Rockets fired by Palestinian militants from Gaza City toward Israel on October 7, 2023. Image credit: © Mahmud Hams, AFP
Rockets fired by Palestinian militants from Gaza City toward Israel on October 7, 2023. Image credit: © Mahmud Hams, AFP
Margaret Thatcher famously stated “crime is crime is crime.” I disagreed with Ms. Thatcher on many issues, but I appreciated the moral clarity of her tautology.
On Friday, October 6, 2023, 50 years and one day after Egypt and Syria staged a surprise attack on Israel (the Yom Kippur War), Hamas terrorists launched an attack on Israel by air (missiles and drones), land (multiple violent breaches of the Israel/Gaza border plus prior infiltration into Israeli communities), and sea. Over the next few hours, Hamas launched over 2,000 missiles at Israel. Concurrently, Hamas gunmen terrorized communities near Gaza, indiscriminately killing civilians and taking dozens of prisoners. On Saturday morning, more than 250 concertgoers were gunned down as they fled. Two days later, Israel was still clearing terrorists from cities. News reports suggest that at least 150 people, mostly civilians, had been taken hostage. Hamas vowed to broadcast the execution of the hostages unless Israel ceases its efforts to destroy Hamas.
As of this writing, more than 1,000 Israelis have been killed by Hamas. To calibrate this number, Israel has a population of 9.4 million people. The United States has a population of 332 million. An equivalent terrorist attack on the United States would have 35,000 deaths. Readers of the ASA Monitor will recall the horror of 9/11 and the numbing dread in the months that followed. About 3,000 people were killed on 9/11. If some infinities are larger than others, then are some depths of hell deeper than others?
Maybe. The terrorists who killed thousands of Americans on 9/11 posed no military threat to the United States. We were terrorized, but our military might was unbowed. In stark contrast, Israel faces a mortal threat from neighboring states that have vowed to destroy it. One of these states, Iran, is developing nuclear weapons. Hamas may not have the military muscle to destroy Israel. However, Hamas terrorism destabilizes the Middle East. The calculus has forced Israel to flex its military muscle, potentially transforming Israel in the eyes of the world as the aggressor, not the victim.
As always with war, the heaviest toll will fall upon the most vulnerable. The Palestinians in Gaza are desperately poor. They are ruled by terrorists drawn from disaffected Palestinians. Hamas became the government of Gaza after a 2006 war with Fatah. A poll in 2021 found that more than 50% of Palestinians in Gaza support Hamas (asamonitor.pub/3RWF4f4). That will prove to be a bad choice. The lives of Palestinians will be immeasurably worse following Hamas' terrorist attack. The current poverty and isolation of Gaza stems from the blockade of Gaza by Israel, a blockade created to limit terrorist attacks from Hamas. Israelis rightly expect their government to keep them safe. As Israel seeks to defang Hamas, the 2.2 million Palestinians confined to a mere 140 square miles have nowhere to go. They are now hostages of Hamas as well.
I write about terrorism, war, and violence because the ASA Monitor is written by physicians for physicians. War is more personal for us than for many of our physician colleagues. Anesthesiologists recoil at intraoperative awareness. Steel slicing unanesthetized flesh is the stuff of our nightmares. However, that is an apt description of the deaths of Israelis gunned down by Hamas terrorists, and the deaths of Palestinians killed in Israeli airstrikes.
In 2022, I wrote about the horror of Russia's unprovoked invasion of Ukraine (asamonitor.pub/45tpXwA). That war, just like this war, was a choice by individuals answerable only to themselves. Warlords who seek power through violence are truly evil. As physicians, respected and rewarded by society for our commitment to healing, we have a duty to condemn war and seek peace.
