Correspondence
The opinions expressed are solely those of the authors. We declare no competing interests.
www.thelancet.com Vol 384 August 16, 2014
*Cindy Sousa, Amy Hagopian, Nancy Stoller, and 17 signatories [email protected] Bryn Mawr College, Graduate School of Social Work and Social Research, Bryn Mawr, PA 19010, USA (CS); University of Washington School of Public Health, Seattle, WA, USA (AH); and Department of Community Studies, University of California, Santa Cruz, CA, USA (NS) 1 2
3
4
5
6
7
8
WHO. World report on violence and health. Geneva: World Health Organization; 2002. Hagopian A, Ratevosian J, deRiel E. Gathering in groups: peace advocacy in health professional associations. Acad Med 2009; 84: 1485. WHO. Situation report #6. Occupied Palestinian territory, conflict escalation in Gaza-complex emergency. http://www.emro. who.int/images/stories/palestine/documents/ WHO_Sitrep_on_Gaza___6_-_August_1. pdf?ua=1 (accessed Aug 5, 2014). Israel Ministry of Foreign Affairs. Israel under fire: July 2014—a diary. http://mfa.gov.il/MFA/ ForeignPolicy/Terrorism/Pages/Israel-underfire-July-2014-A-Diary.aspx (accessed Aug 5, 2014). International Committee of the Red Cross. Geneva Convention relative to the protection of civilian persons in time of war (fourth Geneva Convention). In: 75 UNTS 287; 1949. WHO. WHO calls for the creation of a humanitarian corridor in Gaza. http://www. emro.who.int/media/news/humanitariancorridor-gaza.html (accessed July 29, 2014). Giacaman R, Khatib R, Shabaneh L, et al. Health status and health services in the occupied Palestinian territory. Lancet 2009; 373: 837–49. Becker A, Al Ju’beh K, Watt G. Keys to health: justice, sovereignty, and self-determination. Lancet 2009; 373: 985–87.
I would like to try and explain the very difficult situation in Gaza. The morals, ethics, and values of the Israeli people in general, and of the physicians in particular, are no different than values of British doctors. To see civilians, women, and especially children, wounded or killed during the fighting breaks our hearts. No one owns the monopoly on these universal human values, including the biased, anti-Israel, authors1 and editors of The Lancet, and it is disgraceful to slander 95% of Israeli academics. Where are your protests for an international investigation into the deaths of more than 170 000 Syrians by Syrians—most of them civilians. Where is your outcry to demand an end to the killing of innocent people in Iraq, to protest against the evil regime in Iran, against the massacre of Muslims in Burma, or Copts in Egypt;
there are endless examples. And we search in vain for your expressions of outrage against Hamas leaders, who flagrantly violated the most basic human rights. For an obscure reason, you gave a group of pro-Palestinians a platform to pour poisonous hatred on Israel. This is not the first time. It is an ongoing anti-Israeli and anti-semitic campaign, part of a well orchestrated struggle against Israeli physicians. Hamas, Al Qaeda, and other extreme Islamic fundamentalist organisations were declared by most democratic countries, including the UK, to be terrorist organisations. These groups’ covenant exhort that Jews be killed, because they are Jews. With regards to the number of Palestinian casualties, extremist groups such as Hamas do not seem to value civilian life. They intentionally position their headquarters beneath Shifa hospital and place weapons, rockets, and ammunition in schools, mosques, and shelters. UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) authorities discovered missiles in their schools in Gaza.2 3350 rockets fired so far on Israel were launched from populated areas. Those rockets were fired on Israeli villages and towns with the sole purpose of killing as many civilians as possible. Thanks to the development of the Iron Dome there were minimal casualties. We do not feel a need to apologise for the low number of Israelis killed. The use of civilians, women, and children, as human shields is a crime against humanity that should be condemned by The Lancet and the international community. This is the main cause for the high number of innocent people who are being killed. The repeated violations of Hamas of the ceasefires offered by Israel again and again increases their own casualties. Instead of disproportionately blaming Israel, the right thing to do would be to call for an international tribunal to
For the list of signatories see appendix
Getty images/Planet Observer/UIG
health workers in their attempts to deliver care, or to interrupt services that support health in other ways (such as electric and sanitation systems) is in direct conflict with the fourth Geneva Convention, which assures protection and respect for medical personnel and facilities in occupied territories and military zones.5 As public health professionals, we should be outraged by any violations to these essential guarantees; accountability for adherence to international covenants such as the 1949 Geneva Convention is a basic step in protecting civilians during war and conflict.1,5 We should support, for instance, calls from organisations such as WHO, which issued a plea to respect international law, particularly as it pertains to the obligation to guarantee that people can obtain medical care, and honouring the duty to protect hospitals.6 Health in the occupied Palestinian territory has long deteriorated under the continuous effects of Israeli policies.7 While we advocate for an end to the present bombardment of Gaza that affects civilians, we must also understand how justice, sovereignty, and self-determination for all individuals are fundamental foundations for health.8 We commend the commitment of The Lancet to publishing sound documentation from experts who detail the massive health consequences of the Israeli– Palestinian conflict on civilians. As public health workers and scholars, we need to make space in our journals and forums to share our diverse concerns, experience, and knowledge, especially in times of public health crisis, such as in Gaza today. Only through this sharing of ideas will we effectively understand the many factors affecting health and thereby appropriately uphold our obligations to protect public health.
