In a chapter from Humanitarian Negotiations Revealed: The MSF Experience, Caroline Abu-Sada recounts and analyzes some of the complications Doctors Without Borders//Médecins Sans Frontières (MSF) has grappled with in Palestine. Specifically, Doctors Without Borders has had to navigate a perilous political situation between Hamas and Fatah as well as the tensions between Palestine and Israel. In this excerpt from the chapter “Gaza Strip: A Perilous Transition,” Abu-Sada describes the pressure put upon Doctors Without Borders by Hamas as well their dealings with the Israelis.

MSF saw the Hamas government as wishing to impose both health policy choices and its own vision of society and did not want to be dictated to on how it should behave and how it should run its activities. This stance was due partly to a political desire to limit its collaboration with Hamas and partly to its difficulty in understanding the deep mutations underway in Gaza. The organisation gave the ruling authorities the impression that it had put itself beyond their reach at a time when there was a real need to organise services for the population and consolidate their legitimacy.

Hamas finally left MSF no choice but to negotiate the scope of the organisation’s operations in the Gaza Strip. These negotiations focused on both medical and administrative issues. However, after the political and military defeat of Fatah, its long-standing interlocutor in the Gaza Strip, MSF’s relations with Israel were to be determined by matters of a completely different nature.

Israel and the Humanitarian Management of the Gaza Strip

Israel had evacuated its settlers and the military from the Gaza Strip in August 2005 as part of a non-negotiated withdrawal. However, it continued to control all entries and exits. For MSF, maintaining its activities therefore depended to a large extent on its relations with the Israeli authorities. This was all the more true after the Gaza blockade had been set up which, in theory, allowed through certain essential goods and humanitarian aid. In reality, however, orders of medical supplies and medicines sometimes remained stranded for days or even weeks if all the necessary permits hadn’t been obtained, or if the contents of the crates contravened some aspect of the relatively vague rules governing the embargo—or even for no apparent reason.

The Israeli “Cast Lead” offensive was a perfect illustration of the role Israel intended humanitarian aid to play in Gaza. It also goes some way to explaining the relations between MSF and Israel, which was anxious to demonstrate its concern for humanitarian issues. Thus, in response to a French proposal for a “48-hour ceasefire on humanitarian grounds” on 1 January 2009, and in spite of the fact that 400 people on the Palestinian side had already been killed, the Israeli foreign minister, Tzipi Livni, explained that “aid convoys [were] being allowed through the border crossings” and that consequently there was “no humanitarian crisis in Gaza and […] no need for a truce”. When, on 31 May 2010, the Israeli army attacked a flotilla of six ships transporting humanitarian aid to Gaza, Israel’s deputy ambassador to the United Nations, whose task it was to defend the blockade, took the same position, thereby minimising the consequences of the “strategy designed to throttle Gaza” that had been adopted by successive Israeli governments.

Interviewed in early 2011 about intervention opportunities for MSF during Operation Cast Lead, the head of NGO relations at the Israeli Defence Ministry and Coordinator of Governmental Activities in the Territories (COGAT) retrospectively justified the authorisations given to MSF in the following terms: “During operation ‘Cast Lead’ we authorised entry to any humanitarian operator providing real humanitarian assistance. We allowed MSF entry because we knew it would be useful. MSF asked us if it could take in tent hospitals, medicines and humanitarian workers. And nothing is more humanitarian than medical assistance. If your movements are coordinated with the Israeli Liaison Office (DCL) and you are providing medical assistance, why would we refuse authorisation? Some NGOs wanted to go in just to see what was happening, not to help, and that’s why they were refused access”.

For MSF, along with other humanitarian organisations, difficulties in getting aid into Gaza increased once the embargo was in place. For the organisation, 2007 started badly even before the “Battle of Gaza”, with an incident that had serious consequences for its action. On 17 April, during a trip to Jerusalem to attend a meeting with the coordination team, a Palestinian employee from Gaza was arrested for taking part in a “conspiracy” against Israel. In addition to the dramatic personal consequences of the incident, this arrest and subsequent conviction had numerous repercussions for MSF. Rumours circulated in Gaza that MSF had betrayed its employee and handed him over to the Israelis. In Israel, the organisation was the victim of a short but virulent press campaign during which it was accused of promoting terrorism. For the authorities in Tel-Aviv, this episode was a real opportunity: not only was MSF’s credibility undermined, but the risk of attack could be used as justification for restricting movements between the West Bank, Jerusalem and the Gaza Strip. Yet the organisation managed to keep up its activities, to the extent that some organisations who experienced more difficulty than MSF in obtaining travel permits at the Erez terminal12 border crossing believed it was getting special treatment. The Association of International Development Agencies (AIDA) published a communiqué in December 2008 in which it referred to differences in treatment between organisations: “Consequently, the use of a “security” justification to restrict entry by NGO staff to Erez for over twenty consecutive days beginning the first week of November is not consistent with prior security responses. Furthermore, the granting of permission for entry to MSF, UN, and ICRC staff is also not consistent with the justification of “security””. However, although MSF had very little scope for negotiation with Israel, it appeared to content itself with this. For example, it didn’t ask for more access to Jerusalem for staff in Gaza, and vice versa, in a conflict where access and the free movement of goods and people were major issues.

