A common wisdom regarding cooperation in the health field in an
area of conflict is that health is a "bridge to peace," a
humanitarian issue that addresses crucial needs on the ground, and
does not necessarily engage in politically controversial issues.
Outcomes are tangible and measurable, and parties to the conflict
pay a lower political price for cooperating than do professionals
in other fields. Nevertheless, there are just as many reasons not
to cooperate in the health field, which generally reflect
political, moral, economic and health-related motives. This is
seen, for example, in the very small number of regional projects in
the health field in the Middle East, resulting from the fact that
medical unions in neighboring countries are not supportive of
cooperation with Israel for the time being.
Cooperation in the Field of Health
In 1994, after 27 years of occupation, the Palestinian Authority
(PA) assumed full responsibility for the health sector in the West
Bank and the Gaza Strip, and the Israeli and Palestinian health
systems formally separated. Based on the past experience of the two
peoples, the following questions may be raised:
* What were the reasons for continued cooperation between Israeli
and Palestinian health professionals following the formal
separation of the two systems in 1994?
* Why was the scope of cooperation in the health field so broad -
148 projects during the years 1994-1998?
* Why was the role of NGOs so dominant during the period
studied?
* Do health professionals have a unique role in promoting
cooperation and coexistence in post-conflict eras?
* Did the participation in cooperative activities strengthen the
desire for continued cooperation?
* What lessons from the Israeli-Palestinian situation can be
helpful to other regions in the world?
The answers to these and other questions regarding
Israeli-Palestinian cooperation in the health field are provided by
a study conducted jointly by the Joint Distribution Committee (JDC)
(JDC-Brookdale Institute, JDC-Israel) and Al-Quds University in
East Jerusalem over the past two years. A team of 9 Palestinian and
Israeli researchers mapped 148 cooperative projects, interviewed
112 Palestinian and Israeli health professionals from policy makers
to team members, and learned about the scope of cooperation, its
characteristics, the forces behind it, the factors affecting it, as
well as the outcome of and potential for future cooperation. The
study brings out the voices of health professionals involved in
cooperation, shows that the experience has been positive for most
participants, and indicates that there is a strong interest in
continuing and expanding cooperation.
The shared story of Palestinians and Israelis in the Middle East is
still unfolding, and the future holds many questions. What follows
is a view of this story through one lens, namely that of
cooperation in the health field, as a challenge to leaders and
professionals to care for the health of their people.
Study Findings
All of the projects included in the Al-Quds/JDC study involved at
least two professionals from each side who participated and
represented their respective organizations. These professionals
worked for an extended length of time with joint efforts in at
least two or more of the following areas: project planning,
partnership building, fundraising, implementation in the field, and
project evaluation. Below are some of the findings of the
study:
Between 1994-1998, 148 Israeli-Palestinian health projects were
conducted involving 28 Palestinian and 39 Israeli organizations. A
few were governmental agencies (17%), but most were NGOs (79%).
Some of the NGOs were peace and human-rights organizations that
found themselves learning about health issues in order to build
bridges to cooperation through health. Others were health-oriented
organizations (52%), and universities (18%); some of them learning
for the first time about reconciliation and dialogue between
rivals, and the phenomena of turning enemies into colleagues. This
unexpected link between peace and health organizations joined about
4,000 Palestinian and Israeli professionals in cooperative
activities. The public was not aware of the scope of this activity,
since most cooperative activities during these years maintained a
low profile.
Chart 1: Distribution of Israeli-Palestinian Projects by Primary
Type of
Activity, 1994-1998 (n=148)
Projects and Motivation
The 148 projects identified by the study covered a wide range of
fields and topics. The primary types of activity undertaken were
training (46% of the projects, e.g. public health administration,
clinical topics); research (23%, e.g., in allergies, drug
prevention, health education, oncology, rehabilitation); service
development and provision (19%); policy planning (5%); and
conferences, seminars, dialogues and youth activities (7%) (see
Chart 1).
As for motivation in both communities to cooperate, the main
driving force for 52% of the Palestinian respondents was improving
their professional knowledge and skills, and developing
infrastructure. A significant group of Israelis (53%) and
Palestinians (41%) were motivated to cooperate by a desire to
contribute to the resolution of the Israeli-Palestinian conflict.
This pattern was repeated in the motives that respondents
attributed to their organizations' participation in
cooperation.
One of the driving forces behind cooperation is leading
personalities, usually the heads of organizations or project
directors, who spurred the process within their organizations. The
individuals and organizations involved in health cooperation had a
high level of commitment and continued working together even during
the most tense political periods, overcoming delays in the projects
due to the political situation.
