Peace-building through health: challenges and opportunities for an American NGO working with Israelis and Palestinians

Current events around the world make peace-building more challenging than it has ever been. Yet many health professionals continue to engage in activities that bridge their Hippocratic Oath with community/country-wide and even regional activities that attempt to resolve conflicts. This commentary will summarize the efforts and highlight the challenges of one organization, Healing Across the Divides, in its efforts to improve the health of marginalized populations and sow seeds of peace in an intractable peace-building challenge, the Israeli–Palestinian conflict.

While developed only in the past 25 years, the idea of ‘Peace through Health’ has achieved significant importance, most evident with the award of the Nobel Peace Prize to International Physicians for the Prevention of Nuclear War in 1985 (Nobelprize.org). Despite these achievements, I would like to state at the outset that I do not believe in the phrase ‘Peace through Health’ as first articulated by the health professionals working at the World Health Organization in the early 1990s¹. However, I completely agree with the concept that health professionals working in their professional capacity can contribute to peace-building through health. Peace through health (or any other area) is a political process and requires the intervention of individuals/groups that have political standing (‘multi-track diplomacy’, as it is called in the jargon of peace-building). In contrast, peace-building through health consists of creating ‘an environment that increases people’s investment in peace and can reduce, if not relieve, tensions that contribute to conflict’ (Rubenstein 2010).

Healing Across the Divides is an organization that is committed to peace-building through health. Its mission is health improvement of women and individuals with common chronic diseases such as diabetes via community-based interventions. Funding for Healing Across the Divides comes from both American private donors and foundations; there is no government funding. Peace-building through health is an expectation and a mission objective, but considering the ongoing challenges in the Israeli–Palestinian conflict, it is our position that peace-building through health should not be the overarching focus; it is a hoped for by-product. If we make peace-building through health our overarching focus we will be just another organization that has entered into the Israeli–Palestinian conflict, many of which have spent not insignificant sums of money with minimal impact on the lives of any Israelis and Palestinians. Instead, Healing Across the Divides aims to, at a minimum, improve the health status of Israeli and Palestinian marginalized individuals. We have other objectives, too, in the area of peace-building through health, some of which we have achieved and which will be detailed in this paper.

Below, I outline the context in which Healing Across the Divides is working, in terms of how the agendas of donor agencies play into the conflict. I then briefly describe some of the peace-building through health tools that are relevant to our work, and say more about how Healing Across the Divides seeks to work.

Donors in health care delivery in Israel and the Palestinian Authority

Official and private aid to Israel and Palestine is heavily bound up in the structure and politics of the ongoing conflict. The United States provides billions of dollars to the Israeli government directly for military aid but indirectly this assistance provides support for the Israeli occupation of the West Bank. Americans and Europeans also allocate significant resources (billions of dollars) to improving the organizational capacity of the Palestine Authority which governs the West Bank. Without this aid, simply put, the Palestinian Authority could not subsist on its own resources.

Since the founding of Israel, American individuals and foundations have also provided billions of dollars in infrastructure funds for the Israeli government and to the Israeli people. On the Palestinian side, there is modest charitable American aid provided under provision 501 c3, providing support to the Palestine Authority. There are also a significant number of wealthy Palestinians living in the Gulf States, Europe, and the United States who contribute to Palestinian organizations. The US-based Ford Foundation, which did support civil society initiatives in the West Bank and Gaza, was criticized for supporting what some considered to be terrorist activities, and shifted its resources and made a significant financial commitment several years ago to the New Israel Fund (Black 2003). The Rockefeller Foundation continues to have a Middle East desk based in Amman, Jordan which provides modest support to civil society organizations in the West Bank and Gaza.

Although there are a huge number of other foundations and NGOs active in Israel, the West Bank and Gaza, governments have more leverage (political power) and also more means in comparison to private donors. Hence they can dilute out the efforts of alternative (non-governmental) efforts. This dilution increases the challenges for NGOs to have a measurable impact on either peace-building through health or the health of the population, but it does not make it impossible. It is in this environment that Healing Across the Divides seeks to work.

The tools of peace-building through health

Researchers and policy-makers have identified a number of specific tools that organizations have utilized to encourage peace-building through health (Rodriguez-Garcia et al. 2001). I will identify each of them separately with comments on their place in the Israeli–Palestinian conflict and in the operations of Healing Across the Divides.

