Grassroots medical peace building: training Palestinian physicians in Israel

Abstract

Based on new scholarship on the importance of health in times of conflict, this paper examines the training of Palestinian physicians in Israel from the 1990s to 2010 as a test case for the theory. It shows that although Israeli governments have adopted a passive policy towards such training, and the Palestinian Authority is officially against such cooperation; in practice, individuals and hospitals on both sides work at the grassroots level with the aid of several NGOs to increase cooperation. Thus, grassroots activities are leading to better cooperation between Jewish and Palestinian health professionals, improving Palestinian health capabilities and establishing a bridgehead for better professional cooperation when a peace settlement is achieved. Health, like other social areas, is part of the explanation why the conflict remains stable and how mutual beneficial cooperation has planted the seeds for future cooperation.

Keywords:

• Israel–Palestinian
• medical peace building
• conflict resolution
• health

Introduction

The prevailing literature on the Israeli–Palestinian conflict focuses on difficulties in finding common ground due to the depth of the contested issues on matters such as security, return of refugees and the final status of Jerusalem. According to such literature the Israelis and Palestinians are embroiled in an intractable conflict with no clear conditions for the cessation of hostilities and without a prospect for a comprehensive peace settlement (Bar-Siman-Tob 2010; Bar-Tal 2013; Bercovitch 2003). In this paper, I offer to turn the focus of Israeli–Palestinian relations towards routine activities such as health. I argue that pointing at routine activities may open new avenues of understanding why conflicts remain and how societies and institutions may create the conditions for cooperation between the societies, not only in post-conflict environments but also during conflict.

The history of health in the area west of the Jordan River shows constant improvement, but also that the different political leaderships endeavoured to improve the health systems without encouraging cooperation (Kertcher 2013, 31–47). This policy contradicts the global thinking that gained momentum after the Cold War, which emphasized the need for strategies that would influence the transformation of war-torn societies in political, economic and cultural spheres (Dobbins et al. 2007; Paris 2004). One of the issues which gains dominance deals with health. The health system – the generic term for the people, building, machines, administration, regulations and financing involved in the health procedures – is one of the conditions for maintaining a stable civil society. Therefore, it is not surprising that writing on health and conflict resolution use titles such as Peace through Health (PtH), Health as a Bridge to Peace, Multi-track Peace, Medical Peace Work and Medical Peace Building (hereinafter MPB). The writers on MPB underline the positive contribution of MPB before, during and after a conflict. According to different writers, the people who work in the health system are better agents for reconciliation and cooperation. They can cooperate with the local government because their main goal is to heal. In that respect, they stand opposite security forces whose job demands that they inflict damage. A functioning health system also prevents the spread of contagious diseases; it also symbolizes the potential of a stable society for development; finally, the people in the health system are usually part of the civil society which has an interest in the preservation of peace (Arya and Santa Barbara 2008; MacQueen and Santa Barbara 2008; Rushton 2008).

While several academic works point at achievements in the field of health in the Israeli–Palestinian context (Barnea and Husseini 2002; Kitts 2008; Rubenstein and Kohli 2010), a close examination show discrepancies between the theory and its practice. MPB scholars recommend training physicians only after the cessation of hostilities and the signing of a peace agreement (MacQueen and Santa Barbara 2008). In practice, however, the training of Palestinian physicians in Israel has taken place in the past two decades during periods of increased violence. A second contradiction relates to the agents who implement the MPB. The theory encourages the intervention of third parties in the conflicted region. It also encourages full cooperation with local governments. In the Israeli–Palestinian case, the practitioners of MPB are usually Jews who are part of the same socio-political apparatuses that sustain the conflict in the first place. A third problem with the implementation of MPB theory in the Israeli–Palestinian conflict is its disregard of the definition of the ‘object’ or ‘other’. We don’t know who the objects of change are. Are they the state apparatus, a hospital, the health personnel or the patients? Each of these target groups has its own concerns, ambitions, resources and reacts differently with regard to the conflict. Finally, health systems are open systems. They aspire to attain sustainable development, but are affected by many variables. Thus, development of a health system is always accompanied by tensions between people with different goals and the strategies to achieve them. For example, the goal to develop tertiary capabilities is conditioned by the availability of large sums of money, establishment of good electricity, availability of water supply, building services and above all the availability of highly trained medical staff. If these conditions are not met, there is a danger that the system will deteriorate and even collapse. Therefore, policy-makers may prefer to invest in primary care to make the health system more equitable and available to most of the population, thus preferring quantity to quality. This poses a challenge for MPB experts: When to intervene in a conflict? What are the alternatives to the development of a health system and what to recommend to the local government?

To settle the discrepancies between MPB theory and its practice in the context of the Israelis and Palestinians, this paper analyses the evolution of relations between two levels of agents in the context of the training of Palestinian physicians in Israel. The first agent examined is the Israeli and Palestinian governmental and ministerial level. The paper will show how the two adjacent health systems evolved in the past two decades and how they established strategies for or against the training of Palestinian physicians. This part will also shed light on the role of the donor community, a third party to the conflict, which, with its political and financial assets, can induce or discourage such cooperation. The second level to be examined is the grassroots level which includes mainly high ranking personnel in Israeli and Palestinians hospitals and Non Governmental Organizations (NGOs) as well as private physicians. Combined, these two agencies present us with in-depth knowledge of how the training of Palestinian physicians has affected both Israelis and Palestinians in the past two decades in relation to MPB theory. The questions raised above were confronted by the adoption of a combination of methodologies such as in-depth interviews of 40 Israelis and Palestinians involved at different levels of interaction; primary governmental, hospital, and NGO publications and documents. The majority of Israelis agreed to reveal their identities. On the other hand, almost all Palestinians refused to disclose their identity for fear of negative repercussions.

The governmental level

The Declaration of Principles signed on September 13, 1993 called for the establishment of the Palestinian Authority (PA) as an interim arrangement until the parties reached a comprehensive agreement. The agreement emphasized the separation of the two polities on the basis of two states for two people. From 1 December 1994, the Israelis referred all the authorities concerned with health to the PA (Barnea and Abdeen 2002).

In congruence with MPB theory we could have expected that both sides develop post-conflict strategies concerning health. This expectation is supported by the fact that both nations form one epidemiological family due to geographical proximity and the daily interaction of the people. Therefore, this section analyses the health strategies of each of the nations’ high governmental levels concerning the training of Palestinian physicians in Israel and the role of the donor community in encouraging the development of the Palestinian health system.

