Medical neutrality describes an ethos in which medical personnel and their patients are positioned outside of the field of politics. Medical neutrality differentiates a zone of clinical practice and treatment of suffering in which patients are attended to impartially, and medical personnel themselves are shielded from the demands of politics and conflict [
1]. However, studies of medical neutrality have deconstructed claims to a position “outside” of politics. Redfield characterizes medical neutrality as “an antipolitics with political possibilities” [
1]. Denial and silencing of political conflict often divert attention away from the structural (upstream political, policy, economic, legal) causes of health inequalities and, instead, attribute inequalities to cultural and biological characteristics [
2].
This article contributes to the literature on depoliticization and structural determinants of health by analyzing how medical staff in a Jerusalem Emergency Department (ED) discuss the ethos of medical neutrality. We demonstrate that medical staff endorsed the perspective of medical neutrality and understood it as a humanitarian and nondiscriminatory perspective. At the same time, some medical staff recognized the limits of medical neutrality in the context of the Israeli-Palestinian conflict. While medical staff in the ED identified unique health risks for Arab patients, most did not associate these risks with the effects of conflict and instead explained them in depoliticized terms of culture and behavior. We suggest that the normative demand for neutrality within healthcare institutions shapes how political conflict operates as a structural determinant of health.
The Ethos of Medical Neutrality and Depoliticization
The origins of medical neutrality lie in humanitarian political and legal regimes defining the role of medical personnel and the status of the wounded in contexts of war [
3]. The supposed political neutrality of medicine is undergirded by the epistemics of biomedical sciences, which represent health, disease, and suffering through universal categories [
4], which inflect medical education and practice with universalist assumptions [
5,
6]. This neutrality aims to make the hospital and the clinic safe havens, professional spaces where all patients get equal treatment regardless of their ethnicity, race, class, gender, religion, or other axes of difference and discrimination. In some instances, medical neutrality may even be wielded against state power, as it offers a basis for authoritative claims about the preservation of life in the face of military violence [
7] or as a form of witnessing that sheds light on humanitarian violations [
8]. However, the ethos of medical neutrality can also lead to overlooking the macro-level political, policy, socio-economic, and legal factors that impact patients' health [
2,
9].
The ethos of medical neutrality entails depoliticization which is manifested “in processes through which objects are framed as apolitical, issues are driven outside the political realm and actors minimize, avoid or conceal the political dimension of their action” [
10]. Depoliticization often prevails in contexts of conflict. Hunsmann shows how global health discourse and intervention structurally neglect conflict and minimize their political dimension even though global health work is inevitably conflict-laden [
11]. In global health discourse, policymaking is usually presented as relying on neutral and objective health sciences research evidence, and politics is assumed to be distinct from policy [
9,
12]. However, the concept of evidence-based policy obscures the fundamentally political nature of decision-making and the impact of politics on the creation, selection, and interpretation of evidence [
9,
13].
In Israel, the supposedly depoliticized approach is dominant. Particularly, the Israeli-Palestinian conflict is not seen as a legitimate topic for in-depth discussion or action within healthcare [
2]. The ethos of neutrality has been credited with enabling healthcare to become one of the most diversely integrated sectors [
6]. However, Shalev explains that this neutrality, which he sees as “a shared fiction,” is applied selectively, imposing limitations on some while enabling others [
14].
While Arab Israeli professionals working in healthcare recognize that the ethos of neutrality may support their inclusion within healthcare institutions, neutrality also works to mask experiences of discrimination and the unequal effects of political conflict [
6]. Claims to neutrality in the medical sphere also operate as a powerful justification for ignoring unequal conditions that shape health for non-Jewish Israelis [
15]. Medical neutrality is compatible with the broader practice of sanitizing institutional spaces of political discussions related to the Israeli-Palestinian conflict [
16‐
18].
Structural Determinants of Health and the Conflict in Jerusalem
In recent years, there has been a growing recognition of the structural determinants of health [
19‐
21]. This concept relates to a variety of upstream, macro-level factors that produce and maintain health inequities, often in relation to race, ethnicity, religion, religiosity, class, citizenship status, language, geography, gender, and age. The structural determinants of health include public policies, laws and legal systems, social and economic systems, and political decisions and processes. However, these determinants are often misrecognized and interpreted in biologic or behavioral terms [
22]. When clinicians dismiss structural factors as peripheral, they not only miss opportunities to improve health outcomes, but may also "fail at medicine’s core responsibilities to diagnose and treat illness and to do no harm" [
23].
