‘Health Is Political, the Medical Community Can’t Afford to Ignore Politics of Israel-Gaza Conflict'

New Delhi: James Smith, a lecturer at the University College of London, was one of the authors of an editorial in the journal BMJ Global Health on the ongoing Israel-Gaza conflict. It took a very strong political opinion, and also gave a historical analysis on the conflict, holding Israeli strikes responsible for the humanitarian crisis.

It attracted sharp criticism from a section of healthcare workers across the world. Even the editor-in-chief of the journal was asked to either introduce amendments to the piece or withdraw it. In an interview with The Wire on November 5, Smith said he stands by his piece.

In this conversation, he also discusses why the healthcare community cannot afford to overlook the politics of the conflict if a comprehensive discussion is to be had, and if we are to understand the root causes of illnesses inflicted during this conflict.

He also gave details on the long-term impacts of the use of white phosphorus against civilians, saying that its use is rare by any military. He also spoke about the reasons for targeting limbs, especially those of the injured, the immediate and long-term impacts on hospitals, the mental trauma of healthcare workers who are working non-stop, and the lack of response from the medical community against the conflict, among other things.

The full text of the interview is reproduced below.

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Banjot Kaur: You take a very strong stand and say that the recent attacks on healthcare facilities in Gaza are the most “egregious” in our “collective history”. In an entire paragraph, you have referred to how the “de-development” of Palestinian healthcare facilities by the “Israeli occupation” preceded these attacks. Why do you call these the most egregious and horrific of all the attacks?

James Smith: Thank you Banjot, and thank you for the opportunity to speak to you about an issue that as we all know is timely and also horrific in its scale and severity of violence. I think we all need to be talking about what’s happening in the conflict between Israel and the military wing of Hamas in Gaza at the present time.

The reason we described what’s happening at the moment as the most egregious in a long history is for precisely the scale of violence [which] far surpasses anything that we’ve seen in recent decades, in terms of Israeli violence directed towards the Palestinian people.

The latest statistics from the UN Office for the High Commissioner of Humanitarian Affairs tell us that as of yesterday evening [November 5], almost 10,000 people have been killed in Gaza since October 7. The number currently stands at 9,488, with hundreds, if not thousands of people, still trapped under the rubble.

But what we really wanted to articulate in this paper [editorial] is that this violence hasn’t appeared out of nowhere. This is the latest iteration in a long history of violence and it’s really important for us as healthcare workers and peace advocates, and, in fact, as humanitarian workers to understand the context in which violence is committed, who [is] committing [the] violence against whom, under what political economic and social circumstances and that’s what we’ve tried to articulate in part in this paper.

Why did you choose to provide a political context in your paper? Usually, healthcare workers don’t talk about politics. However, this conflict is all about politics. And you take the conflict back more than 70 years, when it had started. Why did you choose to provide a political context to an editorial which essentially appeared in a medical journal?

I think this is a common misconception with respect to healthcare workers and medical workers. Health as we know is political.

We increasingly talk about the political determinants of health, which is very much in keeping with a public health sort of philosophy when we think about understanding the root causes of ill health. We can’t do our best [not only] for our patients, but also for the communities if we don’t understand the underlying causes of illnesses. So, we have to understand the political dynamics. There are folks within the medical profession who would prefer not to talk about politics but that would really…I would strongly argue that it is a mistake.

So, I think again we’ve tried in some small way to speak, as you’ve mentioned, [about] almost a 100-year history. Now, of course, that’s difficult [to write the full history] in a 1500-word editorial. [So] we’ve alluded to some major incidents or moments in the history of Palestine prior to and following the formation of the state of Israel in 1948, but we can’t, of course, do justice to that full history. We’re trying to really encourage folks to think about these issues and to understand that drawn-out chronology.

In one paragraph, you mentioned that Gazan civilians’ limbs have been specifically targeted. How important is that?

We mentioned this because, again, it’s a really egregious example of violence committed by the Israeli military against Palestinian civilians.

This is a well-documented form of violence. In fact, Israeli soldiers have admitted to this as a military tactic. It was mentioned, as I say, because it’s a particularly horrific form of violence and what we see here is almost double in terms of sort of military strategy, if I could even afford [to use] such a phrase.

It is one [aspect] to inflict harm on the individual, but to burden the health system and to burden social services as they are to be provided for those individuals who are now left with various forms of physical disability [is worthy of attention/worry].

I was  curious about the fact that if limbs are targeted, is it more effective in terms of military strategy? So, why are limbs so particular in your observation?

I should say I’m not a military strategist nor would I want to be but what I would postulate as a healthcare professional is that you have a situation in which physical violence is being committed against an individual. So they are left with a life-altering injury. As a result, they [the injured], rather than being killed, need access to the healthcare system. In some instances, they will become dependent on different forms of social support, either family or other social networks, or the social service system.