Factors Influencing Cooperation and Mechanisms of
Cooperation
* Hindering factors: The main factors identified by both
Israeli and Palestinian respondents as having hindered the
cooperation were logistical difficulties - Israeli hindrances to
permitting travel between the West Bank and Gaza; political
impasses (tension at the political level, government opposition to
cooperative projects); and financial constraints.
* Assisting factors: The main factors identified by both
Israeli and Palestinian respondents as having most assisted
cooperation were the professional interests of the participants and
their belief in the importance of promoting coexistence.
* Equal division of work between partners (symmetry): While
both Israeli and Palestinian respondents consistently assigned a
high degree of importance to symmetry (i.e., equal division of
work, finance and responsibility), Palestinian respondents
particularly emphasized its importance. Equal division of work
while carrying out cooperative projects was also ranked as one of
the four top assisting factors by Palestinian respondents.
* Funding of projects: The major source of funding for the
projects was international (government, public agencies and
foundations), supplemented by small local funding sources. Much of
the funding was directed toward NGO activities. The cost of
projects ranged from under $25,000 for short-term training
projects, to over $1,000,000 for three-year research projects. In
60% of the cooperative projects, the Palestinian partners reported
receiving more than 50% of the funds.
* Publicity: The cooperative projects were selectively
publicized. The main target audience was professional. Eighty
percent of all respondents reported that their projects had been
publicized within their organization; 72% of the Palestinian and
53% of the Israeli respondents reported that their projects had
been publicized externally through professional conferences and
publications. Almost half of the respondents indicated that their
projects had been publicized to the general public. However, a
number of respondents noted that the media is often not interested
in stories on successful cooperation, because they are not
sensational enough.
* Refrainment: It appears that individuals are prepared to
participate in cooperational activities while concurrently
maintaining their respective red lines. Palestinian respondents
noted that they refrained from launching projects that were not a
priority for the Palestinian population, while Israeli respondents
refrained from discussing politically or emotionally charged
issues.
Outcomes of Cooperation
The first outcome is the enhancement of cooperation.
People-to-people activities aim to provide opportunities to meet
and learn about each other, change attitudes, and spread the word
of cooperation. These activities are based on the premise that
close contact between opposing sides can change preconceived
notions about one another and reduce emotional barriers.1 The study
found that the cooperative projects in health were meeting these
goals.
* Opportunities to meet and learn about each other: As noted
earlier, an estimated 4,000 Israeli and Palestinian professionals
took part in cooperative activities in the health field between
1994-1998. The number of participants in each project ranged from
six in research and training projects, to hundreds in seminars and
conferences. Projects with large numbers of participants were often
one-time events, but were the culmination of a planning process
involving a smaller number of participants that took place over
time. All other projects enabled participants to meet regularly
over a period of time. Of the project directors, 44% indicated that
project meetings took place once a month, and 35% indicated that
project meetings took place twice a year. In addition, 46% of
Israeli respondents and 29% of Palestinian respondents reported
that they met colleagues from the other side socially.
The study shows that the cooperative projects gave the participants
a chance to learn about each other, enabling them to replace
stereotypes and myths with first-hand impressions and reality.
Israeli respondents stressed the importance of learning about
Palestinian people, their needs and their culture (and the
limitations the culture sometimes places on them) directly through
cooperative work rather than through reading or the media. They
also learned about the Palestinian drive for education and
training. Almost two-thirds of the Palestinian interviewees said
they learned about Israeli professionalism, particularly stressing
the quality of their system and its advanced technology.
* Changing attitudes: Two-thirds of Palestinian respondents
and one-third of Israeli respondents reported that working on a
cooperative project affected their attitude to coexistence. Over
70% of those who reported a change in attitude said that the effect
was a positive one by showing that cooperation is possible, by
enhancing the desire for coexistence, or by moderating their views
on the Palestinian-Israeli conflict. Of those who reported no
change in attitude, 40% of the Israelis and 20% of the Palestinians
reported having a positive attitude to begin with. A small
percentage of Palestinian respondents reported that being involved
in such activities had a negative effect on their attitude toward
coexistence, saying that "before, the situation was better" and
"hope has vanished." None of the Israelis interviewed reported a
negative effect.
* Spreading the word: Ninety percent of health professionals
involved in cooperative activities shared their experience with
colleagues or friends. The majority (70%) of interviewees said
their friends had positive reactions and expressed their enthusiasm
and support for such programs. The 20% of respondents who reported
negative reactions said that their friends were reluctant,
confused, and had doubts about such activities.
A second outcome is the professional development of individuals and
organizations. Almost 90% of the project directors and team members
reported marked contributions by the projects on the professional
level.
