Gaza's health care system crippled before — and after

The editors of CMAJ chose to publish articles “to provide a perspective on the health-related and health infrastructure consequences of war” CMAJ March 17. The authors present “information” only giving one part of an argument, omitting history and context with regard to Hamas, with the intention of influencing opinions. This is called propaganda. CMAJ would never publish scientific articles without balance. This leads to the question of why these one-sided articles discussing human rights and so-called Israeli war crimes presented in such a warped framework were published in a previously respected peer-reviewed medical journal. The authors certainly do not mention Hamas or their human rights violations and true war crimes. Numerous other readers have expressed outrage at the lack of balance and have presented some of the omitted background and facts.

The devastating and complex situation of the Middle East obviously has resulted in human tragedy on both sides, but human rights in general and rights to health in particular as some of your readers place paramount, do not supersede the right of human beings to exist. The stated goal of Hamas, the “democratically elected government” of Gaza, is the destruction of the state of Israel. The daily Gaza rocket attacks for years endured by a terrorized Israeli civilian population including children, schools, and hospitals has not lead to any public outcry throughout the civilized world, including the NGO’s that supposedly stand for human rights, but apparently selectively. Is this the justice that Canadians for Justice and Peace in the Middle East and similar groups support? Human rights apply to all, regardless of color, nationality, religion or political beliefs. Civilized democratic nations draw the line when governments oppress the rights of their own people. Hamas is an Islamic fundamentalist group cruelly imposing a very strict interpretation on its people and goes to any end to meet its goals without regard for human life, including its own citizens. While Israel has not been faultless, there is an immeasurable value placed on any human life in Israeli and western society. Contrary to its Arab neighbours, there is no dancing in the streets when “enemy” Arabs die.

Terrorism (intentional targeting of a civilian population eg. rocket attacks, homicide bombers aka suicide bombers) initiates a nation’s (any nation) response to protect its civilians. Human tragedy can only be averted if terrorism will be replaced with a basic recognition of a nation (Israel) and its people to exist. Only then can the complex issues be discussed to reach a viable peace. Of all Israel’s neighbours, only Egypt and Jordan have acknowledged that peace is better than no peace. The civilized world should never accept Hamas and other Islamic fundamentalists’ total lack of respect for life let alone health. Hamas must be pressured to change its position to coexist peacefully. As long as people worldwide are blinded with propaganda and prejudices, instead of recognizing the need for the basic right to life and peace, history is likely to repeat itself following the rebuilding of Gaza infrastructure and health facilities.

It would not be surprising to see such articles published in a newspaper where bias is common, but such propaganda has no place in the CMAJ. The editors should recognize their failure for allowing the CMAJ to be a vehicle for propaganda.

Norman Just MDCM, FRCP(C)

Conflict of Interest:

None declared

To the editor:

I note an appalling trend in many of the responses to previous letters. Several people critical of your article pointed out that the situation in Gaza is indeed tragic, and required careful reporting: and yet your correspondents accuse the critics of your article of “muzzling”, “forbidding” and trying to “silence” discussion. This sort of rhetoric, in which “Zionism” (the mere idea that the state of Israel should persist) is used as a critical term to describe an ideology that somehow uses people as “mouthpieces” belongs with the dank tropes of conspiracy theory. Perhaps we will hear dark criticisms of “Switzerlandist ideology” next.

No critic of the article has said anything about muzzling anyone, and the notion that I and others here are somehow comparable to Nazi apologists is one which sheds more light on the odd ways in which people think about the problem at hand than it sheds on the facts of the matter.

The thrust of letters criticising the article has been that if political considerations and blame are going to be discussed in the article then they need to be discussed in a reasonable and balanced manner: not one which reduces (as the article indisputably did) the problems of Gaza’s healthcare to the actions of Israel alone. If people are truly concerned about healthcare in Gaza, they will recognize how problematic and damaging the actions of Hamas have been to the people of Gaza, and discuss that factually, and in proper context. If we want to give help, then the conditions under which one must give help need to be acknowledged and discussed, and not swept under the rug in the guise of objectivity. If the respondents to the critics of this article do not think that the well known actions of Hamas are in any way problematic or relevant(as apparently they do) and that instead that we should be silent about them, I invite the reader to consider which respondents have been complaining about people trying to make others be quiet.

