Israel–Gaza conflict Hospitals are sanctuaries for the sick, injured, and those in need of help. Between their walls are many dedicated professionals who devote their lives to treating illness and relieving the suffering and pain of society’s most vulnerable individuals. Since the start of Israel’s operation in Gaza 3 weeks ago, at least six hospitals and ten primary health-care clinics have been damaged.1,2 Most recently the Al Aqsa Hospital was hit; at least four people were killed and 16 injured, and the hospital’s operating theatre and intensive care unit were destroyed.2,3 More than 40 medical staff have been killed or severely injured.1 Ambulances have attempted to evacuate patients trapped in the rubble of their homes, but have been forced to turn back due to continued shelling.4 A rehabilitation centre for disabled individuals has been hit, killing at least four people and injuring many.5 Several schools from the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) have been hit by shelling, including an elementary school in Beit Hanoun on July 24.6 While the school was a designated safe haven, at least 15 were killed and many more sustained serious injuries. On July 30, another school used as a UN-designated shelter for families in Gaza was repeatedly shelled killing 15 civilians and injuring more than 100 people—most were women and children.7 Hospitals, schools, and UN sites are no longer safe havens in Gaza. These sanctuaries have been repeatedly targeted. Now there is no safe place in this 360 km² enclave holding a captive population of 1·8 million people. In the hospitals, medical staff work without the basic necessities we take for granted. Before this conflict started, supplies were already limited. The tight control of the borders is putting unimaginable pressure on the beleaguered population, as water, food, and medical supplies diminish. www.thelancet.com Vol 384 August 9, 2014
As a medical community, our first responsibility is to help to protect the vulnerable. If we are to remain true to our Hippocratic pledge to “consecrate our lives to the service of humanity”, then our responsibility is to the innocent civilians who are overwhelmingly the victims in this massacre. We condemn civilian deaths on both sides, which as of July 30, are estimated at 852 Palestinian and 2 Israeli civilian casualties.2 We also have a responsibility towards our colleagues in Gaza and their patients, by collectively condemning the targeting of hospitals and demanding the safety of both medical staff and patients. We are physicians and surgeons who have been involved in supporting medical professionals in the occupied Palestinian territories through medical education and service over the last decade. We fully support the recent open letter8 published in The Lancet and Médecins Sans Frontières’ appeal,9 deploring the indiscriminate killing of innocent civilians. We recognise a medical community and society that has been subject to a siege, collective punishment, and sanction. The lives of our colleagues are now threatened by direct attack. We appeal for our medical colleagues worldwide, including in Israel, to stand up and to join us in pressing for an immediate cessation of hostilities. We declare no competing interests.
Tanya Haj-Hassan, Tony McShane, *Imran Mahmud, Peter Watkinson, Chris Conlon, Terence Hope, David Lloyd, Nick Maynard, on behalf of 22 signatories [email protected] Oxford University, Oxford, UK (TH-H); Oxford Children’s Hospital, Oxford, UK (TMS); Harvard School of Public Health, Boston, MA02115, USA (IM); Oxford University Hospitals, Oxford, UK (PW, CC, NM); University Hospital, Nottingham, UK (TH); and Retired, Liverpool, UK (DL) 1
Ministry of Health. Emergency Operation Room Sitrep on Gaza (21st July, 2014). http:// www.lacs.ps/documentsShow.aspx?ATT_ ID=15635 (accessed July 30, 2014).
2
3
4
5
6
7
8
9
Office for the Coordination of Humanitarian Affairs (OCHA). Occupied Palestinian Territory: Gaza Emergency Situation Report, as of July 30. http://reliefweb.int/sites/reliefweb.int/ files/resources/ocha_opt_sitrep_31_07_2014. pdf (accessed July 30, 2014). BBC. Gaza conflict: Five dead at hospital hit by Israeli strike (July 22, 2014). http://www.bbc. co.uk/news/world-middle-east-28399292 (accessed July 30, 2014). Deger A. International activists risk lives to protect Gaza’s ambulances under fire (July 19, 2014). http://mondoweiss.net/2014/07/ international-activists-ambulances.html (accessed July 30, 2014). Al Jazeera. Israel bomb hits disabled centre in Gaza (July 13, 2014). http://www.aljazeera.com/ news/middleeast/2014/07/israel-bombs-hitcentre-disabled-gaza-201471274035753506. html (accessed July 30, 2014). UNRWA. Statement by the UNRWA Commissioner-General Pierre Krähenbühl. http://www.unrwa.org/newsroom/officialstatements/statement-unrwa-commissionergeneral-pierre-kr%C3%A4henb%C3%BChl (accessed July 25, 2014). Sherwood H, Balousha H. “World stands disgraced”–Israeli shelling of school kills at least 15. The Guardian; July 30, 2014. http:// www.theguardian.com/world/2014/jul/30/ world-disgrace-gaza-un-shelter-school-israel (accessed July 31, 2014). Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; published online July 22. http://dx.doi.org/10.1016/S01406736(14)61044-8. Médecins Sans Frontières. Gaza: Israel must stop bombing trapped civilians. http://www. doctorswithoutborders.org/article/gaza-israelmust-stop-bombing-trapped-civilians (accessed July 25, 2014).