Published Online August 8, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61310-6
579
Correspondence
investigate Hamas’ use of their own people as human shields in this war. Whereas Israel develops missiles to protect their children, Hamas uses their children to protect their missiles. The more civilians who are hit, the greater their illusion of victory. As in operation Cast Lead, Israel established a field hospital on the border with Gaza to help wounded Palestinians. But again, very few patients arrived at this hospital. Hamas leaders prevent access to this medical facility, 3 just as it prevented the evacuation of civilians when leaflets were dropped from Israeli planes to warn about areas that Israel planned to bomb. There is unbearable suffering, civilian casualties, and children being wounded and killed, but there is no moral equivalence in this war. It is outrageous to blame Israel and shield Hamas with implausible excuses. I declare no competing interests.
Yoram Blachar [email protected] Peres Academic Center, Rehovot, Israel 1
2
3
Published Online August 8, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61312-X
580
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; 384: 397–98. UNRWA. UNRWA Condemns placement of rockets, for a second time, in one of its schools. http://www.unrwa.org/newsroom/pressreleases/unrwa-condemns-placement-rocketssecond-time-one-its-schools (accessed Aug 6, 2014). Cohen G. Under Hamas fire, Israel keeps humanitarian aid to Gaza flowing. http://www. haaretz.com/news/diplomacy-defense/israelgaza-conflict-2014/.premium-1.608949 (accessed Aug 6, 2014).
I write to join my fellow health professionals in expressing my support for the people of Gaza, 1 and my outrage at Israel’s attacks on Gaza’s civilians in their homes, hospitals, and UN shelters. As health professionals, our voices matter, since our support for victims in such conflicts tends to be borne out of empathy and compassion for human suffering, rather than political interests. I am Palestinian, and I am equally appalled by civilian
death and suffering on both sides. The reality of the present conflict is that it is the Palestinian civilians who overwhelmingly suffered death, injury, and displacement. As of Aug 6, the UN Office for the Coordination of Humanitarian Affairs estimated that the war had led to the deaths of 1354 Gazan civilians, including 415 children, and two Israeli civilians.2 They are trapped within closed borders with no safe havens, under intensifying bombardment by Israel from land, sea, and air. The absence of safe havens was recently highlighted by the UN Secretary General, “These attacks were outrageous, unacceptable, and unjustifiable”, he said.3 The UN also highlighted Gaza’s “health and humanitarian disaster”, in part caused by Israel’s shelling of hospitals and clinics—leading to deaths and injuries among medical staff “in the line of duty”.4 It is an ethical necessity to be outraged at the avoidable killing of hundreds of Palestinian civilians, and the shelling of the hospitals in which they are treated. A medical journal is a fitting place for health professionals to express such outrage. I am a Palestinian doctor, trained and practising in the UK. I declare no competing interests.