Patrick Shannon, FRCPC

I am glad to see that the medical community is being educated about an issue that has been ongoing not only in Gaza but in many war-stricken areas of the world. I commend the CMAJ for bringing the healthcare of those affected to the forefront. Many medical journals and discussion circles shy away from the healthcare issues of the Middle East due to their underlying political roots – and this is not fair for those suffering on the ground, no matter what side they belong to.

It is important that we recognize and report healthcare issues with a conscious awareness for our biases and make attempts to remove our political, religious, or other beliefs when writing or responding to such issues. Are we focusing on the healthcare issues or on forwarding our own political ideology?

As physicians and advocates for healthcare, articles such as the above by Christopher Mason should remind us of the many hidden consequences of war and encourage us to use our leadership positions in society to work towards a common goal of human rights for all.

Conflict of Interest:

None declared

I want to thank the editor for highlighting Gaza in this issue of the CMAJ. I have been writing about this crisis with others for the past couple of years since the siege and blockade by Israel tightened. It has been very well documented. I am an associate member of Physicians for Human Rights Israel which includes both Israeli and Palestinian physicians who treat people in Israel and in the West Bank and Gaza. They have been documenting this deteriorating situation for some time and calling Israeli's treatment of the people of Gaza a human rights violation. It is tantamount to collective punishment which is against international law. I am surprised that physicians would have such a double standard when it comes to assessing such obvious human rights violation in Gaza. The lastest invasion of Gaza which included the use of non-conventional weapons and attacked civilians trapped in a virtual prison is beyond words. On Monday April 6, PHR-Israel is having a press conference to release its reports of its investigation of the invasion. I encourage you all to find out about this and I encourage the CMAJ to report it. Thank you again to the editor. I understand you are receiving some terrible criticisms. I applaud you.

Conflict of Interest:

None declared

re: Gaza's health care system crippled before — and after

Thank you for this article. It stuck to the facts. Those appalled by these facts need to acquaint themselves with the laws of war such as the Fourth Geneva Convention. Sieges like the one Gaza has been subjected to for years by the Israeli occupiers are illegal.

Israel had another option to stop the rockets (which had been stopped for the 6-month ceasefire with Hamas that Israel broke on Nov 4, 2008): agree to the long-term ceasefire that Hamas was offering in exchange for the lifting of this inhumane blockade. Hamas had stuck to the previous one. Israel is not really interested in peace - only in continuing to steal Palestinian land.

Sincerely, Ida C. Henderson

Conflict of Interest:

None declared

I think it is important that CMAJ brought these issues to readers' attention. CMAJ printed nothing radical nor controversial, but simply provided an account of the health care problems crippling Gaza as a result of Israel's (UN-condemned) actions.

The fact that so many misleading responses have been posted speaks volumes about the zionist approach in general. The attackers of this article hope that by keeping Canadians in the dark about the the atrocities committed against Palestinians (ranging from bombing of hospitals, to the use of white phosphorous as a weapon) that Canadians will remain indifferent to the situation.

I pose a question to these zionists: What would your response be to someone who tried to muzzle an article depicting the health atrocities committed against Jews during the Holocaust?

To gentiles who may be reading this, please know that not all of us jews are blinded by fabrications made by our community's mainstream. To jews that may be reading this, it is time for us to stand up, like a minority of Germans did during the Holocaust; we must do what is right, and stand up for the occupied territories of Palestine.

Shadrach Gold A proud (anti-zionist) Jew

Conflict of Interest:

None declared

As co-chair of Canadians for Justice and Peace in the Middle East’s health task force committee, as a resident, and above all else as a believer in the human right to health I would like to express my complete support for the CMAJ’s fair and open publishing policy which allowed for this very informative and relevant article written by Christopher Mason to be published. On the other hand, it was with utter dismay that I read response after response which seemed to characterize the article as some sort of political statement in support of Hamas, or perhaps a one-sided attack on Israel when it was clear that Mason’s piece simply focused on the relevant humanitarian issues, specifically with regards to a very crippled health care system. I’ve entitled my response “Forbidden but not forgotten” as a testimony to the reality that often discussion with regards to the humanitarian travesties and war crimes in the Occupied Territories are forbidden, while other humanitarian crises such as the genocide in Sudan are free and open to discuss. I believe Mason’s article, and CMAJ’s decision to allow for it to be published is testimony that what is forbidden will not be forgotten.