Reality is far from black and white as was depicted in the recent hate-filled Correspondence by Paola Manduca and colleagues.1 The authors of this Correspondence hijacked The Lancet, spewing propaganda that would fail any peer review. Under false claims of “no competing interests”, these authors, deeply involved in pro-Palestinian organisations, cower behind their medical degrees to slander Israel, spread Hamas defamations, and betray our profession. We are baffled by The Lancet’s decision to publish such a slanted, evidence-less, open letter.1 The death of innocent women and children is horrifying. We know—our families lost everyone and everything during the holocaust, which is why we denounce the phrasing of “massacre” by the open letter’s authors. We have treated Israeli and Palestinian patients,
Planetobserver/Science Photo Library
Correspondence
Published Online July 31, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61127-2 See Editorial page 469
Published Online July 30, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61126-0
For the signatories see appendix
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
489
Correspondence
For more on Save a Child’s Heart see http://www.saveachildsheart. org/
Published Online July 30, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61179-X
For the petition see https://www.surveymonkey. com/s/6NH6VV2
490
without distinction, throughout our army service, during times of conflict and calm. We have always maintained objectivity and medical ethics in trying situations. Even in the present conflict, doctors continue to treat Palestinians in Israeli hospitals. In August, 2005, Israel disengaged from Gaza, dismantled settlements, and displaced more than 10 000 Israelis. It withdrew its military and civilian presence from every inch of Gaza, effectively ending the occupation. Israel continued to uphold its obligations under the fourth Geneva Convention in matters where it continues to have effective control, such as providing water and electricity. By contrast with Manduca and colleagues’ claims, 1 Israel has always allowed the passage of food, medicine, and fuel into Gaza. In 2007, Hamas took control of Gaza in a violent coup killing 550 Palestinians, and leaving hundreds injured. Since then, the people of Gaza have been living under tyranny. Manduca and colleagues1 argue that Israel’s policies led to hunger, thirst, pollution, shortage of medicines… They claim “building materials have been blockaded so that schools, homes, and institutions cannot be properly rebuilt.” This is not true. Over the past decade, Hamas has received billions of dollars in foreign aid. Instead of building schools and hospitals, Hamas enriched its leadership,2 and invested in weaponry, tunnels, and ammunition bunkers.3 The people of Gaza were left in ruins long before these past few days. Recently, Hamas again resorted to violence against Israel. The international community has recognised Israel’s right to self-defence, both against rockets and terror tunnels. There is definitely a moral asymmetry in this conflict. Israel’s strategy is aimed at protecting life, whereas Hamas’ strategy has, quite rightly, provoked the condemnation by the European Union (EU): “The EU strongly condemns calls on the civilian population of Gaza to provide
themselves as human shields.” 4,5 Terrorists have been using UN facilities, and ambulances; hospitals such as Shifa, “[have] become a de facto headquarters for Hamas leaders, who can be seen in the hallways and offices”.6 Israel has been working tirelessly to develop precision weapons and warning mechanisms to minimise civilian causalities. Such measures (text messages, leaflets, and repeated announcements) surpass NATO’s operations in precision and in proportionality calculus. For Israel, civilians are never a target. Unfortunately, it seems that Hamas’ tactics ensure maximum civilian casualties among their own people. Israel should not apologise for its low death rates. It has spent billions of dollars on developing the world’s most advanced civil defence systems. Hamas has done nothing for its citizens. Manduca and colleagues claim to hold a moral high ground. Here the asymmetry of morality is most visible. Israeli physicians have treated hundreds of Syrian casualties and offer open-heart surgery (through the Save a Child’s Heart programme) to children from the Palestinian territories, Iraq, Iran, and many other countries that do not even recognise the State of Israel. When the Israeli Defence Forces establish a field hospital to treat Palestinian civilians, it has been targeted by Hamas.7 The high moral ground rests neither with Hamas nor those defending it. The Lancet must practice objectivity, promote informative dialogue and discussion, and refrain from publishing inaccuracies and lies that widen existing gaps between parties already in conflict. The publication of this Correspondence is a first step in the right direction. We wish to thank Miriam B Mandel for her editorial assistance. We declare no competing interests. Our petition “Battling Ignorance in The Lancet” has received more than 3000 signatures, as of July 30, 2014.