Hind Khalifeh [email protected] Division of Psychiatry, University College London, London W1W 7EJ, UK 1
2
3
4
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; 384: 397–98. UNOCHA.Occupied Palestinian Territory: Gaza Emergency Situation Report (as of 5 Aug 2014, 0800 hrs). http://www.ochaopt.org/ documents/ocha_opt_sitrep_05_08_2014. pdf (accessed Aug 6, 2014). UN Secretary-General Ban Ki-moon. New York, 6 Aug 2014, Secretary-General’s remarks to the General Assembly on the situation in Gaza. http://www.un.org/sg/ statements/index.asp?nid=7913 (accessed Aug 6, 2014). WHO and UNRWA. United Nations warns of “rapidly unfolding” health disaster in Gaza. press release. http://www.ochaopt.org/ documents/Press_Release_UN_warns_of_ imminent_health_disaster_in_Gaza.pdf (accessed Aug 6, 2014).
Adhesion barriers for abdominal surgery and oncology We read with great interest Richard ten Broek and colleagues’ meta-analysis 1 about the use of four different anti-adhesion barriers. Reoperation for adhesive small bowel obstruction was the primary outcome. The authors suggest their results should inform the development of guidelines for the use of barriers to prevent long-term adhesion-related complications for abdominal surgery in general. However, these results are not applicable to surgical oncology. In stage IV colorectal cancer, which is the most frequent cancer affecting the abdomen, advances in chemotherapy during the past decade have enabled us to increase the number of patients treated with repeated abdominal surgery and therefore, exposed to adhesiolysis-related morbidity. As ten Broek and colleagues noted, adhesiolysis is associated with an increase in bowel injury and septic complications.2 Moreover, adhesiolysis time predicts enterotomy.3 Reoperation for adhesive small bowel obstruction is a rare event and needs a long follow-up period if chosen as a primary endpoint in studies. Hence, adhesive small bowel obstruction is probably not the most clinically relevant outcome nor the most suited to clinical trials when assessing the consequences of adhesions in surgical oncology. Instead, a more realistic primary outcome should be chosen. Such an outcome should allow objective evaluation and should be assessable over a short timeframe. In surgical oncology, serious adverse events and adhesiolysis time might be of value. We declare no competing interests.
*Aurélien Dupré, David Pérol, Michel Rivoire [email protected] Léon Bérard Cancer Center, Lyon 69008, France
www.thelancet.com Vol 384 August 16, 2014
The opinions expressed are solely those of the authors. We declare no competing interests.
www.thelancet.com Vol 384 August 16, 2014
*Cindy Sousa, Amy Hagopian, Nancy Stoller, and 17 signatories [email protected] Bryn Mawr College, Graduate School of Social Work and Social Research, Bryn Mawr, PA 19010, USA (CS); University of Washington School of Public Health, Seattle, WA, USA (AH); and Department of Community Studies, University of California, Santa Cruz, CA, USA (NS) 1 2
3
4
5
6
7
8
WHO. World report on violence and health. Geneva: World Health Organization; 2002. Hagopian A, Ratevosian J, deRiel E. Gathering in groups: peace advocacy in health professional associations. Acad Med 2009; 84: 1485. WHO. Situation report #6. Occupied Palestinian territory, conflict escalation in Gaza-complex emergency. http://www.emro. who.int/images/stories/palestine/documents/ WHO_Sitrep_on_Gaza___6_-_August_1. pdf?ua=1 (accessed Aug 5, 2014). Israel Ministry of Foreign Affairs. Israel under fire: July 2014—a diary. http://mfa.gov.il/MFA/ ForeignPolicy/Terrorism/Pages/Israel-underfire-July-2014-A-Diary.aspx (accessed Aug 5, 2014). International Committee of the Red Cross. Geneva Convention relative to the protection of civilian persons in time of war (fourth Geneva Convention). In: 75 UNTS 287; 1949. WHO. WHO calls for the creation of a humanitarian corridor in Gaza. http://www. emro.who.int/media/news/humanitariancorridor-gaza.html (accessed July 29, 2014). Giacaman R, Khatib R, Shabaneh L, et al. Health status and health services in the occupied Palestinian territory. Lancet 2009; 373: 837–49. Becker A, Al Ju’beh K, Watt G. Keys to health: justice, sovereignty, and self-determination. Lancet 2009; 373: 985–87.
