Home Global health matters Asylum seeker and refugee health

As global leaders and aid groups speak up about “catastrophic crisis” in Gaza, health professionals are under pressure to remain silent

Melissa Sweet
Sue Wareham
Thursday, February 1, 2024

Asylum seeker and refugee health, Conflict and war, Global health, WHO, Health regulation, Health ethics

Introduction by Croakey: Médecins Sans Frontières (MSF) has expressed alarm about the decision by Australia and other countries to suspend funding to UNRWA, the United Nations Relief and Works Agency for Palestine Refugees in the Near East – a move that aid groups say jeopardises millions of lives.

An MSF statement on 30 January said nearly the entire Gazan population now relies on UNRWA for basic necessities, including food, water and hygiene supplies, and that any additional limitations on aid will result in more deaths and suffering.

The World Health Organization’s Director-General Dr Tedros Adhanom Ghebreyesus joined other UN leaders in a joint statement on 30 January warning that the decisions to pause funds for UNRWA will have catastrophic consequences for the people of Gaza.

“Withdrawing funds from UNRWA is perilous and would result in the collapse of the humanitarian system in Gaza, with far-reaching humanitarian and human rights consequences in the occupied Palestinian territory and across the region,” the statement said. “The world cannot abandon the people of Gaza.”

Meanwhile, 21 aid organisations issued a joint statement on 29 January expressing concern and outrage about the suspension of funding, and noting UNRWA’s swift investigation into the alleged involvement of a small number of UN staff members in the 7 October attacks by Hamas.

“We are shocked by the reckless decision to cut a lifeline for an entire population by some of the very countries that had called for aid in Gaza to be stepped up and for humanitarians to be protected while doing their job,” the groups said.

“This decision comes as the International Court of Justice ordered immediate and effective action to ensure the provision of humanitarian assistance to civilians in Gaza.”

ActionAid said in a statement that this “reckless action spells a death sentence for millions of Palestinians in Gaza and the surrounding region, intensifying an already catastrophic humanitarian crisis for millions of people”.

Funding cuts for UNRWA will also have broader regional consequences for Palestinian refugees in Syria, Jordan and Lebanon, where essential humanitarian aid is crucial for both the refugees and the host communities, ActionAid said.

“We urge the donor states to reverse this decision,” ActionAid said. “It is outrageously irresponsible to sanction an organisation and collectively punish the entire community it serves because a few individuals are accused of criminal acts, especially at a time of war, displacement, and unprecedented humanitarian needs.”

Even as aid agencies are speaking up, health organisations and health professionals are being pressured to remain silent, setting a worrying precedent for health advocacy, reports Dr Sue Wareham OAM, President of the Medical Association for Prevention of War (Australia).

Beneath her article, the Australian Health Practitioner Regulation Agency (Ahpra) responds to concerns raised.

Sue Wareham writes:

It’s not often that healthcare professionals are condemned for speaking out for the protection of healthcare and those who provide it. Yet that is what is happening in Australia – in what can only be interpreted as an attempt to silence critics of Israel’s actions in Gaza.

Since 7 October, when Hamas fighters terrorised, killed and abducted innocent Israeli civilians, Israel’s retaliation has known no bounds. Collective punishment has been applied to the whole population of Gaza with relentless and indiscriminate bombing, and the very basics of survival – food, clean water, fuel and medical supplies – have been blocked.

The World Health Organization reports that from 7 October last year to 30 January this year, there have been 676 attacks on healthcare in the Occupied Palestinian Territories (Gaza and the West Bank). At least 300 healthcare workers have been killed. In the words of Medecins Sans Frontieres, Israel has shown “a blatant and total disregard for the protection of Gaza’s medical facilities”.

Every description coming out of Gaza describes extremes in human suffering – “unprecedented trauma for children” (UNICEF), “epic humanitarian catastrophe” (UN Secretary-General), “never in Oxfam’s history have we seen a humanitarian crisis like the one in Gaza” (Oxfam), “every day…100 children on average have been killed (Save the Children), “unrelenting war on health” (UN Special Rapporteur on the right to health), and many more.