To those health care professionals who are interested in further information on this travesty I would suggest they read the report from the Israeli-run NGO Physicians for Human Rights – Israel: “Ill Morals: Grave Violations of the Right to Health during the Israeli Assault on Gaza” which can be found on http://www.phr.org.il/phr/.

Conflict of Interest:

I am committed to human rights and an end to military occupations worldwide.

As Canadians we recognize health care as an essential human right and a major factor in ensuring our quality of life. We should therefore be able to appreciate how extremely devastating and deadly the effects of conflict are when health care systems are affected, especially in situations where the existing infrastructure is delicate. The destruction of health facilities in any part of the world should be viewed as a human right violation as it prevents people from meeting their basic health needs and therefore meeting all of their other basic needs. This article sheds light on an important issue that we should continue to be aware of and react to.

Conflict of Interest:

None declared

I greatly commend the CMAJ for reporting on this humanitarian disaster that has fallen off the front pages of most of the news agencies in the western world.

Despite the numerous independent and impartial sources that the article has cited, I am astounded by how some members of the medical community here in Canada have the audacity to brush aside the raw data in order to turn this into a political debate.

As doctors, we are obliged to treat those in need regardless of political affiliation, religious beliefs, or any other denominations. The fact of the matter is that the people of Gaza are suffering beyond belief from this humanitarian disaster, and it is our duty as current or future physicians to advocate for their health care.

Conflict of Interest:

None declared

I was truly saddened to read about the humanitarian crisis in Gaza and I commend the CMAJ for publishing the articles describing the current crisis. It is important for physicians to be aware of humanitarian issues, particularly when they involve issues related to health care. Canadians have historically been international leaders in their humanitarian and volunteering efforts, and it is articles like this that may inspire Canadian physicians to address these issues.

I was also very shocked to read the responses to this article. I find it very disappointing that readers would introduce their political biases in interpreting these articles and question their relevance in this journal. There is no disputing the humanitarian crisis that is currently present in Gaza and I commend the articles for trying to discuss the issues in these articles without introducing any bias in their articles. Unfortunately, some people like to minimize or discount the injustices that are occurring due to their political or personal views. As physicians we are obliged to put our political, religious and other personal views aside when serving our communities and protecting the health and well-being of our fellow humans.

I hope the CMAJ will continue to report on this and other humanitarian crises worldwide and will not be pressured by politically motivated responses that try to discourage these articles from being reported.

Conflict of Interest:

None declared

It is unfortunate to read the two articles published on Gaza in the March 17 issue in what one would like to consider a peer reviewed objective medical journal. The discussion of health care in Gaza failed to mention the terrorist run Gaza government of Hamas and its use of monies for weapons to relentlessly attack Israel. The time, money and resources spent over the past several years would have been put to significantly better use by building and maintaining a health care system for the Palestinians in Gaza. Instead, it has been invested in the goal of the destruction of Israel, as stated by the Hamas led Gaza government. This omission is glaring to all knowledgeable in the conflict. Numerous mentions are made in the CMAJ articles of Israel, with the notable absence of the role of Hamas prior to, during and after the Israeli military campaign.

I am disappointed to see the Canadian Medical Association Journal involve itself in one-sided political misrepresentation, however well intentioned. I am further disillusioned by the response of the editor of CMAJ. The editor does not appear to credit the readers of his journal with being intelligent and concerned Canadian physicians opposed to biased articles in their national journal. To consider that individuals can only be concerned about biased and harmful reporting because of “orchestrated e -letter campaigns” is at best a deeply disturbing response, further highlighted by the editor’s silence on the factual oversights in the articles. It would be encouraging for the editor, a respected, internationally recognized leader in medicine, to reconsider the role of the CMAJ in the Canadian medical community and the journal’s responsibility to its readership.

