Politics, medical journals, the medical profession and the Israel lobby

Pepys et al have accused the signatories of the open letter of protest about Gaza 2014, together with Lancet editor Dr Richard Horton, of knowingly publishing fabrications on the basis of a political mindset that “would have made Goebbels proud”. I wonder if Pepys would care to modify these allegations, and set the academic record right, in the light of the findings of the UN Independent Commission of Enquiry, just published.

The report concludes that “the extent of the devastation and human suffering in Gaza was unprecedented and will impact generations to come”. Above all it concludes that the evidence points to the commission of war crimes by Israel, which puts things in the territory of the International Criminal Court. The Commission also states that Hamas in Gaza may also have committed war crimes, which is not to suggest any parity between the effects of homemade rockets on the one hand, and the massive and systematic damage wrought across Gaza on the other: 6000 airstrikes, 50,000 tank and artillery shells fired, deploying US-supplied state-of-the-art bombs which have such broad impact that their use predictably inflicts indiscriminate damage- and this on one of the world’s most heavily populated and congested urban spaces The commission found that at least 142 Gazan families lost three or more members in attacks on their homes, around 742 fatalities at least. Look at the disparity in the overall casualty figures: Palestinian deaths 2251 (mostly civilians, including 551 children); Israeli deaths 73 (almost all soldiers, no children).

I would like to ask Pepys et al why they think that Israel denied the UN Commission access to Gaza, and thus the chance to take firsthand testimony directly?

Israel remains the occupying power in Gaza as far as international law is concerned and is therefore subject to all the legal obligations of an occupying power to protect civilians.

Even Israeli newspapers like the Jerusalem Post cite the phrase “mowing the grass” as capturing the strategic thinking behind the assault on Gaza last year, as with the very similarly conducted assault in 2008- a UN Commission concluded that Israel had committed war crimes in that case too. The core intention is to unmake Palestinian society in Gaza, already imprisoned and impoverished for years by Israeli siege and blockade, to render it traumatised and impotent. Indiscriminate attack is the point of the operation, not a side-effect. The UN report refers to “Israel’s lamentable track record in holding wrong doers accountable”, but the Gaza operation was conducted as intended : the Israeli government and military high command are scarcely likely to hold themselves to account. Who will?

I write as the lead signatory of the open letter published in the Lancet during Operation Cast Lead in Gaza last summer, and which has been the subject of an orchestrated campaign of vilification by Pepys et al. (1-4) 20,000 people signed up to a statement of support for the letter.
I asked academic colleagues in Italy and UK to co-author the letter in order to draw attention of the scientific/medical community to the human costs and health issues mounting implacably day by day in Gaza. Gaza was already in a situation of severe social, economic and health stress as a result of the long running blockade imposed by the Israeli government. Our motivation was to point to the indiscriminate effects of high intensity bombardment in a densely populated urban setting, as well as a ground invasion, and to warn urgently that worse was to come for this 1.8 million besieged people. Another issue was to point to the accumulating clinical and scientific evidence of the impact on physical and mental health of exposure to war and war remnants.
Both myself and other authors of the letter have had substantial academic or clinical experience with Gaza over some years, and it was this experience and knowledge that underpinned what we wrote.
Dr Tony Delamothe in a BMJ editorial last Christmas captured well why we were writing in this way. “I think future generations will judge the journal harshly if we avert our gaze from the medical consequences of what is happening to the occupants of the Palestinian territories and to the Israelis next door”.(5)
It is noteworthy that none of our detractors, including Pepys et al, have paid any attention to the independent evidence base of the effects of previous operation Cast lead and draw implications for the last one in summer 2014, not least allegations of war crimes from a range of sources including the UN, Amnesty International and Physicians for Human Rights Israel. (6-18 )
Another purpose for our letter was to help generate concern and alert for the material help that would ensue long term for the Gazan health service in a deteriorating situation which over the weeks after our letter was published more than bore out our fears and predictions.
Regarding the further collection of evidence, we should note that the Israeli government has not allowed the official UN commission of enquiry to travel to Gaza to investigate war crimes allegations on the spot and to take first hand testimony and has consistently dismissed the relevance of any independent assessment of the damages.(19)
For Gaza the trauma continues. There are now several thousand newly maimed or handicapped people, impossibly stretched health services and clinical questions about longer term issues like reproductive health, chronic illness and mental trauma effects. As ever the Israeli government alone decides what and who is allowed to enter Gaza, or to leave it. The siege continues and remains a serious health determinant in the context. There is still massive destruction of infrastructure, , thousand of internally displaced people, chronic energy scarcity, polluted water supplies etc.
Would Pepys et al consider prioritising the “duty to heal” and see so far as to encourage the Israeli government to lift their siege, allow free entrance in Gaza of foreign professionals to support health and rehabilitation of the environment, and of vital materials, including medical supplies, and to allow Gazan health professionals to exit Gaza for further training without sex and age discrimination?

