equity. Yet as many Palestinian, Israeli, and international human rights organizations have suggested in their descriptions of the apartheid reality, health equity is possible only with the abolition of all oppressive structures that ensure Jewish supremacy and Palestinian inferiority from the Jordan River to the Mediterranean Sea. In our wish to see knowledge production be transformative rather than merely descriptive, this special section seeks, in its small way, to reassemble what settler colonialism would tear apart: Palestinian collective and individual wholeness, health, and thriving on our/their lands.

Acknowledgments

We are deeply grateful for the wisdom of the Advisory Council of the Palestine Program for Health and Human Rights, and for the extraordinary work of the staff and leadership of our partnering institutions at the Institute of Community and Public Health at Birzeit University and the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University.

*All authors contributed equally to this work.

Yara M. Asi, PhD, is an assistant professor at the School of Global Health Management and Informatics, University of Central Florida, Orlando, United States.

Weeam Hammoudeh, PhD, MPH, is an assistant professor at the Institute for Community and Public Health, Birzeit University, Palestine. 

David Mills, MD, is an instructor in pediatrics at Harvard Medical School and faculty affiliate at the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University, Boston, United States. 

Osama Tanous, MD, is a pediatrician and public health scholar, a board member of Physicians for Human Rights Israel and B’Tselem, and a policy analyst for Al Shabaka, Palestine. 

Bram Wispelwey, MD, MS, MPH, is an instructor at Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, United States, and co-founder of Health for Palestine, Palestine. 

The guest editors are the Leadership Collective of the Palestine Program for Health and Human Rights, Birzeit, Palestine, and Boston, United States.

References

  1. L. Simpson, “Anticolonial Strategies for the Recovery and Maintenance of Indigenous Knowledge,” American Indian Quarterly 28/3/4 (2004).
  2. R. Khalidi, The Hundred Years’ War on Palestine: A History of Settler Colonialism and resistance, 1917–2017 (New York: Metropolitan Books, 2020).
  3. D. Chernichovsky, B. Bisharat, L. Bowers, et al., The Health of the Arab Israeli Population: State of the Nation Report 2017 (Jerusalem: Taub Center, 2017); K. Muhsen, M. S. Green, V. Soskolne, et al., “Inequalities in Non-communicable Diseases between the Major Population Groups in Israel: Achievements and Challenges,” Lancet 389/10088 (2017).
  4. H. Yacobi and E. L. Milner, “Beyond ‘Causes of Causes’: Health, Stigma and the Settler Colonial Urban Territory in the Negev/Naqab,” Urban Studies 59/3 (2022).
  5. O. Manor, K. Skorecki, and A. M. Clarfield, “Palestinian and Israeli Health Professionals, Let Us Work Together!,” Lancet Global Health 8/9 (2020); Z. Hagay, “Israeli Aid to the West Bank and the Gaza Strip during the COVID-19 Pandemic,” Lancet 396/10255 (2020).
  6. O. Tanous, “The Dilemmas of Practicing Humanitarian Medicine in Gaza,” Middle East Research and Information Project (2020), https://merip.org/2020/12/the-dilemmas-of-practicing-humanitarian-medicine-in-gaza/.
  7. Y. Asi, “Aid to Palestinians Has Failed. Here’s How to Fix It,” New Humanitarian (May 3, 2022), https://www.thenewhumanitarian.org/opinion/2022/05/03/aid-to-palestinians-has-failed-heres-how-to-fix-it.
  8. W. Hammoudeh, H. Kienzler, K. Meagher, et al., “Social and Political Determinants of Health in the Occupied Palestine Territory (oPt) during the COVID-19 Pandemic: Who Is Responsible?,” BMJ Global Health 5/9 (2020); B. Wispelwey, R. Muhareb, and M. Gilbert, “Permission to Narrate a Pandemic in Palestine,” Middle East Policy 27/2 (2020); S. Asaad and R. Muhareb, “Dismantle What? Amnesty’s Conflicted Messaging on Israeli Apartheid,” Institute for Palestine Studies (2022), https://www.palestine-studies.org/en/node/1652565; Amnesty International, Israel’s Apartheid against Palestinians: Cruel System of Domination and Crime Against Humanity (London: Amnesty International, 2022).
  9. L. Veracini, The Settler Colonial Present (London: Palgrave Macmillan, 2015); L. Ray, L. Wylie, and A. M. Corrado, “Shapeshifters, Systems Thinking and Settler Colonial Logic: Expanding the Framework of Analysis of Indigenous Health Equity,” Social Science and Medicine 300 (2022); K. Burnett, C. Sanders, D. Halperin, et al., “Indigenous Peoples, Settler Colonialism, and Access to Health Care in Rural and Northern Ontario,” Health and Place 66 (2020); M. A. Emerson and T. Montoya, “Confronting Legacies of Structural Racism and Settler Colonialism to Understand COVID-19 Impacts on the Navajo Nation,” American Journal of Public Health 111/8 (2021); O. Tanous, B. Wispelwey, and R. Muhareb, “Beyond Statelessness: ‘Unchilding’ and the Health of Palestinian Children in Jerusalem,” Statelessness and Citizenship Review 4/1 (2022).
  10. F. Sayegh, Zionist Colonialism in Palestine (Beirut: Palestine Liberation Organization, 1965); J. K. Kauanui, “‘A Structure, Not an Event’: Settler Colonialism and Enduring Indigeneity,” Lateral 5/1 (2016).
  11. O. J. Salamanca, M. Qato, K. Rabie, and S. Samour, “Past Is Present: Settler Colonialism in Palestine,” Settler Colonial Studies 2/1 (2012).
  12. A. Sabbagh-Khoury, “Tracing Settler Colonialism: A Genealogy of a Paradigm in the Sociology of Knowledge Production in Israel,” Politics and Society 50/1 (2022).
  13. D. M. Qato, “Introduction: Public Health and the Promise of Palestine,” Journal of Palestine Studies 49/4 (2020).
  14. Harvard Radcliffe Workshop Participants, “Statement: Harvard Radcliffe Workshop on the Past, Present, and Future of Palestinian Health,” Jadaliyya (2022), https://www.jadaliyya.com/Details/44526/Harvard-Radcliffe-Institute-Statement-on-the-Past,-Present,-and-Future-of-Palestinian-Health.
  15. A. Rimawi, A. Shah, H. Louis, et al., “Community Health Worker Program Outcomes for Diabetes and Hypertension Control in West Bank Refugee Camps: A Retrospective Matched Cohort Study,” Global Health: Science and Practice 10/5 (2022); B. Wispelwey, and A. Al-Orzza, “Underlying Conditions,” London Review of Books (2020), https://www.lrb.co.uk/blog/2020/april/underlying-conditions.