I would like to try and explain the very difficult situation in Gaza. The morals, ethics, and values of the Israeli people in general, and of the physicians in particular, are no different than values of British doctors. To see civilians, women, and especially children, wounded or killed during the fighting breaks our hearts. No one owns the monopoly on these universal human values, including the biased, anti-Israel, authors1 and editors of The Lancet, and it is disgraceful to slander 95% of Israeli academics. Where are your protests for an international investigation into the deaths of more than 170 000 Syrians by Syrians—most of them civilians. Where is your outcry to demand an end to the killing of innocent people in Iraq, to protest against the evil regime in Iran, against the massacre of Muslims in Burma, or Copts in Egypt;
there are endless examples. And we search in vain for your expressions of outrage against Hamas leaders, who flagrantly violated the most basic human rights. For an obscure reason, you gave a group of pro-Palestinians a platform to pour poisonous hatred on Israel. This is not the first time. It is an ongoing anti-Israeli and anti-semitic campaign, part of a well orchestrated struggle against Israeli physicians. Hamas, Al Qaeda, and other extreme Islamic fundamentalist organisations were declared by most democratic countries, including the UK, to be terrorist organisations. These groups’ covenant exhort that Jews be killed, because they are Jews. With regards to the number of Palestinian casualties, extremist groups such as Hamas do not seem to value civilian life. They intentionally position their headquarters beneath Shifa hospital and place weapons, rockets, and ammunition in schools, mosques, and shelters. UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) authorities discovered missiles in their schools in Gaza.2 3350 rockets fired so far on Israel were launched from populated areas. Those rockets were fired on Israeli villages and towns with the sole purpose of killing as many civilians as possible. Thanks to the development of the Iron Dome there were minimal casualties. We do not feel a need to apologise for the low number of Israelis killed. The use of civilians, women, and children, as human shields is a crime against humanity that should be condemned by The Lancet and the international community. This is the main cause for the high number of innocent people who are being killed. The repeated violations of Hamas of the ceasefires offered by Israel again and again increases their own casualties. Instead of disproportionately blaming Israel, the right thing to do would be to call for an international tribunal to
For the list of signatories see appendix
Getty images/Planet Observer/UIG
health workers in their attempts to deliver care, or to interrupt services that support health in other ways (such as electric and sanitation systems) is in direct conflict with the fourth Geneva Convention, which assures protection and respect for medical personnel and facilities in occupied territories and military zones.5 As public health professionals, we should be outraged by any violations to these essential guarantees; accountability for adherence to international covenants such as the 1949 Geneva Convention is a basic step in protecting civilians during war and conflict.1,5 We should support, for instance, calls from organisations such as WHO, which issued a plea to respect international law, particularly as it pertains to the obligation to guarantee that people can obtain medical care, and honouring the duty to protect hospitals.6 Health in the occupied Palestinian territory has long deteriorated under the continuous effects of Israeli policies.7 While we advocate for an end to the present bombardment of Gaza that affects civilians, we must also understand how justice, sovereignty, and self-determination for all individuals are fundamental foundations for health.8 We commend the commitment of The Lancet to publishing sound documentation from experts who detail the massive health consequences of the Israeli– Palestinian conflict on civilians. As public health workers and scholars, we need to make space in our journals and forums to share our diverse concerns, experience, and knowledge, especially in times of public health crisis, such as in Gaza today. Only through this sharing of ideas will we effectively understand the many factors affecting health and thereby appropriately uphold our obligations to protect public health.
Published Online August 8, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61310-6
579
Correspondence
investigate Hamas’ use of their own people as human shields in this war. Whereas Israel develops missiles to protect their children, Hamas uses their children to protect their missiles. The more civilians who are hit, the greater their illusion of victory. As in operation Cast Lead, Israel established a field hospital on the border with Gaza to help wounded Palestinians. But again, very few patients arrived at this hospital. Hamas leaders prevent access to this medical facility, 3 just as it prevented the evacuation of civilians when leaflets were dropped from Israeli planes to warn about areas that Israel planned to bomb. There is unbearable suffering, civilian casualties, and children being wounded and killed, but there is no moral equivalence in this war. It is outrageous to blame Israel and shield Hamas with implausible excuses. I declare no competing interests.