One explanation for the training of Palestinian physicians in Israel has its traces in a change of policy by the Israelis in the mid-1980s. At the time Israeli governments thought that they should support local Palestinian institutions so that when Israel left, these institutions could form independent state institutions. These activities were controlled by Haminhal Ha’Ezrahi (Civilian Administration), the body that Israel created in 1981 to supervise the West Bank and Gaza Strip.¹ The director of Haminhal Ha’Ezrahi from 1985 to 1987, Brigadier General Dr Ephraim Sneh, decided to develop the Palestinian hospitals to better prepare them to work under an independent Palestinian government. During these years several dozen Palestinian physicians received brief training in different health fields. Thus, the training of the Palestinian physicians was considered a part of a future disengagement policy and not in order for future cooperation (Israel Ministry of Health 1993; Sever and Peterburg 2002; Sneh 2002).

Another explanation for the training of Palestinian physicians lies in the confidence of the Israelis in their health system. The Israeli health system is ranked near the top in the world World Health Organization (WHO 2000). There are several explanations for this. Israel has a universal and compulsory health care insurance system. It has a mixture of public, private, and semi-private health care providers. The health care system is one of the biggest employers in the country with approximately 170,000 employees (Israel Ministry of Health 2010). In the twentieth century,the Jewish community enjoyed massive immigration of trained Jewish physicians. Israel enjoys a high ratio of physicians to the population, estimated to be 3.3 physicians to 1000 people. The health care system is aided by Israel’s stable economic growth, ranked high according to the human development indices United Nations Development Programme (UNDP 2013).² Thus, high ranking officials in the Israeli Ministry of Health think that their health care system should also be a global centre to train foreigners – mainly from less developed countries – among them Palestine. According to this perspective, Palestinians and other foreigners should train under the same criteria (Shanon 2006).³ From the late 1990s until today, the policy of training Palestinian physicians has been monitored by Dr Amir Shanon, director of the Department of Medical Professions, Israel Ministry of Health. Shanon claims that his department treats Palestinian physicians as any other foreign national physician. Although his department doesn’t have statistics on the issue, he estimates that there has been a constant increase in the number of Palestinian and foreign physicians being trained in Israel since the beginning of the twenty-first century. Shanon recalls that in the 1990s, there were only a few dozen physicians a year in Israel in comparison to 400–500 foreign physicians a year in the past years, many of them Palestinians.⁴

The two explanations given above by Israeli Health Ministry officials for training Palestinian physicians in Israel ignore the difficulties that the Israelis place on Palestinian physicians who want to do their medical fellowships or residency in Israel. The facade of an Israeli technical rubber stamp that approves Palestinian applications ignores the fact that any Palestinian physician who wants to enter Israel must receive a special permit from Haminhal Ha’Ezrahi.⁵ In many instances, the Israeli government ministries create bureaucratic obstacles in the issuance of work permits, study visas or in the payment of salaries to Palestinian physicians. Many of the physicians who arrive from their homes in the West Bank are checked at and delayed by Israeli military roadblocks – scattered in the West Bank – in disregard of their obligations to Israeli hospitals. A special problem occurs in East Jerusalem. For the Palestinians, East Jerusalem is their intended capital. Therefore, they consider the Palestinian population and health institutions there as a part of their future country. Officially, the Israelis claim that the entire city is their capital. They even passed the ‘Jerusalem Law’ that emphasizes that the city is united under Israel rule. Because Israel is the de facto administrator of East Jerusalem, the Israeli Health Ministry sometimes refuses to give work permits to Palestinian physicians who work in the best Palestinian hospitals in East Jerusalem. They also refuse to let the medical graduates of Al Quds University work in Israeli hospitals. They claim that the university is part of its territorial claims but operates without Israel Council of Higher Education guidance. According to a prominent Israeli hospital official: ‘The Ministry of Health put them against a wall. Thus, to the frustration of the (Israeli) hospital staff, the physicians from relatively better hospitals such as “St. Joseph” and “Al-Makased” (in East Jerusalem), are prevented from application for residency’.⁶

From the above analysis, we can assume that for the past three decades, Israeli government policy towards the training of Palestinian physicians in Israel can be explained as a passive MPB rather than part of a comprehensive strategy towards the Palestinians. It wants to improve Israel’s image in the world in general and towards the Palestinians in particular. It wants to increase its prestige as a leading health care provider (Israel Ministry of Foreign Affairs 2013). More rarely some officials claim that they also have a positive effect on the viability of the Palestinian health care system. In fact, the entire health coordination is part of this passive strategy of tolerance to other initiatives on this issue while maintaining no interest in it, as long as it does not pose a threat – to Israel’s policies and health care system. The training of Palestinians is not considered as supportive for the development of the Israeli health care system or for the improvement of relations between the two peoples either (Kertcher 2013, 49–82).

These conclusions are supported by the health coordinator in Haminhal Ha’Ezrahi for the West Bank, Ms Dalia Basa, who has served in this role since 1995. She claims that her recurrent requests in the past two decades for increased manpower to deal with the issuance of permits to Palestinians are being declined. Her suggestions to high ranking officers in the Israeli military to discuss the development of the Palestinian health care system and also for the training of Palestinian physicians are ignored. Frustrated, she compensates for these shortcomings by personally engaging with Israelis and Palestinian 24/7.⁷

The Palestinian health care system that emerged in late 1994, after the signing of the Declaration of Principles, was very fragile. The Palestinian health care system is divided into four medical providers: the governmental PA, the non-governmental, UNRWA and private entities. Each medical provider aspires to increase its assets and capabilities but does not necessarily coordinate its activities with government strategies. This problem of coordination was increased after the Hamas military coup in the Gaza Strip in June 2007 resulting in the creation of two separate political units. Thus, while on paper, the PA governs 25 hospitals, in practice 13 of them are in the Gaza Strip, under Hamas control (Mataria et al. 2009). Israel’s continued control of Palestinian assets, the limitations on the movement of Palestinians by the Israeli Defence Forces (IDF) and their influence on the imports and exports of assets make the PA dependent on the Israelis. The Palestinian health care system is also faced with a constant lack of funding. Part of this challenge is due to military flare-ups with Israel, which slowed its limited economic growth. In 2011, its GDP was estimated at less than 8 billion dollars. Therefore, the PA depends on foreign economic aid to ensure its functioning. In the first decade of the twenty-first century, it received approximately 1 billion dollars from the donor community (Palestinian Ministry of Health 2010a; World Bank 2012, 2013). Economic difficulties are constantly growing due to the demographic challenge. In 1967, there were less than one million people in the Palestinian territories. In 2010, it was estimated that the population reached approximately four million (Palestinian Central Bureau of Statistics 2010). Finally, the PA is often accused of mismanagement and corruption (WHO 2006). Thus, up to the late 1990s, Palestinian physicians were trained according to Jordanian or Egyptian laws and practices. The PA formally legalized the work of the Palestine Medical Council (PMC) in 2006. The training of specialists was legalized in December 2008 (PMC 2011; Schoenbaum, Afifi, and Deckelbaum 2005, 42–45).