So, in a sense, it becomes a secondary burden on a healthcare system that has already been sort of worn away by the Israeli blockades.

So in a way, if my conclusion is correct, this is to inflict a long-term horror instead of just killing the person in an instant. Is that the correct interpretation of mine?

That would be my interpretation as well. Absolutely. So, there’s immediate violence, immediate physical injury and then long-term demand on the health and social system.

There are reports and, again, there are unconfirmed reports, because it’s not perhaps possible to confirm them, of phosphorus being used. You have also referred to that in your editorial. Can you recollect in recent history if phosphorus was used in any such attack?

I’m not aware of the use of white phosphorus in other conflicts in recent history.

However, Human Rights Watch and Amnesty International, both of which are reputable international human rights organisations, have verified the use of white phosphorus by the Israeli military in both Gaza and in southern Lebanon over the course of the last couple of weeks. So, the use of white phosphorus has been verified.

We are also receiving reports from healthcare workers on the ground in Gaza, describing burn injuries consistent with those caused by white phosphorus.

I’m sure many readers and viewers will know [that] white phosphorus in contact with human skin can also damage the respiratory system. It can leave a person with particularly horrific injuries as the chemical itself continues to burn until it is physically removed from the skin. So, it’s a particularly horrific form of incendiary weaponry.

So, you mean to say till the time this chemical remains on the skin, it continues to burn?

It ignites. So you then need to remove it in its entirety from the skin. If it ignites, it will just continue to burn. So [it] can cause really horrific damage to the skin and to soft tissue.

In Gaza, of course, we know that the healthcare systems are particularly overwhelmed. However, if the situation was different, say, where healthcare systems were functioning normally, how difficult would it have been to treat people who have been inflicted with white phosphorus-related injuries?

I would say incredibly difficult. I must say I’m fortunate enough to have never had to treat an individual with a white phosphorus injury.  I’ve never worked in a context where it’s been used.

The World Health Organization provides a lot of factual information related to the white phosphorus chemical and, as I say, it’s this kind of incendiary function [of phosphorus].

So, once white phosphorus has ignited, it can be very very difficult to extinguish this sort of burning chemical. So, it can cause severe burns to the skin, even penetrating as deep as to the bone even after you’ve initially treated. It can reignite.

It can also cause damage to the eyes and to the respiratory tract. It  often requires debridement, that is, removal of damaged skin or soft tissue and in the case of extensive injuries, that can, of course, be a very involved surgical process.

So, does it require healthcare workers from across specialties to treat a person with a phosphorus-related injury?

Absolutely, absolutely!

You wrote that after the US attacked a hospital in Afghanistan in 2015, the UN passed a resolution saying that no healthcare facilities would be attacked in any conflict. How do you think that we reached the point where we sort of undid all our past resolutions and now we have hospitals being bombed and ambulances being hit?

I really appreciate this question because we really need to all be reflecting in a very concerted way on what this means about it with respect to our kind of collective humanity now.

I would say, before I speak to Palestine and Israel specifically, that we’ve seen there’s a trend in attacks against healthcare globally. We’ve seen attacks on healthcare in Ukraine, we’ve seen attacks on healthcare in Sudan. This is not an isolated phenomenon.

As you mentioned, the UN resolution of 2016 was a commitment at the level of the UN. It was a declaration, it was a commitment, but in many respects, as we know of many UN resolutions, it’s very difficult to uphold them.

Attacks against healthcare facilities, ambulances, and healthcare workers have continued in the years and of course, attacks against healthcare facilities were already illegal under the Geneva conventions [before the UN resolution came].

So, we have a long history here, of acts that have already been declared as a breach of international humanitarian law, and yet, such violence,  acts are committed nevertheless.

When an elected government, which is a party to the UN resolution, attacks the healthcare facilities, it creates a conflicting situation. In other conflicts, there are typically two groups, most probably militia groups, fighting against each other and attacking the healthcare facilities. Do you believe that such disparity exists in the current conflict, and therefore, it holds significance?

I think the scale of aggression is important here. I mean the one thing that I would say, as a healthcare worker, is that attacks against healthcare facilities and health workers are a horrific breach of international humanitarian law and they are not permitted under any circumstance in any conflict context.

Next, a discussion about who is the perpetrator, of course, is important when it comes to the pursuit of accountability and justice, people can’t be afforded impunity whoever the perpetrator may be. But for me what’s most important is that we must reiterate and we must ensure adequate protection for our healthcare worker colleagues wherever they’re practising in the world

Do you believe  there were attacks on healthcare facilities in the past and there was not enough reaction against those attacks, and therefore, this, sort of, empowered an elected government to go against these facilities with complete impunity?