A Canadian doctor against medical journals publishing unbalanced articles on politically sensitive issues: Hedy Ginzberg, MDCM, FRCPC, PhD

Conflict of Interest:

None declared

I would like to know exactly what value you thought you were providing your readership with the inclusion of the spurious, Israel- bashing article by Christopher Mason that appeared in the CMAJ March 17,2009 edition. If you wish to stay true to your professional motto, “medical knowledge that matters”, you should commission a story about the Israeli medical profession and/or Israeli medical research that has benefitted mankind throughout the world. Your decision to include the very misleading and dangerous piece by Mr. Mason can only lead the reader to conclude that there is a reckless Israeli war machine on the loose in the Middle East. What other democratic country in the world would be expected to sit idle and allow its citizens to come under daily rocket attack? What other country in the world would airdrop millions of leaflets warning citizens to take cover in advance? There was not even a mention in the article of the Gaza leadership, Hamas, whose charter openly and clearly calls for the destruction of Israel. No mention of the 7000+ rockets that Hamas has launched into Israel proper over the past 3 years, since Israel unilaterally pulled out of Gaza. No mention that the plight of the poor, impoverished Gaza people is inextricably linked to the single-minded focus and promise of Hamas and the Arab world to rid the Middle East of the existence of Israel.

I hope that you will respond to this publishing injustice in a positive manner going forward.

P. Resnick Toronto, ON

Conflict of Interest:

None declared

As a Certified Canadian Family physician with first hand experience in the Middle East Conflict I was shocked and disturbed by 2 recent articles appearing in your March 17, 2009 edition.

These 2 articles ostensibly were to bring attention to the plight of Gazans facing a medical crisis. However, due to what can only be deliberate omissions, the recent conflict was distorted and Israel was portrayed as a villainous entity unconcerned with basic humanitarian values waging a war on a civilian population. Hamas was not referred to even once!

How could the CMAJ publish articles blaming Israel alone for Gaza’s medical problems? There was not a mention of the terrorist group Hamas which caused the conflict by targeting Israeli civilians and then used Palestinian civilians as human shields?

How can the CMAJ report on the difficulties of the medical infrastructure, blaming Israel for disrupting ambulance transportation and damaging medical facilities without mentioning that Hamas used ambulances to transport weapons and used Hospitals for military purposes? They even made grenades from medicine bottles arriving in humanitarian aid from Israel. Hamas went as far as dressing militants as doctors and nurses knowing that this would protect them from the Israeli forces. Were these well documented facts not relevant to the subject?

Why was there no mention of the great efforts of the Israeli military to avoid civilian casualties by warning occupants of Hamas used structures to evacuate before attack, despite the strategic advantage that this would give the militants? There was no mention of the many Palestinians that were evacuated to Israel for medical treatment and attempts by Hamas to prevent it; nor was there any mention of Palestinians attended to, in the field, by Israeli military medical personal despite great risks to themselves.

I saw first hand the methods used by militants to exploit the very basic medical values of democracies such as Canada or Israel. I along with Palestinian medical workers have complained about the use of ambulances to transport weapons and the use of medical symbols and buildings as a cover for military operations.

I hope that the demonizing of the Jewish state by the CMAJ was by accident or due to negligence and not due to more sinister motives. As a Physician who has had research published in the CMAJ, I have a personal interest in the maintainance your good reputation as a politically neutral source of medical research and ideas. I certainly hope that you will take the steps necessary to reverse the damage that was done by these 2 articles.

Yours Sincerely, Dr. Paul Druzin MD CCFP FCFP Fellow of the College of Family Physicians of Canada Past volunteer for Physicians for Human Rights, Israel

Conflict of Interest:

None declared

Dear Editor, I am disappointed by your response to the flurry of emails you received following the two articles on Gaza. I for one do not participate in mass email campaigns and I had never read the Honest Reporting site. I simply read the article and responded as I saw fit. It is frankly disturbing that you would dismiss the concerns of such a wide academic base. To treat such a well educated and concerned constituency as merely responding to a web posting is insulting. To have received as many posts as you have speaks more to the depth of concern than to anything else. I would urge you to reconsider your response to the letters you have received. Otherwise, you continue to do this fine medical journal a great disservice. Such a disservice is not worthy from a fine scientist and physician as yourself. Sincerely, Mikael Swayze University of Toronto

Conflict of Interest:

None declared

The editor in chief of CMAJ, Dr Hebert, in reply to concerns regarding the articles about health care in the Gaza strip, makes several points: firstly he attributes many of the letters to an organized campaign. Secondly he says that “the news article focused on describing the impacts of war on health and health infrastructure in a region, as well as the difficulties that international aid agencies had in providing humanitarian relief.”