* Acquiring knowledge: The most striking finding was the
overwhelming majority (83%) of Palestinians who noted that the
projects enabled them to acquire technical and professional
knowledge and skills. While only 40% of the Israelis mentioned it,
about 30% noted that the projects enabled them to acquire
cross-cultural knowledge, by giving them the opportunity to work in
unfamiliar circumstances, and to learn about conditions in the
Palestinian Authority through personal contacts. Both Israeli and
Palestinian key entrepreneurs noted that the cooperative projects
enabled their organizations to expand their international contacts
and acquire new professional colleagues.
* Economic benefits: Both Israeli (20%) and Palestinian
(22%) project directors noted that cooperative projects provided
opportunities for employment, and the economic advancement of their
staff.
A further outcome of cooperation is the improvement in health
services. The added value in these contexts is the potential impact
of these projects on the health status of the population. This is
difficult to measure directly, and the study learned about the
potential impact on the health of the population by examining the
projects' goals and whether these were achieved. Over 75% of the
project directors said their health-related goals were
achieved.
The specific health-related outcome of the 148 projects covered
many aspects of the health system, including the training of health
personnel; the development of infrastructure; the generation of
data for policy makers and clinicians; and the direct provision of
services to the population through Israeli professional volunteers
working alongside Palestinian professionals.
Looking toward the Future
The prospects for future cooperation can be drawn from the level of
satisfaction found with the cooperative projects, the interest in
continuation, and from the belief about the unique role of health
professionals in promoting coexistence.
* Satisfaction: 82% of Palestinian and 97% of Israeli
respondents were satisfied or highly satisfied with their
cooperative projects; an even bigger percentage reported high
levels of satisfaction (over 90%) among their board of
directors.
* Interest in continued cooperation: 88% of Palestinian and
99% of Israeli respondents expressed an interest in continuing to
work on cooperative projects. In addition, 87% of the Palestinians
and 70% of the Israelis reported that they know of others who would
be interested in participating in cooperative projects.
* Unique role of health professionals: Many of the
respondents viewed health professionals as having an important role
in promoting coexistence. They were able to work together on the
basis of their professional and humanitarian values which supersede
political barriers, and to meet the following two goals:
a. to address the needs of the Palestinian population for services,
programs, and technical assistance;
b. to address the interests of Palestinians and Israelis in
developing patterns of "working together" between organizations and
professionals.
In this way, health professionals, who are highly esteemed in their
societies, prove the feasibility and desirability of cooperation,
and thereby pave the way for others.
The study data provided a broad view of the cooperation that took
place. In addition, it enabled the research team to conceptualize
two crucial elements: patterns of cooperation and the uniqueness of
cooperation in health.
Patterns of Cooperation
The pattern of cooperation is at the heart of the cooperative
project. It is epitomized by working together: not one alongside
the other, but one with the other. Throughout the study, the
research team investigated the patterns of cooperation between
Israelis and Palestinians in the health field during the
post-conflict era (2) (1994-1998), compared to patterns of
cooperation during the conflict era (1967-1994). This analysis led
to the development of two models of professional-to-professional
cooperation: "imposed cooperation" versus "cooperation by
choice."
The most significant factor influencing the pattern of cooperation
during the conflict era was the political imbalance between the
ruler/administrator/occupier and those being ruled. The authorities
of the ruling side set the rules for working together, while the
other side was limited in its choice of whether or not to
cooperate; in order to ensure the health of its population, it was
compelled to cooperate with the authorities.
The most significant factors affecting cooperation during the
post-conflict era are: the freedom of both sides to choose whether
to cooperate or to work separately; the entry of the NGO sector
into the cooperative arena; and the intense involvement of
international players, mainly as funders.
A pivotal factor in developing cooperation is building relations
based on mutual trust and respect at all levels of a project. While
the conflict era was characterized by a culture of suspicion, the
post-conflict era is characterized by a culture of building trust
and respect. The study shows that the professional-to-professional
track is conducive to building such relations around a shared
professional agenda. Trust is needed to overcome obstacles, and
overcoming obstacles builds trust. On this track, project
management skills are no less important than conflict management
skills.
One factor that is crucial to working together in the "imposed
cooperation" model is that of individuals who care about the health
of the population. One of the factors crucial to successful
cooperation within the "cooperation by choice" model is a core of
individuals with vision, persistence, optimism and a strong desire
to promote coexistence. Fortunately, from 1994-1998, there were
such key individuals in both communities who energized the process
and led it.