The sheer scale of the attacks on healthcare is driving healthcare professionals in Australia and elsewhere to speak out – but sometimes with serious personal consequences.

Since October 7 there has been a series of complaints made to Ahpra, the Australian Health Practitioner Regulation Agency, against 39 health practitioners – mostly doctors but other health professionals as well – for social media posts on related matters that are alleged to be antisemitic or anti-Islam. The posts were generally gathered from closed Facebook groups for doctors, not open groups. Objections have included offence at the use of the word “genocide” – more on that in a moment.

According to the Nine Network on 22 January, Ahpra has stated that none of the complaints they had received have yet required formal investigation. While that’s good, it still leaves the problem that to be the subject of a complaint to our health practitioner regulator is no light matter, regardless of the merits – or lack of them – of the complaint.

It can cause very significant anxiety, uncertainty about one’s professional future, especially for early career professionals, and much time spent in defending oneself. Ahpra itself recognises that “being on the receiving end of any notification is a distressing experience for any health practitioner”.

The Medical Association for Prevention of War has communicated and met with Ahpra representatives to urge the Agency to issue clear public guidance and clarification on this matter. We made it known that a concise statement from Ahpra to reassure health professionals about the legitimate and important role of health advocacy in the protection of healthcare, and warning against vexatious complaints, would be very welcome.

Ahpra’s response to MAPW stated in part that: “Practitioners who express views that advocate for the protection of healthcare workers, civilians and infrastructure, without breaching the Code of Conduct or Social Media Guidelines would be very unlikely to prompt an investigation or warrant any form of regulatory action.”

This is reassuring, although given the importance of this issue and the distress that is being caused, a statement to supplement the Code of Conduct and to specifically address the current controversy and context would be of additional benefit, particularly for those who have been made fearful about exercising their right – and our collective obligation – to advocate for the protection of healthcare. Regrettably, Ahpra has declined to issue such a statement.

Nevertheless many healthcare workers and students continue to speak out, in part to put pressure on major medical organisations that have either remained silent or tiptoed around the strong advocacy that’s needed. Medical and other healthcare students are urging their medical schools and other institutions to call for an immediate ceasefire, safety for health care workers and the free passage of humanitarian aid. Healthcare students can sign the call here.

It is critical that efforts such as these continue, not only for the people of Palestine, but also for the future of health advocacy. Silence enforced by intimidation is a dangerous slippery slope.

Further mention of the matter of genocide, and health professionals’ use of the word in relation to Israel’s actions, is warranted. Warnings about genocide unfolding in Gaza are not wild exaggerations designed to damage Israel’s reputation. They have been issued by authoritative non-partisan sources since the very early days of the current war (see, for example, here and here).

The International Court of Justice (ICJ) is currently considering the claim brought by South Africa that Israel is committing genocide, and on 26 January issued an interim judgement indicating that Israel has a case to answer. The Court ordered that Israel take steps to “prevent the commission of [acts within the scope of the Genocide Convention]”, and prevent and punish incitement to commit genocide. Whether or not Israel is already guilty of the crime of genocide will be decided at a later time.

The ICJ also ruled that Israel must enable the provision of urgently needed basic services and humanitarian assistance. It is therefore alarming and unfathomable that almost immediately after the judgement was issued, Australia joined other Western nations in suspending aid to UNRWA, the UN Relief and Works Agency for Palestinian Refugees, which is by far the biggest provider of services to the people of Gaza.

The decision was made on the basis of allegations made against 12 of UNRWA’s 13,000 employees in Gaza, allegations which UNRWA had promptly and appropriately dealt with. It, along with Australia’s other supports for Israel, may render Australia complicit in the crime of genocide.

Prevention is a fundamental goal of the 1948 Genocide Convention, whose full title is the Convention on the Prevention and Punishment of the Crime of Genocide. The Convention places legal obligations on members states (of which Australia is one) to take preventive measures when warnings of genocide first arise. As stated above, these warnings arose months ago. In this respect the law aligns with medical practice, where prevention must always be the priority, especially when faced with a dire situation for which there is no cure.