Despite the increasing awareness of the impact of structural forces on health, violent political conflict is largely overlooked in the scholarship on the topic, in medical providers' structural competency training (see below), and, more broadly, in public health, bioethics, and health promotion. Abuelaish et al. assert that although conflict always affects health, public health and health promotion experts have often failed to recognize the interrelations between health and peace [
24]. This misrecognition likely stems from the dominance of the norm of neutrality, as well as from the focus on the US context in the existing literature on the structural determinants of health. The case of Jerusalem and the Israeli-Palestinian conflict contributes to bridging this knowledge gap. Specifically, our research site in a Jerusalem ED is a suitable case study as the ED is a pivotal interface between the hospital and the city's diverse communities.
Israel has a universal healthcare coverage system that includes high-quality services and technologies that are available to all residents who are recognized as "legal residents" by the state, largely free at the point of service [
25]. However, irregular migrants, migrant workers, asylum seekers, and other undocumented people are not covered by the National Health Insurance Law [
26,
27]. Moreover, there are health disparities between the Jewish and Arab populations in Israel [
28‐
34]. These disparities are manifested in various health indicators, such as higher life expectancy in birth of Jews compared to Arabs (gap of 5 years among males and 3.7 years among females in 2020), and lower infant mortality rate per 1,000 live births among Jews (2.3) compared to Arabs (5.6) in 2015–2019 [
32]. There are inequalities in non-communicable diseases between Jews and Arabs, across socio-economic position levels [
34]. Recent studies found additional health disparities between Jewish and Arab women in Israel. For example, the prevalence of postpartum depression among Arab women is higher compared to Jewish women [
33]. Palestinian-Arab perinatal women have higher anxiety and higher severity of neighborhood violence and disorder compared to Jewish perinatal women. These inequalities likely reflect residential segregation and can be reduced by changing government policies [
30]. Arab Bedouin women experience multiple barriers while accessing healthcare services [
29].
The Palestinian-Arab residents of East Jerusalem, who constitute around 38% of Jerusalem's population [
35], have a unique status. They are entitled to Israeli health insurance, healthcare benefits, and social benefits, as long as they reside or work in Jerusalem, but there is inequity in some aspects of their healthcare [
36,
37]. They have the right to vote in local elections, but they are usually unable to vote in national elections because most are permanent residents rather than citizens. Research found that they interact differently with healthcare services [
38]. They are served by the city's three major general hospitals as well as smaller Palestinian hospitals in East Jerusalem. The latter suffer from a serious shortage of medicines, medical equipment, and staff due to conflict-related reasons such as the Israeli West Bank barrier (Separation barrier) that was constructed following the Al-Aqsa Intifada (Palestinian uprising) and, together with the Israeli permit regime, disconnected the East Jerusalem hospitals from numerous patients and staff from the West Bank. At the same time, the Israeli Health Maintenance Organizations (HMOs) pay these hospitals much less than they pay Israeli hospitals for health services provided to their insured patients [
36,
37,
39]. These hospitals rely on international financial support and are subject to funding cutbacks due to political decisions [
40].
Moreover, the poor infrastructures in East Jerusalem impact people’s health and safety. For instance, as of 2018, only 44% of the Palestinian-Arab residents of East Jerusalem had proper and legal connections to the water grid, and there is a shortage of new sewage lines in East Jerusalem [
41]. According to the State Comptroller of Israel, the social and welfare services and infrastructures in East Jerusalem are inadequate, particularly those for people with disabilities, elderly people, and children at risk, and there are substantial gaps between services provided in East and West Jerusalem [
42]. This affects the physical and mental health of these vulnerable populations. Additional substantial disparities exist in areas such as education, building, planning, and house demolition [
41‐
44]. The transportation infrastructures are insufficient and often unsafe, e.g., lack sidewalks and safety barriers [
41].
The Israeli-Palestinian conflict, directly and indirectly, affects the life and health of Palestinians living in East Jerusalem in multiple ways. For example, these residents face substantial delays in reaching medical care. It often takes much longer for ambulances coming from Palestinian neighborhoods to reach the ED because of conflict-related factors. Israeli medical teams often refuse to enter certain Palestinian neighborhoods in Jerusalem without a police escort due to fear of violence. In certain Palestinian areas, the residents have to use the Palestinian Red Crescent Ambulance Service which provides Basic Life Support only. In the case of a patient requiring intensive care, an Israeli ambulance staffed with a paramedic transfers the patient from the checkpoint for evacuation [
45]. Additionally, Israeli army checkpoints stop ambulances on their way to the hospital from the West Bank and some of Jerusalem’s Palestinian neighborhoods [
46].
