Peacebuilding Through Cooperation in Health Care and Public Health Between Israel and Palestine

Peacebuilding Between Israel and Gaza Public health is a concern for all in a conflict region because populations are healthier during times of peace. Achieving peace is hard following conditions of structural inequalities, political violence, and war and thus requires actions that help the warring parties recognize each other's common humanity. Cooperative projects in conflict settings serve as unofficial diplomacy for peacebuilding and are especially important during periods where official relations are difficult or absent. Health is one of many areas where peacebuilding can occur. Long-term research shows that most who participate in peacebuilding activities are more hopeful about peace and more willing "to act for change. "1 The concept of cooperation in health care as peacebuilding can be traced to the 1990s. 2 In times of crisis, such as the Hamas-Israel war, there is a natural human reaction to withdraw from constructive approaches to conflict and to rely on punitive actions. It is because of this tendency that a full-throated endorsement of support for those who wish to take constructive actions, such as cooperating on shared public health goals, needs to be supported. Israel and Palestine are interdependent, sharing borders and epidemiological risks regarding environmental health, climate change, and during outbreaks of infectious disease. 3 The health of one affects the health of the other, which emboldens the need to find ways to improve the health of both peoples. When the war between Hamas and Israel ends, cooperative actions will be critically needed. In 2023, we submitted to the American Public Health Association (APHA) a proposed policy, developed over 2. 5 years, which called for an application of the World Health Organization's (WHO's) "Global Health Peace Initiative (GHPI) "4-7 model for using public health as a mechanism for peacebuilding. In this approach, health initiatives bring "rival parties" together to work toward mutually beneficial objectives from a neutral starting point. 6 In other conflict settings, 8-12 like or similar programs supported public health and health care cooperation to build the conditions for peace, while resulting in improved health for those in the region. Prior to the APHA annual meeting in November 2023, with the support of APHA's Joint Policy Committee (JPC), organizational endorsement by 6 APHA sections (Ethics, Health Administration, Health Informatics and Information Technology, Maternal Child Health, Mental Health, and Pharmacy) and external endorsement by 2 peacebuilding organizations, the proposed policy was on the path to association approval. However, the Hamas-Israel war, started by Hamas on October 7, 2023, led the JPC to determine that the time was not right for the policy, and, concurring, the authors asked the association to postpone the policy indefinitely. What Cooperation in Health Care and Public Health Can Achieve Wars and armed conflicts are a major cause of mortality, morbidity, and disability and are a significant contributor to disease burden, especially in low- and middle-income countries13 such as Palestine14 and Israel. Aside from deaths and injuries, war negatively affects the physical and emotional health of both civilians and combatants on all sides of a conflict. 6 Recognizing the terrible toll suffered by the Israelis, Gaza is now without a health care system and other necessities that can support health. Prior to the war that began on October 7, 2023, it was clear that both sides had much to offer in many areas of public health. Working together they could accomplish a great deal. The proposed policy advocated for improving the daily lives of Palestinians and Israelis through cooperation to strengthen the health care system, thereby reducing health disparities. Doing so could build and strengthen relations through peacebuilding because they would work together on shared goals. These health initiatives would be developed locally among those who knew specifically what was needed. Such bottom-up, community-based initiatives are the type considered more likely to improve health outcomes15 and contribute to peacebuilding. 8, 15 Some believe16 that if an international investment of cooperative projects could lead to peace in Northern Ireland (a 3-decade conflict between religious groups, which was also, in part, about sovereignty, the use of the military and social justice, and that seemed as intractable as the Palestine-Israel conflict17), then peace between Israel and Palestine is also possible. Missing is an adequate number of projects of sufficient duration to reach enough Israelis and Palestinians to potentially make a difference in the conflict. 16 While more than 6000 projects were provided in the conflict in Northern Ireland, only 164 peacebuilding initiatives occurred between Israel and Palestine since 1963 and only 3. 66% were in health/medicine. 1 Preexisting Needs of Palestinian Health Care System Even before the war begun on October 7, 2023, there was a broad range of disparities between those living in Israel and those living in Palestine. 14, 18 Key to understanding how cooperation in health care and public health could improve the health care system is a recognition of the fractured Palestinian health care system and stark deficiencies that existed before October 7 and that resulted in lack of access to health care. 14, 18-25 The Palestinian Ministry of Health's National Health Strategy26 sought to strengthen partnerships and coordination within the health sector to achieve an independent health care system. History of Cooperation on Health Care and Public Health Since the founding of Israel by the United Nations, 27 levels of official cooperation between the Israelis and Palestinians have varied dramatically, depending on the political situation. Despite intermittent conflict, there have been sustained periods where both formal28-30 and informal31 cooperation occurred regarding health. 