The difficulties described above did not prevent the development of the Palestinian health care system. The number of hospitals in the West Bank and Gaza Strip increased from 28 in 1992 to 76 in 2010. The Palestinian health indicators such as life expectancy, child mortality and the ratio of physicians per thousand people are similar to neighbouring Arab countries such as Egypt, Jordan and Syria before the civil war (Giacaman et al. 2009). Moreover, the PA is ranked in the middle echelon of developing countries together with other countries such as Bolivia, China, Egypt and Paraguay (UNDP 2013).

In spite of its ability to maintain continued development in the health sector, according to the World Bank: ‘Allocations of resources within this sector are still primarily emergency and humanitarian assistance … The projects defined under health quality and health care programs are critical in helping to move back to a development agenda within the health sector’ (World Bank 2008, 8). The international report is in congruence with the Palestinian official policies on the development of the health care system in which the training of Palestinian physician is crucial Palestinian National Authority (PNA 2009, 26).

One of the major challenges in creating a sustainable health care system is the quantity and quality of the physicians available in proportion to the general population. After signing the Declaration of Principles, in 1994, the Palestinians established their first medical school in Al-Quds University, in East Jerusalem. It is estimated that up to 2011 this institution trained approximately 500 physicians. Later on, the Palestinians established two new schools, in Nablus and the Gaza Strip. The entire yearly increase in general physicians stands at best at 120.⁸ In 1994, the Palestinian health care system had 1575 general and specialist physicians. By 2010, this number had increased to 8093. (Palestinian Ministry of Health 2004, 2011). Most of the physicians were trained in hundreds of medical institutions in dozens of countries with different curricula(PMC 2011). In spite of the rise in the total number of physicians, the total number of Palestinians specialists in 2010 was only 2166. The need for specialists is great and it is estimated that by 2015 the Palestinian health care system will have a shortage of 3317 specialists (Palestinian Ministry of Health 2008, 99). In the past two decades, the majority of the specialists worked in non-governmental hospitals in the West Bank and in East Jerusalem. The shortage in specialists who can train others and their concentration in a few hospitals create difficulties for general physicians who aspire to be trained as specialists. For example, due to the Israeli blockade policy, a general physician in Gaza has almost no chance to be trained as a specialist. Other physicians are being prevented from entering East Jerusalem’s main Palestinian hospitals such as Al-Makassed, Augusta Victoria, St. Joseph and St. John due to Israel’s barriers and permits policy.

The shortage in specialists is also one of the explanations for the PA’s difficulty in developing tertiary medical centres (Palestinian Ministry of Health 2010b). Up to 2010, only two NGO hospitals in East Jerusalem, Augusta Victoria and Al-Makassed hospital, had professional residency programmes (Bernhart 2010, 12).

The lack of quality tertiary medical centres forces the Palestinian health care system to send thousands of patients abroad for treatment. In 2005, approximately 42% of the Ministry of Health budget was allocated for treatment outside its medical centres. This trend has decreased but it is still a burden on the health care system.⁹ The Palestinian authorities are aware of the dire need for specialists. Although the PA does not control most of the hospitals in the West Bank and in Gaza Strip, it operates as a regulator. In its work, it also benefits from the support given to it by the donor community, which invest tens of millions of dollars each year to create a sustainable Palestinian health care system. The utility of the development programmes, however, is doubtful. Many of the development projects emphasize construction of infrastructures rather than the training of specialists. For example, the 86 million dollar American ‘Flagship Project’ which operated from 2008 to 2012 allocated very little for the training of Palestinian physicians (Palestinian Ministry of Health 2012). According to a Palestinian professor, critical of American aid policy in the health sector: ‘By the time they finish, they are experts on US regulations and what it takes to follow the USAID guidelines. Alas, what about the different Palestinian health service systems? They [the Americans] are more process-oriented than outcome oriented!’¹⁰

In spite of the tremendous challenges to their health care system, the official stance of the Palestinian Health Ministers rejects training of Palestinian physicians in Israel. It seems that in the past two decades none of the Palestinian Health Ministers approached his Israeli counterpart with such a programme. Israelis complained that even in the heyday of cooperation during the 1990s, the first Palestinian Health Minister, Dr Riad Al-Zanoun (1994–2002), rebuffed initiatives for cooperation and issued anti-Israel statements.¹¹ For example, during the 1990s, following the signing of the Oslo Accords, efforts to develop an oncology hospital in the Gaza Strip with the large Sourasky Medical Centre in Tel Aviv, Israel, failed to materialize in spite the fact that the Israelis promised to provide the funds and the knowledge and to train Palestinian physicians.¹² The official policy against the training of Palestinian physicians in Israel also continued in the tenure of Dr Fathi Abu Moughli as the Palestinian Health Minister from 2007 to 2012. Abu-Moughli was considered bipartisan by many Palestinians because he worked for many years in the WHO, and was not part of the inner Palestinian politics. After becoming a Minister he adopted an anti-cooperation policy with Israel. In one instance, a Palestinian representative came forward to Abu-Moughli with a proposal that an Israeli specialist train Palestinian physicians without charge and in return receive free medical supplies from a medical corporation. Abu-Moughli turned it down and accused the Palestinian physician of cooperation with the Israelis.¹³

