Structural Violence and its Effects on Children Living in War and Armed Conflict Zones: A Palestinian Perspective

The recent events in Palestine–Israel once again have brought anger and frustration to people inside and outside the medical community. Especially for the pediatric community, the recent wars’ toll of at least 67 children in the Gaza Strip and two children in Israel killed warrants attention. ¹ Armed conflicts have both direct effects on children's physical health and indirect harms through toxic stress and deprivation. ² During these troubling times, when civilians, including children, are dying and being mutilated because of conflict, it is crucial to understand the role of structural violence in perpetuating immediate violence.

Although often concealed and unspectacular, structural violence fuels direct political, physical, and psychological violence, which together lead to copious amounts of morbidity and mortality. In multiple settings across time and place—such as the case of police violence against Black Americans ³ ; health disparities in apartheid South Africa ⁴ ; the de-development of health care in sub-Saharan Africa ⁵ ; women's health in Ireland under British occupation ⁶ ; the health of indigenous communities in settler-colonial settings such as Australia, New Zealand, and North America ⁷ ; and all the way back to the health of the working class in England during the Industrial Revolution ⁸ and the ill health of the peasants in Germany during Feudalism ⁹ —a deep historical and structural analysis helped us better understand and contextualize the harsh lived realities of affected populations. The repetitive cycles of military aggression in Palestine–Israel emphasize the need to unveil, analyze, and contextualize structural violence and the underlying conditions of structural ethnic and religious superiority that fuel direct violence. This should provide a deeper understanding of the recent spark of violence that is cutting lives short, including those of children, while physically and emotionally scarring others.

What is Structural Violence?

Structural violence refers to the systematic ways in which social structures harm or otherwise disadvantage individuals and populations. It is the social arrangements that determine hierarchies of power, prestige, and access to resources. The arrangements are structural because they are deeply embedded in the political and economic organization of our world. They are violent because they cause injury to people. Structural violence constitutes an offensive against human dignity and incites racism and social inequalities that put individuals and populations in harm's way. ¹⁰

How Does Structural Violence Affect Child Health?

Structural violence affects health in multiple and complex ways. Unfortunately, these effects are often overlooked, perhaps especially among the medical community, because most practicing physicians are exposed to patients in a limited clinical setting. ¹¹ Public health scholars have warned that one of the powers of structural violence is its silence and hegemony. Whereas direct violence is apparent, easy to detect, and often spectacular, such as “waves on tranquil water,” structural violence is the tranquil water itself. It is all around us and “as natural as the air around us.” ¹⁰ A clear example is the focus of the American Academy of Pediatrics’ policy statement on the devastating effects of armed conflict on children's health, ² yet this statement fails to address much of the structural roots of these conflicts and the importance of addressing them for postconflict societies to reach a true healing process.

Research on the social determinants of health has found that health care is responsible for only ∼10% of the modifiable contributors to health outcomes, whereas social, economic, and educational status are responsible for the majority of health. ¹² Furthermore, the social determinants of health are shaped by political forces. Rudolph Virchow, one of the founding fathers of public health, stated this concept clearly in 1848: “Politics is nothing but medicine on a large scale…the doctor is the natural attorney of the poor.” ⁹ Structural violence is thus often described as the deep roots of health inequalities. It determines many of the social determinants of health into which we are born and thereby shapes our health, disease, and death. Concrete outcomes in the field of pediatrics include, for example, infant mortality rates, obesity rates, and life expectancy, which vary, sometimes considerably, between dominant and marginalized groups. ¹³

How Does Structural Violence Relate to Recent Sparks of Violence in Palestine–Israel?

For a better understanding of the current events in Palestine–Israel, one needs to examine the historical context. A recent statement of Physicians for Human Rights–Israel (PHR-I) states that the recent events are: “Expressions and consequences of profound injustice, an original sin that has never been recognized and has never been addressed—the sin of dispossession and the supremacy of one people over another. This takes the form of valuing some lives over others, discriminatory legislation, and unequal access to spiritual, cultural, and economic resources.” ¹⁴

Structural violence, then, is foundational to the state of Israel. The assignment of value, opportunities, and the rights of sovereignty and self-determination to one religious group over another led to the mass expulsion of Palestinians from their homeland and confiscation of land and property in the Nakba (Catastrophe) of 1948. ¹⁵ This has created the fragmented geographies where Palestinians currently live, many with refugee status. The Gaza Strip and the West Bank were created in 1948, by settler-colonial frontier expansion, also to serve as a warehouse for Palestinian refugees from what became to be defined Israel. In 1967, both the Gaza Strip and the West Bank became subject to Israeli military occupation, the building of Jewish-only settlements, and ongoing dispossession of land. The settler project continues to expand its sovereignty, drawing new frontiers and dispossessing people. ¹⁶

The renowned Jewish political theorist, Hannah Arendt, after witnessing the horrors of anti-Semitism in Europe and the creation of Zionism, wrote, “This division between Jews and all other peoples, who are to be classed as enemies, does not differ from other master race theories.” ¹⁷

A recent report by Human Rights Watch stated that: “Israel is the sole governing power between the river and the sea…Israeli authorities methodically privilege Jewish Israelis and discriminate against Palestinians.” ¹⁸

The Nation-State Law passed in 2018 by the Israeli Knesset officially declared Israel as

This definition of the state as belonging to one religious group and not serving as the state for all its citizens, coupled with settler-colonial policies, engineers very different realities, social determinants of health, and, therefore, health outcomes for different populations based on ethnicity and religion. A Jewish person born anywhere in the world can become a full citizen of Israel and enjoy full access to land, education, and health care. A Palestinian, indigenous to the land, is either a refugee outside his or her country or living under different shades of Jewish supremacy and military occupation. Such structural violence and structural racism constitute a true public health hazard. Structural racism has been extensively studied across the world as an upstream factor for land alienation, ecosystem degradation, historical trauma, and various forms of unequal access to resources and services, and it thus produces an unequal distribution of diseases that disfavor indigenous, Black, and other marginalized communities. ¹³

As the PHR-I report states, “The right to health is first and foremost the right to life; no individual, group, or nation would stand by while their lives are overlooked, treated as inferior to the lives of others.” ¹⁴

The spark of the recent events was the resistance to the forced displacement and ethnic cleansing of the Sheikh Jarrah neighborhood in occupied East Jerusalem ²⁰ and the militarized aggression this resistance has met, which spread to other parts of East Jerusalem and then all over Palestine–Israel. These events must be framed in a larger framework of structural violence and structural racism that privileges one ethnic group over another. Such structural violence will continue to create cycles of aggression and political violence that can only end once true equality and decolonization are achieved. The protests in the streets of cities such as Haifa, Akka, Lydd, and Jaffa ²¹ are all too familiar from images of Black South Africans resisting apartheid and Black Americans resisting various forms of White supremacy.

In many of the geographies where racial or religious superiority exists, no clear line exists between civilians and soldiers. Therefore, structural and political violence will continue to impose a heavy price to be paid by civilians, especially children, until it is completely dismantled.

If we are committed to the health and well-being of all people, it is important for physicians, public health scholars, and policymakers to recognize, address, and work toward dismantling structural violence and structural racism in Palestine–Israel to create a better future for all, without racial or ethnic privileges and hierarchies, where all people can live as equals.