The population most affected by these structural issues is the Arab residents of Jerusalem living on the Eastern side of the West Bank barrier. This population of approximately 120,000–140,000 residents constitutes 33%-39% of the city’s Arab population of 359,000 residents. Several thousand of them live in “enclaves” created along the municipal boundary of Jerusalem [
41]. The Arab residents living in the neighborhoods beyond the West Bank barrier have less access to healthcare services. For example, in these neighborhoods in North-East Jerusalem, there are no Family Health Centers (Tipat Halav)
1 [
48]. The residents face difficulties reaching hospitals and sometimes even community clinics of their HMO [
37]. A case in point is pregnant women in Kufr Aqab, a neighborhood located beyond the West Bank barrier. Hamayel et al. show how Israeli residency and segregation policies adversely affect the women's pregnancy and birth on physical, social, and psychological levels. Among other things, these women need to cross checkpoints to give birth in Jerusalem hospitals for their children to be eligible for permanent residency. During pregnancy, they are exposed to risky conditions and experience increased fear and anxiety. Often, their husband and family cannot accompany them to the hospital due to lack of a permit [
49].
The political conflict also harms the physical and mental health of many Jewish residents of Jerusalem, such as victims of the numerous terror attacks that have taken place in the city in the past decades. For example, Ad-El et al. report that from the beginning of the Al-Aqsa Intifada in October 2000 to January 2004, 577 suicide-bombing victims were admitted to just one of Jerusalem's hospitals, suffering multiple traumas of varying severity [
50]. Pat-Horenczyk screened 1,010 adolescents in Jerusalem and nearby settlements who were subjected to intensive terrorist attacks in the context of the Al-Aqsa Intifada. Two-thirds (67%) of the participants reported high levels of fear, helplessness, and horror, and 5.1% were diagnosed with PTSD. Participants also experienced functional impairment, somatic symptoms, and depression [
51]. While these effects of conflict are often apparent in clinical settings, health care staff are rarely equipped with the expertise to identify and respond to conflict as a determinant of health.
Structural Competency
Structural competency is a framework that has been developed in the past decade to help healthcare personnel identify and address structural determinants of health, such as public policies, economic systems, and healthcare delivery systems, and the ways they shape diseases, affect healthcare, and create health disparities [
52]. Neff et al. define structural competency as "the capacity for health professionals to recognize and respond to health and illness as the downstream effects of broad social, political, and economic structures" [
53]. Structural competency has been proposed as an additional layer of the earlier concepts of cultural competency and the social determinants of health [
52].
Structural competency principles allow healthcare providers to improve treatment and patient experience, and become more engaged in policy leadership, enhancing health equity [
54,
55]. Furthermore, structural competency can promote the development of critical consciousness not only in healthcare professionals but also in disadvantaged patients and community members with whom they collaborate. Critical consciousness enables stakeholders to challenge deep-seated social-political assumptions [
22]. However, we suggest that political conflict is an overlooked structural determinant of health.
Metzl et al. propose that structural competency can contribute to addressing the lasting lesson of COVID-19 that "health and illness are political," hence medicine needs "to have an explicit political voice" [
56]. While health care staff in many regions deal with the direct consequences of political conflict in clinical settings, understanding and addressing conflict is generally considered outside the purview of health care expertise. The dominant ethos of neutrality and the depoliticized approach exclude recognition of political conflict and may contribute to the naturalization of inequality. Naturalizing inequality refers to the "ways in which health disparities are often attributed to the behaviors or innate characteristics of the individuals or groups of people most affected by these disparities" [
53]. This naturalization entails ignoring the social and political origins of health disparities [
57,
58]. Depoliticization may worsen the effects of political conflict as a determinant of health.
Structural competency allows healthcare professionals to understand the process by which structurally-generated health inequalities are perceived as natural and deserved rather than unjust and imposed, and are consequently reproduced and perpetuated [
19,
53]. This understanding "opens up the possibility for challenging ideologies of inequality that justify a pathogenic status quo" [
19]. We propose that broadening the concept of structural competency to include structural determinants that are rooted in political conflicts can challenge the naturalization of these determinants which reproduces health inequity in conflictual settings.