There are several explanations for the official Palestinian moratorium on the training of Palestinian physicians in Israel. For Palestinian authorities who are being screened by the public eye, MPB strategies without a peace treaty is anathema. For them, the dire needs of their health care system and people should be sacrificed to a higher political goal of participating in the campaign for self-determination. Cooperation can also weaken the delegitimization policy of Israel activities. Thus, the Palestinian position against cooperation rejects the aspirations ascribed above to Israeli Ministry of Health and Foreign Office officials. The denouncement of MPB between Israelis and Palestinians is also being fuelled by Arab health societies and professional unions around the Middle East, who have no interest in cooperation with the Israelis and therefore are at ease with sabotaging such initiatives by threatening to boycott high-ranking Palestinians who consider such cooperation.¹⁴ For the committed Dr Dan Shanit, who headed the Medicine & Health Care Division in the Peres Centre for Peace from 1996 to 2010, and who tried to develop such formal cooperation from the 1990s this was a puzzle. ‘The Palestinian Minister of Health decided one day that he didn’t need it. It doesn’t matter if he needed it or not: the calculations were political’.¹⁵

From the Palestinian perspective, the armed struggle with the Israelis also made it more difficult to cooperate with them. The Second Intifada from 2000; Operation Defensive Shield during 2002 in the West Bank; Operation Cast Lead in Gaza Strip 2008–2009 and other small-scale operations as well as routine targeted killings all made it difficult to continue formal cooperation with Israeli agents on health issues (while ignoring the Palestinian suffering imposed by Israelis). Moreover, the Hamas military takeover in the Gaza Strip in June of 2007 weakened the chances for cooperation as the Hamas and Fatah movements struggle for the support of their people. Thus, in several incidents Palestinians who were supposed to reach out to the Israeli side for training or for medical treatment were prevented from it by Hamas security forces.¹⁶

The only formal Palestinian exception to cooperation with the Israelis is on humanitarian aid. Ever since its inception, the PA sends thousands of patients to Israel, Jordan and Egypt. As mentioned above, this eats a large amount of the Health Ministry budget. As the Palestinians fear, this is being used by the Israeli Foreign Ministry to improve Israel’s public image (Israel Ministry of Foreign Affairs 2013).

Side by side with the political explanations given opposing cooperation with the Israelis, there are more concrete professional arguments against the training of Palestinian physicians in Israel. Palestinians claim that the millions of dollars spent on these programmes could also have been spent directly in training Palestinian physicians in their Palestinian hospitals or in other places. Sometimes, the Palestinians suspect that big Israeli NGOs receive high overhead financing for their operations. Another argument is that the Israeli programmes concentrate on visibility rather than on analysis of Palestinian training needs. One example of this is that most of the training programmes for Palestinian physicians are short term, from six months to two years, instead of full-five year residency programmes. The programmes usually do not provide for close orientation programmes to assist the integration of the Palestinian physicians into the Israeli health system and thus may create negative feelings. A high level of training in Israel together with the unstable political and economic environment in the West Bank and Gaza Strip may encourage a brain drain of the local health care system, since Palestinian specialists could leave the area for better and more stable health care systems abroad. Finally, the continuous training of Palestinians in Israel may continue the dependency of the health care system on the more developed Israeli system which will encourage the treatment of Palestinian patients in Israel without the creation of a large medical corps and with continued high costs to the Palestinians.¹⁷

Interim conclusions on the evolution of both the Israeli and the Palestinian health care systems in the past two decades, from the governmental perspective, emphasizes that the directors of these systems navigated them away from and contrary to MPB doctrine. Israeli health officials are more passive observers than players in the process. They don’t see the need to encourage cooperation to form a basis for future institutionalized cooperation that can in turn solidify a future peace agreement. The commitment of Ms Basa, the health coordinator in Haminhal Ha’Ezrahi, to encourage such cooperation is the exception to the rule. The official Palestinian – stance is anti-cooperation with the Israelis for the training of their physicians. They prefer to receive aid from the donor community, while denouncing Israel with disregard for the potential benefits of such cooperation. The passive and even hostile standing of the Israeli and Palestinian officials on the issue of training stands in contradiction to actual events. From the mid 1990s hundreds of Palestinian physicians trained in Israel in short and long programmes. In spite of recurrent cycles of violence, the overall number is on the rise.

The grassroots level

MPB theory generally mentions the involvement of health professionals mainly from outside countries which have no direct interest in the conflict. In practice, any health issue has its own professional demands and internal circumstances that are most influential in the evolution of MPB. In this paper, the main health professionals identified as crucial for training from the Israeli perspective are the hospital directors, heads of hospital departments and directors of NGO programmes. From the Palestinian perspective, the influence of the hospital directors is as important as the personal needs and rational decision-making by hundreds of individual Palestinian physicians. As shown below, this group is responsible for the increase in the number of Palestinian physicians who are training in Israel and for their effect on the quality of Palestinian health care.

The directors and department heads in Israeli hospitals did not approach the training of Palestinians in their hospitals with knowledge in MPB theory. For some hospital directors and department heads such training in their departments may also have a negative impact. For them, training non-Palestinian physicians is easier because it does not create political tension amidst the medical staff or patients. Another advantage when working with non-Palestinian physicians lies in the fact that they will not be detained at roadblocks or have other security issues. Finally, the presence of Palestinian residents (sometimes with Israeli Arabs) along with Palestinian patients may induce tension amidst the large Jewish population, who may view the hospital as less than loyal to its original goal of serving them.¹⁸

In spite of their fears, the Israeli hospital directors and department heads claim that for two decades they have supported such endeavours for several reasons. First, they see a direct link between humanitarian aid (treatment of Palestinian patients) and the training of Palestinian physicians. In that aspect they are committed to providing medical care to Palestinian patients who do not receive proper care in their hospitals. Second, they see eye to eye with the officials in the Ministries of Foreign Affairs and Health who claim that it improves Israel’s image in the world. Some of them hope that a constant increase in the number of Palestinians trained in their departments will support a viable Palestinian medical system which is in dire need of specialists.¹⁹ Finally, those interviewed showed confidence that their treatment of Palestinian physicians will increase the trust between the two peoples, Jews and Palestinians. For Prof Eitan Kerem, Chairman, Department of Paediatrics, Hadassah hospital ‘In the Mount Scopus department there is a physician whose sister was killed in a terror attack on a bus. There is a physician who was badly wounded in another terror attack. She and her husband were in intensive care for two weeks … there are not a few who live in settlements [in the West Bank] … yet the atmosphere is wonderful’.²⁰