Condemning war means condemning the aggressor. Russia invaded Ukraine without provocation. Hamas launched a massive terrorist attack against Israel. Both aggressors intentionally targeted the civilian population. I am tired of the “whataboutism” prevalent in the news, social media, and even from the occasional ASA member. Russia claimed Ukraine was a Nazi state. That is false. Hamas claimed its terrorist assault was in response to another Israeli infraction at the Al-Aqsa Mosque on Temple Mount (known as Har ha-Bayit in Hebrew and al-Haram al-Sharif in Arabic). Yes, Israel has taken actions on the Al-Aqsa Mosque that are an affront to Muslims. Yes, there is a need to discuss the causes and consequences of Israel's longstanding blockade of Gaza. However, nothing justifies the terrorism unleashed on Israel by Hamas.
How should we respond? In this article, I have provided a table of charitable organizations, both for Israel and for Gaza. People are people. I urge readers to help those whose lives have been upended by the senseless violence unleashed by the terrorist assault on Israel.
Lacking answers to questions that have dogged humanity for millennia, I'll resort to platitudes. Quoting Golda Meir, “Peace will come when the Arabs love their children more than they hate us.” Can we learn to hate less? The attacks by Hamas will evoke hatred for Palestinians. I feel my own outrage as I read the news. The news is filled with more images of horrific bloodshed as Israel seeks to defend itself from further attacks by prosecuting its war to destroy Hamas. That will evoke outrage and hatred toward Israelis. Iran and Hezbollah will stoke outrage and hatred, seeking more violence against Israel. On social media, antisemitism and Islamophobia are rising from their already unacceptable levels.
Can this stop? Can we end the cycle of outrage and violence? Can we love our children more than we hate our enemies?
We were drawn to medicine, and to anesthesiology, by our better angels. We are healers. We value each individual human life. We seek to end pain and suffering. We have other useful skills, including negotiating prowess and scientific literacy. As physicians, and as anesthesiologists, we must be voices for a more compassionate, just, and peaceful world.
Note from Dr. Shafer:
I was unaware that the words of Golda Meir were incendiary, particularly to those of Arabic heritage. The quote is so familiar that I failed to hear the dehumanizing subtext. I should not have quoted Golda Meir in a message intended as a call for compassion. It was my mistake. I apologize to our readers. I have revised the text by striking out the words of Golda Meir.
We have received several thoughtful responses, which currently appear as online comments. Some of these commentaries will appear as letters to the editor in the February and March issues of the ASA Monitor.
Readers may welcome the messages published by Johns Hopkins University (publichealth.jhu.edu/2023/violence-and-war-in-israel-and-gaza) and the Society for Pediatric Anesthesia (pedsanesthesia.org/conflict-in-israel-and-gaza/).
Is there anything that can be said as we watch the unfolding humanitarian disaster, first in Israel and now in Gaza, following the October 7 attacks? Bertrand Russell was among the most brilliant mathematicians and philosophers of the 20th century. In 1950, Russell was awarded the Nobel Prize in Literature “in recognition of his varied and significant writings in which he champions humanitarian ideals and freedom of thought.” In 1970, Russell wrote, “All who want to see an end to bloodshed in the Middle East must ensure that any settlement does not contain the seeds of future conflict.”
Perhaps our calls for compassion and dialog, as physicians and healers, can lay a foundation for a future without conflict.
Steven L. Shafer, MD, FASA, Editor-in-Chief, ASA Monitor, and Professor Emeritus of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California.
Steven L. Shafer, MD, FASA, Editor-in-Chief, ASA Monitor, and Professor Emeritus of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California.
Comments
Bertrand Russell Was Right
Dr. Steven Shafer’s compelling commentary in “Terrorism Is Terrorism Is Terrorism" strongly condemned Hamas' role in the tragic terrorist attack on Israel on October 7, 2023. His primary message rallied physicians against terrorism and violence, emphasizing the crucial need for lasting peace – a sentiment we wholeheartedly support.
In the wake of October 7, a profound human tragedy unfolded, with Hamas terrorists committing heinous acts that resulted in the loss of over 1,200 lives, and kidnappings involving both Israelis and foreign citizens. This violence, even against those dedicated to saving lives, highlights the immense humanitarian challenges in conflict zones.
The ongoing conflict has caused significant damage to the Palestinian health care system. In war, every effort should be made to protect health care facilities. However, we also recognize that the misuse of hospitals by combatants for military purposes, such as storing weapons and establishing command centers, jeopardizes their protection under international law.