Among these ‘peace-building through health’ tools, Healing Across the Divides, in particular, has advocated strengthening of communities. The objective behind the strengthening of communities/community-based organizations is not just to achieve health improvement for individuals, but to accomplish this within a community-based framework. It is disparities between communities that lead to disparity in health among individuals. At the same time, an important aim of our grant mechanisms is to strengthen leadership of these organizations. Healing Across the Divides believes that strengthening of communities via health can encourage already disposed leaders of these communities to collaborate with each other across divides. We hope that this type of collaboration across the divides will impact national leaders who are leaders in an ongoing conflict. We have seen this happen across religious and political divides, such as between Israeli Arab and Jewish community-based groups that we have funded and are now collaborating to press the Israeli government on health care inequalities.

Communication of knowledge is another important ‘peace-building through health’ tool. Healing Across the Divides places significant value on training individuals and local organizations in research and evaluation techniques, which are critical to the success of any community-based health intervention.

Personalizing the enemy is another ‘peace-building through health’ tool that attempts to put a human face on suffering that occurs on both sides of the conflict. Healing Across the Divides, Physicians for Human Rights – Israel, and other organizations, have tried to do this. Healing Across the Divides has sponsored speaking tours in the United States of directors of projects aiming to improve diabetes care among Palestinians living in the West Bank, early detection of breast cancer among orthodox Jewish women in Jerusalem, and health improvement among Arab or Palestinian women living in extremely impoverished conditions in the northern part of Israel.

Another peace-building through health tool is ‘construction of goals in common’. It attempts to thread a needle between opposing sides on initiatives where there might be agreement. Bridges, a publication of the World Health Organization, which has both Israeli and Palestinian health professionals on its editorial board, has tried to do this with modest success (Bridges Magazine nd). Unfortunately, the articles themselves are somewhat generic and there appear to be few concrete joint projects that have emerged from this publication. But the publication is an example of construction of goals in common. While Healing Across the Divides does not demand that groups work together on projects, we do bring the organizations together for regular meetings. The meetings themselves do not constitute construction of goals in common, but groups that have attended these meetings have begun to work together across the divides.

Beyond the work of Healing Across the Divides, other activities relevant to peace-building through health are being practiced by medical and health personnel. Health professionals in the Israel–Palestinian conflict have always given of themselves for the treatment of individuals suffering on the other side of the conflict on an altruistic basis. Israeli health professionals – both Jewish and non-Jewish – practice this on a daily basis, particularly in Israeli hospitals. Physicians for Human Rights – Israel, in particular, has engaged in this important ‘peace-building through health’ tool and has directly contributed to saving the lives of thousands of Palestinians.

Medical professionals can also extend solidarity merely by their presence and use of their clinical skills; that is, by risking their own lives to treat people in war zones. Physicians for Human Rights – Israel has done this extensively and was extremely supportive of Palestinians in Gaza and the West Bank during the most difficult and personally endangering times of the first years of the second Intifada which began in 2000 (Physicians for Human Rights – Israel 2003).

‘Non-co-operation and dissent’ describes the refusal of medical personnel to participate in what are considered unjust war campaigns of their governments. In my view, this has happened only minimally on the part of Israelis or Palestinian health professionals in the Israeli–Palestinian conflict.

Healing across the divides

Healing Across the Divides does not fund any political/policy campaigns, efforts to promote democracy or any efforts to explicitly influence governmental policy. As stated in the introduction, it is unclear what if any impact has occurred with grants that explicitly focus on democracy building or increasing civil society (Challand 2009). There is no question that these grants have also increased the ire of governmental policy-makers in both Israel and the Palestinian Authority. We rather espouse a peace-building through health perspective that ties together individual health improvement via community-based interventions with attempts to build bridges across the many divides in the Israeli–Palestinian conflict.

Healing Across the Divides is specifically focused on initiatives to improve women's health and common chronic illness. We only support community-based organizations. We do not insist that the groups that we fund within Israel or the West Bank (we hope to be operating in Gaza by the end of 2011) work together. While they meet each other on a regular basis especially those within Israel (there are still significant physical/time/check point barriers for groups that we fund in Bethlehem and Ramallah in the West Bank to meet) they almost never work together. We have fostered communication between Palestinian groups living in Israel and their counterparts in the West Bank. While outsiders might presume that this communication between Palestinians on both sides of the Israeli–Palestinian conflict occurs frequently, in fact this is not the case.

