Mary Turfah ,?? ??? ?????? ??????? ???????? ?? ??? December 15, 2023

No Side to Fall In

Medical neutrality in Gaza Michael Loadenthal

A couple of weeks into the Israeli attack on Gaza, the Journal of the American Medical Association (JAMA) published an opinion piece titled “Health Professionals and War in the Middle East.” It largely focused on college campus debates around free speech and feelings of safety in the United States, conflating anti-Zionism with anti-Semitism and centering religion as the main issue abroad. It blamed Hamas for Israel’s attacks on Gazan hospitals, parroting the Israeli position—made in 2021, 2014, 2008-2009, and before the siege—that Hamas is “launching attacks from inside or near hospitals and using ambulances to transport weapons and military personnel.” The viewpoint article’s author then turned his attention to Israel, which “has promised not to target medical facilities unless they are being used for offensive purposes, which can make striking them legal under limited circumstances.” He adopts uncritically, over two hundred dead health care providers later, that the occupying power means no harm to “ordinary” Gazans, it’s just that “wartime creates impossible questions” (the question being, and I quote, “Even if it might be legal, is it morallyjustified to strike a medical facility based on intelligence that enemy fighters might be hiding inside along with injured children?”). Mightis the operative word. Racism is the operative framework, through which unsubstantiated Israeli “intelligence” has any currency. JAMA, among the foremost medical journals in the United States, leaves room to justify the targeting of hospitals in Gaza.

The next day, the American Medical Association’s (AMA) Board of Trustees released a statement insisting “it is critical that medical neutrality is observed because physicians and health care professionals must have the ability to carry out their work and administer urgent care to those in need.” “Medical neutrality,” as referenced by the AMA, was born out of war. The concept emerged in the mid-1800s as a way of guaranteeing the soldiers of warring European nations access to medical treatment, were they to “fall into enemy hands.” After helping to care for a volume of injured soldiers that overwhelmed the French and Sardinian armies’ medical services during the bloody Battle of Solferino in 1859, Henry Dunant wrote A Memory of Solferino. In it, he posed a simple question: “Would it not be possible, in time of peace and quiet, to form relief societies for the purpose of having care given to the wounded in wartime by zealous, devoted and thoroughly qualified volunteers?” In 1863, after spending a couple of years lobbying for support, he cofounded (and was later made to resign from) the International Committee of the Red Cross (ICRC). Because ICRC staff were civilian volunteers, their protection and assurance of their safety would require buy-in from warring parties. In exchange they would treat all comers—combatant and civilian—on both sides. That volunteers were initially recruited from nonpartisan bodies conferred “positional neutrality” in the ideological sense—battlefield grievances weren’t theirs. Medical immunity followed.

Guarantees to protect medical infrastructure constituted the basis of modern international humanitarian law. A resolution published following the Geneva International Conference proposed that “the belligerent nations should proclaim the neutrality of ambulances and military hospitals, and that neutrality should likewise be recognized, fully and absolutely, in respect of official medical personnel, voluntary medical personnel, inhabitants of the country who go to the relief of the wounded, and the wounded themselves.” To distinguish medical providers and prevent their targeting, they’d wear a “uniform distinctive sign”: “a white armlet with a red cross.” (The Ottoman Empire adopted a red crescent logo in the 1870s.)?In 1864, as the American Civil War thundered on, European nations met to ratify the First Geneva Convention; within a year, twelve signatories had committed to the principles that would become “inviolability of the wounded, the sick, and medical personnel,” and that the “members of the armed forces and other persons . . . who are wounded or sick, shall be respected and protected in all circumstances.”

Medical neutrality, then, offered a means to an end: medical immunity. Compliance was premised on the need for supplementary medical services by belligerent parties. This presented limitations, nowhere more visible—like all fissures in Europe’s human rights apparatus—than in Europe’s colonies. 1935 saw the first recorded instance of the ICRC engaging in what’s now called “humanitarian diplomacy,” in response to Italy’s efforts to colonize Ethiopia. (The British would take over this colonial project during World War II.) As a neutral body, the ICRC offered medical support to both the Italians and the Ethiopians; the former declined, as they had sufficient personnel and equipment, while the latter, after decades of de-development, welcomed the aid. The Italian military subsequently bombed over a dozen medical facilities clearly marked with red crosses, as part of their fascist aggression aimed at quelling native resistance through collective punishment.