Most Israelis also admit that the training is not only a philanthropic endeavour or part of planned national strategy. They identify a need in the Israeli hospitals for such activities. Israeli hospitals suffer from a shortage of cheap trained available physicians. The presence of Palestinians and other trainees from countries such as China, Cyprus and Georgia help to fill the shortage in manpower. The presence of Palestinian physicians also assists the Israeli medical system in dealing with the Arab minority which comprises approximately 20% of the country’s population. Finally, in one particular case, MPB theory was part of a strategy by the Wolfson Hospital management in the late 1990s to justify the development of a new cardiovascular department to treat children from outside of Israel, many of whom are Palestinians. In this department, they also train Palestinian physicians. To summarize, a mixture of ideological, political and professional calculations are pushing the scale towards acceptance of Palestinian physicians in Israeli hospitals. In most cases, however, the Israeli hospital department heads admit that they were not active in the recruiting stage of Palestinian physicians. With the exception of Hadassah Hospital in Jerusalem, no other Israeli hospitals have permanent programmes for recruiting Palestinian physicians.

From the 1990s, NGOs have been the second crucial agent involved in the training of Palestinians physicians. The Palestinian Israeli Peace NGO Forum recorded more than a hundred Israeli and Palestinian organizations which maintain constant cooperation in different fields. From the late 1980s and especially since the signing of the Framework Agreement, three NGOs have been involved in the work of training Palestinian physicians in Israeli hospitals: the Swiss Karl Kahane Foundation, the Peres Centre for Peace and Save a Child’s Heart (SACH). These organizations raise funds and have special divisions for the sole purpose of training Palestinian physicians in Israel. They maintain contact with Israeli hospitals and induce them to accept Palestinian physicians for training. They also engage with Palestinians to encourage them to apply for positions in Israeli hospitals.

The Karl Kahane Foundation is Swiss. It was the dominant programme for training Palestinians physicians in the 1990s. The Foundation funds full residency in Hadassah hospital in Jerusalem (one of the top secondary and tertiary medical centres in Israel). The Kahane Foundation estimates that from 1987 to 2013 they have been responsible for the full training of close to 50 Palestinian physicians. Their work is held in high regard by Israelis and Palestinians alike.²¹

The second NGO with the largest turnover activity in this respect is the Peres Centre for Peace. The Peres Centre, established in 1996, is committed to the promotion of cooperation with the Palestinians on economic, cultural, social and medical levels. The Centre is known mainly for its support for humanitarian aid for the treatment of thousands of Palestinian children in Israel. From 1999, however, it has also developed a unique programme for the training of Palestinian physicians with French and Danish funding.²² Unlike the Kahane Foundation, the Centre’s programme provides financial support for a fellowship of one to two years, but not a full residency. Since the Israeli Ministry of Health allows the trainees to do medical shifts for a salary after only a year of training, trainees can fund their own stay in Israel by working in the departments. This strategy was successful in terms of quantitative measures and since its inception the Centre receives dozens of Palestinian applications each year. In the Peres Centre, they say that their strategy created a win-win situation for Israelis and Palestinians. The Palestinians receive at least minimal quality training; even the small Israel hospital salaries are better than the small salaries from the PA governmental hospitals; since Israeli hospitals are short of trained physicians, they tend to welcome these trainees; the Palestinians hope that the various department directors will take an interest in them and support their applications for full residency.

Based on the Peres Centre model, SACH – founded in 1995 and committed to heart treatment for children in developing countries – developed a special training programme for Palestinians in the last decade. Their programme works only with the medium size Wolfson Medical Centre (400–600 beds) on paediatric cardiology, cardiac surgery, anaesthesia and paediatric intensive care. They adopted the Peres Centre model and are being funded by private, European Union funds and sometime by the Peres Centre. In recent years, however, they have begun training for full residency.

Unlike the directors and heads of departments in Israeli hospitals, the directors in the Peres Centre for Peace and SACH are well informed in MPB theory. Dr Ron Pundak was in the team that drafted the Oslo Accords by employing ‘Track-II diplomacy’; Dr Dan Shanit founded the health division in the Peres Centre and is committed to improve cooperation between the two peoples; the executive director of SACH, Simon Fisher, is a lawyer by training who says that he learned of MPB by experience. Pundak, Shanit, and Fisher criticize the governments of all sides. They criticize the lack of Israeli government support for development of the Palestinian health system. They also criticize the Palestinians for preferring narrow political gains rather than improving their health care system. They reject the accusations that the funds for training could have gone directly to Palestinians. They show that these programmes are being funded mainly by wealthy Jews or by European and American programmes such as ‘people to people’ funds for the specific objective of promoting cooperation. They also show that they are working against the threat of a Palestinian brain drain. To achieve this goal, they developed a unique system in the Peres Centre for Peace that was later adopted by SACH. In this system, a Palestinian trainee must bring an official commitment from the PA Ministry of Health that it is willing to employ him in a government hospital after the training period. On his part, the trainee must sign a document in which he promises to work in the government hospital for several years. The short programme prevents the trainee from receiving a specialist certificate, thus making it difficult for him to look for work in Western countries. Moreover, because he was trained in Israel, the trainee sometimes find it difficult to work in Arab countries. Therefore, the training programme creates a ‘professional trap’ which induces the Palestinian physician to remain a part of the local Palestinian health system.