Under the guidance of a Board of Directors and Board of Scientific Advisors, Healing Across the Divides pursues initiatives that have resulted in documented improved health status of the population served in the areas of women's health and/or common chronic illnesses such as obesity, diabetes: today's epidemics. We also aim to increase awareness, on the part of policy-makers and other interested parties, of the obstacles to improvement in the health of both populations.

Healing Across the Divides has provided extensive training to community-based groups on both sides of the Green Line on evaluation of health care interventions; quality improvement techniques and organizational capacity building. In peer reviewed publications, community-based organizations partially funded by Healing Across the Divides have documented health disparities and programmatic impact on health of Palestinian diabetics, Orthodox Jewish women, and Palestinian women in the West Bank (Ghosh et al. 2007; Khatib et al. 2007).

Given the fact that foundations have had a significant role on both sides of the Israeli–Palestinian conflict, we've tried to encourage policy engagement and financial partnership with foundations – wherever they might be, whatever might be their political inclinations. Thus far we have worked collaboratively with two Israeli and one American Jewish Federation (city-wide Jewish organizations that fund both in the city and beyond). These groups are, for the first time in their history, willing to fund both Jewish and Palestinian organizations within Israel. This collaboration has resulted in a call for proposals in the area of women's health. Approximately 100 proposals were received and we have funded five organizations. On the Palestinian side, we are in the middle of exploring a major initiative to treat the rapidly rising incidence of breast cancer with the Friends of the United Nations Relief Works Administration (UNRWA) and the part of UNRWA itself serving Palestinian refugees.

Conclusion

Is it realistic to achieve peace-building through health in the Israeli–Palestinian conflict beyond individual health improvement? From my perspective, the answer is an unequivocal yes, as long as the terms are acceptable to both sides in the conflict and are endorsed by non-governmental groups that have significant standing within their own societies. Such an approach provides non-governmental groups with a space for autonomy, that is, choosing the means to organize the group and the vocabulary to refer to this organization's priorities. At a minimum, Healing Across the Divides has documented health improvement in diabetes and women's health in approximately 15 sites in both the West Bank and Israel. In addition there has been increased communication between groups and increased strength of community-based groups.

In what ways if any can we say that health programmes – especially health programmes based on quality improvement – contribute to long-term political stability or peace? In this commentary I've tried to argue that interventions that focus on community-based improvement from the bottom up can interact with other programmatic interventions occurring ‘across the divides’. We believe that communities engaging in these interventions can eventually ‘meet’ in a mutually reinforcing manner and even promote national political changes coming from the top down.

At the same time, would it be intellectually more honest to say that the current political stalemate is overwhelming any political impact of health improvement via community-based interventions? Was there a time when peace-building through health initiatives had more promise, or is now a time when these efforts are even more important? Even though I personally believe that we have come to the end of a negotiated two-state solution, I would try to convince readers that now is the most important time. This is especially true in light of the significant political movement of attitudes and actions in both the Arab world and Israel. We must seize the moment to see if there are any mutually reinforcing community-based health improvements that can occur alongside political changes happening at a national level, distant as they may seem.

Note

1. Peace through health was defined in 1995 by the WHO as follows: ‘Health is valued by everyone. It provides a basis for bringing people together to analyze, to discuss and to arrive at a consensus acceptable to all. The potential for using health as a mechanism for dialogue and even peace, has been demonstrated in situations of conflict’ (WHO 1995). Put differently, in a recent United States Institute for Peace paper (Rubenstein 2010, p. 1) such initiatives are described thus: ‘They are premised on the idea that cooperation among health professionals and health interventions in conflict zones can contribute not only to improved outcomes for populations who suffer from the impact of war, but also to building a lasting peace’.

Note on contributor

Dr Norbert Goldfield is Executive Director of Healing Across the Divides ( www.healingdivides.org), a seven-year-old organization which serves to improve the health, within a community framework, of Israelis and Palestinians. Healing Across the Divides currently supports community organizations in their efforts to improve women's health and common chronic illnesses in approximately 25 sites in Israel and the West Bank. Dr Goldfield also works as an internal medicine physician and applied researcher, developing tools used in many countries linking payment with improvement in outcomes quality.