Who matters? Pandemic in a time of structural violence

Focusing on the COVID-19 pandemic as it impacts Israel/Palestine provides us with a unique case study of the realities of health care and public health in a racialized and unequal society.

Israel reported its first case of coronavirus on February 21, a woman returning from a cruise.* In the second week of February, coronavirus was found in Bethlehem in the West Bank, introduced by foreign tourists, with another wave brought in by day laborers returning from Israel and Jewish settlements. Gaza’s first two cases were noted on March 22, two men returning from Pakistan. The data from East Jerusalem is difficult, partly because Israel considers East Jerusalem part of “unified Jerusalem” while the Palestinian Authority maintains that East Jerusalem is in the occupied West Bank. That said, on March 10, six East Jerusalem Palestinians were quarantined and the first death was reported April 18. The acclaimed world map and dashboard by Johns Hopkins University’s Center for Systems Science and Engineering initially erased the Palestinians altogether, then acknowledged the occupation, and finally changed their “country, region, sovereignty” to the West Bank and Gaza, with no separate designation for East Jerusalem.
While the virus recognizes no boundaries, each of these regions experienced the pandemic with a different underlying social and political reality. Israel, a first world country (the World Health Organization lists Israel in the “European region”) with a history of top-notch hospitals, research facilities, and universal health insurance, also suffers from a decades-long defunding of the social safety net and grave social and economic inequities. Since the1970s, analysts note that investment in health, transportation and education has declined and the government has focused on tax cuts, welfare for the ultra-Orthodox, building settlements, and maintaining an expansive military. Thus decades of neoliberal policies have left critical elements of Israel society neglected and poorly prepared. Much like the US, as the numbers of cases grew, physicians and senior health officials publically noted the lack of ventilators, “disparities between the central and peripheral communities,” structural concerns, inadequate care in retirement communities, the lack of PPEs, suboptimal leadership, and a lack of attention to other diseases.
Palestinians, who make up 20% of Israeli citizens, are systematically disadvantaged with less institutional resources and poorer health outcomes than Jewish citizens. Ultra-Orthodox communities suffer from a lack of modern education and connection to the media and public health. Groups like asylum seekers and prisoners are marginalized economically, politically, and medically.
As the infection rates turned upward during the last two weeks of March, the Israeli government launched an organized public health campaign promoting social distancing, a national emergency was announced with a shelter-in-place order and the closing of all but essential services. Air travel was shut down and entry from Gaza, already severely limited, was closed apart from “exceptional cases.” By the end of March, Israel closed the West Bank as “a precaution against the coronavirus” although the number of coronavirus cases in Israeli citizens was 40 times greater than in the West Bank. By April, Israelis were advised to wear masks, and haredi hot spots were under closure. Sophisticated public health and health care institutions prepared for the rising national medical needs.
In the West Bank and even more so in Gaza, the health care systems have been severely impacted by decades of de-development, occupation, siege, restrictions of movement for health care professionals and patients, and repeated military assaults that have destroyed hospitals, clinics, access to medications, water and sewer treatment plants, and electricity. In the West Bank, of the estimated 775,000 Palestinian refugees, a quarter live in 19 overcrowded refugee camps, while in Gaza 70% of the approximately two million people are refugees, most of that refugee population is spread among eight devastated camps.
Understanding the inherent inability to adequately respond to a massive pandemic, the main focus of the Ministries of Health as well as UNRWA, WHO, UNICEF, and a host of other NGOs, has been on prevention, quarantine and sheltering in place, and upgrading treatment facilities. In early March, the Palestinian Authority declared a state of emergency and instituted strict closures throughout the West Bank with schools, universities, banks, and government offices, hotels, restaurants, and shops shut down. In Gaza, Hamas and the civil authorities closed the Erez crossing to Israel, placed Palestinians entering from Israel or Egypt in isolation, and began the development of isolation facilities in field hospitals, schools, and hotels. Schools, universities and mosques were closed. Crowded refugee camps began disinfection programs all over the occupied territories.