Yes, I mean if we see in situations where there is a complete lack of accountability for such attacks, you can imagine then that parties to a conflict will act with impunity because they know that they can get away with these violations of international law. And again I don’t say this in specific reference to Israel and Palestine. This is a global problem and it should be a concern for us.

We can say a lot about governments and how they reacted to this conflict, but do you also believe that the reaction that should have come from the healthcare community, as a whole, against these horrific ongoing attacks, was also not enough? Why do you think that all doctors, nurses and all healthcare workers could not come out in one single voice saying that we need to stop these attacks?

I would say there have been some strong statements, there have been some health justice organisations that have issued statements calling for an end to the violence, calling for meaningful investment in pathways towards peace and equality.

So, there have been some calls but I would agree that they have not been coordinated or strong or particularly present globally. It’s hard to know why folks, for example, in the UK don’t see this as a shared struggle.

I would argue as a healthcare worker, as someone who has studied, taught and practised humanitarianism, that we should recognise what unites us all and when we see situations such as what we’re seeing now in Gaza, in the West Bank in Israel, we need to be unified in horror, but we also need to be unified in a commitment to doing something about this.

[We need] to speak up in pursuit of an end to the violence, and justice and peace, over the longer term, I do feel that. That is a strong responsibility of healthcare workers that is rooted in our professional commitments to care, not only to our patients but also to care for our community and in the very broadest sense, the global population.

Were you able to speak to any of your colleagues working in Gaza at this point in time? Could you describe the mental well-being of healthcare workers there?

Thank you for this question. I think it is really important that we amplify what we’re hearing from healthcare workers inside Gaza, inside Palestine.I get a few messages from the folks directly, but I also hear a lot through secondary networks.

To [answer] your question about the sort of psychological toll that this ongoing violence is having on healthcare workers, it’s almost unimaginable, even for those of us who’ve worked in conflict settings. It’s almost unimaginable to fathom what our colleagues in Gaza must be going through right now.

We see a progressive increase in the intensity of violence, in the intensity of bombardments. We have colleagues who’ve now been working almost non-stop since October 7, providing surgical and emergency care, and ensuring to the best extent that is possible. Their ability to maintain the continuity of existing services, of course, is important, in addition to providing trauma care and so on.

There are tens of thousands of expectant mothers in Gaza. There are individuals who have been receiving radiotherapy and chemotherapy for cancers. And there are ongoing specialist service provision for children. All of these services have been disrupted to a phenomenal extent.

We have colleagues who are trying to do the best of their ability to maintain some degree of service provision while also responding to the acute conflict-related needs and the psychological impact. They are working almost non-stop, with minimal sleep, not eating well, not sleeping well, if at all. [We are] seeing and experiencing the horrific consequences of violence that will leave a major psychological toll on our colleagues working in Gaza right now.

The governments have done what they could have done or not done, what they were capable of. But what do you expect from them now?

What we need most immediately, Banjot, is an end to the violence. So the call right now is for an immediate ceasefire. Let us make sure that this situation doesn’t get worse than it already is. Beyond that, we have to see a situation in which there is a serious meaningful investment in a peace process.

Also read: ‘De-escalation,’ ‘Ceasefire’ Among Phrases to Avoid in Press Materials, Show US State Dept Emails

There has been criticism, if I may say, of your editorial. I believe some letters were also written to the editor-in-chief of the journal. Would you want to respond to that?

Sure. Thank you for this question. I should begin by saying that while there has been criticism, we’ve received several compliments [as well], as open letters were submitted to the journal in support of not only us for writing this piece but also of the BMJ Global Health for publishing it.

As I’m sure many of your readers have seen, the ongoing conflict and the broader situation in Palestine and Israel is an incredibly polarising topic.

Some individuals [doctors] took issue with the way we had framed this matter. They felt that we were speaking too strongly about the violence committed against Palestinians.

Of course, the BMJ Global Health editorial doesn’t exist in a knowledge vacuum. We know that many major mainstream media outlets are reporting on the violence in Palestine and Israel right now, many have spoken about the horrific atrocities that were committed on October 7 against Israeli civilians.

While we do acknowledge the [violence against Israeli citizens] in the introduction to this editorial, some folks felt that we didn’t speak to that in the way that we should have done, and I say in response to that as I’ve said this editorial exists within that wide knowledge base.

We recognise that many outlets are speaking about these very important issues, particularly the events that took place on October 7 and, of course, the 700 Israeli hostages who are still being held captive inside Gaza.

Other folks, as you’ve alluded to in some of your earlier questions, aren’t happy with this sort of blurring between the medical and healthcare professions and political positioning. But, as I’ve said already, I think that we need to recognise that medicine is political, healthcare is political, and we shouldn’t shy away from navigating the complex and messy world of politics.