Chart 2: Models of Professional-to-Professional
Cooperation
Characteristics "Imposed "Cooperation
Cooperation" by Choice"
Political Environment
Political era conflict post-conflict
Political status unbalanced balanced
Type of patron-client partnership
relationship limited choice available
alternatives
Responsibility one side each side
for health responsible for responsible
two populations for own
population
Dependency for higher level low for both
health care for one side sides
Cooperative Environment
Goal of health of health of
cooperation population population
coexistence
Policy making unilateral cooperative
Essence of working togetherworking
cooperation together
Major players govt agencies NGOs and
universities
Funding local sources local and
int'l sources
authorized many channels
channels
Personalities very important very impt
Terminology sides, parties colleagues,
partners
Culture suspicion trust and
respect
Outcomes of healthy popn healthy popn
Cooperation seeds of healthy
cooperation cooperation
Understanding the pattern of cooperation is not complete without an
additional in-depth study of factors related to those individuals
who refrained from entering into cooperation and those who gave up
at some point in the process.
Uniqueness of Cooperation in the Health Field
In the final analysis, the study offers an answer to the question
"Why health?" The fusion of universal, international and local
conditions formed a critical mass for cooperation, which accounted
for the development of 148 Israeli-Palestinian cooperative projects
in the health field between 1994 and 1998 - the post-conflict era
(see Chart 3).
Chart 3: Factors Affecting Cooperation in Health in the
Post-Conflict Era
* Universal motives: These are the factors related to the
essence of the health field and the medical profession:
1. the humanitarian and emotional aspects of activities, which
touch upon suffering and pain, and saving lives;
2. the need for services to treat acute medical conditions,
alongside the need to develop infrastructure for the future;
3. the unique identity of medicine as a profession, and the
Hippocratic Oath that commends physicians to treat any person in
need, even an enemy.
These factors are very powerful, and explain the willingness of
health professionals to work together even during conflict.
* International conditions: For cooperation to grow in the
health field, as well as in other fields, supportive international
conditions are required:
1. global ideologies and interest in support of cooperation and
peace promotion;
2. provision of funding and facilitating mechanisms to enhance
cooperation.
Such supportive international conditions have existed since 1994 in
the Israeli-Palestinian context and have played a pivotal role in
achieving the current level of cooperation.
* Local conditions: In the Israeli-Palestinian health
context, the following local conditions existed:
1. geographical proximity and a shared ecological environment. The
health of one population is affected by the other, as "viruses know
no borders";
2. formal treaties and agreements between the PA and the Israeli
government which call for cooperation in civilian issues.
Conflict, Post-Conflict and Cooperation
The Geneva Conventions since 1864, (3) the operations of the
International Red Cross and the recent WHO initiative "Health As a
Bridge for Peace," all express the philosophy that even during
conflict, certain humanitarian standards need to be maintained,
particularly with regard to civilian populations and the treatment
of the sick. It may be that the characteristics of national, ethnic
and regional conflicts since the end of the Cold War require a new
convention, one which will legitimize humanitarian activities by
joint teams from conflicting sides along the lines of
people-to-people activities without the stigma of
"collaboration."(4)
The individuals and organizations whose stories are told in the
study prove that cooperation is possible, and show what it can
achieve. The challenge for the future is to enable these
people-to-people efforts to continue and expand. The goals of
cooperation in the health field are healthy populations and healthy
cooperation. Peace is not merely the absence of war, but the
opportunity to contribute to the health and welfare of all the
people in a region.
(1) Bar, H. and Bar-Gal, D. To Live with Conflict. Jerusalem: The
Jerusalem Institute for Israeli Research, 1995.
(2) The international literature struggles with defining the
transition from war to peace in current conflicts. (See Large, J.
Considering Conflict. Concept paper for the first Health As a
Bridge for Peace Working Group Meeting, 1999.
www.who.int/eha/trares/hbp/conflict.htm.)
The most common definition differentiates between three phrases:
war/conflict; post-conflict; and peace. The war/conflict situation
is characterized by continuous confrontation; the post-conflict
situation is characterized by formal cessation of hostilities,
which may be interrupted by outbursts of violence; and the peace
phase follows a formal peace agreement between conflicting sides
and cessation of all hostilities. The transition from conflict to
peace is a gradual one, with regressions and progress. (See
Lederach, J.P. Building Peace, Sustainable Reconciliation in
Divided Societies. Washington, D.C., United States Institute of
Peace, 1997; Post-Conflict Reconstruction. Washington, D.C., World
Bank, 1998.)
(3) "Geneva Convention - An international agreement made in 1864
regulating the treatment of those wounded in war, and later
extended to cover the types of weapons allowed, the treatment of
prisoners and the sick, and the protection of civilians in wartime.
The rules were revised at conventions held in 1906, 1929 and 1949,
and by the 1977 Additional Protocols." The Hutchinson Encyclopedia.
1999. www.helicon.co.uk.
(4) For additional information on this topic see: Russbach, R. and
Fink, D. Humanitarian Action in Current Armed Conflicts:
Opportunities and Obstacles. Medicine and Global Survival. Vol. 1,
No. 4, 1994. www2.healthnet.org/MGS/RussbachMGS1-4.html.