Annex

12 October 2022

Radcliffe Workshop

Past, Present, and Future of Palestinian Health

The following is a statement put forth by the 2022 Radcliffe Workshop on the Past, Present, and Future of Palestinian Health.

In 2021, international human rights groups began to rhetorically recognize what Palestinians on the ground had been reporting for years; that they were living under a system of segregation, discrimination, and violence that constitutes the crime of apartheid. These systems manifest across all aspects of Palestinian life, including movement, education, economics, and health. However, these sectors are too often treated as humanitarian issues to be managed, rather than as the rights denied by settler colonial practices. Instead, humanitarianism in Palestine, in its formation and consolidation, has helped place the responsibility to the health of Palestinians on the fleeting good intentions of the donor community, leaving significant gaps in care while moving away from genuine justice and liberation.

We offer a statement highlighting the key points that should be considered in the practice, scholarship, and advocacy of Palestinian physical and mental health.

  1. Health is political; this is true across all contexts but should be a guiding principle of any scholarship or interventions regarding Palestinian health. Poor health outcomes for Palestinians should not be discussed only in terms of economic or biomedical inputs and outcomes, but with recognition of the social and political forces that control their lives.
  2. Settler colonialism must be identified as a fundamental determinant of health for Palestinians, influencing all aspects of not just the health system, but other social determinants of health including access to food, water, and housing. Thus, Palestine does not just need to strengthen its health system; it requires an anti-colonial approach to dismantle the systems that discriminate against and harm Palestinians, and rebuild systems centered around equity and justice.
  3. Palestinians are not a monolithic group. Their diversity must be appreciated as significant determinants of their health status and the forms of health care they can access. Class, geography, citizenship, gender, and other intersecting characteristics and sub-identities should be acknowledged in health-related scholarship and interventions.
  4. Humanitarian actors have a special responsibility to situate their work in the socio-political context of the populations they have a mandate to serve. The discourse around Palestine as a ‘humanitarian situation’ has been employed in an effort to stifle the political aspirations of Palestinians and as a tool to alleviate Israel from its responsibilities as an Occupying Power. Simply providing relief and response to crises is insufficient, and in fact may continue to enable and entrench the oppressive systems in place.
  5. Health has historically been a significant piece of Palestinian transnational struggle for liberation and a mobilizing force, and should be recognized as such. De-politicizing health has resulted in health being entirely disconnected from the broader Palestinian project, and this has closed multiple avenues of coalition-building, localization, and restoring and reassembling a fragmented society.
  6. Palestinian successes in health, against all odds, must be recognized, amplified, and supported. While measuring deficits and reporting human rights violations are necessary practices, too often they obscure the hard work being done on the ground. Assessing what is working provides evidence for future approaches to build upon, in Palestine and for other contexts experiencing colonial violence and oppression.
  7. Stakeholders interested in Palestinian health should be focused on building solidarity networks to protect against silencing, censorship, and other efforts that restrict meaningful scholarship and practice in health. Each generation should work towards expanding what is possible for the future.
  8. Palestine can and should be a model for a health care system genuinely focused on around community- and patient-centered health. From reform in medical education, to greater emphasis on prevention efforts, to localization efforts that empower Palestinians across geographies to access the care they need, a panoply of efforts is required, many of which are possible under current conditions and should be prioritized.
  9. While unique in many ways, it is vital to de-exceptionalize Palestinian health challenges and situate them more broadly within other systems of domination and oppression, across history and geography. This is vital both for modern advocacy efforts, but also to instill in future generations of Palestinians the idea that they are a significant part of a long-term global struggle.
  10. Practitioners, scholars, and advocates involved with Palestinian health efforts must encourage interdisciplinary and social medicine-based engagement—merging the social sciences with medicine and public health to recognize the multifaceted connections between Palestinian life, health, and death. Social medicine should be widely emphasized across health communities working in Palestine, and relevant evidence should be shared and acted upon within the Palestinian context.