The joint work by the Israeli agents creates the basic organizational and professional platform for the training of Palestinian physicians in Israel. The Israelis believe that the advantages of such programmes overcome the disadvantages on their side. Thus, they ignore that most of the time their programmes work without a real assessment of the needs of the Palestinian health care system. Part of the reason is that they do not initiate studies to examine what the needs of that system are. Another reason is that most trainees are accepted after sending a short letter of application, a CV and being interviewed by an NGO representative and an Israeli hospital department head. Most of the time, the Israelis have no problem with this mode of work because they can continue in their programmes as long as they can convince the Western donor community and wealthy Jews that such endeavours are beneficial to cooperation and to improvement of the Palestinian medical capabilities. Not all Israeli agents, however, are content with the two decades of cooperation. They share their concerns that in the long run, the Palestinians will be less inclined towards such cooperation. Although the number of Palestinian trainees is on the rise, there is no permanent mechanism to maintain cooperation in the long run. A look at the Palestinians reveals a mixture of interests regarding the training in Israeli hospitals. The average Palestinian physician is a product of dozens of countries’ medical schools. Of the 959 physicians who were recognized as specialists by the PMC from 2000 to 2010, only twelve graduated from a Palestinian medical school. The main six countries for training were from Russia (167), Egypt (97), Romania (94), Israel (91), Ukraine (75), Jordan (71) (PMC 2011, 102–103).²³ There are several explanations to the wide diversity in the education of Palestinian physicians. First, as mentioned above, there are only three medical schools in the West Bank and Gaza Strip. The admissions requirements are strict and tuition high. The Israeli Defence Force (IDF) roadblocks in the West Bank and the periodic fighting as well as high unemployment make it difficult to sustain studies in these schools for six years. Finally, the main and best medical training centres to practice in their final learning stages are situated in East Jerusalem under Israeli control. Therefore, in many instances, going abroad is easier. The large Palestinian diaspora sometimes provides a global network of support. Many teaching universities in East Europe are cheaper than the Palestinians ones. They also provide more possibilities for future work. This trend encourages a Palestinian brain drain.

After graduation, a new challenge is presented to the average Palestinian physician who aspires for specialization in Palestine. As mentioned above, the regulation of the specialization process was decided only in December 2008. Palestinian and Israeli interviewees suggested that the specialization programmes are not recognized or supervised by top Western medical authorities. There is lack of congruence between the local curriculum of training and the highest Western standards. Moreover the locally trained Palestinian specialist lacks in knowledge and skill to train new physicians in comparison to a specialist from the Western hemisphere. In the words of a Palestinian professor, ‘We have only one properly trained neurologist. We have people who call themselves neurologists but they are not properly trained.’²⁴

A second problem is that there are only few good places to specialize in the West Bank. Many Palestinians mentioned that the main hospital for Palestinian training is Al-Makassed in East Jerusalem which is under Israeli control. Because Israel’s Health Ministry supervises the Palestinian hospitals in East Jerusalem, it refuses to allow Palestinian physicians from Al-Quds University to be trained in these hospitals since it doesn’t supervise the university’s curriculum. Other physicians are also under scrutiny. This is explained by Israeli health officials as a necessity to ensure a suitable level of health care. It is less understood by Palestinian physicians and hospital directors in East Jerusalem who sees it as a way to politicize and control training.²⁵ In order to bypass these difficulties the Palestinian Medical Council encourages applying for short fellowships or to try and establish a full residency by creating a conglomerate of hospitals in the West Bank that together could offer a better residency programme.

The alternative for such programmes is to initiate periodic visits by foreign specialists to the Palestinian hospitals. The idea’s rationale is that resident physicians can learn from them. These specialists, however, are expensive and they arrive for short periods, while full residents need constant supervision throughout their training.

None of these improvised solutions are available to the Palestinian physician in the Gaza Strip which has been subjected to an Israeli blockade since Hamas usurped the PA institutions. According to the current Minister of Health, Prof Hani Al-Abdeen, the Palestinian trained in Gaza ‘is at a dead end […]. He has to leave Gaza. They don’t train postgraduates in Gaza […] So, when he finishes his sixth year he has to leave Gaza and train outside’.

Other specialization alternatives are also scarce. In Western countries and especially the United States, there are more limitations on the issuance of visas to Palestinians. The competition for residency programmes in Western countries is much tougher. Moreover, these programmes are very expensive. There are similar problems in advanced health care systems in rich Arab countries. Finally, the search for better training encourages the local Palestinian to emigrate from the Palestinian territories. A clear exception to this situation was Qatar’s financing a full residency programme with a cost of three million dollars for 10 Palestinian physicians from 2005 to 2009 Qatar News Agency (QNA 2009). While being supportive of the Qatar model, the Palestinian Ministry of Health is reluctant to encourage the specialization of Palestinians abroad from the simple fear that it will encourage the constant brain drain. It cannot, however, resist the temptation of such prestigious residency programmes if offered. In this case, it is clear that the Qatar offer was an exception.

Therefore, in many instances, Israeli fellowships or residency programmes are very attractive to Palestinian physicians. These programmes are cost free. Even if most of these programmes are short, they allow the Palestinian physicians to gain experience by training in Israeli hospitals which work under Western regulations. Moreover, all the interviews pointed to the high regard Palestinians feel towards the Israeli medical capabilities (Abuelaish 2011). Some of the Palestinians hope that even a short fellowship will give them an edge in their career. After six months of work in an Israeli hospital, they can be part of the department rotation and earn approximately 1300 dollars per month. This salary is similar to the average salaries in governmental hospitals. For others, the prospect of full residency is a ticket to ensure their careers in Palestinian hospitals. The geographic proximity offers other advantages. It allows the physician to keep in contact with his family. It is also a guarantee that in later years, he will be able to bring his patients for consultation with Israeli colleagues.

The argument above explains why in spite of the official Palestinian stance against cooperation, for hundreds of Palestinians physicians training in Israel is a positive career move. For the Palestinian physicians, the Israeli training programme increases their status in their government’s hospitals and in their society. After completion of the residency programme and receiving the specialization credit from the PMC, they will not have to do duty roster in the government hospitals. Their work hours will decrease from the morning to noon and their chances to be appointed as department heads increase. They can also open private clinics that will dramatically increase their basic government salaries.

From the above analysis, it seems that in the past two decades the training of Palestinian physicians in Israel has implemented MPB theory during conflict. Palestinian physicians, however, still confront many challenges. For lack of funds, many Palestinians are being turned down for such programmes. Others have to learn the language and culture quickly to be part of the staff. The Peres Centre sponsors short courses in Hebrew. These activities, however, are not sufficient to ensure acceptance in the Israeli health care system. Daily routine forces the physicians to deal with Israeli society which is sometimes hostile. Moreover, most of the information they have on Israel comes from their direct experience, their families, the PA official statements and from Palestinian news agencies. The Israeli hospitals do not have special departments to ease the transition phase. As a result, sometimes the trainees may feel isolated. Short-term fellows are more likely to feel unequal and frustrated. Furthermore, because the first year is the toughest, there is the danger that Palestinian trainees will transfer professional for political criticism. In two incidents, Palestinian physicians were frustrated at being posted to provincial Israeli hospitals. Finally, even when they work in Israeli hospitals, they see that they are still being treated as regular Palestinians. Thus, they must leave cars at the IDF’s roadblocks and then take several buses to the hospital. Many times they have to stand in long lines early in the morning. The physicians also fear that their decisions may turn their own society against them. In this study, it was clear that Gaza physicians are more afraid than their counterparts from East Jerusalem or Ramallah. Several trainees feared that because they have better training, sometimes even in comparison to Palestinian specialists, the political card will be played against them by the Ministry of Health representatives, in the Palestine board exams, and in the hospitals. In spite of all the difficulties, the number of Palestinian applications in Israel is constantly on the rise.