However, the news article does more than this: as I and others have noted, the article details how many of the difficulties encountered in arranging aid are due to the actions of the Israelis. The article is deafeningly silent about which difficulties, and how many are due to the actions of anyone else, and remarkably fail even to mention Hamas, or indeed any unfortunate actions by any Palestinians. It is this curious silence, and the importance of the facts that the article is silent about, which your readers are bringing to your attention. I for one needed no encouragement or orchestration by, or reference to any advocacy organization to formulate my reply.

I and others have raised the point that there were omissions of relevant fact in your news article. It is notable, and personally insulting, that the editorial response completely ignores the same issues of fact and instead complains about some organized reply. I suggest that perhaps one of the reasons the CMAJ has had so many replies to this article is that the departures from reasonable reporting are so egregious that just about anyone can recognize them, and so outrageous that they need to be addressed.

The editorial board of CMAJ has failed in its duty to its readers: firstly by publishing material of such poor quality that it can readily be employed as propaganda, and secondly by the abject failure of its editorial staff to respond to the substantial issues of fact raised. Unless the editorial board further wishes to become a byword for irresponsibility and self exculpation, it would do well to address the legitimate and obvious issues of fact involved, before complaining too loudly of its victimization by some sort of conspiracy.

Conflict of Interest:

None declared

To the Editor

I have finish reading with sadness the articles written by Francois Dumont and Christopher Mason. I say sadness because as a medical professional I understand very well what injuries and death mean for people and their loved ones, war indeed is tragic for anyone involved. I also say sadness to see how articles like the ones in this issue can be used for propaganda, when the information is so one-sided. As if there is no other side to the tragedy. As if all of this happens in a vacuum with only one side being the victim and the other the aggressor. Closed borders? What about mentioning Egypt's border with Gaza. Is that open for relief? If not, then it begs the question, why not?. Maybe it is time for physicians from the towns in the southern Negev, and especially Sderot to also submit their stories of working under daily shelling coming from Gaza. Of the interruptions of normal activity, and the terror of knowing that you have 15 seconds to get to a shelter before the explosion, occurring daily for 8 years! The article talks about children being traumatized, well the children of Gaza are not the only ones, as the psychiatric associations in Israel can attest, as they treat the children and adults from Sderot. How many of the Hamas terrorists were operating out of hospitals, shielding themselves with civilians? Indeed there are many sides to a story. All death is tragic, as is human suffering. But nobody has a monopoly on them. We should see the situation in the context it exists. I would hope CMAJ as a respected journal that I read, would be better prepared to deal with this complex political issue.

Sincerely,

Sam Marcushamer MD. F.R.C.P.(C), F.C.C.P Associate Clinical Professor Department of Medicine and Critical Care University of Alberta.

Conflict of Interest:

None declared

Greetings!

This note is in reference to the recent article in the CMAJ by Christopher Mason and Francois Dumont.

I am not and never have been a Jew, and to the best of my knowledge and belief, none of my many blood relatives, in-laws, or ancestors have been Jews. Neither am I any type of Zionist. However, I have some good friends and colleagues who are Jews, and even a few who are Orthodox Jews (a relatively rare breed in our city). I also have some good friends who are either practicing Muslims, or non-Muslims from a strong Muslim family background.

I am no expert on the problems of Palestine. However, I do get news from several different sources and viewpoints, including major Canadian newspapers, and I am by both nature and training enough of a sceptic to recognize the propaganda and "spin" that has been used by both sides.

It seems to me that the coverage of the medical situation in Gaza by Christopher Mason and Francois Dumont was rather one-sided. Perhaps if the very significant contribution of Hamas to the health problems in Gaza had been described, their article would have been better balanced.