28-31 When such cooperation was permitted, the combined expertise of Palestinian and Israeli health care professionals made a measurable difference, resulting in mutually beneficial health efforts (T. Tulchinsky, former Israeli Ministry of Health Coordinator for Health in the West Bank and Gaza, personal communication, August 4, 2021). 20, 28, 32, 33 Following the Oslo Accords I (1993) and II (1995), the Palestinian government participated in 148 cooperative Palestinian-Israeli programs to improve the availability and quality of health care for Palestinians. 34 For decades, health practitioners in Israel helped Palestinian health care providers acquire needed public health and medical skills so that they could care for patients independently (personal communication through email/written for both Tulchinsky and Goldstein), 3, 32, 35, 36 further demonstrating the benefits of regional cooperation in planning and carrying out jointly designed projects. Israelis and Palestinians worked together to build capacity for caring for patients with cancer. 20, 37 Cooperative projects such as these are an important example of what can be achieved in the absence of political interference or when efforts are made to overcome political pressure. Even before October 7, 2023, cooperation on health care between Palestinians and Israelis was made more difficult by the politics of governing authorities. The Palestinian Authority, Hamas, and Israeli governments have at times each discouraged or formally forbidden cooperation. While formal cooperative health care training and capacity building occurred from the late 1960s to late 1990s, official cooperation had stopped. 38 Despite this obstacle, groups of individuals have cooperated informally and before this war they believed that further cooperation would benefit their communities39 and the health care systems. How Would Cooperation Occur The US Congress recognized the importance of cooperation in peacebuilding through the passage of the Nita M. Lowey Middle East Partnership for Peace Act (MEPPA) 40 to build a sufficient level of public support as a way to advance peace between Israel and Palestine. 16 Pursuant to MEPPA, the US Agency for International Development (USAID) granted 50 million in funding for 202241 and future proposals are being considered. Demonstrating the federally perceived need for the cooperation this policy calls for, a third of the 9 projects funded in 2022 were for cooperation in health care. In the fourth draft of the WHO's roadmap for implementing its GHPI, 4 the WHO highlighted principles for action. Some key values are that programming be context specific; be adapted to each conflict; include community participation; be "locally owned"; support the work of health care workers and staff; be based on collaboration and coordination; and include monitoring and evaluation. Our strategy includes all of these values. The merit of an investment in bottom-up peacebuilding between Israelis and Palestinians has been demonstrated by the existing small projects that improve everyday life while creating cooperation, partnerships, and especially trust. 42 Once formal cooperation on health care stopped, nongovernmental organizations (NGOs) played a key role in bringing Israeli and Palestinian health care providers together. Training available with neighboring Israeli providers and NGOs already engaged in informal cooperation would help the Palestinian health care system retain health care professionals who would not have to travel abroad to acquire needed skills. In addition to building Israeli-Palestinian relationships and stronger mutual understanding, the quality, technological capacity, and ability of the Palestinian health care system to function independently would improve through cooperative training and exchanges of many kinds, as evidenced by numerous historical and current examples. The work of Project Rozana43 and the Canada International Scientific Exchange Program44 provide examples of how cooperation is operationalized. Both models support the application of the WHO's GHPI by demonstrating how health cooperation at the community level can occur and "create the social infrastructure for peacebuilding. "45 In doing so, health care professionals act jointly on a superordinate goal with tangible public health outcomes. 45 Applications to Policy and Practice As Palestinian health care is being rebuilt and strengthened, with the goal of an independent health care system, cooperation between Palestinians and Israelis at all levels should be encouraged to improve public health, with opportunities for peacebuilding. The US government should support local and global initiatives of NGOs to advance intercommunity and cross-border cooperation between clinicians, public health professionals, and institutions; the US Congress should continue to fund the USAID to implement cooperative programs that improve health and public health in Palestine and Israel with objective outcome evaluations. Israeli and Palestinian health professionals must leverage and expand previous cooperative relationships that are in place and develop new relationships that contribute to regional health and peace. Support of like-minded public health professionals in the region should be formally encouraged to identify and manage issues of public health. There should be public accountability for both successes and challenges; professionals should be required to monitor and evaluate actions so that indirect and direct contributions to health care and public health can be studied and standardized with the goal of understanding the impact on laying foundations for positive peace.