Despite the conflict's origins, the human cost deeply affects us. Dr. Shafer invoked Bertrand Russell's wisdom, emphasizing the importance of avoiding future conflicts in any settlement. While many call for a ceasefire, we believe it should only follow the release of hostages and the dismantling of terrorist infrastructure.
Open dialogue can then pave the way for post-conflict resolution. As healers, we advocate for compassion and dialogue as the foundation for a conflict-free future.
Deepest appreciation for your consideration,
David Adams MD
David Amar, MD
Jeffrey L. Apfelbaum, MD
Itay Bentov, MD, PhD
Ori Gottlieb, MD, FASA
Zvi Grunwald, MD, FASA
David L. Hepner, MD, MPH, FASA
Zeev N. Kain, MD, MBA, FAAP
Suzanne Karen, MD, FASA
Michael C. Lewis, MD, FASA
Ronald G. Pearl, MD, PhD, FASA
David M. Polaner, MD, FAAP
David Salama, DO
Joseph Sanders, MD, FASA
Linda Shore-Lesserson, MD, FASE, FASA, FAHA
Joshua Younger, MD, FASA, FACOG
Carolyn Weiniger, MBChB
REPLY FROM DR. SHAFER
I appreciate the thoughtful dialogue among our anesthesiologist colleagues about the horrific events over the past months in Israel and Gaza. We see the conflict through multiple lenses, often reflecting personal national, ethnic, and religious heritages. As physicians, we have come together in denouncing violence and suffering, and promoting security, health, and well-being.
Last November, I expressed a view that physicians must speak out about war and violence. I encouraged commentaries, which are now published. I hope we set an example for other medical societies to advocate for all who suffer in war and conflict.
The ASA Monitor is not “The Journal of Middle East Conflict Resolution.” This will be our final commentary. I appreciate the efforts of the many authors who found common ground and shared values in calling for compassion, understanding, and lasting peace.
Steven L. Shafer, MD
Editor-in-Chief, ASA Monitor
Safe Spaces
Intentionally inclusive leadership is especially important when professional and even physical safety of individuals is at risk. This requires listening and authentic dialog in a safe space. This falls squarely in the province of DEI (diversity, equity, and inclusion) and physician wellness initiatives. DEI creates a more empathetic and inclusive workplace while demonstrably improving patient outcomes. DEI ensures that underrepresented perspectives inform decisions and guide direction for positive change.
Leaders may rationalize silence regarding the war in Israel and Gaza, citing ongoing disasters, natural or manmade, as occurring all the time. This crisis is different. We are witnessing the death of physicians, nurses, and the violent collapse of an entire health care system serving 2 million people. Nearly the entire population in Gaza has been displaced, with no protection against disease, famine, or even the natural elements. To know that such a catastrophe could not occur without our financial support is a heart-wrenching realization. We need to talk.
Could condemnation and dialogue be a shared starting point to nurture harmony within our workspaces? Possibly, if done appropriately.
The frequent expectation for Muslim and Arab communities to publicly renounce acts of violence, which are contrary to their values, merits thoughtful examination. Violence is contrary to Muslim and Arab values. This request, though seemingly reasonable as an affirmation of common values, often serves to ease the stereotypical fears of those concerned about extremism in Arab and Muslim communities.
To foster healing and workplace harmony, it's imperative to condemn ALL forms of injustice. Condemning the October 7 attack AND the ongoing and violent de-Palestinization of Gaza and the West Bank powerfully affirms our commitment to shared values.
Remaining silent in the face of these issues is irresponsible and perilous. Recognizing our shared humanity and condemning all injustices is essential for initiating meaningful dialogue. Dr. Shafer’s words suggest that was his intent, albeit ineptly executed.
Our current climate is marred by the absence of safe spaces for discussion. Additionally, the escalating menace of doxing poses further personal and professional barriers. This is precisely why preserving dialogue and listening are essential. Failing to foster discourse may serve to escalate tensions and further endanger Israeli, Jewish, Arab, and Muslim communities.
