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.

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(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.