In daily life as well as in times of conflicts and emergencies, health and health security are crucial pillars of medical management that remain the most sensitive of measures of both peace and equality. Whereas health encompasses a broader and more holistic view of an individual’s overall well-being, health security is a specialized field that concentrates on protecting and safeguarding public health, especially in the context of emergencies or threats to populations’ health.Reference Burkle 1 , Reference Burkle 2
Operationally, local physicians and nurses care for and manage individual illnesses. This requires an existing health care structure (primary health care services) that can improve medical conditions and address emergencies. However, whereas primary health care services are essential elements of daily medical service delivery, health security services aim to manage extraordinary events built upon an existing and routine health and public health structure. To name but a few characteristics, health security involves the community’s immediate capacity to ensure timely ambulance transfers, public health surveillance, vaccinations, and a myriad of public health protections and capacities to prevent and respond to public health activities designed to prevent medical issues not available in the community. Therefore, a country lacking both suffers more in any event. 3 –Reference Augustynowicz, Opolski and Waszkiewicz 5
The distinction between health and health security is crucial in conflicts when one side lacks both and thus has less chance of survival.Reference Burkle 1 Training humanitarian workers to respond to a foreign country at war must emphasize that treating illnesses and injuries alone is not enough. The destruction of multiple aspects of the public health system that once functioned becomes a larger and more complicated effort involving resources not normally held by volunteer health care providers alone. Burkle emphasizes that the rise in autocratic regimes has characteristically failed to adopt investments in public health infrastructure, education, and prevention measures to keep pace with population growth and density. “Autocratic leaders have a direct impact on health security, a direct negative impact on health, and create adverse political and economic conditions that only complicate the crisis further. This is most evident in autocratic regimes where health protections have been seriously and purposely curtailed.” All autocratic regimes define public health along economic and political imperatives that are similar across borders and cultures.Reference Burkle 2 As we further analyze the health situation in conflict zones, we also need to identify the current status of health and health security in both systems.
This paper uses the current Israeli-Palestinian conflict as a case study. It does not seek to take sides in the claims over Palestine’s ownership, nor does it support armed attacks on either Israelis or Palestinians. Instead, it aims to scrutinize the plight of both communities and evaluate their basic health and health security services in this conflict area.
Method
This narrative literature review aims to critically analyze the current status of knowledge on the Israeli-Palestinian conflicts with a special focus on health and health security. It aims to identify patterns and trends on the topic from a historical perspective, reveal gaps or inconsistencies in the body of knowledge, and suggest possible future directions for safer health care delivery, peace, and unification.Reference Baker 6 Using the keywords conflict, health care, health security, Israel, and Palestine, we searched for relevant studies in the Google Scholar search engine and PubMed, Scopus, and Web of Science databases. The keywords were used combined or isolated to achieve a reasonable number of hits for review. In contrast to a systematic review, which offers guidelines, such as PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, there are no acknowledged guidelines for narrative reviews. However, the systematic search in reliable databases and Google Scholar has been described as one way to improve the quality of a narrative review.Reference Ferrari 7
The Google Scholar search engine was used as the test bed to obtain an overview of the field and the topic. Despite some pros and cons to this search engine, previous studies have shown that it can collect relevant publications,Reference Nourbakhsh, Nugent and Wang 8 , Reference Gehanno, Rollin and Darmoni 9 together with reliable medical databases. This multi-platform approach was further completed by approaching official homepages of the United Nations and its Library ensuring a comprehensive collection of pertinent literature. The disadvantage of such a comprehensive search is the outcome, which constitutes a high rate of literature, when the selection bias may occur. To eliminate such a bias, as much as possible, both authors extensively searched available literature and decided unanimously on the included papers. The accumulated results were then organized into different topics according to similarities and differences in the results.