Conflict of interests.
I am a geneticist and experimental biologist, working in molecular, cell and development biology in mammals. I retired in 2014 from the position of Professor of Genetics in the University of Genoa, Italy. I have worked in Gaza since 2010. I also work in Italy. In both cases, I am a volunteer, unpaid professional doing scientific research on the determinants of reproductive health. To have transparency in the position of investigator and access to donations for research related expenses and their utilization, I am a member of the volunteer association for research NWRG.
In Gaza I have first hand experience of the strengths and weaknesses of hospital and health service provision. I have been interested in the rise in infertility and the difficulties of adequately treating serious chronic diseases in the Gazan context, subject to Israeli blockade. I have also learned much about the Gazan reality subject to a longstanding Israeli blockade: the shortage of key materials, the costs and insecure availability of food and other market products in Gaza, the electricity cuts, the deteriorating standard of drinking water, the breakdown in sewage disposal.

1- Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S, Hay A, Rose S, Rose H, Stefanini A, Balduzzi A, Cigliano B, Pecoraro C, Di Maria E, Camandona F, Veronese G, Ramenghi L, Rui M, DelCarlo P, D’agostino S, Russo S, Luisi V, Papa S, Agnoletto V, Agnoletto M (2014a). An open letter for the people in Gaza. Lancet 384:397-8. http://www.thelancet.com/gaza-letter-2014

2- “Politics, medical journals, the medical profession and the Israel lobby,” The British Medical Journal Rapid responses http://www.bmj.com/content/350/bmj.h2377/rapid-responses

3- John S. Yudkin and Jennifer Leaning, “Politics, medical journals, the medical profession and the Israel lobby,” The British Medical Journal, http://www.bmj.com/content/350/bmj.h2377, May 12, 2015,

4-Pepys M (2015). Complaint to Reed Elsevier. Email sent to 58 Israeli recipients. 24 February. https://handsoffthelancet.files.wordpress.com/2015/04/pepys-24-feb-2015.pdf

5 -Tony Delamothe. Don’t look away now 2014, http://www.bmj.com/content/349/bmj.g7622

6-https://www.ochaopt.org/documents/ocha_opt_sitrep_19_07_2014.pdf
Situation Report (as of 18 July 2014, 1500 hrs) “The impact of hostilities on Palestinian children has been particularly devastating: 59 killed (11 in the past 24 hours) and 637 injured since 8 July…..48,000 persons hosted at UNRWA shelters and another 700 displaced families hosted by relatives, are in need of emergency food and other assistance…. The vast majority of households receive electricity only four hours a day, due to damage to ten feeder lines; water supply has been further undermined”

7-http://www.emro.who.int/images/stories/palestine/documents/WHO_Situation...
“as of 20 July (16:00), a total of 425 Palestinians have been killed in Gaza (112 children, 41 women and 25 elderly over 60 years) and a total of 3008 Palestinians have been injured (904 children, 533 women and 119 elderly over 60 years). The ongoing ground incursion, begun July 18, has greatly accelerated the casualty rate over the past two days, as well as the numbers of displaced families…… during 12 days of escalated violence in Gaza (July 7-19), 2 medical staff, 3 paramedics and 15 emergency medical services staff and volunteers were injured in attacks. A pharmacist was killed in his home. 17 health-related facilities have been damaged by that hit the structure directly or in the area of the facilities (2 MoH hospitals, 1 NGO hospital; 4 MoH clinics, 5 UNRWA clinics, 3 NGO clinics; 2 NGO nursing care centers; 1 NGO emergency medical services center). Four Palestinian Red Crescent ambulances have been damaged. There are critical concerns with hospital supplies, as both medicines and medical disposables are in serious shortages, both in MoH and NGO hospitals due to the large number of casualties and serious shortages even before the escalation of violence”.