*Tamir Wolf, Danielle H Brown, Shachar M Aharony [email protected]
Accelmed, Herzliya Pituach, 46120, Israel (TW); Abba Eban international diplomacy, Interdisciplinary Center, Hertzliya, Israel (DHB); and Urology Division, Rabin Medical Center, Petach Tikva, Israel (SMA) 1
2
3
4
5
6
7
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; published online July 22. http://dx.doi.org/10.1016/S01406736(14)61044-8. Levy-Weinrib E. Meet the Hamas billionaires (July 24, 2014). http://www.globes.co.il/en/ article-the-phenomenal-wealth-of-hamasleaders-1000957953 (accessed July 25, 2014). Rosen A. Qatar’s purchase of billions of US weaponry—and support for Hamas—shows how awkward foreign policy can be (July 24, 2014). http://www.businessinsider.com.au/ gaza-conflict-qatar-us-relations-2014-7 (accessed July 24, 2014). Freimann M. Hamas killed 160 Palestinian children to build terror tunnels (July 25, 2014). http://www.tabletmag.com/scroll/180400/ hamas-killed-160-palestinian-children-tobuild-terror-tunnels#undefined (accessed July 25, 2014) . Council of the European Union Foreign Affairs. EU Council conclusions on the Middle East Peace Process (22 July 2014, Brussels). http:// www.eu-un.europa.eu/articles/en/ article_15300_en.htm (accessed July 24, 2014). Booth W. While Israel held its fire, the militant group Hamas did not (July 17, 2014). http:// www.washingtonpost.com/world/middle_ east/while-israel-held-its-fire-the-militantgroup-hamas-did-not/2014/07/15/116fd3d73c0f-4413-94a9-2ab16af1445d_story.html (accessed July 23, 2014). Ispish S. Cruelty: Hamas fires on IDF field hospital treating Palestinians (Hebrew). http://www.ch10.co.il/news/56439/#. U9N0aVZ5iC1 (accessed July 24, 2014).
I appreciate and fully support the recent publication “An open letter for the people in Gaza”.1 The siege on Gaza, the previous Gaza wars, and the present war have directly and indirectly caused death and disability and affected all sectors of society, including the health system. Wars cannot solve the root cause of the conflict—namely the occupation. I declare no competing interests.
Espen Bjertness [email protected] Department of Community Medicine, Institute of Health and Society, University of Oslo, 0318 Oslo, Norway 1
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; published online July 22. http://dx.doi.org/10.1016/S01406736(14)61044-8.
www.thelancet.com Vol 384 August 9, 2014
As a medical community, our first responsibility is to help to protect the vulnerable. If we are to remain true to our Hippocratic pledge to “consecrate our lives to the service of humanity”, then our responsibility is to the innocent civilians who are overwhelmingly the victims in this massacre. We condemn civilian deaths on both sides, which as of July 30, are estimated at 852 Palestinian and 2 Israeli civilian casualties.2 We also have a responsibility towards our colleagues in Gaza and their patients, by collectively condemning the targeting of hospitals and demanding the safety of both medical staff and patients. We are physicians and surgeons who have been involved in supporting medical professionals in the occupied Palestinian territories through medical education and service over the last decade. We fully support the recent open letter8 published in The Lancet and Médecins Sans Frontières’ appeal,9 deploring the indiscriminate killing of innocent civilians. We recognise a medical community and society that has been subject to a siege, collective punishment, and sanction. The lives of our colleagues are now threatened by direct attack. We appeal for our medical colleagues worldwide, including in Israel, to stand up and to join us in pressing for an immediate cessation of hostilities. We declare no competing interests.
Tanya Haj-Hassan, Tony McShane, *Imran Mahmud, Peter Watkinson, Chris Conlon, Terence Hope, David Lloyd, Nick Maynard, on behalf of 22 signatories [email protected] Oxford University, Oxford, UK (TH-H); Oxford Children’s Hospital, Oxford, UK (TMS); Harvard School of Public Health, Boston, MA02115, USA (IM); Oxford University Hospitals, Oxford, UK (PW, CC, NM); University Hospital, Nottingham, UK (TH); and Retired, Liverpool, UK (DL) 1
Ministry of Health. Emergency Operation Room Sitrep on Gaza (21st July, 2014). http:// www.lacs.ps/documentsShow.aspx?ATT_ ID=15635 (accessed July 30, 2014).