War and occupation, like medicine, continue to evolve. Today in Israel and elsewhere, occupation soldiers injured on enemy soil are airlifted out of battlefields and taken to their own state-of-the-art military hospitals for treatment. Wartime illuminates the absurdity of ideological neutrality: a military doctor—operatively integral to and salaried by a military body—has functionally taken a side. “Neutrality” was never intended to be a moral commitment, but rather a means to immunity. The logic at Geneva went, “We mean you no harm, and we can help you, so kindly don’t hurt us.” For this reason medical neutrality is easily decoupled from immunity wherever medical services are not needed. It was a solution for a practical problem, and today, the Israeli military has no use for the ambulances, hospitals, and medical staff of Palestinians in Gaza; this disincentivizes, from a purely strategic perspective, commitment to their protection.

The legitimacy of the targeting of medical infrastructure and personnel from an ethical or moral perspective is a different issue. If Palestinian doctors in Gaza emphasize their ideological neutrality, focus on the need to mobilize rapid medical responses, and garner humanitarian support instead of assigning blame, these are (failed) attempts to protect themselves and their people’s hospitals. Tending—the very act of doctoring—amounts to siding, and Palestinian doctors are killed irrespective of the culpability they’re willing to articulate precisely because to act as a doctor in the face of an exterminatory project is a political act, a presentation of oneself and all the resources they’ve accumulated over decades as a final barrier against death. This, against an occupier committed to necropolitics—total control over the who and when and how of life and death, along with what happens to their bodies after. Through this lens, of course the doctor is a threat.

I was talking with my brother, a biostatistician, about the racism embedded in the selective conferral of medical immunity, and geography’s role in it. His science brain jumped to a four-case comparison, a two-by-two table I found helpful: the columns correspond to the physician’s identity, Western/Israeli and Palestinian; the rows correspond to hospital location, Palestine and Israel. In a hospital in Israel, the Western doctor is a “real” doctor, deserving of all protections. Their targeting—the hospital or the doctor—would be condemned in the strongest possible terms. The Palestinian in an Israeli hospital has his doctor-ness, and humanity, conferred so long as they’re within that institution’s walls. Once they step outside, they’re just as liable to be treated as Palestinian as anyone else. In Gaza, Palestinians aren’t human no matter where they go, and their hospitals aren’t hospitals unless proven otherwise. The Western doctor in Gaza gives a hospital some humanity, which is to say medical immunity. If Norwegian doctor Mads Gilbert says he’s never seen Al-Shifa Hospital used as anything except a hospital, his testimony helps. What are you doing in Gaza?Western interviewers ask, as if these doctors don’t belong in these hospitals, as if people don’t belong in Gaza, flickers of humanity out of place.

Per colonial logic, “neutrality,” like its cousins “objectivity” and “detached concern,” are internal states of which the irrational id-driven native is dispositionally incapable. For this, they have no right to medical immunity. Even the colonized doctor who hopes to get ahead of his people’s backwardness by living according to science, by condemning both sides and equivocating between occupier and occupied, walks on thin ice.

In a memoir called I Shall Not Hate, a Palestinian doctor who lived in Gaza and worked in Israel—until the start of the siege, after which he was denied freedom of movement—describes a scene where he is confronted by the racism of an Israeli patient’s husband questioning his ability to doctor (“He saw me first and foremost as an Arab”). The husband is taken to the head of the hospital’s office, where this Israeli colleague steps in to defend the Palestinian. He points at shelves of medical textbooks and says, “‘What [the Palestinian doctor] did came from these textbooks.’” The Palestinian doctor’s humanity is mediated by the allegedly Western knowledge he’s consumed. Medicine cloaks the colonized doctor in civility: no matter how good Palestinian doctors get, this knowledge—and the humanity it confers—will always be external to them. And regardless how much humanity they accrue, it can’t protect them outside of Israeli hospitals: despite investing the majority of his professional life in the Israeli medical apparatus, the Palestinian doctor’s house was bombed during Operation Cast Lead in 2009. Incredulous, he picked up his phone and called a news reporter friend on live air—he was well-connected, after all—to tell him what happened and insist the Israeli military, which controls the population registry of Gaza, had made a mistake. Then, the doctor and his surviving family fled for Canada. Exceptionalizing oneself, unfortunately, doesn’t lead to exceptions being made.

Foreign doctors working in Palestine over the years have documented their experiences. During the First Intifada in the late 1980s, a Chinese orthopedic surgeon volunteered at Al-Ahli Hospital, the one hospital in Gaza that didn’t provide Israelis with security information on admitted patients—as a Christian hospital, it seems they were allowed to answer to God. Recounting her time there in a memoir bearing the same title as Thomas L. Friedman’s inferior From Beirut to Jerusalem, the surgeon describes how on one occasion Israeli soldiers stormed her operating theater while she was in the middle of a surgery. They demanded she hand over her patient. She refused, and they swore they’d come back. When they did, they searched the entire hospital, with the exception of the room belonging to her foreign-born anesthesiologist colleague. The Israelis didn’t find the man they were looking for, who was allowed to recover according to the Geneva Conventions despite their best efforts.