Best wishes,

J.C. (Jim) Kennedy, MD, PhD Professor Emeritus, Department of Oncology Queen's University, Kingston, Ontario

Professor (adjunct), Department of Chemistry and Chemical

Engineering The Royal Military College of Canada, Kingston, Ontario

299 Glen Cairn Terrace, Kingston, Ontario K7M 4A6 telephone (613) 389-3000

Conflict of Interest:

None declared

To the Editor,

I did not expect CMAJ to venture into partisan politics. But - to publish un-researched inaccurate medical information is an outright disservice to readers. If I were to point out the multitude of inaccuracies and omissions in the two articles describing the medical aspects of the Gaza conflict, it would constitute an article in itself. I will point out only the most flagrant.

Which study corroborates an aid worker’s claim that “Gaza has the highest prevalence of traumatized children in the world?” There have been publications about the traumatized children in Israeli border towns. They are under rocket fire 24/7 to this day. [Only the Israeli side is honouring the ceasefire.] These terrorized children would welcome a 3 hour daily predictable respite during which they could feel safe to go to the toilet without a shrill siren warning them that they have 15 seconds to run to a shelter before another rocket lands in their schools, homes and hospitals.

Our Canadian government has declared Hamas a terrorist organization. Not once did either article mention that the main cause of the suffering of the ordinary Palestinian is the elected Hamas government. This government abuses its own citizens by denying them the very aid that is destined for them. Hamas has diverted financial aid and sequestered these funds for their own purposes. Precious funds are being used to “mis- educate” children into thinking that Israel is the cause of their misery and therefore they must destroy Israel. If they had a real education they could accomplish what truly needs to be done. Instead these poor children learn hate and are victimized by their own people who use them as human shields and also urge them to become suicide bombers.

Until the recent conflict Israel has provided non-discriminatory medical care to the Gaza citizens who come to Israel for medical services. Is it worthy of medical news that the Gaza ambulances that have come into Israel are sometimes used to smuggle terrorists and bombs? Are there medical consequences to the delays caused by the Israelis being forced to search ambulances because the supposedly pregnant patient in the ambulance occasionally actually has a bellyful of weapons?

Your articles were misleading to the Canadian who would like to know what is REALLY happening in medical care. Politically, the so-called Israeli offensive happened because Israel was trying to stop the barrage of rockets that had been fired on its citizens ever since Israel had voluntarily withdrawn from Gaza – but that omission was just political misinformation.

Shirley Katz, MD

Conflict of Interest:

None declared

Editor,

As an incoming clinical fellow in the department of psychiatry of Harvard University, and a doctoral student in clinical psychology currently training at a Canadian psychiatric hospital (Centre for Addiction and Mental Health in Toronto), I was outraged to read pages 608- 610 of the March 17th, 2009 edition (volume 180(6)) of the Canadian Medical Association Journal (CMAJ). The two articles printed on these pages by Christopher Mason and Francois Dumont were grossly deficient in presenting the political context in which healthcare practice in Gaza has changed in recent months.

Remarkably, neither report even mentioned the current governing body in Gaza “Hamas” nor its charter which calls explicitly for the destruction of Jewish life and the Jewish state of Israel. Furthermore, neither report referred to the onslaught of violent terrorist activity that has been perpetrated against Israel and her citizens by Hamas nor the defensive purpose of Israel’s operations. Even more disturbing was that the articles failed to report that Hamas has stolen humanitarian aid, actively prevented wounded citizens from seeing medical treatment, strategically placed terrorist activities (e.g., launching of rockets by Hamas militants against Israeli civilian targets) within civilian areas and near medical facilities, and used medical equipment for military purposes.

Were these reports to simply focus on medical issues in Gaza I would not be writing this letter. However, Mason’s article accuses Israel of intentionally targeted Palestinian medical centers. Not only is this claim unfounded, but no citation is provided for this in the paper at all. Furthermore, his citation of a newscaster’s account that “Gaza has the highest prevalence of traumatized children in the world” was spurious. His paper therefore breaks with scientific convention and frankly borders on anti-Semitism.

As a respected medical journal, CMAJ should not have allowed its pages to become a platform for political and religious propaganda.