2
3
4
5
6
7
8
9
Office for the Coordination of Humanitarian Affairs (OCHA). Occupied Palestinian Territory: Gaza Emergency Situation Report, as of July 30. http://reliefweb.int/sites/reliefweb.int/ files/resources/ocha_opt_sitrep_31_07_2014. pdf (accessed July 30, 2014). BBC. Gaza conflict: Five dead at hospital hit by Israeli strike (July 22, 2014). http://www.bbc. co.uk/news/world-middle-east-28399292 (accessed July 30, 2014). Deger A. International activists risk lives to protect Gaza’s ambulances under fire (July 19, 2014). http://mondoweiss.net/2014/07/ international-activists-ambulances.html (accessed July 30, 2014). Al Jazeera. Israel bomb hits disabled centre in Gaza (July 13, 2014). http://www.aljazeera.com/ news/middleeast/2014/07/israel-bombs-hitcentre-disabled-gaza-201471274035753506. html (accessed July 30, 2014). UNRWA. Statement by the UNRWA Commissioner-General Pierre Krähenbühl. http://www.unrwa.org/newsroom/officialstatements/statement-unrwa-commissionergeneral-pierre-kr%C3%A4henb%C3%BChl (accessed July 25, 2014). Sherwood H, Balousha H. “World stands disgraced”–Israeli shelling of school kills at least 15. The Guardian; July 30, 2014. http:// www.theguardian.com/world/2014/jul/30/ world-disgrace-gaza-un-shelter-school-israel (accessed July 31, 2014). Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; published online July 22. http://dx.doi.org/10.1016/S01406736(14)61044-8. Médecins Sans Frontières. Gaza: Israel must stop bombing trapped civilians. http://www. doctorswithoutborders.org/article/gaza-israelmust-stop-bombing-trapped-civilians (accessed July 25, 2014).
Reality is far from black and white as was depicted in the recent hate-filled Correspondence by Paola Manduca and colleagues.1 The authors of this Correspondence hijacked The Lancet, spewing propaganda that would fail any peer review. Under false claims of “no competing interests”, these authors, deeply involved in pro-Palestinian organisations, cower behind their medical degrees to slander Israel, spread Hamas defamations, and betray our profession. We are baffled by The Lancet’s decision to publish such a slanted, evidence-less, open letter.1 The death of innocent women and children is horrifying. We know—our families lost everyone and everything during the holocaust, which is why we denounce the phrasing of “massacre” by the open letter’s authors. We have treated Israeli and Palestinian patients,
Planetobserver/Science Photo Library
Correspondence
Published Online July 31, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61127-2 See Editorial page 469
Published Online July 30, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61126-0
For the signatories see appendix
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
489
Correspondence
For more on Save a Child’s Heart see http://www.saveachildsheart. org/
Published Online July 30, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61179-X
For the petition see https://www.surveymonkey. com/s/6NH6VV2
490
without distinction, throughout our army service, during times of conflict and calm. We have always maintained objectivity and medical ethics in trying situations. Even in the present conflict, doctors continue to treat Palestinians in Israeli hospitals. In August, 2005, Israel disengaged from Gaza, dismantled settlements, and displaced more than 10 000 Israelis. It withdrew its military and civilian presence from every inch of Gaza, effectively ending the occupation. Israel continued to uphold its obligations under the fourth Geneva Convention in matters where it continues to have effective control, such as providing water and electricity. By contrast with Manduca and colleagues’ claims, 1 Israel has always allowed the passage of food, medicine, and fuel into Gaza. In 2007, Hamas took control of Gaza in a violent coup killing 550 Palestinians, and leaving hundreds injured. Since then, the people of Gaza have been living under tyranny. Manduca and colleagues1 argue that Israel’s policies led to hunger, thirst, pollution, shortage of medicines… They claim “building materials have been blockaded so that schools, homes, and institutions cannot be properly rebuilt.” This is not true. Over the past decade, Hamas has received billions of dollars in foreign aid. Instead of building schools and hospitals, Hamas enriched its leadership,2 and invested in weaponry, tunnels, and ammunition bunkers.3 The people of Gaza were left in ruins long before these past few days. Recently, Hamas again resorted to violence against Israel. The international community has recognised Israel’s right to self-defence, both against rockets and terror tunnels. There is definitely a moral asymmetry in this conflict. Israel’s strategy is aimed at protecting life, whereas Hamas’ strategy has, quite rightly, provoked the condemnation by the European Union (EU): “The EU strongly condemns calls on the civilian population of Gaza to provide