Yoram Blachar [email protected] Peres Academic Center, Rehovot, Israel 1
2
3
Published Online August 8, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61312-X
580
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; 384: 397–98. UNRWA. UNRWA Condemns placement of rockets, for a second time, in one of its schools. http://www.unrwa.org/newsroom/pressreleases/unrwa-condemns-placement-rocketssecond-time-one-its-schools (accessed Aug 6, 2014). Cohen G. Under Hamas fire, Israel keeps humanitarian aid to Gaza flowing. http://www. haaretz.com/news/diplomacy-defense/israelgaza-conflict-2014/.premium-1.608949 (accessed Aug 6, 2014).
I write to join my fellow health professionals in expressing my support for the people of Gaza, 1 and my outrage at Israel’s attacks on Gaza’s civilians in their homes, hospitals, and UN shelters. As health professionals, our voices matter, since our support for victims in such conflicts tends to be borne out of empathy and compassion for human suffering, rather than political interests. I am Palestinian, and I am equally appalled by civilian
death and suffering on both sides. The reality of the present conflict is that it is the Palestinian civilians who overwhelmingly suffered death, injury, and displacement. As of Aug 6, the UN Office for the Coordination of Humanitarian Affairs estimated that the war had led to the deaths of 1354 Gazan civilians, including 415 children, and two Israeli civilians.2 They are trapped within closed borders with no safe havens, under intensifying bombardment by Israel from land, sea, and air. The absence of safe havens was recently highlighted by the UN Secretary General, “These attacks were outrageous, unacceptable, and unjustifiable”, he said.3 The UN also highlighted Gaza’s “health and humanitarian disaster”, in part caused by Israel’s shelling of hospitals and clinics—leading to deaths and injuries among medical staff “in the line of duty”.4 It is an ethical necessity to be outraged at the avoidable killing of hundreds of Palestinian civilians, and the shelling of the hospitals in which they are treated. A medical journal is a fitting place for health professionals to express such outrage. I am a Palestinian doctor, trained and practising in the UK. I declare no competing interests.
Hind Khalifeh [email protected] Division of Psychiatry, University College London, London W1W 7EJ, UK 1
2
3
4
Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S. An open letter for the people in Gaza. Lancet 2014; 384: 397–98. UNOCHA.Occupied Palestinian Territory: Gaza Emergency Situation Report (as of 5 Aug 2014, 0800 hrs). http://www.ochaopt.org/ documents/ocha_opt_sitrep_05_08_2014. pdf (accessed Aug 6, 2014). UN Secretary-General Ban Ki-moon. New York, 6 Aug 2014, Secretary-General’s remarks to the General Assembly on the situation in Gaza. http://www.un.org/sg/ statements/index.asp?nid=7913 (accessed Aug 6, 2014). WHO and UNRWA. United Nations warns of “rapidly unfolding” health disaster in Gaza. press release. http://www.ochaopt.org/ documents/Press_Release_UN_warns_of_ imminent_health_disaster_in_Gaza.pdf (accessed Aug 6, 2014).
Adhesion barriers for abdominal surgery and oncology We read with great interest Richard ten Broek and colleagues’ meta-analysis 1 about the use of four different anti-adhesion barriers. Reoperation for adhesive small bowel obstruction was the primary outcome. The authors suggest their results should inform the development of guidelines for the use of barriers to prevent long-term adhesion-related complications for abdominal surgery in general. However, these results are not applicable to surgical oncology. In stage IV colorectal cancer, which is the most frequent cancer affecting the abdomen, advances in chemotherapy during the past decade have enabled us to increase the number of patients treated with repeated abdominal surgery and therefore, exposed to adhesiolysis-related morbidity. As ten Broek and colleagues noted, adhesiolysis is associated with an increase in bowel injury and septic complications.2 Moreover, adhesiolysis time predicts enterotomy.3 Reoperation for adhesive small bowel obstruction is a rare event and needs a long follow-up period if chosen as a primary endpoint in studies. Hence, adhesive small bowel obstruction is probably not the most clinically relevant outcome nor the most suited to clinical trials when assessing the consequences of adhesions in surgical oncology. Instead, a more realistic primary outcome should be chosen. Such an outcome should allow objective evaluation and should be assessable over a short timeframe. In surgical oncology, serious adverse events and adhesiolysis time might be of value. We declare no competing interests.
*Aurélien Dupré, David Pérol, Michel Rivoire [email protected] Léon Bérard Cancer Center, Lyon 69008, France
www.thelancet.com Vol 384 August 16, 2014