David

Conflict of Interest:

None declared

To the Editorial board:

I read with interest the news article “Gaza's health care system crippled before — and after” by Christopher Mason. I note with even greater interest that the article mentioned the results of Israeli military actions on Gaza’s health care repeatedly, but failed to even mention the words “Hamas” or “local government” once. I note that it failed to refer to the theft of aid materials by Hamas, to the deliberate shellings by Hamas of border crossings delivering aid, to the documented propensity for Hamas to inhabit hospital based bunkers, to use mosques, and schools, as shelters for its fighters, and to use ambulances to transport their gunmen. Surely these facts have something to do with the state of Gaza’s health care system, and yet the article is utterly and completely silent about them.

Every member of a western liberal democracy should surely look on the violent, repressive behaviors and the explicitly genocidal policies of the elected government of the Gaza strip with horror. No reasonable reporting of the terrible conflict there can omit a consideration of the effects of such a government. And yet your journal did.

Patrick Shannon MD, FRCPC

Conflict of Interest:

None declared

Dear Editor, As faculty member at the University of Toronto and the friend of many physicians, I find it appalling to see the biased coverage of the Gaza matter in the pages of what is supposed to be a respectable peer reviewed journal. The two articles published in this issue of the Journal are partisan, biased and unworthy of being printed here. The facts should be obvious to anyone - Gaza is run by a terrorist organization (Hamas) which specifically targets civilians and civilian infrastructure in the State of Israel while turning its own civilian infrastructure into legitimate military targets by concealing weapons and fighters therein. These are war crimes under every international standard. Under international law, Hamas bears legal responsbility for all civilian deaths occasioned by Israeli response to military activity originating in civilian locales. This Journal cannot report on the situation in Gaza without reference to the fact that Hamas has chosen to build weapons rather than invest in health care. I frankly would not have expected the CMAJ to engage in this propaganda exercise designed to demonize the State of Israel in the exercise of its legitimate right of self-defence. Mikael Swayze, LLM

Conflict of Interest:

None declared

In my 25 years as a physician I have never written to an editor or responded to a journal article until now. After reading this report I was shocked that the CMAJ would allow such one sided bias to appear in its pages.

The article reports on the crippled health care system in the Gaza strip, an area run by the 'democratically' elected government of Hamas, who bear the brunt of the responsibility for the poor health care of their people. Not ONCE was the word Hamas even mentioned in the entire report which repeatedly names Israel throughout its paragraphs.

Hamas, who misappropriate billions of foreign aid dollars from around the world destined for health care is never discussed. Hamas, who store arsenals of weapons in hospitals and whose own gunmen hide in maternity wards are what cripples health care in Gaza. Hamas, who use ambulances not for the injured but for their own camouflage and imprison detractors in their hospitals evacuating wards to convert them into jails is what impedes proper health care.

Israel has always made an effort to treat the most injured Palestinians in their own facilities. They have made great efforts to continue under hostile conditions to allow humanitarian aid to reach hospitals in Gaza.

I expect better from the CMAJ whom I used to feel were more concerned about a neutral approach to health care than biased political reporting. Shame on you.

Robert Urback MD

Conflict of Interest:

None declared

The two articles are fundamentally and possibly intentionally misleading. Like our Lancet colleagues in the UK, a biased report of the situation in Gaza has been published without any historical context or any mention of why Israel felt compelled to act.

When Israel completely withdrew from Gaza, the Palestinians had the opportunity to begin creating a civil and democratic society. Israel would not have interfered. Instead, via election and civil war, they created a terrorist island that has been arming itself to the teeth and spending maximum effort to kill and terrorize Israeli civilians. When Israeli left Gaza they gambled that the Palestinians would be more interested in building than destroying. Sadly, Israel was wrong. With the aid money promised to the Palestinians, they could have built a hospital on every corner. Instead, the population chose Hamas and it's commitment to the destruction of Israel.

This war would never have happened if Hamas had been even slightly interested in Palestinian health and well-being. What do the Palestinians need this for? Don't they have enough problems of their own? Israel left Gaza. Now, focus on rebuilding your society. If they fire thousands of rockets at Israeli towns, they cannot but expect Israel to act. If this had been Windsor bombing Detroit, the US would not have been nearly so patient.

It is morally bankrupt of the CMAJ to publish these two articles about the tragedy of Gaza (and it is truly a tragedy) that blame Israel without even mentioning Hamas, who has done more to destroy the hope and health of the Palestinians than any other factor in the region.