The Israeli soldiers didn’t search the foreign doctor’s room. Maybe they respected the sanctity of his medical space, maybe they feared the repercussions of disrespecting a foreign national. The surgeon’s description suggests they hadn’t thought to look because they’d trusted he was neutral (which is to say on theirside), despite his conscious decision to travel to Palestine during the First Intifada, when hundreds of injured—children and adults, targeted for throwing rocks—flooded Palestinian emergency rooms. Rock throwing was, by the way, an offense hospital staff across Gaza (except at Al-Ahli) were mandated to report to the Israeli police stationed nearby. Sure, the anesthesiologist was following the need, as all good humanitarians do. There is need all over the world, and he picked Gaza.

Today in Gaza, when humanitarian staff—including UN workers—are targeted, Western media outlets offer justifications like this one made by Politico: “Many of their staff have died in the course of living their everyday lives and outside of their official duties . . . not reported to the notification system.” In other words, “We can’t confirm what they were doing.” The phrase “living their everyday lives” in the middle of a genocidal campaign that’s killed more UN workers than any other conflict, competes with the casual terrorism charge—“maybe they deserved it”—for mind-numbing absurdity. Palestinian deaths become their own faults: more UN workers have died not because Israel is targeting them in greater numbers, but because Palestinians have an above-average gravitational pull, a yearning to be below dirt, that bullets and bombs accommodate. The talking point is old. Interviewed by reporters during the Israeli siege of Beirut in 1982, foreign doctors working in Palestinian refugee camps explained the targeting of civilian homes, schools, places of worship, and even the hospitals where they themselves were stationed, as such: everything that sustains Palestinian life, as far as Israel is concerned, is “terrorist.” All of this, then, becomes a legitimate target.

The existential threat posed by the occupied is as old as occupation. Among the First Geneva Convention’s initial ratifiers were major colonial powers whose commitments to protect and provide for the injured did not extend to the peoples they colonized. Assertions of control over their colonial subjects did not constitute a war (between equals), after all, so international law need not apply. During the Algerian anti-colonial struggle against the French, the latter regularly targeted medical infrastructure, directly and through siege: the French restricted access to medicines and equipment, enabling the proliferation of infectious diseases and other preventable illnesses among the civilian population. More than a decade earlier, elsewhere in Europe’s colonies, the Italians defended their right to target Ethiopian hospitals and medical facilities by asserting that “primitive” civilizations were incapable of comprehending and therefore abiding by the principles of the Geneva Conventions and the Red Cross. The Italian Red Cross claimed that the “barbaric” Ethiopian “warriors” believed hospitals possessed “miraculous powers” and that they exploited hospitals to “conceal ammunition depots and military establishments.” This second point was denied by doctors on the ground, and it quickly became the Italians’ unsubstantiated word against that of their victims. Though both parties were speaking through their local branches of the ICRC, it’s not hard to guess whose word carried more weight.

Justifications for the systematic destruction of medical infrastructure have clear echoes: the statement signed by dozens of Israeli doctors urging their government not to be squeamish when targeting Palestinian hospitals reads, “The residents of Gaza, who saw fit to turn the hospitals into terrorist nests in an attempt to take advantage of Western morality, are the ones who brought their annihilation upon themselves.” Their veneer of morality, cut of famously Western cloth, will fool no one, the Israeli doctors declared. While the Israeli military leadership wasn’t waiting on the doctors’ words, they certainly added to the chorus: Palestinian doctors aren’t doctors, their hospitals aren’t hospitals. Palestinian humanity comes couched in modifiers: human animals, human shields. Palestinian children are described in Western media as “male teenagers,” one growth spurt away from full-blown terrorists or terrorist sympathizers. Israeli finance minister Bezalel Smotrich looks at our newborns and sees through their cherubic faces, these creatures “who might want to kill [his] baby in twenty years.”

That occupying powers don’t lose sleep over the selective application of medical immunity reflects the requisite dehumanization that preempts and sustains occupation: Dunant, who died in 1910, himself worked as a developer in France’s North African colonies in the 1850s; he’d traveled to Solferino—where he witnessed the battle that led him to found the ICRC—seeking an audience with Emperor Napoleon III, and permission to secure water resources for his colonial projects in French-occupied Algeria. Dunant was an ardent Christian Zionist. He advocated for restoring a Jewish homeland as early as the early 1860s. By 1867 he’d formed the Société International de la Palestine, cooperating with “Templers,” European Christians who had settled in places like Jaffa and laid wait to welcome Jesus upon his Second Coming in the Holy Land. At the end of the First Zionist Congress in 1897, Theodor Herzl, the father of Zionism, thanked Dunant by name. This same man who was committed to securing (for Europeans) medical care as a human right did not extend these rights to Algerians or Palestinians.