8-Issues Related to UNOCHA’s “Protection Cluster”Regarding Gaza- Written statement* submitted by the Amuta for NGOResponsibility, a non-governmental organization in special consultative status, august 25, 2014.
9-Meir Amit Terrorism & Intelligence Information Center, “Preliminary, partial examination of the namesof Palestinians killed in Operation Protective Edge and analysis of the ratio between terrorist operatives and non-involved civilians killed in error,” http://www.terrorisminfo.org.il/Data/articles/Art_20687/E_124_14_1121292... http://www.terrorism-info.org.il/en/article/20715 July 28, 2014,
“based on the examination of the lack of appropriate methodologies and independent verifiability regarding the claims of the three key NGOs, the civilian casualty statistics and claims produced by the OCHA are unleliable”… When the names of alleged civilian casualties were examined by the Terror Information Center in Israel, many were shown to be members of terrorist groups. UNOCHA,however, has failed to respond to the analysis published by this Israeli NGO, magnifying Protection Cluster framework must be considered unreliable.”

10-UN OCHAopt, 2014. “Fragmented lives. Humanitarian overview 2014. March 2015. http://www.ochaopt.org/documents/annual_humanitarian_overview_2014_engli...

11-Defense for Children International – Palestine. Operation Protective Edge: A War Waged on Gaza’s Children. http://issuu.com/dcips/docs/ope.awarwagedonchildren.160415?e=0 April 2015.

12 -Bachmann J, Baldwin-Ragaven L, Hougen HP, Leaning J, Kelly K, Özkalipci O, Reynolds L, Vacas L (2014). Gaza, 2014. Findings of an independent medical fact-finding mission. Physicians for Human Rights Israel.https://gazahealthattack.files.wordpress.com/2015/01/gazareport_eng.pdf

13-B’Tselem. Black Flag: The legal and moral implications of the policy of attacking residential buildings in the Gaza Strip, Summer 2014. January 2015. http://www.btselem.org/gaza_strip/2015_black_flag

14-Amnesty International. Families Under The Rubble. Sept 2014. https://www.amnesty.org/download/Documents/8000/mde150322014en.pdf

15-https://aoav.org.uk/2015/new-report-shows-changes-in-israels-use-of-arti...

16-Breaking the Silence http://www.breakingthesilence.org.il/pdf/ProtectiveEdge.pdf , May 2015

17-Drone footage shows how entire neighbourhoods in Gaza were razed to the ground by Israel's bombardment last summer. https://www.youtube.com/watch?v=nZ54x5x9CuQ

18- Satellite recognition http://www.unitar.org/unosat/maps/PSE

19- Netanyahu: UN inquiry commision’s report on 2014 Gaza war is “waste of time” http://www.haaretz.com/news/diplomacy-defense/.premium-1.661066, June 14, 2015

May I reply to the comment by Iain Chalmers [1]. I hope he won’t be offended if I start by saying how very sorry I am to hear of the tragic death of his personal friends in Gaza last July.

He asks how I would have reacted, and what language I would have used, if Israeli children, some of them known personally to me, were being killed by Hamas’ rockets at the rate of one every two hours. My answer is that I should have felt angry and distraught and grieving, and I would have expressed these feelings in private. But if I had written to the medical press my language would have been different from that in the letter to The Lancet that he signed [2].

In particular, I’d have avoided the attribution of unsubstantiated motives to those involved in the fighting, a conspicuous feature of the Lancet letter. Iain Chalmers says that he and his co-authors felt they had a responsibility to draw attention to an unfolding public health disaster (with the implication that they needed to act very urgently); but writing a letter that was not offensive and inflammatory would have taken no longer than writing the letter that The Lancet actually published.

He also asks why I didn’t mention in my very brief response the language of the email (cited in the Editorial by John Yudkin and Jennifer Leaning [3]), that complained about The Lancet letter. The reason is not, as Iain Chalmers alleges, that I apply ‘blatant double standards’, but rather that the two pieces of writing were not comparable, since one was published in a highly reputable medical journal that is read internationally and the other was an email circulated by Mark Pepys to 58 of his colleagues [3]. That said, if I had written that email my language would have been different from that quoted in the Editorial.

A letter in The Lancet acquires prestige and authority from being published in one of the foremost medical journals. As I wrote before, a respected medical periodical is entitled to discuss political situations that have an impact on public health, but if it does so it has a responsibility to stick as far as possible to established facts, to use measured language and not to indulge in hyperbole. Otherwise it ceases to be a learned journal and becomes a political tract.