Taken by itself, it is hard to bridge the gap between the individual will to be trained in Israel and the official PA government’s hostile position towards medical cooperation with the Israelis. From the study it is clear, however, that several hospital directors and mid-ranking officials in the Palestinian Health Ministry support cooperation with the Israelis and oppose the official PA stance. The explanation for this is that the training of Palestinian physicians in Israel is a political as well as a professional decision. Thus, some interviewees pointed out that several directors in East Jerusalem hospitals are politicized – meaning that they oppose cooperation with Israelis. In contrast, others point to the fact that it is difficult to know who is supportive because all directors are under constant pressure from the PA, public opinion, and the Jordanian Medical Association, which works closely with Palestinian hospitals in the West Bank. For example, this kind of pressure forced the termination of joint seminars held by Al-Makassed hospital and the esteemed Israeli Hadassah University Hospital in Jerusalem.

In several cases in the West Bank, government hospital directors encouraged Palestinian trainees to go and train in Israel, promising to give them positions upon their return. In one specific instance, it is clear that a government hospital director in the West Bank paid full salaries for trainees in the Israeli hospital by funnelling funds received from both Israeli and foreign donors. His goal is to train full medical teams by giving them full residency and make them come back to the Palestinian hospital. This will allow him to open new specialized departments in the hospital. This training is not being publicized in order not to aggravate high-ranking officials in the Ministry of Health or the public.

A good example of the potential and problem of medical training can be seen in Augusta Victoria hospital in East Jerusalem, run by the Lutheran World Federation. From the 1950s, this hospital specialized in treating Palestinian refugees. During the 1990s, however, UNRWA, the international authority responsible for the treatment of Palestinian refugees, decreased the number of patients due to the high cost of treatment. Moreover, the collapse of the Oslo Accords and the rising violence between Palestinians and Israel security forces encouraged the building of a security fence and roadblocks, which made it difficult for Palestinians to reach the hospital. As a response to these challenges the hospital’s CEO, Dr Tawfiq Nasser, developed the most advanced cancer centre in the West Bank. The Palestinian Ministry of Health, which claims sovereignty in East Jerusalem, did not take part in this important health project. The Israeli Ministry of Health, which is the de facto regulator, baulked at authorising the programme until it was certain that other Israeli hospitals would not follow suit and request new cancer treatment centres for medical tourism. The main funds came from the Lutheran World Federation and other EU countries and American support. The Peres Peace Centre provided important logistic support. It also created the connections between Dr Nasser and Hadassah’s department heads who treated cancer patients in order to encourage full residency programmes for Palestinian physicians. Some of the physicians continued to work in the hospital and maintain contact with Israeli hospitals in West Jerusalem. Others, who were not qualified to work in the field or were bitter with Palestinian management, left the field. This successful example was achieved without the support of the Palestinian or Israeli Ministries of Health. It was initiated due to economic necessity, the vision of a Palestinian director who saw the benefits of working with Israelis and foreign financial support. Finally, Israelis and Palestinians are cooperating on a permanent professional basis (Lutheran World Federation Jerusalem Programme 2011).²⁶

Conclusion

During the twentieth century medical cooperation between Jews and Arabs in the territory of west of the Jordan River was limited. Health became another field of contention between the two peoples. The Framework Agreement from 1993 promised to settle the protracted conflict by advancing separation of the two nationalities. Unfortunately, the tensions, suspicions and cycles of violence continued. Both parties’ governmental representatives were reluctant to cooperate and didn’t show understanding of the other side’s needs. They usually perceive the ‘other’ as an enemy. By doing this, they are expanding the fields of conflict to health and failing to build bridges for future cooperation. This conclusion should also be a warning sign against the simplistic execution of MPB theory. As was shown in this paper, any medical action such as humanitarian aid, movement of medical staff or the work of Palestinian physicians in East Jerusalem becomes a contested action.

In spite of these grim findings, many Israelis and Palestinians who were interviewed agree on an ideal model that should be advanced as part of other development programmes of the health sector in the Palestinian territories. They claim that the cooperation should result in the training of Palestinian medical teams for periods of 5–10 years. The teams should include full residency programmes in various department specializations, for technicians and nurses as well. They see this as a better model for several reasons: the hospitals are relatively close, it will increase the total number of trainees; it will assimilate the most advanced working norms practiced in Israel and modelled to the norms of Western hospitals in the Palestinian medical core; it will encourage long-term consultation between professionals and with it the building of trust between all participants on more equal terms; the team could then train other teams and increase the overall professional level in Palestinian hospitals and thus create advanced secondary and tertiary medical centres which in turn could provide employment for thousands of Palestinians and become a symbol of development for the society.

The gap between the ideal training model and the uncooperative stance of the two governments was not dominated by political estrangement. While MPB theory insists on government involvement, it is clear that many of the achievements made by Palestinians training in Israel in the past two decades are due to local needs and necessities as well as positive perceptions of the other by thousands of individuals.

This article shows that mutual beneficial cooperation has planted the seeds for future cooperation. Moreover, future studies should also examine how health and other social areas, perhaps provide parts of the explanation why this specific protracted conflict remains stable.

The incentives for such cooperation are different. For the Israelis, cooperation is something to be done while making sure that it will not force them to make too many concessions. Hundreds of people involved in the training of Palestinians see political, professional and moral benefits in this practice. For them this action is a vote of confidence in their system and in the possibility of a future of professional cooperation with Palestinians, as they work with other counterparts around the globe.

For the Palestinians, training in Israel is a professional opportunity that solves individual career needs and helps to create and sustain new tertiary capabilities. What is clear is that in spite of the many difficulties facing Palestinians trained in Israel, the number of Palestinians turning to Israel for training is constantly on the rise.