Our organizations must continuously strive to create leadership structures that embody level-headedness and a commitment to humanity, respect, and compassion for all. ASA can lead the way for other medical societies through courage, character, and commitment to heal.
We respectfully suggest using the “SAFESPACE” framework, which aligns naturally with DEI and physician wellness efforts.
SAFESPACE: A framework for leadership to bridge the divide
Speak Against Injustice: Leaders must actively oppose acts of injustice in all forms, signifying a profound commitment to humanity. Recognizing and condemning injustices provides psychological safety for communities at risk. Without this step, none of the other steps will be effective. When applied to the Israel-Gaza war, a condemnation of October 7 and the condemnation of ongoing de-Palestinization of Gaza and West Bank is a good first step.
Advance Empathetic Dialogue: Creating spaces for open, empathetic discussions on sensitive topics is essential. Leaders should be equipped to manage these dialogues effectively, using organizational support to reduce inflammatory rhetoric.
Foster Diversity of Perspectives: Embracing a wide range of viewpoints is key to inclusive decision-making. Leaders should actively seek diverse opinions, enriching the decision-making process and promoting inclusivity.
Engage Personally in Areas of Conflict: Leaders should visit areas of conflict to deeply understand the challenges faced. This can take the shape of global health missions in post-conflict areas that are deemed safe. This commitment can foster real empathy and healing.
Strive for Precise Language: Precision in language is crucial in discussing sensitive issues. Leaders should use clear, careful language to avoid exacerbating tensions and ensure productive, meaningful dialogue. We must also recognize that even when using the same vocabulary, our inherent biases and perspectives can lead to divergent interpretations of the same words. Therefore, achieving alignment on definitions to avoid confusion or conflation is a critical step of the process. This can also avoid unintentional inflammatory rhetoric due to our own biases.
Promote Healing and Understanding: Leaders must lead the charge in healing divisions, embodying empathy and understanding. This commitment is vital for transformative leadership.
Authentic DEI Implementation: Embracing authentic DEI approaches, leaders should address complex representation issues with sincerity, dedicating significant resources to meaningful and impactful DEI initiatives. Conversely, tokenistic DEI efforts that provide the optics of DEI can dilute trust in leadership’s desire for representative governance and positive change.
Commit to Continuous Learning: Embrace an ongoing learning journey to better understand and address the evolving dynamics of diversity and inclusion. This commitment involves regularly updating strategies and approaches in line with new insights and best practices.
Ensure Inclusive Policies and Practices: Develop and implement policies and practices that support an inclusive environment. This means ensuring that underrepresented voices are heard and respected and that policies are fair and equitable for everyone.
Through the proposed SAFESPACE framework, leaders can effectively navigate the complexities of modern leadership, fostering environments where diversity, empathy, and understanding are not just valued but actively promoted. This comprehensive approach is crucial for creating a more inclusive, harmonious society. Nurturing our own well-being and sense of belonging and safety is essential to providing the best care for our patients. Ultimately, we cannot care for others if we cannot care for ourselves.
Champions of Compassion
Gaza, which gifted medicine the invention of gauze, faces a chilling scarcity of medical supplies, resources, infrastructure, and personnel. Patients endure surgery without anesthesia. Surgeons operate without electricity. Instruments cannot be sterilized. The military destruction of an entire health care system is inhumane.
This is a man-made tragedy, funded in part by us. Leaders have twisted the narrative to widen divisions, spread hate, and continue violence in their quest for power. Nearly half of Gaza's population was not even born when Hamas took power, yet the children in Gaza bear the brunt of the ongoing conflict. Given these stark failures of leadership and as citizens and physicians, it is our duty to stand as beacons of reason and uphold the principle of “do no harm.”
We are physicians. We care for all patients.
Dr. Shafer's analysis helps us understand the impact of the tragic loss of 1,200 Israelis on October 7 by comparing it to the United States. He explains that if a similar event occurred in the U.S., it would be equivalent to 35,000 American lives lost.