Should health professionals remain silent in the face of warnings of genocide, or genocide itself, or other war crimes, particularly when healthcare professionals just like us are under direct attack?

Clearly some members of the community believe so and are using our health practitioner regulator to make their point. But others choose not to remain silent, and for this some of them are paying a heavy personal price. This sets a bad precedent for health advocacy.

• Dr Sue Wareham OAM is President, Medical Association for Prevention of War (Australia)

Responses from Ahpra

Croakey put a series of questions to Ahpra, which are published below, together with responses.

1. Dr Wareham says since 7 October, complaints have been made to Ahpra again 39 health practitioners for social media posts about this conflict.

Q: Is there any update to this number? Is 39 still the correct number?

A: Ahpra has received 59 notifications relating to social media posts by practitioners discussing the conflict in Israel and Palestine. These notifications relate to 39 individual practitioners.

None of the notifications relating to social media posts by practitioners discussing the conflict in Israel and Palestine received to date have required a formal investigation.

2. Dr Wareham states that according to the Nine Network on 22 January, Ahpra says that none of the complaints they had received have yet required formal investigation.

Q: Is this still the case? Have any formal investigations been launched or undertaken in relation to any of these 39 health practitioners?

A: None of the notifications relating to social media posts by practitioners discussing the conflict in Israel and Palestine received to date have required a formal investigation.

Around one third of the practitioners who had received a notification have been informed of an outcome or will be informed of outcomes in the coming days.

We expect a further third of the practitioners who had received a notification will be informed of an outcome in the next 2 to 3 weeks, after their matters are considered by a National Board or committee.

The other cases remain open while we complete our enquiries.

3. The MAPW has asked Ahpra representatives to urge the Agency to issue clear public guidance and clarification on this matter, to reassure health professionals about the legitimate and important role of health advocacy in the protection of healthcare, and warning against vexatious complaints. However, Ahpra has declined to issue this statement.

Q: Why has Ahpra declined to issue such a statement? Is Ahpra considering taking any other action?

A: Ahpra and the National Boards are in the process of updating social media guidance to include a range of case study examples to indicate the types of activities that may or may not lead to a National Board’s consideration of regulatory action.

4. Does Ahpra accept that its complaints process is being weaponised against health practitioners who are seeking to raise legitimate concerns about attacks on civilians, healthcare services and health and humanitarian workers?

Q: If so, what will Ahpra do about this?

If not, does this mean Ahpra regards these complaints as legitimate?

A: Ahpra and the National Boards recognise the freedom of expression for practitioners and their right to advocate for causes via social media, provided their activities do not involve the abuse or discrimination of others, or present a risk to the public. We would ask that everyone use social media to express their thoughts in factual and respectful ways.

We share the concerns of many practitioners that unnecessary notifications to Ahpra cause harm and distress for those subject to those complaints. We aim to do all we can to minimise the stress experienced by practitioners in the notifications process, which includes ensuring that only those matters warranting closer examination are forwarded for a full investigation.

We are obliged by law to consider every notification we receive. This includes conducting an assessment of the merits of any concerns raised.

While everyone has the right to lodge a notification if they are concerned about the social media use of a registered practitioner, there are only limited grounds on which Ahpra and the National Boards would investigate or consider taking action.

Registered practitioners will not be investigated for holding or expressing their views on social media in ways that do not breach the Codes of Conduct set by the National Boards, and further articulated on the social media guidance provided online. Regulatory action (sanctions) may be considered if the way a practitioner expresses their views presents a risk to public safety; risks the public’s confidence in their profession; or requires action to maintain professional standards.

5. This issue was discussed on 26/10/2023 in the Community Affairs Legislation Committee. Senator Ruston asked Ahpra representatives: “I ask that you come back to us in a matter of hours—I will provide you with the information that I have—to let me know what action you intend to take, because these are some of the most offensive things I have seen on social media for the practitioners that you oversee.”

Q: Did Ahpra comply with the Senator’s request?

A: Our response to Senator Ruston’s question is published on the Senate website.