This grassroots action is under constant threat by the political level which is present usually as an obstructive element. Therefore, most people interviewed for this study hoped that the shadow of politics on health would be removed, so that cooperation, development, and trust will become a joint strategy for both parties on all levels.

Notes on contributor

Chen Kertcher received his PhD from Tel Aviv University in 2010 for his dissertation. The United Nations and Peacekeeping in Cambodia, Former Yugoslavia and Somalia, 1988–1995. During 2010–2013, he was a research fellow in the Tami Steinmetz Centre for Peace Research in Tel Aviv University. From 2013, he is a research fellow in the Herzl Institute in Haifa University for his research on the United Nations, Israel and the war on terror. He lectures on global history, conflict resolution, peace building and peacekeeping operations in Tel Aviv University, Haifa University and the Interdisciplinary Centre in Herzliya (IDC).

Acknowledgement

This article is part of a research project that was funded by the Tami Steinmetz Center for Peace Research in Tel Aviv University. I am grateful for Mottie Tamarkin, Ephraim Lavie and the anonymous reviewers for their useful comments.

Notes

1. Haminhal Ha’Ezrahi is subordinated to the The Coordinator of Government Activities in the Territories (COGAT) which is a unit in the Israeli Ministry of Defence which responsible for coordination of civilian issues between the Israeli government offices, international organizations, foreign governments and the PA.

2. The Israeli health system confronts several challenges that may change its policy in future years. The ratio of trained physician is in decline in comparison to population growth. There is growing shortage in several fields such as anaesthesia, intensive care, pathology and geriatrics. Due to low salaries to young physicians, there is a constant brain drain. All in all, the Israel Medical Association official documents warn that the Israeli health system will deteriorate during the second and third decades of the twenty-first century.

3. Prof Alex Leventhal, Director of the Department of International Relations, Israel Ministry of Health, Telephone interview by the author, 10 April 2011.

4. Dr Amir Shanon, Director, Department of Medical Professions, Israel Ministry of Health, Interview by the author, Tel Aviv, 25 March 2011.

5. Brigadier General Yoav Mordechai, Chief of Civilian Administration, COGAT, Interview with the author, Tel Aviv, 19 December 2010.

6. An undisclosed high ranking official in an Israeli hospital in Jerusalem, Interview with the author, Jerusalem, 30 June 2011.

7. Ms Dalia Basa, Health Coordinator, Civilian Administration, Interview with the author, Jerusalem, 26 April 2011. Palestinians who were interviewed for this study confirmed her unique efforts to help them.

8. Undisclosed Palestinian official, interview with Author, Jerusalem, 23 March 2011.

9. PNA, Ministry of Health, Palestinian National Health Strategy 2011–2013, Setting Direction Getting Results (Ramallah: PNA-MH, 2010).

10. Undisclosed Palestinian Physician, interview with author, Jerusalem, 24 March 2011.

11. Ms Tamara Barnea, Director of the JDC’s Unit for Disabilities and Rehabilitation Israel, Interview with the author, Tel Aviv, 28 September 2010; Prof Shaul Harel, retired paediatric neurologist at theTel-Aviv Medical Centre, interview with author, Tel Aviv, 5 August 2010.

12. Prof Shlomi Constantini, director of the Department of Paediatric Neurosurgery at theTel-Aviv Medical Centre, Interview with the author , Tel Aviv, 31 August 2010; Prof Harel, interview; Dr Dan Shanit, former Director of the Medicine & Mealthcare Department, The Peres Centre for Peace, Interview with the author, Tel Aviv, 31 August 2010.

13. This line of criticism was raised by Palestinian and Israeli physicians.

14. Several high-ranking Israelis and Palestinian government officials and physicians pointed on this issue. They also demanded that their name will be omitted for fear of negative repercussion.

15. Dr Shanit, interview.

16. Ms Rachel Harari, Director of the Medicine & Mealthcare Department, The Peres Centre for Peace, Interview with the author, Tel Aviv, 5 April 2011; Dr Ron Lobel, Depurty Director at Barzilai Hospital, Interview with the author, Ashkelon, 8 October 2010; Undisclosed Palestinian Physician, interview with author, Tel Aviv, 8 March 2011.

17. These arguments were raised by several Palestinians who were interviewed. It seems that the higher the rank of the Palestinian medical personal there was also a rise in the suspicion towards Israeli initiatives.

18. The danger in Palestinian medical tourism – from the perspective of Israelis – was mentioned also in several interviews especially in the context of the work of two children’s medical centre, Schneider and Safra, in the centre of Israel. See also: Linder-Ganz, Roni, ‘This is How medical tourists put Israeli patients in danger in the hospitals,’ The marker, 15 November 2011. http://www.themarker.com/consumer/health/1.1566547.

19. Dr Gil Fire, Deputy Director, The Tel Aviv Sourasky Medical Centre, Interview with the author , Tel Aviv, 17 May 2011; Prof Eitan Kerem, Chairman, Department of Paediatrics, Hadassah Ein Karem, Interview with the author, Jerusalem, 11 April 2011.

20. Prof Eitan Kerem, Chairman, Department of Paediatrics, Hadassah Ein Karem, Interview with the author, Jerusalem, 11 April 2011.

21. Personal document received from the Foundation, 6 May 2011; see also the official site of the foundations www.karlkahanefoundation.org. All Israeli and Palestinian physicians who work in Hadassa and Dalia Bassa praised this programme.

22. Ms Gitte Hundahl, Deputy to the Denmark Ambassador to Israel, Interview with the author, Tel Aviv, 17 March 2011; Dr Ron Pundak, Director of Peres Centre for Peace, Interview with the author, Tel Aviv, 5 April 2011; Shanit, Interview.

23. PMC, Palestine Medical Council Guide: Laws-Bylaws-Rules (Ramallah: PMC 2011), 102–103.

24. Undisclosed Palestinian Physician, interview with author, Jerusalem, 24 March 2011. This statement received support by other Israeli and Palestinian physicians who claimed that in many instances there is a gap between the Western criteria for specialists and Palestinian criteria.

25. Dr Amir Shanon, Interview; Undisclosed Palestinian Physician, interview with author, Jerusalem, 4 April 2011.

26. Shanit, Interview; Prof Michael Weintraub, Chairman of the Paediatric Hemato-Oncology, Hadassa Hospital, 13 March 2011; Undisclosed Palestinian physician, interview with the author, 28 February 2011.