References
1. Chalmers I (2015) Politics, medical journals, the medical profession and the Israel lobby. BMJ Rapid Responses 4 June 2015.
2. Manduca P et al. (2014) An open letter for the people in Gaza. Lancet 384: 397-8.
3. Yudkin JS and Leaning J (2015) Politics, medical journals, the medical profession and the Israel lobby. BMJ 350:h2377.

In his response to the editorial by John Yudkin and Jennifer Leaning on politics, medical journals, the medical profession and the Israel lobby (1), Michael Yudkin (2) complains about the “offensive, prejudicial and inflammatory language” used in a letter of which I am a co-signatory, which was published in The Lancet on 22 Jul 2014 (3). His comment prompts me to challenge him on two matters of relevance – the context in which The Lancet letter was written, and the blatant double standards which he has applied.

First the context of the letter. In 2013 my family became very close to a young Palestinian family – the Alhallaqs - during their stay in Oxford. The father, Hassan, was a prize-winning Master’s student at Oxford Brookes University, and the mother, Samar, began working with my wife in an embroidery project. Their sons Kenan (then 5) and Saji (then 3) got on well with our grandchildren, who live with us.

On 20 July 2014, the Alhallaq family was destroyed by Israeli shelling of the residential block to which they had fled from an even more dangerous part of Gaza. Samar, who was 8-months pregnant, was killed, along with her two sons (4). Hassan survived with burns and a crush fracture of his right femur, from which he is slowly recovering (although Israel has denied him access to a rehabilitation hospital in the West Bank, allegedly ‘for security reasons’).

During the 2-day period over which the destruction of the Alhallaq family occurred, a Palestinian child was being killed in Gaza every two hours, and by the end of Israel’s 50-day assault over 500 children had been killed (www.handsoffthelancet.com). It was during that time that I was invited to sign the letter which offends Michael Yudkin. Had I and the other co-authors not felt that we had a responsibility to draw attention to an unfolding public health disaster (which has been amply confirmed by subsequent investigations), more carefully crafted language might have been used. Indeed, publication might have been delayed while information about the reasons for the co-authors’ interest in the people of Palestine was assembled for publication with the letter, rather than in our subsequent response to our critics (5). So my first challenge to Michael Yudkin is to invite him to consider how he would have reacted and what language he might have used if Israeli children, some known personally to him, were being killed by Hamas’ rockets at the rate of one every two hours.

Turning to the double standards operated by Michael Yudkin: the language used in our letter is as nothing compared with the language used by many of those who have criticized me and the other co-authors, and the editor of The Lancet. Instead of using evidence to challenge the assertions made in the letter, critics have stooped to using the most outrageous personal smears. As noted in the editorial (1) that Michael Yudkin calls into question (2), we are deemed to be “dedicated Jew haters” who combined “outright lies and slanted propaganda viciously attacking Israel with blood libels echoing those used for a thousand years to create anti-Semitic pogroms”. Apologists for Israel’s assault on Gaza have asserted that our letter “would have made Goebbels proud, and Streicher would have published it in Der Stürmer as happily as Horton published it in The Lancet.” Michael Yudkin mentions none of this, and one has to ask why. My second challenge to him is to come up with any more obscene libel of a group of medical authors and the editor of a leading medical journal, and to criticize publicly those who have used and endorsed such language.

References
Yudkin J, Leaning J. Politics, medical journals, the medical profession and the Israel lobby. BMJ 2015;350:h2377.
Yudkin MD. Politics, medical journals, the medical profession and the Israel lobby. BMJ Rapid response, 3 June 2015.
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S, Hay A, Rose S, Rose H, Stefanini A, Balduzzi A, Cigliano B, Pecoraro C, Di Maria E, Camandona F, Veronese G, Ramenghi L, Rui M, DelCarlo P, D’agostino S, Russo S, Luisi V, Papa S, Agnoletto V, Agnoletto M. An open letter for the people in Gaza. Lancet 2014;384:397-8.
Chalmers J, Chalmers I. A tapestry of Palestinian life: remembering Samar Alhallaq. Lancet 2014;384:656–657.
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S, on behalf of 24 signatories. Israel-Gaza conflict. Lancet 2014;384:469.