Laz Klein, MD, MSc, FRCS(C)

Conflict of Interest:

None declared

Upon reading both "Gaza's health care system crippled before - and after" as well as "On the ground in the Gaza Strip", I was both saddened and shocked. Saddened at the situation the citizens of Gaza are facing. Shocked that the CMAJ would exploit the situation to produce two pieces of blatant anti-Israel propaganda.

The CMAJ does not mention Hamas once in either of the articles, and both pieces took on a decidedly anti-Israel tone. There was no mention of Hamas neglecting the health of its citizens in favour of building a war machine with the purpose of terrorizing Israelis. There was no mention of Hamas gunmen hiding in hospitals, and even using them as prisons. There was no mention of the efforts of the Israeli medical establishment to help injured Palestinians. There was no mention of the myriad of other abuses committed by Hamas both before and after Israel's hand was forced, all of which contributed significantly to the humanitarian crisis. There were also unsubstantiated claims in this respected journal, such as "Gaza has the highest prevalence of traumatized children in the world".

If the CMAJ wishes to report on situations beyond its stated mandate, it must do so in an unbiased fashion, and provide its readers with accuracy and honesty. That these articles can serve as fodder for Israel's detractors is both a pity, and unacceptable.

Sincerely,

Dr. Robert Zadik Department of Anesthesia Humber River Regional Hospital Toronto,ON

Conflict of Interest:

None declared

In a scant few days, CMAJ has received hundreds of letters in response to a pair of articles that were published Mar. 17: a news article entitled “Gaza’s health care system crippled before – and after”, as well as a Dispatch from the medical front entitled “On the ground in the Gaza strip.”

The news article focused on describing the impacts of war on health and health infrastructure in a region, as well as the difficulties that international aid agencies had in providing humanitarian relief. The Dispatch described an author’s personal viewpoint while working for Médecins Sans Frontières in provision of humanitarian aid and medical treatment during and after a conflict.

As with previous articles that CMAJ has run about health issues in war (such as one on Georgia CMAJ 2008;179[8]:762-3), neither piece forayed into geopolitical debate about its root causes. Therein appears to lie the reason for the bulk of reader dissatisfaction. Most letter writers seemed aggrieved that the articles failed to condemn the Palestinians and Hamas for their actions prior to the commencement of Israel’s “Operation Cast Lead” military campaign on Dec. 27, 2008.

Similarly, most letters appeared to be the product of a campaign launched by a group called “HonestReporting Canada,” which condemned the articles and asked its members to contact CMAJ and express their dissatisfaction. In its letter, the organization errantly identified both CMAJ articles as Dispatches and charged that the articles were misleading because they did not express the opinion that the Israeli operation was “prompted by years of Palestinian rocket and mortar attacks on Israeli civilians.”

Orchestrated e-letter campaigns have become increasingly common in the world of publishing and CMAJ has proven no exception, having been targeted earlier this year in an anti-abortion e-letter campaign. The BMJ recently was the target of such a campaign and subsequently released an editorial which concluded that they would thereafter, ignore such campaigns (BMJ 2009;338:b500). CMAJ, though, will publish letters written in response to the Gaza articles for the foreseeable future, provided that they are not defamatory, libelous, unintelligible or anonymous.

In retrospect, publishing 2 articles on a single subject in one issue, albeit an industry norm, may have somehow made it appear to some readers that CMAJ was taking an editorial position on the Arab-Israeli conflict. This is certainly not the case. For those who would like to see the health effects better described for people in Israel, we invite submissions on the health related consequences of war, whether in the Middle East or anywhere else in the world. As of 4:30 p.m. Mar. 24, 2009, CMAJ had received over 250 letters in response to the 2 articles, which we will continue to post. As always, we welcome your insight, and invite you to continue articulating your opinions.

Paul C. Hébert, MD, MHSc (Epid) Editor-in-Chief, CMAJ / Rédacteur-en-chef, JAMC

Professor of Medicine (Critical Care), Anesthesiology, Surgery and Epidemiology, University of Ottawa Critical Care Physician, The Ottawa Hospital Senior Scientist, Ottawa Health Research Institute (OHRI)

CMAJ – medical knowledge that matters

Conflict of Interest:

None declared