This doesn’t signal inconsistency or hypocrisy: colonizers considered the inhabitants of the Global South to be subhuman, and medical neutrality and broader human rights commitments are definitionally owed only to human beings. Through this line of reasoning, the Global South’s resources and land are the right of “civilized” people who, as with hospitals, know better how to use them. Read like this, the common Zionist refrain, “a land without people for a people without a land” carries different implications, less of a lie than an ideological confession. 

The AMA’s generic call for medical neutrality could have been cut-and-pasted to apply anywhere in the world. Neutrality accommodates a medical solidarity with the doctors of Gaza, one that conceives of doctors as part of a unified class that somehow transcends material reality, with a universal enemy called “death.” The physician’s work—“saving lives”—is framed as “above politics,” as though the things and people and states that kill people aren’t relevant, as though a surgeon has anything on their instrument table that can stop bombs from falling. If solidarity isn’t rooted in material reality, then the doctor’s credibility hinges on their emptying as a sociopolitical actor: they become empty vessels for their technical skillset.

Of course, the expectation of sociopolitical emptying is applied selectively. The AMA refused a motion, proposed by its members, to vote on a resolution calling for a ceasefire in Gaza. One doctor, a former AMA president speaking on his own behalf, said, “This resolution deals with a geopolitical issue, which is in no way the purview of this house.” Compare this to when Russia invaded Ukraine: the AMA condemned the war, opening their statement with emotion, as it was “impossible to watch the heartbreaking images from Ukraine and not feel a deep sense of loss for the proud people defending their homeland.” JAMA asserted in an editorial, in no uncertain terms, that “the war in Ukraine must cease immediately.” I’m having a hard time squaring this circle. If medicine is ideologically neutral as a matter of principle, was that statement outside the scope of the AMA board? Why this selective neutrality—which is to say, keeping culpability at arm’s length?

Let’s say the AMA’s historical position has been “neutral” for neutrality’s sake, rather than consistently in-line with American foreign policy. Neutrality was never intended to be anything except a means to an end. Neutrality as an end in and of itself, outside of medicine, isn’t a respectable or virtuous position: “Neutrality in situations of injustice means taking the side of the oppressor” is a common refrain. Frantz Fanon, a Martinique-born psychiatrist who joined Algerian revolutionaries during their anti-colonial struggle, observed the complicity of his physician-colleagues with the French occupation. In a chapter of A Dying Colonialismdedicated to the role of doctors, he explains that there are only two sides: there are?those who serve the colonizer—which is to say, self-interest—and there are those who serve their people. Struggle doesn’t accommodate a neutral position.

In an interview with Democracy Now!, Dr. Hammam Alloh, calling in from Gaza, was asked about heading south to prioritize his own safety. Before the attacks on October 7, he’d just returned to his homeland after years of medical training abroad, and he’d come to Al-Shifa Hospital in hopes of revitalizing its nephrology department. He responded to his interviewer, “And if I go, who treats my patients? We are not animals. We have the right to receive proper health care. So we can’t ‘just leave.’”

The interviewer then asked Dr. Alloh to describe the impossible choice doctors in Gaza face, between their own lives and those of their patients. He responded without hesitation, “You think I went to medical school and for my postgraduate degrees for a total of fourteen years so I think only about my life and not my patients? I’m asking you, ma’am. Do you think this is the reason I went to med school, to think only about my life? This is not the reason why I became a doctor.” He seems incredulous, disturbed by her question’s premise. He’d already answered this when he became a doctor—he, like Fanon, understood medicine as his way of living in obligation to and in service of people. Nearly two weeks after his interview, Dr. Alloh was killed by an Israeli airstrike—he’d gone home, between his long hospital shifts, to check on his family.

A doctor’s right to treat, unhindered, requires a people’s right to live. A people’s right to live requires they be seen as such. Calls for medical neutrality, and the narrow professionalized solidarity this allows, requires erasure. Doctors pretend other doctors are just like them, and this can be true if doctors exist insulated by hospital walls from the lives around them. Discussions about systemic oppression, barriers to the respect for immunity, are off-limits. Besides, what good are humanitarian aid trucks—schemes for entrenched dependency—without functioning hospitals? What good is a hospital without its doctors? What good is a doctor without her people? What good is a person without commitment? I’m asking you.