Results
Palestinian Health Care
While there are seven medical schools in Palestine, students pre-war were plagued daily with constant ID checks, checkpoints, and physical barriers.Reference Shellah 10 This physical barrier, coupled with a fragmented health care system, limited in its accessibility to vital services, chronic shortages of resources, and assaults on health care facilities compound the difficulties met by Palestinians.Reference Marie and Battat 11 Hospitals and clinics often grapple with insufficient resources, outdated equipment, and a scarcity of proficient health care professionals. This is further complicated by constraints on the mobility of medical personnel and supplies, making it challenging to offer comprehensive and prompt care.Reference Marie and Battat 11 , Reference Qato 12 Consequently, there are substantial hindrances in obtaining necessary physical and mental health care security services, resulting in delays in medical attention, missed appointments, and avoidable loss of life in several specialties such as obstetrics, pediatric, and prenatal care, and public health (vaccination).Reference Marie and Battat 11 –Reference Mataria, Khatib and Donaldson 13 Repeated assaults on health care facilities and personnel have further undermined the already fragile health care infrastructure. These attacks disrupt services, inflict damage on crucial medical equipment, and instill fear among health care workers, resulting in an erosion of trust in the system.Reference Tekin and Öcal 14 The erection of barriers to clean water, sanitation systems, access to health care, and childhood immunizations, and the denial of access to medical supplies, resulted in the detection of chicken pox, scabies, and diarrhea cases.Reference Mahmoud 15 – 17 Predictably, this has also resulted in a greater incidence of chronic diseases such as diabetes, heart disease, and mental illness.Reference Tittle, Bennett and Hajat 18 – 22 The extremely high poverty rate in the Palestinian territories due to the occupation, the blockade of Gaza, and the high unemployment rate have also resulted in a higher rate of malnourishment among the population.Reference Farhat, Ibrahim and Abdul-Sater 23 , Reference Massad, Deckelbaum and Gebre-Medhin 24 In addition, uninterrupted violence has led to physical injuries as well as psychological trauma from both Israeli forces and Palestinian militants.Reference Mahmoud 15 , 16 These factors target vulnerable people with a 70% mortality among women, children, and the elderly, becoming a daily complex and challenging endeavor. 16 , 21 , 22
The Israeli Health Care System
The Israeli health care system, on the other hand, is a publicly funded universal health care system that provides comprehensive medical services to all Israeli citizens and residents. It is known for its high-quality care, advanced medical technology, and a strong emphasis on preventive medicine ensuring both health care and health security, a high standard of care, and accessibility for all. Additionally, Israel boasts a robust network of hospitals, clinics, and medical research facilities, making it a leader in health care innovation and medical tourism. Israeli scientists and institutions have made notable contributions to global health care advancements. 25 –Reference Rotenberg, Stewart-Freedman and Søgaard 27 The main factors contributing to Israel’s progress in health are a clear national vision, a diverse population, democratic politics, relevant legislation, cultural and religious values, a growing economy, and international support. However, there are also several challenges, including sustaining high-quality universal health coverage for an aging population, inadequate funding for health care, a shift toward private health care programs disparity in health outcomes among different communities, gender inequalities, a shortage of health care professionals, and a need for improved health care facilities. These challenges are further complicated in the context of health disparities with the neighboring Palestinian population.Reference Skorecki and Horton 26 , Reference Rosenthal 28 Even Palestinian citizens of Israel face discrimination, experiencing disparities in access to high-quality care, longer wait times, and unequal treatment compared to their Israeli counterparts.Reference Daoud, Soskolne and Mindell 29
Shaping Societies and Globalization
With the collapse of the Soviet Union in 1991, nations transitioned toward market-driven economic models, altering social policies and programs. This shift led particularly to the commodification of essential needs like education, health, and housing, affecting societal well-being and access to crucial services in many nations.Reference Ismael 30 , Reference Petersen, Mioni, Obringer, Nullmeier, González de Reufels and Obinger 31 At least, partially to confront and manage this inequality, the idea of “Globalization,” a controversial process aimed at integrating cultures, economies, and politics, was introduced, aiming to increase interconnectivity, growth, global engagement, and accelerating interdependence, and hoping to achieve a global peace based on global partnership.Reference James 32 , Reference Steger 33 This partnership could