In such conditions, is it possible for medical aid organisations such as MSF to avoid becoming the healthcare assistants of the occupying power? The issue of NGOs assisting the occupation was explicitly raised by the president of MSF in 2002: “Until now, international humanitarian aid has only played a peripheral role in this conflict, but there is a danger of it being expected to assume that of assistant prison guard at the centre of a pitiless system of domination and segregation. After the capacity for resistance of the Palestinian population, it is now the independence of foreign relief workers that is being put to the test”.

Left-wing Israeli intellectuals also questioned the role of humanitarian aid at a time when four-fifths of Gaza’s population were reliant upon it. In their opinion, it was serving to “suspend the catastrophe” and freed Israel from the obligation of finding a way out of the conflict. For Adi Ophir and Arielle Azoulay, “the normal operation [of humanitarian and human rights organisations] is an extension of the ruling apparatus, one of its branches, the one responsible for the suspension of the catastrophe and the creation of chronic disaster” Dov Weissglas, adviser to Prime Minister Ehud Olmert, in an attempt in early 2006 to justify the blockade after Hamas’ victory in the legislative elections, commented: “It’s like an appointment with the dietician. The Palestinians will get a lot thinner, but they won’t die”. Some Palestinians also criticised the presence of NGOs in the occupied territories, believing that assistance programmes helped “normalise” the situation and relieved Israel of its responsibilities as the occupying power.

It should be noted that this notion that humanitarian aid can potentially collude with an oppressive system is not, however, confined to the Palestinian Territories. Furthermore, MSF has only a minor role in the aid operations conducted in the Territories in general, and in Gaza in particular. There are settings in which it is hard to avoid polarisation, and the Palestinian Territories is one of them. MSF has only ever worked with the Palestinian population and never in Israel, something that it is reproached for on occasion in the Israeli press. Consequently, the issue of its “neutrality” in the Israeli-Palestinian conflict has often been raised. It has also been raised with regard to its relations with the two Palestinian political factions, especially as, after the violent transfer of power between Fatah and Hamas in Gaza, its teams were confronted with what was for them a whole new scenario.

The imbalance in the forces involved, the media attention attracted by the conflict which offered countless opportunities for public statements, the proximity of the international teams to the Palestinian staff, as well as their daily exposure to the conflict, made political neutrality difficult and fostered the international teams’ empathy with the Palestinians, whom they perceived as victims. In 2001, the subject was discussed in a board meeting: “Many of them [members of the field team] are asking why their testimony gathering is not being reported by MSF; why we are not publicly denouncing Israel’s policies and practices in the Palestinian Territories”. It was in response to these demands that MSF began publishing its “Palestinian chronicles”18 in 2002. Presented as “an account of the day-to-day reality of a population trapped by war and whose suffering is largely ignored”, these chronicles contained the highlights of MSF’s testimony activity in the Territories and helped soothe tensions between the field teams and headquarters.

Recordings of discussions at board level reveal that several members of the team were considered to be “overly-invested in ‘testimony’ gathering”. Bearing witness to the living conditions of the Palestinians and to the violence they were suffering had become an end in itself for some of the team who expected to see MSF make its position public. Yet the organisation acknowledged that the requirement for “neutrality” was pushed to the limit when, as remarked by its president: “The military occupation is accompanied by such violence against the inhabitants of the Territories, the balance of power is so unequal, that there is a certain indulgence of the weakest, even when they commit crimes”.

A few years later, the programme managers raised the issue again in very similar terms: “Are we neutral? We don’t expect individuals to be completely neutral given their proximity to the Palestinians and the frequent imbalances in the conflict, but the organisation itself must use neutral language. We expect international staff (and, as far as possible, national staff) to try to maintain a certain degree of objectivity, to avoid biased and critical language and to stick to the facts”. The support by some of the teams for the secular and national programme of Yasser Arafat’s party, the recruitment of employees ideologically close to Fatah or to left-wing parties, an intervention initially designed for a situation opposing Palestinians and Israelis—and not two Palestinian factions—were all factors that contributed to make the political transition in Gaza a perilous experience for MSF.