As of this writing, nearly 25,000 lives in Gaza have been lost since October 7. Seventy percent of the fatalities are women and children. This would be the equivalent loss of 3.4 million Americans. More than 80% of hospitals have been destroyed. Hundreds of physicians and nurses have been killed by the Israeli military.
Passive acceptance of these figures as “collateral damage” violates basic principles of human decency. It also violates the Geneva Conventions, which advocate for the sanctity of life and the protection of medical facilities, even in conflict.
We are physicians. We care for all people.
As Dr. Shafer acknowledged in his response above to Dr. Abdo, Dr. Shafer did not appreciate the toxicity and danger of Golda Meir's statement, "Peace will come when the Arabs love their children more than they hate us." This is no innocent platitude. This quote is a textbook example of implicit bias, invoking dehumanization, racism, moral superiority, and oppression.
Consider the full quotation. “When peace comes, we will perhaps in time be able to forgive the Arabs for killing our sons, but it will be harder for us to forgive them for having forced us to kill their sons. Peace will come when the Arabs will love their children more than they hate us.”
Love of children is characteristic of all humanity. Who doesn’t love their children? The statement suggests Arabs lack the fundamental parental love recognized in “civilized” cultures. Furthermore, it suggests Arabs as consumed by intractable hatred. This goes beyond simply dehumanizing Arabs.
How would you respond if someone said, “Peace will come when (a group to which you belong) love their children more than you hate us”?
The statement is racist, because it judges all Arabs with the same toxic brush. That is the definition of racism.
Juxtaposed to the dehumanization and racism is the moral superiority of the speaker, who professes to “forgive” Arabs despite being forced to kill their sons. These three elements: dehumanization, racism, and moral superiority set the groundwork for ongoing violent de-Palestinization.
This racist and dehumanizing framing implicit in Golda Meir’s quote is a prerequisite to rationalizing the irrational and tolerating the scale of "collateral damage" we are witnessing. The quote also distorts the conflict, portraying it as an outcome of cultural incompatibilities, despite centuries of prosperous coexistence that prove otherwise.
Furthermore, it desensitizes the global conscience to the suffering of Palestinians, who urgently require compassion and immediate action to save their very existence as a people and nation.
In the realm of medicine, a fundamental axiom holds: to cure an ailment, one must first accurately diagnose its root cause. In this case, the primary diagnosis is “injustice.” At the crux of these injustices lies the ongoing and violent de-Palestinization in Gaza and the West Bank and the attacks against Israel, including the October 7 attack. Our commitment to healing must be as unflinching against all social injustices as it is against illness. This is particularly evident when we partially fund the horrors, and the victims include fellow doctors and nurses. Our voices, steeped in the empathy intrinsic to our profession, can be instruments of change with a moral duty to deploy them, especially when global leaders fail to do so and physicians and nurses are seen as acceptable “collateral damage.”
Prior to the war, Gaza was desperately poor. Israel's decision to cut off electricity, water, and food inflicted unimaginable suffering. The ensuing humanitarian crisis has been described as apocalyptic. Doctors Without Borders and the United Nations, along with other aid groups, have confirmed these assessments. More than 80 journalists have been killed. The UN has had more than 130 relief workers killed. The Security Council of the United Nations drafted a proposal for an indefinite ceasefire to permit humanitarian aid to reach Gaza. When has calling for a ceasefire been controversial among physicians? The United States, against the view of most Americans and the entire world, vetoed the resolution.
We are physicians. We care for all humanity.
In advocating for a ceasefire, we not only respond to the immediate anguish wrought by conflict but also affirm the shared humanity that binds us all together. This is the clarion call for healing that medical professionals sworn to the Hippocratic Oath must amplify. Silence in such times is a betrayal of the voiceless, notably the children ensnared in strife, and our advocacy for their well-being must be both immediate and unwavering. To ignore this call due to lack of moral courage is to exhibit a “Hypocritic Bias,” selectively applying the values we profess to uphold. Anything less suggests a divergence from our medical ethos.