be governed under international human rights law, obliging governments to promote and protect human rights and fundamental freedoms of individuals and groups by acting in or refraining from certain acts. However, political corruption and economic interests have often led to uneven benefits and worsening societal vulnerabilities.Reference Witvliet, Kunst and Arah 34 , Reference Glynn 35 Recent studies have also identified and underscored the importance of two new dimensions (i.e., ecological and ideological) of which the latter encompasses diverse norms, claims, beliefs, and narratives and cuts across the others (i.e., ecological, economic, political, and cultural).Reference James 32 –Reference Glynn 35 Ideological differences appear to be the most important barrier to some forms of globalization, while they may facilitate the attainment of others as well.Reference James 32 , Reference Deslandes and Anderson 36 –Reference Kriesi, Grande and Lachat 40 Ideological differences may also lead to new or fuel the old conflicts, preparing for a chaotic situation when extremism and narcissism may appear, advocating for uncompromising positions, and perpetuating cycles of violence, and a climate of mistrust, hindering the possibility of meaningful dialogue, destroying existing health care, and health security by retaliatory measures and further worsening tensions on the ground, making the prospect of a peaceful resolution more elusive.Reference Appelbaum 41 –Reference Vergani, Iqbal and Ilbahar 47
Discussion
The Israeli-Palestinian conflict is a protracted conflict between two groups of people who have many common historical, environmental, and social patterns, even as each territory is populated by majorities who practice two different religions. Health care responsibility in Palestine encompasses both private and governmental providers that are accessible to over 5371230 citizens as of 2023, who reside in the Palestinian territories of the Gaza Strip and the West Bank (referred to as the State of Palestine within the country of Israel). Following the 1980 amendment to Israel’s Nationality Law, Palestinians are strictly legal citizens of the State of Israel and represent about 20% of the total Israeli population, but are excluded from several aspects of the Jewish welfare state and are therefore denied equal “democratic citizenship.”Reference Butenschon, Davis and Hassassian 48 –Reference Tanous, Asi, Hammoudeh, Mills and Wispelwey 51
The Palestinian territories house around 60 hospitals and medical centers. However, the true measure of good health lies in access to primary health care and health security services, an aspect where Palestinians face a significant deficit. Specifically, they lack a fundamental and substantive primary care system that can effectively serve the local population. The Palestinian Children’s Relief Fund (PCRF) stands as the primary humanitarian organization in Palestine, delivering crucial medical relief and humanitarian aid where it is most needed.Reference El Achi, Papamichail and Rizk 52 Unfortunately, infrastructural challenges impede the mobility of physicians and medical supplies, and the absence of efficient logistics hampers a united effort by all health care service providers to deliver essential primary care. The Palestinians need a primary care system capable of reaching the local population, regardless of their location. 53 – 55
To make this a reality, Israel must lift its restrictions on the movement of physicians and medical supplies, while Palestinians guarantee the health security needed for mobilization within the Territories. Because all medications must be obtained through Israel, Palestine is unable to benefit from potentially lower prices available in Arab neighbors.Reference Mahmoud 15 In Gaza and the West Bank, restricted access translates to limited health facilities for Palestinians. When they do receive care, it often falls short of the highest quality, but they typically have no other options. Palestinians’ capacity to respond beyond routine primary health care in emergencies (i.e., health security) is nearly nonexistent. The public health infrastructure is consistently strained, the movement of people and goods is limited, and the system is chronically underfunded. The Palestinian Ministry of Health, which serves as the principal provider of public health services in the West Bank and Gaza Strip, has a constrained budget, and it heavily relies on external aid to sustain its operations. It also grapples with challenges in coordinating and delivering services due to the inherent fragmentation of the Palestinian health system. Consequently, UNRWA furnishes primary health care services in the West Bank and Gaza Strip, along with secondary and tertiary care services through a network of contracted hospitals.Reference Al Khaldi, Kaloti and Shella 54 The COVID-19 pandemic, along with the ongoing conflict with Israel, has further strained Palestinian hospitals and clinics, already struggling to meet high daily demands. The current conflict has resulted in damage or destruction of health facilities and disrupted the supply of essential medicines and supplies, including all parts of health security that are essentially absent within the Palestinian health system. 53