With a population of approximately 3.2 million, the West Bank has an estimated 210 ICU beds and between 120 and 256 ventilators. The two million people in Gaza are served by 65 to 120 ICU beds and 56 to 60 ventilators. Both areas have a serious lack of testing capacity as well as an urgent need for more ventilators, intensive care units and equipment, PPEs, medications, and trained staff.
In East Jerusalem, Palestinians are residents rather than Israeli citizens. They have suffered from a combination of chronic and acute Israeli neglect and Israeli refusal to allow the Palestinian Authority to establish efforts to combat the virus. The Israelis only agreed to open testing centers in East Jerusalem in the Shuafat and Kafr Aqab refugee camps after a petition was submitted to the Israeli Supreme Court. The Israeli health ministry does not distinguish between Arab and Jewish neighborhoods when tracking coronavirus cases. Currently, while Palestinians in East Jerusalem can be sent for care in Israeli hospitals, they often seek care in East Jerusalem. Of the six hospitals located in East Jerusalem, there are only 20 to 22 ventilators and 62 to 72 beds prepared for coronavirus patients in two or three high level hospitals. The discrepancies in reported numbers in the oPt speaks to the underlying structural weaknesses, competing authorities, and lack of organization in the region.
One of the critical points to this discussion is that the occupation and underlying racism and discrimination in Israel/Palestine persist unabated despite the public health emergency and the interrelatedness of communities and shared risk.
Israeli forces continue to arrest and imprison Palestinians, including children, demolish homes, and facilitate settler attacks that take advantage of the quarantines. Settler attacks have risen 78%. Soldiers, sometimes wearing protective gear and masks, raid Palestinian homes, fire at Gazan farmers and fisherman, spray herbicide on crops in Gaza, arrest Palestinian volunteers in East Jerusalem engaged in disinfecting public facilities, and dismantle Palestinian field clinics in East Jerusalem and the West Bank. When the coronavirus was documented, Palestinian communities like Bethelehem, Beit Jala, and Beit Sahour were put under Israeli military closure, while surrounding Jewish settlements like Gilo and Har Homa were not. Similarly, areas with documented infection such as Ashkelon, Jerusalem, Ariel, and Petah Tikvah were not placed under military closure or total quarantine. When Hebron was under closure, Jewish settlers were allowed to march the streets in a raucous Purim parade.
Even when there is coordination between Israel and the Palestinian Authority, Israel refuses to release desperately needed funds it deducts from taxing Palestinians. There are a number of reports that Hamas and Israel are holding indirect negotiations for a prisoner exchange deal in exchange for humanitarian aid. Emergency regulations have ended family and lawyer visits for Palestinian prisoners in Israeli jails, with phone consultations allowed only if cases are imminent.
Racist attitudes and behavior are also clearly seen in Israel within the Green Line. Ironically, Palestinian citizens of Israel represent 17% of the country’s doctors, 24% of the nurses, and 48% of the pharmacists and they take care of everyone. An early issue was the lack of Arabic language updates and critical health information coming from the Israeli Ministry of Health, despite the fact that a fifth of the citizens are Palestinian. There was also a wide imbalance in numbers of cases reported in Jewish versus Palestinian communities, particularly Bedouins, due to disparities in the availability of testing. Similar inequities exist in terms of distance learning as 50% of Palestinian students do not have online access and a third do not have a computer or tablet. The situation is even more acute in Bedouin communities who face a lack of electricity, water, and sanitation infrastructure.
Most of the 30,000 asylum seekers from Eritrea and Sudan lost their jobs due to the pandemic and were not eligible for unemployment or national health insurance. Despite an outcry from the World Health Organization, the Office of the United Nations High Commissioner for Human Rights, the International Organization for Migration and the UN Refugee Agency, the Israeli government response was to offer a monetary reward if asylum seekers were to leave the country. In Israeli prisons, Palestinians documented filthy and crowded jails, a lack of hygiene products and a policy of “deliberate medical negligence.”