Dr. Shafer's recommendation to donate reflects a profound understanding of the disparate realities faced by Israelis and Palestinians. Israel has world-class infrastructure. Palestinians are in a living hell confronting a complete disintegration of essential services, including health care and education, resulting in disease and starvation. There is a dire need for humanitarian aid in Gaza, where such support is vital for survival.
The victims of injustice need more than money. They need us to have the courage to say that injustice and unmitigated suffering are wrong. The greatest injustice is more than the atrocities. The greatest injustice is enabling a cultural norm that stifles criticism of these horrors. We must speak up and align our hearts and minds to a “Humanitarian Bias” that always favors our shared humanity.
We are physicians. We are champions of compassion.
As physicians, we must support a ceasefire and sufficient humanitarian assistance for the people of Gaza. As physicians, we must condemn the wholesale destruction of an entire health care system.
We are physicians. We care.
Suffering Is Suffering Is Suffering
In his recent commentary in "Terrorism Is Terrorism Is Terrorism," Dr. Shafer condemned Hamas for the terrorist attack on Israel on October 7. The purpose of the commentary was to use our collective voices as physicians to condemn terrorism and violence, in hopes of adding to the voices for peace.
As physicians, we must not let our shared revulsion of the attacks of October 7 blind us to the ongoing disaster unfolding in Gaza. Immediately after the attack, Israel cut off all food, water, fuel and medical supplies to Gaza. The ensuing air and ground invasion has rendered the Gaza strip a “graveyard,” as stated in a recent New York Times article. Hospitals have turned into war zones, with patients being forced to literally flee the places we work every day as physicians to bring healing to the world. As of this writing, the death count is nearing 15,000, including 6,150 children, and 26 of 35 hospitals are no longer functioning, while 87 ambulances have been damaged. Additionally, 53 journalists have also been killed, along with scores of doctors, nurses, and health care workers.
Some will blame Hamas for the humanitarian disaster, noting it was a predictable response, as evidenced by previous Israeli incursions. Some will blame Israel for the humanitarian disaster, noting the 16-year blockade on Gaza and the oppressive occupation for the past 75 years that has left Palestinians desperate.
At this point, it doesn’t matter. There is plenty of blame to go around to all parties, and assigning blame will not end the suffering of the children, women, and men of Gaza. It won’t bring the desperately needed medical supplies into Gaza. And it won’t stop the bloodshed.
Dr. Shafer recommends that we use our voices as physicians to advocate for a more compassionate, just, and peaceful world. I wholeheartedly agree. I pray that can be the case for all, including the downtrodden and poor of the earth. I echo his thoughts to do what little we can to aid those in need, especially as the need is exceedingly dire. I have been to Gaza and the West Bank on medical missions in the past with the Palestine Children’s Relief Fund, and I feel they are a worthy charity with a proven record of aiding the children of Palestine.
I will add one concern about Dr. Shafer’s comments. In quoting Golda Meir, did he mean to imply that Palestinians don’t value their children or are willing to sacrifice these innocent lives due to their hate for Israelis? I hope not, because such a statement devalues the lives of Palestinians, who love and value their children as much as all people do.
RESPONSE FROM DR. SHAFER:
I appreciate the thoughtful response of Dr. Abdo. The suffering of those in Gaza is unimaginable. As he writes, condemning terrorism does not mean turning a blind eye toward the plight of the Palestinians. Quite the opposite! The terrorism of October 7, and the subsequent suffering of those in Gaza as Israel seeks to destroy Hamas, both speak to the overwhelming need of both Israelis and Palestinians to find a pathway toward mutual security, mutual respect, and lasting peace. Neither the terrorist attacks nor the Israeli response provides a pathway to peaceful coexistence based on mutual respect.
I also appreciate Dr. Abdo pointing out that my quote from Golda Meir might be interpreted as suggesting that Palestinians don’t love their children. I apologize if my words conveyed that. The Palestinians surely love their children as much as anyone. My comment was intended to condemn hate, which has driven both the terrorist attacks on Israel and Israeli indifference to the suffering among Palestinians.