The health and legal challenges faced by Palestinians significantly affect their well-being, health, and overall health security. Effectively addressing these issues needs a collective effort from the international community to hold all involved parties accountable for their actions. A critical impediment to achieving lasting peace between Israelis and Palestinians lies in the presence of extremist elements on both sides. These extremist factions receive backing from foreign entities with vested national interests in the region. Regrettably, the targeting of civilians by these groups underscores the multifaceted nature of this conflict, resembling a hybrid war, a geopolitical chess match involving various countries with narcissistic leaders and stakes in the Israeli-Palestinian dispute, destroying Palestinian infrastructure and health security.Reference Khorram-Manesh and Burkle 56
Despite the myriad threats and risks that loom over the peace process, identifying common ground is imperative for fostering reconciliation between the two nations. Areas such as medical education, health care innovation and delivery, and collaborative efforts on critical health-related endeavors could serve as a platform for unification, coordination, cooperation, and collaboration. Recognizing that robust surge capacity for managing diverse medical conditions and global public health emergencies hinges on the availability of adequate staff, resources, infrastructure, and systems, collaborative endeavors between Israel and Palestine may hold the key to a more pragmatic and sustainable peace, particularly for the beleaguered populations and communities reliant on the services and support of both health care systems.Reference Marie and Battat 11 –Reference Tekin and Öcal 14 , Reference Rotenberg, Stewart-Freedman and Søgaard 27 , Reference Rosenthal 28 , Reference Khorram-Manesh 57 –Reference Phattharapornjaroen, Carlström and Khorram-Manesh 59
Meanwhile, it is of special importance that the UN and its members, particularly the superpowers, start investing in education, accessible health care, and shelter as necessary items for resilient societies, as well as foundational to basic human rights. These investments should be carried out with a special focus on women and children. These three items establish a better ground for the elimination of extremism and the cultivation of truly democratic systems, while religious leadership could promote health initiatives (both health and health security) and call for utilizing health as a common ground to foster peace and equity in the region.Reference Skorecki and Horton 26 With Israel having good experience in democratic governance and Palestine having the workforce needed for future development, these goals are within reach. Ensuring fair access to education, health care, and home is not only a matter of human rights but also a critical step toward building a foundation for lasting peace and stability in the region. Nothing can better guarantee Israel’s safety than an independent, responsible Palestine.
Limitations
The main limitation of this study was the disadvantage aligned with the outcome of this comprehensive search, which constituted a high rate of studies, when the selection bias may occur. To eliminate such a bias, as much as possible, both authors had to go through available literature and decide unanimously on the included papers.
Conclusion
Socioeconomic distress, widespread poverty, and limited access to education and health care, among other factors, transfer conflicts to an instrument, by which religious beliefs convert into fervently defended ideologies, often employing extreme measures in the name of freedom. Conflicts such as the one between Israel and Palestine demand not only investment in social, educational, and cultural advancement but also a security framework that safeguards the interests of both sides of the rivalry. Health and health security assessments remain one of the most sensitive measures of both governance and peace. With the rising severity of public health emergencies, a recommitment must be made to complete and restore the original mandates as a collaborative and coordinated global network responsibility, not one left to the actions of individual countries. The bottom line is that the global community can no longer tolerate an ineffectual and passive international response system that is not responsive to all of one’s population sensitively measured by health and health security assessments.
Data availability statement
All data included.
Acknowledgments
The authors would like to thank Dr. Dan Skinner for the review of the paper and his invaluable comments.
Author contribution
A KM and FB both made substantial contributions to the study’s conception and/or design, literature search, selection of the included articles, analysis, and/or interpretation of the data. A KM drafted the paper. A KM and FB contributed to editing and revising it. Both authors approved the final version for submission and agreed to be accountable for all aspects of the work.
Funding statement
Not applicable.
Competing interest
The authors declare no conflict of interest.
Ethical standard
Not applicable.
Open access