themselves as human shields.” 4,5 Terrorists have been using UN facilities, and ambulances; hospitals such as Shifa, “[have] become a de facto headquarters for Hamas leaders, who can be seen in the hallways and offices”.6 Israel has been working tirelessly to develop precision weapons and warning mechanisms to minimise civilian causalities. Such measures (text messages, leaflets, and repeated announcements) surpass NATO’s operations in precision and in proportionality calculus. For Israel, civilians are never a target. Unfortunately, it seems that Hamas’ tactics ensure maximum civilian casualties among their own people. Israel should not apologise for its low death rates. It has spent billions of dollars on developing the world’s most advanced civil defence systems. Hamas has done nothing for its citizens. Manduca and colleagues claim to hold a moral high ground. Here the asymmetry of morality is most visible. Israeli physicians have treated hundreds of Syrian casualties and offer open-heart surgery (through the Save a Child’s Heart programme) to children from the Palestinian territories, Iraq, Iran, and many other countries that do not even recognise the State of Israel. When the Israeli Defence Forces establish a field hospital to treat Palestinian civilians, it has been targeted by Hamas.7 The high moral ground rests neither with Hamas nor those defending it. The Lancet must practice objectivity, promote informative dialogue and discussion, and refrain from publishing inaccuracies and lies that widen existing gaps between parties already in conflict. The publication of this Correspondence is a first step in the right direction. We wish to thank Miriam B Mandel for her editorial assistance. We declare no competing interests. Our petition “Battling Ignorance in The Lancet” has received more than 3000 signatures, as of July 30, 2014.
*Tamir Wolf, Danielle H Brown, Shachar M Aharony [email protected]
Accelmed, Herzliya Pituach, 46120, Israel (TW); Abba Eban international diplomacy, Interdisciplinary Center, Hertzliya, Israel (DHB); and Urology Division, Rabin Medical Center, Petach Tikva, Israel (SMA) 1
2
3
4
5
6
7
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; published online July 22. http://dx.doi.org/10.1016/S01406736(14)61044-8. Levy-Weinrib E. Meet the Hamas billionaires (July 24, 2014). http://www.globes.co.il/en/ article-the-phenomenal-wealth-of-hamasleaders-1000957953 (accessed July 25, 2014). Rosen A. Qatar’s purchase of billions of US weaponry—and support for Hamas—shows how awkward foreign policy can be (July 24, 2014). http://www.businessinsider.com.au/ gaza-conflict-qatar-us-relations-2014-7 (accessed July 24, 2014). Freimann M. Hamas killed 160 Palestinian children to build terror tunnels (July 25, 2014). http://www.tabletmag.com/scroll/180400/ hamas-killed-160-palestinian-children-tobuild-terror-tunnels#undefined (accessed July 25, 2014) . Council of the European Union Foreign Affairs. EU Council conclusions on the Middle East Peace Process (22 July 2014, Brussels). http:// www.eu-un.europa.eu/articles/en/ article_15300_en.htm (accessed July 24, 2014). Booth W. While Israel held its fire, the militant group Hamas did not (July 17, 2014). http:// www.washingtonpost.com/world/middle_ east/while-israel-held-its-fire-the-militantgroup-hamas-did-not/2014/07/15/116fd3d73c0f-4413-94a9-2ab16af1445d_story.html (accessed July 23, 2014). Ispish S. Cruelty: Hamas fires on IDF field hospital treating Palestinians (Hebrew). http://www.ch10.co.il/news/56439/#. U9N0aVZ5iC1 (accessed July 24, 2014).
I appreciate and fully support the recent publication “An open letter for the people in Gaza”.1 The siege on Gaza, the previous Gaza wars, and the present war have directly and indirectly caused death and disability and affected all sectors of society, including the health system. Wars cannot solve the root cause of the conflict—namely the occupation. I declare no competing interests.
Espen Bjertness [email protected] Department of Community Medicine, Institute of Health and Society, University of Oslo, 0318 Oslo, Norway 1
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; published online July 22. http://dx.doi.org/10.1016/S01406736(14)61044-8.
www.thelancet.com Vol 384 August 9, 2014