Tens of thousands of West Bank Palestinians work in Israel and over half of the coronavirus cases in the West Bank have been traced to workers or their contacts. Nonetheless, the Israeli government has denied any responsiblity to test these workers or safeguard their working conditions. There have been reports of workers suspected of illness being dumped at checkpoints with no concern for their wellbeing and no coordination with Palestinian medical authorities. Similarly, while Gazans are portrayed as “terrorists,” Israeli companies are happy to order protective gear from Gazan sewing factories where workers are paid as little as $8 per day. Millions of masks and hundreds of thousands of gowns and suits have been produced by these exploited workers who are desperate for an income.
Given the militarization of Israeli society, it is not surprising that one of the primary responses to the pandemic was to deploy and empower Israeli soldiers to patrol streets, man barricades, and augment the national and border police. Early on it was reported that the Mossad had become a significant procurer of medical equipment, obtaining test kits, masks and protective gear, medications, and technology that may not have been totally “above board.” In a highly controversial move, the secret police branch the Shin Bet (Shabak), was authorized to use advanced surveillance methods for contact tracing based on mobile phone data, thus employing techniques long used on Palestinians on Jewish Israeli citizens. By the end of April, in a victory for Adalah and the Association for Civil Rights in Israel (ACRI), the Israeli Supreme Court ruled that the Shin Bet must stop using counterterrorism surveillance on coronavirus-positive people in Israel and that tracking must be brought under legislative control.
In a similar vein, the Israeli Defense Ministry is considering working with the NSO group, a contentious spyware firm that produced Pegasus, the malware that can be inserted onto a mobile phone. NSO is currently being sued by Facebook for allegedly hacking WhatsApp. The firm’s goal was to collect and aggregate information about Israelis and then assign each a grade that reflects the likelihood of any resident’s exposure to coronavirus. Palestinians who wish to confirm work, travel, or medical permit requests are now required to “‘download an app that enables the military access to their cell phones.’ The app, known as ‘Al Munasiq,’ or ‘The Coordinator’” in Arabic, allows the army to track the user’s phone location as well as access any notifications they receive, files they download or save, and the device’s camera.” Israel’s top arms exporter, Elbit, is also advocating “health” innovations that can remotely test for coronavirus by using radar to check temperature and pulse.
A review of this data reveals the underlying context of structural racism and apartheid, a reliance on military solutions, and a disregard for the health and lives of Palestinian people who matter less than their Jewish cohorts in the eyes of the Israeli government. When small tokens of support in terms of testing, training, and equipment occur, these are described as humanitarian gifts and examples of Israeli largesse, when Israel as the occupying power is actually responsible for the health and well-being of the people it occupies. The rise in “digital and algorithmic surveillance systems” in the name of public health is a dangerous example of occupation creep that is now leaking into Israeli society as well.
Benjamin Netanyahu and his cohorts are using the pandemic crisis to consolidate racialized surveillance and domination against Palestinians, moving towards further colonization and annexation, and expanding his dominance in Israel itself. Netanyahu has closed the Israeli courts, delaying his corruption case and maneuvering to stay in power by making an emergency deal with Benny Gantz and the Blue and White party. While only a third of Israelis support annexation, public opposition is muted by fears of the virus and extensive lockdowns.
The Israeli occupation and the second-class citizenship of Palestinians can be viewed as a pre-existing condition in this public health crisis. Added to that is the dramatic increase in obesity and diabetes in the oPt as a result of the post Oslo, neoliberal economic changes and the availability of high calorie foods in a population with restrictions on movement and high levels of smoking and other stress-related illnesses. While increased testing, vaccines, and improved health care are critical to everyone in this region, Palestinians have turned to their own ingenuity, creativity, and social cohesiveness in the face of gravely unjust realities.
Ultimately, Israeli citizens will have to face the rising right wing authoritarianism and militarization of their own government and its responses to this public health emergency. Palestinians under occupation understand that their health disparities are embedded within the broader structural violence that is the core of the occupation and siege and that their liberation is the fundamental and necessary treatment during and after this current catastrophe. 
*In this discussion, I acknowledge the limitations of the numbers game: Community spread has been highly underestimated, asymptomatic carriers are important vectors for infection, and the lack of reliable and available testing creates flawed data.